Practice parameter for the assessment and treatment of children and adolescents with tic disorders

Indicators of Social Competence and Social Participation Among US Children With Tourette Syndrome

Children with Tourette syndrome often have behavioral and social difficulties, which may be associated with co-occurring mental, emotional, or behavioral disorders. This study investigated social competence, including behavioral problems and social skills, and social activities between children with and without Tourette syndrome using a nationally representative sample. In the 2007 National Survey of Children's Health, parents reported on health care provider diagnosis of Tourette syndrome, co-occurring mental, emotional, or behavioral disorders, and indicators of social competence. Children aged 6-17 years with and without Tourette syndrome were compared. Most (78.7%) children with Tourette syndrome had a co-occurring mental, emotional, or behavioral disorder. Children with Tourette syndrome had significantly lower social competence, exhibited by higher levels of behavior problems (mean score 11.6 for Tourette syndrome and 9.0 for no Tourette syndrome) and lower levels of social skills (mean 15.3) than children without a Tourette syndrome diagnosis (mean 17.1); however, these associations were no longer significant after controlling for co-occurring mental, emotional, or behavioral disorders. Moderate to severe Tourette syndrome was associated with the highest ratings of behavioral problems and the lowest ratings of social skills. Children with and without Tourette syndrome were equally likely to participate in social activities; the difference for children with moderate to severe Tourette syndrome being less likely to participate in activities compared to children with mild Tourette syndrome had a chi-square test P value of .05. In conclusion, Tourette syndrome was associated with lower social competence, particularly for children with moderate to severe Tourette syndrome. Monitoring social functioning and co-occurring conditions among children with Tourette syndrome, and referral for evidence-based interventions when needed, may benefit overall health and functioning.

Brain functional connectivity in chronic tic disorders and Gilles de la Tourette syndrome

The pathophysiology of chronic tic disorder (cTD) and Gilles de la Tourette syndrome (GTS) is characterized by the dysfunction of both motor and non - motor cortico - striatal - thalamo - cortical (CSTC) circuitries, which leads to tic release and comorbids. A role of fronto - parietal network (FPN) connectivity breakdown has been postulated for tic pathogenesis, given that the FPN entertain connections with limbic, paralimbic, and CSTC networks. Our study was aimed at characterizing the FPN functional connectivity in cTD and GTS in order to assess the role of its deterioration in tic severity and the degree of comorbids. We recorded scalp EEG during resting state in patients with cTD and GTS. The eLORETA current source densities were analyzed, and the lagged phase synchronization (LPS) was calculated to estimate nonlinear functional connectivity between cortical areas. We found that the FPN functional connectivity in delta band was more detrimental in more severe GTS patients. Also, the sensorimotor functional connectivity in beta2 band was stronger in more severe cTD and GTS patients. FPN functional connectivity deterioration correlated with comorbids presence and severity in patients with GTS. Our data suggest that a FPN disconnection may contribute to the motoric symptomatology and comorbid severity in GTS, whereas sensorimotor disconnection may contribute to tic severity in cTD and GTS. Although preliminary, our study points out a differently disturbed brain connectivity between patients with cTD and GTS. This may serve as diagnostic marker and potentially interesting base to develop pharmacological and noninvasive neuromodulation trials aimed at reducing tic symptomatology.

Randomized, Sham-Controlled Trial of Real-Time Functional Magnetic Resonance Imaging Neurofeedback for Tics in Adolescents With Tourette Syndrome

BACKGROUND

Activity in the supplementary motor area (SMA) has been associated with tics in Tourette syndrome (TS). The aim of this study was to test a novel intervention-real-time functional magnetic resonance imaging neurofeedback from the SMA-for reduction of tics in adolescents with TS.

METHODS

Twenty-one adolescents with TS were enrolled in a double-blind, randomized, sham-controlled, crossover study involving two sessions of neurofeedback from their SMA. The primary outcome measure of tic severity was the Yale Global Tic Severity Scale administered by an independent evaluator before and after each arm. The secondary outcome was control over the SMA assessed in neuroimaging scans, in which subjects were cued to increase/decrease activity in SMA without receiving feedback.

RESULTS

All 21 subjects completed both arms of the study and all assessments. Participants had significantly greater reduction of tics on the Yale Global Tic Severity Scale after real neurofeedback as compared with the sham control (p < .05). Mean Yale Global Tic Severity Scale Total Tic score decreased from 25.2 ± 4.6 at baseline to 19.9 ± 5.7 at end point in the neurofeedback condition and from 24.8 ± 8.1 to 23.3 ± 8.5 in the sham control condition. The 3.8-point difference is clinically meaningful and corresponds to an effect size of 0.59. However, there were no differences in changes on the secondary measure of control over the SMA.

CONCLUSIONS

This first randomized controlled trial of real-time functional magnetic resonance imaging neurofeedback in adolescents with TS suggests that this neurofeedback intervention may be helpful for improving tic symptoms. However, no effects were found in terms of change in control over the SMA, the hypothesized mechanism of action.

Pediatric Prevention: Tic Disorders

It is not clear whether the development of tics can be prevented. Contextual variables can impact tic expression; therefore, shifting attention to behaviors that reduce tics is an important part of decreasing tic severity. Several medications are effective in reducing tic severity, but side effects restrict their use. Behavioral treatment is the gold standard psychotherapy intervention for tic disorders, with Comprehensive Behavioral Intervention for Tics being the most well-supported nonpharmacological treatment. Although children may be unable to prevent the development of tics, they can still use several strategies to reduce tic severity and impairment.

Assessment and Management of Tic Disorders in Pediatric Primary Care Settings

Purpose of Review

Pediatricians and other primary care providers are often the first and sole healthcare clinicians of patients who present with tics. However, limited primary care pediatric training in neuropsychiatric concerns, as well as perceived lack of comfort and preparation, make it challenging for these clinicians to confidently identify and manage tic disorders.

Recent Findings

Current empirical findings of tic disorder management relevant to pediatric physicians, including assessment, psychoeducation, behavioral interventions, psychotropic medications, and alternative treatments are reviewed.

Summary

This article discusses neuropsychiatric and medical complexities of tic disorder assessment, with particular emphasis on differential and comorbid diagnoses. Tiered referral recommendations, based on symptom severity, impairment, and consideration of comorbid conditions, are provided. Future directions for tic management, including dissemination of evidence-based treatments of tic disorders and multidisciplinary teams within pediatric primary care settings, are included.

Efficacy of Parent-Delivered, Home-Based Therapy for Tics

BACKGROUND

Although behavioral therapy is an effective approach to reduce tics in children and adults, there is an insufficient availability and accessibility of behavioral therapy in the community.

OBJECTIVE

The goal of the study was to test the clinical efficacy of home-based, parent-provided behavioral therapy in children with Tourette syndrome aged seven to 13 years.

METHOD

An instructional habit reversal training-based video and guide was developed for use by parents. Eligible families, in this 10-week study, were enrolled in either a home-based therapy (DVD) group (received disk and written instructions) or an in-person therapist group (had scheduled visits with the therapist). Outcome scales included the Yale Global Tic Severity Scale, both the total Tic Severity Score and total Global Severity Score, and the parent report of Clinical Global Impressions of Improvement.

RESULTS

Forty-four children (mean age = 10.21 ± 1.69 years) were enrolled into either the DVD (n = 33) or in-person therapist (n = 11) groups. Eighteen completed the study-eight in the DVD and 10 in the in-person therapist group. Outcome measures showed significant reductions in Yale Global Tic Severity Scale change ratios: mean improvement on the Tic Severity Score was DVD 32.4% (P < 0.001) and in-person therapist 26.6% (P = 0.01); and for the Global Severity Score, DVD 33.7% (P < 0.001) and in-person therapist 26.7% (P < 0.001).

