Kevin J. Black, M.D., one of the staff physicians at the Washington University Movement Disorders Clinic, is on the TSA's Physician Referral List. Some of you know him from our support group meetings. Here he answers some questions from our readers for general information. Since each person is different, you will want to contact your personal physician for specific medical advice.
Q: I have heard of a drug-free treatment for TS called habit
reversal therapy (HRT). What is it, and does it work?
A: Basically, HRT is a behavioral treatment for tics. Patients
are taught to notice tics or the urge to tic, and to substitute a non-tic
movement, called a competing response. For instance, for a vocal tic the
competing response might be slow rhythmic deep breathing through the nose
with the mouth closed. Usually the most problematic tic is treated first,
then others are addressed sequentially. The treatment takes a lot of effort
by the patient initially, though if it works, one can expect minimal effort
to maintain the gains after a month or two. The people who originated this
treatment method have done some careful studies, although with a relatively
small number of subjects (about 30). Their results are very promising.
Others have reportedly tried to use HRT and not been as successful, although
the results of these attempts have not been published. I have used HRT
with only one patient. I have posted further information on this subject
on the web at the following address (http://www.nil.wustl.edu/labs/kevin/move/HRT.htm).
Q: What is the current story about whether stimulants like Ritalin®
cause tics?
A: A recent research study addressed this question (Gadow
et al, Arch. Gen. Psychiatry 1999; 56:330-336). In this study 34 children
with chronic tics and attention deficit - hyperactivity disorder (average
age 11) received methylphenidate (Ritalin®) for ADHD. Initially there
was an 8-week phase in which they got either Ritalin or placebo, and tics
were no worse with one than the other. These same children were continued
on Ritalin and evaluated every 6 months for 2 years using reports from
parents and doctors, as well as an artificial, standardized classroom situation.
Although parents and doctors knew the children were on Ritalin, the classroom
visits were videotaped and later rated for tic severity by investigators
who did not know whether the child was on medication. There was no evidence
that the children's tics worsened over time, compared to their initial
evaluation 2 years prior. The conclusion is that, although some individual
children have been known to develop worse tics on Ritalin or similar medications,
most children can tolerate it fine. This is important since often ADHD
presents more problems than the tics themselves in a given child.
Another recent report also addresses the safety
of stimulants such as Ritalin (http://www.pediatrics.org/cgi/content/full/104/2/e20).
Children in a large genetic study of ADHD were evaluated for numerous psychiatric
illnesses. Some children had ADHD while others were brothers, sisters,
cousins, etc., who did not have ADHD. Since some people have worried that
giving children stimulants would lead them to abuse stimulants or other
drugs later, the investigators looked back at their data to see if older
boys (age 15 or up) who had been treated with stimulants (for 4-5 years
on average) were abusing more drugs than boys with ADHD but no stimulant
treatment or boys without ADHD. Strikingly, the opposite was true. 75%
of the untreated boys were abusing alcohol or drugs, compared to 25% of
the boys who had received treatment with stimulants. Perhaps stimulant
treatment for ADHD reduces the risk of subsequent drug abuse. On the other
hand, it is possible that boys who were at high risk of drug abuse were
treated with Ritalin less often than other boys. In either case, there
is clearly no support for the idea that Ritalin treatment of ADHD turns
kids into drug abusers, an important and reassuring message for parents
of kids with ADHD.
Q: I made a comment in the last newsletter which you probably
didn't pick up on. Can anger and "meanness" equate with depression?
A: To answer this remember two guiding principles. (1) Kids
are not small adults. (2) Lots of things cause "depression" other than
major depression.
The official rules for diagnosing major depression
require (among other things) that you either have "markedly diminished
interest" in almost everything you used to enjoy, or else "depressed mood
most of the day, nearly every day . . . Note: In children and adolescents,
can be irritable mood." Sometimes kids who have every other feature of
depression are more irritable than sad. However, lots of things make kids
angry or mean. These include: normal life, child abuse, oppositional defiant
disorder or conduct disorder, among others. If lots of other symptoms of
major depression are present, and the irritability or anger or meanness
is there nearly all day long and is not characteristic of the child, certainly
there is hope that antidepressant treatment may help. Otherwise a different
treatment, often behavioral, may be more appropriate.