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ADHD and Tourette Syndrome — MRCPsych Paper B MCQ

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HardChild & Adolescent PsychiatryADHD and Tourette SyndromeMRCPsych Paper B

An 11-year-old boy with ADHD and Tourette syndrome has a substantial improvement in attention with methylphenidate. During two supervised dose adjustments, however, his motor and vocal tics worsened promptly after each dose increase and returned towards baseline after dose reduction. The tics are now functionally impairing, and the clinician judges that their worsening outweighs the benefit of continuing the stimulant. Which single alternative medication is most appropriate if seeking treatment for ADHD that may also reduce his tics?

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Correct answer: A — Guanfacine prolonged-release monotherapy

A. Guanfacine prolonged-release is a non-stimulant ADHD treatment licensed in the UK for children aged 6–17 years when stimulants are unsuitable, not tolerated or ineffective. NICE advises considering a change to guanfacine when stimulant-related tics cause greater impairment than the benefits of stimulant treatment. Guanfacine may also reduce tics, although its tic effect is variable and severe Tourette syndrome may ultimately require additional behavioural or pharmacological treatment. Haloperidol and aripiprazole can suppress tics but do not treat the core ADHD syndrome. Increasing methylphenidate contradicts the reproducible dose-related tic worsening in this case. Fluoxetine may treat comorbid depression, anxiety or obsessive-compulsive symptoms but does not treat core ADHD symptoms or tics. Blood pressure, pulse, sedation and syncope risk require monitoring.

Reference: NICE. Attention deficit hyperactivity disorder: diagnosis and management (NG87), recommendations 1.8.13–1.8.14, 2018, amended 2019. https://www.nice.org.uk/guidance/ng87/chapter/recommendations