Tics, ADHD, and Medication

ADHD and tics often occur together.  Up to 50% of patients with ADHD may have an underlying tic disorder, while up 70% of patients with chronic tics may have ADHD.  Until very recently, many people in the ADHD community have felt that medication causes or worsens tics.  However, new research is challenging this widely held assumption and changing the face of treatment for people who have both disorders.

To understand the reversal in medical opinion, you must understand a little about tics.  The medical definition of a tic is an involuntary, nonrhythmic movement of any body part.  Tics can include throat clearing or blinking, vocalizations, or even complex actions such as repetitive phrases, picking at clothing, or brushing hair.

Tics come and go in response to a variety of triggers including stress, changes in body chemistry (such as thyroid hormone and blood sugar), or may be seemingly random.  The cause of tics can be genetic, structural (ie brain damage from stroke, trauma or other issues), or unknown.  Once they start, they can stop within a few weeks, months or longer.

Tics are very common in otherwise normal children.  One in 5 children will develop a tic at some point before they turn 10, and most of these children will get better without any treatment.  Because tics are very common, even in normal children, tics are likely to show up coincidentally around the time medication is started in many children.  Tics occur after the introduction of a stimulant in 1 in 5 children who have a known tic disorder and in about 6% of children who have ADHD and no known tic disorder.

Do stimulants cause tics?  NO.

In 2009, a metanalysis of 9 clinical trials in children with ADHD and tic disorder concluded that methylphenidate did not worsen the tic disorder.   Last year, 2015, saw a new metanalysis published, this time examining trials of all children with ADHD who were started on stimulants.  This metanalysis demonstrated that tics were very common, equally common, in fact, both in children who took the stimulant and in those who took placebo.  All of this points to tics not being caused by stimulant medication, even though tics do happen very regularly after medication is started.

Should ADHD be treated differently in patients with tics?  Maybe.

The second article suggests that stimulant medication not be withheld from children with ADHD who happen to have a family or personal history of tics, and that stimulants be continued if tics happen to arise during treatment since in all likelihood, the stimulant was an innocent bystander.

However, in the interest of keeping the number of medications low, patients who have tics and ADHD can be treated with clonidine or guanfacine, both of which are effective for both conditions, and both of which have a fairly safe side effect profile.  However, neither medication is the most effective medication for either ADHD or tics, and treating two conditions with one medication can make dose adjustment difficult.

Should tics be treated differently in patients with ADHD?  Maybe.

Generally speaking, unless tics are very noticeable, it’s best not to treat with medication since most tics will go away on their own.  However, if the tics are bothersome (for example if a child is picking through their skin and leaving scabs) or noticeable (causing disruption in a classroom or workplace) then active treatment may be a consideration.

Treatment for tics generally involves behavioral therapy.  This therapy focuses on habit reversal therapy as well as anxiety reduction/relaxation techniques and has an effectiveness which is comparable to medication, without the same risk of side effects.  The major down side is that it takes time for a patient to learn the techniques effectively.

Medications can be used but sometimes the medication is worse than the tics.  .  Clonidine and guanfacine have both been used effectively in patients with ADHD and tics, but the medication may not be very effective.   The most effective medications for tics, such as risperidone,  can leave a patient with a host of permanent side effects, and so they are reserved for patients who have the most disabling and unresponsive symptoms.  There are other treatments for tics but only clonidine and guanfacine are known to help with ADHD as well.

Overall, clinical trials are starting to point toward encouraging the use of the most effective approach in treating ADHD, toward not discontinuing medication if tics arise, and toward treating tics as an entity mostly independent of ADHD.  Parents of children who develop tics while on medication for ADHD can be reassured that the medication did not cause the tic and that the tic will likely resolve on its own, without change to ADHD therapy.

References:

Thenganatt, Mary Ann, and Joseph Jankovic. "Recent Advances in Understanding and Managing Tourette Syndrome." F1000Research F1000Res (2016): n. pag. Web. 23 May 2016.