Quality of Life in Youth With Tourette's Syndrome and Chronic Tic Disorder

Predictors during childhood of future health-related quality of life in adults with Gilles de la Tourette syndrome

BACKGROUND

Gilles de la Tourette syndrome (GTS) is a chronic neurodevelopmental disorder characterised by multiple motor and phonic tics and behavioural problems. Patients with GTS of all ages often report a poor health-related quality of life (HR-QOL). The diagnosis of GTS is usually established in childhood but little is known about factors that predict the long-term well-being of patients, especially in the presence of co-morbid behavioural problems.

AIM

To investigate the childhood predictors of HR-QOL in a cohort of adult patients with GTS.

METHODS

Forty-six patients with GTS aged 6-16 years underwent a baseline standardised clinical assessment of both tics and behavioural symptoms at a specialist GTS clinic. The same patients were re-assessed aged 16 years and above, with a mean follow-up period of 13 years (range 3-25 years), when they completed the Gilles de la Tourette Syndrome-Quality of Life Scale (GTS-QOL), a disease-specific measure of HR-QOL.

RESULTS

Tic severity, premonitory urges and family history of GTS were identified as predictors during childhood of a poorer HR-QOL in adults with GTS by multiple linear regression analysis. Specifically, tic severity significantly predicted poor outcome across physical, psychological and cognitive domains of the GTS-QOL, reflecting widespread effects on HR-QOL.

CONCLUSION

Young patients with severe tics associated with characteristic premonitory urges and a family history of tic disorders appear to be at higher risk for poorer HR-QOL as adults. Further prospective research into HR-QOL in GTS is required in order to inform long-term strategic resource allocation.

[Changes in comorbid symptoms and subjective interference in a habit reversal therapy in children with chronic tic disorder - a pilot study]

OBJECTIVE

This pilot study investigates the effects of habit reversal training in a German-speaking population of children and young adults with chronic tic disorders on comorbid symptoms and subjective interference.

METHODS

16 children were treated using a manualized program. Comorbid-symptoms (ADHD, anxiety and OCD, depression) were assessed using parent and self-ratings. Additionally, the correlation of tic symptoms with comorbid symptoms at the beginning of the therapy was analyzed.

RESULTS

We obtained positive results in reducing comorbid symptoms during a primary treatment of tic symptoms. We further found a correlation of tic symptoms and comorbid symptoms especially in parent ratings.

CONCLUSIONS

These first findings show that a primary treatment of tics may be indicated in patients with comorbid symptoms, because a therapy of tic symptoms has also positive effects on comorbid symptoms.

Quality of life in adults with Gilles de la Tourette Syndrome

BACKGROUND

Few studies have used standardized QOL instruments to assess the quality of life (QOL) in Gilles de la Tourette Syndrome (GTS) patients. This work investigates the QOL of adult GTS patients and examines the relationships between physical and psychological variables and QOL.

METHODS

Epidemiological investigation by anonymous national postal survey of QOL of patients of the French Association of Gilles de la Tourette Syndrome (AFGTS) aged 16 years or older. The clinical and QOL measures were collected by four questionnaires: a sociodemographic and GTS-related symptoms questionnaire, the World Health Organization Quality Of Life questionnaire (WHOQOL-26), the Functional Status Questionnaire (FSQ), and a self-rating questionnaire on psychiatric symptoms (SCL-90), all validated in French. We used stepwise regression analysis to explicitly investigate the relationships between physical and psychological variables and QOL domains in GTS.

RESULTS

Questionnaires were posted to 303 patients, of whom 167 (55%) completed and returned them. Our results, adjusted for age and gender, show that patients with GTS have a worse QOL than the general healthy population. In particular, the "Depression" psychological variable was a significant predictor of impairment in all WHOQOL-26 domains, psychological but also physical and social.

CONCLUSIONS

The present study demonstrates a strong relationship between QOL in GTS and psychiatric symptoms, in particular those of depression.

