Informativeness of structured diagnostic interviews in the identification of Tourette's disorder in referred youth

In Memoriam: Professor Joseph Biederman's Contributions to Child and Adolescent Psychiatry

OBJECTIVE

To provide an overview of Joe Biederman's contributions to child and adolescent psychiatry.

METHOD

Nine colleagues described his contributions to: psychopharmacology, comorbidity and genetics, pediatric bipolar disorder, autism spectrum disorders, Tourette's and tic disorders, clinical and neuro biomarkers for pediatric mood disorders, executive functioning, and adult ADHD.

RESULTS

Joe Biederman left us with many concrete indicators of his contributions to child and adolescent psychiatry. He set up the world's first pediatric psychopharmacology clinic and clinical research program in child adolescent psychiatry. As a young faculty member he began a research program that led to many awards and eventual promotion to full professor at Harvard Medical School. He was for many years the most highly cited researcher in ADHD. He achieved this while maintaining a full clinical load and was widely respected for his clinical acumen.

CONCLUSION

The world is a better place because Joe Biederman was here.

Utility of the diagnostic interview schedule for children for assessing Tourette syndrome in children

OBJECTIVE

The Diagnostic Interview Schedule for Children IV (DISC) has been used extensively in research and screening. Despite wide use, little information exists on the validity of the DISC for diagnosing tic disorders.

METHODS

Participants were 181 youth with expert clinician-diagnosed Tourette syndrome (TS).

RESULTS

Using expert clinician-diagnosed TS as the gold standard, the sensitivity of the DISC-Y (youth, 0.27) and DISC-P (parent, 0.44) was poor. The DISC-Y identified 29.7% of youth with diagnosed TS whereas the DISC-P identified 47.4% of cases. Only 54% of cases of TS were detected by either the DISC-Y or -P. Diagnostic agreement between the DISC and expert clinician diagnosis was poor. The DISC-Y/P results did not differ as a function of tic severity.

CONCLUSIONS

Despite utility for assessing child psychiatric disorders, the sensitivity of the DISC for detecting TS appears poor. This study suggests that DISC has low agreement with expert clinician diagnosis of TS. Findings highlight the need for modification of the DISC and/or the identification and development of more sensitive measures for TS screening.

Paliperidone extended release for the treatment of pediatric and adolescent patients with Tourette's disorder

OBJECTIVE

A subgroup of patients with Tourette's disorder (TD) has symptoms refractory to haloperidol, a standard therapeutic drug for TD.

METHODS

We report on three cases of pediatric and adolescent patients who were treated with paliperidone extended release.

RESULTS

In two cases, TD symptoms were remarkably improved by switching from haloperidol to paliperidone extended release, and in another case, paliperidone extended release showed significant efficacy in treating TD symptoms as the first-line drug. In all cases, no significant adverse side effects were detected.

CONCLUSION

Paliperidone extended release may be a strong candidate for the treatment of pediatric and adolescent patients with TD.

Children and adolescents with Tourette's disorder in the USA versus Argentina: behavioral differences may reflect cultural factors

To explore behavioral differences as possible cultural factors in presentation of psychiatric comorbidity in two clinically referred, consecutively ascertained samples of youth with Tourette's disorder (TD) from New York and Buenos Aires. Subjects were evaluated between 2002 and 2010 at the Tics and Tourette's Clinical and Research Program at the New York University Child Study Center in New York and the Interdisciplinary Center for Tourette's, Obsessive Compulsive Disorder (OCD) and Associated Disorders (CITTTA)/Institute of Cognitive Psychology (INECO) in Buenos Aires. Demographic, diagnostic, tic severity (Yale Global Tic Severity Scale; YGTSS), clinical (Child Behavior Check List-Parent version; CBCL), and global functioning (Global Assessment of Functioning; GAF) data were compared using descriptive statistics. The sample included 111 subjects ages 6-17 years, who met DSM-IV-TR diagnostic criteria for TD. Findings revealed that the BA sample (n = 35) was significantly older at initial evaluation at the tic specialty clinic, and had higher frequency of oppositional defiant disorder (ODD), mood and non-OCD anxiety disorders than the NY sample (n = 76). There were no differences in gender distribution, age at tic onset or TD diagnosis, tic severity, proportion with current diagnoses of OCD/OC behavior or attention deficit hyperactivity disorder (ADHD), CBCL internalizing, externalizing, or total problems scores, YGTSS scores, or GAF scores. The observed similarities in demographic features, clinical presentation, rates of ADHD and OCD/OCB, and global impairment may reflect similar phenomenology and illness-related characteristics of TD in these referred youth. Differences in age at initial specialty clinic evaluation and rates of ODD, mood and non-OCD anxiety disorders may need further exploration before they may be considered to reflect cultural factors. Because of these limitations (e.g. small sample size), these results can be regarded only as preliminary.

Testing tic suppression: comparing the effects of dexmethylphenidate to no medication in children and adolescents with attention-deficit/hyperactivity disorder and Tourette's disorder

OBJECTIVE

The aim of this study was to conduct a pilot study testing whether single-dose, immediate-release dexmethylphenidate (dMPH) can facilitate tic suppression in children and adolescents with attention-deficit/hyperactivity disorder (ADHD) and Tourette's disorder (TD) or chronic tic disorders. The primary hypothesis is that dMPH will improve behaviorally reinforced tic suppression in a standard tic suppression paradigm (TSP).

