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

Contextual Triggers and Tic Severity Across Life Periods: A Retrospective Analysis in Adults with Tic Disorders

In tic disorders (TD), tic expression varies across the lifespan and as a function of contextual factors. This study explored connections between tic expression and contextual triggers across life periods in 74 adults (Mage = 23.2) with TDs. The Tic History and Coping Strategies form assessed retrospective self-reports of contextual antecedents, consequences, and tic severity during four life periods (middle school; 9th/10th grade; 11th/12th grade; college/work) and past month. Tics reportedly worsened during and after school in school-aged years and worsened in the evening during college/work years. Stress and anxiety were reported to consistently trigger tics across time. The impact of activities, places, and emotions did not differ across life periods. Attention-based consequences, most prevalent during middle school, were more common than escape- or avoidance-related consequences across all periods. Findings illuminate how contextual factors may influence tics across life periods and underscore the consistent impact of tic-triggering emotions and attention-related consequences.

Bedtime Regularity and Sleep Sufficiency in Children With Tourette Syndrome

BACKGROUND

Despite research demonstrating sleep disturbance in children with Tourette syndrome (TS), few studies have examined bedtime regularity and sleep sufficiency, two important sleep health dimensions. Therefore, this study examined bedtime regularity and sleep sufficiency in children with TS relative to matched healthy control subjects, and its associated demographic, clinical, and behavioral factors.

METHODS

Participants were 384 parents or caregivers of children aged three to 17 years, including 192 with current TS and 192 matched healthy control subjects drawn from the 2020-2021 cycle of the National Survey of Children's Health. Parents completed questions assessing demographic (i.e., age, race, sex), clinical (i.e., attention-deficit/hyperactivity disorder [ADHD], autism spectrum disorder, anxiety, depression, tic severity, behavioral or conduct problems, ADHD medication, health condition-related impairment), and behavioral (i.e., screen time) characteristics. Mann-Whitney U test and chi-square test of independence were performed to compare groups on bedtime regularity and sleep sufficiency, respectively. Ordinal regression and binary logistic regression without and with backward elimination were performed to evaluate indicators of bedtime regularity and sleep sufficiency, respectively, in children with TS.

RESULTS

Children with current TS had significantly poorer bedtime regularity, but not sleep sufficiency, relative to matched healthy control subjects. In children with TS, anxiety and two or more hours of daily screen time were associated with higher likelihood of poor bedtime regularity. Autism was associated with lower likelihood of insufficient sleep, and depression was associated with increased likelihood of insufficient sleep.

CONCLUSIONS

Findings put forth screen time, anxiety, and depression as intervention targets to optimize sleep health in children with TS.

[Formula: see text] Beyond the rubicon: a continuum approach to investigating the impact of ADHD like characteristics on everyday executive function in children with Tourette Syndrome

Across a range of neurodevelopmental conditions, a diagnosis of attention deficit hyperactivity disorder (ADHD) has been shown to be associated with executive function impairment. However, the DSM-V emphasis upon viewing psychological characteristics as existing on a continuous distributed quantitative dimension has enabled the opportunity to consider the influence of sub-diagnostic or sub-referral levels of these psychological characteristics upon cognitive function. This study adopted a continuum approach to the consideration of this ADHD influence and examined the extent to which the difference in parental reported executive functions between children with Tourette syndrome (TS) or typically developing children could be mediated by a concurrent group difference in the possession of sub-referral levels of ADHD-like characteristics. A total of 146 children, 58 with reported TS diagnosis, participated. Parental report measures of ecological executive functioning, the Child Executive Functioning Inventory, and the Vanderbilt ADHD Diagnostic Parent Rating Scale were employed. The analyses with a full sample and a sub-referral sample revealed significant group differences in most of the key measures. In addition, these measures were highly correlated even when controlling for age and gender. A series of mediation analyses indicated that in all models, the ADHD-like measures significantly mediated the group difference in executive function. These results suggest that sub-referrals levels of ADHD-like characteristics continue to contribute to executive challenges in TS. Future intervention research targeting these executive functions should consider the presence of ADHD-like characteristics at sub-referral levels of possession.

