Many apologies for not getting back to the Chat page to answer questions. I came down with the worst cold of the season; better now.

Anyway, regarding the question about changing from a pediatric neurologist to an adult neurologist: It really depends on the child and how they feel going to a child neurologist, what kind of a relationship you have with your neurologist, and whether or not you have found an adult neurologist who specializes in Tourette and related disorders. In our practice, we are still seeing “kids” well into their 20’s, as they are comfortable with us. Eventually, if they still need medications, we transition them to an adult person by the mid-20’s. If they do not need medications, then they may not need a neurologist at all, but rather a psychologist or counselor to help with all of the associated issues that may accompany the Tourette.

Hmmm, convincing a 16 year old that they need the medication is a tough question. I guess the bottom line is that if they haven’t figured out that it is beneficial, they won’t take it. So if you are convinced that he/she needs the med, you may want to allow them the opportunity to be med-free for a space of time, with the understanding that both of you will discuss the results after a couple of weeks. Identify with your adolescent that you really don’t enjoy sparring with them over their behavior and you understand that within a few short years, they will be making most decisions about the way he/she lives his/her life. Therefore, a trial of med freedom is not that unreasonable.

With regards to abiding by household rules and ODD behaviors, this is so hard for any parent; I feel for you. If you can work with a counselor/psychologist using logical consequences for his/her behavior, that is likely to be more helpful than other approaches. Here is an example: if you have a rule that he/she must be home by 10 PM, with the understanding that if he/she comes late (synchronize watches, or you will be challanged) there are no privileges to drive the car for a week, then you have a pre-determined consequence which makes sense. You own the car, so you have control over it. If the child owns the car, then you are in trouble, so my advise is to not allow a teen to own his/her own car, unless they have already shown themselves to be responsible.
Good luck.

Symptoms of ADHD in a child with chronic tic disorder appears to be the same as in a child without tics. The core symptoms are hyperactivity (more evident in the younger child), impulsivity and inattention/distractibility. The treatment for ADHD may make tics worse, but not necessarily.

Regarding tic triggers: Probably both viewpoints are valid, though I do know that stress (anxiety producing situations) and anticipation (“Woo hoo, we’re going to Disney World!”) can trigger tics. Also, when a child experiences any respiratory symptoms (allergic or infectious), they are more likely to have prolonged mannerisms consistent with those repiratory symptoms. For example, if a child gets a cold and sniffs frequently, they seem to continue with the sniffing mannerism long after the physiologic need to sniff (i.e., mucusy nose) has resolved; then we call it a tic.

And with regards to simple tics being replaced by complex tic, Well, it could be that his Tourette is getting worse… or it is just “morphing”…

The books on OCD and panic: Tamar Chansky, PhD wrote “Freeing your Child from OCD” and “Freeing your Child from Anxiety”. You can probably check them out at your library or order them from Amazon.com (or Barnes & Noble, etc)

Drugs for OCD making tics worse…Anything is possible, though that has not been my experience. Usually, when the anxiety associated with OCD is lessened, the tics seem to decrease as well.

Meds for ADHD, OCD and Tics. So your child has what I refer to as complex Tourette syndrome, meaning that although we would really like for a single med to work, it is less likely.

In a case like this, I usually have to assess which disorder is causing the most problem and begin to address this first. For example, if he has really BAD impulsivity, his tics are not at all problematic, and his OCD is more “worry”, I would probably start him on something that is likely to decrease his impulsivity. Stimulant meds are the “gold standard”, but may make his tics worse, and are likely to increase his anxiety, so I’d probably not use them first.

If the tics are most problematic, but the child still has considerable anxiety (with OCD mannerisms) and ADHD symptoms, the adrenergics (guanfacine and clonidine) can be useful. They tend to decrease tics, decrease anxiety (a little) and soften ADHD symptoms as well.

For the child with panic, anxiety and Tourette, the parents are referred to Tamar Chansky’s books, as well as urged to find a psychologist who is skilled with cognitive behavioral therapy (CBT). You can start with your insurance company (ask for a list of therapists who do CBT, though they may not even know the term), and then start calling them one by one. When you talk with a prospective therapist, ask them if they have experience helping children with Tourette and panic, using CBT. If/when you find NONE of the psychologists on the insurance list have such experience, call your insurance company and ask for “in-network benefits for an out of network provider”, as they have no one on their list who is qualified to help your child. You MAY get the benefits; you may not. In the end, many parents consider it an investment in their child’s future to just pay out of pocket for psychological services.