KEY POINTS

• Tourette Syndrome (TS) is a condition of the nervous system that causes people to make sudden and repeated twitches, movements, or sounds, called "tics".
• Health professionals look at the person's symptoms to diagnosis TS and other tic disorders.
• Although there is no cure for TS, treatment can help manage the tics.

What it is

Tourette syndrome (TS) is a condition of the nervous system. TS causes people to have "tics".

Tics are sudden twitches, movements, or sounds that people do repeatedly. People who have tics cannot stop their body from doing these things. For example, a person might keep blinking over and over. Or, a person might make a grunting sound unwillingly.

Having tics is a little bit like having hiccups. Even though you might not want to hiccup, your body does it anyway. Sometimes people can stop themselves from doing a certain tic for a while, but it's hard. Eventually the person has to do the tic.

Types

There are two types of tics—motor and vocal.

Motor tics

Motor tics are movements of the body. Examples of motor tics include blinking, shrugging the shoulders, or jerking an arm.

Vocal tics

Vocal tics are sounds that a person makes with his or her voice. Examples of vocal tics include humming, clearing the throat, or yelling out a word or phrase.

Tics can be either simple or complex.

Simple tics

Simple tics involve just a few parts of the body. Examples of simple tics include squinting the eyes or sniffing.

Complex tics

Complex tics usually involve several different parts of the body and can have a pattern. An example of a complex tic is bobbing the head while jerking an arm, and then jumping up.

Symptoms

The main symptoms of TS are tics. A person can have tics ranging from simple, temporary tics lasting a few weeks or months, to having many complex tics that are long-lasting. Symptoms of TS usually begin when a child is 5 to 10 years of age. The first symptoms often are motor tics that occur in the head and neck area.

The types of tics and how often a person has tics changes a lot over time. Even though the symptoms might appear, disappear, and reappear, these conditions are considered chronic.

In most cases, tics decrease during adolescence and early adulthood, and sometimes disappear entirely. However, many people with TS experience tics into adulthood and, in some cases, tics can become worse during adulthood.

Although the media often portray people with TS as involuntarily shouting out swear words (called coprolalia) or constantly repeating the words of other people (called echolalia), these symptoms are rare, and are not required for a diagnosis of TS.

Risk factors

Doctors and scientists do not know the exact cause of TS. Research suggests that it is an inherited genetic condition. That means it is passed on from parent to child through genes.

Diagnosis

There is no single test, like a blood test, to diagnose TS. Health professionals look at the person's symptoms to diagnose TS and other tic disorders. The tic disorders differ from each other in terms of the type of tic present (motor or vocal, or combination of the both), and how long the symptoms have lasted. TS can be diagnosed if a person has both motor and vocal tics, and has had tic symptoms for at least a year.

Diagnosing Tourette syndrome‎

Other concerns and conditions

TS often occurs with other conditions. Most children diagnosed with TS also have been diagnosed with at least one additional mental, behavioral, or developmental disorder such as attention-deficit/hyperactivity disorder (ADHD), anxiety, or obsessive-compulsive disorder (OCD). It is important to find out if a person with TS has any other conditions, and treat those conditions properly.

Treatment and recovery

Many people with TS have tics that do not get in the way of their daily life and, therefore, do not need any treatment. However, medication and behavioral treatments are available if tics cause pain or injury; interfere with school, work, or social life; or cause stress.

KEY POINTS

• The risk factors for and causes of Tourette syndrome are not well understood.
• Current research shows that genes play an important role.
• Scientists are studying other possible causes and environmental factors that may increase risk for Tourette syndrome.

What increases risk

Scientists are studying the causes of and risk factors for Tourette syndrome (TS) in an effort to understand it better, and to find better ways to manage TS and to reduce the chances of a person having TS. The causes of TS and other tic disorders are not well understood.

