Medical Column

Q&A with Dr. Barbara Coffey

Barbara Coffey, M.D., M.S., is an internationally-known specialist in Tourette Disorder and tic disorders who also has expertise in treating ADHD and Obsessive Compulsive Disorder. She has been on the medical advisory board of the Tourette Syndrome Association and is on the advisory board of the New York City Chapter. She is the Director of the Institute for Tourette and Tic Disorders and Associate Professor of Child and Adolescent Psychiatry at the NYU Child Study Center.

Question: My 8 year old son has been diagnosed with Tourette's Disorder and Attention Deficit Hyperactivity Disorder (ADHD). His second grade teacher is concerned that he is unable to sit still in class, is frequently distractible and inattentive, calls out answers before questions are completed, and has difficulty completing his homework assignments. His tics are rather mild. Our pediatrician would like to prescribe medication to help our son, but he is reluctant to do so, since he is concerned that stimulants will increase our son's tics. What treatment options are available to help him?

Answer: This is a very common question from parents of children with ADHD and tics. There is a bidirectional overlap between ADHD and tics; that is, children with ADHD are at higher risk of developing tic disorders (10-30%) than children without ADHD (5%). In addition, children and adolescents with Tourette's Disorder referred for clinical evaluation are very likely to also meet criteria for ADHD (perhaps 50%). Thus, the two conditions often co-occur; the first step is to comprehensively evaluate the child and to try to determine which condition is associated with the most impairment or distress.

In children with comorbid (co-occurring) ADHD and tics, as in the 8 year old described, it is usually the ADHD symptoms (fidgetiness, distractibility, impulsivity and organizational problems) that cause the most clinical concern. Thus, treatment should be targeted to address the ADHD symptoms, and ideally, should not increase the tics.

Treatments of ADHD include medication, behavioral, and educational interventions. Optimal treatment is multi-modal, which means drawing simultaneously upon several different modalities including medical, behavioral and educational components.

From the medical perspective, the most studied and generally most effective medications for ADHD are the stimulants, such as methylphenidate and dextroamphetamine. The first study of stimulants was in 1937, and there have been literally thousands of children and hundreds of adolescence and adults studied since then. The stimulants have been found in randomized, controlled clinical trials to be more effective than placebo for ADHD symptoms in about 80% of subjects. More recent studies have included adults and preschool children. They are generally well tolerated; most adverse effects are mild, such as difficulty falling asleep and reduction of appetite, and can be managed by adjusting the dosage and/or switching agents. The past decade has brought an improvement in stimulant delivery systems such as longer acting agents (Concerta, Metadate, Ritalin LA, Focalin XR and Adderall XR) which can be administered just once daily, and a transdermal (skin) patch (Daytrana) which is changed daily.

Early studies in the 1980s suggested that stimulants could induce or increase tics in patients with tic disorders or in those who are vulnerable to tic disorders, such as those with a family history of tics. As a result, many physicians and parents have been reluctant to prescribe stimulants to children with tic disorders and Tourette's. However, these early studies were confounded by the fact that most children with ADHD who are going to develop tic disorders or Tourette's are first brought in for evaluation at the time when the tics would be most likely to develop, at around age 7 or so. Thus, when a stimulant is prescribed and tics occur, it is most likely a temporal coincidence, and not a true causal association.

Fortunately, more recent studies, starting with the work of Drs. Kenneth Gadow and Jeffrey Sverd in the early 1990s, evaluating different doses of immediate release methylphenidate (Ritalin) on children's ADHD and tic symptoms, indicated that most children experienced a significant improvement in ADHD symptoms with little to minimal increase in tics. A large multi-center placebo controlled study of methylphenidate and clonidine individually and in combination, published by the Tourette Syndrome Study Group in February 2002, found that methylphenidate did not increase tics at a higher rate than placebo.

Of course, some children are sensitive to stimulants and may experience at least a transient increase in tics when a stimulant is started; usually the increase occurs at the beginning of treatment or during dosage titration. Usually the best approach is for physicians and parents to “wait it out” for several days, and most often the tics will return to their previous level. The stimulant can usually be adjusted to find the optimal dose that reduces ADHD symptoms but does not increase tics significantly.

If the tics do not reduce to a manageable level on the stimulant, either clonidine (Catapres) or guanfacine (Tenex) can be added in low doses. Clonidine and guanfacine, known as alpha adrenergic agonists, are anti-hypertensive medications that are commonly used off label as first line treatments for Tourette's Disorder, as they reduce both motor and vocal tics. These agents have also been studied in the treatment of ADHD alone, since these medications reduce motoric hyperactivity, impulsivity and hyperarousal. Clonidine and guanfacine are not particularly helpful for the inattention and distractibility symptoms.

Another medication that has been studied in children with ADHD and chronic tics is atomoxetine (Strattera). This is a non-stimulant selective norepinephrine reuptake inhibitor that is labeled for treatment of ADHD in youth and adults. Strattera is generally well tolerated; adverse effects included reduced appetite, headaches, and nausea. Other medications that have been used off label to treat ADHD in children include modafinil (Provigil), a medication that is indicated for the treatment of narcolepsy in adults, and bupropion (Wellbutrin), an antidepressant medication.

It is important to remember that behavioral treatments are also effective in the management of children with ADHD. Treatment manuals have been developed by experts such Dr. Russell Barkley that include careful attention to behavior in public settings, home token economy reward systems, and use of time outs. These techniques can also be used in school. In addition, educational intervention may include accommodations in the classroom such as preferential seating, frequent breaks, modification of homework assignments, and untimed testing. Full individualized educational plans (IEPs) may also be needed to address academic problems, including use of a resource room, aides in the class room, or substantially separate classrooms.