ADHD and tics: closer than you think

ADHD and tics: closer than you think

October is ADHD Awareness Month and therefore timely to discuss some of the challenges adults and children with ADHD can face and what we can do to support them. One area which people might be less aware of is that of the cross over between ADHD and tics and tic disorders such as Tourette Syndrome (TS).

Misunderstanding tics

As you read this article you may start to recognise tics in yourself or in children, or in other family members or colleagues. Firstly, there are some misunderstandings about tic disorders such as Tourette Syndrome that we should discuss. Often people assume that TS is a very severe condition, which is rare and it always involves people swearing. None of these things are true! Swearing or ‘coprolalia’ can be present but only in 10% of cases. Tourette syndrome is a complex neurodevelopmental disorder with onset of multiple chronic motor and vocal tics beginning in childhood.

Attention-deficit-Hyperactivity disorder (ADHD) is commonly found to occur alongside tics and tic disorders such as Tourette Syndrome (1,2). Often people with TS find a gradual improvement in adolescence and adult life in their tics but for others it is life-long (3). However, one issue with tics is that they come and go in terms of severity and frequency. Tics are involuntary movements (motor) or sounds and can be simple or complex. A simple and very common motor tic is eye blinking which often starts first and complex tics affecting several muscle groups and being made of bigger movements. Motor tics can affect any part of the body with varying location. Vocal tics can include throat clearing, coughing, spitting, barking, hissing, sniffing or grunting for example. Typically, ADHD symptoms appear before the onset of tics(4). Clinicians use the American Psychiatric Association Diagnostic and Statistical Manual (DSM-5) to define what TS is and this suggests that the average tic onset age is between four and six years (5). However, some researchers have suggested onset could be much younger from three to eight years old (3). There does also seem to be a peak in tic severity around 10 and12 years (5).

ADHD & tics often hand-in-hand

The onset of ADHD symptoms is usually between four and five years of age, thus generally appearing before the onset of tics (12). Sometimes there has been an assumption that ADHD medication has led to the onset of tics– this is, in the majority, not the case. Instead, this has to do with the timing of the onset of ADHD symptoms often starting before the tics in the developmental pathway, rather than ADHD medications ‘causing’ the tics. Other conditions come along with tic disorders such as obsessive compulsive disorder(OCD), attention deficit hyperactivity disorder (ADHD), learning difficulties and sleep abnormalities (6,7,8,9,10) but ADHD is the most common (3). Research suggests that ADHD symptoms can be found in 35% to 90% of children with TS(13,14,8,15). Often an iceberg is used as an analogy in looking at the issue that the motor and vocal tics themselves are often only part of the problem, and are those found in the top half of the iceberg, visible above the waterline. This seems small in comparison to the many other challenges that come along with Tourette Syndrome, which is the bottom half of the iceberg which is ‘hidden’ under the water. These unseen issues include sleep, anger, pain, sensory processing issues, anxiety and depression. This often helps explain why tics are often ‘just the tip of the iceberg’ and in fact may not be the most problematic aspects of Tourette Syndrome.

When together – then extra challenges

It has been found from research that when ADHD and TS occur together there greater psychosocial and behavioural challenges to the patient(11). The co-occurrence between TS and ADHD appears to be complex and related to genetic, environmental, and neurobiological factors. Researchers believe there are a lot of brain networks implicated in the development of ADHD and TS, particularly a part of the brain known as the basal ganglia. Just like ADHD, TS has no laboratory test to help with diagnosis and instead there is a clinical diagnosis after the patient has spoken to a clinician and completed questionnaires about their symptoms and past history.

In regards to treatment there are some medications which for some patients can help reduce symptoms and improve quality of life of people with TS. However, side effects of the treatments are common and effectiveness varies from individual to individual, so they are not beneficial for everyone who tries them. Instead behavioural therapy to help people gain control and management of their tics can be offered. A challenge of this however is that trained therapists are often not available. Other more invasive treatments can be suggested such as Botox injections for eye muscle tics, but also Botox can be administered to the vocal chords to help with vocal tics. Other treatments or alternative approaches can be considered such as a healthy, balanced diet and regular exercise.

