The presentation is part of a webinar that discusses the relationship between Tourettes Syndrome and the use of stimulants.

1. Child and Youth Mental Health
Dr. Stanley Kutcher

2. The relationship between Tics, Tourette
Syndrome and Sti l t M di ti
S d d Stimulant Medication: practical
ti l
information for primary health care providers©
Dr. Stan Kutcher
Dr Stan Kutcher
Dr. Iliana Garcia‐Ortega

3. Tic Disorders
Tic Disorders
• The most common tic disorder is called transient tic disorder and may
The 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 under
Teachers 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 called
Some tics do not go away. Tics which last one year or more are called
"chronic tics."
• Chronic tics affect less than one percent of children
Chronic tics affect less than one percent of children

4. DSM‐IV criteria for chronic DSM‐IV criteria for transient
motor or vocal tic disorder
motor or vocal tic disorder tic disorder
tic disorder
• Single or multiple motor or vocal tics (e.g., • Single or multiple motor and/or vocal tics (e.g.,
sudden, rapid, recurrent, non‐rhythmic, sudden, rapid, recurrent, non‐rhythmic,
stereotyped motor movements or stereotyped motor movements or
vocalizations), but not both concurrently, have vocalizations).
been present at some time during the illness. • The tics occur many times a day, nearly every
• The tics occur many times a day nearly every day for at least 4 weeks, but for no longer than
day, or intermittently throughout a period of >1 12 consecutive months.
year, and during this period there was never a • g y
The onset is before age 18 years.
tic‐free period of >3 consecutive months. • The disturbance is not due to the direct
• The onset is before age 18 years. physiological effects of a substance (e.g.,
• The disturbance is not due to the direct
The disturbance is not due to the direct stimulants) or a general medical condition (e.g.,
stimulants) or a general medical condition (e.g.,
physiological effects of a substance (e.g., Huntington's disease or post‐viral encephalitis).
stimulants) or a general medical condition (e.g., • Criteria have never been met for Tourette's
g p p )
Huntington's disease or postviral encephalitis). disorder or chronic motor or vocal tic disorder.
disorder or chronic motor or vocal tic disorder
• Criteria have never been met for Tourette's
syndrome.

5. 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 years
The 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
problems (learning disability), depression, and anxiety.
bl (l i di bilit ) d i d i t
• The prevalence of Tourette is estimated to be between one and ten per 1000
children and adolescents
• Differential diagnosis included many different movement disorders

6. 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).

7. Tourette syndrome
Tourette syndrome
• Symptoms usually begin with simple motor or vocal tics which then evolve
Symptoms 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 genetic
Despite evidence that TS is an inherited disorder, the exact genetic
abnormality is unknown
• Contrary to popular belief, only a small number of patients use curse
Contrary 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_j
p // y / jBFbCCleY
• http://www.youtube.com/watch?v=DPaEdP5y83o&feature=re
lated

8. Tourette Complexities
Tourette Complexities
• Phonic tics usually begin in early adolescence
• The “burst” effect – can make Dx. complicated
• Premonitory urges frequently occur (awareness by early adolescence; subjective
discomfort; impact on suppression?)
di f t i t i ?)
• Factors determining degree of disability are multiple, complex and may differ across
those affected
those 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

9. Treatment of Tics
• Transient tic disorder: education, reassurance; monitoring – NO MEDICATIONS
• Medications for Tourette or chronic tics include: alpha adrenergic agonists anti
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
reports of children d l i tics after i i i i treatment with A
f hild developing i f initiating i h Atomoxetine.
i
• 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

10. The relationship between tics and ADHD
p
• The use of psychostimulant medication to treat ADHD can be associated with
py
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

11. Conclusions Practical
Conclusions 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
significantly worse when ADHD medications are prescribed but medications are very helpful in
significantl orse hen ADHD medications are prescribed b t medications are er helpf l 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

12. Conclusions Pharmacological
Conclusions Pharmacological
• Psychostimulants are equally effective in improving ADHD symptoms whether the disorder is
Psychostimulants 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 psychostimulants
According 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
It is medically appropriate to provide treatment with psychostimulant medication in persons
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 tics.
Atomoxetine 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.

13. References
– 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.ncbi.nlm.nih.gov/pubmed/21880899
– http://www.ncbi.nlm.nih.gov/pubmed/15721825
– http://www.ncbi.nlm.nih.gov/pubmed/22064610
– http://www.ncbi.nlm.nih.gov/pubmed/16780292
– http://www.biomedcentral.com/1471‐2431/5/34

14. 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 sold.
This 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 skutcher@dal.ca or from Dr. Dan MacCarthy
(dmaccarthy@bcma.bc.ca) at the British Columbia Medical Association (BCMA).
(dmaccarthy@bcma bc ca) at the British Columbia Medical Association (BCMA)