Psychological morbidity and caregiver burden in parents of children with Tourette's disorder and psychiatric comorbidity

Caregivers of Children with Autism Spectrum Disorders: The Role of Guilt Sensitivity and Support

Background/Objectives: Burden Syndrome, also known as Caregiver Syndrome, particularly affects those who serve in the role of informal caregiver in the presence of family members with conditions. The ABCX dual model examines the impact on the caregiver of the diagnosis of autism spectrum disorder (ASD) on the family. This model considers the severity of the stressor (A), the additional demands of life stress (aA), the family's internal resources (B), the family's external resources (bB), the family's assessment of the situation (C), coping strategies (cC), and outcome (X). The purpose of the present study is to investigate the relationships between resilience, guilt, and burden of care in caregivers of children with ASD. Methods: Various assessment instruments were used, including the "Caregiver Burden Inventory" to measure burden, the "Brief Resilience Scale" to assess resilience, the "Guilt Sensitivity Questionnaire" to examine guilt sensitivity, and the "DA.L.I.A." to collect information on parent and child characteristics. A total of 80 parents/caregivers participated in the research, including 53 women (Age M = 41.72; SD = 7.8) and 27 men (Age M = 43.35; SD = 6.29). Results: The findings indicate that individuals' resilience to stressful events correlates negatively with burden, a developmental subtype. However, guilt seems not to play a significant role in the overall perception of burden. In contrast, it was found that the use of informal supports is associated with higher levels of guilt and emotional burden, whereas the use of formal supports is correlated with higher emotional burden, but not higher perceptions of guilt. Conclusions: This study provides important information about the support needed by caregivers and suggests how to address emotional burdens to prevent burnout and support families with children with ASD.

Coping with Tourette's syndrome: a meta-ethnography of individual and family perspectives

OBJECTIVE

This systematic review and meta-ethnography aimed to examine how children, adults and families cope with Tourette's syndrome (TS).

METHODS

A systematic search of four databases was completed in October 2022. Sixteen papers met the inclusion criteria and were synthesised using Noblit and Hare's (1988) meta-ethnographic approach.

RESULTS

Three themes were constructed: redefining the self and social identity, controlling the visible presentation of Tourette's syndrome, and challenging the narrative.

CONCLUSION

Findings indicate that coping involves the need to integrate TS with identity, to exert control over tics and to challenge the misrepresentations of TS in wider society. A supportive environment provided by parents and friends enables individuals to feel proud that they can control their tics, and this allows for the positive integration of TS into identity. Raising awareness at a societal level through educational campaigns is important when aiming to improve coping with a stigmatised condition. Further research is recommended, for example, to understand how common co-occurring conditions, such as attention deficit hyperactivity disorder, impact coping.

Burden Experienced by Primary Caregivers of Children With Psychotic Disorders and at Clinical High Risk for Psychosis

BACKGROUND

Despite the existing research exploring caregiver burden in adult psychosis, few studies have examined the experience of providing care to children diagnosed with psychotic disorders (PDs) and those identified as having clinical high risk for psychosis (CHR-P).

AIM

This study measured the level of burden in caregivers of children with PD and CHR-P and examined associated risk factors, including social support, caregiver-child relationship, severity of illness, and frequency of psychiatric hospitalizations.

METHODS

A total of 56 caregivers completed validated measures and provided demographic information. Measures included the Zarit Burden Interview, the Multidimensional Scale of Perceived Social Support, the Behavior Assessment System for Children, Third Edition, Parenting Relationship Questionnaire-Child and Adolescent Form (BASC-3 PRQ-CA), and the Clinical Global Impression-Severity scale.

RESULTS

The majority of caregivers were women (86%), mothers (84%), White (63%), married (66%), working full-time (50%), college-educated (79%), and whose mean age was 45.7 years (SD = 8.09). Nearly half of the caregivers (45%) reported a high level of caregiver burden, 39% rated their burden in the mild to moderate range, and 16% reported little to no burden. There was no significant difference in mean burden between PD and CHR-P groups. Higher caregiver burden was associated with lower levels of social support (r = -.408, p = .002), lower levels of parenting confidence (r = -.514, p < .001), higher levels of relational frustration (r = .612, p < .001), and higher severity of illness (r = .316 p = .025).

CONCLUSIONS

These findings underscore the critical unmet need for support for caregivers of children with PD and CHR-P. Applications to clinical practice are discussed.

Agreement between self-, mother and father proxy-reports on health-related quality of life in adolescents with Tourette syndrome

This study aimed to investigate agreement and discrepancies between parent proxy- and adolescent self-reports on assessments of adolescents' health-related quality of life (HRQoL), and the role that individual factors may play in parent-adolescent agreement, in a sample of adolescents with Tourette syndrome (TS) compared to a control group of healthy adolescents. Adolescents aged 12-18 years diagnosed with TS were recruited with their parents from primary and secondary referral centres. Adolescent healthy controls were matched for gender and age. Adolescents and each of their parents completed a set of questionnaires including a HRQoL evaluation of adolescent, the 'Vécu et Santé Perçue de l'Adolescent'. Mother-adolescent, father-adolescent and mother-father agreements on adolescents' HRQoL scores were investigated at individual and group level, both in TS and control groups. Data were available for 75 adolescents, 75 mothers and 63 fathers, in the TS group. Agreement between mother, father proxy-reports and TS adolescents self-reports of HRQoL varied from poor to good, without significant difference with the control group. In TS group, mothers and fathers underestimated adolescents' HRQoL in 'Psychological well-being' subscale and mothers underestimated it in 'Physical 'well-being' subscale, while controls overestimated adolescents' HRQoL in these subscales. Larger mother-adolescent discrepancies for 'Psychological well-being' and 'Physical well-being' subscales were associated with internalizing symptoms. Regarding future studies, comprehensive evaluation of the various dimensions of adolescents' HRQoL with TS requires the integration of the perspectives of both adolescents, mothers and fathers. Clinicians should take into account this point to provide comprehensive care and services.

A qualitative study of Chinese parental perspectives on the causes of Tourette syndrome in children

Parents' beliefs and attitudes toward their children with Tourette syndrome (TS) influence treatment-seeking behaviors. This study aimed to explore and describe the Chinese parents' perspectives on the causes of TS for their children. A qualitative study using semi-structured interviews was conducted with the parents of TS patients from a children's hospital in western China from June to July 2021, and thematic analysis was performed to transcribe interviews and identify themes. A total of 13 participants were interviewed in this study. Five themes were developed in relation to the cognition of the causes of TS in parents, including physical problems, parenting and education problems, mental problems, bad habits, and neurological problems. Due to the insufficient awareness of TS, most parents repeatedly seek medical advice that they regarded the symptoms as physical problems or neurological problems. They generally felt guilty and blamed themselves for their parenting styles and education methods. And some parents attributed it to the poor psychological quality or the bad habits of children. Study findings showed a lack of scientific understanding of the causes of TS among parents further hindered the timely effective treatment for patients and affected the family relationships, which highlights the importance of public education and raising awareness of the disease.