CONCLUSIONS

Home-based, parent-administered habit reversal training behavioral therapy is efficacious for reducing tics in children. Telephone contacts early in the DVD treatment course might reduce the number of dropouts.

Clinical Profile of Tic Disorders in Children and Adolescents from a Tertiary Care Center in India

BACKGROUND

Tic disorders (TDs) are common neurodevelopmental disorders in children and adolescents. To date, there is very scant literature on TDs in children and adolescents in the Indian setting.

AIM

The objectives of this study were to characterize the clinical profile, including comorbidities and pattern of medication use in the treatment of TDs, in children and adolescents.

MATERIALS AND METHODS

The present study is a retrospective chart review of children and adolescents up to age 18 years diagnosed with TD in a tertiary care center in India. Data were derived from case records of patients with a diagnosis of TD, coded as F 95 according to ICD 10, from 1^st January 2014 to 31^st December 2017.

RESULTS

We recruited 85 subjects. The majority (95.29%, n = 81) of them were male, and the mean age of onset was 8.4 years. Chronic tic disorder was the most common subtype, followed by Tourette syndrome and provisional or transient tic disorder. Eighty patients (94%) had a comorbid disorder, with attention deficit hyperactivity disorder being the most common, followed by obsessive compulsive disorder. Eighty-two percent of patients received pharmacotherapy. Risperidone was the most frequently used medication, followed by clonidine, haloperidol, and aripiprazole. Moderate to significant improvement with medications was seen in 88% of the patients.

CONCLUSION

The present study of children and adolescents with TDs highlights very high rate of comorbidity and a favorable short-term course with medication use.

Sleep and Sleep Disorders in Tourette Syndrome: What is Known and What is Still Unknown

Background:

Most of the patients with Tourette Syndrome (TS) present additional comorbidities. Attention Deficit Hyperactivity Disorder (ADHD) and Obsessive-Compulsive Disorder (OCD) are the most common. Sleep Disorder has been suggested also as common comorbidity.

Objective:

To review the literature on sleep characteristics and sleep disorder in patients with Tourette Syndrome (TS), with emphasis on the contribution of specific co-morbidities to the severity of impaired sleep and life quality of the patients.

Results:

In general, sleep problems are not frequent at the age when tics appear which are estimated to affect about 10 % of these children. In severe cases, tics appear in all sleep stages. In a large study, the prevalence of sleep problems was 17.8% but was 12 % in “TS-only” (9.4% in children and 7.5 in adults) compared to 22% in children and 18% in adults with TS+ADHD. Unfortunately, in most of the studies, the characteristics of these “sleep problems” are not defined. In spite of the scarcity of data, the two main sleep disorders in TS patients are insomnia and parasomnias. Although much more data is needed, many TS subjects are sleep deprived (which exacerbate the tics) and may suffer from excessive daytime sleepiness, which negatively affects normal functioning.

Conclusions:

Although the literature is not conclusive, children and adolescents with TS appear to suffer more from sleep disturbances and sleep disorders than age-matched controls. Not all patients have tics during sleep, but in severe cases, tics may appear in all sleep stages. It is clear that when patients present both TS and ADHD, (a very common condition), the sleep difficulties are related mainly to ADHD. Much more research is warranted in all aspects of sleep and sleep disorders in TS.

Drug and Non-drug Treatment of Tourette Syndrome

Background:

Tourette Syndrome (TS) is a neurodevelopmental disorder characterized by multiple repetitive motor and vocal tics. In most patients, its clinical course has a waxing and waning nature and most patients, usually children, will benefit from tolerant environmental and psychoeducation. Patients with more complicated tics, in particular, those with significant comorbidities will require drug therapy.

Objective:

The present paper is a mini-review of the current therapeutic arsenal for TS with reference to drug and non-drug management approach.

Methods:

A systematic survey of medical literature regarding the treatment decision making and the reported clinical trials or accumulating experience with different medications or other therapeutic modalities which were proven beneficial over the years.

Results:

Reviewing the literature indicates that dopamine antagonists, such as haloperidol and pimozoide, are the most reliable agents in terms of treatment response. Due to numerous adverse effects, newer atypical anti-psychotic drugs have been shown effective. Other widely accepted medications include alpha-2 adrenergic agonists, benzamides, dopamine depleting agents, benzodiazepines and dopamine depleting agents. In more selective and intractable cases botulinum toxin, dopamine agonists and cannabinoids should be also considered. Non-pharmacologic therapies reported beneficial effects, which include on the one hand, non-invasive behavioral techniques, such as comprehensive behavior therapy for tics. While on the other hand, in cases with particular protracted pharmaco-resistant tics electric stimulation techniques, such as deep brain stimulation, have been shown to be successful.

Conclusion:

Currently, there are numerous multifarious options for treatment of tics and other comorbid symptoms of TS. Nevertheless, treatment options and decision-making algorithms are still a clinical challenge.

Area Covered:

A step by step decision-making and various drugs and non-pharmacologic modalities appropriate for the management of TS.

Assessment and management of tic disorders and Tourette syndrome by Australian paediatricians

AIM

The diagnosis and management of tic disorders and Tourette syndrome (TS) can be challenging. A better understanding of current approaches by paediatricians is important to inform research and education to improve patient outcomes. We aimed to investigate current assessment and management practices for tics/TS by Australian paediatricians.

METHODS

An online survey was sent to members of the Australian Paediatric Research Network. Primary outcomes of interest included assessment processes, referrals, behavioural interventions and pharmacological management. Four scenarios were presented to elicit information regarding treatment of different types of cases.

RESULTS

Of 340 eligible paediatricians, 139 (41%) responded, with 116 (84%) reporting that they diagnose and manage tics/TS as part of their practice. Questionnaires were used more to identify comorbidities (43%) than to quantify tics (12%). Referrals were most likely to be made to psychologists. Medication was considered important in the management of TS by 45% of respondents, with clonidine identified as the first-choice medication by 69%. There was wide variation in both the pharmacological and behavioural management strategies reported.

CONCLUSIONS

There is substantial practice variation among Australian paediatricians in the assessment and management of patients referred with tics/TS. This may reflect insufficient evidence regarding best practice, as well as limited training in this area. There is a need for improved education of Australian paediatricians in the assessment and management of tics/TS, as well as further research to identify optimal treatments.

Meta-analysis: Adulthood prevalence of Tourette syndrome

BACKGROUND

Tourette syndrome (TS) is estimated to have a prevalence of 0.30-0.77% in school aged children. Longitudinal studies suggest that roughly half-to-two-thirds of children with TS experience a substantial improvement in tic symptoms during adolescence. By contrast, few studies have examined adulthood prevalence of TS. Accurate prevalence estimates across the lifespan are needed to support regulatory and public health decisions.

METHODS

We searched PubMED and EMBASE for studies that examined the prevalence of TS in adults. We conducted a random-effects meta-analysis of logit event rates to estimate prevalence of TS across studies. Too few studies are available to conduct moderator analysis or examine publication bias. We also examined the risk ratio of TS prevalence in adults for males compared to females.

RESULTS

Three studies involving 2,356,485 participants were included. There were significant differences in TS adulthood prevalence estimates between studies ranging from 49 to 657 cases of TS per million adults. Overall prevalence of TS in adulthood was estimated to be 118 cases of TS per million adults (95%CI: 19-751 cases per million adults). There was a large amount of heterogeneity between studies (I² = 99%) that was likely related to differences in their methods of identification of TS cases. By contrast, the male:female ratio of risk of adulthood TS was similar between studies with a Risk Ratio = 2.33 (95% CI: 1.72-3.16).

