distinguish from tics that have an organic (rather than psychological) cause. they may occur alone or co-exist in individuals with tic disorders. these tics are inconsistent with the classic tics of ts in several ways: the premonitory urge (present in 90% of those with tics disorders) is absent in functional tic-like movements; the suppressibility seen in tic disorders is lacking; there is no family or childhood history of tics and there is a female predominance in functional tics, with a later-than-typical age of first presentation; onset is more abrupt than typical with movements that are more suggestible; and there is less co-occurring ocd or adhd and more co-occurring disorders. functional tics are "not fully stereotypical", do not respond to medications, do not demonstrate the classic waxing and waning pattern of tourettic tics, and do not progress in the typical fashion, in which tics often first appear in the face and gradually move to limbs. other conditions that may manifest tics include sydenham's chorea; idiopathic dystonia; and genetic conditions such as huntington's disease, neuroacanthocytosis, pantothenate kinase-associated neurodegeneration, duchenne muscular dystrophy, wilson's disease, and tuberous sclerosis. other possibilities include chromosomal disorders such as down syndrome, klinefelter syndrome, xyy syndrome and fragile x syndrome. acquired causes of tics include drug-induced tics, head trauma, encephalitis, stroke, and carbon monoxide poisoning. the extreme self-injurious behaviors of lesch-nyhan syndrome may be confused with tourette syndrome or stereotypies, but self-injury is rare in ts even in cases of violent tics. most of these conditions are rarer than tic disorders and a thorough history and examination may be enough to rule them out without medical or screening tests. screening for other conditions although not all those with tourette's have comorbid conditions, most presenting for clinical care exhibit symptoms of other conditions along with their tics. adhd and ocd are the most common, but autism spectrum disorders or anxiety, mood, personality, oppositional defiant, and conduct disorders may also be present. learning disabilities and sleep disorders may be present; higher rates of sleep disturbance and migraine than in the general population are reported. a thorough evaluation for comorbidity is called for when symptoms and impairment warrant, and careful assessment of people with ts includes comprehensive screening for these conditions. comorbid conditions such as ocd and adhd can be more impairing than tics, and cause greater impact on overall functioning. disruptive behaviors, impaired functioning, or cognitive impairment in individuals with comorbid tourette's and adhd may be accounted for by the adhd, highlighting the importance of identifying comorbid conditions. children and adolescents with ts who have learning difficulties are candidates for psychoeducational testing, particularly if the child also has adhd. management main article: management of tourette syndrome there is no cure for tourette's. there is no single most effective medication, and no one medication effectively treats all symptoms. most medications prescribed for tics have not been approved for that use, and no medication is without the risk of significant adverse effects. treatment is focused on identifying the most troubling or impairing symptoms and helping the individual manage them. because comorbid conditions are often a larger source of impairment than tics, they are a priority in treatment. the management of tourette's is individualized and involves shared decision-making between the clinician, patient, family and caregivers. practice guidelines for the treatment of tics were published by the american academy of neurology in 2019. education, reassurance and psychobehavioral therapy are often sufficient for the majority of cases. in particular, psychoeducation targeting the patient and their family and surrounding community is a key management strategy. watchful waiting "is an acceptable approach" for those who are not functionally impaired. symptom management may include behavioral, psychological and pharmacological therapies. pharmacological intervention is reserved for more severe symptoms, while psychotherapy or cognitive behavioral therapy (cbt) may ameliorate depression and social isolation, and improve family support. the decision to use behavioral or pharmacological treatment is "usually made after the educational and supportive interventions have been in place for a period of months, and it is clear that the tic symptoms are persistently severe and are themselves a source of impairment in terms of self-esteem, relationships with the family or peers, or school performance". psychoeducation and social support further information: management of tourette syndrome § psychoeducation and social support knowledge, education and understanding are uppermost in management plans for tic disorders, and psychoeducation is the first step. a child's parents are typically the first to notice their tics; they may feel worried, imagine that they are somehow responsible, or feel burdened by misinformation about tourette's. effectively educating parents about the diagnosis and providing social support can ease their anxiety. this support can also lower the chance that their child will be unnecessarily medicated or experience an exacerbation of tics due to their parents' emotional state. people with tourette's may suffer socially if their tics are viewed as "bizarre". if a child has disabling tics, or tics that interfere with social or academic functioning, supportive psychotherapy or school accommodations can be helpful. even children with milder tics may be angry, depressed or have low self-esteem as a result of increased teasing, bullying, rejection by peers or social stigmatization, and this can lead to social withdrawal. some children feel empowered by presenting a peer awareness program to their classmates. it can be helpful to educate teachers and school staff about typical tics, how they fluctuate during the day, how they impact the child, and how to distinguish tics from naughty behavior. by learning to identify tics, adults can refrain from asking or expecting a child to stop ticcing, because "tic suppression can be exhausting, unpleasant, and attention-demanding and can result in a subsequent rebound bout of tics". adults with ts may withdraw socially to avoid stigmatization and discrimination because of their tics. depending on their country's healthcare system, they may receive social services or help from support groups. behavioral further information: management of tourette syndrome § behavioral behavioral therapies using habit reversal training (hrt) and exposure and response prevention (erp) are first-line interventions in the management