This current tic phenomenon is primarily impacting teen girls, many of whom have no previous history of tics. That’s not typical for most tic disorders, such as Tourette syndrome. Tourette’s is a neurological movement disorder that is more common among boys and typically starts between ages 5 and 7 years.

Zelime Elibol, M.D., a pediatric neurologist with a special interest in cognitive and neurobehavioral disorders and director of Cook Children’s Tourette Syndrome Clinic, says the majority of tics observed in this current surge are called functional tics. Functional neurologic symptoms are not associated with any known neurologic cause. There is no structural damage to the brain or a lesion causing them, like in the case of a stroke or multiple sclerosis. Something is wrong, but it’s difficult to identify a physical cause, and it’s not likely to respond to typical medical treatments for tics.

An article published in the British journal “Archives of Disease in Childhood” in March, shed light on the issue. It detailed both an increase in tic symptoms during the pandemic among adolescents already diagnosed with tic disorders, as well as a sharp rise in the sudden and new onset of tic-like attacks among teenage girls. Pandemic stress and social media may be to blame, according to the article’s authors.

The piece highlights a recurring factor at play with this new set of functional tic disorders—the viral TikTok trend of showing one’s tic attacks. Views of #tourettes videos doubled between January and February 2021, and some teen girls report an increased consumption of these videos prior to onset of symptoms. Some also said they post videos of their own tic attacks and gain a level of support and attention from them, according to the article.

We sat down with Dr. Elibol to learn more about functional tic disorders and what parents and caregivers need to know about the recent rise in cases.

How common are tics in general?

About 25% of children will develop tics during early childhood, known as developmental tic disorders. The most common are called transient tics. They get them for a period of time, but they’re gone within a year. A much smaller percentage, about 1%, go on to have what we call chronic tics that last more than a year, often many years. Aside from developmental tic disorders, there are medical and metabolic disorders that cause tics. There are also medications that may cause tics as a side effect.

What are you seeing in your own practice right now related to functional tics?

We see functional neurologic disorder symptoms at times, meaning we see neurologic symptoms that contradict known patterns of disease and are often thought to have a psychological underpinning. They’ve always been around, but there is a notable increase right now. Specifically, what I’m seeing in my practice is a significant increase in explosive tics in otherwise healthy adolescents with a normal neurologic exam. So far, all of my functional tic patients are adolescent girls with symptom onset well after 11 years old and, by this age, 95% of Tourette patients will have already developed tics.

This is outside of the norm for typical tic disorders, like Tourette syndrome, which more often occur in boys between ages 5 and 7, and wax and wane over time. Some of the children I see with Tourette’s do have severe tics, but that’s a little less common. The tics in the girls I’m seeing right now are all very severe. I would describe them as tic attacks, where they have these sudden attacks of various and complicated vocalizations, curse words, body movements, sometimes hitting themselves and hitting others. They often are not waxing and waning, but sustained and so severe that they can’t go to school. There is a typical course, evolution and appearance for most developmental tic disorders. This current wave of functional tics I’m seeing does not follow that typical course and does not improve with tic medication.

What do you think has caused this increase in tic attacks?

Kids with functional neurologic disorders will sometimes deny that they are experiencing any type of psychological stress, but over time, they often recognize that something was, in fact, going on. They’ll return and say they were actually super anxious or even suicidal, and it started coming out in this physical way. There is an evolving theory behind functional neurologic disorders that a predisposing factor is an impairment in emotional processing and difficulty identifying one’s own internal emotional states.

I think the pandemic is playing a significant role in the increase. I’ve never seen it to this degree or had this many functional patients present to my clinic. We’ve seen an increase in mental health struggles like anxiety and depression, and I think it’s triggered an increase in functional neurologic disorders.

Have your patients referenced pandemic stress and restrictions as a trigger for their tics?

My patients don’t necessarily say that they’re stressed because of the pandemic, but when I ask them when things got worse, almost all of them say it’s all been within the past year. Most of them look back and give a history of some anxiety or depression in the past with significant worsening within the last year, including the onset of tic attacks. A lot of them will say they don’t want to go to school for whatever reason or that school is stressful for them and, when they go back to school, they’ll have tic attacks and end up back at home.

