Treatment for Tic Disorder or Tourette's Syndrome in Children
Comprehensive Behavioral Intervention for Tics (CBIT) should be the first-line treatment for most children with bothersome tics, especially those with mild to moderate severity, as it has been designated as first-line therapy by the American Academy of Neurology and European medical academies based on robust randomized controlled trial evidence. 1, 2
Initial Management Approach
When to Treat vs. Monitor
- Reassurance and monitoring alone are appropriate when tics do not impair function or quality of life, as medications do not alter the natural prognosis of tic disorders 1
- Treatment becomes necessary when tics cause functional impairment, social problems, or are accompanied by neuropsychiatric symptoms 1
- Consider that nearly half of patients experience spontaneous remission by age 18, making watchful waiting reasonable in milder cases 3
First-Line Behavioral Therapy
CBIT combines habit reversal training (HRT) with functional interventions to address the urge-tic relationship and environmental triggers 2
- CBIT has demonstrated efficacy in two large randomized controlled trials involving 248 patients aged 8-69 years 2
- Treatment can be delivered effectively in-person, via telehealth, or through internet-based programs 4
- CBIT shows advantages in improving quality of life over pharmacotherapy alone, particularly in emotional and psychosocial functioning 5
- Intensive group-based formats (4-day programs) show promise for improving both tic severity and quality of life 6
Pharmacological Treatment
When to Initiate Medications
Pharmacotherapy should be considered when:
- Tics significantly impair daily functioning 1
- The patient is unlikely to benefit from or access CBIT 1
- Behavioral therapy alone provides insufficient relief 1
First-Line Pharmacological Options
Alpha-2 adrenergic agonists (clonidine, guanfacine) are preferred first-line medications, particularly when comorbid ADHD or sleep disorders are present 3, 7
- These provide "around-the-clock" effects and are uncontrolled substances 3
- Expect 2-4 weeks until therapeutic effects are observed 3
- Monitor pulse and blood pressure regularly 3
- Common adverse effects include somnolence, fatigue, and hypotension; evening administration is preferable 3
Second-Line Pharmacological Options
Atypical antipsychotics are more effective than alpha-2 agonists but carry greater side effect burden 7, 1
Aripiprazole
- Start at 5 mg daily; flexible dosing range 5-15 mg/day 7
- Demonstrated 56% positive response vs. 35% on placebo in pediatric trials 7
- Significant improvements in irritability, hyperactivity, and stereotypy 7
Risperidone
- Start at 0.25 mg daily at bedtime; maximum 2-3 mg daily in divided doses 7
- Titrate gradually to minimize side effects 7
- Monitor for extrapyramidal symptoms at doses ≥2 mg daily 7
- Avoid coadministration with QT-prolonging medications 7
Other Atypical Antipsychotics
- Olanzapine: initial dose 2.5 mg daily at bedtime 7
- Quetiapine: initial dose 12.5 mg twice daily 7
- These have diminished risk of extrapyramidal symptoms compared to typical antipsychotics 7
Medications to Avoid or Use with Extreme Caution
- Typical antipsychotics (haloperidol, pimozide) should not be first-line due to higher risk of irreversible tardive dyskinesia 7
- Pimozide requires cardiac monitoring due to significant QT prolongation risk 7
- Avoid benztropine or trihexyphenidyl for managing extrapyramidal symptoms in this population 7
Critical Comorbidity Management
ADHD (Present in 50-75% of Cases)
- Atomoxetine or guanfacine are preferred when treating comorbid ADHD with tics, as they may improve both conditions 3, 8
- Methylphenidate is acceptable if needed for ADHD, though stimulants are controlled substances 3
- Avoid amphetamine-based medications, as they may worsen tic severity 7
Obsessive-Compulsive Behaviors (Present in 30-60% of Cases)
- Screen for and treat OCD symptoms separately, as they may require distinct interventions 8, 7
- Ensure stable, optimized treatment for comorbidities for at least 6 months before considering advanced interventions 3
Treatment-Refractory Cases
A patient is considered treatment-refractory only after failing behavioral techniques (habit reversal training, exposure and response prevention) AND therapeutic doses of at least three proven medications, including anti-dopaminergic drugs and alpha-2 adrenergic agonists 3, 7
Deep Brain Stimulation (DBS)
- Reserved exclusively for severe, treatment-refractory cases with significant functional impairment 3, 8
- Recommended only for patients above 20 years of age due to uncertainty about spontaneous remission 3
- Targets include centromedian-parafascicular thalamus and globus pallidus interna 7
- Approximately 97% of patients show improvement in published studies 8
- Requires comprehensive neurological, neuropsychiatric, and neuropsychological assessment by a multidisciplinary team 3, 7
Common Clinical Pitfalls to Avoid
- Do not misdiagnose tics as habit behaviors or psychogenic symptoms, which leads to inappropriate interventions 9, 7
- Avoid excessive medical testing; diagnosis is primarily clinical and unnecessary testing causes iatrogenic harm 9, 7
- Do not fail to screen for and address ADHD and OCD comorbidities, as these may exacerbate tic symptoms 8
- Do not delay diagnosis by misinterpreting tics as habit behaviors 8