Contextual Triggers and Tic Severity Across Life Periods: A Retrospective Analysis in Adults with Tic Disorders.

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Published in final edited form as: Child Psychiatry Hum Dev. 2024 Jul 8;57(3):659–668. doi: 10.1007/s10578-024-01733-y Contextual Triggers and Tic Severity Across Life Periods: A Retrospective Analysis in Adults with Tic Disorders Kathryn E Barber 1 , Qiang Ding 2 , Flint M Espil 3 , Douglas W Woods 1, 4, * , Matthew W Specht 5 , Shannon M Bennett 6 , Jordan T Stiede 7 , John T Walkup 8 , Emily J Ricketts 9 , Joseph F McGuire 10 , Alan L Peterson 11 , Scott N Compton 12 , Sabine Wilhelm 13 , Lawrence Scahill 14 , John Piacentini 15 Author information Article notes Copyright and License information 1 Department of Psychology, Marquette University, Milwaukee, WI, USA 2 Department of Psychological Medicine, Children’s Hospital of Fudan University Shanghai, Shanghai, PR China 3 Department of Psychiatry, Stanford University, Stanford, CA, USA 4 Department of Psychology, Loyola University Chicago, Chicago, IL, USA 5 Connecticut OCD, Anxiety, and Tic Specialists, Greenwich, CT, USA 6 Department of Psychology, Cornell University, New York, NY, USA 7 Baylor College of Medicine, Houston, TX, USA 8 Department of Psychiatry and Behavioral Health, Lurie Children’s, Chicago, IL, USA 9 Department of Neuroscience, UCLA Semel Institute, Los Angeles, CA, USA 10 Department of Psychiatry and Behavioral Sciences, Johns Hopkins Medicine, Baltimore, MD, USA 11 Department of Psychiatry & Behavioral Sciences, University of Texas San Antonio, San Antonio, TX, USA 12 Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC, USA 13 Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA 14 Emory University School of Medicine, Atlanta, GA, USA 15 Department of Child & Adolescent Psychiatry, UCLA Semel Institute, Los Angeles, CA, USA * Corresponding Author: Please direct all correspondence to Douglas W. Woods, Department of Psychology, Loyola University Chicago, Chicago, IL, USA. douglas.woods@luc.edu Issue date 2026 Jun. PMC Copyright notice PMCID: PMC13222070  NIHMSID: NIHMS2164753  PMID: 38976153 The publisher's version of this article is available at Child Psychiatry Hum Dev Abstract In tic disorders (TD), tic expression varies across the lifespan and as a function of contextual factors. This study explored connections between tic expression and contextual triggers across life periods in 74 adults ( M age =23.2) with TDs. The Tic History and Coping Strategies form assessed retrospective self-reports of contextual antecedents, consequences, and tic severity during four life periods (middle school; 9 th /10 th grade; 11 th /12 th grade; college/work) and past month. Tics reportedly worsened during and after school in school-aged years and worsened in the evening during college/work years. Stress and anxiety were reported to consistently trigger tics across time. The impact of activities, places, and emotions did not differ across life periods. Attention-based consequences, most prevalent during middle school, were more common than escape- or avoidance-related consequences across all periods. Findings illuminate how contextual factors may influence tics across life periods and underscore the consistent impact of tic-triggering emotions and attention-related consequences. Keywords: tic disorders, Tourette syndrome, environment, contextual factors, developmental Tic disorders (TDs), including Tourette Syndrome, are child-onset neuropsychiatric conditions characterized by the presence of motor and/or vocal tics lasting longer than one year. TDs are associated with variability in tic expression across different periods of life ( Black et al., 2021 ). Tics typically onset between ages four and eight, peak in severity during early adolescence, and steadily decline during late adolescence ( Hirschtritt et al., 2015 ; Leckman et al., 1998 ; Wolicki et al., 2019 ). Most individuals experience a significant improvement in tic symptoms by early adulthood; yet, around two-thirds continue to experience tics in adulthood ( Black et al., 2021 ; Bloch & Leckman, 2009 ). While fluctuations in tic severity may be partly due to developmental and biological processes, this variability is also believed to reflect the impact of contextual factors ( Godar & Bortolato, 2017 ; Horesh et al., 2018 ). It is well-recognized that contextual factors impact tic expression ( Conelea & Woods, 2008 ; Iverson & Black, 2022 ), and this is likely a reflection of context-dependent learning processes ( Himle et al., 2014 ). Contextual factors that influence tics can be categorized into antecedents (situations/events that precede a tic) and consequences (events that follow a tic). Past research has explored common tic-worsening antecedents in individuals with TDs. Tics have been reported to worsen as a function of locations (e.g., public places, classrooms, cars) and during specific times of day (e.g., after school, mealtime, bedtime; Himle et al., 2014 ). Stress, anxiety, and fatigue have been associated with increased tic expression in adults and youth with TDs ( Bornstein et al., 1990 ; Eaton et al., 2017 ; Wolicki et al., 2019 ; Yates et al., 2016 ). In children and adolescents, tics have been found to increase while watching TV, playing video games, and completing homework ( Barnea et al., 2016 ; Himle et al., 2014 ; Silva et al., 1995 ), although other studies have shown that participating in sports and watching TV alleviated tics in some ( Silva et al., 1995 ; Wolicki et al., 2019 ). Horesh et al. (2018) reported on the differential impact of life events (e.g., family, friends, school, work, health) on tic severity in patients aged 8–18. These mixed findings could be attributable to the individualized nature of contingencies, or that certain antecedents impact tics differently depending on period of life, thus leading to inconsistent results in samples with wide age ranges. Studies have also identified common tic-exacerbating consequences. Eaton et al. (2017) found that attention, escape, and aversive consequences reliably predicted tic severity in a sample of youth aged 9–17. In a study by Himle et al. (2014) , children (aged 9–17 years) with TDs and their parents frequently endorsed attention-based