The Association of Quality of Life with Psychosocial Factors in Adolescents with Tourette Syndrome

Individuals with Tourette syndrome (TS) have poorer quality of life (QoL) than their peers, yet factors contributing to poor QoL in this population remain unclear. Research to date has predominantly focused on the impact of tics and psychiatric symptoms on QoL in TS samples. The aim of this cross-sectional, multi-informant study was to identify psychosocial variables that may impact adolescent QoL in TS. Thirty-eight adolescents aged 13 to 17 with TS and 28 age-matched controls participated with a caregiver. No group differences were found on QoL, although the TS group reported reduced QoL compared to population normative data. In the TS group, reduced QoL was associated with lower self-esteem, poorer family functioning, higher stress, and greater depression and anxiety; QoL was unrelated to tic severity. In regression analyses, after adjusting for covariates, family functioning was the strongest predictor of QoL. These results emphasize the need to further explore the influence of psychosocial factors, particularly family functioning, on QoL in adolescents with TS.

Door-to-door Video-Enhanced Prevalence Study of Tourette Disorder Among African Americans

Tourette syndrome (TS) affects about 0.5% of the population worldwide, but only sparse and conflicting data exist on TS prevalence among minority samples. Here we used VISIT-TS (a survey preceded by a short video showing tic phenomenology) and community outreach to provide estimates of tic disorder prevalence in African Americans. Community health workers (CHWs) left flyers at households in a predominantly minority neighborhood and approached people at a community health fair. Of 606 such contacts, 222 individuals agreed to discuss the study. Of these, 70% enrolled, of whom 82% identified as Black and 64% female. The VISIT-TS was well received. Lifetime prevalence of TS or another chronic tic disorder (TS/CTD) was 3.2%, and 31% endorsed any lifetime simple tic. The number of enrolled Black participants is remarkable compared to earlier TS studies, allowing one of the first prevalence estimates in this population (TS 2.3%, TS/CTD 3.9%). Tic disorders were endorsed only by Black respondents, though the small White sample precluded statistical comparison. Women had higher rates than men of TS (M:F = 0:1) and of any lifetime simple tic (M:F = 0.85), differing significantly from the expected 4:1 ratio (p = .009 and p < .001, respectively). For TS/CTD the ratio was 1.2:1 (p > .15). We conclude that VISIT-TS is a feasible tic screening tool in a minority population, that CHW community outreach increases enrollment of Black participants, that TS/CTD is no less common in this population, and that tics were as common in female as in male respondents.

Anxiety and depression among caregivers of pediatric patients with tic disorder in western China: A cross-sectional study

BACKGROUND

Caregivers of pediatric patients with tic disorders (TD) are at high risk for anxiety and depression, but the situation of this disorder was rarely reported based on the Chinese population. The purpose of this study was to investigate the prevalence and potential contributing factors of anxiety and depression among caregivers of Chinese pediatric patients with TD.

METHODS

A cross-sectional study was carried out on caregivers of pediatric patients with TD at a women's and children's hospital in western China from January to June 2020. A structured questionnaire was designed to collect data, including socio-demographic information, disease and medication status, family situation and social relationship, cognition and attitude towards TD and treatment. Anxiety and depression were assessed using the self-rating anxiety scale (SAS) and self-rating depression scale (SDS), respectively. The univariate analysis and multivariate logistic regression were used to analyze the cross-sectional data.

RESULTS

A total of 318 participants were included in this study, with a response rate of 89.58% (318/355). The average age of pediatric patients with TD was 8.38 ± 2.54 years, and 78.30% (249/318) of caregivers were aged between 30-50 years old. Overall, 14.78% (47/318) of caregivers presented the symptom of anxiety, with a mean SAS score of 54.81±5.26, and 19.81% (63/318) of caregivers presented the symptom of depression, with a mean SDS score of 59.64±5.83. Logistic regression analysis revealed that the common family relationship (OR = 2.512, p = 0.024), and pediatric patients with unharmonious social relationships (OR = 5.759, p = 0.043) and with introverted personality (OR = 2.402, p = 0.023) were significantly associated with anxiety in caregivers of pediatric patients with TD, as well as the single-parent family (OR = 4.805, p = 0.011), mistaken cognition of TD (OR = 0.357, p = 0.031), and pediatric patients with fewer friends (OR = 3.377, p = 0.006) were significantly associated with depression.

CONCLUSIONS

Anxiety and depression are prevalent among caregivers of TD pediatric patients, which brings up the importance of psychiatric support for this group. Longitudinal studies need to be conducted to further confirm the causality before interventions to improve mental health are developed.

How do children with Tourette's syndrome and their caregivers live with the disorder? A systematic review of qualitative evidence

Background

Tourette's syndrome (TS) is a childhood neurodevelopmental disorder characterized by sudden, repetitive, involuntary, and irregular muscle movement and vocalization. Recently, non-pharmaceutical methods, such as behavioral therapy, psychotherapy, and deep brain stimulation, have been introduced as alternatives to pharmacological treatment for TS. This study aimed to systematically review and synthesize qualitative evidence on the experiences of children with TS and their caregivers. A meta-synthesis of qualitative evidence could help provide a comprehensive understanding of the challenges experienced by children with TS and their caregivers with the aim of providing more effective treatment and services for them.

Materials and methods

A systematic search was conducted using MEDLINE/PubMed, EMBASE, Cumulative Index to Nursing and Allied Health Literature, PsycARTICLES, and three Korean databases (Korean Medical Database, Research Information Sharing Service, and ScienceON) in July 2021. Studies were included if they collected and analyzed qualitative data from children with tic disorder or TS, or their caregivers. Qualitative research findings on the experiences and perspectives of children with TS and their caregivers were critically appraised and synthesized using the Joanna Briggs Institute methodology.

Results

Eight eligible studies were included. The findings from these studies (i.e., themes or subthemes of qualitative research) were aggregated into categories (a group of similar findings) and synthesized findings (a group of categorized findings). Ultimately, the 60 findings were aggregated into 15 categories. Finally, four synthesized findings were derived from the 15 categories: (i) continuation of challenging daily life, (ii) denying that TS causes emotional distress, (iii) accepting and understanding TS as part of oneself, and (iv) looking to the future.

Conclusion

Children with TS and their caregivers experience physical and psychological distress and social deprivation. Avoiding and suppressing TS causes secondary distress such as guilt. However, seeking social support and accepting the disorder reduce the distress caused by symptoms and lays the foundation for later growth. Even in the face of adversity, children with TS and their caregivers find personal value and acquire a more open and optimistic attitude toward life. This review shows that acceptance-based therapy and social support should be provided for the treatment and management of TS.

Effectiveness of 'Tackle Your Tics', a brief, intensive group-based exposure therapy programme for children with tic disorders: study protocol of a randomised controlled trial

INTRODUCTION

This paper outlines the study protocol for the Dutch Tackle Your Tics study in youth with tic disorders. Tourette syndrome and chronic tic disorders are prevalent neurodevelopmental disorders, placing considerable burden on youth and their families. Behavioural treatment is the first-line, evidence-based intervention for tic disorders, but tic reduction and availability remain relatively low. Patient associations stress the need for more accessible high-quality treatments, also focusing on improving quality of life. Therefore, the brief, intensive group-based treatment Tackle Your Tics was developed.

