Parent Resources Tic Disorders blog

ADHD medications and tics

Recently, two different families asked me about whether it was safe for their child with tics to take medication for ADHD. Short answer: yes, it’s safe.

Here’s the long answer.

ADHD is very common in children with tics—nearly half of children with Tourette syndrome (TS) have ADHD. So the question comes up often.

First I should point out that there are several treatments for ADHD that no one worries about in terms of their effect on tics. Examples are clonidine, guanfacine, desipramine and atomoxetine. They have their own side effects to consider, but they don’t worsen tics. Behavior therapy for ADHD is also effective and safe.

The concern has traditionally been about stimulants. Stimulants are medicines related to amphetamine or methylphenidate. There are numerous brand names, but two of the oldest are Dexedrine® and Ritalin®. At this time, stimulants are the most effective known treatments for ADHD.

About 30 years ago, doctors wrote about several cases in which a child being treated with a stimulant for ADHD developed tics. Because of these case reports, the FDA put a warning on the product labeling for all stimulants that says that these medications may worsen tics. But since then, it has become crystal clear that that warning is just wrong.1 The evidence is strongest for methylphenidate. Let me describe two studies that provide some of the best evidence.

In one study, children with ADHD were treated for a whole year with either methylphenidate or a placebo.2 No one knew who was taking which except for the research pharmacy, which kept that information secret until the study ended. Children with severe tics at baseline were excluded, but mild to moderate tics were present in 30% of the 91 children who enrolled. During the year of follow-up, “clinically significant tics for the first time (i.e., moderate or worse)” developed in 23.6% of children who took the active drug … but also in 22.2% of children who were on placebo! And tics improved with treatment in two thirds of the children with a previous history of tics.

Another large study enrolled 136 children with both Tourette syndrome and ADHD, with the goal of determining which was the most effective and safest treatment for ADHD in children with TS, methylphenidate, clonidine, both, or neither.3 The children were treated for 16 weeks, and again no one knew until all the results were in which of these medications a given child was taking. The not surprising result from this study was that ADHD symptoms improved with either drug, more so with methylphenidate. The surprising result was that tics also improved more with either drug. Some children’s tics got worse during the study, but the chance of tics getting worse was identical in children taking methylphenidate (33%) and in those taking placebo (33%). Note that in ordinary clinical care, if you were one of the children whose tics got worse on methylphenidate, you would blame the drug. Only the double-blind, placebo-controlled design allowed us to realize that it wasn’t the drug at all—that child’s tics were going to get worse anyway. These research studies are essential!

In another large ADHD study—this one observational rather than controlled—new onset of tic disorder was actually less common in children treated with stimulants, and tics remitted earlier in children who took stimulants.4

There is other evidence, too, but it all fits this same pattern. While it’s possible that methylphenidate may truly worsen tics in a child here or there, on average it is much more likely to improve tics, and worsening with the drug is most likely to be coincidental.

The amphetamine class of drugs has not been tested as carefully as to whether it helps or worsens tics, and in fact there is some evidence that children with tics tolerate methylphenidate better than amphetamine.5

Now on the other hand, having tics doesn’t protect you from other possible side effects of stimulants. The best known is appetite suppression, but others can occur, too. Some of these can be addressed by changing the dose or timing. In general, though, the stimulants are relatively safe medications—safer than nicotine or Tylenol®, for example.

I’m a parent and a physician, and I get it, you never want to do the wrong thing for a child. But going without treatment for ADHD can also be the wrong thing: ADHD can interfere with school, but also with sports or friendships. And there are other consequences, too. After a child hears “you’re scatter-brained” (or worse) for the hundredth time, he may start to believe it’s all his fault, and no one needs that extra burden.

So if the main concern with starting stimulants is that you heard they may worsen tics, you can stop worrying.


