Pediatric Movement Disorders - Tics

Treatment

The most effective treatment for tics remains neuroleptic medications, with pimozide (Orap®) and haloperidol (Haldol®) being two of the most commonly used. Newer atypical neuroleptics may have fewer or different side effects, including risperidone, quetiapine, olanzapine, and clozapine. Clozapine requires frequent blood tests for check for the rare occurrence of a blood disorder known as agranulocytosis. Unfortunately, up to 20% of children experience side effects from neuroleptic medications; side effects include dystonia, akathisia, and tardive dyskinesia. Therefore, many clinicians initiate treatment with safer, but somewhat less effective medications, such as clonidine, clonazepam, or an antidepressant (such as fluoxetine [Prozac®], sertraline [Zoloft®], amitryptaline, nortryptaline, or desipramine). Clonidine and antidepressant medicines are often very helpful when attention deficit disorder (ADD) is associated with tics.

The goal of treatment for tics is to improve the quality of life, not to eliminate the tics. For example, if a child experiences social embarrassment, the tics need to be treated during school hours and perhaps not eliminated completely at other times. In addition, a change in a social situation may be equally effective in improving the child's sense of well-being. No benefit has yet been shown from treatment with antibiotics. The dose of a particular medication may often be decreased during the summer months or when the child is not under stress. Often, tics will change character; it is possible that during adolescence, the tics may spontaneously improve or resolve.

Compulsions are usually treated with selective serotonin reuptake inhibitors (SSRIs), such as Prozac®, Zoloft®, or Celexa®. Neuroleptics may be helpful as well, and may sometimes be used in combination with an SSRI. Some children respond to tricyclic antidepressants. Behavioral therapy may help the child to reduce the frequency or change the nature of the compulsion. If anxiety or panic symptoms are present, a combination of psychotherapy and anti-anxiety medications may be needed.

Stereotypies usually do not require treatment. If stereotypies interfere with normal, daily activities or become self-injurious, behavioral therapy may be helpful. In some cases, SSRIs may also be effective.

Akathisia is treated by identifying and discontinuing the drug that caused the disorder. In acute akathisia, there may be improvement with an anticholinergic medication, such as diphenhydramine (Benadryl®), although benzodiazepines are likely to be effective in a greater number of children.

Restless legs syndrome responds to dopaminergic medications, including L-dopa and dopamine agonists, such as pramipexole or ropinirole. These medicines also improve periodic leg movements of sleep. There is sometimes additional improvement with certain benzodiazepines, such as clonazepam.