Parent perceptions of symptom severity in Tourette's syndrome

Tics emergencies and malignant tourette syndrome: Assessment and management

Tourette syndrome (TS) is a complex neurodevelopmental disorder characterized by the presence of tics, frequently accompanied by a variety of neuropsychiatric comorbidities. A subset of patients with TS present with severe and disabling symptoms, requiring prompt therapeutic intervention. Some of these manifestations may result in medical emergencies when severe motor or phonic tics lead to damage of anatomical structures closely related to the tic. Examples include myelopathy or radiculopathy following severe neck ("whiplash") jerks or a variety of self-inflicted injuries. In addition to self-aggression or, less commonly, allo-aggression, some patients exhibit highly inappropriate behavior, suicidal tendencies, and rage attacks which increase the burden of the disease and are important components of "malignant TS". This subset of TS is frequently associated with comorbid obsessive-compulsive disorder. Therapeutic measures include intensive behavioral therapy, optimization of oral pharmacotherapy, botulinum toxin injections, and deep brain stimulation.

Addressing co-occurring conditions in behavioural therapy for tic disorders: a review and guideline

Co-occurring psychiatric conditions are very common in tic disorders and Tourette syndrome. These additional symptoms are often detrimental to quality of life and may impact upon the implementation and efficacy of evidence-based behavioural therapies (BT) for tics. Combining a review of the available literature, relevant theory, and expert clinical practice, we present a guideline for implementing behavioural and psychosocial interventions when common comorbidities are present. These include attention-deficit hyperactivity disorder (ADHD), obsessive-compulsive disorder (OCD), anxiety, disruptive behaviour, autism spectrum disorder (ASD) and depression. Practical recommendations are provided for assessment, formulation and management of specific and multiple comorbidities in BT for both children and adults. Despite comorbidities being common in tic disorders, few studies have comprehensively addressed how they may influence the efficacy or implementation of existing therapies or how such treatments may need to be modified or sequenced. We outline recommendations for future research, including randomised control trials of BT for those with specific or multiple comorbidities, as well as adequately powered sub-group analyses within larger scale trials or naturalistic study designs. Transdiagnostic models of psychiatric disorders and treatment, including modular cross-diagnostic therapies, which recognise the dimensionality of psychiatric disorders are also highlighted as an important focus in treatment development in tic disorders.

An observational study of emotion regulation in children with Tourette syndrome

BACKGROUND

Explosive outbursts occur in 25%-70% of children with Tourette syndrome (TS) and may cause more distress than the tics themselves. Previous studies have indicated that a comorbid diagnosis of attention-deficit/hyperactivity disorder (ADHD) is associated with emotional dysregulation in TS; however, this relationship has almost exclusively been studied using parent-reported questionnaires.

METHODS

We examined emotion regulation (ER) with an observational measure in 150 medication-naïve children aged 7-12 allocated to four groups: Forty-nine children with TS, 23 children with ADHD, 16 children with TS + ADHD, and 62 typically developing controls. We assessed participants' ER ability, as well as parent-child interactions in the context of a complex puzzle task, and coded the observed behavior with the Tangram Emotion Coding Manual (TEC-M). We examined group differences in ER, as well as associations between ER and severity of symptoms pertaining to TS and ADHD.

RESULTS

Children with TS did not differ from controls in their ER ability. However, children with ADHD and TS + ADHD had more problems with ER than those with TS only and controls. Finally, parents of children with ADHD displayed more tension during the experimental task. ER ability was not associated with tic severity nor premonitory urges; however, better ER ability was associated with less severe symptoms of ADHD.

CONCLUSIONS

This study is the first to evaluate ER with an observational, clinician-rated measure in a controlled social setting in children with TS. Our findings support earlier questionnaire-based studies by showing impaired ER in children with TS + ADHD, but not in children with TS without comorbidity. These findings inform our understanding of the phenomenology of emotional dysregulation in TS and the role of comorbid disorders.

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.