Although the risk factors for and causes of TS are unknown, current research shows that genes play an important role. Some research has shown that TS is a genetically complex disorder that likely occurs as a result of the effects of multiple genes interacting with other factors in the environment. Scientists are studying other possible causes and environmental risk factors that might contribute to TS. Some studies have shown that the following factors might be associated with TS, but additional research is needed to better understand these associations:

• Smoking during pregnancy.
• Pregnancy complications.
• Low birthweight.
• Infection. Researchers have found mixed results about whether certain children are more likely to develop tics following infections.

A variety of genetic and environmental factors likely play a role in causing Tourette syndrome. Most of these factors are unknown, and researchers are studying risk factors before and after birth that may contribute to this complex disorder. Scientists believe that tics may result from changes in brain chemicals (neurotransmitters) that are responsible for producing and controlling voluntary movements.

Variants (also called mutations) involving the SLITRK1 gene have been identified in a small number of people with Tourette syndrome. This gene provides instructions for making a protein that is active in the brain. The SLITRK1 protein probably plays a role in the development of nerve cells, including the growth of specialized extensions (axons and dendrites) that allow each nerve cell to communicate with nearby cells. It is unclear how variants in the SLITRK1 gene can lead to this disorder.

Most people with Tourette syndrome do not have a variant in the SLITRK1 gene. Because variants have been reported in so few people with this condition, the association of the SLITRK1 gene with this disorder has not been confirmed. Researchers suspect that changes in other genes, which have not been identified, are also associated with Tourette syndrome.

Normal Function

The SLITRK1 gene provides instructions for making a protein that is a member of the SLITRK family. Proteins in this family are found in the brain, where they play a role in the growth and development of nerve cells. The SLITRK1 protein may help guide the growth of specialized extensions (axons and dendrites) that allow each nerve cell to communicate with nearby cells.

Health Conditions Related to Genetic Changes

Tourette syndrome

Mutations involving the SLITRK1 gene have been identified in a small number of people with Tourette syndrome. One of these mutations, written as del1264C, deletes a single DNA building block (base pair) from the gene. This mutation leads to the production of an abnormally short, nonfunctional version of the SLITRK1 protein. Another mutation changes a single base pair in a region of DNA near the gene. This change probably interferes with production of the SLITRK1 protein. Although the SLITRK1 gene is active in areas of the brain known to be involved in Tourette syndrome, it is unclear how mutations in or near the gene lead to the behavioral features of this condition. Because mutations have been reported in so few people with Tourette syndrome, the association of the SLITRK1 gene with this disorder has not been confirmed.

Other Names for This Gene

• KIAA0918
• KIAA1910
• leucine rich repeat containing 12
• LRRC12
• SLIK1_HUMAN
• SLIT and NTRK-like family, member 1
• slit and trk like 1 protein
• slit and trk like gene 1

Genomic Location

The early symptoms of Tourette syndrome are almost always noticed first in childhood, with the average onset between the ages of 3 and 9 years. Although the symptoms of Tourette syndrome vary from person to person and range from very mild to severe, the majority of cases fall into the mild category. The repetitive, stereotyped, involuntary movements and vocalizations called tics are classified as either simple or complex. Simple motor tics are sudden, brief, repetitive movements that involve a limited number of muscle groups. Some of the more common simple tics include eye blinking and other eye movements, facial grimacing, shoulder shrugging, and head or shoulder jerking. Simple vocalizations might include repetitive throat-clearing, sniffing/snorting, grunting, or barking sounds.

Complex tics are distinct, coordinated patterns of movements involving several muscle groups. Complex motor tics might include facial grimacing combined with a head twist and a shoulder shrug. Other complex motor tics may actually appear purposeful, including sniffing or touching objects, hopping, jumping, bending, or twisting. Complex vocal tics include words or phrases. Perhaps the most dramatic and disabling tics include motor movements that result in self-harm such as punching oneself in the face or vocal tics including coprolalia (uttering swear words) or echolalia (repeating the words or phrases of others). Some tics are preceded by an urge or sensation in the affected muscle group, commonly called a premonitory urge. Some individuals with Tourette syndrome will describe a need to complete a tic in a certain way or a certain number of times in order to relieve the urge or decrease the sensation.Tics are often worse with excitement or anxiety and better during calm, focused activities. Certain physical experiences can trigger or worsen tics, for example tight collars may trigger neck tics, or hearing another person sniff or throat-clear may trigger similar sounds. Tics do not go away during sleep but are often significantly diminished.