Do the patients you see for tic attacks report watching more TikTok videos of someone with tics prior to the onset of their symptoms?

The TikTok factor is new to me. More recently, I’ve been asking my patients if they’ve seen it and they say yes. They’ll also show me videos they’ve recorded of themselves having tic attacks. They’re not necessarily posting their attack on TikTok, but a number of them do say they have seen the videos.

How do you counsel these patients and their parents? What course of treatment do you advise?

The most important thing I tell parents is that I don’t think their child is faking it or that they are crazy. There is something going on, we just have to get to the bottom of it. I have a very long discussion with them about functional neurologic disorders—how the brain is not functioning correctly but there is nothing structurally wrong with it, like a lesion. We talk about why I have diagnosed their child with functional tics versus another developmental tic disorder, like Tourette Syndrome, based on their medical history and the evolution of their symptoms. It’s worth noting that you can have both Tourette’s and functional tics, so that can be difficult to tease apart, but the majority of the increase I’m seeing right now are kids that have no past history of tics.

Then, we talk about what we can do to help their child. Tic medications do not help children with functional tics. We need to address their child’s anxiety and underlying mental health issues, whether it’s with depression and anxiety medication, or therapy, or a combination of both. I will refer them to a psychiatrist or counselor, if they don’t already have one. I have also recommended a type of cognitive behavioral therapy for tics, called CBIT (Cognitive Behavioral Intervention for Tics), where they learn how to identify the things that trigger their tics and coping strategies such as relaxation and breathing techniques to help lessen their severity or stop them all together.

We’ll often work with schools to put a plan in place where the student can take a break or go to another room if they need to. But, we emphasize with the patient that this is not going to allow them to get out of their school work. They can take a break, but they need to return to class and complete their work. This is not a reason to go home for the day. It’s important that we have empathy and understanding for these patients and help them work their way through it, but also not allow the tics to keep them out of school.

I would also recommend to children and families to stop watching tic videos on social media. I don’t have a study where I can prove that watching these videos incites tics in others, but if you’re anxious and depressed and not processing your emotions, it’s going to come out in some way. If you are watching a lot of other teens showing their tics on social media and talking about their tic attacks, it makes sense that you might be influenced to release your stress in that way, too. Step away from social media for a while and focus on developing coping strategies for your stress and for managing your tics.

In today’s society, social media is a major part of life for all age groups. While some use the platforms to keep up with family and friends, others use the sites for networking and job hunting. For those 18 and younger, social media has changed the way young people communicate with each other, often leading to inappropriate use, and bullying among other things.

As part of Cook Children’s Joy Campaign, which aims to reduce the number of children and teens attempting suicide, we’re looking at the role social media plays in the mental well-being of young people.

Kristen Pyrc, M.D., medical director of Psychiatry Outpatient Services and the Partial Hospitalization Program at Cook Children’s, says the number of her patients dealing with anxiety and depression has significantly increased over the past year. She’s concerned that social media is playing a role, especially during the pandemic when young people are online more than ever.

“I have seen an increase in depression symptoms in teenagers who had not had them before,” Dr.Pyrc said. “So maybe I regularly see them for something like ADHD, and now they are showing symptoms of depression on top of that.”

Dr. Pyrc said she often hears complaints from parents that their children are ‘tied’ to their phones. She believes a major problem with that is a lack of exposure to seeing friends in person, and the opportunity for kids to feel left out when they see peers online having fun without them.

“I think online culture can worsen students’ feelings of loneliness and rejection because they see their friends doing things together without them in real time,” she explained. “Also we tend to post things that highlight what’s going well in our lives, but may not tell the full story of the times that we feel sad or inadequate. When teens are feeling down, seeing everyone else having fun without them can make them feel worse.”

Katie Greer, an internet safety expert, has spent the past 15+ years educating students, parents, law enforcement, and large companies across the country about the importance of online safety.