METHODS AND ANALYSIS

Tackle Your Tics is a 4-day intensive and comprehensive group-based intervention for children and adolescents (9-17 years) with Tourette syndrome or a chronic tic disorder. The programme encompasses exposure and response prevention treatment and additional supporting components (coping strategies, relaxation exercises and parent support). To study the effectiveness of Tackle Your Tics and identify predictors/moderators at baseline, a single-blinded randomised controlled trial (n=104) is conducted, comparing Tackle Your Tics (n=52) with a waiting list condition lasting 3 months (n=52). Assessments are performed at similar time points for both groups: at baseline, after 4 weeks, and at 3 and 6 months of follow-up, on tic severity, quality of life and other psychosocial variables.

ETHICS AND DISSEMINATION

Ethics approval has been obtained from the medical ethical committee of the Amsterdam Medical Centre (METC nr NL66340.018.18, v3 June 2020). Findings will be presented on national and international conferences, peer-reviewed scientific journals, patient organisation meetings and public media. Patient representatives are fully integrated as part of the research team. If Tackle Your Tics proves to be effective, it can expand evidence-based treatment possibilities for children and adolescents with tic disorders. Identifying the psychosocial predictors/moderators for the effectiveness of this intervention can provide personalised treatment advice in the future.

TRIAL REGISTRATION NUMBER

NL8052.

Living with tics: Nursing Care of Pediatric Tourette Syndrome

Tourette syndrome (TS) is a neurodevelopmental movement characterized by abrupt, rapid, repetitive, and non-rhythmic tics. While TS is not life-threatening, such tics and comorbidities affect a children's physical and mental health and social interactions. Treatment is necessary when the children experience physical discomfort, functional dysfunction, and poor interpersonal interaction and mental health. Common management strategies for TS include psychological interventions and pharmacological treatment. Additionally, it is important to consider the individual needs of youths with TS and reassess the treatment outcomes and the need to receive continuous treatment regularly. This review summarizes the symptom management and nursing care measures for youths with TS. Understanding and listening to the healthcare problems of youths with TS can help providers develop healthcare interventions tailored to the youths' needs. Providing the youths with strategies to reduce the tics' interference with their learning outcomes and helping them develop strategies to cope with diverse interpersonal interactions at school are also important. Further, enhancing acceptance given by parents, teachers, and peers, as well as improving the general public's understanding of TS are important measures that promote the youths' social adjustment as well as their ability to coexist with TS.

Ticked Off: Anger Outbursts and Aggressive Symptoms in Tourette Disorder

Tourette disorder is a complex neuropsychiatric syndrome of childhood onset characterized by multiple motor and phonic tics and is associated with high rates of psychiatric comorbidity. Symptoms of impulsive aggression (explosive outbursts or "rage") are commonly encountered in the clinical setting, cause significant morbidity, and pose diagnostic and treatment challenges. These symptoms may be multifactorial in etiology and result from a complex interplay of illness severity and psychosocial factors. Treatment strategies require careful differential diagnostic evaluation and include both behavioral and pharmacologic interventions.

Longitudinal Bidirectional Relationships Between Maternal Depressive/Anxious Symptoms and Children's Tic Frequency in Early Adolescence

Background: Previous studies have revealed an association between maternal depressive/anxious symptoms and children's tics. However, the longitudinal relationships between these symptoms remain unclear. We examined the longitudinal relationships between maternal depressive/anxious symptoms and children's tic frequency in early adolescence with a population-based sample. Methods: The participants consisted of 3,171 children and their mothers from the Tokyo Teen Cohort (TTC) study, a population-representative longitudinal study that was launched in Tokyo in 2012. Maternal depressive/anxious symptoms and children's tics were examined using self-report questionnaires at the ages of 10 (time 1, T1) and 12 (time 2, T2). A cross-lagged model was used to explore the relationships between maternal depressive/anxious symptoms and children's tic frequency. Results: Higher levels of maternal depressive/anxious symptoms at T1 were related to an increased children's tic frequency at T2 (β = 0.06, p < 0.001). Furthermore, more frequent children's tics at T1 were positively related to maternal depressive/anxious symptoms at T2 (β = 0.06, p < 0.001). Conclusions: These findings suggest a longitudinal bidirectional relationship between maternal depressive/anxious symptoms and children's tic frequency in early adolescence that may exacerbate each other over time and possibly create a vicious cycle. When an early adolescent has tics, it might be important to identify and treat related maternal depressive/anxious symptoms.

Tic Disorders are Associated With Lower Child and Parent Quality of Life and Worse Family Functioning

OBJECTIVE

Chronic tic disorders occur in approximately 3% of children. Neuropsychiatric symptoms of attention-deficit/hyperactivity disorder, obsessive-compulsive disorder, anxiety, and depression are common. We evaluated the impact of tic disorders and comorbid symptoms on individual and parent quality of life and family functioning.

METHOD

In two cross-sectional studies children with tic disorders were enrolled at the University of Rochester or the University of South Florida; data were pooled for analyses. Control subjects were enrolled at the University of Rochester. We compared quality of life and function in youth and families with and without tic disorders. We evaluated the associations between comorbid symptoms and individual quality of life and family impact in youth with tic disorders using multiple regression analyses.

RESULTS

We enrolled 205 youths with tic disorders and 100 control subjects. Psychosocial (P < 0.0001) and physical (P < 0.0001) quality of life were lower in individuals with tic disorders compared with controls. Severity of attention-deficit/hyperactivity disorder (P < 0.0001) and depression (P = 0.046) symptoms were associated with lower psychosocial quality of life in youth with tic disorders. Families of youths with tic disorders had worse parent quality of life (P < 0.001) and family functioning (P < 0.001) than control families. Severity of attention-deficit/hyperactivity disorder (P < 0.0001), obsessive-compulsive disorder (P = 0.0004), and depression (P = 0.01) symptoms were associated with predicted worse family impact.

CONCLUSION

Youths with tic disorders had lower individual and parent quality of life and worse family functioning than controls. The impact of tic disorders on the family may have significant implications for approaches to providing comprehensive care to these families.

Medication Adherence and Associated Factors for Children With Tic Disorders in Western China: A Cross-Sectional Survey

Background: Adherence to treatment remains important for successful tic disorder (TDs) management, but no studies had previously been carried out to assess adherence or the factors that affect it in children with TDs. This study therefore aimed to explore adherence to prescribed medication among children with tic disorders and to examine the associated factors.

Methods: This was a cross-sectional study in western China, where children with tic disorders were recruited consecutively in 2018. We used the eight-item Morisky Medication Adherence Scale (MMAS-8) to assess adherence. We included sociodemographic data, disease status, medication status, and family conditions as independent variables and used an ordinal logistic regression model to examine the factors affecting medication adherence.

Results: A total of 204 patients were included, with a response rate of 96.2%. The majority of participants (77.5%) were male, aged 7.69 ± 2.58 years. In total, 37.7% were newly diagnosed, 46.1% were review patients, and 16.2% were recurrent patients. Only 40.7% of patients showed high adherence (MMAS-8 score, 8). Decreasing quality of life (adjusted odds ratio 0.974) and living in non-rural areas (adjusted odds ratio 2.361) were significant independent determinants of non-adherence.

Conclusion: The results suggest that primary healthcare providers in pediatric clinics should focus on medication adherence counseling for children with tic disorders who have a lower quality of life and live in non-rural areas.