KEY POINTS

• There are three main types of tic disorders.
• Health professionals consider the type of tic present and how long the symptoms have lasted to diagnosis a specific tic disorder.
• Talk to your child's healthcare provider if your child makes sudden and repeated twitches, movements, or sounds.

Why diagnosis is important

Although there is no cure for tic disorders, there are treatments available to help manage the tics. Medication and behavioral treatments are available if tics cause pain or injury; interfere with school, work, or social life; or cause stress.

Did you know?‎

Types of tic disorders

The American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5-TR) 1is used by health professionals to help diagnose tic disorders.

Three tic disorders are included in the DSM-5-TR:

• Tourette syndrome (TS, sometimes called Tourette disorder)
• Persistent (sometimes called chronic) motor or vocal tic disorder
• Provisional tic disorder

The tic disorders differ from each other in terms of the type of tic present (motor or vocal, or a combination of both), and how long the symptoms have lasted. People with Tourette syndrome have both motor and vocal tics and have had tic symptoms for at least 1 year. People with persistent motor or vocal tic disorders have either motor or vocal tics and have had tic symptoms for at least 1 year. People with provisional tic disorders can have motor or vocal tics, or both, but have had their symptoms less than 1 year.

Fact‎

Tourette syndrome

To be diagnosed with TS, a person must

• Have two or more motor tics (for example, blinking or shrugging the shoulders) and at least one vocal tic (for example, humming, clearing the throat, or yelling out a word or phrase), although they might not always happen at the same time.
• Have had tics for at least a year. The tics can occur many times a day (usually in bouts) nearly every day, or off and on.
• Have tics that begin before age 18 years.
• Have symptoms that are not due to taking medicine or other drugs or due to having another medical condition (for example, seizures, Huntington disease, or postviral encephalitis).

Persistent (chronic) motor or vocal tic disorder

To be diagnosed with a persistent tic disorder, a person must

• Have one or more motor tics (for example, blinking or shrugging the shoulders) or vocal tics (for example, humming, clearing the throat, or yelling out a word or phrase), but not both.
• Have tics that occur many times a day nearly every day or on and off throughout a period of more than a year.
• Have tics that start before age 18 years.
• Have symptoms that are not due to taking medicine or other drugs, or due to having a medical condition that can cause tics (for example, seizures, Huntington disease, or postviral encephalitis).
• Not have been diagnosed with TS.

Provisional tic disorder

To be diagnosed with a provisional tic disorder, a person must

• Have one or more motor tics (for example, blinking or shrugging the shoulders) or vocal tics (for example, humming, clearing the throat, or yelling out a word or phrase).
• Have been present for no longer than 12 months in a row.
• Have tics that start before age 18 years.
• Have symptoms that are not due to taking medicine or other drugs, or due to having a medical condition that can cause tics (for example, Huntington disease or postviral encephalitis).
• Not have been diagnosed with TS or persistent motor or vocal tic disorder.

Tics after a strep infection‎

Sudden onset of tic-like behaviors

Sometimes people have tic-like behaviors that look like tics, but that are distinctly different from those typically seen in Tourette syndrome and other tic disorders. The people who develop these tic-like behaviors are often experiencing movement symptoms for the first time, with no reported history of tics. These types of tic-like behaviors are more common among teenagers and more often seen in girls than boys. Sometimes these tics can happen in groups of children. Many experts believe these sudden onset tic-like behaviors can happen for different reasons, and tic-like behaviors may need different treatment compared to tic disorders including Tourette syndrome. The best first step is usually to talk to a healthcare provider who is familiar with tics and get a thorough assessment.