CONCLUSION

Estimates of adulthood prevalence of TS are sparse and likely highly affected by differences in method of case identification. Diagnosis and diagnostic estimates of TS could be aided by including a requirement for impairment as well as potential remission criteria similar to other psychiatric conditions.

Treatment options for tic disorders

Introduction: Gilles de la Tourette syndrome (GTS) is a neurodevelopmental disorder, characterized by the presence of multiple motor and, at least one, phonic tics, for more than one year, beginning before 18 years of age; its treatment is often a challenge for the clinicianAreas covered: GTS treatment requires a multidisciplinary management to treat each patient's symptom. Although individuals with GTS often have comorbid psychiatric disorders, the focus of this review will only be on the management of tics.Expert opinion: The authors summarized the steps that clinicians should follow treating GTS patient; the impact of the tics on a patients' life should be the first step; different patients could present different levels of tolerance to the symptoms. Second, comorbidities should be considered before starting a treatment for tic. Finally, clinicians must focus the attention of the patient and family, on the length of the treatment and the duration of time after which the effects of the drug will occur. Before the treatment, the potential side effects must be mentioned to the parents, and the choice of treatment must be made in the light of the patient's tolerance to these.

Evidence-based treatment of Tourette's disorder and chronic tic disorders

Introduction: Chronic Tic Disorders and Tourette's Disorder (collectively referred to as TD) are characterized by sudden, rapid, and repetitive motor movements or vocalizations called tics. Children, adolescents, and adults with TD often experience co-occurring psychiatric symptoms and impairments in multiple domains. As a result of tics and other symptoms, patients with TD can develop negative self-views, require considerable accommodations, and experience a poor quality of life. Therefore, the efficient and effective management of TD bears considerable importance. Areas covered: This expert review evaluated the empirical support for behavioral and pharmacological interventions based on the results of randomized controlled trials (RCTs). Behavioral interventions evaluated include habit reversal training (HRT), comprehensive behavioral intervention for tics (CBIT), and exposure response prevention (ERP). Reviewed pharmacological interventions included alpha-2 agonists, antipsychotics, and anticonvulsants. Expert opinion: This review identified several efficacious behavioral and pharmacological interventions for TD. However, several gaps in the management of TD include: (1) the access/availability of behavioral interventions, (2) novel and more efficacious treatment approaches, and (3) the development of more comprehensive interventions to manage TD. In order to advance the treatment of TD, additional research is necessary to efficiently, effectively, and comprehensively develop and evaluate new treatments for patients with TD.

Psychobiotics in mental health, neurodegenerative and neurodevelopmental disorders

Psychobiotics are a group of probiotics that affect the central nervous system (CNS) related functions and behaviors mediated by the gut-brain-axis (GBA) via immune, humoral, neural, and metabolic pathways to improve not only the gastrointestinal (GI) function but also the antidepressant and anxiolytic capacity. As a novel class of probiotics, the application of psychobiotics has led researchers to focus on a new area in neuroscience. In the past five years, some psychobiotics strains were reported to inhibit inflammation and decreased cortisol levels, resulting in an amelioration of the symptoms of anxiety and depression. Psychobiotics are efficacious in improving neurodegenerative and neurodevelopmental disorders, including autism spectrum disorder (ASD), Parkinson’s disease (PD) and Alzheimer’s disease (AD). Use of psychobiotics can improve GI function, ASD symptoms, motor functions of patients with PD and cognition in patients with AD. However, the evidence for the effects of psychobiotics on mental and neurological conditions/ disorders remains limited. Further studies of psychobiotics are needed in order to determine into their effectiveness and mechanism as treatments for various psychiatric disorders in the future.

Expert consensus on pharmacotherapy for tic disorders in Japan

OBJECTIVE

We aimed to clarify the current status of pharmacotherapy for tic disorders and comorbidities in Japan. We used a systematic survey to collate the consensus of Japanese experts and compare it with the recent international evidence.

METHODS

We devised a questionnaire on pharmacotherapy for tics and comorbidities and sent it to Japanese experts on tic disorders. Based on the response to the first survey, we revised the questionnaire and conducted a second survey to determine the consensus among the experts on a 4-point Likert scale by the Delphi method.

RESULTS

The first survey revealed variability in preferred medications and dosages among the experts in Japan. However, we were able to build a general consensus on pharmacotherapy for tic disorders and comorbidities based on the second survey. Aripiprazole and risperidone were the first- and second-line medication for tic disorders, respectively. Agonists of α-₂ adrenergic receptors were seldom prescribed. Fluvoxamine was the first-line medication for comorbid obsessive-compulsive disorder, and atomoxetine for comorbid attention deficit/hyperactivity disorder.

CONCLUSIONS

This study will help Japanese physicians choose medications for tic disorders more judiciously and will improve the quality of tic pharmacotherapy in Japan.

An exploratory study into an adapted use of the Alert Program for tic disorder in children

OBJECTIVES

This preliminary study explored whether an adapted approach to the Alert Program, that uses sensorimotor strategies, might assist with management of tic disorders in children. The Alert Program, a program that uses sensorimotor strategies for self-regulation in children with neurodevelopmental disorders, had not been trialled with children with tic disorders.

METHODS

Ten children with tic disorder were assessed using the Dunn Sensory Profile 2 (SP2), the Yale Global Tic Severity Scale (YGTSS) and the Parent Tic Questionnaire (PTQ). Participants attended three 60-90-minute appointments with an occupational therapist and clinical psychologist for implementation of the adapted Alert Program.

RESULTS

The YGTSS showed tic reduction in all participants. The total YGTSS pre-intervention mean score of 46.5 improved to 17.7 post-therapy. Five participants reported no impairment post-therapy. PTQ scores reduced in nine participants. On the SP2, 30% of participants scored as having sensory sensitivities that impaired daily function.

CONCLUSIONS

This exploratory study found trialling an adapted approach to the Alert Program that uses sensorimotor-based approach decreased tic severity in children with tic disorders. A randomised controlled trial is needed to establish the effectiveness and feasibility of this approach.

Tourette's syndrome is associated with an increased risk of traumatic brain injury: A nationwide population-based cohort study

INTRODUCTION

Violent motor tics or severe self-harm behaviors have been reported in patients with Tourette's syndrome (TS) and leading to traumatic brain injury (TBI). The study aimed to determine the risk of TBI in TS patients, the effects associated with concurrent psychiatric disorders (attention-deficit/hyperactivity disorder (ADHD), obsessive-compulsive disorder (OCD), or depressive disorder), and the effects of medication treatment (antipsychotics, antidepressants, or clonidine) on the risk of TBI.

METHODS

Using the National Health Insurance Research Database of Taiwan, 2261 TS patients and 20349 non-TS controls matched by gender and age were enrolled between 2000 and 2012, and followed until the end of 2013. Participants who developed TBI during the follow-up period were identified. Cox regression analysis was performed to examine the risk of TBI between TS patients and non-TS controls.

RESULTS

TS patients were associated with an increased risk of TBI compared to non-TS controls (hazard ratio (HR): 1.59, 95% confidence interval (95% CI): 1.37-1.85). Also, this study revealed TS patients with ADHD, OCD, or depressive disorder predicted a higher TBI incidence rate than those who did not, but the estimate was not statistically significant. Moreover, this study found that TS patients with frequent use of antipsychotics were associated with a lower risk of TBI than infrequent users (HR: 0.76, 95% CI: 0.57-0.99).

CONCLUSIONS

This study highlights the need to pay more attention to the risk of TBI in TS patients, and the importance of adequate antipsychotic medication may reduce the risk of TBI.

