Meta-analysis: treatment of attention-deficit/hyperactivity disorder in children with comorbid tic disorders.
OBJECTIVE
The Food and Drug Administration currently requires the package inserts of most psychostimulant medications to list the presence of a tic disorder as a contraindication to their use. Approximately half of children with Tourette's syndrome experience comorbid attention-deficit/hyperactivity disorder (ADHD). We sought to determine the relative efficacy of different medications in treating ADHD and tic symptoms in children with both Tourette's syndrome and ADHD.


METHODS
We conducted a PubMed search to identify all double-blind, randomized, placebo-controlled trials examining the efficacy of medications in the treatment of ADHD in the children with comorbid tics. We used a random effects meta-analysis with standardized mean difference as our primary outcome to estimate the effect size of pharmaceutical agents in the treatment of ADHD symptoms and tics.


RESULTS
Our meta-analysis included nine studies involving 477 subjects. We assessed the efficacy of six medications-dextroamphetamine, methylphenidate, alpha-2 agonists (clonidine and guanfacine), desipramine, atomoxetine, and deprenyl. Methylphenidate, alpha-2 agonists, desipramine, and atomoxetine demonstrated efficacy in improving ADHD symptoms in children with comorbid tics. Alpha-2 agonists and atomoxetine significantly improved comorbid tic symptoms. Although there was evidence that supratherapeutic doses of dextroamphetamine worsens tics, there was no evidence that methylphenidate worsened tic severity in the short term.


CONCLUSIONS
Methylphenidate seems to offer the greatest and most immediate improvement of ADHD symptoms and does not seem to worsen tic symptoms. Alpha-2 agonists offer the best combined improvement in both tic and ADHD symptoms. Atomoxetine and desipramine offer additional evidence-based treatments of ADHD in children with comorbid tics. Supratherapeutic doses of dextroamphetamine should be avoided.
Bloch
Michael H
MH
Panza
Kaitlyn E
KE
Landeros-Weisenberger
Angeli
A
Leckman
James F
JF
D000316:Adrenergic alpha-Agonists / Q000009:adverse effects / Q000627:therapeutic use; D000069445:Atomoxetine Hydrochloride; D001289:Attention Deficit Disorder with Hyperactivity / Q000175:diagnosis / Q000188:drug therapy* / Q000453:epidemiology* / Q000523:psychology; D002648:Child; D015897:Comorbidity; D000075202:Contraindications; D004305:Dose-Response Relationship, Drug; D004311:Double-Blind Method; D006801:Humans; D008774:Methylphenidate / Q000009:adverse effects / Q000627:therapeutic use; D011437:Propylamines / Q000009:adverse effects / Q000627:therapeutic use; D011619:Psychotropic Drugs / Q000009:adverse effects / Q000627:therapeutic use*; D016032:Randomized Controlled Trials as Topic; D013981:Tic Disorders / Q000175:diagnosis / Q000453:epidemiology* / Q000523:psychology; D005879:Tourette Syndrome / Q000175:diagnosis / Q000453:epidemiology* / Q000523:psychology
D000316:Adrenergic alpha-Agonists; D011437:Propylamines; D011619:Psychotropic Drugs; D008774:Methylphenidate; D000069445:Atomoxetine Hydrochloride