The first step is a careful evaluation of all potential problems, including an analysis of tics, documentation of comorbid conditions, assessment of problem severity and determination of resulting impairment. The next step is to determine the priority of symptoms, that is, in conjunction with the patient, family, and school personnel, the physician must determine whether tics or associated problems represent the greatest handicap. Just because a symptom exists, tics or otherwise, is not an adequate reason to initiate pharmacotherapy. Medications should be targeted and reserved for only those problems that are functionally disabling and not remediable by non-drug interventions. Lastly, it should be recognized that the treatment of a child with TS requires a chronic commitment and at times a comprehensive multidisciplinary approach.
Tics - Patients considering behavioral or pharmacological treatments should be aware of the natural waxing and waning of tics, large placebo response and the influence of psychopathologies on outcome. A variety of nonpharmacologic behavioral treatments (conditioning techniques, massed negative practice, awareness training, habit reversal, relaxation training, biofeedback, and hypnosis) have been proposed as alternative therapeutic approaches, but few have been adequately evaluated. To date, there is no cure for tics and all pharmacotherapy must be considered symptomatic therapy. If tic-suppressing medication is indicated, a two-tiered approach is recommended: 1) non-neuroleptic drugs for milder tics, and 2) typical/atypical neuroleptics for more severe tics. The goal of treatment is not complete suppression of all motor and phonic tics, but to reduce them to a level where they no longer cause a significant psychosocial disturbance.
ADHD - Similar to treatment in any child with this problem, a variety of behavioral and educational approaches should be implemented before pharmacotherapy is considered. Psychostimulant medications are generally regarded as the treatment of choice for ADHD and their use in children with TS is not contraindicated. Alternative medications for the treatment of ADHD symptoms in children with TS include clonidine, guanfacine, atomoxetine, desipramine, and nortriptyline. In the occasional situation where a stimulant is required for attendance in school or performance at work and tics remain constant, stimulants and tic-suppressing medications are used simultaneously.
OCD - In TS patients with OCD, pharmacologic and cognitive-behavioral therapy should be considered. Several selective serotonin reuptake inhibitors may be beneficial.