ADHD and Tic Disorders

May 14, 2011

Tic Disorders can co-occur with ADHD 8-15% of the time. In other words, children diagnosed with ADHD are at greater risk for developing tics than the general population. If you have a child with ADHD, know what to watch for. Tics can be either motor tics (involuntary muscle movements) or vocal tics often characterized by throat clearing, repetitive cough, or other involuntary noises. Motor tics frequently involve muscles around the face or neck area, but can occur anywhere. Vocal tics, particularly of the throat clearing/coughing type, tend to be initially mistaken as an allergy.

If your ADHD child does develop tics, don’t panic. Most of the time tics are benign and kids grow out of them even with no medical intervention. The peak age for symptoms of tics is approximately age 10 or 11 and then by adolescence usually the tics will begin to fade. Knowing that tics will generally improve on their own, how do you decide when to treat them? My simple answer – treat the tic if it’s bothersome to the individual and/or interfering with daily functioning. The decision should be a collaborative one among the patient, the patient’s family, and the treating physician.

Some of the medications we use to treat tics are actually blood pressure medications called clonidine and guanfacine. They work well to decrease the frequency and severity of tics. If you do decide to try these medicines, be patient. They take time to work and initially can cause some sedation, particularly in the first few weeks.

In children with combined ADHD and tics, prior studies have shown stimulant medications can exacerbate tics so the treatment may simply be to stop the stimulant. This is not to say that stimulant medications cause tics, in fact they don’t. Many patients with ADHD and co-existing tics are able to successfully take the stimulants. If however the stimulant medications do cause problematic side effects for your child, remember there are also non-stimluant medications for treating ADHD such as Strattera or Intuniv.

In summary, tics are fairly common with ADHD, are usually benign, and tend to improve by late adolescence even without treatment. Be able to recognize symptoms of motor and vocal tics in your ADHD child so you can talk to your doctor about treatment options.

Theresa Cerulli, M.D.

Brand vs. Generic Medications – Does It Matter?

February 23, 2011

Taking prescription medications can be cumbersome. It certainly challenges ones working memory skills to remember the names of medications we take, the dose, what time of day to take it, what the pill is for, the side effects, where we store it in the house so we can find it when we need it, when to call the doctor for a refill, the list goes on. To add more confusion to the mix, most prescriptions have two names, the brand name (like Benadryl) and it’s generic name (diphenhydramine).  So I’ll share a question patients frequently ask me – does it matter?

Traditionally when medication is first approved by the FDA there is a patent placed on the newly “branded” drug. After a certain number of years the patent expires and any other company is welcome to make a copy-cat “generic” of the drug. Is there any difference between the original and the copy? Yes. Does it matter? That depends on who you ask. My opinion -ultimately it depends on the person taking the drug – the patient!

When generics are manufactured, the FDA allows a slight deviation from the amount of active ingredient compared with the original branded version of the medication. Maybe Brand X has 32% of the active ingredient and Generic X has 30%. Probably not a noticeable difference clinically for most people. But, where brands and generics differ the most are in the filler components – the stuff that literally holds the tablet together. These filler components can be completely different, resulting in the pill looking nothing like the original one. The size, shape, and color may be may be unrecognizable when you go to pick it up at the pharmacy. The name – the generic name – may be unrecognizable as well. This is a source of many frustrated phone calls to our office from patients worried that the pharmacy gave them the wrong bottle.

Rule of thumb is that most generics will work fine for most people. However, there are some exceptions so certainly let your doctor know if you are experiencing any change in symptoms or side effects when going to a generic. For example, you could be allergic to the red dye coating of generic Y that wasn’t in brand Y. Or your child may have trouble swallowing generic Z because it’s twice the size of brand Z.

Cost cutting is generally driving the substitution of generic medications in place of the brand. That’s good news if both drugs are equally effective for you. But if you have noticed differences in effectiveness or side effects, ask your doctor to contact your insurance company to do a “Prior Authorization” requesting coverage for the brand. It will usually take 3-5 business days for your insurance company to respond to the doctor’s request so patience and planning are helpful in these situations.

ADHD and Sleep

March 21, 2010

Children and adults with AD/HD may frequently experience problems with sleep. You may know this all too well in your family. Many people have difficultly falling asleep while others nod off easily, but then wake frequently during the night. Unfortunately the resulting lack of sleep exacerbates the primary AD/HD problems with attention, concentration, and impulsiveness.

Phase delayed sleep is the most common sleep disorder that accompanies AD/HD. Phase delayed sleep disorder is a fancy way to say the person goes to bed too late and then has trouble getting up in the morning. The hypothalamus in our brains helps to regulate sleep/wake cycles and is basically malfunctioning in an individual with phase delayed sleep.

Is your family short on rest? Try good sleep hygiene including consistent sleep/wake times and creating comfort around your bedtime routine. Reduce energizing activities a few hours before going to bed. Leave the shades open so sunlight shines through early in the morning; light tells the brain it is time to get up!

When behavioral strategies fail, consider over the counter remedies such as melatonin or valerian root. These are natural supplements that help induce sleep and have some clinical research studies to support their benefits and safe use.

You may also want to talk to your doctor about medication. There are newer non-addicting sleep medications such as lunesta and rozerem that have been FDA approved for chronic use in adults and other medication options for children with sleep issues. In our practice I do prescribe sleep medications temporarily to assist patients in getting on a good sleep schedule. Once sleep is well regulated, we recommend weaning off the medication and using behavioral strategies to continue getting your zzzz’s.

Have a restful night!

Theresa Cerulli, M.D.

ADHD Client Self-Awareness and Confidence

February 9, 2009

 I was struck by the pain a very successful entrepreneur shared with me. He grew up hearing that he was lazy and stupid because he couldn’t manage his time and stay ahead of his school work. Even after he was diagnosed with ADHD late in high school, his family couldn’t understand what he was struggling with and accused him of being undependable and dumb.

This bright, creative, kind man still carried many of the weaknesses that you might expect from someone with ADHD, but he does well with the occasional support of medication. He has made an impressive life for himself with huge successes in his personal and business life.  He is the CEO of the midsized company he founded and has two great kids.

What hurts me is that he doesn’t know how good he is. He still feels like that kid his parents mistakenly thought he was. He has carried that false image forward through college graduation, a successful start-up business and the current, profitable company he has grown into a recognizable brand.

He came to me because inside he feels like a fraud. He wonders how others can keep from seeing the truth about him. This is one of the tragedies of ADHD, a person is functioning well, but hasn’t taken time out to correct and update their personal-awareness file. They are in an enviable position in their lives, but can’t enjoy the success.

My entrepreneurial client was stunned to hear from me that many around him were almost assuredly also feeling anxious about their competence, that early information so impresses itself on our brains that it’s difficult to shake up our primal self-image.

Understanding what was happening and having a chance to talk it out gave my client a great boost of self-confidence.  He is surprised and pleased that there was this next level of confidence that he didn’t even know was available to him.

I asked him what kind of difference he thought this increased confidence would make in his life. He grinned and said that with everything he had going for him, he figured he could change the world if he wanted. He just might!

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