NEW YORK – Clinical acumen and up-to-date knowledge about the literature remain paramount in diagnosing and treating pediatric tics, Tourette syndrome, and obsessive-compulsive disorder in the continuing absence of rigid treatment protocols, according to Dr. Barbara J. Coffey.
“Until we reach the point of having genomics and medical data available to help us treat our patients, we have to rely upon our own clinical acumen and a whole array of treatments,” Dr. Coffey, director of the Tics and Tourette's Clinical and Research Program at NYU Child Study Center, said at a psychopharmacology update sponsored by the American Academy of Child and Adolescent Psychiatry.
She began by pointing out that not all tics need to be treated.
The way in which young patients who need treatment are identified is the challenge, said Dr. Coffey, also an associate professor in the department of child and adolescent psychiatry at the New York University. “The most important part of treatment is sorting out the diagnostic picture and targeting symptoms.”
Even so, she added: “The tics might be mild, but the kid can have tremendous distress about it. On the other hand, I've seen kids who have tremendous tics and are shouting out but are not distressed about it. So part of the work in a case like that is really settling the environment down.”
Although the DSM-IV defines a transient tic disorder as lasting at least 4 weeks, Dr. Coffey said she sees children as early as 2 weeks after the onset of tics. “Parents want to know: 'Is my child going to have Tourette's?' Sorting that out is part of the diagnostic challenge,” she said.
A diagnosis of Tourette, she noted, requires a year-long period of frequent daily tics in which there was never more than 3 continuous tic-free months. “You have to be precise,” she said. “Was it exactly 3 months?” Parents often want to know, she said, whether the child's Tourette will last the rest of his or her life.
“The DSM says the duration is usually lifelong,” Dr. Coffey said. “The good news is that research in the past decade finds that peak lifetime severity occurs at about age 10 or 11, with improvement through adolescence.” To support that view, she cited her 2004 prospective study in the Journal of Nervous and Mental Disease (192:776–80).
“The take-home point is this is a childhood disorder,” Dr. Coffey said. “About two-thirds of children will have their symptoms attenuated by adolescence, if not in complete remission.”
Still, she added: “There's good news and bad news about clinically referred children with Tourette's. The bad news is that OCD tends to kick in and become more prevalent after puberty. Tic severity goes down over time; OCD severity goes up over time. You're kind of trading one disorder for another. When you see a child in the clinic, there's a great likelihood they're going to have these together.”
When parents ask her what they can expect from medications to treat Tourette, Dr. Coffey said she tells them they generally provide about a 30% improvement on symptom scores. “This doesn't fly too well with the parents,” she said. “But this is what we have. If you treat kids with Tourette's, you're always looking for something new in terms of efficacy and tolerability.”
She pointed to an open-label safety and tolerability study she recently published on the use of aripiprazole for children and adolescents with Tourette disorder (J. Child Adolesc. Psychopharm. 2009;19:623–33).
“We saw this as a pilot study,” Dr. Coffey said. “We found it really did seem to help tics over time. The downside is we did see a fair amount of appetite increase and weight gain.”
For the treatment of OCD, she described the Pediatric OCD Treatment Study (POTS), and early, unpublished results from the new Pediatric OCT Treatment Study (POTS II).
“If there's a trend in our field, we have to pay attention to this: The treatment effect size was higher for cognitive-behavioral therapy (CBT) than for sertraline alone,” Dr. Coffey said. “The challenge in real life is that it's very hard to find well-trained cognitive-behavioral therapists for children. But I think CBT is going to be the wave of the future.”
A particularly effective use of CBT, she said, is for the treatment of tics, using procedures that train patients to become aware of premonitory sensations prior to the tic, and then taught a competing response. “It can be done with motor tics, complex tics, simple tics,” Dr. Coffey said. “The effect size is at least comparable to what we're getting with medication, and there are no side effects.”