A new treatment for children with chronic tic disorders - Resource activation

The aim of this pilot study is to evaluate the efficacy of a resource activation (RA) program as an alternative intervention for children and adolescents with tic disorders. RA interventions focus on the strengths and abilities of the patients. This is expected to improve the patients' perceptions regarding their own resources, which may indirectly result in a reduction of tic symptoms, impairment and comorbid conditions. A within-subject design with two phases (8 weeks diagnostic; 16 sessions treatment) was analyzed using multilevel modeling (n = 24). During the treatment phase, significant reductions of tics were found in clinical rating (Yale Global Tic Severity Scale; YGTSS), parent rating and video observation (motor tics). Moreover, an improvement was shown on most tic-related impairment and subjective burden (SB) ratings. No significant improvement was found regarding comorbid problems and self-esteem. Compared to the preceding diagnostic phase, a significant incremental treatment effect emerged in clinical rating of tic symptoms (YGTSS) and video observation (motor tics). This pilot study provides first hints that RA may represent an effective treatment for reducing tic symptoms, impairment and SB. However, further research is needed in order to establish RA as an effective treatment for tic disorders.

An Examination of the Relations Between Symptom Distributions in Children Diagnosed with Autism and Caregiver Burden, Anxiety and Depression Levels

High stress levels and impairment of physical/mental health in parents can delay early and effective intervention in autism. The purpose of this study was to examine relations between the clinical characteristics of children diagnosed with autism spectrum disorder (ASD) and caregiver burden, and anxiety and depression levels. Seventy cases under monitoring at the Namık Kemal University Medical Faculty Child and Adolescent Psychiatric Polyclinic with a diagnosis of ASD, and their principal caregivers, were included in the study. The Autism Behavior Checklist (ABC), Beck Depression Inventory (BDI), Beck Anxiety Inventory, and the Zarit Caregiver Burden Scale were completed. At multiple regression analysis, autism symptom severity and caregiver depressive symptom levels emerged as significant predictors of total caregiver burden scores. Only the ABC language subscale score had a determining effect on caregiver burden (r = 0.51, r² = 0.26, p = 0.04). ABC body and object use subscale scores were identified as the symptom cluster affecting depression and anxiety scores (r = 0.25, r² = 0.06, p = 0.03 and r = 0.28, r² = 0.08, p = 0.01). Our findings show that ASD symptom severity and depressive symptoms in the caregiver are the most important factors giving rise to the caregiver burden, and that the main ASD symptom cluster affecting the caregiver burden was problems associated with language development. Better understanding of variables impacting on the caregiver burden will increase the quality of psychosocial services for caregivers.

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.

Correlates of Subjective Caregiver Strain in Caregivers of Youth Evaluated in a Pediatric Psychiatric Emergency Room

BACKGROUND

Although caregiver burden is relevant to the outcome for psychiatrically ill youth, most studies have focused on caregiver burden in the community or research settings. Therefore, we aimed at evaluating the subjective caregiver strain (SCS) at the time of presentation of youth to a pediatric psychiatric emergency room (PPER), assessing potential correlates to provide leads for improvements in formal support systems.

METHODS

In this retrospective cohort study, the internalized, externalized, and total SCS were assessed in caregivers of youth <18 years of age consecutively evaluated at a PPER during a 1 year period using the Caregiver Strain Questionnaire. Sociodemographic and a broad range of clinical data were collected during the PPER visit using a 12-page semistructured institutional evaluation form. The Appropriateness of Pediatric Psychiatric Emergency Room Contact scale, incorporating acuity, severity and harm potential, was used to rate appropriateness of the visit.

RESULTS

In caregivers of 444 youth, the internalized SCS was significantly higher than the externalized SCS (p < 0.001). Multivariable analyses indicated that higher total and externalized SCS were associated with disruptive behavior or substance abuse/dependent disorder diagnosis, presenting complaint of aggression, and discharge plan to the police. Higher total and internalized SCS were associated with lower child functioning, whereas total and internalized SCS were lower in adopted children. In addition, higher externalized SCS was associated with investigator-rated inappropriateness of the emergency visit, presenting complaint of defiance, and a lack of prior psychiatric ER visits.

CONCLUSIONS

High levels of CS in PPER highlight the necessity to adhere to existing guidelines regarding the inclusion of caregivers' perceptions into comprehensive psychiatric assessments. The particularly high strain in caregivers of children with externalizing disorders and in families with low-functioning youth may need to prompt PPER staff to provide efficient information on appropriate treatment options for these children and on support facilities for the parents.

Health-related quality of life, anxiety and depression in parents of adolescents with Gilles de la Tourette syndrome: a controlled study

Our objectives were to assess health-related quality of life (HRQoL), anxiety, depression of Gilles de la Tourette syndrome (GTS) adolescents' parents compared to controls; to assess GTS adolescents' HRQoL compared to controls; to investigate which parental and adolescent variables are associated with poorer parental HRQoL. The controlled study involved GTS outpatients and their parents, adolescent healthy controls matched for gender and age and their parents. Parents' HRQoL was assessed using SF-36 and WHOQOL-BREF; anxiety, depression using HADS. Adolescents' HRQoL was assessed by adolescents using VSP-A instrument and by their parents using VSP-P. A total of 75 GTS adolescents, 75 mothers, 63 fathers were compared to 75 control adolescents, 75 mothers, 62 fathers. GTS mothers had worse HRQoL than controls on 5 of the 8 SF-36 dimensions and 1 of the 4 WHOQOL-BREF dimensions, while GTS fathers had worse HRQoL on 2 of the WHOQOL-BREF dimensions. GTS mothers had poorer HRQoL than fathers. GTS mothers had more depression than control mothers and GTS fathers had more anxiety than control fathers. GTS adolescents had worse HRQoL than controls on 5 of the 9 VSP-A dimensions. Factors significantly related to parental HRQoL were anxiety, depression, GTS adolescents' HRQoL and, concerning mothers, behavioural and emotional adolescents' problems; concerning fathers, severity of vocal tics, duration since first symptoms. This study provides a better understanding of poorer HRQoL and psychiatric morbidity of GTS adolescents' parents. Clinicians should pay attention to their emotional well-being and HRQoL and be aware that mothers and fathers are differently affected.

Parental Psychopathology and Tourette Syndrome/Chronic Tic Disorder in Offspring: A Nationwide Case-Control Study

OBJECTIVE

To determine the associations between maternal and paternal psychiatric diagnoses and Tourette syndrome (TS)/chronic tic disorder (CT) in a nationwide study.

METHOD

This nested case-control study linked data derived from three national registers. All singletons born and diagnosed with TS/CT in Finland between January 1991 and December 2010 were identified (n = 1,120) and matched to four controls (n = 4,299). Conditional logistic regression was used to examine the associations between parental psychopathology and TS/CT.

