Impact of tic disorders on ADHD outcome across the life cycle: findings from a large group of adults with and without ADHD

OBJECTIVE

The impact of tic disorders on the outcome of attention deficit hyperactivity disorder (ADHD) remains a subject of high scientific and clinical interest. To evaluate the impact of comorbid ADHD and tic disorders from a lifespan perspective, the authors systematically examined data from adults with and without ADHD.

METHOD

They comprehensively evaluated 312 consecutively referred adults with ADHD and 252 comparison subjects without ADHD. Tic disorders were characterized along with a wide range of neuropsychiatric correlates, including other comorbid disorders as well as indexes of function in the domains of school, cognition, and interpersonal functioning.

RESULTS

A significantly greater proportion of adults with ADHD (12%) than those without ADHD (4%) had tic disorders. Tic disorders followed a mostly remitting course and had little impact on functional capacities. In addition, tic disorders were not associated with stimulant use.

CONCLUSIONS

These findings in adults with ADHD confirm and extend previous findings in young subjects with ADHD, documenting that although individuals with ADHD are at greater risk for tic disorders, the presence of tic disorders has a limited impact on ADHD outcome.

The 4-year course of tic disorders in boys with attention-deficit/hyperactivity disorder

BACKGROUND

Despite long-standing clinical concerns, relatively little is known about the comorbidity between attention-deficit/hyperactivity disorder (ADHD) and tic disorders. Therefore, we examined tic disorders in an ongoing prospective follow-up study of male subjects with ADHD, a sample unselected for any comorbid disorder.

METHODS

One hundred twenty-eight male children and adolescents with ADHD and 110 male controls were comprehensively evaluated at baseline and 4 years later. We characterized tic disorders along with a wide range of neuropsychiatric correlates, including other comorbid disorders and indices of psychosocial function in multiple domains (school, cognitive, social, and family).

RESULTS

Compared with controls, subjects with ADHD showed more tic disorders at baseline and more new onsets were reported at follow-up. Attention-deficit/hyperactivity disorder and tic disorders appeared to be independent in course: in contrast to low rates of ADHD remission, tic disorders mostly remitted. The age-adjusted rate of ADHD remission was 20% and that of tic remission, 65%. Tic disorders had little effect on the psychosocial functioning of subjects with ADHD.

CONCLUSIONS

These findings suggest that comorbidity with a tic disorder has a limited effect on ADHD outcome. However, because of the relatively small sample of subjects with tic disorders, our conclusions should be considered preliminary until confirmed in larger studies of medicated and unmedicated children with ADHD with and without tic disorders.

Comparisons of eye movements before and after a speed-reading course

BACKGROUND

The techniques of speed reading are widely used and generally accepted, but few studies have investigated whether- and how-speed reading actually improves reading ability in the typical reader.

METHODS

Using the Ober2, an infrared monitoring device that accurately tracks eye movements, we measured the eye movements of 59 students. The Ober2 calculates reading speed, number of fixations per 100 words, number of words seen in each fixation, number of regressions per 100 words, and duration of fixation. Comprehension was assessed with ten detailed true or false questions.

RESULTS

One group of the students (n = 25) participated in a speed reading class; the other group (n = 34) did not. After completion of the course, all 59 were re-measured on the Ober2. The speed-reading group improved significantly in five of the six aspects tested. Comprehension for the speed reading group showed an insignificant decrease.

CONCLUSIONS

We conclude that measurable changes in reading eye movements accompany successful completion of a speed-reading course.

Disentangling the overlap between Tourette's disorder and ADHD

OBJECTIVE

To identify similarities and differences in neuropsychiatric correlates in children with Tourette's syndrome (TS) and those with ADHD.

METHOD

The sample consisted of children with Tourette's syndrome with ADHD (N = 79), children with Tourette's syndrome without ADHD (N = 18), children with ADHD (N = 563), psychiatrically referred children (N = 212), and healthy controls (N = 140).

RESULTS

Disorders specifically associated with Tourette's syndrome were obsessive compulsive disorder (OCD) and simple phobias. Rates of other disorders, including other disruptive behavioral, mood, and anxiety disorders, neuropsychologic correlates, and social and school functioning were indistinguishable in children with Tourette's and ADHD. However, children with Tourette's syndrome plus ADHD had more additional comorbid disorders overall and lower psychosocial function than children with ADHD.

CONCLUSIONS

These findings confirm previously noted associations between Tourette's syndrome and OCD but suggest that disruptive behavioral, mood, and anxiety disorders as well as cognitive dysfunctions may be accounted for by comorbidity with ADHD. However, Tourette's syndrome plus ADHD appears to be a more severe condition than ADHD alone.

Is juvenile obsessive-compulsive disorder a developmental subtype of the disorder? A review of the pediatric literature

OBJECTIVE

To examine the clinical correlates of obsessive-compulsive disorder (OCD) in children and adolescents.