consequences, including being told to stop ticcing and receiving comfort. Escape-based consequences, such as being able to leave a situation or not complete a task, were also reported to be associated with increases in tics ( Capriotti et al., 2015 ; Himle et al., 2014 ). Other aversive consequences, such as not being able to participate in preferred activities, perceiving negative reactions from others (e.g., staring, laughing, teasing), and being left out of social situations have also been reported ( Edwards et al., 2017 ; Malli et al., 2019 ; Smith et al., 2015 ). In addition to the aforementioned descriptive research, small experimental studies have shown that both attention- and escape-based consequences increased tic frequency ( Carr et al., 1996 ; Malatesta, 1990 ; Scotti et al., 1994 ; Watson & Sterling, 1998 ). Combined, these findings suggest that attention, escape, and aversive consequences are reliably associated with increased tic expression. Still, it is possible that specific types of consequences are more common during certain life periods, and these consequences may have a varying impact on tics across time. Research has not explored whether the impact of tic-exacerbating variables differs as a function of life period. For example, it is possible that classroom-related triggers and receiving comfort have a greater impact on tics in childhood, while variables like social settings and reactions from others might exacerbate tics consistently across the lifespan. Exploring these questions could contribute to a more nuanced understanding of the relationships between the environment, period of life, and tic expression. A more detailed evaluation of the contextual factors that worsen tics across periods of life also has clinical relevance for guiding treatment. Therefore, this exploratory study analyzed retrospective reports of antecedents, consequences, and self-reported tic severity across different periods of life in a sample of patients with TDs. Methods Participants Data utilized for this study were collected as part of a long-term follow-up of a randomized controlled trial (RCT) examining the efficacy of comprehensive behavioral intervention for tics (CBIT; Espil et al., 2022 ). As discussed in Piacentini et al. (2010) where primary outcomes of the trial were published, the RCT compared CBIT to a psychoeducation and supportive therapy control condition (PST) in 126 youth participants. Of these participants, 80 took part in the long-term follow-up evaluations (see Espil et al., 2022 for detailed information about the follow-up). The present study included 74 adults aged 19 to 31 years ( M =23.16 S D =2.52), who completed the Tic History and Coping Strategies (THCS) form as part of the long-term follow-up evaluation. Most participants in this study reported their biological sex as male (74.3%; 25.7% female). Regarding gender identity, 55 (74.2%) identified as men, 17 (23.0%) as women, one (1.4%) as transgender, and one (1.4%) participant did not report gender identity. Most participants were White (86.5%; 1.4% Black; 4.1% Asian; 5.4% Biracial; 2.6% race not reported). In the original study, 35 of these participants received CBIT and 39 received PST. At the time of follow-up, 32 participants had a current comorbid diagnosis, as determined by the MINI ( Sheehan et al., 1998 ). Comorbid conditions included anxiety disorders ( n =18), post-traumatic stress disorder ( n =11), attention-deficit/hyperactivity disorder ( n =10), major depressive disorder ( n =8), obsessive-compulsive disorder ( n =7), bipolar 2 disorder ( n =1), and any psychotic disorder ( n =1). Participants had varying levels of education, including partial high school ( n =1), high school graduate ( n =12), technical college ( n =4), partial college ( n =28), college graduate ( n =23), and professional degree ( n =1), and 5 did not report their highest level of education attained. Procedures Participants from the original study ( Piacentini et al., 2010 ) were recruited for follow-up assessments ( Espil et al., 2022 ) through telephone, mail, e-mail, and social media invitations. Recruitment and data collection occurred between March 2014 and January 2019. The average duration between the original RCT and follow-up evaluation was 11.17 years (SD = 1.25; range = 7.08 to 13.67 years). Participants provided institutional review board-approved consent. Trained independent evaluators masked to original treatment assignment interviewed participants either in-person or via web-based videoconferencing. Measures Tic History and Coping Strategies (TCHS) Form As part of the follow-up evaluation, independent evaluators used the THCS to collect information about participants’ experiences with tics over the course of their lives. The THCS asked about experiences with tics at each of four life periods (middle school/junior high; 9 th /10 th grade; 11 th /12 th grade; and beginning of college/work) and during the past month. For each period, participants reported their age during that time, the age during which their tics were the worst in that period, and the severity of their tics at their worst in that period. Tic severity was rated on a Likert scale with the following anchors: “0 – No tics,” “1 – Borderline,” “2 – Mild,” “3 – Moderate,” “4 – Marked,” “5 – Severe,” and “6 – Extreme.” Next, for each life period, participants were asked “When tics were at their worst during middle school/junior high (question 2), were your tics worse than usual in any of the following situations?” Participants checked boxes to indicate whether their tics were worse than usual in specific types of situations. These included times (e.g., morning, school, immediately after school, evening, bedtime), places (e.g., in the car, with specific people, in church, in crowds, in restaurants), activities (e.g., eating, doing homework, watching television, playing video games, having an argument, exercising), and feelings (e.g., current stress, anxiety about future event, anticipation about positive event, bored, tired, angry). Participants could also check “other” for each category. Participants also checked boxes to indicate how other people responded to their tics during each time period. Factors were categorized into the following antecedent and consequence