RESULTS

Altogether, 24.9% of patients with TS/CT and 12.0% of controls had a mother with a psychiatric diagnosis. Similarly, 17.9% and 12.9% had a father with a psychiatric diagnosis. Any maternal and any paternal psychiatric diagnosis was associated with offspring TS/CT (odds ratio [OR] 2.3; 95% CI 1.9-2.7 and OR 1.2; 95% CI 1.01-1.5, respectively). The association between maternal psychiatric diagnosis and TS/CT was stronger than that between paternal psychiatric diagnosis and TS/CT (p < .001). Maternal personality disorders (OR 3.1, 95% CI 1.9-5.1), anxiety disorders (OR 2.6, 95% CI 1.9-3.5), affective disorders (OR 2.3, 95% CI 1.8-2.9), psychotic disorders (OR 2.0, 95% CI 1.2-3.3), and addiction disorders (OR 1.8, 95% CI 1.1-2.8) were associated with TS/CT. Paternal OCD (OR 6.5, 95% CI 1.1-39.5) and anxiety disorders (OR 1.5, 95% CI 1.1-2.3) were associated with TS/CT.

CONCLUSION

Parental psychiatric diagnoses (especially in the mother) are associated with diagnosed offspring TS/CT. Further studies are required before the results can be generalized to all children with TS/CT. The associations between maternal psychiatric disorders and TS may reflect both maternal specific environmental and/or genetic influences.

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.

Clinical effectiveness and patient perspectives of different treatment strategies for tics in children and adolescents with Tourette syndrome: a systematic review and qualitative analysis

BACKGROUND

Tourette syndrome (TS) is a neurodevelopmental condition characterised by chronic motor and vocal tics affecting up to 1% of school-age children and young people and is associated with significant distress and psychosocial impairment.

OBJECTIVE

To conduct a systematic review of the benefits and risks of pharmacological, behavioural and physical interventions for tics in children and young people with TS (part 1) and to explore the experience of treatment and services from the perspective of young people with TS and their parents (part 2).

DATA SOURCES

For the systematic reviews (parts 1 and 2), mainstream bibliographic databases, The Cochrane Library, education, social care and grey literature databases were searched using subject headings and text words for tic* and Tourette* from database inception to January 2013.

REVIEW/RESEARCH METHODS

For part 1, randomised controlled trials and controlled before-and-after studies of pharmacological, behavioural or physical interventions in children or young people (aged < 18 years) with TS or chronic tic disorder were included. Mixed studies and studies in adults were considered as supporting evidence. Risk of bias associated with each study was evaluated using the Cochrane tool. When there was sufficient data, random-effects meta-analysis was used to synthesize the evidence and the quality of evidence for each outcome was assessed using the Grading of Recommendations Assessment, Development and Evaluation approach. For part 2, qualitative studies and survey literature conducted in populations of children/young people with TS or their carers or in health professionals with experience of treating TS were included in the qualitative review. Results were synthesized narratively. In addition, a national parent/carer survey was conducted via the Tourettes Action website. Participants included parents of children and young people with TS aged under 18 years. Participants (young people with TS aged 10-17 years) for the in-depth interviews were recruited via a national survey and specialist Tourettes clinics in the UK.

RESULTS

For part 1, 70 studies were included in the quantitative systematic review. The evidence suggested that for treating tics in children and young people with TS, antipsychotic drugs [standardised mean difference (SMD) -0.74, 95% confidence interval (CI) -1.08 to -0.41; n = 75] and noradrenergic agents [clonidine (Dixarit(®), Boehringer Ingelheim) and guanfacine: SMD -0.72, 95% CI -1.03 to -0.40; n = 164] are effective in the short term. There was little difference among antipsychotics in terms of benefits, but adverse effect profiles do differ. Habit reversal training (HRT)/comprehensive behavioural intervention for tics (CBIT) was also shown to be effective (SMD -0.64, 95% CI -0.99 to -0.29; n = 133). For part 2, 295 parents/carers of children and young people with TS contributed useable survey data. Forty young people with TS participated in in-depth interviews. Four studies were in the qualitative review. Key themes were difficulties in accessing specialist care and behavioural interventions, delay in diagnosis, importance of anxiety and emotional symptoms, lack of provision of information to schools and inadequate information regarding medication and adverse effects.

LIMITATIONS

The number and quality of clinical trials is low and this downgrades the strength of the evidence and conclusions.

CONCLUSIONS

Antipsychotics, noradrenergic agents and HRT/CBIT are effective in reducing tics in children and young people with TS. The balance of benefits and harms favours the most commonly used medications: risperidone (Risperdal(®), Janssen), clonidine and aripiprazole (Abilify(®), Otsuka). Larger and better-conducted trials addressing important clinical uncertainties are required. Further research is needed into widening access to behavioural interventions through use of technology including mobile applications ('apps') and video consultation.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42012002059.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

A qualitative exploration of the daily experiences and challenges faced by parents and caregivers of children with Tourette’s syndrome

Few studies address the daily challenges faced by parents of children diagnosed with Tourette’s syndrome. This article reports on a qualitative interview study with 15 parents exploring their experiences, the challenges they face and the support mechanisms they have found to be most helpful. Thematic analysis identified four core categories which represented shared experiences of the participants: coping with children’s challenging behaviours, misconceptions and lack of understanding of professionals and the lay public, negative experiences of their children’s education and lack of support and services for families with Tourette’s syndrome. The findings highlight the challenges of parenting a child with Tourette’s syndrome, particularly with respect to family life and the child’s schooling.

Practitioner Review: Treatments for Tourette syndrome in children and young people - a systematic review

BACKGROUND

Tourette syndrome (TS) and chronic tic disorder (CTD) affect 1-2% of children and young people, but the most effective treatment is unclear. To establish the current evidence base, we conducted a systematic review of interventions for children and young people.

METHODS

Databases were searched from inception to 1 October 2014 for placebo-controlled trials of pharmacological, behavioural, physical or alternative interventions for tics in children and young people with TS or CTD. Certainty in the evidence was assessed with the GRADE approach.

RESULTS

Forty trials were included [pharmacological (32), behavioural (5), physical (2), dietary (1)]. For tics/global score there was evidence favouring the intervention from four trials of α2-adrenergic receptor agonists [clonidine and guanfacine, standardised mean difference (SMD) = -0.71; 95% CI -1.03, -0.40; N = 164] and two trials of habit reversal training (HRT)/comprehensive behavioural intervention (CBIT) (SMD = -0.64; 95% CI -0.99, -0.29; N = 133). Certainty in the effect estimates was moderate. A post hoc analysis combining oral clonidine/guanfacine trials with a clonidine patch trial continued to demonstrate benefit (SMD = -0.54; 95% CI -0.92, -0.16), but statistical heterogeneity was high. Evidence from four trials suggested that antipsychotic drugs improved tic scores (SMD = -0.74; 95% CI -1.08, -0.40; N = 76), but certainty in the effect estimate was low. The evidence for other interventions was categorised as low or very low quality, or showed no conclusive benefit.

CONCLUSIONS

When medication is considered appropriate for the treatment of tics, the balance of clinical benefits to harm favours α2-adrenergic receptor agonists (clonidine and guanfacine) as first-line agents. Antipsychotics are likely to be useful but carry the risk of harm and so should be reserved for when α2-adrenergic receptor agonists are either ineffective or poorly tolerated. There is evidence that HRT/CBIT is effective, but there is no evidence for HRT/CBIT alone relative to combining medication and HRT/CBIT. There is currently no evidence to suggest that the physical and dietary interventions reviewed are sufficiently effective and safe to be considered as treatments.

