Tics, Tourettes and ADHD (Part 1)

This article is the first of a two part discussion regarding the diagnosis and treatment of Attention Deficit Hyperactivity Disorder (ADHD) in individuals with tics and/or Tourette syndrome.  This first article will discuss some of the issues, controversies and misunderstandings about treating children who have tics with ADHD medications. The traditional “stimulant” drugs will be discussed. In the next newsletter, some of the other medications and alternative or complimentary therapies will be reviewed.

As a pediatrician for over 30 years, I have frequently evaluated, diagnosed and treated many children with ADHD.  I have also diagnosed many children with tics and Tourette syndrome.  Until recently, when children were evaluated for attention and hyperactivity, they were diagnostically labeled as having either Attention Deficit Disorder (ADD) or Attention Deficit Hyperactivity Disorder (ADHD) respectively.  Currently, the proper designation for both is ADHD.  Then, the diagnosis is further differentiated as the predominantly “Inattentive” type, predominantly “Hyperactive/Impulsive” type or “Combined” type.  

The treatment of ADHD in children with tics and Tourette syndrome is widely misunderstood both by the general public and the physician community. Many are still under the mistaken impression that the use of stimulant medications, such as the methylphenidates (ex.Ritalin, Concerta, Daytrana, Focalin, Metadate) and the amphetamines (ex. Dexadrine, Adderall, Vyvanse), is absolutely contraindicated in individuals with tics or Tourettes.  Additionally, this misconception is sometimes still being taught in some of our medical schools.  There is an overstated concern that these drugs will increase the severity of the tics.  One reason this misconception still exists is that years ago the FDA required such a warning based upon, what we now know, was incorrect information. 

Subsequent studies and a review of the literature revealed that, with careful monitoring and supervision, physicians could prescribe stimulants to children and adolescents with Tourette  syndrome or tics.   The presence of tics is not an absolute contraindication for treatment with stimulant medications because, in most instances, the tics will not increase.  Some experts in the field of Tourettes unofficially speak of the 1/3 rule.  That is, in children with Tourettes who are treated with stimulant medications, 1/3 of the time the tics get worse, 1/3- the tics get better and 1/3 -the tics remain the same.  In some observations, even if the tics initially worsen, if the individual remains on the medication, over time the severity of the tics often go back to baseline or even improve. One hypothesis is that the drugs initially “stimulate” the neurological “tic” pathways ( ie. dopamine and dopamine receptors in the brain).  However, over time, as these pathways accommodate to the drug, the tics diminish.  Another thought is that when the ADHD symptoms improve on medication, the child’s self-esteem improves, stress and mental fatigue decreases, resulting in fewer tics.  Having said all this, over the years have I treated children where their tics increased so significantly that I had to discontinue a stimulant?  The answer is yes, but rarely.  

In summary, in most instances the stimulant medications remain the most effective medication to treat ADHD symptoms in children, adolescents and adults without having an adverse affect on their tics.  When contemplating an evaluation and possible treatment for ADHD, one must ensure that the professional being considered has the knowledge and experience with tics, Tourettes and ADHD to provide well-founded recommendations.  This will be further discussed in the next newsletter, in addition to a discussion of other medications and alternative or complimentary treatments.

Gary J. Bergman, M.D., F.A.A.P.

Disclaimer:

Please note that the views and opinions expressed above are Dr. Bergman’s, not those of TSAGW, and are intended for informational and educational purposes only.  The information is not intended to replace professional advice from one’s own physician.  With respect to treatment, you should contact your own medical provider(s).  There are no express or implied warranties or representations of any kind regarding any of the information above.  Dr. Bergman and TSAGW disclaims all liability of any kind for the content of any information transmitted to or received by any individual or entity in connection with such individual or entity's use of this article and does not endorse or recommend in any way any such information.