References

  1. Kurlan R: Methylphenidate to treat ADHD is not contraindicated in children with tics. Movement Disorders 17:5–6, 2002. DOI: 10.1002/mds.10094
  2. Law SF, Schachar RJ: Do typical clinical doses of methylphenidate cause tics in children treated for Attention-Deficit Hyperactivity Disorder? Journal of the American Academy of Child and Adolescent Psychiatry 38:944–951, 1999. DOI: 10.1097/00004583-199908000-00009
  3. Tourette’s Syndrome Study Group: Treatment of ADHD in children with tics: a randomized controlled trial. Neurology 58:527–536, 2002. DOI: 10.1212/WNL.58.4.527
  4. Spencer T, Biederman M, Coffey B, Geller D, Wilens T, Faraone S. The 4-year course of tic disorders in boys with attention-deficit/hyperactivity disorder. Arch Gen Psychiatry. 1999 Sep;56(9):842–847. PubMed PMID: 12884890. DOI: 10.1001/archpsyc.56.9.842
  5. Castellanos FX, Giedd JN, Elia J, Marsh W, Ritchie GF, Hamburger SD, Rapoport JL. Controlled stimulant treatment of ADHD and comorbid Tourette’s syndrome: effects of stimulant and dose. Journal of the American Academy of Child and Adolescent Psychiatry 36:589–596, 1997. DOI: 10.1097/00004583-199705000-00008

Edited 2018-09-28 to add Spencer et al 1999 study.

20 Comments

  1. in my son’s case all stimulants have made his tics reappear after being dormant and made them worse and intensify. He had tics prior to ever taking stimulants but when we take him off for long periods of time the tics disappear completely.

    1. I think there are a few likely possibilities here: (1) he’s on an amphetamine-type medicine rather than methylphenidate or dexmethylphenidate, (2) when he’s prescribed a stimulant, he or you are watching more carefully for tics, or (3) he’s just not the average person with tics. As to (1), there are some hints that amphetamine derivatives may worsen tics, whereas methylphenidate improves them on average. That’s a question we need more evidence on.

      1. Dexmethylphenidate and methylphenidate both exacerbated my son’s tics, without a doubt. As soon as he stops the meds, they start to very slowly decrease. We’ve tried a variety of strenths/types of release over the past 6 months so I’m sure of this. We are going to try Strattera next.

        1. Again, personal experience is valuable, but without studies like the ones cited above, we would not know that usually such experiences are coincidental. What we do know now is that if there are people whose tics worsen because of methylphenidate products, they are quite rare. People whose tics worsen when they take methylphenidate? Common—but no more common than tics worsening when people take a placebo.

  2. My son is nine years old he has ADHD but whenever he takes his Concerta 18 mg it gives him tics he doesn’t have tics until he takes that medicine is there something else we can give him is there something else he needs the tics get so bad that the other kids tease him about them.

    1. That’s an unusual reaction, but it sounds like you’ve tried it more than once and are pretty sure.

      Yes, there are other medications, including atomoxetine, guanfacine and clonidine. Discuss it with your doctor, and consider showing her/him this web page.

  3. This article is plain wrong. My daughter has either extremely mild or no tics unless on a stimulant…we have tried every type and her tics, that are essentially non existent become insanely bad!

    1. I believe this does happen occasionally—some people may just have the bad luck to have this response. The point of the post is that we actually have data now to show that most people don’t have that experience. Also, if your daughter’s stimulants were amphetamine derivatives, trying methylphenidate could be a reasonable option that may not worsen, or may even improve, her tics.

    2. This also happens to my son who is 16 now. He has been on almost every ADHD stimulant and non-stimulant. Even Saphris and recently Mydayis. He was weaned off Concerta because of side effects and his tics started to decrease after about 2-3 months. He just started Mydayis and the tics started again, full force, neck, shoulders, arms, hands twisting . Facial tics, eyes blinking, mouth writhing. It affects his daily life just as much as the ADHD does. His teachers keep a chart and log because he has Autism, as well. It is so hard for his Psychiatrists to figure this out. It’s so depressing for me to watch him. He can’t focus without the meds and he can’t function with the meds.