METHODS

Ten children with ADHD and TD were given dMPH on one visit and no medication on another, using a random crossover design. On both days, following a baseline period, subjects were reinforced for suppressing tics using a standard TSP.

RESULTS

Thirteen subjects were enrolled; 10 subjects (mean age 12.7 +/- 2.6; 90% male) completed all study procedures. Relative to the no-medication condition, tics were reduced when children were given a single dose of dMPH. Behavioral reinforcement of tic suppression resulted in lower rates of tics compared to baseline, but dMPH did not enhance this suppression.

CONCLUSION

Preliminary results indicate replication of prior studies of behavioral tic suppression in youths with TD and without ADHD. In addition, our findings indicate tic reduction (and not tic exacerbation) with acute dMPH challenge in children and adolescents with ADHD and TD.

Aripiprazole in children and adolescents with Tourette's disorder: an open-label safety and tolerability study

OBJECTIVE

The aim of this study was to conduct a prospective safety and tolerability study of aripiprazole for the treatment of tics in children and adolescents with Tourette's disorder (TD).

METHOD

Eleven subjects (10 males) with TD (age 9-19 years, mean 13.36, standard deviation [SD] 3.33) who did not respond or were unable to tolerate previous tic medication were treated with aripiprazole in an open-label, flexible-dosing study over 10 weeks. Tic severity was rated using the Yale Global Tic Severity Scale (YGTSS) and the Clinical Global Impressions Scale for tics (CGI-Tics) at baseline and at follow-up.

RESULTS

The mean (+/-SD) daily dose for aripiprazole was 4.5 +/- 3.0 mg. Mean (+/-SD) YGTSS Global Severity scores reduced from 61.82 +/- 13.49 at baseline to 33.73 +/- 15.18 at end point; mean YGTSS total tic scores reduced from 28.18 +/- 7.74 at baseline to 16.73 +/- 7.54 at end point. Mean (+/-SD) CGI-Tic severity scores reduced from 4.45 +/- 0.52 (moderate-marked) at baseline to 3.18 +/- 0.60 (mild) at end point. On the CGI-Tic improvement scale, 10 (91%) subjects achieved 1 ("very much improved") or 2 ("much improved") at end point. Most common adverse effects included appetite increase and weight gain in 5 subjects, mild extrapyramidal effects in 7 subjects, and headaches and tiredness/fatigue in 7 subjects; 1 subject experienced akathisia and muscle cramps.

CONCLUSION

Aripiprazole appears to be a safe and tolerable treatment in children and adolescents with TD that appears to reduce tics; it should be further investigated as a treatment option in controlled trials.

Aripiprazole in children and adolescents with Tourette disorder with and without explosive outbursts

OBJECTIVE

We conducted a retrospective, observational study of aripiprazole for the treatment of tics and/or co-morbid explosive outbursts in 37 children and adolescents with Tourette disorder (TD).

METHOD

Thirty seven children and adolescents with TD, with and without explosive outbursts, and refractory to previous treatment were treated at one of two university affiliated specialty clinics. All diagnoses were made using Diagnostic and Statistical Manual of Mental Disorders, 4th edition, Text Revision (DSM-IV-TR) criteria. Tic severity was rated using the Clinical Global Impressions Scale for tics (CGI-Tics) and frequency of explosive outbursts was assessed using the CGI-Rage; both measures were obtained at pretreatment baseline and at posttreatment follow up.

RESULTS

High rates of psychiatric co-morbidity were observed in these subjects: 31 of 37 (84%) subjects met criteria for obsessive-compulsive disorder (OCD), and 31 of 37 (84%) met criteria for attention-deficit/hyperactivity disorder (ADHD). Twenty nine of 37 (78%) subjects met criteria for intermittent explosive disorder (IED) minus criterion C; the remaining 8 subjects had TD only. Eight subjects (22%) discontinued treatment before 12 weeks due to inability to tolerate the drug. At follow up, tics reduced at a mean daily dose of 12.3 (7.50) mg in 29 of 29 (100%) subjects who completed the study, and explosive outbursts improved in 24/25 subjects (96%) who completed the study. Aripiprazole was tolerated reasonably well, although 8/37 (22%) subjects discontinued treatment; most common side effects included weight gain, akathisia, and sedation.

CONCLUSION

Aripiprazole should be investigated further as a treatment option for TD with and without co-morbid explosive outbursts.

Pediatric autoimmune neuropsychiatric disorders associated with streptococcus: comparison of diagnosis and treatment in the community and at a specialty clinic

OBJECTIVES

This study aimed to examine whether pediatric autoimmune neuropsychiatric disorders associated with streptococcus were appropriately diagnosed in the community and to determine subsequent rates of unwarranted use of antibiotic treatment for tics and obsessive-compulsive symptoms without the identification of an infection.

