Tics are rapid, repetitive movements or vocal utterances. They may be motor (like excessive eye blinking) or vocal (such as a habitual cough or chronic repetitive throat clearing noises), chronic (continuing throughout childhood), or transient (lasting less than 1–2 years). In children who eventually develop tic disorders and ADHD, the ADHD usually develops 2 to 3 years before the tics.
Tourette syndrome, which is quite rare, is a more severe form of tic disorder involving motor and vocal tics that occur many times per day. The average age at which it appears is 7 years. While children with Tourette syndrome may develop ADHD, the 2 disorders are separate and independent conditions. Attention-deficit/hyperactivity disorder is not a variant of Tourette syndrome, and Tourette syndrome is not just a variety of ADHD. Research has shown that chronic tic disorders, Tourette syndrome, and OCD may stem from some common factors, and a child with any of these conditions is quite likely to also have ADHD.
Obsessive-compulsive disorder involves such symptoms as obsessive thoughts (such as a highly exaggerated fear of germs) and compulsive behaviors (for example, excessive hand-washing in an attempt to reduce the fear of germs) that the child is unable to control or limit. In this sense, OCD is similar to tic disorders and Tourette syndrome, and creates additional functioning problems for children with ADHD.
What to Look For
Tics tend to resemble certain ADHD-related symptoms— fidgeting and making random noises in particular—and may occasionally are mistaken for signs of ADHD. True tics, however, differ from ADHD-type fidgetiness or hyperactivity in that they almost always involve rapid, repeated, identical movements of the face or shoulders or vocal sounds or phrases—they may cause a child to become socially isolated. To receive a diagnosis of Tourette syndrome, the tics need to have developed before 18 years of age, include motor and vocal tics, occur many times each day, and continue for at least a year. Though the intensity of the tics may increase or decrease periodically, a child with active Tourette syndrome is rarely completely tic-free for more than 3 months at a time.
While tic disorders and Tourette syndrome involve outbursts of simple movements or vocalizations, OCD consists of obsessive thoughts and compulsive behaviors. In contrast to the common childhood “obsessions” with computer games or television, OCD-type obsessive thoughts and behaviors provide no pleasure and stem from no rational desire or motivation. Rather they occur because the child is unable to stop them, even when he realizes that they are inappropriate—and they can interfere with a child’s functioning for literally hours a day.
Mild or transient tics may not need to be treated with any medication. Until recently, stimulant medication was not recommended for children with ADHD and a coexisting tic disorder because the stimulants were thought to be a possible cause of Tourette syndrome. It is now known that starting stimulants does not cause Tourette syndrome or even increase tics in most children with ADHD. Stimulants may actually result in improvements in the tics in some cases. However, stimulants at high doses may bring out or exaggerate tics in a child with ADHD, who would have eventually developed them even without stimulants. The potential disadvantage of mildly increased tics is often outweighed by stimulants’ effectiveness in treating the symptoms of ADHD. Meanwhile, lowering the stimulant dose or switching to a different medication can sometimes decrease or eliminate some tics altogether. If your child’s tics are especially severe or socially disruptive, a combination of stimulants and clonidine, guanfacine, or other medications (including TCAs, pimozide, and haloperidol) or newer medications (such as risperidone) may also be considered. Possible side effects must be taken into account when using these medications.
Children with ADHD and coexisting OCD are generally prescribed an SSRI or the tricyclic medication clomipramine. Stimulants and SSRIs or clomipramine can be combined to treat OCD and ADHD.