Tics are sudden, rapid, non-rhythmic movements or sounds that occur involuntarily, often preceded by an uncomfortable sensation called a premonitory urge. Motor tics involve movements like eye blinking or head jerking, while vocal tics include throat clearing or sniffing. Tics are common, with up to one in eight school-aged children experiencing them temporarily, though chronic tic disorders last longer than a year. The frequent co-occurrence of tics and Attention-Deficit/Hyperactivity Disorder (ADHD) requires a specialized approach to management.
Clarifying the Connection Between ADHD and Tics
ADHD and tic disorders, including Tourette’s Syndrome (TS), often occur together at high rates, suggesting a shared underlying vulnerability in the brain. More than half of children diagnosed with TS also meet the criteria for ADHD, and approximately 20% of children with ADHD have a persistent tic disorder.
The shared mechanism is believed to involve the brain’s dopamine system and the cortico-striatal-thalamo-cortical (CSTC) pathway, which regulates movement and behavior. Both conditions involve dysfunction in these neural circuits, though ADHD does not directly cause tics. The presence of both conditions can complicate treatment, as ADHD symptoms like inattention and impulsivity are often more functionally impairing than the tics themselves.
Non-Pharmacological Strategies for Tic Management
Behavioral interventions are recognized as a first-line treatment for managing tics, particularly for individuals with mild to moderate symptoms. Comprehensive Behavioral Intervention for Tics (CBIT) is the most studied and recommended non-drug approach, helping individuals gain better control over their symptoms. CBIT also incorporates function-based environmental interventions and relaxation techniques. Tics are highly sensitive to emotional and environmental factors, often worsening during periods of stress, excitement, or fatigue.
Habit Reversal Training (HRT)
A core component of CBIT is Habit Reversal Training (HRT). The first step is awareness training, where the individual learns to identify the specific sensations, or premonitory urges, that precede the tic. Following this, the individual learns a “competing response”—a voluntary movement or posture that is incompatible with the tic and is performed whenever the urge is felt. For example, a person with a head-jerking tic might learn to gently tense their neck muscles for a short period when they feel the urge to jerk their head.
Lifestyle Adjustments
Simple lifestyle adjustments can help stabilize tic severity and frequency. Ensuring adequate sleep hygiene is important, as fatigue is a common trigger for tic exacerbation. Practicing relaxation methods, such as diaphragmatic breathing or progressive muscle relaxation, can also help reduce the anxiety and muscle tension that frequently make tics worse.
Medical Treatment Options and Considerations
Pharmacological treatment is reserved for tics that are severe, disruptive, or unresponsive to behavioral interventions. The choice of medication depends on the severity of tics and the presence of co-occurring conditions. Alpha-2 adrenergic agonists, such as clonidine and guanfacine, are often the first class of medication tried due to their favorable side effect profiles, as they can reduce both tic severity and ADHD symptoms.
For more severe or treatment-resistant tics, atypical antipsychotics may be considered. Medications like risperidone and aripiprazole are effective at reducing tics by blocking dopamine receptors. While potent, these agents carry a higher risk of side effects, including weight gain, sedation, and movement issues, necessitating careful monitoring.
A major consideration is the interaction with stimulant medications commonly used for ADHD. While older concerns suggested that stimulants could worsen tics, recent studies indicate that medications like methylphenidate are often safe and effective in children with both conditions. Stimulants, particularly the amphetamine class, may occasionally exacerbate tics, requiring close supervision. Non-stimulant ADHD medications, such as atomoxetine, are often preferred when tics are a significant concern.