  4. My son has tics. We tried Strattera (Atomoxetine) which reduced his tics in general but did not treat his ADHD effectively. We tried Concerta (methylphenidate) and his tics went through the rough. He was exhausted by them. It may be a “rare” case, but based on the comments on this post, it doesn’t sound that rare to.

    1. That’s why the research is so important. The research showed that yes, people’s tics go through the roof fairly often, but they did not do so one bit more often in people assigned to stimulants than in people assigned to placebo. So generally it’s not the medicine.

  5. Some people–ME–get tics from taking stimulant medications. Maybe it didn’t show up in the study with children, but I have taken stimulant meds for ADHD, developed a twitchy lower lip and chin and a clenching in my diaphragm when I breathe out. I stop the meds, the tics go away.

    1. You’re not the only one!

      There are two possibilities to explain experiences like yours, given the facts in the original post. Both are probably true to some extent:
      (1) stimulants cause tics in a small fraction of people, but help them slightly in most people, or
      (2) factors other than a direct effect of the drug–like expectation or nocebo effects–worsen tics.

      But it’s important to emphasize that the careful, prospective research studies above prove that in _most_ people, stimulants are not actually causing the tics, even in people whose tics start when they’re taking stimulants.

      You raise a good point, that responses of children and adults may be different. I wouldn’t expect that, but it would be worth testing.

  6. I have had ADHD since I was a child which was left untreated and developed a movement disorder called Generalized Dystonia as an adult in my mid-twenties, which is of sorts related to Tourette’s, like it’s lesser known cousin. After a decade of trying to get a diagnosis with the Dystonia, or find anyone who had a clue of what I was suffering from, which took many, many Doctors of many different specialties and ultimately turned out to be genetic, then years of trying to find an effective treatment, Focalin was a last ditch effort, it made it where I could work again by putting my symptoms for the most part into remission. I found your post and just wanted to put it out there, just in case it might save someone or their child the pain and agony I went through.

  7. I am 38 years old, I was diagnosed with ADHD at the age of 35 and prescribed Adderall. Prior to Adderall, I had never had a TIC in my life. Post-Adderall, it took about a year but I developed a TIC where I would shake my head slightly. It would come and go throughout the day but was present more than it wasn’t. It lasted about 2 months before it finally went away but only when I developed a new and different TIC. The second TIC caused me to have body twitches while I was laying in bed at night trying to fall asleep. It caused me to take an hour or more to fall asleep each night. This twitch is also something I had never had until Adderall. This lasted for about 4 months before I finally stopped taking Adderall and wouldn’t you know it the TIC’s stopped shortly after.

    You can say that it’s generally not the medicine but when thousands of people are reporting this, its the medicine. You can show us all of the research in the world involving prescribed medicine and placebo’s but at the end of the day there is an action and a reaction. The action being people taking Adderall or other prescribed ADHD meds and the reaction being developed TIC’s, often in patients who never previously had TIC’s. You can call it whatever you want, Adderall, placebo, coincidence, etc. but if someone takes prescribed medicine and it causes something to happen that has never happened before in a patient, who cares what label you give it, it’s still the problem. What I would love to see is studies showing how to combat this problem, not studies to defend it in the first place.

    1. Thanks for taking the time to share your experience. I disagree with your conclusions.

      The statement, “people who take stimulants sometimes develop tics, so it must be the stimulants,” is an example of a classic logical fallacy called the “post hoc, ergo propter hoc” error. This is easier to see if I make a silly, extreme example, like, “so-and-so got elected President, and a year later I had to have a root canal. Darn that President!” A more typical example is the placebo effect. If you give people an empty pill for almost any condition, lots of them get better. But obviously in that case it’s not the pill. There are lots of other possible explanations, and _the only way to tell_ is to do controlled studies. Please also see my response to Amy Phalon above.

      As a side note, the head shaking sounds like it very much could be a tic. However, the body twitches in bed are very likely a different problem, and more likely to be caused by the Adderall.

