Radically different
There are several kinds of medication than can help kids with Tourette’s or another tic disorder. But it’s important to note that not all kids who develop tics need treatment. Tics are very common. They often go away on their own, and they tend to bother parents more than they do the children experiencing them. Drawing attention to them can make them worse. So doing nothing can be the best strategy — at least initially.
Treatment comes into play if tics are upsetting your child, giving them pain, or making it hard for them to function in everyday life — say they’re disrupting class or getting bullied because of their tics.
The first recommended step in treatment is a specialized form of therapy called comprehensive behavioral intervention for tics (CBIT). CBIT is centered on habit reversal training, in which the child learns to recognize when they have an urge to tic and substitute a competing response — an easier, more comfortable, or less noticeable action or behavior that makes the tic impossible. For instance, if a child’s tic is jerking their head to the side, the strategy might be to put their chin down instead.
But if therapy isn’t effective in reducing a child’s tics, medication can help.
First-line medications for Tourette’s and other tic disorders are a class of drugs called alpha-2 agonists, explains Paul Mitrani, MD, PhD, a child and adolescent psychiatrist at the Child Mind Institute. Alpha agonists decrease the release of a neurotransmitter called norepinephrine, which stimulates the nervous system. Alpha agonists serve as a kind of dimmer switch — by calming down the system, they make the urge to tic less frequent, less intense, and by extension, easier to control.
The two alpha-2 agonists usually prescribed for tics are guanfacine and clonidine. Dr. Mitrani reports that he usually starts by prescribing guanfacine because it comes in a longer-acting form (Intuniv), which reduces symptoms for a full 24 hours. Clonidine’s long-acting form (Kapvay) is effective for 12 hours.
Dr. Mitrani adds that there is a new liquid form of clonidine called Onyda XR that lasts 24 hours, but there isn’t yet a strong body of evidence regarding its effectiveness for tics. Onyda XR is FDA-approved for ADHD, as are Kapvay and Intuniv.
While no alpha agonist medications are FDA-approved specifically for tics, Kapvay and Intuniv are frequently used off-label for them. There is ample research on their effectiveness for tics, and they are recommended by clinical practice guidelines.
Some children respond better to several doses of short-acting guanfacine or clonidine, Dr. Mitrani notes, rather than a smoother dose of a long-acting medication. This may be because medication can be timed to peak at times when kids need tic suppression most, such as at school.
Alpha agonists are the preferred first line medications for tic disorders because their side-effects, including drowsiness and low blood pressure, are relatively mild.
If alpha agonists aren’t helping, the next step would be to try an antipsychotic medication, which can be more effective for treating tics, Dr. Mitrani notes, but their side effects are potentially more difficult to tolerate.
Aripiprazole (Abilify), which is FDA-approved for tics, is often Dr. Mitrani’s first choice among the antipsychotic medications. Abilify is a second-generation, or atypical, antipsychotic, a group of medications that have fewer side effects than older antipsychotics. Side effects of Abilify can include restlessness, agitation and weight gain.
Haloperidol (Haldol) is also effective for tics, but it’s an older antipsychotic with more side effect concerns, Dr. Mitrani notes. “I’ve only had one patient ever on Haldol, and he tolerated it well and it really helped with his tics when other things did not.”
Risperidone (Risperdal) is another atypical antipsychotic that can help, but its side effects tend to be worse than Abilify. Risperidone can cause more concerning weight gain and metabolic, neurological, and hormonal changes that can be harmful. Sometimes other medications are used to manage the weight gain from antipsychotics.
More than three-quarters of kids diagnosed with a tic disorder also have another disorder. When a child has multiple disorders, a clinician will want to evaluate which is causing the child the most difficulty and prioritize treating that.
The most common co-occurring disorder with tics is ADHD. “If tics are the bigger problem, we would start with treating them,” says Dr. Mitrani. “If the ADHD is the bigger problem, which it typically is, we usually treat that first.”
In the past, it was recommended that children with tics and ADHD avoid stimulant medication, based on research that showed it made tics worse. But newer studies counter that finding, Dr. Mitrani notes, concluding that the old research was based on very high doses of amphetamine-based medications. To lower the risk of exacerbating tics, he recommends starting kids with ADHD and tics on methylphenidate-based medication.
“If your child is starting a stimulant,” he adds, “and you see worsening of tics — and it’s clearly related to when the stimulant is in their system — the best approach might be a lower dose of stimulant combined with guanfacine or clonidine.”