Obsessive-compulsive and tic-related disorders

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

Living With Tics

Available treatment for chronic tic disorders (CTD) focuses on the reduction of tics but often does not directly address the psychosocial impairment associated with tics. There is empirical support for a new psychosocial intervention to reduce tics and their related impairment, but this treatment has not yet been applied to adults with CTD. With this in mind, the authors report on the case of “Jim,” a 22-year-old male with significantly impairing tic symptoms. Following 10 sessions of weekly cognitive-behaviorally oriented therapy combining habit reversal training, distress tolerance, cognitive restructuring, and problem solving, Jim exhibited marked improvement in tic severity as illustrated by a decrease in his score on the total tic score of the Yale Global Tic Severity Scale from 16 at baseline to 8 at posttreatment. Therapeutic gains were maintained at 4-month follow-up. This case study provides preliminary support for the use of a psychosocial intervention for addressing coping with CTD in young adults.

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.

Psychosocial Treatment to Improve Resilience and Reduce Impairment in Youth With Tics: An Intervention Case Series of Eight Youth

Background: Many youth with tic disorders experience distress about having tics and how others may perceive them. Such symptoms are often more impairing and distressing than the tics themselves and negatively impact self-concept, psychosocial functioning, and quality of life. Objective: Although there exist pharmacological and behavioral treatments that target the frequency and severity of tics, no intervention has been developed specifically to help youth with tics cope with their condition and limit associated functional impairment and distress. With this in mind, we report an intervention case series of eight youth (ages 8–16 years) supporting the initial efficacy of a cognitive-behavioral therapy program entitled “Living with Tics” that promotes coping and resiliency among youth with tics. Method: Eight youth with a principal diagnosis of a tic disorder (i.e., Tourette syndrome [N = 6]; Chronic Tic Disorder [N = 2]) and associated psychosocial impairment participated. Assessments were conducted at screening, pretreatment, and posttreatment by trained raters. Treatment consisted of 10 weekly individual psychotherapy session focused on improving coping with having tics. Results: Six of eight youth were considered treatment responders. On average, participants exhibited meaningful reductions in tic-related impairment, anxiety, and overall tic severity as well as improvements in self-concept and quality of life. Conclusions: These data provide preliminary evidence for conducting a larger controlled trial to examine the utility of the Living with Tics psychosocial intervention for promoting adaptive functioning among youth with tics.

Tourette syndrome and other tic disorders

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

A comparative analysis of health-related quality of life and family impact between children with ADHD treated in a general pediatric clinic and a psychiatric clinic utilizing the PedsQL

OBJECTIVE

To evaluate health-related quality of life (HRQOL) from the perspective of children with ADHD and their parents being seen in a Pediatric Clinic in comparison to healthy children and children with ADHD being seen in a Psychiatric Clinic.

METHOD

Participants were children with a physician diagnosis of ADHD ages 5-18 years and their parents (n=17, General Pediatric Clinic; n=181, Psychiatric Clinic). Children and parents completed the PedsQL™ 4.0 Generic Core Scales. Parents completed the PedsQL Family Impact Module and Vanderbilt ADHD Diagnostic Rating Scales.

RESULTS

Pediatric patients with ADHD being seen in the Pediatric Clinic demonstrated substantially lower HRQOL in comparison to the matched healthy sample, and significantly higher HRQOL and family functioning than pediatric patients with ADHD being seen in the Psychiatric Clinic.

CONCLUSION

These data demonstrate the substantial negative impact of ADHD on HRQOL from the perspective of both children and parents.).

Patient-reported Pediatric Quality of Life Inventory™ 4.0 Generic Core Scales in pediatric patients with attention-deficit/hyperactivity disorder and comorbid psychiatric disorders: feasibility, reliability, and validity

OBJECTIVES

The primary objective of the study was to evaluate the feasibility, reliability, and validity of the Pediatric Quality of Life Inventory™ (PedsQL) 4.0 Generic Core Scales as a patient self-reported health-related quality of life measurement instrument in pediatric patients with attention-deficit/hyperactivity disorder (ADHD) and physician-diagnosed comorbid psychiatric disorders being seen in a pediatric psychiatric clinic. The secondary objective was to evaluate parent proxy-reported PedsQL in this population.