of tourette syndrome, and have been shown to be effective. because tics are somewhat suppressible, when people with ts are aware of the premonitory urge that precedes a tic, they can be trained to develop a response to the urge that competes with the tic. comprehensive behavioral intervention for tics (cbit) is based on hrt, the best researched behavioral therapy for tics. ts experts debate whether increasing a child's awareness of tics with hrt/cbit (as opposed to ignoring tics) can lead to more tics later in life. when disruptive behaviors related to comorbid conditions exist, anger control training and parent management training can be effective. cbt is a useful treatment when ocd is present. relaxation techniques, such as exercise, yoga and meditation may be useful in relieving the stress that can aggravate tics. beyond hrt, the majority of behavioral interventions for tourette's (for example, relaxation training and biofeedback) have not been systematically evaluated and are not empirically supported. medication further information: management of tourette syndrome § medication clonidine is one of the medications typically tried first when medication is needed for tourette's. children with tics typically present when their tics are most severe, but because the condition waxes and wanes, medication is not started immediately or changed often. tics may subside with education, reassurance and a supportive environment. when medication is used, the goal is not to eliminate symptoms. instead, the lowest dose that manages symptoms without adverse effects is used, because adverse effects may be more disturbing than the symptoms being treated with medication. the classes of medication with proven efficacy in treating tics—typical and atypical neuroleptics—can have long-term and short-term adverse effects. some antihypertensive agents are also used to treat tics; studies show variable efficacy but a lower side effect profile than the neuroleptics. the antihypertensives clonidine and guanfacine are typically tried first in children; they can also help with adhd symptoms, but there is less evidence that they are effective for adults. the neuroleptics risperidone and aripiprazole are tried when antihypertensives are not effective, and are generally tried first for adults. because of lower side effects, aripiprazole is preferred over other antipsychotics. the most effective medication for tics is haloperidol, but it has a higher risk of side effects. methylphenidate can be used to treat adhd that co-occurs with tics, and can be used in combination with clonidine. selective serotonin reuptake inhibitors are used to manage anxiety and ocd. other further information: management of tourette syndrome § other complementary and alternative medicine approaches, such as dietary modification, neurofeedback and allergy testing and control have popular appeal, but they have no proven benefit in the management of tourette syndrome. despite this lack of evidence, up to two-thirds of parents, caregivers and individuals with ts use dietary approaches and alternative treatments and do not always inform their physicians. there is low confidence that tics are reduced with tetrahydrocannabinol, and insufficient evidence for other cannabis-based medications in the treatment of tourette's. there is no good evidence supporting the use of acupuncture or transcranial magnetic stimulation; neither is there evidence supporting intravenous immunoglobulin, plasma exchange, or antibiotics for the treatment of pandas. deep brain stimulation (dbs) has become a valid option for individuals with severe symptoms that do not respond to conventional therapy and management, although it is an experimental treatment. selecting candidates who may benefit from dbs is challenging, and the appropriate lower age range for surgery is unclear; it is potentially useful in less than 3% of individuals. the ideal brain location to target has not been identified as of 2019. pregnancy a quarter of women report that their tics increase before menstruation; however, studies have not shown consistent evidence of a change in frequency or severity of tics related to pregnancy or hormonal levels. overall, symptoms in women respond better to haloperidol than they do for men. most women find they can withdraw from medication during pregnancy without much trouble. when needed, medications are used at the lowest doses possible. during pregnancy, neuroleptic medications are avoided when possible because of the risk of pregnancy complications. when needed, olanzapine, risperidone and quetiapine are most often used as they have not been shown to cause fetal abnormalities. one report found that haloperidol could be used during pregnancy, to minimize the side effects in the mother, including low blood pressure, and anticholinergic effects, although it may cross the placenta. if severe tics might interfere with administration of local anesthesia, other anesthesia options are considered. neuroleptics in low doses may not affect the breastfed infant, but most medications are avoided. clonidine and amphetamines may be present in breast milk. prognosis tim howard, described in 2019 by a staff writer for the los angeles times as the "greatest goalkeeper in u.s. soccer history", attributes his success in the sport to his tourette's. tourette syndrome is a spectrum disorder—its severity ranges from mild to severe. symptoms typically subside as children pass through adolescence. in a group of ten children at the average age of highest tic severity (around ten or eleven), almost four will see complete remission by adulthood. another four will have minimal or mild tics in adulthood, but not complete remission. the remaining two will have moderate or severe tics as adults, but only rarely will their symptoms in adulthood be more severe than in childhood. regardless of symptom severity, individuals with tourette's have a normal life span. symptoms may be lifelong and chronic for some, but the condition is not degenerative or life-threatening. intelligence among those with pure ts follows a normal curve, although there may be small differences in intelligence in those with comorbid conditions. the severity of tics early in life does not predict their severity in later life. there is no reliable means of predicting the course of symptoms for a particular individual, but the prognosis is generally favorable. by the age of fourteen to sixteen, when the highest tic severity has typically passed, a more reliable prognosis might be made. tics may be at their highest severity when they are diagnosed, and often improve as an individual's family and friends come to better understand the condition. studies report that almost eight out of ten children with tourette's experience a reduction in the severity of their tics by adulthood, and some adults who still