Review of the evidence for the management of co-morbid Tic disorders in children and adolescents with attention deficit hyperactivity disorder

Complex ADHD in a Child With Tic Disorder

CASE

Jaxon is a healthy 12-year-old boy who is referred to your clinic for medication management. He was diagnosed with ADHD using a validated questionnaire at age 9 years. He is currently prescribed OROS methylphenidate 54 mg capsules once daily in the morning, which he has taken for 3 years. This has generally worked well to improve his attention, focus, task persistence, and task completion. However, his parents now report increasing disruptive behaviors over the past 18 months, both at home and at school. There have been no major stressors over this period nor significant life changes or trauma in Jaxon's history.Jaxon's teachers report that although he remains in his seat, he constantly "squirms" and moves about. He also makes quick, jerky movements with his hands several times each class period. They report no specific trigger or activity for when this movement occurs, but report it being more intense when Jaxon is working hard to concentrate and stay focused. His mother also reports noticing the frequency increase if Jaxon thinks he is in trouble or when he is very excited (e.g., when he is playing video games). His parents share home videos to support these concerns.His teachers report problems with attention, fidgeting, and talking out of turn. They also report that his movements distract and disrupt the class. These reports are most often from his afternoon classes. Academically, he is doing well. He turns in most of his work, but his grades have dropped this semester. His teacher reports that he seems to lack the focus to complete his assignments and he rushes through them to go to the next activity.When you talk to Jaxon, he reports that he likes school, but he does not like how often he gets into trouble. He admits he gets embarrassed during quiet time when his hands randomly "move without me moving them."When observing Jaxon, you notice that he fidgets in his seat, often moving his hands over anything that is holding his attention (toys, papers). He is also verbally impulsive, interrupting the discussion with his mother multiple times during the visit. Twice, you witness a brisk single jerk of his right hand. It originates at the wrist and rotates away from his body with his hand closed. There was no accompanying vocalization with this movement.His parents are requesting a medication adjustment or change. What would you do?

Deep brain stimulation for Tourette's syndrome

Tourette's syndrome is a neuropsychiatric disorder characterized by formidable motor and vocal tics. Many individuals also present with comorbid neuropsychiatric conditions. Though patients often benefit from pharmacological and behavioral therapies, a subset of individuals develop severe, treatment-resistant symptoms that might necessitate more invasive interventions, such as Deep Brain Stimulation (DBS). DBS, particularly targeting regions like the globus pallidus internus (GPi) and the centromedian-parafascicular complex (CM-Pf) of the thalamus, has demonstrated effectiveness in reducing tic severity and improving quality of life. This review outlines the mechanism, clinical efficacy, and long-term outcome of DBS in TS. Results from clinical studies reveal significant reductions in tics. However, success with DBS is variable depending on a number of factors, including target selection and electrode placement. The use of DBS has ethical considerations, which include risks to the surgical procedure, the need for full and complete informed consent, and questions about the implications of such treatment on cognitive and emotional growth. Long-term follow-up will be required to ensure appropriate patient outcomes and complication management. Additional research and ethical debate will be needed with advancing DBS technology to ensure responsible and equitable treatment. This paper narratively summarizes the surgical options available for TS, with a focus on the current status of DBS in the management of the disease.

Discovery of key biomarkers in tourette syndrome by network pharmacology

Background

Yangxue Xifeng Decoction (YXD) has been utilized in clinical settings for the treatment of Tourette Syndrome (TS). However, the action mechanism of YXD needs further research.

Methods

The ingredients and targets of YXD were identified via database searches and then constructed an active ingredient-target network using Cytoscape. Pathway enrichment analysis was performed via Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG). The core genes were determined by LASSO regression and SVM algorithm. Additionally, we analyzed the immune infiltration. The signaling pathways associated with core genes were investigated through KEGG and GO. We predicted the transcription factors using "RcisTarge".

Results

127 active ingredients of YXD and 255 targets were obtained. TNF and the IL-17 signaling pathway were the main pathways. OPRM1 and VIM were screened out as core genes, which were associated with the immune infiltration. The signaling pathways involved in OPRM1 and VIM were enriched. Furthermore, remarkable correlation was found between OPRM1 and VIM levels and other TS-related genes such as MAPT and MAPT.

Conclusion

OPRM1 and MAPT, and the signaling pathways are associated with TS. YXD exerts its therapeutic TS through multi-component and multi-targets including immune infiltration.

Time is ticking for TikTok tics: A retrospective follow-up study in the post-COVID-19 isolation era

INTRODUCTION

During the COVID-19 pandemic, an influx of adolescents presented worldwide with acute onset of functional tic-like behaviors (FTLBs). Our goal was to evaluate psychosocial factors around onset, to elucidate outcomes after pandemic isolation protocols were lifted, and to examine therapy and medication management.

METHODS

A retrospective review was performed of 56 patients ages 10-18 years with new-onset FTLBs seen at Boston Children's Hospital beginning in March 2020. Demographic factors, medical history, and treatment were evaluated. Patient outcomes were determined retrospectively based on the Clinical Global Impression Improvement (CGI-I) and Severity (CGI-S) scales from follow-up visits. CGI-I scores assessed the progression of FTLBs; CGI-S assessed overall function.

RESULTS

Ninety-six percent of patients were female-assigned at birth with high rates of comorbid anxiety (93%) and depression (71%). Forty-five percent were gender-diverse. Based on scales that assessed FTLBs (CGI-I) and overall functioning (CGI-S), up to 79% of patients improved independent of comorbid diagnosis or treatment. Evidence-based tic-specific treatments were not more effective than other treatments. A subset of patients had improvement in their FTLBs but not in their general functioning and continued to have other psychosomatic presentations.

