pediatrics
Tic Disorders and Tourette Syndrome in Children and Adolescents
Treatment of Tic Disorders
Comprehensive Behavioral Intervention for Tics (CBIT) Sometimes alpha-adrenergic agonists or antipsychotics Treatment of comorbidities (See also the American Academy of Neurology'sreview summary of treatment of tics in people with Tourette syndrome and chronic tic disorders[2019].) Treatment to suppress tics is recommended only if they are significantly interfering with children’s activities or self-image; treatment does not alter the natural history of the disorder. Often, treatment may be avoided if clinicians help children and their families understand the natural history of tics and if school personnel can help classmates understand the disorder. A type of behavioral therapy called CBIT should be strongly considered and may help some older children control or reduce the number or severity of their tics. It includes cognitive-behavioral therapy such as habit reversal (learning a new behavior to replace the tic), education about tics, and relaxation techniques. Sometimes the natural waxing and waning of tics makes it appear that the tics have responded to a particular treatment. Oral alpha-adrenergic agonistsare usually used for mild symptoms and also are helpful for treatment of ADHD: Clonidineis started with 0.05 mg at bedtime and is increased gradually (eg, by 0.05 mg every 7 days) up to 0.1 to 0.4 mg/day in 2 divided doses. Guanfacineis started with 0.25 mg at bedtime and is increased gradually (eg, by 0.25 mg every week) up to 4 mg/day in 2 divided doses (unless long-actingguanfacineis prescribed). An adverse effect ofclonidineis fatigue, which may limit daytime dosage; hypotension is uncommon. Oral antipsychoticsmay be required for symptoms that are more difficult to control—for example: Risperidone0.25 to 1.5 mg 2 times a day Haloperidol0.5 to 2 mg 2 or 3 times a day Pimozide1 to 2 mg 2 times a day Olanzapine2.5 to 5 mg once a day Fluphenazineis also effective in suppressing tics. With any medication, the lowest dose required to make tics tolerable is used; doses are tapered as tics wane. Adverse effects of dysphoria, parkinsonism, akathisia, and tardive dyskinesia are rare but may limit use of antipsychotics; using lower daytime doses and higher bedtime doses may decrease adverse effects. Treating comorbidities is important. ADHD can sometimes be successfully treated with low doses of stimulants without exacerbating tics, but an alternative treatment (eg,atomoxetine) may be preferable. If obsessive or compulsive traits are bothersome, a selective serotonin reuptake inhibitor may be useful. Children who have tics and who are struggling in school should be evaluated for learning disorders and provided with support as needed. 