**4.6 Treatment of ADHD**

For patients with tics and ADHD without response to behavioral therapies, options of treatment including the use of the norepinephrine reuptake inhibitor atomoxetine. This drug has documented efficacy for ADHD and has been associated with either no change or a slight reduction in tics49. Stimulants remain the most potent and most predictably effective medications for treating ADHD in children with tics and they are well tolerated by the majority of patients. It does seem that upon initiation of therapy stimulants can worsen tics in some patients but this effect is temporary and tic severity usually returns to baseline or even declines from baseline within a few weeks50. The efficacy and good tolerability of the stimulant methylphenidate in children with tics and ADHD has been well documented in placebo-controlled trials51. Methylphenidate may be less likely to exacerbate tics than some other stimulant preparations, such as mixed amphetamine salts and dextroamphetamine52. Newer extended release preparations of methylphenidate tend to provide good coverage of ADHD during the school day and have been very well tolerated by patients with tics. Supplemental use of short-acting methylphenidate formulations can be useful, particularly for college students who have unpredictable study hours.

etiological role in causing tics. Children with documented streptococcal infections be treated with an appropriate course of antibiotics, but that treatment with chronic antibiotics or immune-modifying therapies like plasma exchange or intravenous immuneglobulin are not

Tic disorders secondary to CNS lesions or infection may improve with antipsychotic drug therapy. Tics are not commonly a disabling feature of neurodegenerative diseases such as Huntington's disease and antipsychotics have the potential to worsen overall motor function. In tardive phenomena patients including tics, discontinuation of the offending agent is suggested as first-line treatment and improvement can be attained with use of

Behavioral therapies have not been particularly beneficial for patients with disabling tics. Behavioral approaches have included operant conditioning models, rewarding tic suppression and discouraging disruptive tics and massed practice, repeated, voluntarily performance of a tic until fatigue occurs. Habit reversal therapy (HRT) can be considered if a single tic or small subset of tics is unduly disruptive or causing self-injury or pain. HRT trains patients to recognize their tics and to perform a volitional movement different from the tic each time a problem tic occurs. Open-label assessments have identified sustained benefit from HRT for up to 10months48. However, current trials will include raters blinded

In the school setting, approaches often include preferential classroom seating, extra time for tests, an opportunity to take tests in a separate quiet room and assistance with organizing schoolwork. An alpha-2-agonist, such as guanfacine, is a good first choice medication for patients experiencing problematic tics and ADHD because this type of drug can improve

For patients with tics and ADHD without response to behavioral therapies, options of treatment including the use of the norepinephrine reuptake inhibitor atomoxetine. This drug has documented efficacy for ADHD and has been associated with either no change or a slight reduction in tics49. Stimulants remain the most potent and most predictably effective medications for treating ADHD in children with tics and they are well tolerated by the majority of patients. It does seem that upon initiation of therapy stimulants can worsen tics in some patients but this effect is temporary and tic severity usually returns to baseline or even declines from baseline within a few weeks50. The efficacy and good tolerability of the stimulant methylphenidate in children with tics and ADHD has been well documented in placebo-controlled trials51. Methylphenidate may be less likely to exacerbate tics than some other stimulant preparations, such as mixed amphetamine salts and dextroamphetamine52. Newer extended release preparations of methylphenidate tend to provide good coverage of ADHD during the school day and have been very well tolerated by patients with tics. Supplemental use of short-acting methylphenidate formulations can be useful, particularly

clonazepam, clozapine, an alpha-2-agonist46 or reintroduction of an antipsychotic47.

justified based on existing evidence.

**4.5 Behavioral treatment** 

both conditions.

**4.6 Treatment of ADHD** 

**4.4 Treatment of secondary tic disorders** 

to treatment assignment lacking in previous trials.

for college students who have unpredictable study hours.