groups: being removed from something they wanted to do (e.g., asked to leave a sport, asked to leave restaurant, sent to bed early), getting out of something they did not want to do (e.g., allowed to miss class, allowed to not finish homework), being left out (e.g., not allowed to participate in a sport/activity, not invited to social events, people tried not to sit near me) or being given attention (e.g., teased, told to stop, had arguments, comforted). Participants could also check “other” for each category. Data Analysis Statistical analyses were performed using SPSS software (Version 29.0, SPSS Inc., Chicago, IL, USA). We first examined differences in self-reported worst-ever tic severity across different life periods using repeated ANOVAs. Greenhouse-Geisser test results are reported if the homogeneity of variances was not equal. Cochran’s Q tests were used to identify differences in the frequencies of participants endorsing each antecedent and consequence across each life period. For analyses that yielded significant Cochran’s Q tests ( Seeger & Gabrielsson, 1968 ), post-hoc McNemar’s tests with Holm-Bonferroni corrections were used to compare each life period. Results Variations in Tic Severity Across Life Periods Table 1 presents mean tic severity scores across four life periods and the past month. The homogeneity of variances test indicated unequal variances (p < .001), and tic severity was found to differ across time periods ( F (3.11,158.73) = 17.43, p < .001). Subsequent post hoc analysis revealed that the middle school/junior high period was associated with significantly higher tic severity compared to the other four life periods and past month ( p < .001), while no significant differences were observed among the other four life periods and past month ( p s > .05). Table 1. Tic Severity Ratings During Worst-Ever Point Across Different Life Periods Life Period M SD Middle School/Junior High 5.06 1.23 High School 9 th & 10 th Grade 3.71 1.81 High School 11 th & 12 th Grade 3.52 1.72 Beginning of College/Work 3.52 1.70 Past Month 3.31 1.50 Open in a new tab Note. Tic severity was rated on a scale of 1=no tics to 7=extreme. Time Triggers and Tic Severity Across Life Periods There were significant differences across life periods for tics being worse during school hours (χ 2 (4) = 29.22, p < .001; see Table 2 ), with tic worsening during school occurring more often in middle school/junior high than in other life periods, aside from early high school (9 th /10 th ). Immediately after school was reported to be associated with tic worsening more often during middle school as compared to later life periods (χ 2 (4) = 17.73, p = .001). During school hours, tics were more likely to be exacerbated across all life periods except for beginning of college/work. There were significant between-group differences for the evening as a time trigger for tics (χ 2 (4) = 13.17, p = .010), but pairwise comparisons were not significant after applying Holm-Bonferroni corrections. Table 2. Participants Endorsing Tic-Exacerbating Antecedents Across Life Periods Middle School/Junior High High School (9 th & 10 th ) High School (11 th & 12 th ) Beginning of College/Work Past Month X 2 p N (%) N (%) N (%) N (%) N (%) Times of day In the morning 6 (8.1%) a 8 (1.8%) a 3 (4.1%) a 7 (9.5%) a 4 (5.4%) a 4.30 .367 During school 36 (45.0%) a 27 (36.5%) a,b 20 (27%) b 16 (21.6%) b 15 (20.3%) b 29.22 <.001 *** After school 20 (27%) a 11 (14.9%) a 10 (13.5%) a 10 (13.5%) a 5 (6.8%) b 17.73 .001 ** In the evening 25 (31.3%) a 19 (25.7%) a,b 15 (20.3%) a,b 20 (27%) a,b 12 (16.2%) b 13.17 .010 * + At bedtime 16 (21.6%) a 14 (18.9%) a 11 (14.9%) a 9 (12.2%) a 10 (13.5%) a 7.08 .132 Places In car 10 (13.5%) a 7 (9.5%) a 5 (6.8%) a 8 (1.8%) a 7 (9.5%) a 3.77 .438 With certain person 9 (12.2%) a 4(5.4%) a 4 (5.4%) a 6 (8.1%) a 7 (9.5%) a 5.14 .273 In church 6 (8.1%) a 5 (6.8%) a 2 (2.7%) a 3 (4.1%) a 1 (1.4%) a 9.05 .060 In crowds 18 (24.3%) a 13 (17.6%) a 12 (16.2%) a 12 (16.2%) a 9 (12.2%) a 10.19 .037 * + In restaurant 4 (5.4%) a 1(1.4%) a 3 (4.1%) a 1 (1.4%) a 1 (1.4%) a 4.71 .319 Activities Eating 6 (8.1%) a 3(4.1%) a 5 (6.8%) a 5 (6.8%) a 1 (1.4%) a 8.00 .092 Homework 28 (37.8%) a 25 (33.8%) a 19 (25.7%) a,b 20 (27%) a,b 13 (17.6%) b 16.96 .002 ** Watching television 16 (21.6%) a 18 (24.3%) a 12 (16.2%) a 11 (14.9%) a 10 (13.5%) a 10.49 .033 * + Video games 5 (6.8%) a 7 (9.5%) a 4 (5.4%) a 8 (1.8%) a 5 (6.8%) a 5.40 .249 Argument 15 (20.3%) a 13 (17.6%) a 13 (17.6%) a 12 (16.2%) a 8 (1.8%) a 6.54 .163 Sport/exercise 6 (8.1%) a 5 (6.8%) a 5 (6.8%) a 6 (8.1%) a 3 (4.1%) a 2.73 .605 Emotions Stress 51 (68.9%) a 49 (66.2%) a 47 (63.5%) a 50 (67.6%) a 50 (67.6%) a 1.24 .871 Anxiety 50 (67.6%) a 48 (64.9%) a 45 (60.8%) a 43 (58.1%) a 43 (58.1%) a 4.73 .316 Anticipation 16 (21.6%) a 17 (23.0%) a 16 (21.6%) a 15 (20.3%) a 15 (20.3%) a 0.93 .920 Bored 14 (18.9%) a 14 (18.9%) a 11 (14.9%) a 14 (18.9%) a 12 (16.2%) a 3.81 .432 Tired 23 (31.1%) a 18 (24.3%) a 20 (27%) a 20 (27%) a 17 (23.0%) a 6.24 .182 Angry 14 (18.9%) a 12 (16.2%) a 17 (23.0%) a 16 (21.6%) a 13 (17.6%) a 5.73 .220 Open in a new tab Note . * p < .05 ** p < .01 *** p < .001. Columns show the number and percentage of participants who endorsed that the contextual trigger worsened their tics during that life period. Each subscript letter denotes a subset of categories whose column proportions do not differ significantly from each other at the .05 level. + indicates that post-hoc pairwise comparisons were not significant after Holm-Bonferroni corrections were applied. Place Triggers and Tic Severity Across Life Periods Cochran’s Q tests indicated no significant differences across life periods for tics worsening in the car, with certain people, in church, or in restaurants (see Table 2 for details). Reports of tics worsening in crowds differed between groups (χ 2 (4) = 10.19, p = .037), but corrected pairwise comparisons were not significant. Across all life periods, participants consistently reported that crowded places were the most common setting associated with tic worsening. Activity Triggers and Tic Severity Across Life Periods Cochran’s Q tests revealed no significant differences across different life periods for eating, playing video games, having arguments, and