Rage attacks in Tourette Syndrome and Chronic Tic Disorder: a systematic review

Tourette syndrome (TS) and chronic motor/vocal tic disorder (CTD) are neurodevelopmental conditions defined by the occurrence of multiple tics. Besides the well-known association with attention deficit/hyperactivity disorder (ADHD) and obsessive-compulsive disorder (OCD), rage attacks (RA) represent common and detrimental symptoms for patients. Inorder to explore prevalence of RA in tic disorders, relation to tic severity/comorbidities and available treatments, we performed a systematic literature review based on PRISMA Guidelines. 32 studies published between January 2008 - December 2019 were deemed suitable for the analysis and provided a prevalence of 20-67 %. Most findings showed a direct correlation with tic severity and a significant impact on psychosocial functioning. Although apparently related to comorbid ADHD, RA also frequently occur as independent manifestations. Association with other comorbidities, such as OCD, impulse control and mood disorders has also been reported, not yet fully established. Behavioral interventions appear to be effective, whereas there is limited evidence concerning the efficacy of medication. In TS/CTD, RA may be regarded as a major comorbidity that requires clinical investigation in order to develop personalized treatments.

The Rage Attack Questionnaire-Revised (RAQ-R): Assessing Rage Attacks in Adults With Tourette Syndrome

INTRODUCTION

Although defined by the presence of tics, most patients with Gilles de la Tourette syndrome (TS) also suffer from different psychiatric disorders. While much is known about clinical characteristics of comorbidities such as attention deficit/hyperactivity disorder (ADHD), obsessive compulsive disorder (OCD), depression, and anxiety disorders, only very little is known about rage attacks. Most of this data is based on small studies in children. Until today no larger studies have been performed in adults with TS-most likely because of the lack of validated instruments. The aim of this study was to develop a new assessment and investigate rage attacks in a large sample of adults with TS and healthy individuals.

MATERIALS AND METHODS

Based on a parent questionnaire for children with TS, we generated 27 items for a revised version of a rage attack questionnaire (RAQ-R) and tested factor structure, internal consistency, as well as convergent and discriminant validity. We used an online survey and included 127 patients with TS and 645 control subjects. In addition to the RAQ-R, we used several other self-assessments to measure tic severity, quality of life, as well as several psychiatric symptoms including ADHD, OCD, depression, anxiety, and impulsivity.

RESULTS

Based on expert option and statistical analyses [including item-total correlation, skewness, inter-item correlation, and principal component analysis (PCA)], we performed an item reduction resulting in a final, 22-items version of the RAQ-R (range, 0-66). Investigating internal consistency, discriminant validity, test reliability, and factor structure, the RAQ-R demonstrated good to excellent quality criteria. As assessed by RAQ-R, rage attacks were significantly more common in patients with TS compared to controls (p < 0.001). Rage attacks could be clearly differentiated from the phenomenon of impulsivity. Although rage attacks occurred more often in individuals with ADHD, they were also found in patients with "TS only", independently from comorbid ADHD, impulsivity, and OCD. Rage attacks were found to significantly influence patients' quality of life.

CONCLUSIONS

Thus, from our data based on a large sample it is suggested that rage attacks represent a discrete comorbidity in adults with TS.

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

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

Distinct Patterns of Everyday Executive Function Problems Distinguish Children With Tourette Syndrome From Children With ADHD or Autism Spectrum Disorders

OBJECTIVE

The aim is to investigate the everyday executive function (EF) in children with Tourette syndrome (TS), Inattentive or Combined presentations of ADHD (ADHD-I/ADHD-C), autism spectrum disorders (ASD), and typically developing children (TDC).

METHOD

Nineteen TS, 33 ADHD-C, 43 ADHD-I, 34 ASD, and 50 TDC participated (8-17 years). Parents completed the Behavior Rating Inventory of Executive Function (BRIEF).

RESULTS

TS, ADHD-C, ADHD-I, or ASD were rated with significantly more regulation problems on all scales compared with TDC. Considerable overlap of symptoms between clinical groups made differentiation difficult on individual scales. Scale configurations showed children with TS to have more problems with emotional control (EC) than cognitive flexibility in relation to children with ASD, more problems with EC than inhibitory control in relation to ADHD-C, and more problems with EC than planning/organizing in relation to ADHD-I.

CONCLUSION

Paired BRIEF scales dissociated EF problems in children with TS from children with ADHD-C, ADHD-I, or ASD. Clinical relevance is discussed.

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.