METHODS

One hundred seventy-nine children with ADHD and comorbid psychiatric disorders ages 5 to 18 years and 181 parents completed the PedsQL 4.0 Generic Core Scales and parents also completed the Vanderbilt ADHD Diagnostic Rating Scales. Known-groups discriminant validity comparisons were made between the sample of pediatric patients with ADHD and comorbid psychiatric disorders and healthy, cancer, and type 1 diabetes samples.

RESULTS

The PedsQL evidenced minimal missing responses for patient self-report and parent proxy-report (0.2% and 0.5%, respectively), demonstrated no significant floor or ceiling effects, and achieved excellent reliability for the Total Scale Score (α = 0.85 patient self-report, 0.92 parent proxy-report). Pediatric patients with ADHD and comorbid psychiatric disorders and their parents reported statistically significantly worse PedsQL scores than healthy children, with large effect sizes across all domains, supporting known-groups discriminant validity. Pediatric patients with ADHD and comorbid psychiatric disorders and their parents reported worse PedsQL scores compared to pediatric patients with cancer and diabetes with the exception of physical health, in which pediatric cancer patients manifested lower physical health, indicating the relative severe impact of ADHD and comorbid psychiatric disorders. More severe ADHD symptoms were generally associated with more impaired PedsQL scores, supporting construct validity.

CONCLUSIONS

These data demonstrate the feasibility, reliability, and validity of patient self-reported PedsQL 4.0 Generic Core Scales in this high risk population of pediatric patients and highlight the profound negative impact of ADHD and comorbid psychiatric disorders on generic health-related quality of life, comparable to or worse than serious pediatric chronic physical diseases.

European clinical guidelines for Tourette syndrome and other tic disorders. Part I: assessment

A working group of the European Society for the Study of Tourette Syndrome (ESSTS) has developed the first European assessment guidelines of Tourette Syndrome (TS). The available literature including national guidelines was thoroughly screened and extensively discussed in the expert group of ESSTS members. Detailed clinical assessment guidelines of tic disorders and their comorbidities in both children and adults are presented. Screening methods that might be helpful and necessary for specialists' differential diagnosis process are suggested in order to further analyse cognitive abilities, emotional functions and motor skills. Besides clinical interviews and physical examination, additional specific tools (questionnaires, checklists and neuropsychological tests) are recommended.

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

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

Clinical Characteristics of Children and Adolescents with a Primary Tic Disorder

The clinical characteristics and rates of co-occurring psychiatric conditions in youth seeking treatment for a chronic tic disorder (CTD) were examined. Children and adolescents (N = 126) with a primary CTD diagnosis were recruited for a randomized controlled treatment trial. An expert clinician established diagnostic status via semi-structured interview. Participants were male (78.6%), Caucasians (84.9%), mean age 11.7 years (SD = 2.3) with moderate-to-severe tics who met criteria for Tourette's disorder (93.7%). Common co-occurring conditions included attention-deficit/hyperactivity disorder (ADHD; 26%), social phobia (21%), generalized anxiety disorder (20%), and obsessive-compulsive disorder (OCD; 19%). Motor and vocal tics with greater intensity, complexity, and interference were associated with increased impairment. Youth with a CTD seeking treatment for tics should be evaluated for non-OCD anxiety disorders in addition to ADHD and OCD. Despite the presence of co-occurring conditions, children with more forceful, complex, and/or directly interfering tics may seek treatment to reduce tic severity.

Gilles de la Tourette syndrome: the complexities of phenotype and treatment

Tourette syndrome is a chronic motor and vocal tic disorder, which is common (1%). The aetiology is complex (mostly genetic) and 90% of people have co-morbid psychiatric disorders and reduced quality of life. Management includes reassurance, education, behavioural treatments and medications for tics and psychopathology.

Evidence-based pharmacotherapy for pediatric obsessive-compulsive disorder and chronic tic disorders

In recent years, much progress has been made in pharmacotherapy for pediatric obsessive-compulsive disorder (OCD) and chronic tic disorders (CTDs). What were previously considered relatively intractable conditions now have an array of efficacious medicinal (and psychosocial) interventions available at clinicians’ disposal, including selective serotonin reuptake inhibitors, atypical antipsychotics, and alpha-2 agonists. The purpose of this review is to discuss the evidence base for pharmacotherapy with pediatric OCD and CTDs with regard to efficacy, tolerability, and safety, and to put this evidence in the context of clinical management in integrated behavioral healthcare. While there is no single panacea for these disorders, there are a variety of medications that provide considerable relief for children with these disabling conditions.