Caregiver Perspectives on the Health Care System for Tic Disorders: Utilization and Barriers

OBJECTIVE

This study aimed to understand health care experiences among a sample of caregivers of children with TDs to inform future directions for improving the health care system.

METHODS

We conducted a survey of caregivers of youth with TDs and used descriptive statistics and quantitative analyses to characterize the health care utilization practices of the sample.

RESULTS

The majority (70%) of families first consulted their pediatrician/primary care provider, and caregivers reported receiving care in line with current best practice guidelines. However, caregivers in the current sample perceived a lack of knowledgeability on the part of their first providers, which significantly predicted more providers seen and also reported difficulty finding specialty providers (63% of the sample reported difficulty finding a treatment provider who understood tics).

CONCLUSION

Results suggest that improving caregiver satisfaction with early health care experiences for their child's TD may help to relieve the burden on families and the health care system more broadly, along with continued efforts to increase the number of specialty providers available.

Teacher Knowledge of Tourette Syndrome and Associated Factors

BACKGROUND

TS is associated with learning disabilities and educational impairment. Teacher knowledge about TS may have a positive impact on students with TS, but factors associated with teacher knowledge of TS are not known.

METHODS

In this cross-sectional study, teachers of youth with TS and of a community control group completed a Teacher Understanding of Tourette Syndrome Survey (TUTS), a pilot questionnaire enquiring about self-perceived understanding, teacher knowledge, and sources of information. We compared TUTS scores between TS and control groups and between those who did and did not use specific sources of information about TS using Wilcoxon rank-sum tests. Bivariate correlation analyses were used to evaluate associations between teacher knowledge and potential contributing factors.

RESULTS

Data from 114 teachers of children with TS and 78 teachers of control subjects were included. Teachers of youth with TS had significantly more knowledge, had higher self-perceived understanding, and used more sources of information than teachers of the control group. Teachers who knew of the Tourette Association of America and who gathered information themselves had higher knowledge about TS than those who did not.

CONCLUSION

Teachers of children with TS know more about TS and use more sources to learn about TS than teachers of children without TS.

Clinical Characteristics of Children With Tourette Syndrome With and Without Sleep Disorder

BACKGROUND

Sleep problems are common in children with Tourette Syndrome (TS). However, research regarding their demographic and clinical profile is limited.

METHODS

We examined characteristics of 114 children aged five to 17 years with a lifetime diagnosis of TS and compared children with sleep disorder (n = 32) and without sleep disorder (n = 82). Parent report from the 2014 National Survey of the Diagnosis and Treatment of ADHD and Tourette Syndrome provided demographics and clinical information, other diagnosed disorders, medication use, TS severity, and impairment.

RESULTS

More children with TS with sleep disorder were from households with lower parental education (P < 0.01) and poverty (P = 0.04); had other diagnoses (P = 0.03), including obsessive-compulsive disorder (P < 0.01), oppositional defiant disorder or conduct disorder (P < 0.01), attention-deficit/hyperactivity disorder (ADHD) (P = 0.02), and autism (P = 0.03); and had ever used TS medication (P = 0.01) than children with TS without sleep disorder. More children with TS with sleep disorder had severe TS symptoms (P <0.01), tic-related impairment (P<0.01), and severe ADHD symptoms (P < 0.01) compared with children with TS without sleep disorder.

CONCLUSIONS

Findings suggest greater parent-reported impact and tic-related interference in children with TS with sleep disorder compared with TS without sleep disorder. Results underscore the importance of monitoring and intervention for TS exacerbations, other diagnosed disorders, and medication use, and consideration of socioeconomic context in sleep disorder management and prevention in children with TS.

