What is the recommended treatment for Tourette's syndrome in children?

Treatment of Tourette's Syndrome in Children

The recommended first-line treatment for Tourette's syndrome in children is Comprehensive Behavioral Intervention for Tics (CBIT), which has demonstrated significant efficacy and durability with minimal side effects compared to pharmacological approaches. 1, 2

Treatment Algorithm

First-Line Treatment: Behavioral Interventions

• CBIT combines habit reversal training (HRT) and functional intervention to address the urge-tic relationship and identify environmental triggers 1
• CBIT has been designated as first-line treatment by American Academy of Neurology, European and Canadian medical academies 1
• Demonstrated efficacy in large-scale randomized controlled trials with 248 participants aged 8-69 years 1
• Produces significant reduction in tic severity compared to supportive therapy (effect size = 0.68) 3
• Treatment benefits are durable, with 87% of responders maintaining improvement at 6-month follow-up 3
• Can be delivered effectively via individual face-to-face sessions, videoconferencing, or internet-based programs 2

Second-Line Treatment: Pharmacological Options

When behavioral therapy is insufficient or unavailable, medication may be considered:

• Alpha-2 adrenergic agonists (clonidine, guanfacine)

  • Effective for tic reduction (standardized mean difference -0.72) 4
  • Generally better tolerated than antipsychotics 4

• Antipsychotic medications

  • Effective for moderate to severe tics (standardized mean difference -0.74) 4
  • Risperidone and aripiprazole have favorable benefit-risk profiles 4
  • Should be considered when tics significantly impair functioning or when behavioral interventions are ineffective 5

Important Clinical Considerations

• Treatment should be initiated only when tics cause functional impairment, social problems, or significant distress 5
• For mild tics without functional impairment, reassurance and monitoring may be sufficient 5
• Comorbidities are common and may require separate treatment:
  • ADHD (present in 50-75% of children with Tourette's) 6
  • Obsessive-compulsive behaviors (present in 30-60% of cases) 6

Common Pitfalls to Avoid

• Delaying diagnosis by misinterpreting tics as habit behaviors 6
• Initiating pharmacotherapy before trying behavioral interventions 1, 2
• Failing to address common comorbidities that may exacerbate tic symptoms 6
• Concerns about tic suppression causing "rebound" effects are unfounded; behavioral interventions are safe 1

Advanced Treatment Options

• Deep brain stimulation (DBS) should be reserved only for severe, treatment-refractory cases with significant functional impairment 7
• DBS has shown promising results in treatment-resistant cases, with approximately 97% of patients showing improvement in published studies 7
• DBS should only be considered after failure of standard pharmacological and behavioral therapies 7