engaging in sports/exercise ( p s > .05). Results showed group differences for reports of tics worsening during homework (χ 2 (4) = 16.96, p = .002), and pairwise tests showed that homework was a more common trigger in middle school/junior high and high school (9 th & 10 th ) as compared to past month. During each life period, homework was the most frequently reported activity to worsen tics. There were between-group differences for watching television, (χ 2 (4) = 10.49, p = .033), but corrected pairwise comparisons were not significant. Emotional Triggers and Tic Severity Across Life Periods For emotional triggers, results from Cochran’s Q tests showed no significant differences between different life periods ( p s > .05). Across all life periods, stress about current events and anxiety regarding upcoming events were more commonly reported to worsen tics than any other types of triggers (i.e., times of day, places, activities). Stress and anxiety were reported to worsen tics by over 63.5% (47/74) and 58.1% (43/74) of participants, respectively, for every life period. Consequences and Tic Severity Across Life Periods Across all life periods, few participants (<10.8%; 8/74) reported being removed from preferred activities, removed from non-preferred activities, or left out because of tics ( Table 3 ). Examining specific consequences within these categories, Cochran’s Q tests showed significant differences in reports of being asked to leave class/meeting/school/work because of tics (χ 2 (4) = 18.73, p < .001), which was reported more frequently in middle school/junior high. Results also showed differences in being allowed to miss school/work entirely because of tics (χ 2 (4) = 16.48, p = .002), but corrected pairwise comparisons were not significant. Table 3. Participants Endorsing Consequences of Tics Across Life Periods Middle School/Junior High High School (9 th & 10 th ) High School (11 th & 12 th ) Beginning of College/Work Past Month X 2 p N (%) N (%) N (%) N (%) N (%) Removed from activity/setting Asked to leave activity 1 (1.4%) a 0 1 (1.4%) a 0 0 3.00 .558 Asked to leave class/meeting/ school/work 8 (10.8%) a 1 (1.4%) a 1 (1.4%) a 2 (2.7%) a 0 b 18.73 <.001 *** Asked to leave meals early 1 (1.4%) a 1 (1.4%) a 1 (1.4%) a 0 0 2.40 .663 Escape from nonpreferred activity/setting Allowed to get out of chores 0 a 1 (1.4%) a 1 (1.4%) a 0 a 0 a 4.00 .406 Allowed to not finish homework 2 (2.7%) a 2 (2.7%) a 2 (2.7%) a 0 a 0 a 5.33 .255 Allowed to miss class/school/work 7 (9.5%) a 5 (6.8%) a 5 (6.8%) a 0 a 0 a 16.48 .002 ** + Allowed to leave meals early 0 a 1 (1.4%) a 3 (4.1%) a 0 a 0 a 3.00 .558 Left out Not allowed to participate in a sport/activity 1 (1.4%) a 1 (1.4%) a 1 (1.4%) a 0 a 0 a 2.00 .736 Not invited to social events 2 (2.7%) a 2 (2.7%) a 1 (1.4%) a 2 (2.7%) a 2 (2.7%) a 4.00 .406 People tried not to sit near me 1 (1.4%) a 1 (1.4%) a 2 (2.7%) a 1 (1.4%) a 1 (1.4%) a 1.33 .856 Attention Teased 34 (45.9%) a 18 (24.3%) b 12 (16.2%) b,c 3 (4.1%) c 3 (4.1%) c 69.68 <.001 *** Told to stop 39 (52.7%) a 18 (24.3%) b 9 (12.2%) c,d 5 (6.8%) d,e 0 e 89.79 <.001 *** Had arguments about tics 15 (20.3%) a 7 (9.5%) a,b 9 (12.2%) b 3 (4.1%) b 2 (2.7%) b 23.30 <.001 *** Comforted 42 (56.8%) a 31 (41.9%) b 21 (28.4%) c 15 (20.3%) c 15 (20.3%) c 56.33 <.001 *** Asked unwanted questions 23 (31.1%) a 13 (17.6%) a,b 12 (16.2%) a,b 12 (16.2%) a 4 (5.4%) b 27.28 <.001 *** Stared at 20 (27.0%) a 15 (20.3%) a 10 (13.5%) a,b 11 (14.9%) a,b 5 (6.8%) b 23.36 <.001 *** Open in a new tab Note . * p < .05 ** p < .01 *** p < .001. Columns show the number and percentage of participants who endorsed that they experienced that consequence after tics during that life period. Each subscript letter denotes a subset of categories whose column proportions do not differ significantly from each other at the .05 level. + indicates that post-hoc pairwise comparisons were not significant after Holm-Bonferroni corrections were applied. Attention-based consequences were reported more commonly than other types of consequences (e.g., removal from activity/setting, escape from nonpreferred activity/setting, being left out). Regarding specific attention-based consequences of tics, Cochran’s Q tests revealed significant differences between life periods for the following factors: being teased (χ 2 (4) = 69.68, p < .001), being told to stop (χ 2 (4) = 89.79, p < .001), having arguments (χ 2 (4) = 23.30, p < .001), receiving comfort (χ 2 (4) = 56.33, p < .001), being asked unwanted questions (χ 2 (4) = 27.28, p < .001), and being stared at (χ 2 (4) = 23.36, p < .001). All attention-related consequences were most frequently reported to occur during the middle school/junior high period ( Table 3 ). Frequencies of all attention-based reactions to tics decreased across life periods. For each life period, being comforted was the most commonly reported reaction to tics. Discussion Tic expression is influenced by contextual factors across various life periods, but the interactions between environmental factors, life periods, and tic severity have not been thoroughly investigated. The purpose of this retrospective study was to explore differences in reported tic-influencing antecedents and consequences across various periods of life. Tic Severity In our sample, retrospective reports of tic severity were highest during middle school, with a notable drop in early high school and further slight decreases in late high school and college. Such findings are consistent with the established developmental trajectory of tics, as demonstrated by previous research indicating that tic severity typically peaks around age 10–12 ( Leckman et al., 1998 ; Wolicki et al., 2019 ) and gradually declines in later adolescence and early adulthood ( Bitsko et al., 2014 ; Bloch & Leckman, 2009 ). Antecedents Our study expanded upon past research assessing tic-worsening antecedents by exploring these triggers across discrete life periods. Regarding times of day, participants frequently reported tic worsening during school hours, especially in middle school. This is consistent with prior research ( Himle et al., 2014 ), and might be related to the presence of other tic-exacerbating factors during these hours (e.g., stress related to completing schoolwork, reactions from