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PHILADELPHIA — An expert subcommittee of the American Academy of Neurology (AAN) has released an updated evidence-based clinical practice guideline on treating Tourette syndrome and other chronic tic disorders. The guideline, endorsed by the European Academy of Neurology and the Child Neurology Society, was published in Neurology.

Recommendation 1: Counseling on Natural History of Tourette Syndrome

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Clinicians are advised to give patients and families information about the disorder to help guide treatment decisions. After evaluating the level of functional impairment, clinicians should inform patients and caregivers that watchful waiting is the appropriate response for individuals not experiencing functional impairment from their tics. For patients motivated to start treatment in this population, cognitive behavioral intervention for tics (CBIT) can be prescribed as an initial treatment relative to watchful waiting. Clinicians who prescribe medications for tics that are causing functional impairments must periodically re-evaluate the need for ongoing treatment.

Recommendation 2: Psychoeducation, Teacher, and Classroom

Tourette syndrome affects approximately 1% of children and psychoeducation about the disorder with a patient’s peers and teachers can result in more positive classroom outcomes. Clinicians should refer patients to psychoeducation resources that can be offered at schools, such as the Tourette Association of America.

Recommendation 3: Assessment and Treatment of ADHD in Children with Tics

ADHD is a common comorbidity in patients with Tourette syndrome (30% to 50%). Clinicians should perform an ADHD assessment and evaluate the symptom burden in patients with both disorders. Appropriate ADHD treatment should be provided for patients with both tics and functionally impairing ADHD. Clinical trials have shown atomoxetine does not worsen tics compared with placebo and reduces ADHD symptoms, and clonidine, clonidine plus methylphenidate, methylphenidate, and guanfacine are more likely to reduce tic severity and ADHD symptoms compared with placebo.

Recommendation 4: Assessment and Treatment of OCD in Children with Tics

Obsessive-compulsive disorder (OCD) is a common comorbidity in patients with Tourette syndrome (10% to 50%). Clinicians should perform an assessment for OCD and provide appropriate treatment when warranted. Trials of OCD interventions for children suggest that patients with tics may not respond to selective serotonin reuptake inhibitors as well as those without tics, but do respond equally well to cognitive behavioral therapy (CBT) for the symptoms of OCD.

Recommendation 5: Other Psychiatric Comorbidities

Patients with Tourette syndrome are at high risk for psychiatric comorbidities such as mood disorders, oppositional defiant disorder, and anxiety disorders, and patients with comorbidities run an increased risk for suicide. Appropriate screenings must be performed, and treatments provided. Clinicians should also inquire about suicidal ideations and actions and refer patients to appropriate resources if needed.

Recommendation 6: Tic Severity Assessment and Treatment Expectations

Using one of the available rating scales, such as the Yale Global Tic Severity Scale, clinicians should measure tic severity in order to be able to assess treatment effects. Patients should be advised that while behavioral therapy, medications, and neurostimulation can significantly reduce tics, they rarely lead to complete cessation.

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Recommendation 7: Behavioral Treatments

Patients receiving CBIT are more likely to experience reduced tick severity than those receiving psychoeducation and supportive therapy. After an 8-session protocol, most patients age 9 and older who have a positive response will maintain these gains for at least 6 months. CBIT can be effective in younger patients, but there is little evidence relating to efficacy. If face-to-face CBIT is unavailable, clinicians may offer sessions via teleconference or online delivery.  Other acceptable behavioral interventions include exposure and response prevention when CBIT is unavailable.

Recommendation 8: α-Agonists for the Treatment of Tics

Clinicians should counsel patients with comorbid ADHD that α2 adrenergic agonists can be beneficial for both conditions but there are common side effects, such as sedation. Clinicians should only prescribe α2 adrenergic agonists when the benefits outweigh the risks and patients taking these medications should have their heart rate and blood pressure monitored. Patients taking guanfacine extended release must have the QTc interval monitored if they have a history of cardiac conditions, are taking other QT-prolonging agents, or have a family history of long QT syndrome. Clinicians discontinuing treatment with α2 adrenergic agonists must gradually taper the medication to avoid rebound hypertension.

This article originally appeared on Neurology Advisor