Children with Tourette Syndrome in the United States: Parent-Reported Diagnosis, Co-Occurring Disorders, Severity, and Influence of Activities on Tics

OBJECTIVE

Describe the diagnostic process for Tourette syndrome (TS) based on parent report, as well as TS severity and associated impairment; the influence of common daily activities on tics; and the presence of co-occurring mental, behavioral, and developmental disorders among children in the United States.

METHODS

Parent-report data from the 2014 National Survey of the Diagnosis and Treatment of ADHD and Tourette Syndrome on 115 children ever diagnosed with TS were analyzed. Descriptive, unweighted analyses included frequencies and percentages, and means and standard deviations. Fisher's exact test and t-tests were calculated to determine statistically significant differences.

RESULTS

The mean age that tics were first noticed was 6.3 years, and, on average, TS was diagnosed at 7.7 years. The time from initially noticing tics to TS diagnosis averaged 1.7 years. The mean age when TS symptoms were most severe was 9.3 years. Tic severity was associated with impaired child functioning but not tic noticeability. Almost 70% of parents reported that fatigue and major transitions made their child's tics worse. Children with ever-diagnosed TS had a mean of 3.2 ever-diagnosed co-occurring mental, behavioral, or developmental disorders; a quarter (26.9%) had 5 or more co-occurring disorders.

DISCUSSION

In this sample of children with TS, the time to diagnosis averaged less than 2 years from when tics were initially noticed. More severe TS was associated with greater functional impairment, and co-occurring disorders were common among children with TS. This study provides insight into the current experiences of children with TS in the United States and their families.

Pharmacoepidemiology of Tourette and Chronic Tic Disorders in Sweden 2005-2013

BACKGROUND

Monitoring "real world" dispensation patterns over time is important to build the evidence base for safe and efficient use of psychotropic drugs. In this study, we aimed to comprehensively examine the patterns of psychotropic drug dispensations in patients with Tourette and chronic tic disorders (TD/CTD) in Sweden between 2005 and 2013.

METHODS

A cohort of 6979 TD/CTD patients was identified through the Swedish National Patient Register. Their drug dispensation patterns, collected in the Swedish Prescribed Drug Register, were examined between July 1, 2005 and December 31, 2013. Frequencies of drug dispensations were further stratified by gender and comorbidities. Additionally, differences in the patterns of dispensation in children and adolescents versus adults in the last year of the follow-up were examined, as well as the time trends of the dispensations over the 8-year study period.

RESULTS

A total of 5299 (75.9%) TD/CTD patients were dispensed at least one drug during the study period. The most frequently dispensed medications were attention-deficit/hyperactivity disorder (ADHD) drugs (53.8%), antidepressants (50.7%), hypnotics/sedatives (41.7%), and antipsychotics (41.5%). Most of the medicated patients (72.1%) were dispensed more than one drug during the study period. Patterns of dispensation varied according to patient's gender, associated comorbidities, and age group. Dispensation of quetiapine and aripiprazole, antiadrenergics, ADHD drugs, antiepileptics, and hypnotics/sedatives and anxiolytics (particularly the nonbenzodiazepine types) significantly increased over time, whereas dispensation of antidepressants, typical antipsychotics, and benzodiazepine-based anxiolytics significantly decreased over the study period.

CONCLUSIONS

Long-term monitoring of these drug dispensation patterns and the study of both their beneficial and adverse effects is warranted.

Deep brain stimulation for Gilles de la Tourette syndrome in children and youth: a meta-analysis with individual participant data

OBJECTIVE

Gilles de la Tourette syndrome (GTS) is a disorder characterized by motor and vocal tics. Although by definition the onset of GTS is before age 18 years, clinical trials of deep brain stimulation (DBS) have been conducted only in adults. Using individual participant data (IPD) meta-analysis methodology, the current study investigated the safety and efficacy of DBS as a treatment for GTS in children and youth.

METHODS

A systematic review with no date or language restrictions was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement. Three electronic databases were searched: PubMed, EMBASE, and Web of Science. From 843 articles screened, the IPD of 58 children and youth (ages 12–21 years) extracted from 21 articles were collected and analyzed. A mixed-effects univariable analysis followed by multivariable hierarchical regression was performed using change in the Yale Global Tic Severity Scale (YGTSS) score as the primary outcome and reported measures of comorbidities as secondary outcomes.

RESULTS

The authors’ results showed an average improvement of 57.5% ± 24.6% across studies on the YGTSS. They also found that comorbid depression and stimulation pulse width each correlated negatively with outcome (p < 0.05). In patients with less severe GTS, greater improvements were evident following thalamic stimulation. More than one-quarter (n = 16, 27.6%) of participants experienced side effects, the majority of which were minor.

CONCLUSIONS

DBS in the pediatric population may be an effective option with a moderate safety profile for treatment of GTS in carefully selected children and youth. Large, prospective studies with long-term follow-up are necessary to understand how DBS influences tic symptoms and may alter the natural course of GTS in children.

Efficacy of Habit Reversal Training in Children With Chronic Tic Disorders: A Within-Subject Analysis

The aim of this study is to evaluate a cognitive-behavioral treatment for children and adolescents with tic disorder including habit reversal training (HRT) in a sample of children and adolescents (n = 27). Multiple outcome measures were used to assess the effects of the treatment on tic symptoms. In addition, impairment/subjective burden ratings and the self-efficacy to control tics were assessed. A within-subject design with two phases (8 weeks diagnostic; 16 sessions treatment) was analyzed using multilevel modeling (MLM). During the treatment phase, significant improvements in tic symptoms, impairment, and self-efficacy to control tics were found on most outcome measures. Treatment effects were found on the clinical rating of tic symptoms (Yale Global Tic Severity Scale [YGTSS]), the self-efficacy to control tics, and the video-observed motor tic frequency by comparing the improvements during treatment with the course of the outcome measures during the preceding diagnostic phase.

Cognitive Behavioral Therapy for Anger and Aggression in a Child With Tourette’s Syndrome

Tourette syndrome (TS) is a neurodevelopmental disorder that is characterized by vocal and motor tics. Children with TS often also exhibit disruptive behaviors including sudden anger outbursts accompanied by verbal and physical aggression. This case study presents cognitive behavioral therapy (CBT) treatment of anger and aggression in a 9-year-old girl with TS, co-occurring generalized anxiety disorder (GAD), and oppositional defiant disorder (ODD). At initial assessment, tics were well-managed and disruptive behavior concerns, including near-daily tantrums lasting 20 min to 1 hr, were primary clinical concerns. The child and her mother received 12 weekly sessions of CBT for anger and aggression, with select supplements and modifications that related to the context of TS. Posttreatment assessment indicated a significant decrease in noncompliance, anger outbursts, and aggressive behavior. CBT for anger and aggression can be a useful treatment for the disruptive behaviors that often co-occur with TS.

Pharmacotherapies to tics: a systematic review

The efficacy of all pharmacotherapies for patients suffering from tics were unclear. Literatures were searched from Medline, Embase, The Cochrane Library, and four Chinese databases. The primary efficacy outcome scale was defined as the Yale Global Tic Severity Scale (YGTSS). Overall estimates of pooled weighted mean difference (WMD) with 95% confidence interval (CI) were calculated for each outcome measure. A total of 53 trials were included. Meta-analysis suggested that alpha-2 adrenergic agonist agents and atypical antipsychotic agents were effective in improving tics, which included the maximum number of trials. Typical antipsychotic agents were associated with severer side-effects than alpha-2 adrenergic agonist agents. Besides, Traditional Chinese Medicine showed positive effects in YGTSS (NingDong Granule: WMD=-7.100, 95% CI, -10.430- -3.770; 5-Ling Granule: WMD=-11.300, 95% CI, -14.208- -8.392), while glutamate modulators (D-serine, N-Acetylcysteine and riluzole) might not be working. In summary, alpha-2 adrenergic agonist agents were associated with the optimal weigh between efficacy and safety. However, the significant factor of limited trials and sample sizes discounted these findings. Further better studies are necessary to ascertain them.