Difficulties experienced by young people with Tourette syndrome in secondary school: a mixed methods description of self, parent and staff perspectives

BACKGROUND

Tourette syndrome (TS) is a neurodevelopmental disorder characterised by motor and vocal tics. These involuntary movements and vocalizations can have a negative impact in the school environment. The paper presents a mixed methods description of the difficulties experienced by UK students with TS in secondary school, drawing on multiple perspectives.

METHODS

Thirty-five young people with TS (11 to 18 years), their parents (n = 35) and key members of school staff (n = 54) took part in semi-structured interviews about TS-related difficulties in secondary school. Theme analysis was used to identify school difficulties reported by the young people, before moving on to analysis of the parents' and staff members' transcripts. The most frequently occurring themes from the young people's accounts were then quantified in order to examine the level of agreement between informants and the association with clinical symptom severity.

RESULTS

A range of TS-related difficulties with academic work, and social and emotional well-being in school were reported by young people, parents and staff. Three superordinate themes are described: 1) TS makes school work more difficult, 2) Negative response to TS from staff and fellow students and 3) TS makes it more difficult to manage emotions in school. The three difficulties most frequently reported by the young people were problems concentrating in class, unhelpful responses by school staff to tics and difficulties with other students such as name-calling and mimicking tics. Additional difficulties reported by more than a quarter of young people related to homework, examinations, writing, anxiety and managing anger in school. Having more severe motor tics was associated with reporting difficulties with homework and handwriting, whereas having more severe phonic tics was associated with reporting unhelpful responses from staff. Young people and parents agreed more strongly with each other than they did with staff regarding school difficulties faced by individuals, and staff generally reported fewer TS-related difficulties.

CONCLUSIONS

TS can present a barrier to learning in several ways and can also affect interactions with others and emotional experiences in secondary school. Implications for supporting secondary school-aged students with TS are considered.

Rage attacks in pediatric obsessive-compulsive disorder: phenomenology and clinical correlates

OBJECTIVE

Rage attacks have been documented in youth with varied psychiatric disorders, but few data have been reported on the clinical characteristics and correlates of rage attacks among children with obsessive-compulsive disorder (OCD).

METHOD

Participants were 86 children (ages 6-16 years) with a primary diagnosis of OCD. Patients and their primary caregiver were administered clinician-rated measures of obsessive-compulsive severity and rage severity. Children completed the Center for Epidemiologic Studies Depression Scale and the Child Sheehan Disability Scale-Child, whereas parents completed the Rage Attacks Questionnaire, Aberrant Behavior Checklist-Irritability Scale, Children's Affective Lability Scale, and Child Sheehan Disability Scale-Parent.

RESULTS

Rage was common among youth with OCD and was associated with varied clinical characteristics. Rage severity accounted for functional impairment beyond the influence of obsessive-compulsive symptom severity; however, these relations were explained by the impact of family accommodation.

CONCLUSIONS

These data suggest that rage attacks are relatively common, have a negative impact on illness presentation, and contribute to functional impairment above and beyond obsessive-compulsive symptom severity. Rage may contribute to family accommodation of symptoms, which may further affect obsessive-compulsive symptom severity and impairment.

Peer victimization in youth with Tourette syndrome and other chronic tic disorders

Chronic tic disorders including Tourette syndrome have negative impact across multiple functional domains. We explored associations between peer victimization status and tic subtypes, premonitory urges, internalizing symptoms, explosive outbursts, and quality of life among youth with chronic tic disorders, as part of the internet-based omnibus Tourette Syndrome Impact Survey. A mixed methods design combined child self-report and parental proxy-report (i.e., parent reporting on the child) demographic and quantitative data for affected youth ages 10-17 years addressing gender, mean age, ethnicity and other socioeconomic features, and presence of tic disorders and co-occurring psychiatric disorders. Peer "Victim" versus "Non-victim" status was determined using a subset of four questions about being bullied. "Victim" status was identified for those youth who endorsed the frequency of the occurrence of being bullied in one or more of the four questions as "most of the time" or "all of the time". Data from 211 eligible youth respondents and their parents/guardians showed 26% reporting peer victimization. Victim status was associated with greater tic frequency, complexity and severity; explosive outbursts; internalizing symptoms; and lower quality of life. Peer victimization among youth with chronic tic disorders is common and appears associated with tic morbidity, anxiety, depression, explosive outbursts, and poorer psychosocial functioning. Anticipatory guidance, specific bullying screening and prevention, and further studies are indicated in this population.

