Tourettes Syndrome

Child and Youth Mental Health

Dr. Stanley Kutcher

The relationship between Tics, Tourette S d d Sti l t M di ti ti lSyndrome and Stimulant Medication: practical information for primary health care providers©

Dr Stan KutcherDr. Stan Kutcher

Dr. Iliana Garcia‐Ortega

Tic DisordersTic Disorders

• The most common tic disorder is called "transient tic disorder" and mayThe most common tic disorder is called transient tic disorder and may

affect up to 10 percent of children during the early school years.

• Teachers or others may notice the tics and wonder if the child is underTeachers or others may notice the tics and wonder if the child is under

stress or "nervous."

• Transient tics go away by themselves. Some may get worse with anxiety,Transient tics go away by themselves. Some may get worse with anxiety,

tiredness, and some medications.

• Some tics do not go away. Tics which last one year or more are calledSome tics do not go away. Tics which last one year or more are called

"chronic tics."

• Chronic tics affect less than one percent of childrenChronic tics affect less than one percent of children

DSM‐IV criteria for chronic motor or vocal tic disorder

DSM‐IV criteria for transient tic disordermotor or vocal tic disorder

• Single or multiple motor or vocal tics (e.g.,

sudden, rapid, recurrent, non‐rhythmic,

tic disorder

• Single or multiple motor and/or vocal tics (e.g.,

sudden, rapid, recurrent, non‐rhythmic,

stereotyped motor movements or

vocalizations), but not both concurrently, have

been present at some time during the illness.

stereotyped motor movements or

vocalizations).

• The tics occur many times a day, nearly every

• The tics occur many times a day nearly every

day, or intermittently throughout a period of >1

year, and during this period there was never a

day for at least 4 weeks, but for no longer than

12 consecutive months.

• The onset is before age 18 years.

tic‐free period of >3 consecutive months.

• The onset is before age 18 years.

• The disturbance is not due to the direct

g y

• The disturbance is not due to the direct

physiological effects of a substance (e.g.,

stimulants) or a general medical condition (e.g.,The disturbance is not due to the direct

physiological effects of a substance (e.g.,

stimulants) or a general medical condition (e.g.,

Huntington's disease or postviral encephalitis).

stimulants) or a general medical condition (e.g.,

Huntington's disease or post‐viral encephalitis).

• Criteria have never been met for Tourette's

disorder or chronic motor or vocal tic disorderg p p )

• Criteria have never been met for Tourette's

syndrome.

disorder or chronic motor or vocal tic disorder.

Tourette Syndrome

disorder named after Georges Gilles de la Tourette

• Tourette syndrome is a common neuropsychiatric disorder characterized by the

presence of fluctuating motor and phonic tics.

• The typical age of onset is 5‐7 years but age of first diagnosis is often > 10 yearsThe typical age of onset is 5 7 years but age of first diagnosis is often > 10 years

• Boys are more commonly affected than girls

• The majority of children improve by their late teens or early adulthood

• Affected individuals are at increased risk for comorbid conditions, such as:

obsessive‐compulsive disorder, attention deficit hyperactivity disorder, school

bl (l i di bilit ) d i d i tproblems (learning disability), depression, and anxiety.

• The prevalence of Tourette is estimated to be between one and ten per 1000

children and adolescents

• Differential diagnosis included many different movement disorders

DSM‐IV criteria for Tourette's syndrome (combined vocal and multiple motor tic disorder)

• Both multiple motor tics and ≥1 vocal tics must be present at the same time but p p

both can occur independently as well

• The tics must occur many times a day (usually in bursts), nearly every day or

intermittently over >1 year, during which time there must not have been a tic‐free

period of >3 consecutive months.

• The age at onset must be <18 years.

• The disturbance must not be due to the direct physiological effects of a substance

(e g stimulants) or a general medical condition (e g Huntington's disease or(e.g., stimulants) or a general medical condition (e.g., Huntington's disease or

postviral encephalitis).

Tourette syndromeTourette syndrome

• Symptoms usually begin with simple motor or vocal tics which then evolveSymptoms usually begin with simple motor or vocal tics which then evolve

into more complex motor and vocal tics over time

• Despite evidence that TS is an inherited disorder, the exact geneticDespite evidence that TS is an inherited disorder, the exact genetic

abnormality is unknown

• Contrary to popular belief, only a small number of patients use curseContrary to popular belief, only a small number of patients use curse

words or other inappropriate words or phrases (coprolalia)

• http://www.youtube.com/watch?v=G jBFbCCleYp // y / _j

• http://www.youtube.com/watch?v=DPaEdP5y83o&feature=related

Tourette ComplexitiesTourette Complexities

• Phonic tics usually begin in early adolescence

• The “burst” effect – can make Dx. complicated

• Premonitory urges frequently occur (awareness by early adolescence; subjective

di f t i t i ?)discomfort; impact on suppression?)