What to do when your child is diagnosed with Tourette syndrome

Taking an active role, learning about TS, and understanding treatment and ways to manage symptoms can help you make the best possible choices for your child and for your family.

• Talk to a healthcare provider about any questions or concerns.
• Learn as much as you can about TS.
• Ask your provider about concerns and symptoms beyond tics. Most children with TS also have been diagnosed with at least one additional mental, behavioral, or developmental condition and these conditions often add to stress and difficulty in managing health care. Many children with TS also experience learning difficulties. Getting proper treatment and coordinated care is very important.
• Visit the website of the Tourette Association of America to find information, resources, newsletters, videos, and more. In addition, the Tourette Association can be helpful with finding local healthcare providers.

Finding support

Parenting is often challenging and parenting a child with a chronic condition like TS can add additional stress to the day-to-day challenges. If you are the parent of a child with TS, it might be helpful to talk with other parents who have a child with the same condition, to share concerns and information. Similarly, if you are an adult with TS, talking to other adults with TS might be helpful.

Remember that the choices for another family might not be best for your family, so it's important to understand all options and discuss them with your healthcare providers.

• Your local Tourette Association chapter can help you connect with other families through conferences, support groups and other events.
• Parent-to-Parent Programs provide information and emotional support to families of children who have special needs.

KEY POINTS

• Although there is no cure for Tourette syndrome (TS), medication and behavioral treatments can help manage tics if they get in the way of daily life.
• Training and other educational resources can help parents and schools support children with TS in achieving their full potential.

Treatment overview

Although there is no cure for Tourette syndrome (TS), there are treatments to help manage the tics caused by TS. Many people with TS have tics that do not get in the way of their living their daily life and do not need any treatment. However, medication and behavioral treatments are available if tics cause pain or injury; interfere with school, work, or social life; or cause stress.

It is common for people with TS to have other conditions, particularly attention-deficit/hyperactivity disorder (ADHD), anxiety, and obsessive-compulsive disorder (OCD). People with additional conditions will require different treatments based on the symptoms. Sometimes treating these other conditions can help reduce tics. To develop the right treatment plan, people with tics, parents, and healthcare providers can work together and include teachers, childcare providers, coaches, therapists, and other family members. Taking advantage of all the resources available will help guide success.

Treatments and interventions

Medications

Medications can be used to reduce severe or disruptive tics that might have led to problems in the past with family and friends, other students, or coworkers. Medications also can be used to reduce symptoms of related conditions, such as ADHD or OCD.

Medications do not eliminate tics completely. However, they can help some people with TS in their everyday life. There is no one medication that is best for all people. Most medications prescribed for TS have not been approved by the US Food and Drug Administration (FDA) for treating tics.

Medications affect each person differently. One person might do well with one medication, but not another. When deciding the best treatment, a doctor might try different medications and doses, and it may take time to find the treatment plan that works best. The doctor will want to find the medication and dose that have the best results and the fewest side effects. Doctors often start with small doses and slowly increase as needed.

As with all medications, those used to treat tics can have side effects. Side effects can include weight gain, stiff muscles, tiredness, restlessness, and social withdrawal. The side effects need to be considered carefully when deciding whether or not to use any medication to treat tics. In some cases, the side effects can be worse than the tics.

Even though medications often are used to treat the symptoms of TS, they might not be helpful for everyone. Two common reasons for not using medications to treat TS are unpleasant side effects and failure of the medications to work as well as expected.

Behavioral therapy

Behavioral therapy is a treatment that teaches people with TS ways to manage their tics. Behavioral therapy is not a cure for tics. However, it can help reduce the number of tics, the severity of tics, the impact of tics, or a combination of all of these. It is important to understand that even though behavioral therapies might help reduce the severity of tics, this does not mean that tics are just psychological or that anyone with tics should be able to control them.

