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Tics in child with ADHD

My 8 year old son was diagnosed with ADHD in summer of 2012. We started him on a low does (5 mg) of Adderall because of worsening issues in school. He has been on it for about 4/5 months now. We have little to no side effects (a few sleepless nights, a couple emotionL breakdowns, etc). School started going picture perfect. Recently we noticed that the medicine is less effective and his normal behavior is returning. We are hesitant to up the meds due to him developing some tics. We notice that he is excessively blinking and has started some throat clearing sounds. Im afraid this will be irreversible and not sure what to do. Anyone who has experienced this and can give advice would be greatly appreciated!

Replies

You should contact your physician with those concerns.  Maybe what you are describing is due to dry eyes & dry throat.  “Tics” are something uncontrollable, not necessarily what you describe, but without more info I can’t really make an educated guess on that.

Posted by BC on Feb 27, 2014 at 9:04am

My son’s tics are very responsive to stress, so at the moment your son may be feeling a little bit more stress than usual. It’s nothing to worry about since the tics are not permanent if the medicine is changed or discontinued. Talking to your son’s pediatrician is the best advice. He/she should be able to narrow down the cause of the problem. You may very well find that it’s a momentary blip and go away as soon as they showed up.

Finding out about my son’s tics was upsetting to us as well, but truthfully the very best decision we made is to make sure the ADHD symptoms are treated as effectively as possible first. A lack of sleep, an illness, or some extra stress, may be the cause so try not to worry!

Posted by Havebeenthere on Feb 27, 2014 at 1:16pm

Sometimes ADHD has comorbid conditions,one of which can be Tourette’s. Speak with your doctor about receiving an evaluation from a neurologist.

Posted by Speduc8r on Feb 27, 2014 at 4:00pm

Havebeenthere: I like the way you look at it—I, too, have a tic (blepharospasm) that only comes out when I’m incredibly stressed out.  When I notice my right eyelid start to twitch it’s like having a warning light on the dashboard that says “time to de-stress, delegate…”

Posted by BC on Feb 27, 2014 at 5:54pm

You should definitely bring this up with your doctor.  Some medicines can cause tics.  Also, your child may have had tics prior to the medicines.  My son has tics along with his ADHD and anxiety.  They come and go from year to year, but generally increase around stressful times or what he deems stressful.  Another person posted that throat clearing and blinking are not tics, but they ARE!  Changing medication may be all you have to do to decrease them.  In my experience, don’t highlight them to your child or make a big deal about them unless they are distracting to others or potentially embarrassing to your child.  They usually go away.  Your child can’t control them anyway or it’s very difficult.  As they get older they may have more self control. At age 8 I would speculate that your child will have trouble controlling the tics on his own.
-Katherine Price
ADHDC
Coaching Parents of Kids
with Special Needs.

http://www.adhdc.com
http://www.facebook.com/AdhdcParentCoaching

Posted by KatherineADHDC on Feb 27, 2014 at 6:29pm

Stimulants definitely cause tics. My son has had the blinking. Sometimes he gets one that makes him look up. They do come and go. He doesn’t get them when he has a summer break off medication. When he was about 7 he had one that kept making him wipe something off his pants. I told him that it wasn’t real and there was nothing on him. We prayed together about it and it never happened again. He just needed to know it wasn’t real. Now that he is sixteen he is able to control them better but it takes effort. Seems interesting that medication that helps impulsiveness causes something so impulsive.

Posted by leslie 1 on Feb 27, 2014 at 9:38pm

KatherineADHDC:  “another poster” did not say they are not tics, that poster said they are not “NECESSARILY” tics…and that ***without more information***, whether these ARE or ARE NOT tics is something that cannot be determined by any of us on this forum regardless of our “real life” credentials (I’m a physician assistant who specialized in NEUROsurgery), hence the recommendation to have them evaluated by a medical professional.

Posted by BC on Feb 27, 2014 at 9:59pm

Have you considered trying a non-stimulant like Intuniv? Just a suggestion.

Hope this information is helpful.
Susan in PC, Ohio

Posted by SueH on Feb 27, 2014 at 11:44pm

My son is 11 and has tics (and ADHD of course).  He started cracking his knuckles around your son’s age (8? 9?) and then moved on to cracking his elbows.  We thought this was weird, but had no idea they were tics (he wasn’t diagnosed with ADHD until he was 9).  He now cracks his neck and shoulders, and sometimes his ankles.  It’s the worst I’ve ever seen it at the moment.  He usually does it when he’s calm (reading, watching TV) but they’re bad enough right now that he’s doing them all the time.