• Factors determining degree of disability are multiple, complex and may differ across

those affectedthose affected

• Interventions must address tics plus affected domains and often require multimodal

approaches

• Interpersonal stressors can increase tic severity (complex positive feedback loop

problem)

• Assess for the presence of learning disabilities

Treatment of Tics

• Transient tic disorder: education, reassurance; monitoring – NOMEDICATIONS

• Medications for Tourette or chronic tics include: alpha adrenergic agonists anti• Medications for Tourette or chronic tics include: alpha adrenergic agonists, anti‐

dopaminergics (eg. fluphenazine, haloperidol, pimozide and risperidone). Severe

or treatment non‐responsive Tourette may be helped with deep brain stimulation

or TMS.

• Habit reversal therapy is a validated non‐pharmacological option: especially in mild

cases: see ‐ http://onlinelibrary.wiley.com/doi/10.1002/9780470713518.app4/pdf

• Atomoxetine may be useful for youth with ADHD and tics, although there are case

f hild d l i i f i i i i i h A ireports of children developing tics after initiating treatment with Atomoxetine.

• Presence of tics is not a contraindication for the use of ADHD medications

• Specialty treatment for Tourette is suggested: a stepped approach is often used• Specialty treatment for Tourette is suggested: a stepped approach is often used

The relationship betweenThe relationship between tics and ADHDtics and ADHDpp

• The use of psychostimulant medication to treat ADHD can be associated with p y

the onset of tics – causal linkage unclear

• No significant increase in tics when psychostimulants are used in patients with

tics compared with controls

• Youth with Tourette Syndrome have higher prevalence of ADHD, high

variability in reports: 35% to 90%variability in reports: 35% to 90%

• ADHD in youth with Tourette Syndrome may make impact of both disorders

more severe

• Psychostimulants are equally effective in improving ADHD symptoms whether

the disorder is associated with tics or not

Conclusions PracticalConclusions Practical

• Many young people have tics – they most often do not need medical intervention: education and

watchful waiting if not Tourette Syndrome

• Youth with ADHD may have more tics than youth without ADHD. Tics are not a contraindication to

the use of ADHD medications (psychostimulants or atomoxetine)

• Referral if: 1) diagnostic uncertainty (is it chronic tic disorder or Tourette Syndrome); 2) tics become

significantl orse hen ADHD medications are prescribed b t medications are er helpf l insignificantly worse when ADHD medications are prescribed but medications are very helpful in

control of ADHD symptoms; 3) tics appear whenever any ADHD medication is prescribed; 4) patient

has Tourette Syndrome with comorbidities. y

A practical clinical tool to monitor motor and vocal tics in children:

Yale Global Tic Severity Scale (YGTSS)

http://dcf.psychiatry.ufl.edu/files/2011/06/TIC-YGTSS-Clinician.pdf

Conclusions PharmacologicalConclusions Pharmacological

• Psychostimulants are equally effective in improving ADHD symptoms whether the disorder isPsychostimulants are equally effective in improving ADHD symptoms whether the disorder is

associated with tics or not

• According to recent RCT studies there is no significant increase in tics when psychostimulantsAccording to recent RCT studies there is no significant increase in tics when psychostimulants

are used in patients with tics compared with controls – individuals may vary!

• It is medically appropriate to provide treatment with psychostimulant medication in personsIt is medically appropriate to provide treatment with psychostimulant medication in persons

with tics when ADHD symptoms are significantly disturbing their quality of life.

• Atomoxetine may be an alternative medication for those who have co‐morbid anxiety or ticsAtomoxetine may be an alternative medication for those who have co morbid anxiety or tics.

Although there are case report of children developing tics after initiating treatment with

Atomoxetine.

ReferencesReferences

http://aacap org/page ww?name Tic+Disorders&section Facts+for+Families– http://aacap.org/page.ww?name=Tic+Disorders&section=Facts+for+Families

– http://www.ncbi.nlm.nih.gov/pubmed/20951354





– http://www.biomedcentral.com/1471‐2431/5/34

For more information about child and youth mental health

visit: www.teenmentalhealth.org

© This material is under copyright.This material cannot be altered modified or soldThis material cannot be altered, modified or sold.

Teens and parents are welcome to use this material for their own purposes.

Health providers are welcome to use this material in their provision of health care.

Educators are welcome to use this material for teaching or similar purposes.Educators are welcome to use this material for teaching or similar purposes.

Permission for use in whole or part for any other purpose must be obtained in writing

from either Dr. Stan Kutcher at [email protected] or from Dr. Dan MacCarthy

(dmaccarthy@bcma bc ca) at the British Columbia Medical Association (BCMA)([email protected]) at the British Columbia Medical Association (BCMA).

Health & Medicine

Tourettes Syndrome