The Normal Inhibition of Associations is Impaired by Clonidine in Tourette Syndrome

OBJECTIVE

We examined the inhibition of stimulus-stimulus associations (formally 'conditioned inhibition') in Tourette syndrome (TS).

METHOD

The present study used video game style conditioned inhibition procedures suitable for children and adolescents. We tested 15 participants with a clinical diagnosis of TS in the absence of co-morbid attention deficit hyperactivity disorder and compared them with 19 typically developing age and sex matched controls (both groups aged 10-20 years). All children were tested for inhibition by summation test using two test stimuli in each of two conditioned inhibition tasks.

RESULTS

TS participants showed overall normal inhibition of stimulus-stimulus associations, and there was no correlation between inhibitory learning scores and symptom severity ratings. However, there was a clear reduction in conditioned inhibition in 7 TS participants medicated with clonidine. There was no significant effect of medication on excitatory learning of the stimulus-stimulus associations.

CONCLUSIONS

We suggest that clonidine's effect on inhibitory as opposed to excitatory learning could be related to reduced noradrenergic activity. In terms of clinical implications for TS, impaired conditioned inhibition could reduce the ability of susceptible individuals to learn to control tics in the presence of associative triggers.

Methylphenidate and comorbid anxiety disorder in children with both chronic multiple tic disorder and ADHD

OBJECTIVE

To determine if comorbid anxiety disorder is associated with differential response to immediate release methylphenidate (MPH-IR) in children with both ADHD and chronic multiple tic disorder (CMTD).

METHOD

Children with (n = 17) and without (n = 37) diagnosed anxiety disorder (ANX) were evaluated in an 8-week, placebo-controlled trial with rating scales and laboratory measures.

RESULTS

The +ANX group obtained more severe parent, teacher, and child ratings of anxiety and more severe parent ratings of depression, tics, oppositional defiant disorder (ODD), and peer aggression than the -ANX group. Treatment with short-term MPH-IR was associated with improvement in ADHD, ODD, and peer aggression in the +ANX group. When controlling for ODD severity, there were no apparent group differences in therapeutic response to MPH-IR in children ±ANX. There was little evidence that MPH-IR contributed to improvement in anxiety or depression symptoms in the +ANX group. There was some indication that children with comorbid anxiety may differentially experience greater increase in systolic blood pressure (0.5 mg/kg of MPH-IR > placebo).

CONCLUSION

Findings suggest that the co-occurrence of diagnosed CMTD+ADHD+ANX represents a particularly troublesome clinical phenotype, at least in the home setting. Comorbid anxiety disorder was not associated with a less favorable response to MPH-IR in children with ADHD+CMTD, but replication with larger samples is warranted before firm conclusions can be drawn about potential group differences.

European clinical guidelines for Tourette syndrome and other tic disorders. Part III: behavioural and psychosocial interventions

This clinical guideline provides recommendations for the behavioural and psychosocial interventions (BPI) of children and adolescents with tic disorders prepared by a working group of the European Society for the Study of Tourette Syndrome (ESSTS). A systematic literature search was conducted to obtain an update on the efficacy of BPI for tics. Relevant studies were identified using computerised searches of the Medline and PsycINFO databases and the Cochrane Library for the years 1950-2010. The search identified no meta-analyses, yet twelve (systematic) reviews and eight randomised controlled trials provided evidence for the current review. Most evidence was found for habit reversal training (HRT) and the available but smaller evidence also supports the efficacy of exposure with response prevention (ERP). Both interventions are considered first line behavioural treatments for tics for both children and adults and should be offered to a patient, taking into account his preference. Treatments that are considered second line or add-on behavioural treatments are contingency management, function based interventions and relaxation training. Neurofeedback is still experimental. Almost no research was identified that examined the efficacy of psychosocial interventions, e.g., psychoeducation and group work. Based on clinical practice, this guideline recommends behavioural treatment as first line offer to patients in most cases. It should be embedded within a psychoeducational and supportive context and can be combined with drug treatment.

Children and Their Parent's Perceptions of Symptom Severity and Treatment Preference for Tourette Syndrome

OBJECTIVES

This study surveys children and their parent's perceptions, and their treatment preference of significant/bothersome symptoms in children with Tourette syndrome.