Habit reversal

Habit reversal is one of the most studied behavioral interventions for people with tics. 1 It has two main parts: awareness training and competing response training. In the awareness training part, people identify each tic out loud. In the competing response part, people learn to do a new behavior that cannot happen at the same time as the tic. For example, if the person with TS has a tic that involves head rubbing, a new behavior might be for that person to place their hands on their knees, or to cross their arms so that the head rubbing cannot take place.

Comprehensive behavioral intervention for tics

Comprehensive behavioral intervention for tics (CBIT) is an evidence-based type of behavioral therapy for TS and chronic tic disorders. CBIT includes habit reversal in addition to other strategies, including education about tics and relaxation techniques. 2 CBIT has been shown to be effective at reducing tic symptoms and tic-related impairment among children and adults.

In CBIT, a therapist will work with a child (and their parents) or an adult with TS to better understand the types of tics the person is having and to understand the situations in which the tics are at their worst. Changes to the surroundings may be made, if possible, and the person with TS will also learn to do a new behavior instead of the tic (habit reversal). This helps to decrease how often the tic occurs by doing a new behavior. CBIT skills can be learned with practice, with the help of an experienced therapist, and with the support and encouragement of those close to the person with TS.

In recent years, more health professionals have recognized that behavioral therapy can be very effective in managing the symptoms of TS. So far, few clinicians have been trained in these types of treatments specifically for TS and tic disorders. The CDC and The Tourette Association of America have been working to educate more health professionals in this approach to managing TS symptom

Free training‎

Supporting children and families

Parent training

Children with TS and related conditions and their families also can benefit from parent training, which has been shown to be successful among children with both TS and other disruptive behaviors. Parent training also has been shown to be helpful for children with ADHD. Parent training helps parents better understand their child's behavioral issues and learn parenting skills specific to these problems. The training might include learning about the effective use of positive reinforcement and discipline that is effective with their particular child.

Educating others

People with TS cannot help having tics and are not being disruptive on purpose. One way to help someone with TS with school, work, and other activities is to educate people about TS. When people know more about the disorder, they might be more understanding, helpful, and accommodating. For example, an employer might be willing to rearrange desk seating to provide more privacy. Or, a sports coach might encourage teammates to ignore a child's tics instead of teasing the child. When people with TS receive more support, their tic symptoms might lessen.

Using school resources

TS can affect a child's experience at school. For example, some tics make it difficult to read or write. Or, a child might get distracted by tics or trying to not have a tic. In addition, because many people do not understand TS, children are sometimes teased, bullied, or rejected by other kids. However, with some planning, children with TS can have a positive, successful school experience.

Generally, children with TS have the same intelligence range as other children. But problems with tics, often combined with attention deficits and other learning difficulties, can mean that children with TS will need special education assistance. Types of assistance might include different seating arrangements, additional time for testing, or computer accommodations for children who have problems with writing. For example, if a child with TS often has a certain tic during math class, the math teacher can be educated about TS, and perhaps the child's seat can be changed so that the tics are not as visible.

An Individualized Education Plan (IEP)—is necessary for children who need special education services. AN IEP is a legal document that tells the school what it must do to help meet your child's needs.

For children who do not have an IEP, a different type of plans—called 504 plans—can be written by a committee that includes parents and teachers. A 504 plan lists your child's disability and how the school can help. This plan is updated once a year.

KEY POINTS

• Tourette syndrome (TS) often occurs with attention-deficit/hyperactivity disorder, obsessive-compulsive disorder, or other behavioral or conduct problems.
• People with TS also can be at higher risk for learning, behavioral, and social problems.
• It is important for doctors to assess every child with TS for other conditions and problems.

Attention-deficit / hyperactivity disorder

Attention-deficit/hyperactivity disorder (ADHD) is a common co-occurring condition among children with TS. 1 Children with ADHD have trouble paying attention and controlling impulsive behaviors. They might act without thinking about what the result will be and, in some cases, they are also overly active. It is normal for children to have trouble focusing and behaving at one time or another. However, for children with ADHD, symptoms can continue, can be severe, and cause difficulty at school, at home, or with friends.