METHOD

A systematic review of the extant literature on juvenile OCD was conducted examining age at onset, gender distribution, symptom phenomenology, psychiatric comorbidity, neurological and perinatal history, family psychiatric history, cognitive and neuropsychological profiles, and treatment and outcome in juvenile OCD subjects.

RESULTS

Juvenile OCD was associated with a unique peak of age at onset indicating a bimodal incidence of the disorder, male preponderance, a distinct pattern of comorbidity with attention-deficit/hyperactivity disorder and other developmental disorders as well as frequent associated neuropsychological deficits, an increased familial loading for OCD, and frequent absence of insight.

CONCLUSION

These findings show that juvenile OCD is associated with a unique set of correlates that appear to differ from findings reported in studies of adult OCD subjects. Although in need of confirmation, these findings suggest that juvenile OCD may be a developmental subtype of the disorder. Since juvenile OCD is likely to continue into adulthood, these findings stress the importance of considering age at onset in clinical and research studies of adults with OCD.

Optometric trends in sports vision: knowledge, utilization, and practitioner role expansion potential

BACKGROUND

The optometric discipline of sports vision is a relatively young and actively growing area which has spurred the interest of optometrists and sports organizations at the high school, college, and professional levels.

METHODS

473 optometrists were surveyed and compared to a similar survey sent to 100 optometrists in 1980 and 1983. Also, college and professional teams were surveyed.

RESULTS

Optometrists felt there were more opportunities available in sports vision. Contact lenses, particularly soft lenses, were found to be continued in favor over rigid lenses, and nearly half surveyed have utilized vision training in their practices. College and professional sports suggest a broader acceptance and utilization of sports vision services.

CONCLUSIONS

Since the establishment of the American Optometric Association Sports Vision Section (AOA-SVS) fourteen years ago, advances have been made in utilization and acceptance of sports vision worldwide. However, this survey demonstrates that despite the increase of vision care consultants, there is still an unmet need for vision care/screening services at the collegiate and professional levels.

Binocular vision section

The participants at the 1991 Meetings of the Section on Binocular Vision and Perception presented a substantial amount of valuable theoretical and clinical information. There was considerable and valuable interaction between the audience and panel, especially after the symposium concerned with new techniques and how to use them. The exchange of specialized knowledge through discussions at symposiums such as these represents one of the best features of Academy meetings. These symposiums reemphasize and remind us of the expertise of our Academy members in management of binocular vision anomalies.

Treatment options in intermittent exotropia: a critical appraisal

Clinical opinions regarding treatment of intermittent exotropia (IXT) vary widely and there is controversy as to which treatment modality is most successful. This paper reviews the clinical literature related to five different treatment modalities used for IXT: overminus lens therapy, prism therapy, occlusion therapy, extraocular muscle surgery, and orthoptic vision therapy. Based upon review of 59 studies of treatment of IXT, and using each author's stated criteria for success, the following pooled success rates were revealed: over-minus lens therapy (N = 215), 28%; prism therapy (N = 201), 28%; occlusion therapy (N = 170), 37%; extraocular muscle surgery (N = 2530), 46%; and orthoptic vision therapy (N = 740), 59%. Success rates for IXT surgery differed depending upon whether a functional (43%) or cosmetic (61%) criterion was used to evaluate treatment success. These pooled success rates must be viewed carefully because nearly all the studies suffer from serious scientific flaws such as small sample sizes, selection bias, inadequately defined treatments and success criteria, absence of statistical analysis, and results reported in a manner that makes interpretation difficult. These problems indicate the need for a careful, circumscribed, and well controlled clinical trial to study the efficacy of different treatment modalities in remediating IXT.

Effects of disinfecting solutions recommended by the Centers for Disease Control on Goldmann tonometer biprisms

Twelve new Goldmann biprisms were used to measure the intraocular pressure of one eye of one subject, four times each day for 15 days. Between measurements, each biprism was disinfected by soaking in one of the three solutions recommended by the Centers for Disease Control (CDC) as effective against HIV, or by rubbing with an isopropyl alcohol swab. Intraocular pressure measurements, clarity of the biprism front surface, and ring image were statistically evaluated to determine whether any regimen negatively affected the biprisms. Biprisms soaked in alcohol were unusable after 4 days due to front surface roughness. No clinically significant differences were found in IOP measurements or clarity of the remaining groups, but the ring image was significantly less distorted with hydrogen peroxide treatment. These results suggest that hydrogen peroxide should be used to disinfect Goldmann biprisms.