METHODS

Thirty five children and adolescents who referred to an out-patient clinic of a Child Psychiatry Clinic were selected as subjects for this study. The children and their parents were interviewed about their perception of significant/bothersome symptoms of motor tics, vocal tics, learning difficulties, attention deficit disorder, hyperactivity, obsessions, compulsions, and rage attacks.

RESULTS

About two thirds of the subjects had symptom of rage. Inattentiveness and hyperactivity were observed in more than half of the children. There was a statistically significant difference between parents and their children in frequency of motor tics and rage attacks. Children reported the necessity for controlling and management of these symptoms less than their parents.

DISCUSSION

The rates of motor, vocal tics and rage attacks in the Iranian sample are similar to other studies. Rage attack is one of the most common significant/bothersome symptoms reported that should be treated. While motor tics were not rated among the most common features that should be treated in a study in Canada, it was the most common significant/bothersome symptom in Iran. Parents perceive motor tics and rage attacks as more significant/bothersome symptoms compared to children.

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

OBJECTIVE

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

METHOD

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

RESULTS

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

CONCLUSION

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

Validation of the presence of comorbidities in a Danish clinical cohort of children with Tourette syndrome

Tourette syndrome (TS) is characterized by the presence of motor and vocal tics and is often accompanied by comorbid symptoms. We assessed the frequency of the comorbid symptoms obsessive-compulsive disorder obsessive-compulsive disorder, attention-deficit hyperactivity disorder (ADHD), rage attacks, sleeping disturbances, and depressive symptoms in a Danish clinical cohort of 314 children with TS using validated diagnostic instruments. For the assessment of symptoms of seasonal affective disorder and stuttering, we used a nonvalidated systematic interview. In total, only 10.2% of the children did not have any comorbid symptoms at all. If ADHD and/or obsessive-compulsive disorder were present, the rates of the comorbidities rage, symptoms of seasonal affective disorder, sleep disturbances, and depressive symptoms were significantly higher than if ADHD and/or obsessive-compulsive disorder were absent. The most severe tics were found in the group for which both ADHD and obsessive-compulsive disorder were present. Furthermore, there was a tendency toward more severe tics if other comorbid symptoms were present.

Group Work in Young People with Tourette Syndrome

Gilles de la Tourette Syndrome (TS) is characterised by motor and vocal tics, although it is often associated with learning, emotional or behavioural problems that tend to account for most of the impairment experienced. Recognising, naming and learning to cope with the range of difficulties arising in TS is an important part of treatment. Group working was used as a way of helping young people understand and deal with TS. Sessions focused on managing tics, building self-esteem, learning and bullying, anger management and obsessive-compulsive symptoms.

Factor-analytic study of the Yale Global Tic Severity Scale

We report on the factor structure of the Yale Global Tic Severity Scale. Participants were 76 children and adolescents diagnosed with tic disorders. Overall, the model proposed by Leckman et al. [Leckman, J.F., Riddle, M.A., Hardin, M.T., Ort, S.I., Swartz, K.L., Stevenson, J., Cohen, D.J., 1989. The Yale Global Tic Severity Scale: initial testing of a clinician-rated scale of tic severity. Journal of the American Academy of Child and Adolescent Psychiatry 28, 566-573.] represented an adequate fit. The internal consistency of the factors was acceptable and the convergent and divergent validity was supported vis-à-vis correlations with parent ratings of Tourette's Disorder symptoms. These findings support the use of the original scoring structure in assessing pediatric tic severity.

Attitude and knowledge of high school pupils towards adolescents with special needs (Tourette's syndrome)

OBJECTIVE

To determine high school pupils' attitudes towards adolescents with special needs (for example: TS); to learn what they know about the symptomatology and the exceptional behavior of TS; and what they think about their social future.

METHODS

Ninety-nine pupils participated in the study. Their mean age was 16.7 +/- 0.8 years. Forty-eight point five percent were boys, and the rest girls. They completed a questionnaire concerning knowledge and attitudes towards adolescents with special needs (diagnosed as TS). They had participated in lessons and class talks about handicapped children with psycho- behavioral symptoms.