METHODS

The design was a retrospective, cross-sectional, observational study of 176 children and adolescents who were evaluated in a specialty program for tics, Tourette's disorder, and related problems. Previously published diagnostic criteria were used to establish the diagnosis of pediatric autoimmune neuropsychiatric disorders associated with streptococcus in our clinic.

RESULTS

Subjects were significantly less likely to receive a diagnosis of pediatric autoimmune neuropsychiatric disorders associated with streptococcus at the specialty clinic than in the community. In the community, subjects were significantly more likely to be treated with antibiotics or immunosuppressant medication if they received a diagnosis of pediatric autoimmune neuropsychiatric disorders associated with streptococcus. Of the 27 subjects with a community diagnosis of pediatric autoimmune neuropsychiatric disorders associated with streptococcus who were treated with antibiotics, 22 (82%) were treated without laboratory evidence of an infection; 2 were treated with immunomodulatory medications.

CONCLUSIONS

Our results support our hypothesis that pediatric autoimmune neuropsychiatric disorders associated with streptococcus are frequently diagnosed in the community without the application of all working diagnostic criteria. This phenomenon has resulted in unwarranted use of antibiotic treatment for tics/obsessive-compulsive disorder without evidence of laboratory infection.

Developmental psychopathology of children and adolescents with Tourette syndrome--impact of ADHD

BACKGROUND

In Tourette syndrome (TS) as a neurodevelopmental disorder not only the tics but also the comorbid conditions change with increasing age. ADHD is highly comorbid with TS and usually impairs psychosocial functioning more than the tics. Its impact on further comorbidity during development is important for clinical practice and still a matter of debate.

METHOD

Aspects of developmental psychopathology considering the impact of ADHD were examined by logistic regression (year wisely) in a cross-sectional sample of children and adolescents (n = 5060) from the TIC database.

RESULTS

In TS+ADHD (compared to TS-ADHD) higher rates of comorbid conditions like OCD, anxiety disorders, CD/ODD and mood disorders were found in children (5-10 years). In adolescents (11-17 years) higher comorbidity rates in TS+ADHD remained only for CD/ODD and mood disorders. Accordingly, for OCD and anxiety disorders there was a steeper year wise increase of these comorbidities in TS-ADHD while it was a similar for CD/ODD and mood disorders in TS-ADHD as well as TS+ADHD.

CONCLUSION

Children with TS+ADHD have more comorbidities than the TS-ADHD group, whereas in both adolescent groups this did no longer hold for OCD and anxiety disorders. These findings indicate that in TS comorbid ADHD is associated with high rates of externalizing and internalizing problems, whereas TS without ADHD is associated only with internalizing problems in adolescence.

Psychopathology in a Swedish population of school children with tic disorders

OBJECTIVE

To examine patterns of psychiatric comorbid disorders and associated problems in a school population of children with tic disorders.

METHOD

From a total population of 4,479 children, 25 with Tourette's disorder (TD), 34 with chronic motor tics (CMT), 24 with chronic vocal tics (CVT), and 214 with transient tics (TT) during the past year were found. A three-stage procedure was used: tic screening, telephone interview, and clinical assessment. The TD group was compared with 25 children with TT and 25 controls without tics.

RESULTS

Psychiatric comorbid disorders were found in 92% of the children with TD. Attention-deficit/hyperactivity disorder was most common, and patterns of psychiatric comorbidity were similar in children with TD and CVT, but not with CMT and TT. Aggressive behavior was more common in children with TD than other tic disorders.

CONCLUSIONS

Psychiatric comorbid disorders are common even in community-based samples of children with TD and CVT. TD and CVT seem to be part of the same disease entity, with TD being a more severe form. Chronic tics may be a marker for behavioral and learning difficulties in children, and awareness of these associations is critical to the care and treatment of children with tics.

Reexamining Tic persistence and Tic-associated impairment in Tourette's Disorder: findings from a naturalistic follow-up study

The objective of this study was to assess tic persistence and tic-associated impairment in referred youth with Tourette's Disorder (TD). Subjects were 50 youth (ages 6-17 years) who met DSM-IV diagnostic criteria for TD, were referred to a specialized TD program, and were evaluated by clinical and structured diagnostic interview. Tic severity and impairment was measured using the Yale Global Tic Severity Scale. The total tic score at or above minimal range defined tic persistence, and a TD impairment score at or above moderate range defined tic-associated impairment. Results were assessed during administration of the Kiddie-Schedule for Affective Disorders and Schizophrenia for School-Age Children-Epidemiological Version. Mean age of onset of TD was 5.1 +/- 2.3 years, and mean illness duration was 5.6 +/- 3.2 years. At baseline, 88% of subjects met threshold criteria for at least mild tics, but only 30% met criteria for tic-associated impairment. At 2-year follow-up, 82% of these subjects met criteria for tic persistence (NS change from baseline), but only 14% met criteria for TD-associated impairment (p < .04 change from baseline). Although tics followed a persistent course in the majority of youth with TD, they were infrequently associated with impairment. There was a significant reduction in the proportion of youth with TD impairment from baseline to follow-up. These results support the view that TD is a persistent disorder, but suggest a dissociation between tic persistence and tic-associated dysfunction.