Cognitive Flexibility and Social Responsiveness in Children and Adolescents with Tourette Syndrome

A Metacontrol Perspective on Neurocognitive Atypicality: From Unipolar to Bipolar Accounts

Standard clinical and psychiatric thinking follows a unipolar logic that is centered at "normal" conditions characterized by optimal performance in everyday life, with more atypical conditions being defined by the (degree of) absence of "normality." A similar logic has been used to describe cognitive control, assuming that optimal control abilities are characterized by a strong focus on the current goal and ignorance of goal-irrelevant information (the concept of willpower), while difficulties in focusing and ignoring are considered indications of the absence of control abilities. However, there is increasing evidence that willpower represents only one side of the control coin. While a strong focus on the current goal can be beneficial under some conditions, other conditions would benefit from a more open mind, from flexibility to consider alternative goals and information related to them. According to the metacontrol model, people can vary in their cognitive processing style, on a dimension with the extreme poles of "persistence" on the one hand and "flexibility" on the other. Whereas a high degree of persistence corresponds to the original idea of cognitive control as willpower, with a strong focus on one goal and the information related to it, a high degree of flexibility is characterized by a more integrative, less selective and exclusive processing style, which facilitates switching between tasks, ideas, and actions, and taking into consideration a broader range of possibilities. We argue that this approach calls for a more bipolar account in the clinical sciences as well. Rather than considering individuals as typical or atypical, it would theoretically and practically make more sense to characterize their cognitive abilities in terms of underlying dimensions, such as the persistence/flexibility dimension. This would reveal that possible weaknesses with respect to one pole, such as persistence, and tasks relying thereupon, may come with corresponding strengths with respect to the other pole, such as flexibility, and respective tasks. We bolster our claim by discussing available evidence suggesting that neurodevelopmental atypicality often comes with weaknesses in tasks related to one pole but strengths in tasks related to the other.

A neural noise account of Gilles de la Tourette syndrome

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A neural noise account on Tourette syndrome is conceptualized.

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We outline how neurophysiological methods can be used to test this account.

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The neural noise account may lead to novel treatment options.

Tics, often preceded by premonitory urges, are the clinical hallmark of Tourette syndrome. They resemble spontaneous movements, but are exaggerated, repetitive and appear misplaced in a given communication context. Given that tics often go unnoticed, it has been suggested that they represent a surplus of action, or motor noise. In this conceptual position paper, we propose that tics and urges, but also patterns of the cognitive profile in Tourette syndrome might be explained by the principle of processing of neural noise and adaptation to it during information processing. We review evidence for this notion in the light of Tourette pathophysiology and outline why neurophysiological and imaging approaches are central to examine a possibly novel view on Tourette syndrome. We discuss how neurophysiological data at multiple levels of inspections, i.e., from local field potentials using intra-cranial recording to scalp-measured EEG data, in combination with imaging approaches, can be used to examine the neural noise account in Tourette syndrome. We outline what signal processing methods may be suitable for that. We argue that, as a starting point, the analysis of 1/f neural noise or scale-free activity may be suitable to investigate the role of neural noise and its adaptation during information processing in Tourette syndrome. We outline, how the neural noise perspective, if substantiated by further neurophysiological studies and re-analyses of existing data, may pave the way to novel interventions directly targeting neural noise levels and patterns in Tourette syndrome.

Relations Between Tic Severity, Emotion Regulation, and Social Outcomes in Youth with Tourette Syndrome

This study examined associations between tic severity, emotion regulation, social functioning, and social impairment in youth with Tourette Syndrome (TS). Emotion regulation was examined as a mediator between tic severity and social outcomes. Seventy-seven caregivers of youth with TS (M age = 13.1 years; SD = 2.29) were administered proxy-report measures of tic severity, emotion regulation, social functioning, and social impairment. Total and motor tic severity were negatively associated with emotion regulation and social functioning, and positively associated with social impairment (r's = 0.23 to 0.43). Vocal tic severity was not related to emotion regulation or social functioning, but was positively associated with social impairment (r = 0.36). Emotion regulation mediated the relations between total tic severity and both social outcomes, and motor tic severity and both social outcomes. Interventions that target emotion regulation would likely be a beneficial adjunctive therapy for youth with TS, and may result in improved social outcomes.

