Case Report: Four Purported Cases of Methylphenidate-Induced Tic Exacerbation: Methodological and Clinical Doubts

The role of stimulant medication in the induction and exacerbation of tics in ADHD children has been controversial. We have identified four seemingly apparent cases of methylphenidateinduced tic exacerbation that, on closer examination, did not seem as convincing as initially perceived. Case reports are presented of these prepubertal children, who experienced a marked worsening of tics during medication evaluation or maintenance treatment. Patient A is a child with severe ADHD whose tic disorder gradually became more severe during methylphenidate treatment; he was found to have less severe tic symptoms when larger doses of medication were used. Patient B is an example of apparent methylphenidate-induced Tourette's syndrome in a child who had a preexisting but undiagnosed tic disorder despite multiple evaluations. Patients C and D illustrate how standard dosage titration procedures could lead to erroneous conclusions about medication and fluctuation in tic frequency. These case reports underscore the importance of unbiased and accurate information about pretreatment status, symptom fluctuation over time, and response to medication in making appropriate clinical management decisions. It is advised that clinicians and researchers carefully evaluate apparent links between tic exacerbation and stimulant use in individual cases.