One advantage to that combination, he notes, is that kids with ADHD who have behavior problems can benefit from the guanfacine or clonidine being active in the mornings before the stimulant starts working and in the evenings when it’s out of their system.
When children with tics have other co-occurring disorders, such as anxiety, OCD, or depression, treating them with medication needs to be done very carefully, Dr. Mitrani says. Since children are typically not bothered by the tics themselves, it’s almost always the other disorder that is more problematic for them. And, he adds, when the other problems cause distress, it can make the tics worse.
For anxiety, OCD, and depression, the first-line medication treatment is an antidepressant. Antidepressants can actually help alleviate tics indirectly, since they reduce anxiety. “Stress increases tics, so if there is significant anxiety and you treat the anxiety, the tics may get better,” Dr. Mitrani says. “And then maybe you don’t need the guanfacine or clonidine. But again, it depends on what the co-occurring disorders are and what’s the bigger problem for the child.”
Due to the waxing and waning nature of tics, it can be challenging to see the full effect of medication and other interventions. It is important to give medication enough time to work, Dr. Mitrani notes, typically a few weeks, to see if the overall pattern, frequency, and severity of tics has improved. And children who are being treated should continue to be monitored regularly for any changes, as tics can recur or worsen, especially when a child is excited, tired, or experiencing more stress.
Most children with tics see a natural improvement or even resolution of tics as they progress through adolescence. If there seems to be a long-standing improvement, it is appropriate to consider reducing or stopping medication, especially if the child is experiencing side effects, Dr. Mitrani notes. If tics continue and are causing distress, it is important to keep treating them.
A child going off any of these medications — alpha agonists or antipsychotics — should do so gradually, by having their dose reduced over weeks or even longer, to avoid unpleasant or dangerous side effects of sudden withdrawal.
The post Medication Treatment for Tics and Tourette’s appeared first on Child Mind Institute.
A common misconception about tantrums and meltdowns is that they’re interchangeable. But while they share some similarities in their initial expression — crying, screaming, door slamming, harsh words — they’re actually quite different. Dealing with a meltdown requires a more specialized approach, especially with kids on the autism spectrum.
The two events happen for different reasons. A child throws a tantrum when they’re angry or frustrated, acting out because they feel an injustice has been done to them. They are aware of what they’re doing and still have some sense of control. And if a child’s tantrum is ignored by their parent or caregiver, it will likely subside quickly.
Meltdowns, on the other hand, happen involuntarily and seemingly out of nowhere. They also tend to become much more intense than a typical tantrum and may involve violent behavior such as head banging, hitting others, and damaging property. Once a meltdown has started, intervention is needed to stop it, whether it’s self-imposed (e.g., removing oneself from the trigger) or external (e.g., support from the parent or caregiver). The event can last between a few minutes and several hours.
Tantrums are common among all children, but kids with autism are more likely to experience meltdowns of varying degrees, says Conner Black, PhD, associate director of the Autism Center at the Child Mind Institute.
For a child with autism, a meltdown is triggered when they become overwhelmed, whether it’s by stress, powerful emotions, sensory input, change, or something else. Their sympathetic nervous system — the network in the body responsible for our “fight-or-flight” response — goes into overdrive and they lose control.
There are several stages to an autistic meltdown and understanding them can help you know how to respond effectively. The duration and intensity of the meltdown depend on whether intervention, including learned coping skills, can stop the child from reaching a crisis point, Dr. Black explains. “Certain skills may not work every time, and that’s really no one’s fault,” he says, but once a child reaches that crisis stage, intervention is no longer useful. He describes the course of a meltdown via the phases of the behavior escalation cycle:
Once a child has started to experience a meltdown, it’s hard to get them back to baseline. Depending on the phase, certain interventions may help while others might make things worse.
First, you want to avoid triggers, Dr. Black advises. “Autistic individuals can have a lot of difficulty talking about or even understanding what their emotions are. So, it’s typically up to the parents or caregivers to identify what things can trigger them in a certain way,” he says.
For instance, some kids with autism really thrive with routine and can become agitated when there are unexpected changes. Having a visual schedule of exactly what’s going to happen during the day can help prevent that, says Dr. Black. “If you know there’s going to be a change, you can pick a time, maybe a couple of days in advance, where you talk to them about what that difference is going to be.”
