ADHD and Tics and Tourette Syndrome

What Is a Tic Disorder?

Simple tics are sudden, purposeless, repetitive, involuntary movements or vocalizations. They occur in up to 20 percent of all children and may be temporary (lasting less than 12 months) or chronic.

Common simple tics

• Eye-blinking
• Mouth-opening
• Sniffing
• Throat clearing

What Is Tourette Syndrome?

Tourette's Disorder (popularly called Tourette Syndrome) is a complex, inherited disorder whose primary symptoms include both motor and vocal tics lasting for more than one year. It is usually mild and is often accompanied by other conditions, including ADHD.

How ADHD and Tics or Tourette Syndrome Overlap

Some children develop a simple motor tic disorder that first appears during treatment for ADHD. Most experts believe this co-occurrence is, in most cases, purely coincidental. Roughly 60 percent of children with Tourette Syndrome also have ADHD. The ADHD diagnosis usually precedes the onset of the motor or vocal tics of Tourette's, though sometimes the two emerge together.

Which Disorder Do You Treat First?

With simple tics, the doctor may treat the ADHD first, because it offers the greater benefit for the child and its treatments are more effective. Tics may only need treatment if they are causing significant difficulties. In most cases involving Tourette Syndrome, however, doctors will treat the Tourette's symptoms first.

Treatment of Tourette Syndrome

Patient and family education is the first step. Before deciding how to treat, it is important to decide whether the Tourette Syndrome-related symptoms need treatment at all.

• Counseling and behavioral modification may be sufficient for individuals with mild symptoms.
• Medications may be considered when symptoms interfere with activities of daily living.
• Therapy should be geared to the individual's needs, targeting the most troublesome symptoms first.

Medication

In children with ADHD and Tourette Syndrome, milder symptoms can usually be treated with clonidine, which has the advantage of addressing all the symptoms of Tourette Syndrome. Its major side effect is sedation or tiredness if the dose is too high or raised too rapidly. Other medications, such as haloperidol or pimozide, may also be used.

Behavioral Interventions

There is growing evidence that behavioral interventions can substantially reduce tics. Practicing tic control in everyday situations can be part of therapy, and self-monitoring has shown temporary but significant benefit. Habit reversal therapy combines awareness training with competing response training — performing a competing movement for three minutes after each tic and after each sensation that a tic is about to occur.

Comprehensive Behavioral Intervention for Tics (CBIT) is based on the fact that tics are preceded by a sensation signaling a tic is coming. CBIT includes:

• Guidance for parents on what makes tics better or worse
• Relaxation techniques
• Strategies to reduce tic severity
• Counseling for individuals and families on dealing with tic symptoms, peer rejection, school problems, and other issues

Treating the ADHD

After the tics are controlled, appropriate medication may be needed to treat the ADHD symptoms. ADHD medication is often effective in controlling ADHD and may improve school performance. In some individuals, treatment may cause a mild to significant increase in tics, although this is not common at doses typically prescribed in practice. If a moderate increase in tic medication cannot control it, the ADHD medication may be stopped or replaced with a different medication. A child's doctor can determine whether ADHD medication is an appropriate treatment for a child with a co-occurring tic disorder.