Revised Oct 5, 2006
Pediatric Tourette Syndrome and Tic Disorders:
Medication Guide for Physicians
Compiled by Dr. Michael Cheng, MD
About
This handout provides summary of treatment options for Tourette syndrome and tic disorders for
primary care physicians. An accompanying guide, Tourette’s Syndrome and Tic Disorders: Guide
for Families is also available.
Where to Get this Handout
This handout is available from http://www.drcheng.ca in the Mental Health Information section.
Any comments and suggestions are welcome and will help ensure this handout is helpful.
Disclaimer
The content of this document is for general information and education only. The accuracy, completeness, adequacy, or
currency of the content is not warranted or guaranteed. The content is not intended to be a substitute for professional
medical advice, diagnosis, or treatment. Users should always seek the advice of physicians or other qualified health
providers with any questions regarding a health condition. Any procedure or practice described here should be applied by
a health professional under appropriate supervision in accordance with professional standards of care used with regard to
the unique circumstances that apply in each practice situation. The authors disclaim any liability, loss, injury, or damage
incurred as a consequence, directly or indirectly, or the use and application of any of the contents of this document.
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Table of Contents
Management of Tics ........................................................................................................................ 2
Medications ...................................................................................................................................... 2
Medication Dosages for Tics and Tourette Syndrome .................................................................... 3
Psychotherapy ................................................................................................................................. 4
Interesting Research ....................................................................................................................... 4
Tourette’s and Tic Resources .......................................................................................................... 4
References ...................................................................................................................................... 5
Management of Tics
Mild tics, that do not cause severe difficulties, are usually not treated.
Moderate to severe tics however, which cause problems at home or at school/work, may be
treated with medications.
In addition, newer research suggests that certain behavior strategies may be helpful, but
medications remain the mainstay of treatment.
Medications
Coffey (Advanced Psychopharmacology Institute, presented at the joint AACAP/CACAP Meeting
in Toronto, 2005) recommends the following:

With mild symptoms
 Monitoring, education, guidance and support
 Reassurance, given that tics will most likely improve after age 10-12

Monotherapy (with one medication) ideally, but often targeted, combined therapy (with more
than one medication) is needed, particularly for comorbid disorders (such as ADHD, OCD)

For mild to moderate tics, first-line is:
 Alpha adrenergic agonists
 Clonidine
 Guanfacine (not available in Canada)

For moderate to severe tics, first line is:
 Atypicals
 Risperidone, has greatest amount of evidence
 Start 0.25 mg once daily to bid, increase to 0.5 mg once daily to initial target of 12 mg daily
 Raise up to 2-4 mg daily if required
 Dr. Coffey also now using Aripiprazole (Abilify), but not yet available in Canada
 Has atypical antipsychotic DA stabilizing properties
 Dosage in Tourette’s 2.5-10 mg
 Open label tolerability study showing excellent response rate (Coffey, 2005)
 Used dosage range of Aripiprazole 5-40 mg daily
 Mean dosage of 11 mg, modal dose of 10 mg

With comorbidities
 With comorbid ADHD
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


