For people with Tourette syndrome (TS), a
disorder marked by repetitive, involuntary movements and vocalizations
called tics, and their parents or caregivers, this finding may come as
no surprise: More than eight in 10 people with Tourette's will be
diagnosed with a psychiatric condition such as obsessive-compulsive
disorder (OCD), attention deficit hyperactivity disorder (ADHD), or a
mood disorder like depression or anxiety during their lifetime, and more
than half will receive two or more such diagnoses. That's according to a
Tourette Syndrome Association International Consortium for Genetics
study led by researchers from the University of California, San
Francisco, and Massachusetts General Hospital (MGH) published in JAMA Psychiatry in February.
“The fact that other psychiatric disorders like OCD and
ADHD often occur along with TS is something the Tourette's community has
recognized for several years,” says Jeremiah Scharf, MD, PhD, one of
the study's lead authors, director of the Neurology Tic Disorders Clinic
at MGH, an assistant professor of neurology at Harvard Medical School,
and a member of the American Academy of Neurology.
“Tics are really a marker for neurodevelopmental
disturbance,” says John T. Walkup, MD, vice chair of psychiatry and
director of the division of child and adolescent psychiatry at Weill
Cornell Medical College and New York-Presbyterian Hospital. “In and of
themselves, they may not have that much meaning, but they can signal to
families and doctors that something is going on.”
That's hopeful news, because it means physicians and
parents can intervene earlier and get control of both tics and
psychiatric and behavioral conditions before they disrupt a child's
life.
ATTENTION PROBLEMS AT A YOUNG AGE
Examining data on more than 1,300 people with TS
gathered over a 16-year period, Dr. Scharf and colleagues found that 72
percent also received a diagnosis of either ADHD or OCD, and nearly
one-third were diagnosed with all three—TS, ADHD, and OCD. Children with
TS were frequently diagnosed with these conditions at a younger age—as
early as age three for ADHD, and before age 10 for OCD—than children
without the syndrome.
For many children with TS, the tics themselves may be
relatively mild. It's the symptoms of these hidden coexisting conditions
that may cause most of the problems at home or at school, says Dr.
Scharf.
“If clinicians aren't specifically screening for them,
they may be overlooked,” he says. For example, if a young child is
hyperactive, impulsive, or inattentive to the point that it causes
significant disruption at home and at preschool, this could be a sign of
ADHD. But diagnosing ADHD is tricky. “Doctors need to be very
experienced in distinguishing age-appropriate inattention and
hyperactivity from inattentiveness, hyperactivity, or impulsivity that
is above and beyond that of a typically developing child,” he says.
MOOD IS AFFECTED, TOO
The study also revealed that about 30 percent of people
with TS had been diagnosed with mood disorders, anxiety disorders,
and/or disruptive behavior disorders—and much earlier in life than
people without TS. “We found that the high-risk period for anxiety
begins at age four, while for depression it is around age 10,” says Dr.
Scharf.
Signs of anxiety in a four-year-old may include
excessive worrying that persists for more than a couple of weeks,
trouble sleeping and concentrating, and irritability, he says. Depressed
children may be sad frequently for no apparent reason. They often lack
energy and no longer enjoy activities they used to. They may be
irritable, angry, or anxious, or feel guilty or worthless. Depressed
kids may also eat too much or too little and experience unexplained
aches and pains. They may be unable to concentrate or to show interest
in being with friends or family members, and they may even have frequent
thoughts about suicide or death.
FINDINGS MAY SIGNAL OTHER RISKS
The findings from this study may help doctors predict
other behavioral problems in their patients with TS, says Dr. Scharf.
For example, if a child has tics and OCD, the physician may want to
screen him or her for oppositional defiant disorder (ODD), a condition
in which a child's uncooperative and hostile behavior toward parents and
other adults goes beyond age-appropriate behavior and disrupts normal
activities. Dr. Scharf's research found that kids with tics and OCD tend
to have ODD more frequently than other children. “Just as pediatricians
and internists screen for conditions like high cholesterol and
diabetes, we're getting a better sense of how to screen for psychiatric
conditions in patients with TS,” he says.
A thorough assessment is crucial because some of these
conditions can manifest differently in kids with tics than in other
children. “When a child has had symptoms of ADHD or OCD before the onset
of tics, that is more likely to be ‘classic’ ADHD or OCD than if those
symptoms showed up after the tics began,” explains Dr. Walkup. “A kid
who has tics and is anxious is going to have substantial attention
problems, because he's thinking about his tics. And a child with tics
who has repetitive behaviors usually is more focused on making things
line up and be symmetric, rather than worrying about germs and
contamination, as with classic OCD. So we would treat those differently
than someone who had classic forms of ADHD or OCD.”
And in some cases, the concentration problems and
repetitive behaviors may actually stem from social anxiety or separation
anxiety or generalized worry, Dr. Walkup says. “Anxiety and depression
in people with tic disorders can exacerbate the tics. If children have
anxiety, we need to treat the anxiety. If they have depression, we need
to treat the depression. What's most important is a thorough assessment
to make sure the treatment matches the underlying cause.”
MEDICATION AND THERAPY CAN HELP
Many doctors avoid using stimulants to treat ADHD in
their patients with TS because they fear the medication might aggravate
the tics. But that may be an unfounded fear, says Dr. Scharf. “For kids
who have mild tics but significant ADHD or OCD, stimulants such as
dexmethylphenidate (Focalin) and methylphenidate (Ritalin) are the most
effective medications. And in many cases the ADHD or OCD, not the tics,
is the source of the anxiety and social difficulties,” he says.
Studies establishing the effectiveness of these
medications in treating ADHD among children with TS include the
Treatment of ADHD in Children with Tourette Syndrome (TACT) study. This
randomized controlled trial, published in Neurology in 2002 by
the Tourette Syndrome Study Group, looked at kids who had ADHD and
either chronic tics or TS. Those who took a stimulant had the most
improvement in their ADHD symptoms compared with children who took
either a non-stimulant drug or a placebo, and they did not have any
worsening of their tics.
Cognitive behavioral therapy (CBT), a form of short-term
psychotherapy, may also be helpful, says Dr. Scharf. “CBT is considered
the gold standard therapy for people with these conditions,” helping
them recognize and redirect negative thoughts and behaviors, he says.
DON'T DELAY DIAGNOSIS OR TREATMENT
Identifying and treating related psychological or
behavioral problems early on is key, says Dr. Scharf. “For many children
with TS, the tics themselves are not bothersome enough to warrant
treatment of tics per se. In fact, as their brains develop, the majority
of kids with TS will see their tics diminish in late adolescence to
early adulthood. Only about 10 to 15 percent of people who've had tics
in childhood will have significantly impairing tics as adults.”
However, “those who have a coexisting condition such as
OCD, ADHD, anxiety, depression, or disruptive behaviors do require
treatment, which is why these are important to recognize,” Dr. Scharf
says.
Diagnosing and treating these conditions early and
getting them under control with medication or behavioral therapy can
often change the trajectory of a child's development. “Early
identification and early treatment can make a huge difference,” he says.
“I see that every week.”
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