Saturday, October 25, 2008

Do ADHD Stimulant Medications Worsen Tourette's and Tic Disorders?

Main Categories: ADHD Stimulant Medications and Comorbid Disorders

In an earlier post, I commented on how Atomoxetine (Strattera) was a good possible medication option for treating ADHD comorbid with Tourette's Syndrome. One of the reasons I gave was that ADHD stimulant medications have been linked to worsening Tourette's cases and tic disorders. But how much of a link is there really between these disorders (which frequently are seen alongside each other, that is they are comorbid disorders).

I examined a review article from a couple years ago recently, and I think that it made some interesting points. Additionally, it did a very thorough investigation on the topic of ADHD, Tourette's and tic disorders, covering a number of previous experiments and journal articles. This review article was from the 2006 journal of Seminars in Pediatric Neurology, researched by G. Erenberg. A link summarizing some major points of this article on Tourette's, ADHD and Stimulant Medications may be found here. I will summarize some other important findings of this article below:

  • ADHD has been seen in up to 90% of children with Tourette's, with studies post-1980 studies showing higher percentages that pre-1980 ones
  • Although the two disorders are often seen alongside each other, the "form" of ADHD seen alongside Tourette's is the same as the form of ADHD seen without Tourette's
  • Increases in the frequency or severity of "tic" disorders (twitching, eye-blinking, etc., and occasional vocal outbursts) have been seen in a number of individuals following treatment with ADHD stimulant medications, but at the population level, these symptoms increases are typically insignificant.
  • After 1995, studies with Tourette's often separated out samples with ADHD and those without ADHD. For studies before 1995, this was often not the case. Therefore, studies after 1995 comparing Tourette's, ADHD and combinations of the two are often preferred when studying the two disorders.
  • A pre-1995 study (1992), concluded that individuals with Tourette's along with Obsessive Compulsive symptoms had worse attention span, while a post-1995 study (1998) showed that individuals with ADHD and individuals with a combination of ADHD and Tourette's had a worse attention ability than those with only Tourette's. Again, this may have been due to the later addition of the "post-1995 ADHD + Tourette's" subcategory.
  • Tourette's Syndrome (TS) is typically not associated with learning disabilities by itself, while ADHD and ADHD with TS are.
  • For individuals with Tourette's, ADHD can make tics worse. Additionally, ADHD boosts levels of rage, anxiety, delinquencies and oppositional tendencies in indviduals with TS (i.e., for those with both symptoms, the ADHD is thought to be the one at work for these negative side effects).
  • For individuals with Tourette's, aggressive behavior is often not an issue, but if it is accompanied by either ADHD or OCD (Obsessive Compulsive Disorder), aggression is often seen at noticeably higher levels.
  • The effectiveness of stimulant medcations for ADHD is typically unaffected by whether the individual also has accompanying TS.
  • The Physicians Desk Reference (PDR) includes a warning on individuals with tics (or a parent or sibling with tics) to avoid stimulant medications. This decision was influenced in part by a pre-1995 (1983) study linking ADHD stimulants to the development of tics.
  • "Questionable" ADHD stimulant drugs that allegedly boost tic disorders include: Methylphenidate (Ritalin, Concerta, Focalin), Dextropamphetamine (Dexedrine), and Pemoline (Cyclert).
  • If an individual has a current or pre-existing condition of tics, then the influence of ADHD stimulant drugs on this tics has produced a host of mixed results.
  • Within individuals who have Tourette's Syndrome, tic symptoms are often slow to appear (i.e. it take months or even years for individuals with Tourette's to see tic disorders set in).
  • For individuals who take ADHD stimulants and develop tics, the timeframe between starting the medication and developing tics is often relatively long (several months to 1 year, as opposed to immediately). Therefore, if tics show up within a short time-frame in and individual after taking stimulants (less than a month), there is significant possibility that the cause of the tics is medication-related.
  • A small sample study demonstrated that methylphenidate (Ritalin, Concerta) was less likely to promote tics than dextroamphetamine (Dexedrine).
  • Methylphenidate was shown to be "tic-safe" when combined with another anti-hypertensive agent also used as a non-stimulant medication used for ADHD (clonidine).
  • Additionally, minimal research has been done to see whether "anti-tic" medications such as Risperidone or Guanfacine (Tenex) are more or less effective for so-called stimulant-induced tics vs. "natural" tics.