He started on medication in December (so the tics are not *caused* by the medication, though I know medication can make them worse).  Things were really bad at school at that point and honestly, my son was on the verge of a mental breakdown from the stress.  His tics were also the worst I’d ever seen and really worrying me.  After about a month, his teachers let me know what a difference they’d seen in him.  It wasn’t perfect, but he was back to how he was at the beginning of the year again.  He might not always be able to do the work/concentrate/etc, but he was *willing* which was a massive improvement.  I noticed the tics also started easing off a bit.

Unfortunately, I’m seeing the tics get really bad again and also hearing reports from his teachers that he’s been “off” the last week or two.  I don’t know if that means the medication isn’t working, if things are more stressful at school for some reason, or what.  But it’s interesting that I’m starting to see a trend… a connection between the ADHD anxiety and the tics.

I went to a seminar put on by our local ADHD clinic and learned a bunch about tics.  They are involuntary, in much the same way as an itch is involuntary.  Imagine you had a horrible itch but someone told you you couldn’t scratch it.  You could probably resist scratching for a while, but eventually it would be the only thing you could think about… you might sneak in a scratch when they weren’t looking… and when you were finally allowed to scratch you might go nuts doing it and feel a huge sense of relief.  This is how many people describe tics.  (There was a link on YouTube they gave us, but I can’t seem to find it now.  If you search for Tourettes in children, you’ll find a bunch though.  Be forewarned, they’re informative, but if you’re like me, you’ll see your kid in them and just bawl the whole way through.)

I also learned that this age (Middle School, so 9-13) is one of the worst for tics, meaning your child may always have been predisposed, but now they show up and may even peak about this age.  Most people’s tics fade by adulthood.  Also, they’re quite common… something like 25% of kids, and 11% of kids with ADHD will have both.  Plus, they’re far more common in boys.  (There’s some recent evidence to suggest that medications are not the cause at all, and may not even make tics worse, though I don’t know that they’ve proven that conclusively yet or not.)  Also, most tics are temporary.

I would definitely go back and talk to your Dr. about the tics.  You’ll want to rule out medication as a factor.  After that, there are a few options… One is medication.  I believe this one is only for the worst possible cases.  The second is therapy.  This one apparently works amazingly, but the patient needs to be 100% onboard because they will have to work hard to do the homework or they won’t see results.  The third option is to ignore it.  Seriously.  Any comments while the tics are happening, any attention at all, and you may be reinforcing the tics. 

For now we’re ignoring our son’s tics (it’s hard to watch at the dinner table though, or sit next to him on the couch where he’s tic-ing so bad it’s shaking the couch), and trying to get the ADHD under control.  We’re hoping that having that in check will lessen the stress on him and also lessen the tics.

Posted by Rai0414 on Feb 28, 2014 at 12:29am

Just one clarification, tics *are* controllable (people don’t tic at night when they’re asleep), but the *urge* to tic is not something within their control.  In the same way that depression or OCD is not something within a person’s control (there’s something chemical in their brain, it’s not something they did).  But they’re not involuntary like eye twitches, for example.

Posted by Rai0414 on Feb 28, 2014 at 12:35am

It’s hard to adequately and fully describe tics, and differentiating them from other things, such as stereotypies can sometimes be very difficult.  And yes, calling them “uncontrollable” (as I did earlier) is not as accurate as simply saying they are not purely under voluntary control which is more accurate than saying they are “involuntary”—which is honestly what I thought I had mistakenly/erroneously posted until I went back and double-checked (and lesson learned about posting anything WAY too early in the morning for me).

If we were to get real technical about it, I don’t think saying “tics *are* controllable” is completely accurate either. That implies that any person who wants to control it can do so (and almost makes it sound pretty easy, which makes NOT controlling them some sort of character defect).

The description that seems to capture it best, IMO, is that tics are generally “suppressable”—but suppressing that urge can then lead to an even more pronounced urge & then a more pronounced activation of the motor/vocal behavior itself.  So in that regard tics kinda tend to have a “mind of their own”...not completely under voluntary control.

The long and short of it, though, is that there is just no great short-answer description.  More importantly, “tics” cannot be diagnosed very well without a fairly exhaustive & detailed description from someone.  When neurologists face that diagnostic challenge they usually try to find a way to personally witness the event if at all possible, or to have it captured on video.

There was an earlier reference to “cracking knuckles,” which technically can be either a complex motor tic OR a mannerism OR a compulsive habitual behavior.  I’ve also found that behavior on at least one list of stereotypies. 