And if your child is known to have meltdowns in public spaces, says Dr. Black, think about what those outside triggers are and how to prepare ahead of time. If they tend to get upset by loud noises, for example, a pair of headphones can be an item — along with phone, wallet, keys! — that you never leave the house without. If possible, work with a mental health professional to identify triggers and develop an escalation plan.
If your child has reached the agitation phase, says Dr. Black, you can try to intervene with coping skills that you’ve learned in therapy, whether it’s something as simple as removing a trigger or giving them a preferred activity in that moment to help prevent their behaviors from escalating.
Sometimes kids encounter an environment, like school, that is beyond your control but contains a wide range of potential triggers and pushes them into the agitation phase. Because their house is a more comfortable environment, kids with autism may keep themselves together at school and then quickly melt down once they get home.
“In that case, for that first hour, let them have their alone time where they can just chill,” Dr. Black suggests. “It could be eating snacks, watching a TV show, or even just sitting quietly in their room. Maybe it’s engaging in some sort of self-stimming behavior.” This can give them the space to cool down and take some time away from any sort of outside stimuli that could push them to move from the agitation phase into the escalation point of a meltdown.
It can be hard to anticipate every possible trigger, especially when there might be multiple at once on any given day. And sometimes coping strategies aren’t enough to keep a child from escalating or the trigger is too strong. Still, there are some things that Dr. Black suggests you can do to try to keep them from reaching that crisis point.
Too much talking can be overwhelming for the child at this stage and might push them to crisis, Dr. Black explains, so the less communication the better. “A simple instruction looks like using just a short sentence. Say there’s a loud noise, for example. You can just say, ‘Go get your headphones,’” he says.
Instead of trying to communicate verbally, you can hold up a visual prompt. “If your child has already been working with a therapist or if they’ve learned some coping skills, it would be helpful to have a laminated sheet readily available with their name and pictures of four different coping skill options — like headphones, deep breathing, coloring, sitting alone in their room.”
Dr. Black advises only giving a few options, as it’s already difficult for the child to focus while they’re upset. Additionally, if they don’t choose one right away and you want to try again, he recommends that you “let there be silence for 60 seconds at minimum between prompts, because you don’t want to over-prompt and exacerbate the situation even more.” But providing these choices allows them to maintain their autonomy, which is important during escalation.
“Once they get to that apex, they’ve reached the point of no return and just need to go through the process,” says Dr. Black. He stresses that at this point, communication needs to be very minimal or nonexistent.
“The goal switches to really being able to maintain safety for both the individual as well as the family members in the area,” Dr. Black explains. “If they’re harming themselves, such as head banging, move them to their bed so at least it’s on something that’s softer and not going to potentially cause significant injury.”
Efforts to make sure the child is as safe as possible can put you in harm’s way. “If there’s aggression, you can be watching and making sure they’re safe but not getting too close where you could get aggressed upon,” says Dr. Black.
If there are other children in the house, Dr. Black advises that you make plans for how to keep them safe. “Maybe they can go to their room and lock the door while it’s happening,” he says. “Some families have the other kids go to the car and sit and wait until their parents come out to get them.”
If the crisis phase goes on for a long period of time, says Dr. Black, “this is when you’d have to think about calling 911. And as kids become adolescents, the response is going to look a lot different. Because of size alone, it’s a little bit easier to manage the situation in a 5-year-old than it would be in a 15-year-old.”
Dr. Black advises that you get in touch with your local police department or EMT service in advance to let them know you have a child with autism in the home, so if you call during an emergency, they are already familiar with your family.
Watch for signs that the child is beginning to de-escalate, Dr. Black says. “All you’re doing at this point is maintaining safety until you’re really able to see a lessening of the intensity of the behavior or the frequency decreases a little bit.” Then, he says, you can start to slowly communicate with them again. You really need to be careful here, because it may look like they’re calming down, but if they’re pushed too hard and they’re not ready to talk, they might go right back into crisis phase.
At the recovery phase, “the whole family is recovering,” Dr. Black says. It’s at this point where you can all debrief and work through what may have triggered this escalation and how to possibly prevent it in the future.
“Make sure you’re also debriefing separately with the other siblings in the home after it happens,” Dr. Black adds. “They’ve just witnessed something that may have been traumatic and really stressful for them. There’s often so much focus given to the child with the big behaviors in the moment.”
Sometimes, a child or teen may suffer from frequent meltdowns to the point that it’s interfering with their quality of life and their ability to attend school. At that time, a mental health professional may recommend working with a psychiatrist to add medication to their treatment.