The Impact of Tic Severity, Comorbidity and Peer Attachment on Quality of Life Outcomes and Functioning in Tourette's Syndrome: Parental Perspectives

The aim of this controlled, community-based study based on data from parents of youth (aged 7-16 years) with Tourette's syndrome (TS; n = 86) and parents of age and gender matched peers (n = 108) was to test several hypotheses involving a range of variables salient to the TS population, including peer attachment, quality of life, severity of tics, comorbidity, and psychological, behavioural and social dysfunction. Multivariate between-group analyses confirmed that TS group youth experienced lower quality of life, increased emotional, behavioural and social difficulties, and elevated rates of insecure peer attachment relative to controls, as reported by their primary caregiver. Results also confirmed the main hypothesis that security of peer attachment would be associated with individual variability in outcomes for youth with TS. As predicted, multivariate within-TS group analyses determined strong relationships among adverse quality of life outcomes and insecure attachment to peers, increased tic severity, and the presence of comorbid disorder. Findings suggest that youth with TS are at increased risk for insecure peer attachment and that this might be an important variable impacting the quality of life outcomes for those diagnosed.

Comorbidities, Social Impact, and Quality of Life in Tourette Syndrome

Tourette syndrome (TS) is more than having motor and vocal tics, and this review will examine the varied comorbidities as well as the social impact and quality of life (QoL) in individuals with TS. The relationship between any individual and his/her environment is complex, and this is further exaggerated in the case of a person with TS. For example, tics may play a significant role in shaping the person's experiences, perceptions, and interactions with the environment. Furthermore, associated clinical features, comorbidities, and coexisting psychopathologies may compound or alter this relationship. In this regard, the common comorbidities include attention-deficit hyperactivity disorder and disruptive behaviors, obsessive compulsive disorder, and autism spectrum disorder, and coexistent problems include anxiety, depression, and low self-esteem, which can all lead to poorer psychosocial functioning and QoL. Thus, the symptoms of TS and the associated comorbid conditions may interact to result in a vicious cycle or a downward spiraling of negative experiences and poor QoL. The stigma and social maladjustment in TS and the social exclusion, bullying, and discrimination are considered to be caused in large part by misperceptions of the disorder by teachers, peers, and the wider community. Improved community and professional awareness about TS and related comorbidities and other psychopathologies as well as the provision of multidisciplinary services to meet the complex needs of this clinical population are critical. Future research to inform the risk and resilience factors for successful long-term outcomes is also warranted.

Family quality of life among families with a child who has a severe neurodevelopmental disability: Impact of family and child socio-demographic factors

We aimed to examine family quality of life (FQOL) of Northern Israeli families having a child with a severe neurodevelopmental disability and its relation to socio-demographics. The cohort included caregivers of 70 children ages (mean ± standard deviation) 5.36 ± 3.53 years. Families were two-parent (85.7%), lived in the periphery (67.1%) and included Jews (60%), Muslims (18.6%), Druze (14.3%) and Christians (7.1%). Religiosity included: secular (38.6%), traditional (31.4%), religious (30%). Children's diagnosis included autistic spectrum disorder (41.4%), intellectual disability (21.4%), cerebral palsy (17.1%), genetic syndromes (17.1%) and sensorineural hearing loss (2.9%). Degree of support (1-minimal,5-greatest) required by the child was 3.67 ± 1.28 for physical and 3.49 ± 1.36 for communication. Primary caregivers completed the FQOL Survey. Domain scores were highest for family relations and lowest for financial well-being. Dimension scores were highest for importance and lowest for opportunities. Overall FQOL approximated average. Jewish families and residents of a major urban area reported higher and more religious families reported lower overall FQOL. Regression analysis found ethnicity contributing to overall FQOL and domain scores with residence contributing to support from services. Ethnicity and child dependence contributed to dimension scores. Northern Israeli families having a child with a severe neurodevelopmental disability report average FQOL scores. However, family and child dependence characteristics affect FQOL scores. Professionals working with these families should consider FQOL information when making recommendations.

Impact of Perceived Stress, Anxiety-Depression and Social Support on Coping Strategies of Parents Having A Child With Gilles de la Tourette Syndrome

PURPOSE

Previous reports have indicated that raising a child with Gilles de la Tourette syndrome (GTS) could be considered a stressful experience. Thus our study aimed to assess the impact of perceived stress (i.e. parental cognitive perception of their child's disorder) and social support (number of people surrounding the subject providing support) on coping strategies-defined as processes of restoring balance between excessive demands and inadequate resources-of parents having a child with GTS.

METHODS

Twenty-eight parents of 21 patients with GTS (aged 6 to 16years) completed questionnaires on perceived stress (ALE Scale), social support (SSQ6), coping strategies (WCC-R) and anxiety-depression (HAD).

RESULTS

Principal component analysis showed a negative correlation between social support on one side and perceived stress and anxiety/depression on the other. Problem- and emotion-focused coping both correlated with social support, all of them being independent from perceived stress and anxiety/depression. Hierarchical ascendant classification showed three clusters of individuals in our parents' groups: i) those having high scores in perceived stress and anxiety-depression; ii) those having high scores in social support associated with low scores in perceived stress; iii) parents having lower than average scores on both problem- and emotion- focused coping and social support.

CONCLUSION

Our results reinforce the need for developing training programs for parents with GTS children to better understand and tolerate the disorder to decrease their stress.

Parenting Interventions for Children with Tic Disorders: Professionals' Perspectives

Tic disorders can have an emotional and social impact on children and families, which can in turn have a reciprocal impact on tics. Research into parenting interventions within this population is limited. Twenty-five professionals' views on the acceptability, effectiveness, feasibility and utility of parenting interventions were explored using Q-methodology. Three highly correlated factors emerged, indicating three viewpoints with discrete elements that were underpinned by similar general perspectives. All factors endorsed a psychological approach, the importance of parenting practices, and theoretical and clinical justifications for parenting interventions. Discrete elements of the viewpoints debated the advocated focus, barriers and audience of interventions. Multidisciplinary professionals endorsed parenting interventions as a therapeutic tool within tic disorders. Results provide suggestions to further develop and implement interventions.

Factors impacting the quality of peer relationships of youth with Tourette's syndrome

Background

Tourette’s syndrome (TS) is a poorly understood neurodevelopmental disorder consistently associated with impaired peer relationships. This research aimed to investigate the relationship between TS and the ability of diagnosed youth to form secure attachment relationships with peers. A quantitative study examined differences between youth with TS and typically developing peers in social functioning, relationship problems and attachment security. Qualitative studies sought to identify factors that enhanced or impeded the ability to form secure peer relationships, including the impact of tic severity, comorbidity and personality traits. All research was conducted from the parental perspective.

Methods

The research consisted of a controlled, survey-based qualitative and quantitative study (Study One) of parents of youth with TS (n = 86) and control group peers (n = 108), and a qualitative telephone interview-based study of TS group parents (Study Two, n = 22). Quantitative assessment of social functioning, peer problems and peer attachment security was conducted using the Paediatric Quality of Life inventory, the Strengths and Difficulties Questionnaire and the Attachment Questionnaire for Children. Qualitative data relating to personality was classified using the Five Factor Model.