Abnormal dynamics of brain functional networks in children with Tourette syndrome

Tourette syndrome (TS) is a childhood-onset neurodevelopmental disorder characterized by the presence of multiple motor and vocal tics. Research using resting-state functional magnetic resonance imaging (rfMRI) have found aberrant static functional connectivity (FC) and its topological properties in the brain networks of TS. Our study is the first to investigate the dynamic functional connectivity (dFC) in the whole brain network of TS patients, focusing on the temporal properties of dFC states and the temporal variability of topological organization. The rfMRI data of 36 male children with TS and 27 matched healthy controls were collected and further analyzed by group spatial independent component analysis, sliding windows approach based dFC analysis, k-means clustering analysis, and graph theory analysis. The clustering analysis identified three dFC states. Of these states, state 2, characterized by increased inter-network connections in subcortical network (SCN), sensorimotor network (SMN), and default mode network (DMN), and decreased inter-network connections between salience network (SAN) and executive control network (ECN), was found to have higher fractional window and dwell time in TS, which was also positively correlated with tic severity. TS patients also exhibited higher temporal variability of whole-brain-network global efficiency and local efficiency, and higher temporal variability of nodal efficiency and local efficiency in SCN, DMN, ECN, SAN, and SMN. Additionally, temporal variability of the efficiency and local efficiency in insula was positively correlated with tic severity. Our findings revealed abnormal temporal property of dFC states and temporal variability of topological organization in TS, providing new insights into clinical diagnoses and neuropathology of TS.

Sleep Disorders, Sleep Medication Use, and Predictors of Sleep Disturbance in Children with Persistent Tic Disorders

The present study examined rates of sleep disorders and sleep medication use, and predictors of sleep disturbance in children with persistent tic disorders (PTD). Sixty-three parents of children aged 10 to 17 years with PTDs completed an internet survey evaluating sleep patterns and clinical symptoms. Insomnia (19.4%), nightmares (16.1%), and bruxism (13.1%) were the most commonly reported lifetime sleep disorders. Fifty-two percent endorsed current sleep medication use. Higher ADHD severity, overall life impairment, and female sex predicted greater sleep disturbance. Findings suggest the utility of clinical management of co-occurring ADHD and impairment to mitigate sleep disturbance in children with PTDs.

A Population-Based Study of the Utility of Screening for Tics and the Relative Contribution of Tics and Psychiatric Comorbidity to Academic and Social Impairment in Adolescents

This study examined the performance of a brief screening tool for tics in adolescents. Academic and social impairment in students by tic screen status and emotional/behavioral problem status were examined. Data were collected as part of an epidemiologic study, the Project to Learn about Youth - Mental Health. Participants were 2,312 secondary school students at the Ohio site (47.4% female; 94.4% non-Hispanic white) and their teachers. Students completed 6 items from the Motor tic, Obsessions and compulsions, Vocal tic Evaluation Survey (MOVES-6) and the Strengths and Difficulties Questionnaire (SDQ). Teachers completed the Proxy Report Questionnaire for tics and SDQ. Based on responses to the MOVES-6, 11.1% of students screened positive for tics. Internal consistency was adequate (α = 0.76); inter-rater consistency between teachers and students was low (0.03). Based on student self-report, those who screened positive for tics self-reported more academic and social impairment than students who screened negative for tics; teacher-report of impairment was similar between those with a positive or negative tic screen. Students who screened positive for tics and reported internalizing difficulties reported more academic and social impairment than students with only a positive tic screen. Teachers perceived those screening positive for tics and externalizing difficulties as the most socially impaired. In conclusion, a positive self-reported tic screen was associated with self-reported academic and social impairment. Findings reveal the independent contribution of tics to impairment, even when internalizing and externalizing problems are present, and the potential utility of a school-based screening for tics in adolescents.

Evaluation of new instruments for screening and diagnosis of tics and tic disorders in a well-characterized sample of youth with tics and recruited controls

Tics and tic disorders can significantly impact children, but limited screening tools and diagnostic challenges may delay access to care. The current study attempted to address these gaps by evaluating sensitivity and specificity of the Motor or Vocal Inventory of Tics (MOVeIT), a tic symptom screener, and the Description of Tic Symptoms (DoTS), a brief diagnostic assessment for tic disorders. Children (n=100, age 6-17 years old) with tic disorders attending a Tourette specialty clinic and a community-recruited sample without tics completed a gold-standard assessment by a tic expert; these evaluations were compared to child self-report and parent and teacher report versions of the MOVeIT, and child and parent versions of the DoTS. The parent and child MOVeIT met or exceeded pre-specified 85% sensitivity and specificity criteria for detecting the presence of tics when compared to a gold-standard tic expert diagnosis. The Teacher MOVeIT had lower sensitivity (71.4%) but good specificity (95.7%) for identifying any tic symptoms compared to gold standard. For determination of the presence or absence of any tic disorder, sensitivity of both parent and child DoTS was 100%; specificity of the parent DoTS was 92.7% and child DoTS specificity was 75.9%. More work may be needed to refine the teacher MOVeIT, but it is also recognized that tic expression may vary by setting. While the MOVeIT and DoTS parent and child questionnaires demonstrated adequate sensitivity and specificity for determining the presence of tics and tic disorders in this well-defined sample, additional testing in a general population is warranted.

