Tics, Tourettes and ADHD (Part 2)

This is the second of a two part discussion on tics, Tourette syndrome and ADHD.  In the last newsletter, some of the issues of treating individuals who has both tics and ADHD with the traditional stimulant medications of methylphenidate (ex. Ritalin, Concerta, Daytrana, Metadate, Focalin) or amphetamine (ex. Dexadrine, Adderall, Vyvanse) were examined.  In this article some other treatments and issues will be discussed

Despite the fact that the stimulant medications are the most efficacious medications for treating ADHD in persons with or without tics, it has been reported that the most common drug prescribed in this country for children and adolescents with TS to initially treat their ADHD (or even their tics) is clonidine (Catapres) or, more recently, a related compound, guanfacine (Tenex).  These medications are not very effective for the treatment of either ADHD or tics, but they are relatively safe and have not been felt to increase tic severity.  It has been observed that these medications may decrease tic severity by as much as twenty-five percent.  In some individuals the improvement might be greater and in others, less or not at all.  The major drawback, especially with clonidine, is that these medications can cause sedation and cognitive dulling.  Not exactly the type of side effect one desires in a child with ADHD or, for that matter, in any child.  Actually, because of its sedative properties, clonidine may be prescribed to treat the insomnia side effect sometimes seen with stimulant therapy.

Another, medication to treat ADHD and FDA approved in 2003 is atomxetine (Strattera).  Although this drug was initially touted as not increasing tics, subsequently there have been occasional reports that it does. In fact, just this year, the FDA instructed its manufacturer, Eli Lilly, to stop promoting it as a “tic-free” medication.  Additionally, although there was much promotion of and excitement about atomexitine when it was first released, it has not seemed to be as effective in treating ADHD as once hoped.  Many physicians only prescribe it as a back-up or second-line drug.

Another drug that has been very occasionally used in the treatment of ADHD is bupropion (Wellbutrin).  This medication is an anti-depressant and not specifically indicated for the treatment of ADHD.  It is of questionable efficacy but is occasionally prescribed by some physicians when other medications fail or have intolerable side effects.  Another drug, modofinil (Provigil), originally developed for the treatment of narcolepsy, has been studied for the treatment of ADHD and initially showed some promise.  However, the FDA refused to approve it for this indication because during the drug trials several cases of Stevens-Johnson syndrome, a significant and potentially life-threatening side effect, were reported.  The FDA concluded that the risk was too high to justify approval.  In spite of this and allowed under FDA statutes concerning off-label use, some physicians are judiciously prescribing modofinil with anecdotal reports of some good results.

There are other alternative or complimentary treatments being advocated by some.  These include optometric interventions such as special glasses and vision therapy.  The American Academy of Pediatrics and the American College of Pediatric Ophthalmology and Strabismus Surgery have both published policy statements against recommending these therapies as there does not seem to be any credible, scientifically valid studies to support their efficacy.  Additionally, biofeedback, hypnosis, magnet therapy, homeopathic remedies, and other alternative medications, including omega 3 fatty acids, have been touted and promoted, especially on the internet.  Although one often hears claims and testimonials of remarkable improvements or cures for many non-traditional therapies, all have yet to be proved to be effective by rigorous scientific study and many have been proved to be totally ineffective. And although some of these methods may seem safe and innocuous, others may not be without risk.

Another diagnostic and treatment method being touted is the use of brain SPECT (single photon emission computed tomography) and PET (positron emission tomography) scans to diagnose and help direct the choice of medication in the treatment of ADHD. Unfortunately, these radiological scans are still very much research tools and have yet to be proved to be useful in clinical practice.  Although the scientific explanations sound convincing and the pictures look impressive, the claims about the efficacy of using these kinds of studies are currently not warranted as noted by most reputable specialists, researchers and organizations in the field.  Additionally, the work-up is expensive and not usually covered by most health care insurance plans.

Finally, when evaluating any child for ADHD, the medical professional must also consider other disorders that can masquerade as ADHD or co-exist with ADHD.  These include conditions such as depression, anxiety, OCD and sleep disorders.  One can imagine that if a child is sad, worrying, obsessing over something or not sleeping well, he/she may not be able to pay attention in the classroom, concentrate while doing homework or may become frustrated and moody and perform what appears to be impulsive acts.

In conclusion, if one is a parent of a child with Tourette syndrome and possible ADHD, or an adult with Tourette syndrome and ADHD, ensure that the professional providing the evaluation and potential treatment is fully knowledgeable and experienced in all the issues discussed above.  Although I would encourage one to start with a recommendation from one’s own primary care physician, often he/she may have their own bias or may not be well informed about the issues or know the appropriate people to which to refer.  Do your homework.  Consider contacting a specialist affiliated with an academic medical center or check with advocacy organizations such as TSAGW, TSA and CHADD.  Be careful of claims on internet websites.  Failure to find the right professional could result in an incorrect diagnosis, inappropriate and/or inadequate treatment and, most importantly, continued difficulties in school, at home and/or in the workplace.  Proper diagnosis and treatment can make tremendous difference for an individual and his/her family.

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.