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Question 36: Our 8 year old son has ADHD and his doctor suggested Concerta but my wife's brother has TS. The manufacturer of Concerta warns against giving Concerta to people with a history of TS but our pediatrician is not concerned. Have you have any knowledge of this issue or do you known anyone who would? Thanks. M.G., New Hampshire, USA

Hello M.G:

I recently attended a research symposium at which the topic of stimulant medications and tics arose -- many doctors, preeminent in the TS field, are quite excited about Concerta (Roger Kurlan for example calls it a 'great drug').

Concerta is simply Ritalin (methylphenidate) sporting a new look. Concerta time-releases Ritalin into an individual's system over a 12-hour period. While other forms of time-release Ritalin have existed in the past (e.g. Methyllin), Concerta provides a much more sophisticated delivery method. Laser-generated holes in the Concerta tablets allow gastric fluids to enter in a controlled fashion, systematically pushing the methylphenidate out through osmotic pressure.

Early 80's warnings that "Ritalin causes TS" have been invalidated. The current belief is that while stimulant medications may exacerbate tic symptoms, these initial exacerbations often later subside. There are also other tricks that physicians use as well -- some stimulant medications (e.g. Dexedrine) exacerbate tics more than others. Also, low dosages can minimize the tic increase.

The reason it was thought at one point that "Ritalin causes TS" was because of reports of physicians giving the stimulant medication which then elicited tics that DIDN'T GO AWAY once the medication was removed. What likely happened was that these individuals displaying ADHD symptoms were going to develop tic symptoms anyway (many people with TS also have ADHD, however developmentally the ADHD symptoms often appear first). Whether the onset of stimulant medication unfortunately coincided with the beginning of tic symptoms, or whether the stimulant medication 'sped up' the appearance of the tics, it only APPEARED that the medication created the problem. I mention this last part only because, given that your boy is 8, and given that there is a positive family history for TS, there is still a likelihood that he could develop tics. Whether he does or not though, difficulties in paying attention are still often determined to be the 'bigger fish to fry' by parents, who then choose this battle over a battle with tics.

I hope this helps M.G!
cheers,
Dr. Dunc.

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