Lifetime Prevalence, Predictors and Comorbidities of Tic Disorders: A Population-Based Survey of Children and Adolescents in Iran

In this population-based survey, we have evaluated the lifetime prevalence of tic disorders and related sociodemographic factors and comorbidities of them. The data obtained from face-to-face interviews with 29,885 children and adolescents aged 6-18 years. We used the multistage cluster sampling method and a cross-sectional design. Tic disorders and other psychiatric disorders were assessed using the Persian version of the Kiddie Schedule for Affective Disorders and Schizophrenia-Present and Lifetime Version (K-SADS-PL). The lifetime prevalence of tic disorders was 1.5% (95% CI  (1.3-1.7%)). The highest prevalence was in the age range of 15-18 years old with 1.9% (95% CI  (1.6-2.3%)).57.7% (95% CI 51.8-63.3%) of patients with tic disorders had comorbidity with other psychiatric disorders. Increasing the prevalence of tic disorder with increasing age among Iranian children and adolescents, emphasizes the need to pay more attention to use of pharmacological and non-pharmacological treatments and increase education to families in this regard.

Incidence and prevalence of Tourette syndrome and chronic tic disorders in Taiwan: a nationwide population-based study

PURPOSE

The incidence of Tourette syndrome and chronic tic disorders has seldom been evaluated in Asia.

METHODS

Using the National Taiwan Insurance Research Database, the annual standardized incidence and prevalence of Tourette syndrome (TS) and chronic tic disorders were estimated from 2007 to 2015. The pre-existing comorbidity at disease diagnosis was also evaluated.

RESULTS

From 2007 to 2015, the age- and sex-standardized incidence increased from 5.34 (95% confidence interval [CI] 5.06-5.62) per 100,000 person-years to 6.87 (95% CI 6.53-7.21) per 100,000 person-years. In children and adolescents, the age- and sex-standardized incidence increased from 19.58 (95% CI 18.42-20.75) per 100,000 person-years to 31.79 (95% CI 30.09-33.49) per 100,000 person-years. In adults, the age- and sex-standardized incidence decreased from 2.01 (95% CI 1.79-2.23) per 100,000 person-years to 1.24 (95% CI 1.07-1.42) per 100,000 person-years. The incidence rate ratio (IRR) between males and females was 3.74 (95% CI 3.32-4.22). The age- and sex-standardized prevalence increased from 37.51 (95% CI 36.75-38.27) per 100,000 people in 2007 to 84.18 (95% CI 83.02-85.35) per 100,000 people in 2015. The rate risk (RR) between males and females was 3.65 (95% CI 3.53-3.78).

CONCLUSION

The annual incidence rates of TS and chronic tic disorders increased in childhood and adolescence but decreased in adulthood from 2007 to 2015. The prevalence rates increased over the same period.

Multivariate Classification of Brain Blood-Oxygen Signal Complexity for the Diagnosis of Children with Tourette Syndrome