Results

Results revealed significantly higher rates of insecure peer attachment, problems in peer relationships, difficulty making friends, stigmatisation and lower levels of social functioning for the TS group. Significant between-group differences in number and type of factors impacting peer relationships were also determined with ‘personality’ emerging as the most prevalent factor. Whilst Extraversion and Agreeableness facilitated friendships for both groups, higher rates of Neuroticism were barriers to friendship for individuals with TS. The TS group also identified multiple ‘non-personality’ factors impacting peer relationships, including TS and comorbid symptom severity, the child’s psychological and behavioural adjustment to their disorder, coping strategies and the behaviour and attitudes of peers.

Discussion

Our findings suggest that, whilst Extraversion and Agreeableness facilitated friendships for both groups, higher rates of Neuroticism were barriers to friendship for individuals with TS. Notwithstanding the fact that these findings are based on parental report and not the perceptions of youth themselves, this study may help clinicians to identify youth at increased risk of developing insecure peer relationships and guide the development of targeted supports.

Conclusions

The findings from the study may help clinicians, parents and individuals with TS to better understand and cope with the difficulties experienced in interactions with peers.

Electronic supplementary material

The online version of this article (doi:10.1186/s40359-015-0090-3) contains supplementary material, which is available to authorized users.

Clinical correlates of parenting stress in children with Tourette syndrome and in typically developing children

OBJECTIVE

To determine the impact of tic severity in children with Tourette syndrome on parenting stress and the impact of comorbid attention-deficit hyperactivity disorder (ADHD) and obsessive-compulsive disorder (OCD) symptomatology on parenting stress in both children with Tourette syndrome and typically developing children.

STUDY DESIGN

Children with diagnosed Tourette syndrome (n=74) and tic-free typically developing control subjects (n=48) were enrolled in a cross-sectional study.

RESULTS

Parenting stress was greater in the group with Tourette syndrome than the typically developing group. Increased levels of parenting stress were related to increased ADHD symptomatology in both children with Tourette syndrome and typically developing children. Symptomatology of OCD was correlated with parenting stress in Tourette syndrome. Parenting stress was independent of tic severity in patients with Tourette syndrome.

CONCLUSIONS

For parents of children with Tourette syndrome, parenting stress appears to be related to the child's ADHD and OCD comorbidity and not to the severity of the child's tic. Subthreshold ADHD symptomatology also appears to be related to parenting stress in parents of typically developing children. These findings demonstrate that ADHD symptomatology impacts parental stress both in children with and without a chronic tic disorder.

Parenting interventions in tic disorders: an exploration of parents' perspectives

BACKGROUND

Parents of children with tic disorders (e.g. Tourette syndrome) experience multiple challenges and stresses, which can impact on family functioning, children's well-being and could indirectly affect tic severity. Parenting interventions have been recommended for tic disorder populations; however, little is known about parents' views.

METHOD

The views of parents of children with tic disorders were sought. Using Q-methodology, 23 parents provided their opinions regarding the acceptability, effectiveness, feasibility and utility of parenting interventions.

RESULTS

Four factors emerged, representing four groups of parents with similar opinions. Although all factors evidenced support for parenting interventions, subtle differences emerged between factors regarding the endorsed content, barriers and delivery of interventions.

CONCLUSION

Results indicate a perceived clinical need for parenting interventions and provide guidance to further develop and implement such interventions.

A personal 35 year perspective on Gilles de la Tourette syndrome: assessment, investigations, and management

After having examined the definition, clinical phenomenology, comorbidity, psychopathology, and phenotypes in the first paper of this Series, here I discuss the assessment, including neuropsychology, and the effects of Gilles de la Tourette syndrome with studies showing that the quality of life of patients with Tourette's syndrome is reduced and that there is a substantial burden on the family. In this paper, I review my local and collaborative studies investigating causal factors (including genetic vulnerability, prenatal and perinatal difficulties, and neuro-immunological factors). I also present my studies on neuro-imaging, electro-encephalograms, and other special investigations, which are helpful in their own right or to exclude other conditions. Finally, I also review our studies on treatment including medications, transcranial magnetic stimulation, biofeedback, target-specific botulinum toxin injections, biofeedback and, in severe refractory adults, psychosurgery and deep brain stimulation. This Review summarises and highlights selected main findings from my clinic (initially The National Hospital for Neurology and Neurosurgery Queen Square and University College London, UK, and, subsequently, at St George's Hospital, London, UK), and several collaborations since 1980. As in Part 1 of this Series, I address the main controversies in the fields and the research of other groups, and I make suggestions for future research.

Pilot Open Case Series of Voice over Internet Protocol-delivered Assessment and Behavior Therapy for Chronic Tic Disorders

Comprehensive Behavioral Intervention for Tics (CBIT) is an efficacious treatment for children with Chronic Tic Disorders (CTDs). Nevertheless, many families of children with CTDs are unable to access CBIT due to a lack of adequately trained treatment providers, time commitment, and travel distance. This study established the interrater reliability between in-person and VoIP administrations of the Yale Global Tic Severity Scale (YGTSS), and examined the preliminary efficacy, feasibility, and acceptability of Voice over Internet Protocol (VoIP)-delivered CBIT for reducing tics in children with CTDs in an open case series. Across in-person and VoIP administrations of the YGTSS, results showed mean agreement of 91%, 96%, and 95% for motor, phonic, and total tic severity subscales. In the pilot feasibility study, four children received 8-weekly sessions of CBIT via VoIP and were assessed at pre- and post-treatment by an independent evaluator. Results showed a 29.44% decrease in clinician-rated tic severity from pre to post-assessment on the YGTSS. Two of the four patients were considered treatment responders at post treatment, using Clinical Global Impressions-Improvement ratings. Therapeutic alliance, parent and child treatment satisfaction and videoconferencing satisfaction ratings were high. CBIT was considered feasible to implement via VoIP, although further testing is recommended.

Tourette syndrome, parenting aggravation, and the contribution of co-occurring conditions among a nationally representative sample

BACKGROUND

Previous research suggests that parents of a child with Tourette Syndrome (TS) have lower self-concepts, higher caregiver burden, and more difficulties with home activities. However, the contributions of TS and mental, emotional, or behavioral (MEB) conditions to family functioning are difficult to identify from previous research due to relatively small TS sample sizes and high rates of co-occurring conditions within samples of children with TS.

OBJECTIVE

The current study hypothesized that families of children with TS would report significantly more family functioning difficulties (more parenting aggravation, more difficulty with coping with the child's care, less parent-child communication, and less consistent family routines). Specifically, co-occurring conditions would contribute substantially to reported parenting aggravation.

METHOD

Parent-reported data from the 2007 National Survey of Children's Health were analyzed, including whether the child had been diagnosed with TS or an MEB. Weighted analyses were restricted to US children 6-17 years of age (n = 64,034) and adjusted for child age, sex, race and ethnicity.

RESULTS

Parents of children with TS were more likely to fall into the high parenting aggravation index category compared with parents of children without TS (aPR = 3.8, 95% CI: 2.2-6.6). Controlling for the co-occurring MEB conditions attenuated the relations between TS and parenting aggravation; however, a significant effect for TS remained in some cases.

CONCLUSION

Parents of children with TS may face significant challenges in raising their children, leading to increased parenting aggravation; these challenges appear to be primarily associated with the presence of co-occurring MEB conditions.

