【醫生信箱】Q65. 使用ADHD 藥物後，抽動情況增加？
- 童樂行動
- 2天前
- 讀畢需時 3 分鐘
Q65. 孩子一直有服用 專注達 Concerta 27mg和Abilify 20mg，在小學階段只有輕微的右眼袋抽動情況，今年上中一後，在10月份出現右肩頻繁抽動，一分鐘達30次以上，向政府精神科醫生反映後，醫生指示暫停服用專注達及安排12月初覆診。而在停药這一個月，孩子不能導守課堂常規要求，而肩抽動在停藥初的兩星期有明顯減少，但在後两星期又频繁達每分鐘20次以上。而12月9日見醫生後轉用 Vyvanse 20mg，抽動情況有所減少。而按孩子所說，他在班上覺得受三位同學聯合對付，很不開心，而老師/家長又幫不上忙，所以感覺很大壓力，很不快樂，而學校EP有提醒我，孩子可能出现"解離"的狀況，現在，我很迷茫如何去幫孩子解決抽動這个狀況，而現時也只有多幫他按摩放鬆肩膀，另外，我觀察到孩子睡眠時，沒有抽動的情況。
Ans (✍🏻精神科專科醫生 王崇瀚醫生)
在適應中學生活時期肌肉抽動增加的情況是很常見的。
研究指出大概20%至30%的ADHD兒童同時患有肌肉抽動症。ASD的兒童當中也有20%的共病率。傳統上的理解是治療ADHD的刺激中樞神經藥物，如Concerta 與 Vyvanse 是有機會增加肌肉抽動的可能性。雖然，在2015年的一份 包含了22份研究的綜合分析發現，刺激中樞神經藥物在整體上是沒有增加肌肉抽動的。然而，在個別的層面中有些兒童還是會對個別的刺激中樞神經藥物肌肉抽動 的副作用。有些兒童對 Concerta 或 Vyvanse 的反應比另一隻好 - 你的兒童在轉藥之後肌肉抽動減少，也許就是其中一個例子。
如果 興奮劑 還是增加了孩童的 肌肉抽動，醫生也許會考慮一些個別的藥物，譬如：
● Atomoxetine (Strattera): 一種非刺激中樞神經類 的 ADHD 藥物。
● Alpha-2 Agonists (Clonidine/Guanfacine): 非刺激中樞神經類 的ADHD 藥物。研究還顯示 這對 tics 是 有所幫助。
● Abilify/Risperidone…etc.: 比較嚴重的tics 可以考慮 一些專門治療 肌肉抽動 的 藥物。
最後的是，環境的轉變 是對 肌肉抽動是有很大影響的。心理上的壓力，如對中學生活的轉變 或 面對欺凌的情況，經常是 病情變差的原因。一些受欺凌的學生 因壓力 增加了抽動，而抽動又加劇了被欺凌的頻率。因此，改善欺凌 是一種 跟藥物 一樣重要 的 治療方針。
It is completely understandable that seeing an increase in your child’s tics during the transition to secondary school is stressful.
Research indicates that approximately 20% to 30% of children with ADHD have a comorbid tic disorder. For children with ASD, the prevalence of motor tics is also elevated, estimated at around 20%. Historically, stimulants like Concerta (methylphenidate) and Vyvanse (lisdexamfetamine) were thought to cause tics. However, a major meta-analysis by Cohen in 2015 involving 22 studies found that, at a group level, stimulants do not significantly worsen tics compared to a placebo. Individual responses, however, can vary significantly. Some children find that an individual stimulant (e.g. Vyvanse or Concerta) increases tic frequency while another does not, or vice versa. Your child’s improvement after switching to Vyvanse is a recognized clinical outcome where a specific delivery mechanism or molecule is better tolerated.
If stimulants continue to be a concern, certain alternatives provide a better profile for tics:
● Atomoxetine (Strattera): A non-stimulant shown in systematic reviews to improve ADHD symptoms without increasing (and sometimes even reducing) tic severity.
● Alpha-2 Agonists (Clonidine/Guanfacine): Treating both ADHD and the tics directly. However, its efficacy is in general inferior to traditional stimulants.
● Abilify/Risperidone: For severe tics, these medications have been shown to be a highly effective treatment for reducing tic severity in children.
Lastly, tics frequency is highly sensitive to the environment. Psychosocial stress, such as the transition to secondary school and the trauma of bullying, can trigger an increase in tics. Oftentimes, it creates a vicious cycle where the child is bullied because of tics, and the increased stress increases the tics further. Although understandable that it can be difficult, addressing the bullying is a critical intervention as a high-stress environment can undermine the effectiveness of any medication.