In no particular order
 Stimulants
 Atomoxetine
 Clonidine
 TCA
With comorbid OCD  SSRI
With comorbid rage attacks 
 According Budman and Bruun, 2003, medications useful for rage attacks in
Tourete’s include:
 Serotonin medications
 Clomipramine
 Fluoxetine
 Sertraline
 Fluvoxamine
 Paroxetine (interestingly, they note Paroxetine appears the most effective)
 Atypical antipsychotics
 Risperidone
 Mood stabilizers
 Lithium
 Valproate (Depakote)
 Carbamazepine (Tegretol)
 Anti-adrenergics
 In situations when tics are exacerbated by stimulants (i.e. methylphenidate,
dextroamphetamine)
Medication Dosages for Tics and Tourette Syndrome
Medication
Dopamine blocking
Risperidone (Risperdal)
Olanzapine (Zyprexa)
Ziprasidone (Geodon),
not yet in Canada
Haloperidol
Fluphenazine
Pimozide
Alpha 2-adrenergic
agonists
Clonidine (Catapres)
Guanfacine (Tenex), not
yet in Canada
Dosage
Child: not established; use 0.25-2 mg po bid or equivalent dosage
qhs
Adult: 0.25-3 mg po bid or equivalent dosage qhs
Child: not established; 2.5-5 mg po qhs
Adult: 2.5-20 mg po qhs
Child: 5-40 mg po qhs
Adult: not established;10-40 mg po qhs
Child: same as adult dosage
Adult: 0.25-5 mg po qhs
Watch for possible extrapyramidal syndromes (EPS)
Child: not established
Adult: 0.25-5 mg po qhs
Child: 0.05 mg/kg or 1 mg po qhs initially; not to exceed 0.2 mg/kg or
10 mg po qhs
Adult: 1-6 mg po qhs, up to 10 mg max
Less effective than neuroleptics with tics, but benefits some patients
Child: 0.05-0.1 mg bid/qid po
Adult: 0.05-0.3 mg po bid/divided tid or by transdermal patch
Child: 0.5-1 mg po tid
Adult: 0.5-2 mg pot id
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Retrieved Jan 5, 2007 from http://www.emedicine.com/neuro/topic664.htm
Psychotherapy
A specific type cognitive behavioral therapy known as “habit reversal” shows some promise for
mild tics. Habit reversal essentially involves training oneself to replace the problematic tic
behavior with a different, less impairing behavior. Habit reversal has also been described for
trichotillomania.
Coffey describes three phases to this therapy:
1. Awareness training
 Child is taught to identify premonitory feelings prior to tic
 View is that tics are felt to be a somewhat voluntary symptom
 Train the child to be aware of what goes on prior to the tic
2. Competing response training
 E.g. if child has a left lateral neck movement/tic, child is to then taught a a right side
lateral neck movement to compensate for the tic
3. Social support
 Ensuring that the individual with tics has full support from their social support network,
including family, friends and school/work.
Reference: Woods & Piacentini et al., 2004; Wilhelm, Deckersbach, Coffey et al.: Habit reversal
versus supportive psychotherapy for Tourette’s Disorder: Am J. Psych 2003; 160: 1175-1177.
Interesting Research
As of fall 2005, the New York University (NYU) is currently conducting a trial looking at the use of
Omega 3 Fatty Acids for Tourette’s. Their active treatment has an EPA/DHA ratio of 2:1, and their
protocol starts at 500 mg bid, titrated up to 6000 mg bid. Results are pending….
Tourette’s and Tic Resources
This is a list of various resources available to the families in the Ottawa area, though not
necessarily located physically in Ottawa. A listing does not imply endorsement of a resource, nor
does the absence of a listing imply that we do not endorse a resource. As it is difficult keeping
lists of this nature up to date, feel free to give us any comments or
suggestions for this resource list.

Tourette's Support Group, Ottawa Chapter, 900 Greenbank Road, Suite
386, Ottawa, Ontario, Canada K2J 4P6, Tel: (613) 823-1471, Fax: (613)
825-7758, Email: tsottawaATigs.net

Tourettes Syndrome Foundation (of Canada), National Office, Suite 206,
194 Jarvis Street, Toronto, Ontario M5B 2B7, Phone: 1-800-361-3120 or
416-861-8398, Fax: 416-861-2472, E-mail: tsfc@tourette.ca, Web:
http://www.tourette.ca

Tourette Syndrome Association, Inc (USA), 42-40 Bell Blvd, Suite 205,
Bayside NY 11361, USA, Tel 718-224-2999, The Tourette Syndrome Association is a
national, non-profit organization dedicated to identifying the cause, finding the cure, and
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controlling the effects of Tourette Syndrome. The Association funds research; develops and
disseminates educational material to individuals, healthcare and educational professionals
and provides support services to affected individuals and their families. Web: http://tsausa.org
References

See the excellent online article “Tourette Syndrome and Other Tic Disorders” at
http://www.emedicine.com/neuro/topic664.htm with comprehensive information concerning
diagnosis and treatment. Free registration required.

U. Chowdhury and I. Heyman. Tourette's syndrome in children. BMJ, December 11, 2004;
329(7479): 1356 - 1357.

Scahill L, Leckman JF, Schultz RT, Katsovich L, Peterson BS. A placebo-controlled trial of
risperidone in Tourette syndrome. Neurology 2003;60: 1130-5. Study involved 34 subjects
(26 children, 8 adults) treated with Risperidone.
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