RESULTS

The scores for their knowledge were at a level of 68.9%. Half of the pupils knew and responded correctly that TS was of genetic origin; but the most important: they expressed a comprehensive and tolerant attitude towards impaired behavior in TS at a level of 55.3%. The tolerant attitude increased with advancing age and with school grades. The attitudes were more comprehensive in families suffering form their own emotional or other psychiatric difficulties. Forty-three point four percent of pupils understand and consider TS to be an emotional, behavioral and psychiatric entity. Sixty-two point six percent of pupils understand as well and believe that the disruptive behavior and outbursts in TS are involuntary and not under the adolescent's control. On the other hand, a quarter of the pupils see justification for repeated punishment of TS adolescents for their impaired behavior. Fifty-six point six percent of regular pupils were ready to develop friendship with TS classmates in spite of their unexpected and unruly behaviour. Eight-three point eight percent of pupils believe it is better to inform teachers and classmates about the impaired behavior of these TS adolescents. Concerning the future of these disabled adolescents, pupils scored a level of 44% for their optimistic beliefs about success in future life; 52% believe that in spite of all difficulties TS adolescents would be able to live an ordinary life, to raise a family and to work.

CONCLUSIONS

It is crucial to improve pupils' attitudes in schools (as well as their teachers') towards adolescents with special needs (including TS). The authors recommend that TS be considered as a neuro-behavioral and psychiatric disorder; it should be considered as a disability, which calls for comprehension, (not punishment). It would also be of value to speak in classes about the handicaps and neurobehavioral limitations for example of these TS adolescents, as well as about other pupils in school with special needs, in order to behave socially correctly towards them. The final aim will be that pupils in school will learn to accept the different child and adolescent as they are.

Tic disorders in childhood

Despite our familiarity with tic disorders, their management remains challenging. The difficulty seldom relates to the diagnosis, which is usually based on the history, but rather in dealing with the impact of the tics and multiple comorbidities. The child and family must be educated and must be taught how to facilitate a positive attitude among others who come in contact with the patient. Knowledge and acceptance of the tics by other family members, peers, teachers, and coaches often become central to the child's well-being. Although many children can be managed without pharmacotherapy, medications are often central to achieving success. The goals of therapy and the appropriate choice of medication must be individualized. We are frequently challenged not only by the wide array of medication choices available but also by the decision of which symptom to treat first. The tics, despite being flamboyant, are often viewed by the child and family as less disabling than co-occurring conditions, such as attention-deficit hyperactivity disorder, obsessive-compulsiveness, or rage. Even when tics are the major issue, patients must define their goals for therapy. It is unreasonable to expect a complete resolution of tics and safety usually rules in favor of better tolerated but potentially less efficacious therapies. Developing strategies to minimize the lifelong impact of the multiple components of Tourette syndrome is an essential aspect of the care of these patients.

Tic-related school problems: impact on functioning, accommodations, and interventions

Children with Tourette's syndrome (TS) are statistically overrepresented in special education classes; however, the extent to which tics contribute to such placement is unclear. In this article, the results of a survey of parents or guardians of 71 children and adolescents with TS are described within the broader context of discussing the impact of tics and educational practices. One half of the respondents reported moderate to significant tic-related academic impact, and 48% reported moderate to significant tic-related peer problems. Peer education and in-school counseling were generally not offered nor provided. In the minority of cases where behavioral interventions for tics were reported, contingent aversive consequences were reported to be ineffective or counterproductive, while positive reinforcement for modifying tics reportedly produced some successful results. The identification of research-validated academic accommodations and increased involvement of school psychologists are suggested as necessary and potentially helpful supports for students with TS and their teachers.

The relationship between tourette syndrome, attention deficit hyperactivity disorder, and stimulant medication: a critical review