Obsessive-compulsive and tic-related disorders

This article presents an overview of the existing, as well as newly developed, cognitive behavior therapy methods for treating the child anxiety triad (separation anxiety disorder, generalized anxiety disorder, and social phobia). For each disorder of the triad, the authors review diagnostic criteria, clinical presentation, disorder-specific treatment methods and innovations, and future directions for research.

Linking caregiver strain to diabetes illness management and health outcomes in a sample of adolescents in chronically poor metabolic control

OBJECTIVE

This study examined a multivariate model of the relationship between caregiver strain and adolescent diabetes illness outcomes in a sample of caregivers of adolescents in chronically poor metabolic control (hemoglobin A1c ≥8.0% at enrollment and for previous 12 mo). Caregiver mental health symptoms were hypothesized to mediate the relationship between caregiver strain and adolescent illness management behavior and metabolic control. Caregivers' perceptions of social support and their level of responsibility for diabetes care tasks were hypothesized to be directly related to caregiver strain and indirectly to caregiver mental health symptoms.

METHODS

One hundred forty-six caregiver-adolescent dyads completed baseline measures of caregiver strain, responsibility for diabetes care, social support, mental health symptoms, and illness management behavior. Adolescent metabolic control was also assessed.

RESULTS

Findings from structural equation modeling suggested that caregiver strain was directly and positively associated with caregiver mental health symptoms which mediated the relationship to adolescent diabetes management behavior and metabolic control. Caregivers' responsibility for diabetes care tasks was directly related to caregiver strain and indirectly to caregiver mental health, but caregivers' perception of social support was not.

CONCLUSIONS

These findings suggest that caregiver strain is an important dimension of the caregiving context of diabetes. Clinicians and researchers should consider how caregiving strain, responsibility for illness management, and mental health symptoms might be impacting children's diabetes care behavior and diabetes health when working with and designing interventions for adolescents with diabetes.

What Patients With Gilles de la Tourette Syndrome Should Be Treated With Deep Brain Stimulation and What Is the Best Target?

BACKGROUND:

Gilles de la Tourette syndrome (GTS) is a chronic neurodevelopmental disorder characterized by tics and associated behavioral symptoms. Over the past decade, deep brain stimulation (DBS) has been increasingly advocated as a reversible and controllable procedure for selected cases of GTS.

OBJECTIVE:

We set out to answer 2 clinically relevant questions: what patients with GTS should be treated with DBS and what is the best target?

METHODS:

We conducted a systematic literature review of the published studies of DBS in GTS and critically evaluated the current evidence for both patient and target selection.

RESULTS:

Since 1999, up to 99 cases of DBS in GTS have been reported in the scientific literature, with varying selection criteria, stimulation targets, and assessment protocols. The vast majority of studies published to date are case reports or case series reporting successful outcomes in terms of both tic severity improvement and tolerability. The reviewed studies suggest that the best candidates are patients with significant functional impairment related to the tic symptoms, who did not respond to conventional pharmacological and behavioral interventions. The globus pallidus internus and thalamus appear to be the safest and most effective targets, especially for patients with “pure” GTS and patients with comorbid obsessive-compulsive symptoms, anxiety, and depression.

CONCLUSION:

DBS is a promising treatment option for severe cases of GTS. There is a need to reach consensus on the definition of “treatment-refractoriness” and to conduct larger double-blind randomized controlled studies on the most promising targets.

Tourette syndrome and other tic disorders

Tic disorders, including Tourette syndrome, are an intriguing group of paroxysmal movement abnormalities that begin in childhood, have a fluctuating course, are capable of causing psychosocial and physical problems, and often improve by early adulthood. These disorders are frequently associated with a variety of comorbid problems whose negative effects may exceed those of tics. Therapy is strictly symptomatic and usually includes educational, behavioral, and a variety of pharmacological therapies. Although there is strong evidence supporting an inherited basis, the precise genetic abnormality remains unknown. A proposed poststreptococcal autoimmune etiology remains controversial. Pathophysiologically, tics appear to arise from an alteration within cortico-striatal-thalamo-cortical circuits, but the definitive site is unknown. Evidence supports an abnormality of synaptic neurotransmission, likely involving the dopaminergic system.

Exploring the impact of chronic tic disorders on youth: results from the Tourette Syndrome Impact Survey

Prior research has demonstrated that chronic tic disorders (CTD) are associated with functional impairment across several domains. However, methodological limitations, such as data acquired by parental report, datasets aggregated across child and adult samples, and small treatment-seeking samples, curtail interpretation. The current study explored the functional impact of tics among youth in a large, "virtual" community sample. An Internet-based survey was completed by families with children who had CTD. The sample included 740 parents and 232 of their children (ages 10-17 years). The survey assessed impact across five functional domains: physical, social, familial, academic, and psychological. Health-related quality of life and perceptions of discrimination resulting from tics were also assessed. Results suggest that (1) youth with CTD experience mild to moderate functional impairment, (2) impairment is generally positively correlated with tic severity, (3) children with CTD plus one or more co-occurring psychiatric conditions tend to have greater functional impairment, and (4) a notable portion of youth with CTD experience discrimination due to tics. Implications and limitations of these findings are discussed.

Neurosurgical treatment for Gilles de la Tourette syndrome: the Italian perspective

Despite the availability of both pharmacological and behavioral therapies for Gilles de la Tourette Syndrome (GTS), a subgroup of patients suffer intractable disease and require treatment through non-conservative means. Since 1955, various neurosurgical procedures have been considered as a potential resort for this severely affected sub-group; this article reviews the neurosurgical treatment for GTS, with in-depth discussion on deep brain stimulation (DBS). Internationally, 39 cases of GTS undergoing DBS treatment have been published. Yet, despite the small numbers of patients assessed in centers involved and the inconsistency of postoperative assessment between centres, DBS has been considered the most promising neurosurgical procedure. Patients resorting to surgical measures often carry the additional burden of a diverse range of behavioral disturbances found to significantly impair health-related quality of life; comorbid psychopathologies must be considered when postoperatively evaluating the benefits of DBS. The authors acknowledge that out of the 39 documented cases of GTS treated with DBS, 18 cases originate from Italy; thus, it seems both relevant and pertinent to recount and present the lived Italian experience of that subgroup of GTS treated by DBS, for the first time. Recommendations from such experience are presented.

Tourette syndrome in children and adolescents: special considerations

Tourette syndrome (TS) affects people of all ages, with onset in early childhood and continuing through the different stages of the life cycle into adolescence and adults. This review focuses on barriers to diagnosis and challenges in the management of young patients with TS. Barriers to identification occur at multiple levels, including detection in the community setting (including schools), parents' help-seeking behavior, and cultural influences on such behavior, as well as diagnosis by the medical provider. Challenges to management include unfamiliarity of primary care providers, inconsistencies in the diagnosis and management plan, and failure to recognize comorbid conditions, as well as inadequate knowledge and lack of resources to effectively deal with comorbidities. In addition to the complexities posed by pharmacological interactions, there are unique psychosocial challenges experienced by young people with TS and their families. Effective communication and collaboration between families, health care providers, and school personnel, as well as supportive communities, are essential components of comprehensive management.