Obsessive-compulsive behaviors

People with obsessive-compulsive behaviors have unwanted thoughts (obsessions) that they feel a need to respond to (compulsions). Examples of obsessive-compulsive behaviors are having to think about, say, or do something over and over. More than a third of people with Tourette syndrome have obsessive-compulsive disorder (OCD). Sometimes it is difficult to tell the difference between complex tics that a child with TS may have and obsessive-compulsive behaviors.

Behavior or conduct problems

Oppositional defiant disorder

Oppositional Defiant Disorder (ODD) usually starts before a child is 8 years of age, but no later than early adolescence. Children with ODD might show symptoms most often with people they know well, such as family members or a regular care provider. The behavior problems associated with ODD are more severe or persistent than what might be expected for the child's age, and result in major problems in school, at home, or with peers.

Examples of ODD behaviors include

• Losing one's temper a lot
• Arguing with adults or refusing to comply with adults' rules or requests
• Getting angry or being resentful or vindictive often
• Annoying others on purpose or easily becoming annoyed with others
• Blaming other people often for one's own mistakes or misbehavior

Conduct disorder

Children with conduct disorder (CD) act aggressive toward others and break rules, laws, and social norms. They might have more injuries and difficulty with friends. In addition, the symptoms of CD happen in more than one area in the child's life (for example, at home, in the community, and at school).

Behavior problems can be highly disruptive for the child and others in the child's life. It is important to get a diagnosis and treatment plan from a mental health professional as soon as possible. Effective treatments for disruptive behaviors include behavior therapy training for parents.

Rage

Some people with TS have anger that is out of control, or episodes of "rage." Rage that happens repeatedly and is disproportionate to the situation that triggers it may be diagnosed as a mood disorder, like intermittent explosive disorder. Symptoms might include extreme verbal or physical aggression. Examples of verbal aggression include extreme yelling, screaming, and cursing. Examples of physical aggression include extreme shoving, kicking, hitting, biting, and throwing objects. Rage symptoms are more likely to occur among those with other behavioral disorders such as ADHD, ODD, or CD.

Among people with TS, symptoms of rage are more likely to occur at home than outside the home. Treatment can include behavior therapy, learning how to relax, and social skills training. Some of these methods will help individuals and families better understand what can cause the symptoms of rage, how to avoid encouraging these behaviors, and how to use appropriate discipline for these behaviors. In addition, treating other behavioral disorders that the person might have, such as ADHD, ODD, or CD can help to reduce symptoms of rage.

Anxiety

There are many different types of anxiety disorders with many different causes and symptoms. These include generalized anxiety disorder, OCD, panic disorder, post-traumatic stress disorder, separation anxiety, and different types of phobias. Separation anxiety is most common among young children. These children feel very worried when they are apart from their parents.

Depression

Everyone feels worried, anxious, sad, or stressed from time to time. However, if these feelings do not go away and they interfere with daily life (for example, keeping a child home from school or other activities, or keeping an adult from working or attending social activities), a person might have depression. Having either a depressed mood or a loss of interest or pleasure for at least two weeks might mean that someone has depression. Children and teens with depression might be irritable instead of sad.

To be diagnosed with depression, other symptoms also must be present, such as

• Changes in eating habits or weight gain or loss
• Changes in sleep habits
• Changes in activity level (others notice increased activity or that the person has slowed down)
• Less energy
• Feelings of worthlessness or guilt
• Difficulty thinking, concentrating, or making decisions
• Repeated thoughts of death
• Thoughts or plans about suicide, or a suicide attempt

Depression can be treated with counseling and medication.

Other health concerns

Children with TS can also have other health conditions that require care.

