NJCTS webinar notes

Here are most of my notes from a talk by Dr. Lawrence Brown, professor of neurology at UPenn. All errors and omissions are mine, I have attempted to take comprehensive (if somewhat illegible) notes, but it is possible that I misheard or have misquoted something. This should not be taken as medical advice, read at your own risk, etc.

Dr. Brown's research focus includes; TS and ADHD drug trials; new methods for social skills training; development of emerging treatments. An archived version of Dr. Brown’s presentation will be available on the NJCTS website (www.njcts.org) within seven days.

Tics tend to increase in times of stress/anxiety, tend to decrease with distraction or when the child is focused on something. Kids tend to tic more at home. It is possible to tic in one’s sleep. The maddening aspect of treating a disorder that waxes and wanes….

Note that tics can overlap with compulsive behaviors.

Re: DSM-IV criteria: The “causes distress” requirement might be removed for the DSM-V. Note the importance that the tics not be caused by something else.

TS is not defined by co-existing neuropsychiatric problems.

How prevalent is TS? Somewhere between 0.1% and 1.0% Studies of children near Rochester, NY and in CT (Yale) suggest rates of 0.3 – 1.0%, with another 20+% demonstrating transient tic disorders. Israeli army study showed 1:2000 male recruits, 1:5000 female recruits.

When/why to treat TS: -- causes functional impairment; causes psychosocial impairment; causes school disruptions; causes pain. Meds often are not needed for the tics; treat the disabling symptoms, which often are the co-morbidities. Reassess the need for meds when the child is doing well.

“First-line” meds:
Alpha-adrenergics (Tenex, Catapres); can take four to six weeks to take effect
-- are effective about 50% of the time; may improve sleep, aggression and ADHD
-- are sedating

Atypical neuroleptics: Abilify and Risperdal

Typical neuroleptics:
Haldol, Orap, Prolixin
Topamax (also used for headaches, weight loss)
Levetiracetam (sp?)
Clonazepan (especially good when anxiety is an issue)
Baclofen (good for tics and spasticity; sedating)
Botox (good for painful neck, extremity, and eye tics)

Non-pharmacological treatments:
Cognitive-behavioral therapy (CBT)
Habit reversal; exposures
Education
Relaxation
Counseling
TMS (trans-cranial magnetic stimulation)

Comorbid issues:
ADHD
OCD
Other anxiety disorders
Mood disorders (and rages)
Emotional lability
Learning disabilities
Sleep disorders
Migraine

Treating TS/ADHD
- behavioral/educational interventions
- stimulants
- alpha-adrenergic antagonists
- Strattera
- Imipramine, bupropion
- Use combination of neuroleptics and stimulants (to combat tics) as a last resort


Stimulants are most effective, even if there is a temporary increase in tics. Strattera is effective about 50 percent of the time, often is less potent/effective than stimulants. ADHD tends to precede tics by 2-3 years. Stimulants may exacerbate or provoke tics. Co-morbid ADHD is a leading indicator of academic problems, even after accounting for the effects of TS and learning disabilities.

60-75% of kids with TS have ADHD

TS/OCD
-- OCD looks different in kids with TS
-- Anxiety, phobias, depression
-- The irrational fear of consequences associated with OCD may not be present with TS/OCD
-- 20-30% of kids with TS meet OCD diagnostic criteria, 50-60% demonstrate obsessive-compulsive behaviors

Treating TS/OCD:
CBT works well. SSRIs work well; an 8-12 week trial of the med is needed to see if it works. CBT/SSRI combination can be very effective.

SSRIs and suicide:
-- There seems to be a lower risk of suicidality if the SSRIs are being given for OCD rather than for depression. Frequent monitoring is needed. No evidence of increased rate of suicide (vs. suicidality). Need to balance the risk vs. need for treatment

“Natural History” of TS:
Age: 4-6 ADHD appears
6-8 simple tics appear
7-9 OCD appears
8-10 complex tics

Tics peak around age ten. 1/3 experience full remission; 1/3 experience some improvement; 1/3 experience stabilization without worsening. Tics often are outgrown. Co-morbid issues, however, are not outgrown.

Questions:
Q: Effects of diet in childhood on tics?
A: reports are unsubstantiated. A recent NYU study on the effect of Omega-3s and fatty acids showed no change in tics.

Q: Explain premonitory urges?
A: [explanation provided] The interesting thing about these urges is that they suggest a sensory component to TS.

Q: Elaborate on the persistence of OCD/anxiety into adulthood?
A: It is important to maintain a healthy attitude. An increase in problem behaviors is seen if these issues are left untreated into adolescence.

Q: Are internal tics possible?
A: Yes, tics can happen anywhere.

Q: If the tics are severe, des that mean the child will not outgrow them?
A: Reasons for remission are not understood. There is no obvious correlation between severity and probability for remission.

Q: PANDAS – is it real?
A: It is a hypothesis. It is possible that a strep infection could cause an autoimmune reaction which could cause a movement disorder (usually chorea). Dr. Singer at Johns Hopkins performed a study examining kids for evidence of strep and tics, and saw no relation between them. Does not think it is a serious problem, certainly it is not a public health hazard.

Q: Can stuttering be a verbal tic?
A: YES. A doctor at CHOP has been studying stuttering and TS. Stuttering has been shown to have a biological correlate in the basal ganglia, which also are linked with TS.

Q: Why do rages occur with TS?
A: Doesn’t know why. Frustration, perhaps? – especially when linked with OCD/perfectionism?

Q: How does CBT help with TS?
A: It helps with urges. By far is most effective with co-morbid anxiety disorders