The psychology of Tourette disorder: Revisiting the past and moving toward a cognitively-oriented future

Tourette syndrome is a neurodevelopmental disorder characterized by chronic tics (i.e., repetitive and stereotyped movements and vocalizations) and premonitory urges (i.e., aversive sensations preceding tics that are alleviated once a tic is performed). Research supports that dysfunctional neurobiological and psychological processes interact and contribute to the development and maintenance of tics. However, psychological theories of Tourette syndrome and accompanying research have mainly focused on the emotional states (e.g., anxiety and frustration) and behavioural principles (i.e., operant conditioning) that play a role in tic exacerbation. This selective review summarizes key discoveries pertaining to the emotional and behavioural aspects of Tourette syndrome but also proposes a more comprehensive, cognitively-oriented conceptualization of the disorder. Specifically, it is proposed that maladaptive beliefs about discomfort and about one's ability to cope with discomfort underlie negative appraisals of unpleasant sensory experiences in individuals with Tourette syndrome. It is further suggested that these beliefs lead individuals to perceive premonitory urges in a catastrophic manner and thereby enhance tic frequency. Concrete research avenues to empirically examine these hypotheses are outlined and clinical implications for the field of cognitive-behaviour therapy are discussed.

Are the components of social reciprocity transdiagnostic across pediatric neurodevelopmental disorders? Evidence for common and disorder-specific social impairments

Deficits in social communication are a core feature of autism spectrum disorder (ASD), yet significant social problems have been observed in youth with many neurodevelopmental disorders. In this preliminary investigation, we aimed to explore whether domains of social reciprocity (i.e., social communication, social cognition, social awareness, social motivation, and restricted and repetitive behaviors) represent transdiagnostic traits. These domains were compared across youth ages 7-17 with obsessive-compulsive disorder (OCD; N = 32), tic disorders (TD; N = 20), severe mood dysregulation (N = 33) and autism spectrum disorder (N = 35). While the ASD group was rated by parents as exhibiting the greatest social reciprocity deficits across domains, a high proportion of youth with severe mood dysregulation also exhibited pronounced deficits in social communication, cognition, and awareness. The ASD and severe mood dysregulation groups demonstrated comparable scores on the social awareness domain. In contrast, social motivation and restricted and repetitive behaviors did not appear to be transdiagnostic domains in severe mood dysregulation, OCD, or TD groups. The present work provides preliminary support that social awareness, and to a lesser extent social communication and cognition, may represent features of social reciprocity that are transdiagnostic across ASD and severe mood dysregulation.

Social cognition and self-other distinctions in neuropsychiatry: Insights from schizophrenia and Tourette syndrome

Impairments in social cognition may reflect dysfunction of disorder specific or disorder general mechanisms. Although cross-disorder comparison may prove insightful, few studies have compared social cognition in different neuropsychiatric disorders. Parallel investigation of schizophrenia and Tourette syndrome (TS) is encouraged by similarities including the presence of problematic social behavior, echophenomena, emotional dysregulation and dopamine dysfunction. Focusing on tests of social cognition administered in both disorders, this review aims to summarize behavioral, neurophysiological and neuroimaging findings, before exploring how these may contribute to clinical symptoms. Studies investigating social cognition (imitation, emotion recognition, and understanding of beliefs or intentions) in patients with schizophrenia or TS were identified through Web of Science and PubMed searches. Although findings indicate that social cognitive deficits are more apparent in schizophrenia, adults with TS can exhibit similar task performance to patients with paranoia. In both disorders, behavioral and neuroimaging findings raise the possibility of increased internal simulation of others' actions and emotions, in combination with a relative under-application of mentalizing. More specifically, dysfunction in neurobiological substrates such as temporo-parietal junction and inferior frontal gyrus may underlie problems with self-other distinctions in both schizophrenia and TS. Difficulties in distinguishing between actions and mental states linked to the self and other may contribute to a range of psychiatric symptoms, including emotional dysregulation, paranoia, social anhedonia and socially disruptive urges. Comparing different patient populations could therefore reveal common neuro-cognitive risk factors for the development of problematic social behaviors, in addition to markers of resilience, coping strategies and potential neuro-compensation mechanisms.

A Review of the Neuropsychological Dimensions of Tourette Syndrome

Neurocognitive functioning in Tourette syndrome (TS) has been the subject of intensive research in the past 30 years. A variety of impairments, presumably related to frontal and frontostriatal dysfunctions, have been observed. These impairments were found in various domains, such as attention, memory, executive functions, language, motor and visuomotor functions, among others. In line with contemporary research, other neurocognitive domains have recently been explored in TS, bringing evidence of altered social reasoning, for instance. Therefore, the aims of this review are to give an overview of the neuropsychological dimensions of TS, to report how neuropsychological functions evolve from childhood to adulthood, and to explain how various confounding factors can affect TS patients' performance in neuropsychological tasks. Finally, an important contribution of this review is to show how recent research has confirmed or changed our beliefs about neuropsychological functioning in TS.