Among the more common health conditions that can occur with TS are

• Asthma
• Hearing loss or vision problems
• Bone, joint, or muscle problems
• Brain injury or concussion

A CDC study showed that the rates of asthma and hearing or vision problems were similar to children without TS, but bone, joint, or muscle problems as well as brain injury or concussion were higher for children with TS. Children with TS were also less likely to receive effective coordination of care or have a medical home, which means a primary care setting where a team of providers provides health care and preventive services.

Educational concerns

As a group, people with TS have levels of intelligence similar to those of people without TS. However, people with TS might be more likely to have learning differences, a learning disability, or a developmental delay that affects their ability to learn.

Many people with TS have problems with writing, organizing, and paying attention. People with TS might have problems processing what they hear or see. This can affect the person's ability to learn by listening to or watching a teacher. Or, the person might have problems with their other senses (such as how things feel, smell, taste, and movement) that affects learning and behavior. Children with TS might have trouble with social skills that affect their ability to interact with others.

As a result of these challenges, children with TS might need extra help in school. Many times, these concerns can be addressed with accommodations and behavioral interventions (for example, help with social skills).

Accommodations can include things such as providing a different testing location or extra testing time, providing tips on how to be more organized, giving the child less homework, or letting the child use a computer to take notes in class. Children also might need behavioral interventions, therapy, or they may need to learn strategies to help with stress, paying attention, or other symptoms.

KEY POINTS

• Children with Tourette syndrome (TS) experience more bullying than children without TS.
• Bullying is unwanted, agressive behavior that is repeated or has the potential to be repeated.
• Bullying can cause serious, lasting problems for children.
• Laws and other resources help protect children from bullying.

Overview

Bullying doesn't just happen to the smallest kid in the class. Children who bully others target those who seem to be less powerful or not as strong. Children who bully others also often target those who seem "different." Children with Tourette syndrome (TS) experience more bullying than children without TS. Children with TS also may experience being treated differently by teachers and other adults. It is important to understand the effects of bullying, a child’s legal right not to be bullied, and where to find additional resources.

What is bullying?

Bullying is unwanted, aggressive behavior that involves a real or perceived imbalance of power. The aggressive behavior is repeated, or has the potential to be repeated, over time.

• Bullying can be physical, involving hitting or attacking another person or their possessions.
• Bullying also can come in the form of verbal aggression, including teasing, name calling, verbal threats, inappropriate sexual comments, taunting, putting someone down, and threatening to cause harm.
• Bullying can also come in the form of social aggression, which involves hurting someone's reputation or relationships. Social bullying can include leaving someone out on purpose, declaring them as different, telling other children not to be friends with someone, spreading rumors about someone, or embarrassing someone in public.

Bullying can be in person, but it can also come in the form of electronic aggression (e.g., cyberbullying using the Internet or cell phones). It can include threatening, embarrassing, or insulting emails, texts, or social media posts.

What are the effects of bullying?

Children and youth who are bullied are more likely than other children to

• Be depressed, lonely, anxious
• Have low self-esteem
• Experience headaches, stomachaches, tiredness, and poor eating
• Be absent from school, dislike school, and have poorer school performance
• Think about or plan suicide

Bullying can cause serious, lasting problems, not only for the children who are bullied but also for the children who bully and those who witness bullying. Children who bully others may do so to gain social status or as a reaction to being bullied. Some children with TS may also bully others.

Legal rights

There are laws to protect children from bullying by peers, school personnel, or other adults. TS is recognized as a disability in the Individuals with Disabilities Education Act. Disability harassment is discrimination that violates Section 504 and its regulations. Under Section 504 and Title II of the Americans with Disabilities Act, disability harassment in schools is defined as

"Intimidation or abusive behavior toward a student based on disability that creates a hostile environment by interfering with or denying a student's participation in or receipt of benefits, services, or opportunities in the institution's program. Harassing conduct may take many forms, including verbal acts and name-calling, as well as nonverbal behavior, such as graphic and written statements, or conduct that is physically threatening, harmful, or humiliating."