“I have seen social media used to bring out the best in humanity, but I have also seen it rip families apart in a matter of minutes,” she said.

Greer, who began her work as the director of Internet Safety with the Massachusetts Attorney General’s Office, believes social media has evolved in ways no one was ready for. Not so long ago, bullying was something that happened mostly at school. Now, young people are bullied online, in front of countless people. Even worse, a bully’s comments can be liked and shared by others.

“Kids were already spending a lot of time on their phones and online, then came a global pandemic. Now, they’re attending school online and relying on things like gaming online and social media platforms to connect,” Greer said. “There’s a lot more opportunity for cyberbullying and while it can start with one person, it can be a matter of seconds for others to jump in with a like or a comment and gang up on the victim.”

Situations like this increase a child’s chances of dealing with anxiety, depression, and self-harm.

“We know that developmentally, children’s brains aren’t fully formed,” she said. “When we put something in front of them as complex as social media, it’s almost as if we are asking for trouble.”

Greer also warns parents about the newfound TikTok culture.

“TikTok is a platform that has created unrealistic expectations about everyday life,” she explained.

She said children and teens see their peers or influencers having “perfect” lives and begin to feel as if they’re inadequate, or aren’t enough or worth it.

“Children have a desire to fit in and they want to have as much or more than their friends,” Greer said. “When children see their friends flaunt material things, or lavish experiences, that can make them spiral.”

Another issue putting kids’ mental health in danger is ‘sexting’ or the exchange of nude photos and videos, which has become quite prevalent.

“I recently was made aware of an incident where a girl sent a guy nude photos and he leaked them. Once they were leaked, so many people saw them, the young girl was humiliated,” Greer recalled. “The family reported that this led to the young girl untimely killing herself out of embarrassment and humiliation that her photos were leaked.”

Greer said, in cases like these, it is vital to remember that not only does suicide hurt a family, it also tears apart the people who loved and supported the victim.

Cook Children’s launched the Joy Campaign, which this story is a part of, to bring awareness to the increase in suicides and suicide attempts being seen at the medical center. In 2020, seven Cook Children’s patients died of suicide, making suicide the leading cause of traumatic death for the first time ever. The hospital has also seen record numbers of patients being admitted for suicide attempts month after month, most recently in March when 43 children and teens were treated for injuries. While the increase in suicide attempts cannot directly be tied to the pandemic, Dr. Pyrc said children need certain things to properly function in day-to-day life.

“Kids need in-person interactions. They need sunshine and exercise and all things encompassing,” Dr. Pyrc said. “Whenever your world is mostly virtual, it can hurt both your physical health and mental health.”

What does Greer suggest parents do? Stay alert and ask questions.

“A simple, “How was your day?” or “How are your friends doing?” can go a long way in opening the lines of communication,” she said.

She emphasizes knowing what your child is looking at online and know who they are talking to. If you are concerned about your child’s safety, there are measures you can take.

“While I am typically against this and wouldn’t always recommend it, there are ways parents can use apps that will mirror their children’s phone,” Greer said. “I do believe this could hurt the trust between a parent and a child, and isn’t the best way to go about typical monitoring, and I only recommend phone mirroring for dire situations.”

Before leaving any session, Greer reminds everyone she speaks with about the importance of a trusted adult.

“I tell parents and all adults it is important that children have a trusted adult they know they can come to at all times. Parents have to be okay with the fact that the adult may be someone other than them, it is all about a child feeling safe and opening up,” she said. “I also remind every child that I come in contact with that having an adult you trust is one of the most important things you can do to protect yourself and even help a friend.”

Both Greer and Dr. Pyrc see the issue and know there is a lot of work to be done to ensure we are helping our children with their new reality. Both professionals share their tips to help parents and families better support their children.