Tourette syndrome (TS) is a childhood-onset neuropsychiatric disorder characterized by the presence of multiple motor and vocal tics. Because of its varied clinical expressions and lack of reliable diagnostic biomarker, present TS diagnosis still depends on qualitative descriptions of symptoms. Our study aimed to investigate whether the complexity of resting state brain activity can serve as a potential biomarker for TS diagnosis, since it has been used successfully in various neuropsychiatric disorders, including two common TS comorbidities: attention-deficit hyperactivity disorder (ADHD) and obsessive-compulsive disorder (OCD). In the current study, we used both univariate analysis and multivariate searchlight analysis with both linear and non-linear classification methods to explore the group differences in the complexity of resting state brain blood oxygen level-dependent (BOLD) signals between 25 TS boys without comorbidity and 25 sex, age and educational years matched healthy controls (HCs). We also investigated the relation between symptom severity in TS patients (YGTSS scores) and complexity indices derived from different analysis methods. We found: i) univariate analysis revealed reduced complexity in TS patients in the left cerebellum, left superior frontal gyrus, and left medial frontal gyrus; ii) multivariate analysis with non-linear classification method achieved the highest performance (accuracy: 0.94, sensitivity: 0.96, specificity: 0.92, AUC: 0.95) in bilateral supplementary motor areas; iii) significant correlations were found between complexity index derived from multivariate analysis with non-linear classification method and Tic severity (YGTSS scores) in the left cerebellum (r = 0.523, with YGTSS phonic) and in the right supplementary motor area (r = 0.767, with YGTSS motor). Taken together, these results suggested that complexity of resting state BOLD activity is a highly effective index for differentiating TS patients from normal controls. It has a good potential to be a quantitative biomarker for TS diagnosis.

Bullying Victimization and Perpetration Among US Children with and Without Tourette Syndrome

OBJECTIVE

Tourette syndrome (TS) and co-occurring mental, behavioral, and developmental disorders (MBDDs) have been shown to affect peer relationships. This study provides nationally representative estimates of diagnosed TS prevalence and the prevalence of parent-reported bullying victimization and perpetration among US children with and without TS.

METHODS

This study included 2016-2017 National Survey of Children's Health data on children aged 6 to 17 years (N = 51,001) with parent-reported responses about TS diagnosis and their child's experiences with bullying victimization and perpetration. We calculated weighted prevalence estimates of diagnosed TS and of bullying indicators among children ever diagnosed with TS compared with peers without TS. We conducted a logistic regression analysis to estimate adjusted prevalence ratios of bullying involvement by TS status, controlling for age, sex, and co-occurring MBDDs.

RESULTS

By parent report, 0.3% of US children had ever received a diagnosis of TS; most children with a TS diagnosis (83.2%) had a co-occurring MBDD. Among children with TS, 56.1% experienced bullying victimization, 20.7% experienced bullying perpetration, and 15.9% experienced both, compared with 21.6%, 6.0%, and 4.1% for children without TS, respectively. After adjusting for age, sex, and co-occurring MBDDs, only the association between TS and bullying victimization remained statistically significant.

CONCLUSION

Compared with children without TS, children with TS overall experience more bullying victimization and perpetration. Health care professionals treating children with TS could assess challenges with peer relationships and co-occurring disorders to provide targeted support and referral.

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.

An International Survey of Health Care Services Available to Patients With Tourette Syndrome

Objective: Tourette syndrome (TS) is a neuropsychiatric disorder that is highly associated with several comorbidities. Given the complex and multifaceted nature of TS, the condition is managed by a wide variety of practitioners in different disciplines. The goal of this study was to investigate health service delivery and care practices by clinicians who see TS patients across different geographic settings internationally. Methods: A comprehensive questionnaire was developed to assess clinical care resources for patients with TS and was sent to clinicians in Canada (CA), the United States (US), Europe (EU), and the United Kingdom (UK). Responses were compared quantitatively between geographic regions. Results: The majority of respondents, regardless of region, reported that fewer than 40% of their case-load are patients with tics. The accessibility of TS services varied among regions, as indicated by differences in wait times, telemedicine offerings, comorbidity management and the availability of behavioral therapies. First-line pharmacotherapy preferences varied among physicians in different geographical regions with CA respondents preferring alpha-2-adrenergic agonists and respondents from the UK and EU preferring dopamine receptor antagonists. Discussion: The results suggest that there is a scarcity of specialized TS clinics, potentially making access to services challenging, especially for patients newly diagnosed with TS. Differences in regional pharmacotherapeutic preferences are reflected in various published treatment guidelines in EU and North America. The lack of dedicated specialists and telemedicine availability, coupled with differences in comorbidity management, highlight the need for interprofessional care and holistic management to improve health care delivery to patients with TS.

