Provider News

Managing Tics in Primary Care

February 5, 2020

Our Neurosciences Center recently developed a standard of care for tic disorders/Tourette syndrome to assist referring providers (see below). It offers a provider checklist with helpful resources, including a list of local therapy resources in Western Washington and Yakima.

Tic Disorders/Tourette Syndrome Policy

Background

Gilles de la Tourette syndrome (Tourette syndrome) is an early childhood-onset neurodevelopmental disorder marked by the appearance of multiple involuntary movements and vocalizations, referred to as “tics.”
Tourette syndrome is commonly associated with comorbid conditions such as attention-deficit hyperactivity disorder (ADHD), obsessive-compulsive disorder, anxiety disorder and other behavioral problems.
According to some reports, 80% to 90% of patients with Tourette syndrome have both tics and psychiatric manifestations.
These comorbid disorders can cause significant functional impairment and poor self-esteem and can affect the quality of life of patients with Tourette syndrome.

Management

Behavioral treatment can reduce the frequency of tics and increase functioning, adaptation and coping skills.
Behavioral therapy specific for tics:
- Comprehensive behavioral intervention for tics (CBIT)
- Habit reversal training (HRT)
- Exposure and response prevention therapy (ERP)
There is no cure for tics, and while pharmacologic agents can reduce tic frequency, there are potential significant side effects from medications, and they rarely eradicate tics completely.
The pharmacologic treatments for tics include alpha agonists, anticonvulsants, dopamine depletors and antipsychotics.

Provider Checklist

Provide patient with the handout Tics and Tic Disorders.
Direct patient to Tourette Association of America website to find “Tools for Parents,” “Parent and Family Resources,” “Tourette in the Classroom – Helpful Resources” and a Resource Library. The Centers for Disease Control (CDC) offers Information about Tourette Syndrome for Families.
Refer a patient for a psychological evaluation to screen for co-morbid conditions and to provide cognitive behavioral therapy. Families can call the Washington Mental Health Referral Service for Children and Teens at 833-303-5437 for assistance finding qualified therapists who have access and take their insurance. Alternatively, you can use the Partnership Access Line (PAL) to request to connect your patient with a qualified therapist (PAL will transfer the request to the Washington Mental Health Referral Service for Children and Teens, who will reach out to the family directly and notify you when a referral is made).

Refer patient for specific behavioral therapies such as CBIT, HRT or ERP, if available (see earlier).
- Bellingham – Katharine Wolhart, MSW, LICSW, at Sendan Center, Bellingham, WA, 360-305-3275
- Gig Harbor – Diana Dean, MA, CCC, 253-851-6922
- Issaquah – Leafar Espinoza, PhD; Tana Carpita, MSW, LICSW, 425-877-3484
- Seattle – Amy Bohlander, PhD; EBT Centers; Suzanna Eller, MA, LMHC, 206-320-5331; Matt Hopperstad, MD; Rachel Montague, PhD (Brooks Powers Group); Seattle Children’s Hospital; Seattle Clinic (Andrew Fleming, PhD, and Julia Hitch, PhD)
- Yakima – Renee Slaven, LICSW, 509-823-4130
Consider daily preventive medications for patients with pain or impairment in social functioning as a result of the tics.
- First line:
  - Clonidine: 0.05 mg per day; maximum 0.1 to 0.3 mg per day, divided one to three times per day, or
  - Guanfacine: 5 mg per day; maximum 4 mg per day, divided one to two times per day
- Second line:
  - Topiramate: 1 to 9 mg/kg/day; maximum 200 mg per day, divided one to two times per day