Cognitive flexibility and its electrophysiological correlates in Gilles de la Tourette syndrome

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Gilles de la Tourette syndrome (GTS) may involve cognitive inflexibility.

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A meta-analysis reveals GTS-related deficits on the Wisconsin Card Sorting Test.

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Card-sorting deficits are larger in children than in adults with GTS.

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Adults with GTS show electrophysiological signs of enhanced cognitive control.

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This change may underlie the normalization of cognitive flexibility in adult GTS.

Motor symptoms in Gilles de la Tourette syndrome (GTS) have been related to changes in frontostriatal brain networks. These changes may also give rise to alterations in cognitive flexibility. However, conclusive evidence for altered cognitive flexibility in patients with GTS is still lacking. Here, we meta-analyzed data from 20 neuropsychological studies that investigated cognitive flexibility in GTS using the Wisconsin Card Sorting Test (WCST). Results revealed medium-sized GTS-related performance deficits, which were significantly modulated by age: Whilst being substantial in children and adolescents with GTS, WCST deficits seem to dissolve in adult patients with GTS. This age-related normalization of WCST performance might result from the compensatory recruitment of cognitive control in adult patients with GTS. We addressed this possibility by examining neural correlates of proactive and reactive cognitive control in an event-related potential (ERP) study. We analyzed cue- and target-locked ERPs from 23 adult patients with GTS and 26 matched controls who completed a computerized version of the WCST. Compared to controls, patients with GTS showed a marked increase in parietal cue-locked P3 activity, indicating enhanced proactive cognitive control. We conclude that the additional recruitment of proactive cognitive control might ensure flexible cognitive functioning in adult patients with GTS.

"I'm not being rude, I'd want somebody normal": Adolescents' Perception of their Peers with Tourette's Syndrome: an Exploratory Study

Tourette's syndrome (TS) is a highly stigmatised condition, and typically developing adolescents' motives and reasons for excluding individuals with TS have not been examined. The aim of the study was to understand how TS is conceptualised by adolescents and explore how individuals with TS are perceived by their typically developing peers. Free text writing and focus groups were used to elicit the views of twenty-two year ten students from a secondary school in South East England. Grounded theory was used to develop an analytical framework. Participants' understanding about the condition was construed from misconceptions, unfamiliarity and unanswered questions. Adolescents who conceived TS as a condition beyond the individual's control perceived their peers as being deprived of agency and strength and as straying from the boundaries of normalcy. People with TS were viewed as individuals deserving pity, and in need of support. Although participants maintained they had feelings of social politeness towards those with TS, they would avoid initiating meaningful social relationships with them due to fear of 'social contamination'. Intergroup anxiety would also inhibit a close degree of social contact. Participants that viewed those with TS as responsible for their condition expressed a plenary desire for social distance. However, these behavioural intentions were not limited to adolescents that elicited inferences of responsibility to people with TS, indicating that attributional models of stigmatisation may be of secondary importance in the case of TS. Implications for interventions to improve school belonging among youth with TS are discussed.

Tourette syndrome research highlights 2015

We present selected highlights from research that appeared during 2015 on Tourette syndrome and other tic disorders. Topics include phenomenology, comorbidities, developmental course, genetics, animal models, neuroimaging, electrophysiology, pharmacology, and treatment. We briefly summarize articles whose results we believe may lead to new treatments, additional research or modifications in current models of TS.

Changes in Socio-Emotional and Behavioral Functioning After Attending a Camp for Children with Tourette Syndrome: A Preliminary Investigation

Children and adolescents with Tourette syndrome are at risk for social, emotional, and behavioral difficulties that may negatively influence feelings of self-competence and attitudes toward having this diagnosis. Attending a camp for children with Tourette syndrome may facilitate improvements in overall socio-emotional and behavioral functioning and self-perception. The current study obtained data from 37 campers (76 % male, 24 % female) and 47 caregivers of campers to investigate changes in children's emotional and behavioral functioning, self-perception (i.e., social and general), attitudes towards having Tourette syndrome, and how different they felt from peers after attending a 1-week summer camp for youth with Tourette syndrome using a pre-post design. Results indicated that campers endorsed a significantly improved sense of social self-competence and more favorable attitudes toward having Tourette syndrome post-camp. Campers also tended to endorse feeling less different than peers at camp versus peers in general. Caregivers endorsed significantly less severe symptoms associated with Tourette syndrome for campers after attending camp. No pre-to-post-camp changes were observed for campers' levels of anxiety or obsessive-compulsive symptoms. These preliminary findings suggest that attending camp or having other opportunities to interact with similar peers may promote better perceptions of social self-competence, more favorable attitudes toward having Tourette syndrome, and a stronger sense of affiliation with peers for children with Tourette syndrome.