Update on the Pharmacological Treatment of Tics with Dopamine-Modulating Agents

More than 40 years of research and clinical practice have proven the effectiveness of dopamine receptor antagonists in the pharmacological treatment of tics. A blockade of the striatal dopamine-D2 receptors is mainly responsible for their tic-reducing effect. A broad spectrum of dopamine-modulating agents, such as typical and atypical antipsychotics, but also dopamine receptor agonists are used with an immanent discord between experts about which of them should be considered as first choice. The present Review outlines the state of the art on pharmacological treatment of tics with dopamine-modulating agents by giving an systematic overview of studies on their effectiveness and a critical discussion of their specific adverse effects. It is considered as an update of a previous review of our research group published in 2013. The Review closes with a description of the current resulting treatment recommendations including the results of a first published revised survey on European expert's prescription preferences. Based on the enormously growing evidence on its effectiveness and safety, aripiprazole currently seems to be the most promising agent in the pharmacological treatment of tics. Furthermore, benzamides (especially tiapride), which are commonly used in Europe, have proven their excellent effectiveness-tolerability profile over decades in clinical practice and are therefore also highly recommended for the treatment of tics. Nevertheless, pharmacological treatment of tics remains an indiviual choice depending on each patient's own specific needs.

A multicenter examination and strategic revisions of the Yale Global Tic Severity Scale

OBJECTIVE

To examine the internal consistency and distribution of the Yale Global Tic Severity Scale (YGTSS) scores to inform modification of the measure.

METHODS

This cross-sectional study included 617 participants with a tic disorder (516 children and 101 adults), who completed an age-appropriate diagnostic interview and the YGTSS to evaluate tic symptom severity. The distributions of scores on YGTSS dimensions were evaluated for normality and skewness. For dimensions that were skewed across motor and phonic tics, a modified Delphi consensus process was used to revise selected anchor points.

RESULTS

Children and adults had similar clinical characteristics, including tic symptom severity. All participants were examined together. Strong internal consistency was identified for the YGTSS Motor Tic score (α = 0.80), YGTSS Phonic Tic score (α = 0.87), and YGTSS Total Tic score (α = 0.82). The YGTSS Total Tic and Impairment scores exhibited relatively normal distributions. Several subscales and individual item scales departed from a normal distribution. Higher scores were more often used on the Motor Tic Number, Frequency, and Intensity dimensions and the Phonic Tic Frequency dimension. By contrast, lower scores were more often used on Motor Tic Complexity and Interference, and Phonic Tic Number, Intensity, Complexity, and Interference.

CONCLUSIONS

The YGTSS exhibits good internal consistency across children and adults. The parallel findings across Motor and Phonic Frequency, Complexity, and Interference dimensions prompted minor revisions to the anchor point description to promote use of the full range of scores in each dimension. Specific minor revisions to the YGTSS Phonic Tic Symptom Checklist were also proposed.

Psychiatric Treatment and Management of Psychiatric Comorbidities of Movement Disorders

Pediatric movement disorders may present with psychiatric symptoms at many points during the course of the disease. For the relatively common pediatric movement disorder, Tourette syndrome, psychiatric comorbidities are well-described and treatment is well-studied. Managing these comorbidities may be more effective than improving the movements themselves. For more uncommon movement disorders, such as juvenile-onset Huntington disease, treatment of psychiatric comorbidities is not well-characterized, and best-practice recommendations are not available. For the least common movement disorders, such as childhood neurodegeneration with brain iron accumulation, psychiatric features may be nonspecific so that underlying diagnosis may be apparent only after recognition of other symptoms. However, psychiatric medication, psychotherapy, and psychosocial support for these disorders may prove helpful to many children and adolescents.

Neurocognitive correlates of treatment response in children with Tourette's Disorder

This paper examined neurocognitive functioning and its relationship to behavior treatment response among youth with Tourette's Disorder (TD) in a large randomized controlled trial. Participants diagnosed with TD completed a brief neurocognitive battery assessing inhibitory functions, working memory, and habit learning pre- and post-treatment with behavior therapy (CBIT, Comprehensive Behavioral Intervention for Tics) or psychoeducation plus supportive therapy (PST). At baseline, youth with tics and Attention Deficit Hyperactivity Disorder (ADHD) exhibited some evidence of impaired working memory and simple motor inhibition relative to youth with tics without ADHD. Additionally, a small negative association was found between antipsychotic medications and youth's performance speed. Across treatment groups, greater baseline working memory and aspects of inhibitory functioning were associated with a positive treatment response; no between-group differences in neurocognitive functioning at post-treatment were identified. Within the behavior therapy group, pre-treatment neurocognitive status did not predict outcome, nor was behavior therapy associated significant change in neurocognitive functioning post-treatment. Findings suggest that co-occurring ADHD is associated with some impairments in neurocognitive functioning in youth with Tourette's Disorder. While neurocognitive predictors of behavior therapy were not found, participants who received behavior therapy exhibited significantly reduced tic severity without diminished cognitive functioning.

Review of the evidence for the management of co-morbid Tic disorders in children and adolescents with attention deficit hyperactivity disorder

Attention deficit hyperactivity disorder (ADHD) is the most common neurodevelopmental disorder in children and adolescents, with prevalence ranging between 5% and 12% in the developed countries. Tic disorders (TD) are common co-morbidities in paediatric ADHD patients with or without pharmacotherapy treatment. There has been conflicting evidence of the role of psychostimulants in either precipitating or exacerbating TDs in ADHD patients. We carried out a literature review relating to the management of TDs in children and adolescents with ADHD through a comprehensive search of MEDLINE, EMBASE, CINAHL and Cochrane databases. No quantitative synthesis (meta-analysis) was deemed appropriate. Meta-analysis of controlled trials does not support an association between new onset or worsening of tics and normal doses of psychostimulant use. Supratherapeutic doses of dextroamphetamine have been shown to exacerbate TD. Most tics are mild or moderate and respond to psychoeducation and behavioural management. Level A evidence support the use of alpha adrenergic agonists, including Clonidine and Guanfacine, reuptake noradrenenaline inhibitors (Atomoxetine) and stimulants (Methylphenidate and Dexamphetamines) for the treatment of Tics and comorbid ADHD. Priority should be given to the management of co-morbid Tourette’s syndrome (TS) or severely disabling tics in children and adolescents with ADHD. Severe TDs may require antipsychotic treatment. Antipsychotics, especially Aripiprazole, are safe and effective treatment for TS or severe Tics, but they only moderately control the co-occurring ADHD symptomatology. Short vignettes of different common clinical scenarios are presented to help clinicians determine the most appropriate treatment to consider in each patient presenting with ADHD and co-morbid TDs.

Benchmarking Treatment Response in Tourette's Disorder: A Psychometric Evaluation and Signal Detection Analysis of the Parent Tic Questionnaire

This study assessed the psychometric properties of a parent-reported tic severity measure, the Parent Tic Questionnaire (PTQ), and used the scale to establish guidelines for delineating clinically significant tic treatment response. Participants were 126 children ages 9 to 17 who participated in a randomized controlled trial of Comprehensive Behavioral Intervention for Tics (CBIT). Tic severity was assessed using the Yale Global Tic Severity Scale (YGTSS), Hopkins Motor/Vocal Tic Scale (HMVTS) and PTQ; positive treatment response was defined by a score of 1 (very much improved) or 2 (much improved) on the Clinical Global Impressions - Improvement (CGI-I) scale. Cronbach's alpha and intraclass correlations (ICC) assessed internal consistency and test-retest reliability, with correlations evaluating validity. Receiver- and Quality-Receiver Operating Characteristic analyses assessed the efficiency of percent and raw-reduction cutoffs associated with positive treatment response. The PTQ demonstrated good internal consistency (α = 0.80 to 0.86), excellent test-retest reliability (ICC = .84 to .89), good convergent validity with the YGTSS and HM/VTS, and good discriminant validity from hyperactive, obsessive-compulsive, and externalizing (i.e., aggression and rule-breaking) symptoms. A 55% reduction and 10-point decrease in PTQ Total score were optimal for defining positive treatment response. Findings help standardize tic assessment and provide clinicians with greater clarity in determining clinically meaningful tic symptom change during treatment.