There is a saying: “there is a fine line between where a complex motor tick ends and a compulsive habitual behavior begins.”  I’m willing to bet you could get 10 neurologists into a passionate & lively debate over exactly where the majority of cases of “cracking knuckles” should generally be placed.  When you add in some of the common parental reactions to that behavior—“stop or you’ll get arthritis” (the functional equivalent of “stop that or you’ll go blind”) ETC—a compulsive habitual behavior can be reinforced by preadolescent rebellion and a mind set that may get a kick just out out of annoying adults or being contrary.

Then there’s what’s commonly referred to as a “nervous tic” which can happen in totally “normal” people which only comes out during times of high anxiety—and honestly, I’m not sure what ICD/DSM code that gets…if it even has one…or if it gets grouped somewhere else.  In a report from a specialty Tourette’s clinic which deals mainly with “tough” cases that are directly referred to them by other doctors, a full one-third of the patients who had a diagnosis of Tourette’s or “tic disorder not otherwise specified” turned out to not even have tics at all—they had been misdiagnosed. 

What caught my attention early yesterday morning (and which I based my answer on) was the fact that it has only been 4-5 months of taking a stimulant, and at that point in my own stimulant-taking experience I was experiencing a lot of discomfort with dry mucous membranes (“cotton mouth”)—and for some, particularly the allergy prone, that also extends to dry eyes & needing to use artificial tears.  On any given day someone might have viewed me (and the various new mannerisms I had developed) and mistakenly interpreted them as tics.  They might have thought I was even mildly intellectually challenged because my speech was altered by the horrible cotton mouth (which eventually went away).

Since the OP has still not supplied any additional information, technically, the jury is still out as far as I’m concerned.  One of the very first things you learn in medicine is how to take an accurate medical history; rule #1 is to never, ever, ASSUME anything. When someone briefly describes two behaviors that just happen to be on the list of things which CAN BE/ARE classified as tics (but not ALL instances of those behaviors ARE tics) if there are any other possible explanations one MUST first obtain more information before simply jumping to the conclusion that the most likely diagnosis also just happens to be the correct one. 

They have all sorts of amusing test cases (to literally beat this idea into your head right out of the starting gate).  These test cases get run by medical students and they are set up only to provoke knee-jerk diagnoses based on false assumptions, most likely diagnoses PLUS an inadequate history given, so that after the student picks the knee-jerk most likely diagnosis but does not obtain a complete and detailed history the joke is now “on the student” after the sage advice dispensed turns out to be either absurdly ridiculous…or dangerously bad…or somewhere in between.

I hope that explains my basic answer (which was not worded very well on a couple different levels).  Let me try to reword that better: blinking & throat clearing are not NECESSARILY tics but ARE examples of things that can be tics.  It could be something as simple as the effects of stimulants on mucous membranes or it could be a tic.  Without having more information that cannot be positively determined.  Once that becomes positively determined (or reasonably determined to be probable) the next question becomes what to do next given the lack of any real consensus on the role stimulants play on the development of tics.  Some people say they have zero effect, some say they have some effect but not much, others say they can actually “cause” tics but only in a very small number of select cases, etc.  What I found to be most interesting in the research I’ve done over the past 24 hours (but which is not exhaustive) is, among other things, this: 
• in at least one study it was found that methylphenidates actually decrease tic severity & frequency;
• in only one study it was found that amphetamines (but not methylphenidates) can increase severity/frequency (but that study reportedly had some design flaws)
• in the recent changes to the DSM-V in 2013, stimulant use as a cause of tics was completely removed; it was concluded that there is no evidence that the use of stimulants causes tics. [It says nothing about whether it might make them worse…as far as my limited research can tell…].

So I’m interested to know how what the OP’s doctor may add to this.  I hope you’ll update us.

Posted by BC on Feb 28, 2014 at 10:44pm

Well explained! I especially liked your substitution of “suppressable” for controllable or voluntary/involuntary. That more accurately describes it I think.

I also agree that most of these behaviours (eg cracking knuckles) could very easily have multiple causes. For example, my oldest son (non-ADHD) cracks his knuckles. I would guess that’s a habit. He seems able to control it if he wanted, but he doesn’t. Even my younger son’s knuckle cracking could be a habit actually. The shoulder cracking or shrugging seems to be a tic though. He seems unable to stop and complains to me that he wishes he didn’t do it and that his neck or shoulders hurt. He’s even started using his hands to hold his head and crack his neck (ew!!) and been upset it won’t crack. Watching that made me wonder about OCD. It could still be a habit… it could be a tic… or it could be OCD starting… not sure… Waiting to meet with his teacher, then we’re going back to his psychiatrist.

Posted by Rai0414 on Feb 28, 2014 at 11:15pm

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