Clinical correlates of quality of life in Tourette syndrome

Tourette syndrome (TS) is a neurodevelopmental disorder involving tics, which is frequently accompanied by comorbid obsessive compulsive (OCD) or attention deficit hyperactivity disorder (ADHD). Individuals with TS often report poor quality of life (QoL) in comparison with the general population. This study investigated the clinical correlates of QoL in young people with TS using a self-report multidimensional QoL measure, and a range of clinical scales used to assess tic severity and the symptoms of anxiety, depression, OCD, ADHD and other emotional and behavioral symptoms. Symptoms of depression, OCD, and ADHD appeared to have a widespread negative impact on QoL, but poorer QoL was not associated with increased tic severity. Greater emotional and behavioral difficulties, including symptoms of OCD, were among the best predictors of poor QoL in young people with TS.

Health-Related Quality of Life in children with autism spectrum disorders: results from the autism treatment network

We examined data collected as a part of the Autism Treatment Network, a group of 15 autism centers across the United States and Canada. Mean Health-Related Quality of Life (HRQoL) scores of the 286 children assessed were significantly lower than those of healthy populations (according to published norms). When compared to normative data from children with chronic conditions, children with ASD demonstrated worse HRQoL for total, psychosocial, emotional and social functioning, but did not demonstrate differing scores for physical and school functioning. HRQoL was not consistently related to ASD diagnosis or intellectual ability. However, it was consistently related to internalizing and externalizing problems as well as repetitive behaviors, social responsiveness, and adaptive behaviors. Associations among HRQoL and behavioral characteristics suggest that treatments aimed at improvements in these behaviors may improve HRQoL.

Psychosocial outcome and psychiatric comorbidity in older adolescents with Tourette syndrome: controlled study

BACKGROUND

Children with Tourette syndrome generally experience improvement of tics by age 18 years, but psychosocial and comorbidity outcomes at this age are unclear.

AIMS

To compare psychosocial outcomes and lifetime comorbidity rates in older adolescents with Tourette syndrome and controls. We hypothesised a priori that individuals with Tourette syndrome would have lower Children's Global Assessment Scale (CGAS) scores.

METHOD

A total of 65 individuals with Tourette syndrome, identified in childhood, and 65 matched community controls without tic or obsessive-compulsive disorder (OCD) symptoms were assessed around 18 years of age regarding psychosocial functioning and lifetime psychiatric disorders.

RESULTS

Compared with controls, individuals with Tourette syndrome had substantially lower CGAS scores (P = 10(-8)) and higher rates of attention-deficit hyperactivity disorder (ADHD), major depression, learning disorder and conduct disorder (P< or =0.01). In the participants with Tourette syndrome, poorer psychosocial outcomes were associated with greater ADHD, OCD and tic severity.

CONCLUSIONS

Clinically ascertained children with Tourette syndrome typically have impaired psychosocial functioning and high comorbidity rates in late adolescence.

Health-related quality of life in patients with Gilles de la Tourette's syndrome

To investigate the health-related quality of life (HrQoL) of adult patients with Gilles de la Tourette's syndrome (GTS) in Germany. HrQoL was evaluated in 200 adult patients with GTS (Mean age: 34.9 +/- 11.8 years). Patients were recruited from three outpatient departments in Germany and completed a semi-structured, self-rating interview. HrQoL was measured using the EQ-5D. Depression was assessed using the Beck's depression inventory (BDI) and clinical symptoms using the Yale Tourette syndrome symptom list (TSSL) and the Shapiro Tourette-syndrome severity scale (STSSS). Multivariate regression analyses were performed to identify independent predictors of HrQoL. Patients with GTS proved to have a worse HrQoL than a sample from the general German population. The domains most affected were anxiety/depression (57.1%), followed by pain/discomfort (47.5%), usual activities (38.4%), mobility (14%), and self-care (6.6%). The mean EQ-5D visual analog scale (EQ-VAS) was 65.4 +/- 21.9. The patients had a mean BDI score of 12.3 +/- 9.9, which was considerably worse compared to a healthy group who had a score of 6.45 +/- 5.2. The mean STSSS value was 3.2 +/- 1.1. In multivariate analyses, depressive symptoms contributed considerably, whereas the severity of symptoms as well as age only contributed minimally to HrQoL in the model (R(2) = 0.54). HrQoL is considerably reduced in adult patients with GTS. The main independent factors for determining HrQoL were depression, severity of symptoms, and age. Although, treatment of tics is important, co-morbidities such as depression should be diagnosed and treated vigorously.