Clinical features and neuropsychiatric comorbidities in pediatric patients with tic disorders: a retrospective chart review study from South Korea

BACKGROUND

Tic disorders are childhood-onset neuropsychiatric disorders characterized by multiple motor or vocal tics with frequent comorbidities and a broad spectrum of phenotypic presentations. In this study, we aimed to investigate the clinical characteristics and comorbid neuropsychiatric conditions in pediatric patients with tic disorders.

METHODS

We retrospectively reviewed the medical records of 119 pediatric patients (89 males, 30 females) who were diagnosed with tic disorders according to the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) at Uijeongbu St. Mary's Hospital, Republic of Korea, between January 2012 and July 2019.

RESULTS

The mean age of tic onset was 6.9 years (range, 1-14) and the mean age at diagnosis was 8 years (range, 1-17). The mean lag between tic onset and diagnosis was 13.3 months (range, 0.25-132). The most common, first-presenting tics were eye blinking (50.4%), followed by jaw or lip movement (29.4%) and throat clearing (29.4%). Thirty-seven (31.1%) patients had at least one co-occurring neuropsychiatric disorder at the time of tic diagnosis. Subtypes of tic disorders, types of initial tics, and presence of neuropsychiatric comorbidities were not associated with tic severity. Tic severity was associated with greater functional impairment and tic noticeability (p < 0.05). A relatively shorter time to diagnosis was associated with tic severity (Spearman's ρ = - 0.14, p = 0.11).

CONCLUSIONS

The evolving nature of tic expression and severity, high prevalence of neuropsychiatric comorbidities, and associated functional impairments emphasize the importance of comprehensive assessment during the disease course for determining and prioritizing goals of treatment.

Treatment use among children with Tourette syndrome living in the United States, 2014

Treatment of Tourette syndrome (TS) can be complicated by changes over time in tic expression, severity, and co-occurring disorders. Using the 2014 National Survey of the Diagnosis and Treatment of ADHD and Tourette Syndrome, this study provides descriptive estimates of the use of behavioral interventions and medication among children living with TS. Parent-reported data on 115 children aged 5-17 years ever diagnosed with TS were analyzed to provide descriptive, unweighted results. Overall, 77.4% of children had current or past use of any TS treatment; 59.1% ever used behavioral interventions and 56.1% had ever taken TS medication. Children with "moderate" or "severe" versus "mild" TS, ≥1 co-occurring disorders, and tics that interfered with functioning were significantly more likely to have used one or more TS treatments. Side effects were reported for 84.4% of children who took TS medication. Most parents of children with current TS (87.2%) were satisfied with the management of their child's TS. However, parents of children with "moderate" or "severe" current TS were significantly more dissatisfied compared to parents of children with "mild" TS. Findings from this study could be used to inform efforts to support children living with TS and their families.

Handwriting skills of children with tic disorders

INTRODUCTION

Although circumstantial evidence suggests children with tic disorders (TD) experience challenges in handwriting which may be attributed to their tics, few studies have systematically investigated handwriting performance among children with TD. This study examined the relationship between handwriting deficits and TD using a causal comparative research design.

METHODS

Thirty-four children with TD completed the Test of Handwriting Skills-Revised (THS-R). The overall percentile ranks of the THS-R were analysed to determine if children with TD have lower scores compared to the test's normative values. Writing speed, letter reversals, touching letters and case errors were also evaluated.

RESULTS

Data revealed the median percentile rank of the THS-R for the participants was significantly lower than the median percentile score of the THS-R for the normative sample. Close to 80% (n = 27) of writing samples were scored below 50th percentile. More than one-third (35.3%, n = 12) of the writing samples were scored greater than one standard deviation below the normative mean on the THS-R. Of the four ancillary scores, 82.4% (n = 28) of the participants' writing samples scored below 50th percentile (in the categories of watch or test further) on case errors and 67.6% (n = 23) scored below 50th percentile on writing speed.

CONCLUSION

Findings suggested that children with TD took longer to complete the writing task, and committed more case substitution errors than the normative sample of the THS-R and were likely to exhibit handwriting deficits.