teachers/classmates, etc.). In later periods of life, the impact of school hours on tics diminished, potentially reflecting evolving coping strategies with age. In middle school, tics frequently worsened during the time immediately after school, but this effect became less pronounced starting in high school. A possible explanation for this is that middle schoolers likely have more contact with caregivers after school compared to high schoolers, which could increase the chance of receiving attention that reinforces tics. Supporting this hypothesis, Himle et al. (2014) reported that 82% of children with TDs and their parents endorsed attention-based consequences occurring at home after school. The decreased impact of after-school hours upon entering high school could also be related to adolescents’ increased involvement in after-school activities, which may have tic-alleviating effects (e.g., sports, art, music; Conelea & Woods, 2008 ; Wolicki et al., 2019 ). Evening was frequently reported as a tic-worsening time across various periods of life. Fatigue and tiredness are well-known factors that can adversely impact tics, potentially due to impaired tic inhibition ( Godar & Bortolato, 2017 ; Ricketts et al., 2023 ). This might explain tic exacerbation reported in the evening. Another contributing factor to higher tic severity in the evening may be general stress and anxiety ( Ricketts et al., 2023 ). For example, accumulated stress from school or work, or anticipatory concerns about the following day, may peak during the evening and exacerbate tic expression. Moreover, as sleep disturbance is common in both children and adults with TDs ( Jiménez-Jiménez et al., 2020 ), the anticipation of sleep challenges might also evoke tic-triggering feelings of anxiety. Places that triggered tic severity did not differ across life periods. Crowds were the most frequently reported tic-exacerbating setting across all periods, aligning with findings showing that public places and social gatherings worsened tics ( Himle et al., 2014 ; Silva et al., 1995 ). These results may also underscore the influence of sensory stimuli on tic expression. As sensory sensitivity is often heightened in both children and adults with TDs, it follows that highly stimulating environments like crowds could consistently exacerbate tics ( Belluscio et al., 2011 ; Houghton et al., 2014 ). The impact of crowds on tic severity could also be related to the potential for certain tic-exacerbating consequences in this setting (e.g., being looked at, shushed, asked questions; Himle et al., 2014 ). The tic-exacerbating effects of other activities (e.g., participating in sports, watching television, playing video games) also did not differ as a function of life period. Past research has reported variable rates of tic exacerbation linked to these activities, and our findings suggest that these variations may not be attributable to life period. Instead, it is plausible that the varying impact of these activities on tic expression is due to other influencing factors, such as stress, and focus, that may be present during an activity ( Conelea & Woods, 2008 ; Iverson & Black, 2022 ). To illustrate, stress during a competitive sports performance could exacerbate tics, whereas a state of focused concentration while exercising may diminish tics. Across all periods of life, doing homework was frequently reported to worsen tics across all periods, consistent with past findings ( Barnea et al., 2016 ; Himle et al., 2014 ; Wolicki et al., 2019 ). Homework might induce feelings of stress or frustration, which are linked to tic exacerbation ( Leisman & Sheldon, 2022 ). Additionally, as homework requires significant cognitive resources, it may leave fewer such resources available for managing tics ( Baym et al., 2008 ). Emotional triggers, especially stress and anxiety, had a consistent influence on tic severity across life periods. This finding is congruent with previous research pointing to the significant impact of negative emotions on tic expression ( Conelea & Woods, 2008 ; Eaton et al., 2017 ; Himle et al., 2014 ; Iverson & Black, 2022 ), and highlights that this impact is relatively persistent across life periods. Notably, emotional triggers for tics were the most commonly endorsed antecedents. Emotions were frequently and consistently reported to exacerbate tics across life periods, while reports of other contextual influences (e.g., activities, places) showed a diminishing trend over time. Reasons for this are unclear but warrant further exploration. Consequences Although prior studies have predominantly concentrated on antecedents when exploring contextual triggers of tic expression, our study also investigated retrospective reports of tic-exacerbating consequences across life periods. Results showed that attention-based consequences occurred more frequently during middle school. The high frequency of reactions, arguments, and comfort during the middle school period could be related to unfamiliarity with or misconceptions about tics from family, friends, and peers, who may become more accustomed to and less reactive to tics over time. Additionally, considering tic severity peaks during middle school years, it is plausible that tics are more noticeable during this time and inherently garner more attention and reactions from others. Further research is needed to elucidate the potential cyclical nature of attention and heightened tic expression during this life period. Across all life periods, our results showed that attention-based consequences were reported more often than escape, avoidance, or aversive consequences. This highlights the significance of attention and social reactions on tic expression across the lifespan, aligning with previous findings ( Capriotti et al., 2015 ; Eaton et al., 2017 ; Himle et al., 2014 ). In our sample, being comforted emerged as the predominant attention-based consequence across all life periods. Implications This study’s findings have clinical implications. Behavior therapy for TDs typically involves conducting a functional analysis to identify a patient’s tic-worsening antecedents and consequences and developing interventions to reduce the impact of those variables on the patient’s tics ( Woods et al., 2008 ). Treating