Quality of life in children and adolescents with obsessive-compulsive disorder: base rates, parent-child agreement, and clinical correlates

The presence of obsessive-compulsive disorder (OCD) has been linked to decreased quality of life (QoL) among adults, yet little is known about the impact of OCD on QoL in pediatric patients. Sixty-two youth with OCD and their parent(s) were administered the Children's Yale-Brown Obsessive Compulsive Scale following a clinical interview. Children completed the Pediatric Quality of Life Inventory and parents completed the Pediatric Quality of Life Parent Proxy Inventory and Child Behavior Checklist. QoL scores for OCD patients were significantly lower than for healthy controls, but similar to QoL in a general psychiatric sample on the majority of domains. Parent-child agreement on QoL was moderate to strong across age groups. Results indicate that, in youth with OCD, QoL is reduced relative to healthy controls, related to OCD symptom severity per parent-report, and are strongly predicted by the presence of comorbid externalizing and internalizing symptoms.

Tourette syndrome-associated psychopathology: roles of comorbid attention-deficit hyperactivity disorder and obsessive-compulsive disorder

OBJECTIVE

Individuals with Tourette syndrome (TS) often display comorbid symptoms of attention-deficit hyperactivity disorder (ADHD) and obsessive-compulsive disorder (OCD), as well as externalizing and internalizing behaviors. This study was aimed to examine the impacts of tic severity, ADHD symptoms, and OCD on internalizing (e.g., anxiety) and externalizing (e.g., aggression) psychopathology.

METHODS

Using linear regressions, we examined how tics, ADHD, and OCD symptoms predicted the externalization and internalization behaviors measured by the Child Behavior Checklist in a clinical sample of children and adolescents with TS. In addition, Child Behavior Checklist scales were compared among children with TS without ADHD, TS and ADHD, ADHD without TS, and unaffected control group.

RESULTS

In the TS group, externalizing behaviors were predicted by tic severity, inattention, and hyperactivity/impulsivity but not by OCD symptoms, whereas internalizing behaviors were predicted by inattention and OCD symptoms but not by tic severity or hyperactivity/impulsivity. Comparison among different clinical groups revealed main effects of TS and ADHD on both externalizing and internalizing behaviors.

CONCLUSION

These findings suggest that tics, ADHD, and OCD symptoms differentially explain the variance in externalizing and internalizing behavioral problems in individuals with TS. In addition, the data support the notion that TS is itself a risk factor for behavioral problems, mandating that children with TS even without ADHD and OCD still need to be assessed and treated for psychopathology.

The quality of life of young people with Tourette syndrome

BACKGROUND

The study examined a UK sample of 57 young people with Tourette syndrome (TS).

AIMS

The purpose of this study was to consider the impact of TS on young people's Quality of Life (QoL).

METHODS

The study used a mixed methods design, combining focus groups and questionnaire data. Child report questionnaires measured QoL and TS symptom severity.

RESULTS

The results showed that the QoL of children with TS was significantly worse than that of children in a UK normative sample. Analysis of transcripts from the groups identified four main themes; 'TS can be distressing and disabling', 'struggling to fit into society's expectations of normal behaviour', 'needing to control tics' and 'TS is one part of who I am'.

CONCLUSIONS

Poorer QoL was associated with increased symptom severity in terms of tics, Attention Deficit Hyperactivity Disorder diagnosis and obsessive compulsive behaviours.