CONCLUSION

While many patients' FTLBs improved, it is critical to remain alert to patients' overall function and to assess for other functional neurological disorders and mental health concerns. The tendency of FTLBs to improve in this population, independent of treatment, highlights the unique pathophysiology of FTLBs. Future research on contributing psychosocial factors and specific treatment protocols will allow optimal support for these patients.

Classification, prevalence and integrated care for neurodevelopmental and child mental health disorders: A brief overview for paediatricians

'Neurodevelopmental disorders' comprise a group of congenital or acquired long-term conditions that are attributed to disturbance of the brain and or neuromuscular system and create functional limitations, including autism spectrum disorder, attention deficit/ hyperactivity disorder, tic disorder/ Tourette's syndrome, developmental language disorders and intellectual disability. Cerebral palsy and epilepsy are often associated with these conditions within the broader framework of paediatric neurodisability. Co-occurrence with each other and with other mental health disorders including anxiety and mood disorders and behavioural disturbance is often the norm. Together these are referred to as neurodevelopmental, emotional, behavioural, and intellectual disorders (NDEBIDs) in this paper. Varying prevalence rates for NDEBID have been reported in developed countries, up to 15%, based on varying methodologies and definitions. NDEBIDs are commonly managed by either child health paediatricians or child/ adolescent mental health (CAMH) professionals, working within multidisciplinary teams alongside social care, education, allied healthcare practitioners and voluntary sector. Fragmented services are common problems for children and young people with multi-morbidity, and often complicated by sub-threshold diagnoses. Despite repeated reviews, limited consensus among clinicians about classification of the various NDEBIDs may hamper service improvement based upon research. The recently developed "Mental, Behavioural and Neurodevelopmental disorder" chapter of the International Classification of Diseases-11 offers a way forward. In this narrative review we search the extant literature and discussed a brief overview of the aetiology and prevalence of NDEBID, enumerate common problems associated with current classification systems and provide recommendations for a more integrated approach to the nosology and clinical care of these related conditions.

European clinical guidelines for Tourette syndrome and other tic disorders-version 2.0. Part III: pharmacological treatment

In 2011, the European Society for the Study of Tourette Syndrome (ESSTS) published the first European guidelines for Tourette Syndrome (TS). We now present an update of the part on pharmacological treatment, based on a review of new literature with special attention to other evidence-based guidelines, meta-analyses, and randomized double-blinded studies. Moreover, our revision took into consideration results of a recent survey on treatment preferences conducted among ESSTS experts. The first preference should be given to psychoeducation and to behavioral approaches, as it strengthens the patients' self-regulatory control and thus his/her autonomy. Because behavioral approaches are not effective, available, or feasible in all patients, in a substantial number of patients pharmacological treatment is indicated, alone or in combination with behavioral therapy. The largest amount of evidence supports the use of dopamine blocking agents, preferably aripiprazole because of a more favorable profile of adverse events than first- and second-generation antipsychotics. Other agents that can be considered include tiapride, risperidone, and especially in case of co-existing attention deficit hyperactivity disorder (ADHD), clonidine and guanfacine. This view is supported by the results of our survey on medication preference among members of ESSTS, in which aripiprazole was indicated as the drug of first choice both in children and adults. In treatment resistant cases, treatment with agents with either a limited evidence base or risk of extrapyramidal adverse effects might be considered, including pimozide, haloperidol, topiramate, cannabis-based agents, and botulinum toxin injections. Overall, treatment of TS should be individualized, and decisions based on the patient's needs and preferences, presence of co-existing conditions, latest scientific findings as well as on the physician's preferences, experience, and local regulatory requirements.

Current Status, Diagnosis, and Treatment Recommendation for Tic Disorders in China

Tic disorders (TD) are a group neuropsychiatric disorders with childhood onset characterized by tics, i.e. repetitive, sudden, and involuntary movements or vocalizations; and Tourette syndrome (TS) is the most severe form of TD. Their clinical manifestations are diverse; and are often associated with various psychopathological and/or behavioral comorbidities, including attention deficit hyperactivity disorder (ADHD), obsessive-compulsive disorder (OCD), anxiety, depression, and sleep disorders. Individual severity and response to treatment are highly variable, and there are some refractory cases, which are less responsive to conventional TD treatment. TD/TS are also common in the Chinese pediatric population. To help improve the understanding of TD for pediatricians and other health professionals, and to improve its diagnosis and treatment in China, the Chinese Child Neurology Society (CCNS) has developed an Expert Consensus on Diagnosis and Treatment of TD in China, which is based on our clinical experience and the availability therapeutic avenues. It is focused on clinical diagnosis and evaluation of TD and its comorbidities, psychological and educational intervention, nonpharmacological therapy, pharmacological treatment, including traditional Chinese medicine and acupuncture, as well as prognosis in children with TD in China. A summary of the current status of TD and up-to-date diagnosis and treatment recommendations for TD in China is presented here.

Treating pediatric acute-onset neuropsychiatric syndrome

Pediatric acute-onset neuropsychiatric syndrome (PANS) can be caused by infectious and noninfectious triggers. NPs can help children with PANS recover from their symptoms and prevent future recurrences by appropriately screening, recognizing, and diagnosing the clinical presentation of PANS. PANS treatment includes pharmacologic therapies as well as cognitive behavioral therapy.