TwitchingSizedQuestion: My son has "tics" with the ADD and I am looking for information on the treatment of both conditions as the medication seems to contradict each other - e.g. Ritalin and Solian.

Reply:

This is a confusing co-occurring condition and can cause a lot of distress when it's not understood properly.

Tic's is a mild condition that is not life threatening. For children the worst part of it is getting teased - but I know that can be devastating.

Methylphenidate - the active ingredient in Ritalin and Concerta - sometimes aggravates tics, making them more pronounced and in a few cases, even setting them off.

Dr Stephen Copps, a respected world authority on ADHD and related conditions said at the ADHD international conference in Pretoria in 2002, that you shouldn't withdraw Ritalin or Concerta due to tics. The consequences of not treating ADHD are far more dire than not treating the tics.

The key issue here - and in all cases of ADHD - is ensuring that the child's self esteem is not in deficit, rather it should be as high as possible. Failing due to poor ADHD management always reduces self esteem, which then makes it almost impossible to combat or ignore the teasing about the tics.

Solian is according to the package insert used for Schizophrenia. I have not heard of it being used for tics before, but sometimes medications are used off-label.

Here is some information that I have found:

Tics can sometimes be suppressed, but most people's experience is that the tics will eventually be released. Thus, if we were to ask someone who felt that the tics were consciously released to not tic, we might observe that they could suppress a tic for a while, but eventually, they would release it.

What happens if the individual tries to suppress the tics?

Some individuals have no control at all over their tics, while others have varying degrees of control. Most adults report that their ability to modify or suppress their tics improved as they matured, and recent research supports the notion that as the child matures, their awareness of their tics and their ability to suppress them increases.

With young children, it is important to remember that the child may not be aware of their tics, and even if they are aware, they may have no ability to suppress them. Asking a young child who has tics to suppress them is generally not a good idea because the effort involved in suppressing the tics will distract the child from tasks requiring their attention and may decrease their accuracy on the task (cf, Conelea & Woods, 2008) .

Parents frequently report that children or adolescents who try to suppress their tics in school all day (with varying degrees of success) will come home from school, walk in the door, and explode in tics often accompanied by a lot of emotional behaviors. For years, many of us considered these explosions of tics to represent an actual worsening of tics due to inhibition or suppression of tics during the school day. Recent research, however, casts some doubt on that interpretation. Data from some studies suggest that even when tics are being consciously and actively suppressed, there is no rebound effect (Himle & Woods, 2005; Verdellen et al., 2007).

Keeping in mind that each child is unique, the parents and child are often the teacher's best source of information about a particular child's tics and patterns. But if you are a parent or teacher who is thinking of discussing the child's tics with them, also keep in mind that not all young children are aware of their tics. When a child or adult denies ticcing it may not mean that they are in ""denial."" They may really be unaware of their movements or sounds. And just talking about their tics may induce a temporary worsening of their tics (Woods, Watson, et al. 2001).

Banaschewski et al. (2003) conducted a survey on premonitory sensory phenomena (PSP) and suppressibility of tics in children and adolescents. Over a third of the children and adolescents in the sample reported experiencing PSP, and almost two-thirds reported being able to suppress their tics. Slightly more than one quarter of the sample (28%) reported both PSP and the ability to suppress tics, indicating that the majority of children and teens do not have awareness of sensory urges building up with the ability to suppress their tics. Changes in reports were noted at two ages developmentally. At age 10, there seemed to be an increased ability to suppress tics, and at age 14, there was more reporting of PSP. It is important to note that awareness of premonitory sensory urges did not precede ability to suppress tics, but rather, ability to suppress tics actually preceded awareness of (or experience of) premonitory sensory urges.

If tics are actively suppressed, what happens to any preceding urges? Do they diminish over time or do they intensify and then diminish, or what? Woods and colleagues found that suppressing tics when reinforcement was provided was associated with intensified urges during tic suppression for 5-minute periods (Himle & Woods, 2007). Their data provide some support for the notion that people tic to decrease or alleviate the unpleasant sensation that is building up. But what if we allow the period of tic suppression to go even longer? Would the urge continue to build or would it eventually extinguish? Verdellen et al. (2008) provide data indicating that the urge does decrease both within 2-hour sessions and between sessions using an Exposure-Response Prevention treatment. Exposure-Response Prevention for tics is the same approach used in treating Obsessive-Compulsive Disorder.

What factors predict ability to suppress tics or severity of sensory urges during training? Data provided by Woods, Himle, et al. (2008) suggest that errors of ommission on a continuous performance task correlated with ability to suppress tics, while Verdellen et al. (2008) found that tic frequency at baseline but not tic severity was correlated with reductions in frequency of tics and severity of sensory urges during training sessions.

So.... can tics be actively suppressed without any rebound effects or worsened sensory urges? The answer appears to be "Possibly, but not in children under 10, and not without risking distracting the person from attention-demanding tasks." Hopefully, longer-term studies will shed light on whether suppression can become more automatic and less of a risk of distracting the individual. In any event, these studies offer hope and promise of nonmedication treatments that may be of value, and suggest that what we all described as "involuntary" may be more modifiable than we had recognized.

I hope this is of help to you. Please stay in touch and let me know how things progress.