I know I have made a number of "points" summarizing Dr. Erenberg's article on stimulant ADHD medications and tic disorders. However, even if you've skipped down to this point, it seems that based on the research that is currently out there and what we have so far, taking ADHD stimulant medications is relatively safe, even if an individual has Tourette's. Although there is a warning in the Physician's Desk Reference about psycho-stimulant medications worsening tics, the overall effects are relatively small, especially when compared to other disorders that sometimes occur alongside ADHD (such as ADHD and eplilepsy).

Please keep in mind, it is not my intention to try to override this PDR warning or your physician's choice of prescriptions! However, if you are currently diagnosed with ADHD and Tourette's and are on a stimulant medication, please don't run to change your prescription. From the evidence we have currently seen, it appears that ADHD stimulants, especially methylphenidate (currently thought to be one of the safest stimulant medications for ADHD) are still thought to be relatively safe, even for Tourette's. However, keep in mind that if tic disorders are not seen prior to medication, and show up within a month or less, there is a good chance that the ADHD stimulant you were prescribed is to blame. If it is significantly longer (i.e. several months or years), chances are the tics are probably unrelated to the medication. I will continue to investigate these connections and keep on the lookout for more useful articles on the subject matter of ADHD, Tourette's and tic disorders.

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Anonymous said...

I came across your blog while researching the topic of adhd/stimulant medication and the development of tics. It's very important to me right now as my 11 year son just developed tics last week while we were out of town. Treating his inattentive type ADHD is truly like working a puzzle. Thank you for your efforts. Please keep writing and please keep citing your sources. Thank you very much.

Anonymous said...

I also came across this blog researching ADHA stimulant meds and the development of tics. It too is important to me. My son developed a tic involving eye twitches less than one week after he began taking Vyvanse. By the second week it involves his arm arms and head also. I was told it was not the meds. I took him off immediately and it took a few months for the tics to completely go away. I didn't know what to do because and thought he could no longer take any stimulants. Maybe I will give something else a try now that I know the tics will go away. I will be watching him much closer.

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Unknown said...

This post presents a very clear rationale for considering stimulant medication to treat tic disorders. For the past few years after trialling various dopamine blocking agents which have only served to severely exacerbate my tics and OCD symptoms and having seen remarkable reduction in tics following the withdrawing of antipsychotics, it would seem that the claims and evidence provided within this post do correlate with the hypothesis that stimulants may actually be efficacious for certain individuals with TS/OCD/ADHD.

You'll often see literature claiming the TS is believed to be a result of a 'dopamine imbalance' - the imbalance it would seem now could be either a result of an underproduction just as much as it could be an overproduction.

Again, great post. I found this very helpful and reassuring.

Anonymous said...

My son was on Straterra for ADHD and it made his tics worse. Once he was off of the medicine his tics lessened to almost non-noticeable. I know this sounds odd because this is considered a non-stimulant med but, never the less, true.

Unknown said...

My nine year old son was diagnosed five with adhd and tourettes. He has been taking concerta for years. We moved and his doctor changed. My son is growing and he gained some weight. The dosage of his concerta began to become ineffective. His pics have never been a. Huge issue. Because he was also taking guanfacine for the pics with the concerta. In a matter of the last month hid new doctor has changed his medication to vyvance 70 mg. The child began to become to have insomnia and could not function. The vyvance took to long to take affect in the a.m and when it did he became elated and his changed and he acted high as a kite. I complained to his new psychiatrist and he switched my son to adderal xr 30 mg immediately the first day of taking the adderal my son began to have tourettes pics at a new severity level than I have never seen before. I called the doctor he then prescribed tenex to treat the tide affect of the tourettes pics. I'm scared my son's tourettes will get worse and not go away. I do not have faith in this doctor anymore. My son will be seeing his regular pediatrician tommoro. And I will have them handle it from here. I will be asking them to put him back on concerta and or clonodine. This shit Is killing us.

Anonymous said...

This is a question for Samantha Mcallister- my son has been on concerta for 5 or 6 years now and within this time developed tics which have been coming and going. We had it addressed recently after realizing its not just a "habit thing" and the dr. is wanting to start my son on tenex to help reduce the tic. I am hoping you could share some more info with me on what you've seen with your son and the concerta and tenex used together. Thanks for any help as I start this journey ~ SKK

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Most research review boards have traditionally been reluctant to approve psychotropic medication studies in preschoolers,

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