Relationship of clinical severity to packed cell rheology in sickle cell anemia

There is wide variation in the clinical manifestations of sickle cell disease (SCD) from one affected individual to another. Many investigators have sought to discern parameters that would explain this variability. In the present studies we have attempted to correlate the frequency of painful events and the extent of end organ failure in SCD with rheologic properties of packed suspensions of sickle cells, using a magneto-acoustic ball microrheometer developed in our laboratory. Using this device we have measured the steady-state viscosity, and the viscous and elastic moduli of cell suspensions in 16 individuals with hemoglobin SS disease who were untransfused and in their steady state. The rheologic parameters were then correlated with clinical parameters. The clinical parameters measured were emergency department visits, hospitalizations, hemoglobin, reticulocyte count, age, and end organ failure (nephropathy, avascular necrosis of bone, stroke, retinopathy, resting hypoxemia after acute chest syndrome(s), leg ulcer, and priapism with impotence). The P value for the correlation between the steady state viscosity and end organ failure was .001 with a correlation coefficient (R value) of .73. The P value for the correlation between the viscous modulus of viscosity and end organ failure was .00006 with an R value of .83. The P value for the correlation between the elastic modulus of viscosity and end organ failure was .0006 with an R value of .76. However, there was no significant correlation between any component of packed cell rheology and emergency department visits or hospitalizations for pain.

Influence of ocular gaze and head position on 4 m heterophoria and fixation disparity

Four-meter heterophoria and fixation disparity measurements were taken from a sample of 40 young adults in primary gaze, 33 degrees left and right lateral gaze, and in 2 head/gaze positions related to golf putting. Comparisons using analysis of variance were made between the mean values in each gaze position and between the test-retest range of values in each gaze position. Mean heterophoria was more eso (p less than 0.05) in the two head/gaze positions related to golf putting than in other gaze positions, whereas mean fixation disparity was more eso (p less than 0.05) in rightward than in primary gaze. Phoria test-retest range was less (p less than 0.05) in all nonprimary gaze positions than in primary gaze. One of the putting-related gaze positions showed smaller (p less than 0.05) fixation disparity ranges than the primary or leftward position of gaze. All measures were highly variable among subjects. Trends present in the data suggested greater esophoria and eso fixation disparity mean values, and lesser heterophoria and fixation disparity test-retest range values in all nonprimary positions relative to primary gaze. The behavior of exophoric and esophoric subjects differed only in regard to changes in heterophoria associated with left and right lateral gaze. These data indicate differences in oculomotor postural tendencies relative to position of gaze. Relevance of the results to athletes is discussed.

Pain insensitivity in schizophrenia. Case report and review of the literature

We describe a schizophrenic man whose lack of pain and related objective signs of a perforated small bowel led to a delay in diagnosis and surgical intervention. A review of the literature suggests that both psychodynamic and specific biologic factors can produce atypical presentations in psychotic patients with illnesses in which pain is characteristically a prominent presenting symptom. While research into the cause of altered pain perception in psychotic patients is continuing, clinicians should maintain a high index of suspicion of serious medical illness when evaluating such patients.

Comparison of Snellen letter and Vistech grating charts as refraction targets

Snellen letter and Vistech sine wave grating charts were used as refraction targets to determine differences in times required to accomplish subjective refractions, endpoint refractive values, and subject preferences. Thirty hyperopes and 30 myopes, divided into three age groups, were selected as subjects. Two examiners tested each subject using each chart. Both timed their subjective refractions and recorded their findings. After all data were recorded, each subject completed a questionnaire to determine chart preference. There were no clinically significant mean differences between the charts in terms of endpoint refractive data, but, on average, the Snellen chart was faster to use. Chart rating depended on the subject's refractive status with more myopes preferring the Snellen chart and more hyperopes rating the grating chart higher.

Night calls: an Irish dimension

Night calls made by 17 general practitioners in Cork in the Republic of Ireland in 1980 were analysed and compared with similar studies in the UK. There were 323 night calls: 11 per cent were classified as irresponsible, 59 per cent of which involved patients in social classes IV and V who make up 26.5 per cent of the population of Cork. Young children and the elderly had more calls than expected, and significant sex differences emerged in all age groups apart from the 45-65 age group. The incidence of night calls done comes towards the lower range of studies in the UK.

Pharmacokinetics of benzodiazepines and psychostimulants in children

The pharmacokinetics of benzodiazepines and psychostimulants are reviewed and an overview of the kinetic principles relevant to the utilization of these drugs in infancy and childhood is provided. Newborns and premature infants can metabolize and eliminate diazepam, although the parent drug has a longer half-life and decreased rate of biotransformation to its primary metabolites than in older children and adults. The newborn's capacity to carry on metabolic processes involved in the biotransformation of diazepam, including hydroxylation, demethylation, and glucuronide conjugation, is also limited before 5 months of age; after this time hepatic enzymes develop to adult capacity. Kinetic studies of psychostimulants in childhood indicate that methylphenidate is metabolized in the child as it is in the adult. The drug appears to be rapidly metabolized to ritalinic acid and the half-life seems to be relatively short. Volumes of distribution appear to be relatively large, suggesting extensive distribution of the drug to body tissues. Neither diazepam nor methylphenidate is without the potential for toxicity, which increases with dosage. The authors conclude that advancements in the technical capacity for obtaining and analyzing microsamples of blood as well as the use of noninvasive urinary studies will make future research in children possible.