The relationship between tic disorders and attention deficit hyperactivity disorder (ADHD) is of great clinical importance because both disorders can lead to emotional, social, and academic difficulties. To further complicate this interrelationship is the concern that the use of psychostimulant medication to treat ADHD will help the hyperactivity and attention problems but will lead to the onset of tics or will worsen preexisting tics. The first part of this review investigates how often Tourette syndrome (TS) is associated with ADHD and finds that ADHD has been reported in 35% to 90% of children with TS. The second part of the review looks at whether the ADHD seen in TS is the same as in children who do not have tics. Recent studies lead to the conclusion that the ADHD seen in TS is the same, although the attentional difficulties seen in TS are influenced also by the distraction of the tics themselves as well as by internal distractions such as is seen in comorbid anxiety or obsessive-compulsive behavior. The final part of the review investigates the question of whether psychostimulants worsen or cause tics. Twenty-two studies were found that investigated this possible relationship. Earlier studies were confounded by the natural pattern seen in TS in which tics spontaneously wax and wane in occurrence, intensity, and frequency. More recent double-blind, placebo-controlled studies have shown that psychostimulants are equally effective in improving ADHD symptoms whether the disorder is associated with tics or not. When group data are analyzed, there is no significant increase in tics when psychostimulants are used in patients with tics compared with controls. Individual patients, however, may experience an increase in tics. This increase is not appreciated in analysis of group data. In conclusion, it is medically appropriate to provide treatment with psychostimulant medication in persons with tics where the ADHD symptoms are significantly disturbing their quality of life.

The Tourette's Disorder Scale (TODS): development, reliability, and validity

To address the lack of a simple and standardized instrument to assess overall illness severity of Tourette's disorder (TD), the authors developed and tested a 15-item scale to measure a broad range of common symptoms including tics, inattention, hyperactivity, obsessions, compulsions, aggression, and emotional symptoms. Independent investigators used the 15-item Tourette's Disorder Scale (TODS) to assess 60 TD patients who were taking part in a double-blind placebo-controlled multicenter 8-week treatment study. Interrater reliability, internal consistency, convergent and discriminant validity, and sensitivity to change were examined. The TODS was associated with good interrater reliability, excellent internal consistency, and favorable levels of validity and sensitivity to change. Individual TODS items showed good convergent and discriminant validity against other measures. The TODS is a simple, efficient way for clinicians and parents to rate the severity of multiple symptoms commonly found in patients with Tourette's disorder.

Clinical phenomenology of episodic rage in children with Tourette syndrome

OBJECTIVE

Episodic rage of unknown etiology causes significant morbidity in children with Tourette's syndrome (TS). Using modified Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) criteria for intermittent explosive disorder (IED), we developed a screen and symptom questionnaire to explore rage attack phenomenology and to preliminarily investigate whether symptom clusters can identify clinical subgroups of TS children with rage attacks.

METHODS

48 children with TS between ages 7 and 17 years consecutively presenting with rage attacks completed the Rage Attacks Screen and Questionnaire. Data was subjected to factor analysis. Cluster analytic procedures were used to identify clinical subgroups.

RESULTS

Final cluster solution revealed four homogeneous subgroups of TS children with rage who were differentiated by predominant clinical characteristics: specific urge resolution, environmentally secure reactivity, nonspecific urge resolution or labile nonresolving.

CONCLUSION

Episodic rage in TS has stereotypic features, but diverse and complex etiologies. Identifying particular symptom clusters may facilitate improved treatment strategies.

Disruptive behavior in children with Tourette's syndrome: association with ADHD comorbidity, tic severity, and functional impairment

OBJECTIVE

To examine the association of disruptive behavior with social, adaptive, and family functioning in Tourette's syndrome (TS) with and without comorbid attention-deficit/hyperactivity disorder (ADHD).

METHOD

The sample included 207 children (144 boys and 63 girls) between the ages of 7 and 18 years. Forty-two children received a diagnosis of TS-only, 52 received a diagnosis of ADHD-only, 52 children had TS+ADHD, and there were 61 unaffected control children. Best-estimate DSM-IV diagnoses were assigned on the basis of structured interviews and clinical ratings. Dependent measures included parent and teacher ratings of disruptive behavior, parent ratings of social and family functioning, and the Vineland Adaptive Behavior Scales.

RESULTS

Children with TS-only did not differ from unaffected controls on the parent ratings of aggression and delinquent behavior or on the teacher ratings of conduct problems. By contrast, children with TS+ADHD were rated significantly above unaffected controls and similar to children with ADHD-only on these indices of disruptive behavior. Hierarchical regression analyses revealed that aggression and delinquency scores added unique contributions to impairment in social and family functioning, controlling for age, gender, and diagnostic status.

CONCLUSIONS

Comorbid ADHD is highly associated with disruptive behavior and functional impairment in children with TS. When disruptive behavior problems are present, there is an additional burden on children's social and family functioning.