The type of medication depends on the underlying mechanisms contributing to the behaviors, Dr. Black says. “For instance, if it’s coming from significant anxiety, psychiatrists may prescribe an SSRI like Prozac or Zoloft. If a child has co-occurring ADHD, which is very common, stimulant or non-stimulant ADHD medication might be recommended. And if the behavior stems from irritability or some kind of rigidity, antipsychotic medications like Abilify or risperidone can be useful.”
Dr. Black notes that when kids receive the support they need, their quality of life really improves. “I’ve seen that when families work with therapists to come up with different behavioral plans and figure out a proper medication regimen, there’s a lot of improvement in behavior challenges,” he says. “The duration, frequency, and intensity of the meltdowns decrease as the child learns how to handle strong emotions and parents learn how to respond to them. And the medication can help to increase their likelihood of being able to use coping skills or regulation techniques to calm back down when they start to get really frustrated.”
The post How to De-Escalate an Autistic Meltdown appeared first on Child Mind Institute.
Circa 1970, the renowned Russian neuropsychologist Alexander Luria together with Karl Pribram from Stanford University and other neuroscientists of that era introduced the term “executive functions” into the scientific lexicon to denote complex behaviors such as attention and awareness. They identified the frontal lobe — the front of the brain — as the “executive of the brain” responsible for these behaviors based on their experiments with primates and patients with specific brain injuries.
Over time, the concept evolved to include mental processes needed to focus, concentrate, and pay attention when challenged by multiple simultaneous sources of information to weigh options and make informed decisions as opposed to impulsive ones.
Thousands of genes are expressed differently in the brains of men and women, researchers have discovered.
The findings could help explain differences in neurodevelopmental, psychiatric, and neurodegenerative disorders between the sexes.
While men are more likely to experience schizophrenia, attention deficit hyperactivity disorder, and Parkinson’s disease, women are more prone to mood disorders and Alzheimer’s disease.
The U.S. study, in Science, is the first systemic single-cell survey of sex differences in gene expression across multiple regions of the human brain.
“Together, these findings provide a comprehensive map of molecular sex differences in the human brain and offer initial insight into their underlying mechanisms and potential functional consequences,” Alex DeCasien, PhD, from the National Institute of Mental Health in Bethesda, Maryland, told Inside Precision Medicine.
DeCasien and co-workers conducted a high-resolution analysis of gene expression in tissue samples from the brains of 15 men and 15 women using single-nucleus RNA sequencing.
They then used data from earlier large neuroimaging studies to select six cortical regions to sample, four of which showed sex-related differences in grey matter volume and two in which no such differences were found.
The team found subtle but widespread differences in gene activity between men and women. Biological sex explained very little of the variance in gene expression across the brain, at less than 1%, but differences were widespread—with more than 3000 genes showing different expression according to sex in at least one cortical region.
The greatest sex-related differences in gene expression were on the sex chromosomes. However, most of the genes showing sex-related variations in expression were autosomal—carried on one of the 22 numbered non-sex chromosomes.
The predominant driver for sex-biased expression of genes on these autosomal chromosomes were sex steroid hormones such as estrogen and testosterone.
Surprisingly, more than half the X chromosome genes in women were expressed in both alleles for at least one cell type. This indicated that many had escaped X chromosome inactivation—a female phenomenon in which one of the two X chromosomes is switched off early in development to stop women producing double the number of X-linked gene products to men.
“That finding has implications for understanding sex-biased disease susceptibility because several genes implicated in neurodevelopmental disorders reside on the X chromosome,” commented Jessica Tollkuhn, PhD, from Cold Spring Harbor Laboratory, and S Marc Breedlove, from Michigan State University, in an accompanying Perspective article.
They noted that autosomal genes showing sex-biased expression were substantially enriched for extracellular matrix components, hormone signaling pathways, and metabolic processes. “Genes with greater expression in women were enriched for mitochondrial and synaptic functions, whereas male-biased genes were associated with metabolic and structural pathways,” the editorialists added.
“By pinpointing these sexually differentiated processes, the data provide a treasure trove for the discovery of biomarkers of and/or therapeutic targets for differential disease risk in men and women.”
DeCasien and team added: “These findings raise the possibility that sex differences in gene expression modulate the magnitude of genetic effects at risk loci, contributing to differences in disease vulnerability and to reduced portability of polygenic risk prediction across sexes.”
The post Brain Gene Variations Help Explain Neurological and Psychiatric Sex Differences appeared first on Inside Precision Medicine.