A Randomized Controlled Trial Comparing Behavioral, Educational, and Pharmacological Treatments in Youths With Chronic Tic Disorder or Tourette Syndrome

CONTEXT

The existing literature on the treatment of pediatric chronic tic disorder (CTD) and Tourette syndrome (TS) indicates that both behavioral therapy (BT) and pharmacotherapy (PT) are effective for reducing symptoms.

OBJECTIVE

To evaluate the efficacy of BT compared to psychoeducation (PE) or PT for reducing tics and co-occurring symptoms and for improving quality of life (QoL) in a sample of youths with CTD and TS.

DESIGN

A 10 weeks, 2 sites (Catania, Rome) randomized controlled trial. Participants were randomized to receive one of the following treatments: BT, PE, or PT.

PARTICIPANTS

110 outpatients aged between 8 and 17 years affected by CTD or TS.

RESULTS

Patients in the BT and PT groups showed a significant reduction in the severity of tic symptoms, while the PE group did not show any improvement. PT was more effective for reducing obsessive compulsive symptoms than BT, while PE group did not show any improvement. Both BT and PT groups showed an improvement in most QoL domains, whereas no differences were found in the PE group.

CONCLUSIONS

BT is as effective as pharmacological therapy in the treatment of tic disorders in children and adolescents, thus offering an alternative to medications for CTD and TS.

Quality assessment of clinical practice guidelines on tic disorders with AGREE II instrument

To assess the methodological quality of existing clinical practice guidelines (CPGs) on the treatment of tic disorders (TDs) using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument and summarize the guideline recommendations. Five CPGs met our inclusion criteria. The mean percentages for the AGREE II domain scores were: scope and purpose 83.33% (95% confidence interval [CI], 77.78-94.44%), stakeholder involvement 62.22% (95% CI, 38.89-94.44%), rigor of development 47.08% (95% CI, 6.25-83.33%), clarity of presentation 87.78% (95% CI, 72.22-94.44%), applicability 56.67% (95% CI, 33.33-87.50%), and editorial independence 46.67% (95% CI, 8.33-91.67%). There were large differences among the five CPGs concerning the categorization of evidence and recommendations. The recommendations for drug therapy were similar in all five CPGs, although there was controversy in certain areas. The methodological quality of CPGs for TDs was acceptable in terms of scope and purpose, stakeholder involvement, and clarity of presentation. However, CPG developers need to pay more attention to rigorous development processes, applicability, and editorial independence. Developers of future CPGs should improve adherence to the AGREE II guidelines. In addition, high quality studies on the treatment of TDs are needed to provide more evidence for developing guidelines.

The Effect of Fecal Microbiota Transplantation on a Child with Tourette Syndrome

Tourette syndrome is a neuropsychiatric disorder with onset in childhood. New therapies are needed to effectively manage and treat this condition. Gut microbiota can affect central physiology and function via the microbiota-gut-brain axis. Here, we report a case in which fecal microbiota transplantation (FMT) is used to treat a child with Tourette syndrome, whose symptoms ameliorated dramatically in the following eight weeks.

Tics and Tourette: a clinical, pathophysiological and etiological review

PURPOSE OF REVIEW

Describe developments in the etiological understanding of Tourette syndrome.

RECENT FINDINGS

Tourette syndrome is a complex heterogenous clinical syndrome, which is not a unitary entity. Pathophysiological models describe gamma-aminobutyric acid-ergic-associated disinhibition of cortico-basal ganglia motor, sensory and limbic loops. MRI studies support basal ganglia volume loss, with additional white matter and cerebellar changes. Tourette syndrome cause likely involves multiple vulnerability genes and environmental factors. Only recently have some vulnerability gene findings been replicated, including histidine decarboxylase and neurexin 1, yet these rare variants only explain a small proportion of patients. Planned large genetic studies will improve genetic understanding. The role of inflammation as a contributor to disease expression is now supported by large epidemiological studies showing an association with maternal autoimmunity and childhood infection. Investigation of blood cytokines, blood mRNA and brain mRNA expression support the role of a persistent immune activation, and there are similarities with the immune literature of autistic spectrum disorder. Current treatment is symptomatic, although there is a better appreciation of factors that influence treatment response.

SUMMARY

At present, therapeutics is focused on symptom-based treatments, yet with improved etiological understanding, we will move toward disease-modifying therapies in the future.

Tic Severity and Treatment in Children: The Effect of Comorbid Attention Deficit Hyperactivity Disorder and Obsessive Compulsive Behaviors

While attention deficit hyperactivity disorder (ADHD) and obsessive compulsive disorder have been shown to have major impacts on quality of life in individuals with Tourette syndrome, there is comparatively little data on how the presence of these comorbidities influence tic severity and treatment. 114 children (mean age 10.25 years) were extensively clinically phenotyped at a single specialty clinic. While there was no difference in Yale Global Tic Severity Scale (YGTSS) scores in children with versus without ADHD, children with obsessive compulsive behaviors had significantly higher YGTSS scores (p = 0.008). There was a significant correlation between YGTSS scores and age (r = 0.344, p < 0.001). Children with ADHD were more likely to be treated for their tics within the first two years of diagnosis (OR 3.51, p = 0.009). As tic severity does not appear to be greater in children with ADHD, this association may relate to greater overall psychosocial impairment in children with this comorbidity.

Extended-Release Guanfacine Does Not Show a Large Effect on Tic Severity in Children with Chronic Tic Disorders

OBJECTIVE

To evaluate the tolerability, safety, and preliminary efficacy of extended-release guanfacine in children with chronic tic disorders, including Tourette's disorder (collectively referred to as CTD).

METHODS

This was a multisite, 8-week, randomized, double-blind, placebo-controlled trial. The primary outcome measure was the Yale Global Tic Severity Scale (YGTSS) total score. Key secondary outcomes included the Improvement item of Clinical Global Impressions-Improvement (CGI-I) scale and the Tic Symptom Self-report (TSSR). Adverse events were monitored at each visit.

RESULTS

Thirty-four subjects (23 boys and 11 girls) of ages 6 to 17 years (mean = 11.1 ± 3.1) with CTD were randomly assigned to extended-release guanfacine (n = 16) or placebo (n = 18). At baseline, the mean YGTSS total score was 26.3 ± 6.6 for the guanfacine group versus 27.7 ± 8.7 for the placebo group. Within the guanfacine group (mean final daily dose of 2.6 ± 1.1 mg, n = 14), the mean YGTSS total score declined to 23.6 ± 6.42 [t(15) = 1.84, p = 0.08; effect size = 0.35]. The results were similar in the placebo group with a score of 24.7 ± 10.54 at week 8 [t(17) = 1.83, p = 0.08; effect size = 0.38]. There was no significant difference in the rate of positive response on the CGI-I between the guanfacine group and placebo (19% [3/16] vs. 22% [4/18], p = 1.0). The most common adverse events were fatigue, drowsiness, dry mouth, headache, and irritability. Two subjects in the guanfacine group discontinued early-one because of an adverse event (depressed mood) and one because of lack of efficacy; two subjects in the placebo group discontinued because of lack of efficacy.

