Children with tic disorders: How to match treatment with symptoms
Algorithm helps determine when behavioral therapy, medication is appropriate
| Clinical information | Frequency |
|---|---|
| Family history | Initial visit |
| Weight | Baseline, monthly |
| Height | Baseline, monthly |
| BMI | Baseline, monthly |
| Waist circumference | Baseline, annually |
| Blood pressure | Baseline, 3 months after treatment starts, and annually thereafter |
| Fasting lipid profile | Baseline, every 3 months initially, then every 6 months thereafter |
| Fasting serum glucose | Baseline, every 3 months, then every 6 months thereafter |
| BMI: body mass index | |
| Source: References 14,16 | |
You recommend that Sammy remain on risperidone for another 3 months of stability and then begin to taper this medication. You review the risks and benefits of long-term treatment with risperidone, pointing out that it may lead to abnormal movements upon withdrawal, and explain that you typically do not treat children with antipsychotics for more than one year continuously.
CASE CONTINUED: Comorbid symptoms
Since starting 7th grade, Sammy has worried excessively about making mistakes. He spends 6 hours each night on homework, which he often does not turn in because of anxiety about not getting answers perfectly right. Classmates notice that Sammy taps the door 3 times when he comes into the classroom and that he steps over the black tiles in the hallway.
Consider the presence and impact of comorbid OCD or ADHD, which can impair children’s quality of life more than tics themselves.15 Assessment scales can help you make a diagnosis and monitor treatment.
If you suspect OCD, the clinician-rated Children’s Yale Brown Obsessive Compulsive Scale is the gold standard for describing the phenomenology and measuring symptom severity. Additional scales to measure symptoms’ impact on family life include the Leyton Obsessional Inventory—child version, Family Accommodation Scale for OCD, and Child OCD Impact Scale.
ADHD scales include the Conners Parent Rating Scale—Revised, Conners Teacher Rating Scale—Revised, Swanson, Nolan, and Pelham, or the Vanderbilt ADHD Diagnostic Parent and Teacher Rating Scales. Because ADHD symptoms must be present in more than 1 environment to meet diagnostic criteria, ask parents and teachers to complete the Conners or Vanderbilt scales.
In children who present with a tic disorder plus a comorbid condition, prioritize treatment by determining which symptoms interfere with the child’s ability to function at school, at home, and in the social arena. Children who require treatment for >1 disorder often are referred initially for cognitive-behavioral therapy for OCD symptoms while receiving pharmacologic treatment for ADHD and/or Tourette syndrome. When necessary, it is usually safe to combine antipsychotics, stimulants, and selective serotonin reuptake inhibitors, although medication interactions should be reviewed in each specific case.
Related resources
- Woods DW. Managing Tourette syndrome: a behavioral intervention for children and adults. Therapist guide. New York, NY: Oxford University Press; 2008.
- Tourette Syndrome Association. www.tsa-usa.org.
- International OCD Foundation. www.ocfoundation.org.
Drug brand names
- Baclofen • Lioresal
- Botulinum toxin • Botox, Myobloc
- Clomipramine • Anafranil
- Clonidine • Catapres
- Guanfacine • Tenex
- Fluphenazine • Prolixin
- Flutamide • Eulexin
- Haloperidol • Haldol
- Mecamylamine • Inversine
- Nicotine patch • NicoDerm
- Olanzapine • Zyprexa
- Pimozide • Orap
- Risperidone • Risperdal
- Tetrabenazine • Xenazine
- Ziprasidone • Geodon
Disclosures
Dr. Harris has received research support from the Translational Research Initiative at Cincinnati Children’s Hospital Medical Center.
Dr. Wu reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
