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Treating tics: an overview

What can I do for my child with tics?

A mother of a child with tics emailed me to ask about treatment options, including information about medical cannabis and a dental device that some tic patients have tried. Here are my current “big picture” thoughts about this question.

The first question is whether s/he needs treatment. Most children probably don’t. All of our current treatments just reduce the symptoms. A key question is, are the tics really interfering (now) with schoolwork or friendship, or interfering with other students’ learning? If so, then that’s a good time to discuss treatment options with your doctor. If it’s more just worrying about tics, or tics bothering adults, then no. 

Even without treatment, tics fluctuate in severity over time. Many people with tics have “bad days” or good weeks, etc. Besides, both patients and doctors tend to be hopeful, and think that whatever they try is working. For these and other reasons, randomized, placebo-controlled studies are very important to know whether a new treatment really works. Fortunately, such studies have been done for many medication and behavioral therapies.

For children who need treatment, there are many options. An important question in selecting a treatment is whether tics are the biggest problem, or whether ADHD or OCD or other symptoms are bigger problems. Even if tics are the biggest problem at the moment, knowing whether the child has problems other than tics can help direct treatment. For instance, a child with tics and ADHD may benefit from methylphenidate (click here for more information on stimulants in tic patients). Or a child with tics and compulsions may benefit from exposure and response prevention, or from risperidone.

Treatments for tics include medications of various types, or focused behavior therapy.

  1. CBIT (Comprehensive Behavioral Intervention for Tics) is a good first choice for most people with tics. The Tourette Association of America has a list of people who can provide CBIT in your area. Or, there’s a commercial online program called TicHelper.com that may help. Here’s a link to some info about this program and a couple of other online treatment options. Here’s a page with additional information about CBIT, aimed at professionals, and here’s a message for those who have concerns about CBIT.
  2. There are several medications known to help with tics. Basically there are meds that are quite effective, and meds that are less effective but have some other benefit (e.g. they may have few side effects, or cost less, or help with sleep). Most people with tics tolerate aripiprazole quite well, so it’s often a first choice if tics are really problematic. Clonidine and guanfacine are among the most commonly prescribed medications. However, the list of medications with some evidence for tic efficacy is quite long, and if you get to this point your physician will have his or her own ideas about how to proceed.
  3. Both cannabis and the dental device are experimental at this point. I wouldn’t jump to them unless proven treatments failed. Cannabis may help some people with tics, but its benefits are not proven, and it brings its own problems. Most experts doubt that the dental thingy will work better than a placebo device, but a controlled trial is underway, with support from the TAA.

In a very helpful book chapter, Dr. Donald Cohen and James Leckman remind us of some important principles.1 These include remembering that the person with tics is first of all a person, with his/her own strengths and personality. The tics shouldn’t become the focus of the patient’s, the family’s, or the doctor’s attention to the point that they distract from the enjoyment of life or from putting work into positive relationships. Additionally, family members may benefit from support or advice just as much as or more than the person with tics. Finally, most people with tics do well over the years, so maintaining hope is also important.

The information above is general advice, and you should contact your own physician for advice tailored to your particular case.

1Cohen DJ, Leckman JF: Introduction: the self under siege. Chapter 1 (pp. 1-20) in Leckman JF, Cohen DJ: Tourette’s Syndrome—Tics, Obsessions, Compulsions: Developmental Psychopathology and Clinical Care. New York: Wiley, 1999.

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