CONCLUSIONS

This pilot study did not confirm a clinically meaningful effect size within the guanfacine group. These results do not support the launch of a larger efficacy trial for tics in children and adolescents with CTD.

Randomized, Double-Blind, Placebo-Controlled Trial Demonstrates the Efficacy and Safety of Oral Aripiprazole for the Treatment of Tourette's Disorder in Children and Adolescents

OBJECTIVES

Aripiprazole modulates dopaminergic and serotonergic pathways that may play a role in the pathogenesis of Tourette's disorder (TD). This trial evaluated the efficacy and safety of oral aripiprazole in the suppression of tics in children and adolescents with TD.

METHODS

This phase 3, randomized, double-blind, placebo-controlled trial ( ClinicalTrials.gov , NCT01727700) recruited patients who were 7-17 years old with a diagnosis of TD from hospitals, private practices, and research clinics at 76 sites in the United States, Canada, Hungary, and Italy. Patients were randomized in a 1:1:1 ratio by using an interactive voice/web-response system to low-dose aripiprazole (5 mg/day if <50 kg; 10 mg/day if ≥50 kg), high-dose aripiprazole (10 mg/day if <50 kg; 20 mg/day if ≥50 kg), or placebo for 8 weeks. Randomization was stratified by region (North America or Europe) and baseline body weight (<50 kg vs. ≥50 kg). The primary efficacy endpoint was mean change from baseline to week 8 in the Yale Global Tic Severity Scale Total Tic Score (YGTSS-TTS) for the intent-to-treat population.

RESULTS

Between November 2012 and May 2013, 133 patients were recruited and randomized to low-dose aripiprazole (n = 44), high-dose aripiprazole (n = 45), or placebo (n = 44). Least-squares mean treatment differences versus placebo in change from baseline to week 8 in the YGTSS-TTS were statistically significant (high dose, -9.9 [95% confidence interval, CI, -13.8 to -5.9], low dose, -6.3 [95% CI, -10.2 to -2.3]). At week 8, 69% (29/42) of patients in the low-dose and 74% (26/35) of patients in the high-dose aripiprazole groups demonstrated a Clinical Global Impression-Tourette's Syndrome improvement score of 1 (very much improved) or 2 (much improved) compared with 38% (16/42) in the placebo group. The most common adverse events (AEs) were sedation (low dose, 8/44 [18.2%], high dose, 4/45 [8.9%], placebo, 1/44 [2.3%]), somnolence (low dose, 5/44 [11.4%], high dose, 7/45 [15.6%], placebo, 1/44 [2.3%]), and fatigue (low dose, 3/44 [6.8%], high dose, 7/45 [15.6%], placebo, 0). No serious AEs or deaths occurred.

CONCLUSIONS

This study indicates that oral aripiprazole is a safe and effective treatment for tics in children and adolescents with TD.

Clinical Management of Pediatric Acute-Onset Neuropsychiatric Syndrome: Part I-Psychiatric and Behavioral Interventions

OBJECTIVE

This article outlines the consensus guidelines for symptomatic treatment for children with Pediatric Acute-Onset Neuropsychiatric Syndrome (PANS) and Pediatric Autoimmune Neuropsychiatric Syndrome Associated with Streptococcal Infection (PANDAS).

METHODS

Extant literature on behavioral, psychotherapeutic, and psychopharmacologic treatments for PANS and PANDAS was reviewed. Members of the PANS Research Consortium pooled their clinical experiences to find agreement on treatment of PANS and PANDAS symptoms.

RESULTS

Current guidelines result from consensus among the Consortium members.

CONCLUSION

While underlying infectious and inflammatory processes in PANS and PANDAS patients are treated, psychiatric and behavioral symptoms need simultaneous treatment to decrease suffering and improve adherence to therapeutic intervention. Psychological, behavioral, and psychopharmacologic interventions tailored to each child's presentation can provide symptom improvement and improve functioning during both the acute and chronic stages of illness. In general, typical evidence-based interventions are appropriate for the varied symptoms of PANS and PANDAS. Individual differences in expected response to psychotropic medication may require marked reduction of initial treatment dose. Antimicrobials and immunomodulatory therapies may be indicated, as discussed in Parts 2 and 3 of this guideline series.

Outpatient Treatment Patterns of Pediatric Obsessive-Compulsive Disorder

INTRODUCTION

Little is known about community physician treatment practices for children with obsessive-compulsive disorder (OCD). This study is the first to describe the treatment of pediatric OCD in office-based and outpatient department-based physicians in the United States.

METHODS

Data from the 2003-2011 National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey were used. We provided descriptive statistics for sample characteristics and treatments administered during the visit, and examined differences in treatment by comorbid conditions and settings using logistic regression.

RESULTS

Psychotherapy was provided in 46% of visits in children with OCD overall, while serotonin reuptake inhibitor (SRI) medication was prescribed to 55% overall, atypical antipsychotics were prescribed to 22% of youth either alone or in combination with another medication; 11% received no psychotherapy or pharmacotherapy. Psychotherapy and at least one pharmacotherapy were provided to 36% of patients. There were no significant differences in characteristics of patients receiving each class of medication.

CONCLUSION

Among children and adolescents, OCD was primarily treated by physicians using SRI medication and/or psychotherapy. A sizeable proportion of children were given atypical antipsychotic medications. Wider dissemination of evidence-based psychological treatments and continued monitoring of adherence to guidelines is warranted.

Tourette syndrome increases risk of bone fractures: a population-based cohort study

This study assesses the risk of fractures among children with Tourette syndrome (TS), and identifies the effects of comorbidities and antipsychotics. We randomly sampled the claims data of 1 million enrollees in the National Health Insurance program of Taiwan, and identified 1258 children with TS diagnosed between 2000 and 2010. Additionally, 12,580 children without TS who were frequency matched for sex, age, residential area, parental occupation, and index year were identified for comparison. The children's cases were followed until December 31, 2010, or censored to ascertain incident fractures cases and associations with comorbidities of attention-deficit/hyperactivity disorder (ADHD) or obsessive-compulsive disorder (OCD) and treatments with antipsychotics, antidepressants, or clonidine. The TS cohort had a 1.27-fold higher incidence of fractures than did the comparison cohort (190.37 vs. 149.94 per 10,000 person-years), with an adjusted hazard ratio (HR) of 1.28 [95% confidence interval (CI) 1.06-1.55] based on multivariable Cox regression analysis. This increased risk of fractures was apparent for fractures of the skull, neck, and spine. Comorbid ADHD and OCD did not result in an additional risk of fractures. The children without both ADHD and OCD were also at a higher risk of fractures, indicating that TS alone increases the risk of fractures. The children taking antipsychotics had a reduced risk of fractures, and the adjusted HR decreased to 1.17 (95% CI 0.90-1.52). Children with TS have an increased risk of fractures. ADHD and OCD do not increase the risk further.

Behavioral therapy for Tourette syndrome and chronic tic disorders

Purpose of review

To summarize behavioral interventions for the treatment of primary tic disorders.

Recent findings

Although tics were attributed to a disordered weak volition, the shift towards neurobiological models of tic disorders also transformed nonpharmacologic treatment practices. Current international guidelines recommend habit reversal training, comprehensive behavioral intervention, and exposure and response prevention as first-line therapies for tics. Appropriate patient selection, including age and presence of comorbidities, are salient clinical features that merit consideration. Evidence for further behavioral interventions is also presented.

