A Primer for the Treatment of Tic Disorders in Youth

by Robert R. Selles and Jennifer B. Freeman, PhD

Tic disorders commonly occur among youth and are characterized by the presence of sudden and repetitive body movements and/or vocalizations. Tics range in location (e.g., face, legs) and complexity (e.g., eye blinks, humming, multistep movements, phrases). Typically, tics onset early in childhood (i.e., ages 5 to 8), peak in severity and prevalence in preadolescence (i.e., ages 10 to 12), and begin to decline during adolescence. Only a small percentage of youth (around 20%) continue to have moderate or severe tics in adulthood.

CABL logoThis article was published in the Brown University Child and Adolescent Behavior Letter in cooperation with Bradley Hospital.

Treatment of a child with tics should begin with a thorough assessment, including differential diagnosis from stereotypes, compulsive behaviors, or other movement disorders (see Scahill et al., 2006, and Murphy et al., 2013, for a detailed guide). In the case that symptoms are identified as tics, use of evidence-based assessment measures (see McGuire et al., 2012, for a review), including the clinician-rated Yale Global Tic Severity Scale (Leckman et al., 1989), is helpful in establishing a clinical picture of the tics. Knowledge of the number, frequency, intensity, complexity and interference of tics, as well as the extent of impairment specific to tics, will be useful for informing treatment decisions. In addition, in youth with tic disorders, clinicians should assess for comorbid conditions, such as attention-deficit hyperactivity disorder (ADHD), obsessive compulsive disorder (OCD), anxiety, and depressive disorders, as these conditions frequently co-occur and are often associated with greater functional impairment than the tics.

Once appropriately assessed, provision of psychoeducation regarding tics is recommended as a first treatment step. At a minimum, patients should be provided with information on the nature of tics (e.g., etiology, course, prognosis, presentations) and their options for treatment; however, identification/development of basic coping strategies (e.g., tic acceptance; strategies for talking about tics with others) as well as a discussion around obtaining accommodations for school/activities (e.g., extra time, permission to leave the classroom) should also be included. This information is beneficial, as it can reduce misunderstanding and stigma surrounding tics and has been shown to help alleviate tic-related emotional consequences. For youth with mild tics (i.e., minimally invasive, noticeable and/or bothersome), this brief information, followed up with symptom monitoring, is likely sufficient, given that in the majority of youth the natural course of tics is to decline during adolescence.

A Primer for Treatment of Tic Disorders in YouthFocus on impairment

As is generally true, intervention decisions should focus on addressing the most functionally impairing symptoms in youth. Due to the high rates of comorbidity in youth with tics, in many cases this will not be the tics themselves. In these cases, clinicians should use appropriate interventions for the primary concern but may benefit from considering treatments that could potentially address both concerns, such as α-2 agonists for primary ADHD, or exposure and response prevention for primary OCD.

In youth where tics represent the primary concern, typically in cases where tics are in the moderate (i.e., relatively cumbersome, invasive, noticeable, orchestrated and/or time-consuming, and distressing) or severe range (e.g., highly complex, time-consuming, physically injurious, socially inappropriate, and significantly distressing), direct intervention is recommended. Behavioral treatments, specifically habit reversal training (HRT), which employs awareness training/self-monitoring and the use of competing responses to resist tic completion, and comprehensive behavioral intervention for tics (CBIT), which incorporates psychoeducation, HRT, and other behavioral techniques (e.g., functional analysis, relaxation), have been found to be efficacious and safe in reducing tic severity and tic-related impairment in youth with tics. As a result, these treatments are recommended as a first-line option for youth with moderate and severe tics.

Pharmacological interventions

Occasionally, high tic severity/impairment necessitates pharmacological, in addition to psychosocial, intervention. In these cases, the most appropriate agent is selected in an attempt to balance evidence for efficacy, necessity for improvement given the patient’s severity, the risk of adverse events, comorbid conditions, and patient characteristics. At this time, evidence exists for three general classes of pharmaceutical intervention, specifically: α-2 agonists (e.g., clonidine, guanfacine), atypical antipsychotics (e.g., risperidone, aripiprazole), and typical antipsychotics (e.g., haloperidol, pimozide).

Shown to be efficacious, relatively tolerable, and safe, α-2 agonists are recommended as a first-line medication in ticdisordered youth with comorbid ADHD.

For youth without comorbid ADHD, it is less clear that α-2 agonists have meaningful benefit in the treatment of tics; however, if children have personal characteristics that contraindicate the use of antipsychotics (e.g., obesity), a trial of α-2 agonists may still be advisable. If not, atypical antipsychotics are the second-line medication option. In particular, risperidone has the largest body of empirical support and, while still associated with a number of serious side effects, is better tolerated than typical antipsychotics. Aripiprazole may be comparably efficacious and generally more tolerable than risperidone, although research is more preliminary. Failing improvement with the above interventions, typical antipsychotics pimozide and haloperidol, which are empirically supported but associated with the risk of severe side effects, are considered as thirdline treatment options for youth with tics.

Limitations

The review and recommendations provided above are limited by the brief nature of this publication. As a result, clinicians are directed to a number of more lengthy reviews and guidelines for more specific and detailed information, including specifics on differential diagnosis, additional assessment tools, specific treatment studies, treatment components and implementation, dosing recommendations, and adverse effect profiles.

In particular, readers may look to the Practice Parameter for the Assessment and Treatment of Children and Adolescents With Tic Disorders (Murphy et al., 2013), the European guidelines for treatment (Roessner et al., 2011; Verdellen et al., 2011), and the Canadian guidelines for treatment (Pringsheim et al., 2012; Steeves et al., 2012), as well as a number of other reviews (e.g., Parraga et al., 2010; Selles et al., 2013; Weisman et al., 2013) for additional information.


Robert R. Selles is a doctoral student from the University of South Florida completing his clinical psychology residency in the Warren Alpert Medical School of Brown University. His clinical and research interests focus on the presentation and treatment of obsessive compulsive spectrum, anxiety, and tic disorders. 

Jennifer B. Freeman, PhD is a child and family psychologist at Rhode Island Hospital and an associate professor of psychiatry and human behavior at Brown University. Her research areas are in the areas of child and anxiety disorders.


References

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