ATTENTION DEFICIT HYPERACTIVITY DISORDER (ADHD) AND TIC DISORDERS

There is bi-directional overlap of Attention Deficit Hyperactivity Disorder (ADHD) and tic disorders; rates of tic disorders and Tourette's Disorder (TD) are higher in clinically referred children with ADHD than children in without ADHD. Prevalence of tic disorders in ADHD ranges from 10 to 30–40%.

Prevalence of ADHD in TD in clinically referred samples is 50–75%. ADHD symptoms tend to persist, but tic symptoms tend to remit over time.

ADHD symptoms are generally associated with greater levels of impairment for both youth and adults than tic symptoms. Data from two prospective studies of the impact of tics on ADHD will be reviewed.

Treatment should be individualized, multi-modal and directed toward the symptoms of most clinical priority. Most clinically referred patients will need treatment for ADHD, but tics may or may not need treatment.

Monotherapy with a broad-spectrum agent such as clonidine or guanfacine is recommended as an initial treatment approach for ADHD + tics when tics are the most problematic symptom. Stimulants or atomoxetine are indicated when ADHD symptoms are the most problematic. If monotherapy is not effective, or is limited by side effects, targeted combined pharmacotherapy (systematic use of more than one medication in combination) with clonidine/guanfacine and a stimulant or atomoxetine is indicated. Data from randomized clinical trials, including results of one of the few targeted combined pharmacotherapy trials, for treatment of ADHD and tics will be discussed.

Educational Objectives:

To review:

• Prevalence and impact of tic disorders in clinically referred children and adolescents with ADHD.

• Relevant research on these disorders, including randomized clinical trials.

• Treatment implications and guidelines.

References:

Coffey B, Biederman J, Spencer T, Geller D, Faraone S, Bellordre, C.

Informativeness of Structured Diagnostic Interviews in the Identification of Tourette's Disorder in Referred Youth. Journal of Nervous and Mental Disease 2000, 188: 583–588.

Spencer T, Biederman J, Coffey BJ, Geller DA, Wilens T, Faraone S. The four-year course of tic disorders in boys with Attention Deficit Hyperactivity Disorder. Archives of General Psychiatry 1999: 56: 842–847.

Spencer TJ, Biederman J, Farone S, Mick E, Coffey B, Geller D, Kagan J, Bearman SK, Wilens T. Impact of Tic Disorders on ADHD Outcome Across the Lifecycle: Findings from a Group of Adults with and without ADHD. American Journal of Psychiatry 2001;158 (4): 611–17.

Sukhodolsky, D., Scahill, L, Zhang, H. Peterson, B. et al Disruptive Behavior in Children with Tourette's Syndrome: Association with ADHD Comorbidity, Tic Severity, and Functional Impairment. Journ Amer Acad Child and Adoles Psych 2003; 42(1) 98–105.