Summary

Currently recommended behavioral interventions view tics as habitual responses that may be further strengthened through negative reinforcement. Although availability and costs related to these interventions may limit their effect, Internet-based and telehealth approaches may facilitate wide accessibility. Novel nonpharmacologic treatments that take different approaches, such as autonomic modulation or attention-based interventions, may also hold therapeutic promise.

Outpatient Treatment of Tic Disorders Among Children and Adults

Introduction

Limited information is available regarding treatment practices in applied settings for children and adults with tic disorders (TDs). We describe, for the first time, the treatment of TDs in U.S. children and adults in the outpatient setting.

Methods

Data from the 2003-2010 National Ambulatory Medical Care Survey and the National Hospital Ambulatory Care Survey were used. Descriptive statistics for modality of treatment and class of pharmacological medications were reported by patient and visit characteristics. Separate multivariable logistic regression models were used to examine associations between patient and visit characteristics and classes of medications prescribed.

Results

One third (n = 99) of the sample did not receive any psychiatric or psychological treatment. Nearly two-thirds received a psychotropic medication. The most common class of medication was alpha-2 agonists (25%), followed by stimulants (23%), serotonin-reuptake inhibitors (SRIs) (19%), atypical antipsychotics (18%), anxiolytics (14%), anticonvulsants (11%), and typical antipsychotics (8%). Comorbid disorders and chronicity of problems were significantly associated with the receipt of certain classes of medications. Relatively few patients (18%) received psychotherapy.

Conclusions

If the decision is made to treat tic disorders, the choice of medication is dependent on the primary complaints, severity, chronicity, and the presence of comorbid psychiatric disorders. In general, comorbid externalizing, anxiety and mood disorders appear to influence treatment decisions in addition to TDs.

Tics in the Pediatric Population: Pragmatic Management

BACKGROUND

Primary tic disorders, notably Tourette syndrome, are very common movement disorders in childhood. However, the management of such patients still poses great therapeutic challenges to medical professionals.

METHODS

Based on a synthesis of the available guidelines published in Europe, Canada, and the United States, coupled with more recent therapeutic developments, the authors provide a pragmatic guide to aid clinicians in deciding when and how to treat patients who have primary tic disorders.

RESULTS

After a systematic assessment of tics and common neuropsychiatric comorbidities (primarily attention-deficit hyperactivity disorder [ADHD] and obsessive-compulsive disorder [OCD]), the first step in treatment is a comprehensive psychoeducation of patients and families that addresses the protean phenomenology of tics and associated behaviors, coping mechanisms, prognosis, and treatment options. When more active intervention beyond watchful monitoring is indicated, hierarchical evaluation of treatment targets (i.e., tics vs. comorbid behavioral symptoms) is crucial. Behavioral treatments for tics are restricted to older children and are not readily available to all centers, mainly due to the paucity of well-trained therapists. Pharmacological treatments, such as antipsychotics for tics, stimulants and atomoxetine for ADHD, and α2A-agonists for children with tics plus ADHD, represent widely available and effective treatment options, but safety monitoring must be provided. Combined polypharmacological and behavioral/pharmacological approaches, as well as neuromodulation strategies, remain under-investigated in this population of patients.

CONCLUSIONS

The treatment of children with tics and Tourette syndrome is multifaceted. Multidisciplinary teams with expertise in neurology, psychiatry, psychology, and pediatrics may be helpful to address the complex needs of these children.

A search for the common ground between Tic; Obsessive-compulsive and Autism Spectrum Disorders: part I, Tic disorders

This article is the first of four articles designed to explore the complex interrelationship between Autism Spectrum Disorders (ASD); Obsessive compulsive and Related Disorders (OCRD) and Tic Disorders/Tourette's Syndrome (TD/TS). We begin with an overview TD/TS and follow-up with reviews of OCRD and ASD. The final article in this series represents a synthesis of the neurobiological and genetic markers shared by patients presenting with all three syndromes. The goal is to describe the complex endophenotype of these patients in an effort to better define gene markers that underlie these heterogeneous clinical syndromes. Tic disorders (TD) are a collection of hyperkinetic movements that begin in early childhood. Tics are transient for most affected preschool children but a subgroup development persistent movements or progress to develop Tourette Syndrome (TS). TDs as a group display high heritability rates but definitive gene markers still elude us. The difficulty defining genetic markers is in large part due to the diverse neurodevelopmental trajectory, changing topography and typology, development of a broad spectrum of neurocognitive and behavioral complications, and a mixed pattern of psychiatric comorbidities.

Moderators and predictors of response to behavior therapy for tics in Tourette syndrome

OBJECTIVE

To examine moderators and predictors of response to behavior therapy for tics in children and adults with Tourette syndrome and chronic tic disorders.

METHODS

Data from 2 10-week, multisite studies (1 in children and 1 in adults; total n = 248) comparing comprehensive behavioral intervention for tics (CBIT) to psychoeducation and supportive therapy (PST) were combined for moderator analyses. Participants (177 male, 71 female) had a mean age of 21.5 ± 13.9 years (range 9-69). Demographic and clinical characteristics, baseline tic-suppressing medication, and co-occurring psychiatric disorders were tested as potential moderators for CBIT vs PST or predictors of outcome regardless of treatment assignment. Main outcomes measures were the Yale Global Tic Severity Scale Total Tic score and the Clinical Global Impression-Improvement score assessed by masked evaluators.

RESULTS

The presence of tic medication significantly moderated response to CBIT vs PST (p = 0.01). Participants showed tic reduction after CBIT regardless of tic medication status, but only participants receiving tic medication showed reduction of tics after PST. Co-occurring psychiatric disorders, age, sex, family functioning, tic characteristics, and treatment expectancy did not moderate response. Across both treatments, greater tic severity (p = 0.005) and positive participant expectancy (p = 0.01) predicted greater tic improvement. Anxiety disorders (p = 0.042) and premonitory urge severity (p = 0.005) predicted lower tic reduction.

CONCLUSIONS

Presence of co-occurring attention-deficit/hyperactivity disorder, obsessive-compulsive disorder, or anxiety disorders did not moderate response to CBIT. Although participants on tic medication showed improvement after CBIT, the difference between CBIT and PST was greater for participants who were not on tic-suppressing medication.

CLINICALTRIALSGOV IDENTIFIERS

The child and adult CBIT studies are listed on clinical trials.gov (NCT00218777 and NCT00231985, respectively).

CLASSIFICATION OF EVIDENCE

This study provides Class I evidence that CBIT is effective in reducing tic severity across subgroups of patients with chronic tic disorders, although the difference between treatments was smaller for participants on tic-suppressing medications, suggesting reduced efficacy in this subgroup.

Gilles de la Tourette syndrome

Gilles de la Tourette syndrome (GTS) is a childhood-onset neurodevelopmental disorder that is characterized by several motor and phonic tics. Tics usually develop before 10 years of age, exhibit a waxing and waning course and typically improve with increasing age. A prevalence of approximately 1% is estimated in children and adolescents. The condition can result in considerable social stigma and poor quality of life, especially when tics are severe (for example, with coprolalia (swearing tics) and self-injurious behaviours) or when GTS is accompanied by attention-deficit/hyperactivity disorder, obsessive-compulsive disorder or another neuropsychiatric disorder. The aetiology is complex and multifactorial. GTS is considered to be polygenic, involving multiple common risk variants combined with rare, inherited or de novo mutations. These as well as non-genetic factors (such as perinatal events and immunological factors) are likely to contribute to the heterogeneity of the clinical phenotype, the structural and functional brain anomalies and the neural circuitry involvement. Management usually includes psychoeducation and reassurance, behavioural methods, pharmacotherapy and, rarely, functional neurosurgery. Future research that integrates clinical and neurobiological data, including neuroimaging and genetics, is expected to reveal the pathogenesis of GTS at the neural circuit level, which may lead to targeted interventions.