What are the treatment options for managing tics in children?

Treatment of Tics in Children

Behavioral interventions—specifically habit reversal training (HRT) and exposure with response prevention (ERP)—should be the first-line treatment for tics in children, before considering any pharmacological options. 1, 2, 3

Initial Management Strategy

Step 1: Confirm Diagnosis and Rule Out Mimics

• Ensure the child meets diagnostic criteria for a tic disorder: multiple motor tics and at least one vocal tic persisting for at least 1 year with childhood onset for Tourette syndrome 2
• Look for core features that distinguish tics: suppressibility, distractibility, suggestibility, variability, waxing-waning pattern, and presence of premonitory sensations 1, 2, 4
• Critical pitfall: Do not misdiagnose tics as "habit cough" or "psychogenic cough"—these outdated terms should be replaced with "tic cough" or "somatic cough disorder" respectively, and only after extensive evaluation 1
• Remember that transient tic disorder (affecting 4-24% of elementary school children) typically resolves within one year and may not require intervention 2, 4

Step 2: Screen for Comorbidities (Essential Before Treatment)

• ADHD is present in 50-75% of children with tics and must be identified 2, 3, 4
• OCD or obsessive-compulsive behaviors occur in 30-60% of these children 2, 3, 4
• Anxiety and depression should also be evaluated 1
• These comorbidities often cause more functional impairment than the tics themselves and may require treatment first 2

Step 3: Consider Watchful Waiting in Mild Cases

• Nearly half of patients experience spontaneous remission by age 18 2
• If tics are mild and not causing significant functional impairment or distress, observation may be appropriate 2

First-Line Treatment: Behavioral Interventions

Start with behavioral therapy before medications. 1, 2, 3

Recommended Behavioral Approaches:

• Habit reversal training (HRT): Multi-component intervention teaching awareness of premonitory urges and competing responses 5, 6, 7
• Exposure and response prevention (ERP): Deliberately experiencing premonitory sensations without performing the tic 1, 3, 6, 7
• Comprehensive Behavioral Intervention for Tics (CBIT): Combines HRT with additional components 7

Evidence Quality:

High-quality randomized controlled trials demonstrate efficacy of face-to-face individual behavioral therapy, with effect sizes comparable to pharmacological interventions 7. One study found behavioral therapy with ERP or HRT provides similar benefit to antipsychotic medications 7.

Delivery Options:

• Individual face-to-face therapy is most effective 7
• Video conferencing provides similar benefit to in-person treatment 7
• Internet-based programs are more effective than waitlist or psychoeducation alone, though effect sizes are smaller 7
• Group treatment appears inferior to individual therapy 7

Second-Line Treatment: Pharmacological Options

If behavioral interventions are insufficient, unavailable, or tics are severe, proceed to medications. 2, 3

First-Choice Medications: Alpha-2 Adrenergic Agonists

Start with clonidine or guanfacine, especially when ADHD or sleep disorders are comorbid. 1, 2, 3

Advantages:

• Provide "around-the-clock" effects 2
• Not controlled substances 2
• May improve both tics and ADHD symptoms simultaneously 2
• Particularly beneficial when comorbid ADHD is present 1, 3

Practical Implementation:

• Expect 2-4 weeks until therapeutic effects appear 2
• Administer in the evening to minimize daytime sedation 2
• Monitor pulse and blood pressure regularly 2
• Common adverse effects: somnolence, fatigue, hypotension 2

Second-Choice Medications: Antipsychotics

Reserve anti-dopaminergic medications for more severe tics or when alpha-agonists fail. 2, 3

Atypical Antipsychotics (Preferred):

• Risperidone: Start 0.25 mg daily at bedtime, maximum 2-3 mg daily in divided doses 2

  • Monitor for extrapyramidal symptoms at doses ≥2 mg daily 2
  • Avoid coadministration with other QT-prolonging medications 2
  • Two high-quality RCTs demonstrate efficacy in children ages 6-17 2

• Aripiprazole: Flexibly dosed 5-15 mg/day 2

  • RCT showed 56% positive response on 5 mg versus 35% on placebo 2
  • Significant improvements in irritability, hyperactivity, and stereotypy 2
  • Evidence-based for treatment-refractory cases 2

• Olanzapine: Initial dose 2.5 mg daily at bedtime 2

• Quetiapine: Initial dose 12.5 mg twice daily 2

Typical Antipsychotics (Use with Caution):

• Haloperidol and pimozide are effective but carry higher risk of irreversible tardive dyskinesia 2
• Do not use as first-line due to side effect profile 2
• Pimozide requires cardiac monitoring due to significant QT prolongation risk 2
• Avoid benztropine or trihexyphenidyl for managing extrapyramidal symptoms in this population 2

Managing Comorbid ADHD with Tics

Stimulants can be used safely in children with tics and ADHD. 1, 3

Key Evidence:

• Multiple double-blind placebo-controlled studies show stimulants are highly effective for ADHD in children with tic disorders 1
• In the majority of patients, tics do not increase with stimulant treatment 1, 3
• Early concerns about stimulants worsening tics have not been replicated in larger clinical trials 1

Practical Approach:

• Obtain proper informed consent discussing potential tic worsening 1, 3
• Initiate stimulant trial for ADHD symptoms 1
• If tics worsen markedly, switch to an alternative stimulant 1
• Methylphenidate is preferred over amphetamine-based medications, as amphetamines may worsen tic severity 2
• If stimulants cannot be tolerated, use atomoxetine or guanfacine, which may improve both ADHD and tics 2
• If tics remain problematic despite ADHD improvement, add an alpha-agonist (clonidine or guanfacine) to the stimulant 1

Defining Treatment-Refractory Cases

A child is considered treatment-refractory only after specific failures. 2

Criteria:

• Failed behavioral techniques (HRT and/or ERP) AND 2
• Failed therapeutic doses of at least three proven medications, including: 2
  • Anti-dopaminergic drugs (antipsychotics)
  • Alpha-2 adrenergic agonists
• Comorbid conditions must be stable and optimally treated for at least 6 months 2

Advanced Intervention: Deep Brain Stimulation

• Reserved exclusively for severe, treatment-refractory cases with significant functional impairment 2, 3
• Recommended only for patients above 20 years of age due to uncertainty about spontaneous remission 2, 3
• Targets include centromedian-parafascicular thalamus and globus pallidus interna 2
• Requires comprehensive multidisciplinary assessment (neurologist, psychiatrist, psychologist) 2, 3

Monitoring and Follow-Up

• Assess health-related quality of life using disease-specific instruments (e.g., GTS-QOL) 2
• Document impact on function and quality of life at each visit 2
• Monitor treatment adherence and psychosocial factors 2
• Avoid excessive medical testing, as diagnosis is primarily clinical and over-investigation causes iatrogenic harm 2, 4

Critical Clinical Pitfalls to Avoid

• Do not use outdated terminology: Replace "habit cough" with "tic cough" and "psychogenic cough" with "somatic cough disorder" 1
• Do not skip behavioral therapy: Medications should not be first-line unless tics are severe 1, 2, 3
• Do not withhold stimulants in children with ADHD and tics based on outdated concerns 1, 3
• Do not use typical antipsychotics as first-line due to tardive dyskinesia risk 2
• Do not misdiagnose tics as habit behaviors or psychogenic symptoms, which leads to inappropriate interventions 2, 3, 4