Sometimes people notice that their tics worsen when they eat foods that contain additives, artificial colourings and high levels of sugar but there is little/no research evidence for this. Other people find massage, yoga and meditation techniques useful. In a small number of people with Tourette Syndrome (TS) tics can be so severe and extreme that treatments have no effects. Often these patients have some of the co-occurring conditions we have mentioned such as ADHD but also obsessive compulsive disorder (OCD),depression, anxiety, and self-injurious behaviours. When an adult with TS has tried many treatments without success then neurosurgery called Deep Brain Stimulation(DBS) may be offered.

How do we support people with ADHD & tics?

It is hoped that clinicians and other healthcare professionals become more familiar (if not already) with these diagnoses and their management. An important aspect of this combination of ADHD and TS is that the symptoms of ADHD will most likely often appear before any TS related symptoms. Healthcare professionals in ADHD specialist centres or mental health services will already be seeing and treating patients with ADHD, some of whom will have tics, therefore by clinicians being knowledgeable about what tics are and how to treat them they can help their patients who also have tics quickly. There are opportunities for healthcare professionals to be trained in behavioural therapy which is another skill which will benefit them and their patients By providing information about ADHD and tics for patients, their families and healthcare professionals then it is hoped that people can have a better quality of life and psychosocial impairments or learning challenges can be improved. By providing schools and teachers with information and training to better understand tics this can greatly help in better supporting students who have both ADHD and tics and learning support measures can lead to better outcomes when these conditions are understood.

The other way we can support people who have tics or a tic disorder like Tourette Syndrome is to invite them to contact the Tourette Syndrome patient associations in their country. This has been made very easy now with the creation of the Directory of Tourette Syndrome Patient Associations This online directory lists the known patient associations in each country giving an overview of the most important services they offer and their contact details.

I hope this article has given an insight into ADHD and tics and tic and how we might better support people with a better understanding of the challenges they face with ADHD and tics.

Literature references

1 . Biederman J, Kwon A, Aleardi M, Chouinard VA, Marino T,Cole H, Mick E, Faraone SV (2005b) Absence of gender effects on attention deficit hyperactivity disorder: findings in nonreferred subjects. Am JPsychiatry 162:1083–1089

2. Rothenberger A, Dopfner M, Sergeant J, Steinhausen HC(eds) (2004) ADHD beyond core symptoms—not only a European perspective. EurChild Adolesc Psychiatry 13(suppl 1):1–130

3. Leckman JF (2002) Tourette’s syndrome. Lancet 360:1577–1586

4. Robertson MM (2006) Attention deficit hyperactivity disorder, tics and Tourette’s syndrome: the relationship and treatment implications: a commentary. Eur Child Adolesc Psychiatry 15:1–11

5. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders fifth edition. Washington (DC): American Psychiatric Association; 2013

6. Gillberg C, Gillberg IC, Rasmussen P, Kadesjo B,Soderstrom H, Rastam M, Johnson M, Rothenberger A, Niklasson L (2004)Co-existing disorders in ADHD—implications for diagnosis and intervention. EurChild Adolesc Psychiatry 13(suppl 1):180–192

7. Wilens TE, Biederman J, Brown S, Tanguay S, Monuteaux MC,Blake C, Spencer TJ (2002) Psychiatric comorbidity and functioning in clinically referred preschool children and schoolage youths with ADHD. J AmAcad Child Adolesc Psychiatry 41:262–268

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9. Tallur K, Minns RA. Tourette’s syndrome. Paediatr ChildHealth. 2010;20:88–93.

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12. Bagheri MM, Kerbeshian J, Burd L. Recognition and management of Tourette’s syndrome and tic disorders. Am Fam Physician.1999;59:2263–272, 2274.

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