clinicians could use the information gleaned in this study to anticipate what contextual antecedents might be more relevant for a patient based on their life period. At the same time, our results suggest that the influence of certain variables (e.g., activities, settings) is unique to each individual, irrespective of life period. This further emphasizes the importance of conducting a thorough assessment to clarify each patient’s idiosyncratic triggers and tailoring personalized interventions. Nevertheless, our findings demonstrated the ubiquity of stress and anxiety as tic triggers across life periods, suggesting the potential benefit of including relaxation strategies (e.g., progressive muscle relaxation, diaphragmatic breathing) as a supplementary component of comprehensive behavioral tic treatment. This study also points to the relevance of addressing tic-worsening consequences in treatment, particularly attention-based consequences. Clinicians should provide psychoeducation to patients and families on the impact of attention on tics, including comfort, and teach family members to shift their focus away from tics to create a “tic neutral” environment. It may also be important to consider interventions aimed at reducing attention to tics within the school setting. Limitations and Future Directions This study had several limitations, which may also point to avenues for future research. First, given the retrospective, self-report nature of this study, results may have been partially influenced by recall bias. Potential variability in participants’ recall accuracy and level of insight should also be considered when interpreting these findings. Additionally, the inclusion criteria for the original RCT from which our sample was drawn (e.g., tics as the primary treatment concern, minimum level of tic severity) may limit the generalizability of our findings to the broader TD population. It should also be noted that the THCS form was specifically designed for use in the CBIT follow-up study and has not yet been validated or used by other research groups. Further, while participants reported whether their tics were worse in relation to certain factors, we cannot confirm the directionality of reported antecedents, consequences, and tic expression. Future research could use ecological momentary assessment or observational methodology to capture the temporal connections between contextual variables and tic expression. The THCS form assessed all tics, but specific tic types (vocal vs. motor) might be reinforced by different contextual factors (e.g., quiet environments for vocal tics). Future research could explore this potential differential influence across life periods. Moreover, while our results suggest reduced school-related tic triggers over time, missing data and varying educational backgrounds among participants (i.e., some did not attend an educational institution after high school) highlight the need for future studies to explore the impact of educational experiences on tics across the lifespan. Limitations notwithstanding, the present study makes important contributions to the literature. Our study is the first to examine tic-exacerbating contextual variables across discrete life periods. Additionally, previous studies examining contextual triggers of tic expression have largely focused on antecedents; thus, our study provides valuable information regarding tic-worsening consequences. Overall, our findings shed light on the complex, nuanced relationships between contextual variables, tic severity, and life periods, which can inform a more comprehensive biobehavioral model of TDs. Funding This research was conducted with research support from the Tourette Association of America Research Grants Award and the National Institute of Mental Health (NIMH R01MH070802). This research was also supported by the 2023 Fudan-Sydney Brain and Intelligence Science Alliance Seed Fund (Project ID: IDH6282016/052/006/005). The content of this project is the responsibility of the authors and is not necessarily representative of the views of the Tourette Association of America, the National Institutes of Health, or the Brain and Intelligence Science Alliance. Footnotes Author Declarations Ms. Barber, Mr. Ding, Mr. Stiede, and Dr. Compton declare that they have no conflicts of interest. Dr. Espil has received research support from the Foundation for OCD Research and honoraria from Springer Nature. Dr. Woods receives royalties from Guilford Press, Springer Press, and Oxford University Press and royalties for www.tichelper.com . Dr. Woods also receives speaking fees from the Tourette Association of America. Dr. Specht receives research support and speaking honoraria from the Tourette Association of America. Dr. Bennett receives royalties from UpToDate for an entry on child anxiety, and honoraria from the Tourette Association of America for CBIT training/talks and Lyra Health for speakers’ bureau. Dr. Walkup has served on advisory boards for the TLC Foundation for Body-Focused Repetitive Behaviors, Tourette Association of America, and the Anxiety and Depression Association of America. He has received speaking fees from and American Academy of Child and Adolescent Psychiatry, American Academy of Pediatrics and American Psychiatric Association. Dr. Walkup receives research funding from Patient Centered Outcome Research Institute and royalties from Oxford Press and Wolters Kluwer. Dr. Ricketts has received research funding from the National Institute of Mental Health (NIMH), Brain and Behavior Research Foundation, the TLC Foundation for Body-Focused Repetitive Behaviors, American Academy of Sleep Medicine, and National Heart, Lung, and Blood Institute PRIDE. She has received honoraria and research funding from the Tourette Association of America (TAA). She has received honoraria from Wink Sleep, Centers for Disease Control and Prevention, and Springer Nature. Dr. McGuire has received research support from the American Academy of Neurology, American Brain Foundation, American Psychological Foundation, Hilda and Preston Davis Foundation, Misophonia Research Fund, Tourette Association of America, and National Institutes of Health. Dr. McGuire has received royalties from Elsevier and serves as a consultant for Signant Health, and