      1. How much does Big Pharma pays you? I don’t trust you at all. If anyone sounds silly it’s you. More specifically your example with a president and rooting a canal sounds like an arrogant nonsense. I had the exact same problem. I never got any tics, and it didn’t run in the family, and after taking methylphenidate my head shakes constantly to the left for almost a year. How and why would any placebo cause anything similar? How many cases were there of people, who never got tics and developed it after some placebo? The DSM-IV said that stimulants can cause a tic disorder, but your superiors from the Big Pharma probably lobbied APA to remove it as a cause.

        1. I thought about just rejecting this comment, since it’s rude to assume anyone is a sellout or stupid. But I think the world needs more of people trying to understand each other, so let me try and provide polite answers to the questions you raise. Of course this approach will only work if you actually listen and try to understand, but I’ll take that chance. I am quite honestly willing to clarify anything I say here that doesn’t make sense to you, if you are willing to listen.
          1. It’s fair to ask me if I’ve ever been paid by pharmaceutical companies, and I have. The information is publicly available from CMS. But it’s not relevant here because I’ve never been paid by a company that sells a stimulant. It was for research or education relating to completely different medications, in one case a serotonin-2A inverse agonist and in two cases presynaptic dopamine depleting agents. I’ll point out also that I said up front that stimulants have side effects and may not be for everyone. I even said that it’s conceivable that they cause tics, and that we have less proof of safety for amphetamine derivatives than we do for methylphenidate derivatives. But the evidence is now clear that if methylphenidate drugs (like Ritalin(R)) ever cause tics, that is a very rare event, and (more importantly), happens much less often than stimulants improve tics.
          2. The example of the president and the root canal was supposed to sound silly. That was my point. That example assumes that because B happened after A, A must have caused B. Sure, that’s a possibility, but it proves nothing without more evidence. A less silly example that makes the same point would be, I take an aspirin and I get Covid-19. Could it be the aspirin? I mean, I suppose it’s possible that aspirin weakens the immune response to SARS-CoV-2. If a lot of people report the same thing, we could test whether aspirin does that. But of course it’s also quite possible that I was going to get Covid anyway. Lots of people take aspirin, after all.
          3. “How and why would any placebo cause anything similar [i.e., a negative effect like new tics]?” (a) This happens all the time! Doctors don’t believe that the inert substance in a placebo pill actually causes the good or bad outcome. But our minds are powerful, and they can make us feel better (placebo effect) or worse (technically, the name for negative effects from an empty pill is the nocebo effect). But that’s not the only possibility. (b) A second possibility is that when a patient or his doctor reads on the label, “watch for tics,” well, you watch more closely, and of course that means you’re going to notice more tics than if no one said to watch for them. (c) But there’s a third possibility. In the real science I quoted, the most likely interpretation is not that it was a nocebo effect or that people were watching more closely. Rather, it’s that the controlled study lets us find out what would have happened in these kids without any (real) pills at all! The fact is that most boys with ADHD develop tics even without taking any medication! We know that mostly from carefully controlled studies like this one, but also from natural history studies in which someone just tracks patients who aren’t on medications.
          4. “How many cases were there of people who never got tics and developed it after some placebo?” Ah, that’s easy. Please read the original post. It says that in one study, 22.2% of the children who took placebo developed problematic tics for the first time on placebo. It’s not that the placebo caused tics, it’s that a fifth to a quarter of these kids would have developed tics anyway. In the second study, one third of kids had tics get worse on placebo. Again, it’s not because they were on the placebo, the placebo group just reveals that a third of them would have had tics get worse anyway. So the real question is not “how many people first developed tics on placebo,” the real question is, “how many people first developed tics on their own without taking a stimulant?” And of course that’s almost everyone with tics.
          5. I know the people who wrote the DSM-5 section on tic disorders. They have publicly described their reasoning for any changes. The real change from older versions is the new (last 20 years or so) and important research that showed that usually methylphenidate improves tics. This evidence is all summarized in the original post above.
          Best wishes to you.

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