What is the recommended treatment approach for tic disorder in children using Abilify (aripiprazole)?

Aripiprazole for Tic Disorders in Children

Aripiprazole is an effective treatment option for tic disorders in children, showing comparable efficacy to traditional antipsychotics like haloperidol but with a generally milder side effect profile, making it a reasonable alternative when first-line behavioral interventions are insufficient or when typical antipsychotics cause intolerable adverse effects. 1

Treatment Hierarchy

First-Line Approach: Behavioral Interventions

• Non-pharmacological interventions should be attempted before medication for tic disorders, including habit reversal training, exposure and response prevention, and cognitive behavioral therapy 2
• The goal is no longer complete tic elimination but rather functional improvement and symptom management 3

When to Consider Pharmacotherapy

• Medication becomes appropriate when tics significantly impair functioning, quality of life, or cause substantial distress despite behavioral interventions 3, 4
• Comorbid conditions (ADHD, OCD, anxiety) should be prioritized and treated before addressing tics specifically, as managing these may reduce overall stress that triggers tics 4

Aripiprazole Efficacy Data

Clinical Effectiveness

• A systematic review and meta-analysis of 935 children (ages 4-18 years) found aripiprazole showed no significant difference in tic reduction compared to traditional antipsychotics like haloperidol and tiapride when measured by Yale Global Tic Severity Scale (YGTSS) 1
• In a case series of 7 patients treated for 8 weeks, motor tics decreased by 66% and vocal tics by 26% with mean effective dosage of 14.3 mg/day (range 5-30 mg) 5
• Effects were quick, significant, and sustained 5

Dosing Parameters

• Treatment duration in studies ranged from 8-12 weeks 1
• Effective doses ranged from 5-30 mg/day, with mean around 14 mg/day 5

Safety Profile

Common Adverse Effects

The most frequently reported side effects include:

• Drowsiness (5.1%-58.1%) - most common 1
• Increased appetite (3.2%-25.8%) 1
• Nausea (2%-18.8%) 1
• Headache (2%-16.1%) 1
• Abdominal pain, fatigue, and increased emotional sensitivity 5

Critical Safety Advantage

• Side effects were generally mild and transient, with no patient dropouts due to adverse effects in the case series 5
• This represents a significant advantage over typical antipsychotics, which often cause intolerable side effects leading to treatment discontinuation 3, 1

Comparative Positioning

Versus Traditional Antipsychotics

• Haloperidol and pimozide remain standard first-line pharmacologic agents for tics 3
• However, concern about short- and long-term side effects of typical neuroleptics has driven interest in atypical antipsychotics like aripiprazole 3
• Aripiprazole shows equivalent efficacy with better tolerability 1

Important Limitation

• The quality of evidence is poor - only one placebo-controlled study exists, with most comparisons against active controls 1
• More well-conducted randomized controlled trials are needed to definitively establish aripiprazole's role 1

Clinical Caveats

Comorbidity Considerations

• Aripiprazole did not significantly influence comorbid ADHD or OCD symptoms in the case series 5
• When ADHD coexists with tics (50-75% of Tourette's cases), address ADHD first as proper treatment may reduce stress-triggered tics 6, 7

Realistic Goal-Setting

• Establish mutual and realistic goals with families - complete tic elimination is not the target 3, 4
• Focus on functional improvement, adaptation, and managing comorbidities as priorities 4

Diagnostic Precision

• Use the term "tic disorder" rather than "habit cough" or "psychogenic cough" to align with DSM-5 classification 8
• Ensure extensive evaluation has ruled out other causes before diagnosing somatic cough disorder 8

Practical Algorithm

1. Assess functional impairment - Does the tic disorder significantly impact daily functioning, social interactions, or quality of life?
2. Screen and treat comorbidities first - ADHD, OCD, anxiety, depression 4
3. Initiate behavioral interventions - Habit reversal training, CBT 2
4. If behavioral interventions insufficient after adequate trial:
   • Consider aripiprazole starting at low dose (5 mg/day)
   • Titrate based on response and tolerability up to 30 mg/day
   • Monitor for drowsiness, appetite changes, nausea, headache 1, 5
   • Assess response at 8-12 weeks 1
5. If aripiprazole causes intolerable side effects or is ineffective, consider traditional antipsychotics (haloperidol, pimozide) with careful monitoring 3