Syneos Health, and Emalex. He has received editorial honoraria from Springer Nature and serves on the Tourette Association of America Scientific Advisory Board. Dr. Peterson reports receiving royalties from Oxford University Press for treatment manuals on tic disorders and receiving honoraria for CME presentations from the Tourette Association of America. Dr. Wilhelm is a presenter for the Massachusetts General Hospital Psychiatry Academy in educational programs supported through independent medical education grants from pharmaceutical companies. She has received royalties from Elsevier Publications, Guilford Publications, New Harbinger Publications, Springer, and Oxford University Press. Dr. Wilhelm has also received speaking honoraria from various academic institutions and foundations, including the International Obsessive Compulsive Disorder Foundation, the Tourette Association of America, and the Centers for Disease Control and Prevention. In addition, she received honoraria for her role on the Scientific Advisory Board for One-Mind (PsyberGuide), Koa Health, Inc, and Noom, Inc. Dr. Wilhelm has received research and salary support from Koa Health, Inc. Dr. Scahill has received research support from the Eunice Kennedy Shriver National Institute of Child Health and Human Development, the US Department of Defense, and the Marcus Foundation. He has served as a consultant to Cogstate. Dr. Scahill has received licensing fees from Roche, Yamo Pharmaceuticals, and Abbvie. He has received royalties from Guilford Press, Oxford University Press, and American Psychiatric Association Publishing. Dr. Piacentini receives research support from NIMH, Patient-Centered Outcomes Research Institute (PCORI) and the TLC Foundation for BFRBs, advisor fees and equity from Lumate Health; publication royalties from Guilford Press, Oxford University Press, and Elsevier; and travel/speaking honoraria from the Tourette Association of America and International OCD Foundation. References Barnea M, Benaroya-Milshtein N, Gilboa-Sechtman E, Woods DW, Piacentini J, Fennig S, Apter A, & Steinberg T (2016). Subjective versus objective measures of tic severity in Tourette syndrome – The influence of environment. Psychiatry Research, 242, 204–209. 10.1016/j.psychres.2016.05.047 [ DOI ] [ PubMed ] [ Google Scholar ] Baym CL, Corbett BA, Wright SB, & Bunge SA (2008). Neural correlates of tic severity and cognitive control in children with Tourette syndrome. Brain, 131(1), 165–179. 10.1093/brain/awm278 [ DOI ] [ PubMed ] [ Google Scholar ] Belluscio BA, Jin L, Watters V, Lee TH, & Hallett M (2011). Sensory sensitivity to external stimuli in Tourette syndrome patients. Movement Disorders, 26(14), 2538–2543. 10.1002/mds.23977 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] Bitsko RH, Holbrook JR, Visser SN, Mink JW, Zinner SH, Ghandour RM, & Blumberg SJ (2014). A national profile of Tourette syndrome, 2011–2012. Journal of Developmental and Behavioral Pediatrics, 35(5), 317–322. 10.1097/dbp.0000000000000065 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] Black KJ, Kim S, Yang NY, & Greene DJ (2021). Course of tic disorders over the lifespan. Current Developmental Disorders Reports, 8(2), 121–132. 10.1007/s40474-021-00231-3 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] Bloch MH, & Leckman JF (2009). Clinical course of Tourette syndrome. Journal of Psychosomatic Research, 67(6), 497–501. 10.1016/j.jpsychores.2009.09.002 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] Bornstein RA, Stefl ME, & Hammond L (1990). A survey of Tourette syndrome patients and their families: The 1987 Ohio Tourette Survey. Journal of Neuropsychiatry and Clinical Neurosciences, 2(3), 275–281. 10.1176/jnp.2.3.275 [ DOI ] [ PubMed ] [ Google Scholar ] Capriotti MR, Piacentini JC, Himle MB, Ricketts EJ, Espil FM, Lee HJ, Turkel JE, & Woods DW (2015). Assessing environmental consequences of ticcing in youth with chronic tic disorders: The tic accommodation and reactions scale. Children’s Health Care, 44(3), 205–220. 10.1080/02739615.2014.948164 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] Carr JE, Taylor CC, Wallander RJ, & Reiss ML (1996). A functional-analytic approach to the diagnosis of a transient tic disorder. Journal of Behavior Therapy and Experimental Psychiatry, 27(3), 291–297. 10.1016/S0005-7916(96)00025-0 [ DOI ] [ PubMed ] [ Google Scholar ] Conelea CA, & Woods DW (2008). The influence of contextual factors on tic expression in Tourette’s syndrome: A review. Journal of Psychosomatic Research, 65(5), 487–496. 10.1016/j.jpsychores.2008.04.010 [ DOI ] [ PubMed ] [ Google Scholar ] Eaton CK, Jones AM, Gutierrez-Colina AM, Ivey EK, Carlson O, Melville L, Kardon P, & Blount RL (2017). The influence of environmental consequences and internalizing symptoms on children’s tic severity. Child Psychiatry & Human Development, 48(2), 327–334. 10.1007/s10578-016-0644-5 [ DOI ] [ PubMed ] [ Google Scholar ] Edwards KR, Mendlowitz S, Jackson E, Champigny C, Specht M, Arnold P, Gorman D, & Dimitropoulos G (2017). A qualitative exploration of the experiences of children and adolescents with Tourette syndrome. Journal of the Canadian Academy of Child and Adolescent Psychiatry, 26(1), 39–44. [ PMC free article ] [ PubMed ] [ Google Scholar ] Espil FM, Woods DW, Specht MW, Bennett SM, Walkup JT, Ricketts EJ, McGuire JF, Stiede JT, Schild JS, Chang SW, Peterson AL, Scahill L, Wilhelm S, & Piacentini JC (2022). Long-term outcomes of behavior therapy for youth with Tourette disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 61(6), 764–771. 10.1016/j.jaac.2021.08.022 [ DOI ] [ PubMed ] [ Google Scholar ] Godar SC, & Bortolato M (2017). What makes you tic? Translational approaches to study the role of stress and contextual triggers in Tourette syndrome. Neuroscience & Biobehavioral Reviews, 76(Pt A), 123–133. 10.1016/j.neubiorev.2016.10.003 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] Himle MB, Capriotti MR, Hayes LP, Ramanujam K, Scahill L, Sukhodolsky DG, Wilhelm S, Deckersbach T, Peterson AL, Specht MW, Walkup JT, Chang S, & Piacentini J (2014). Variables associated with tic exacerbation in children with chronic tic disorders. Behavior Modification, 38(2), 163–183. 