The Treatment of Tics in Children with ADHD

At the 2020 Virtual Conference on Pediatric Health Care, Dawn Garzon Maaks, PhD, CPNP-PC, PMHS, FAANP, FAAN, the immediate past president of the National Association of Pediatric Nurse Practitioners and the associate professor at the University of Portland in the School of Nursing, discussed important elements in the diagnosis and treatment of tics in children with attention deficit hyperactivity disorder (ADHD).

Maaks explained in her lecture that tics and ADHD are commonly comorbid, with certain fears precipitating tics in children. These tics commonly begin between the ages of 4 and 8 years old.

In order to be considered tics, the behaviors must begin by age 18, be present for at least 1 year, and consist of at least 2 motor tics and 1 vocal tic during the course of the disease.

However, Maaks noted that ADHD and tics do not need to present concurrently, although tics should be present during the course of a child’s experience with ADHD. Some patients report that they can initially tell when a tic is coming on, and they can express relief and comfort when they do engage in them. For many children, tics are started by an action that moves from a conscious act to a semi-conscious movement.

Tic symptoms can be treated with methylphenidate, clonidine, methylphenidate and clonidine, guanfacine, and desipramine. Studies have shown that of stimulants used to treat ADHD, a high dose of dextroamphetamine worsen occurrences of tics in one study investigating its use in children.

In the management of tics, a psychotherapy treatment called comprehensive behavioral intervention for tics (CBIT) has the best supporting evidence available. This therapy teaches patients to recognize when the tic is coming on in order to make the movements conscious again. This treatment also aims to help patients identify situations in which triggers for tics occur, develop techniques that promote relaxation, and identify replacement activities.

The clinical practice guidelines from the American Academy of Neurology states that if a patients has tics with functionally impairing ADHD, ADHD treatment should be the main focus for treatment.

However, CBIT and alpha-adrenergics like clonidine and guanfacine can also help, if necessary, following ADHD treatment. Botulism toxin injections for adolescents with simple motor tics or topiramate may also be helpful, while antipsychotics would only be used when benefits outweigh the risks.

Maaks added in her presentation that it is also important to rule out non-tic behaviors, such as fidgeting, compulsions, and stereotypies, before diagnosing a child with tics and pursuing any treatment for it. These other behaviors can resemble tics but have a different source. For this reason, it is important to investigate the cause for tics in order to ascertain whether the behavior is a tic or something else.

REFERENCE

Maaks DG. ADHD 300: Beyond the Basics. Paper presented at: 2020 Virtual Conference on Pediatric Health Care; June 4 — June 5, 2020; virtual. event.vconferenceonline.com/vconference/odplayer_flash.aspx?id=16559. Accessed July 2, 2020.