1. Take your child’s phone before they go to sleep at night. Disrupted sleep has a negative impact on adolescents.
2. Have an open dialogue with your child without judgment and give them the ability to freely express themselves to you. Given the amount of time kids are online, these conversations should happen every day.
3. Ask about their social media. Talk to your child about what they’re seeing, how it impacts them/makes them feel, and know who they’re communicating with.
4. Ensure your child can identify a trusted adult and make sure they understand that an adult can be their go-to person at all times.
5. Talk to your child about good social media etiquette. Remind them if they see something, say something and describe how that can help save someone’s life.
6. If you believe your child is in danger, there are apps available that can monitor their phone so you can see everything they see and get them the help they need immediately.
7. Reach out for help. Do not wait until your child is in a dire situation to reach out for help and get them the resources that could save their life.

Monitor your child’s social media, and make sure you have their usernames/passwords in case of an emergency situation.

Important to note:

Instagram has an anonymous reporting tool that allows users to report when they believe something could be wrong with a friend. The site sends the person resources depending on what was reported on their behalf. These resources could be vital in saving someone’s life by simply reporting.

“We've definitely seen a high number of adolescent suicide attempts over the past couple of months, especially during COVID-19,” said Kia Carter, M.D., medical director of psychiatry at Cook Children’s Medical Center. “We've also seen younger kids endorse suicidal ideation.”

At Cook Children’s, the vast majority of patients treated for self-harming are girls, typically between the ages of 13 and 15. But Dr. Carter says she’s had patients in her unit as young as 4 years old talking about wanting to die.

“We've seen a huge increase with younger kids knowing what death is because of video games,” said Dr. Carter. “We have to assess their cognitive level and find out if they know what death means or do they think it’s like the video game where they die, but get a backup player.”

So far in 2020, 192 kids have been admitted to Cook Children’s for attempting suicide. Compare that to the same time period in 2015 when the hospital saw 88 patients - less than half of the current statistics.

Unfortunately, the data from Cook Children’s Behavioral Health Center is in line with a new study from the Centers for Disease Control and Prevention (CDC). The article, released Sept. 11, shows suicide rates among 10 to 24 year olds have increased 57.4% from 2007 to 2018.

"It's a real trend that has been demanding, for a while, a serious public health and research effort to understand what is happening and why," said Anna Mueller, an associate professor of sociology at Indiana University Bloomington. In an interview with USA Today, Mueller said she doesn’t buy that it’s just social media, though we do know many children express anxiety and depression linked to social media.

“Social media plays a big role in the mental health of children and teens,” said Dr. Carter. “They experience bullying online, they may not feel self-worth because they’re comparing themselves to what they see on Instagram. They’re also getting ideas on the internet about how to harm themselves.”

Dr. Carter says social media and sites like YouTube have made self-harm almost acceptable. She says children are looking to those avenues to find out how many pills to take or other ways they can attempt suicide.

“A lot of kids will research how much medication to take to not wake up,” said Dr. Carter. “I would say 99% of the overdoses we see have some over-the-counter component.”

Since January, 31 children have been admitted to Cook Children’s for ingesting too much Benadryl. At least three of the Benadryl overdoses are linked to a TikTok challenge, but the majority of cases were among patients intending to harm themselves. Other drugs commonly found in medicine cabinets such as Tylenol, aspirin and ibuprofen are also frequently used.

So why do children and teens take these drastic measures?

“When people feel like they're not going to get better and there's no way out, they tend to go to these levels,” Dr. Carter explained. “I think the biggest thing is hopelessness. When kids feel like they don't have anyone to talk to, they don’t feel like they can communicate with their parents or they’re getting bullied and they don’t have a social circle. Some kids also are struggling with gender and sexual identity.”

About 30% of the children assessed by Cook Children’s Behavioral Health Center report issues with gender or sexual orientation. Among those are patients diagnosed with gender dysphoria, a feeling of discomfort or distress that can occur when someone feels their gender identity differs from their sex.

“There are some kids who physically don't feel comfortable in the body they're in and they don't feel that they relate to the other girls or the other boys. We see this occur a lot around age 10,” said Dr. Carter. “A lot of times parents feel like it's a phase, and that might be true, but I would encourage parents to not minimize it because kids can begin to feel hopeless.”