10.1177/0145445514531016 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] Hirschtritt ME, Lee PC, Pauls DL, Dion Y, Grados MA, Illmann C, King RA, Sandor P, McMahon WM, Lyon GJ, Cath DC, Kurlan R, Robertson MM, Osiecki L, Scharf JM, Mathews CA, & Genetics, f. t. T. S. A. I. C. f. (2015). Lifetime prevalence, age of risk, and genetic relationships of comorbid psychiatric disorders in Tourette Syndrome. JAMA Psychiatry, 72(4), 325–333. 10.1001/jamapsychiatry.2014.2650 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] Horesh N, Shmuel-Baruch S, Farbstein D, Ruhrman D, Milshtein NBA, Fennig S, Apter A, & Steinberg T (2018). Major and minor life events, personality and psychopathology in children with Tourette syndrome. Psychiatry Research, 260, 1–9. 10.1016/j.psychres.2017.11.016 [ DOI ] [ PubMed ] [ Google Scholar ] Houghton DC, Capriotti MR, Conelea CA, & Woods DW (2014). Sensory phenomena in Tourette syndrome: Their role in symptom formation and treatment. Current Developmental Disorders Reports, 1(4), 245–251. 10.1007/s40474-014-0026-2 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] Iverson AM, & Black KJ (2022). Why tic severity changes from then to now and from here to there. Journal of Clinical Medicine, 11(19), 5930. https://www.mdpi.com/2077-0383/11/19/5930 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] Jiménez-Jiménez FJ, Alonso-Navarro H, García-Martín E, & Agúndez JAG (2020). Sleep disorders in tourette syndrome. Sleep Medicine Reviews, 53, 101335. 10.1016/j.smrv.2020.101335 [ DOI ] [ PubMed ] [ Google Scholar ] Leckman JF, Zhang H, Vitale A, Lahnin F, Lynch K, Bondi C, Kim YS, & Peterson BS (1998). Course of tic severity in Tourette syndrome: The first two decades. Pediatrics, 102(1 Pt 1), 14–19. 10.1542/peds.102.1.14 [ DOI ] [ PubMed ] [ Google Scholar ] Leisman G, & Sheldon D (2022). Tics and emotions. Brain Sciences, 12(2). [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] Malatesta VJ (1990). Behavioral case formulation: An experimental assessment study of transient tic disorder. Journal of Psychopathology and Behavioral Assessment, 12(3), 219–232. 10.1007/BF00960619 [ DOI ] [ Google Scholar ] Malli MA, Forrester-Jones R, & Triantafyllopoulou P (2019). “Tourette’s is a lonely place”: An interpretative phenomenological analysis of the personal experience and identity of adults with Tourette’s syndrome. Journal of Developmental and Physical Disabilities, 31(6), 819–845. 10.1007/s10882-019-09676-2 [ DOI ] [ Google Scholar ] Piacentini J, Woods DW, Scahill L, Wilhelm S, Peterson AL, Chang S, Ginsburg GS, Deckersbach T, Dziura J, Levi-Pearl S, & Walkup JT (2010). Behavior therapy for children with Tourette disorder: A randomized controlled trial. JAMA, 303(19), 1929–1937. 10.1001/jama.2010.607 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] Ricketts EJ, Swisher V, Greene DJ, Silverman D, Nofzinger EA, & Colwell CS (2023). Sleep disturbance in Tourette’s Disorder: Potential underlying mechanisms. Current Sleep Medicine Reports, 9(1), 10–22. 10.1007/s40675-022-00242-5 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] Scotti JR, Schulman DE, & Hojnacki RM (1994). Functional analysis and unsuccessful treatment of Tourette’s syndrome in a man with profound mental retardation. Behavior Therapy, 25(4), 721–738. 10.1016/S0005-7894(05)80206-0 [ DOI ] [ Google Scholar ] Seeger P, & Gabrielsson A (1968). Applicability of the Cochran Q test and the F test for statistical analysis of dichotomous data for dependent samples. Psychological Bulletin, 69(4), 269–277. 10.1037/h0025667 [ DOI ] [ PubMed ] [ Google Scholar ] Sheehan DV, Lecrubier Y, Sheehan KH, Amorim P, Janavs J, Weiller E, Hergueta T, Baker R, & Dunbar GC (1998). The Mini-International Neuropsychiatric Interview (M.I.N.I.): The development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. Journal of Clinical Psychiatry, 59(Suppl 20), 22–33. [ PubMed ] [ Google Scholar ] Silva RR, Munoz DM, Barickman J, & Friedhoff AJ (1995). Environmental factors and related fluctuation of symptoms in children and adolescents with Tourette’s disorder. Journal of Child Psychology and Psychiatry, 36(2), 305–312. 10.1111/j.1469-7610.1995.tb01826.x [ DOI ] [ PubMed ] [ Google Scholar ] Smith H, Fox JRE, & Trayner P (2015). The lived experiences of individuals with Tourette syndrome or tic disorders: A meta-synthesis of qualitative studies. British Journal of Psychology, 106(4), 609–634. 10.1111/bjop.12118 [ DOI ] [ PubMed ] [ Google Scholar ] Watson TS, & Sterling HE (1998). Brief functional analysis and treatment of a vocal tic. Journal of Applied Behavior Analysis, 31(3), 471–474. 10.1901/jaba.1998.31-471 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] Wolicki SB, Bitsko RH, Danielson ML, Holbrook JR, Zablotsky B, Walkup JT, Woods DW, & Mink JW (2019). Children with Tourette syndrome in the United States: Parent-reported diagnosis, co-occurring disorders, severity, and influence of activities on tics. Journal of Developmental & Behavioral Pediatrics, 40(6), 407–414. 10.1097/dbp.0000000000000667 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] Woods DW, Piacentini J, Chang S, Deckersbach T, Ginsburg G, Peterson A, Scahill LD, Walkup JT, & Wilhelm S (2008). Managing Tourette syndrome: A behavioral intervention for children and adults therapist guide. Oxford University Press. 10.1093/med:psych/9780195341287.001.0001 [ DOI ] [ Google Scholar ] Yates R, Edwards K, King J, Luzon O, Evangeli M, Stark D, McFarlane F, Heyman I, İnce B, Kodric J, & Murphy T (2016). Habit reversal training and educational group treatments for children with tourette syndrome: A preliminary randomised controlled trial. Behaviour Research and Therapy, 80, 43–50. 10.1016/j.brat.2016.03.003 [ DOI ] [ PubMed ] [ Google Scholar ] ACTIONS View on publisher site PDF (382.4 KB) Cite Collections Permalink RESOURCES Similar articles Cited by other articles Links to NCBI Databases Follow NCBI NCBI on X (formerly known as Twitter) NCBI on Facebook NCBI on LinkedIn NCBI on GitHub NCBI RSS feed Connect with NLM NLM on X (formerly known as Twitter) NLM on Facebook NLM on YouTube National Library of Medicine 8600 Rockville Pike Bethesda, MD 20894 Web Policies FOIA HHS Vulnerability Disclosure Help Accessibility Careers NLM NIH HHS USA.gov Back to Top

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