11 Therefore, clinicians must be alert to this heightened challenge and include a focus on ADHD when considering evaluation and management.Ĭhildren with co-occurring ADHD and Tourette disorder show poorer social adaptation and are more likely to be bullied than those who have Tourette disorder alone and to have cognitive and other neuropsychiatric impairments. 10 Most often, however, those with co-occurring ADHD and tics have greater functional and quality-of-life impairment than do those solely with tic disorders. His mother states that Henry seems unusually fretful and has become caught up in peculiar rituals, including “counting and checking everything” over and over.īoth ADHD and tics each place the affected children, adolescents, and adults at risk for psychosocial and neurodevelopment challenges. Henry has performed well academically and socially, but for the past 2 weeks, he refuses to go to school. Henry is an 11-year-old diagnosed with ADHD and Tourette disorder whose ADHD symptoms are treated with methylphenidate and behavior-management support. 7-9 Conditions associated with co-occurring ADHD and tics 7 The mechanism has not been fully characterized, but ongoing epidemiologic, pathophysiologic, and genetic investigations support the relationship between ADHD and tics, as well as other related neurodevelopment disorders of disinhibition including obsessions and compulsions, anxiety, and “rage” attacks. The physiologic model of disinhibition centers largely on dysfunction in monoamine neurotransmitter systems in communications among the basal ganglia, the frontal and other cortex regions, and the thalamus. Most specifically, impulsive actions in ADHD (sudden and unpremeditated, unfiltered behaviors often prompted by a sense of urgency) and tics (sudden stereotyped movements or noises usually prompted by unpleasant warning sensations) may suggest a neural circuitry “disinhibition,” or release, of undesired patterns of behavior linked to emotion, sensation, movement, and cognition. 6 Signs of ADHD typically emerge before the onset of tics.Īlthough the respective diagnostic features of ADHD and tic disorders differ, there are some important overlapping phenomena that may help to explain their frequent co-occurrence and guide management. 5 Conversely, half or more of children diagnosed with Tourette disorder are found also to have ADHD. 2 All tics are stereotyped to the patient, which means that the affected person performs the tics again and again in a repeated, similar way.Ĭhildren with ADHD are even more likely than unaffected children to have tics, and up to 20% of children diagnosed with ADHD will develop a chronic tic disorder. Chronic tics are often simple but may also be complex (Table 1). 3Ĭhronic tic disorders usually persist beyond the first decade and often into adulthood, customarily reaching peak clinical severity when the patient is aged between 10 and 12 years, 4 with symptoms naturally waxing and waning over time. In contrast, chronic tic disorders, including chronic motor or vocal tic disorder and Tourette disorder (chronic motor and vocal tic disorder, also known as Tourette syndrome), last more than a year 2 and are less common, affecting about 1% of all children. The tics often go unnoticed and resolve within a year of onset. 1 For most such children, tics are mild in severity and simple in complexity (eg, isolated to muscle groups or body regions and appear not to mimic purposeful movements or spoken language). Tic disorders affect up to 20% of all children at some time. Beginning 1 month ago, Jacob began frequent eye blinking. Since then, Jacob’s parents have opted to “wait and see” before starting any medication treatment. Jacob is an 8-year-old with ADHD-combined type diagnosed a year ago by his primary care provider. Consequently, these children may not be adequately treated, jeopardizing optimal social and academic outcomes. Particular concern often stems from the apprehension that use of stimulant medications in treating ADHD will cause or exacerbate tics. They are common, but general pediatricians who report competence in their clinical management of patients with ADHD are sometimes confused by lingering controversy over appropriate clinical management when these patients also have, or later develop, tics. Attention-deficit/hyperactivity disorder (ADHD) and tic disorders often co-occur.
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