She suggests parents keep an open mind, listen to their children and get them in to see a licensed professional counselor. And she says it’s ok to not agree with their feelings, but to share those thoughts with your spouse or a friend instead of the child.

“If you're resistant to it, your child's going to shut down and that can cause a whole realm of depression, hopelessness and not wanting to be alive anymore,” she said.

With COVID-19 and social distancing, spotting signs of depression and hopelessness can be challenging. Things that may have seemed out of the norm in the past, like avoiding social activities, may not be so odd now. But Dr. Carter says watching for changes in behavior is still key.

“Most kids still want to play video games and have their cell phones, so if they don’t want a new video game and all they want to do is sleep, you’re going to want to assess where that change is coming from,” she said.

Other signs of depression to look out for include:

• Declining grades
• Lack of concern about appearance and hygiene
• Changes in eating and/or sleep
• Self-injury such as cutting
• Less motivation
• Alcohol/drug use
• Acting highly anxious or agitated
• Recklessness

If you feel your child needs help, please talk to your pediatrician or call 682-885-3917 for a referral to Cook Children's Behavioral Health Center.

Three teens were treated at Cook Children’s in May after overdosing on the common allergy medicine diphenhydramine aka Benadryl. Each of these patients said they got the idea from videos on TikTok that claimed users could get high and hallucinate if they took a dozen or more of the allergy pills.

One of the teens who ended up at Cook Children’s is a 14-year-old named Rebekah. She took 14 Benadryl pills in the middle of the night on Memorial Day.

“I got a call from mom and she was telling me I need to wake up,” said Katie, Rebekah’s mother. “I didn’t know what was happening.”

Katie was asleep when Rebekah appeared in her older sister’s bedroom, obviously intoxicated from the pills. The eldest sister called their grandmother for help, likely trying to avoid getting in trouble with their parents.

“It was scary. She had fractured sentences, hallucinations. Her resting heart rate was 199,” Katie explained. “We rushed her to the local ER and they decided to transport her to Cook Children’s.”

While at Cook Children’s, doctors performed an electrocardiogram (EKG) and they didn’t like the results. Rebekah was admitted to the hospital and observed overnight. Thankfully, her heart rate returned to normal the next day and she was able to go home.

“What struck me was that we had three teens come in for the same thing in one week,” said Amber Jewison, a hospitalist nurse practitioner at Cook Children’s Medical Center. “None of these patients were trying to harm themselves. They all said they saw videos on TikTok and were curious to try it.”

What these patients didn’t realize is that not only can a Benadryl overdose be harmful to your health, it can also be deadly.

“Too much diphenhydramine can cause a high heart rate and trigger arrhythmias,” said Jewison. “It can also cause hallucinations, seizures and require a catheter to drain urine from the bladder due to not being able to urinate.”

For Katie, the experience was eye opening. She said she never imagined her daughter would try such a thing and was completely shocked by the ordeal.

“As a parent, you worry about drugs and you know the signs for drug use. I never thought about having to lock up my allergy medicine,” she said. “I just want other parents to know about this because it’s dangerous and I had no idea. And I’m angry. These people are essentially prescribing medication without a medical degree and our kids are trusting them.”

Fortunately, Rebekah shouldn’t have any long-term health effects due to her overdose. Her mother hopes this incident will be a wakeup call for the teen and prevent her from putting herself in danger in the future.

In addition to the Benedryl videos, parents should also be aware of a popular TikTok challenge. It’s called the nutmeg challenge, in which TikTok users drink two to four tablespoons of nutmeg with milk or water and film their reactions. The objective is to get high from the large amount of the spice, but doing this can have detrimental effects on the body.

According to the American Association for Clinical Chemistry (AACC), one to four teaspoons of nutmeg can cause dry mouth, agitation, hypothermia, hallucinations, among others — and in some cases, coma and death.

So if your child or teen has a TikTok account, or spends any time online at all, it’s a good idea to monitor what they’re watching. Remember, they’re still developing the part of the brain that controls judgement and impulsivity. It may help to remind them that online challenges, even with things that may seem harmless, can have scary and serious consequences.