School problems in Tourette's syndrome

Academic, Interpersonal, Recreational, and Family Impairment in Children with Tourette Syndrome and Attention-Deficit/Hyperactivity Disorder

This study describes impairment in academic, interpersonal, recreational, and family financial or occupational domains across children in three mutually exclusive diagnostic groups: ever diagnosed with Tourette syndrome (TS), attention-deficit/hyperactivity disorder (ADHD), and both disorders. In 2014, parents reported on impairment and diagnostic status of children aged 4-17 years (n = 3014). Weighted analysis and pairwise t-tests showed more children with ADHD (with or without TS) experienced impairment in overall school performance, writing, and mathematics, relative to children with TS but not ADHD. More children with TS and ADHD had problematic handwriting relative to children with ADHD but not TS. More children with TS and ADHD had problematic interpersonal relationships relative to those with ADHD but not TS. Children with TS and ADHD had higher mean impairment across domains than children with either TS or ADHD. Findings suggest assessing disorder-specific contributions to impairment could inform targeted interventions for TS and ADHD.

Chronic tic disorders in children with ADHD

OBJECTIVE

To examine in a community-based cohort: (1) the prevalence of chronic tic disorder (CTD) in children with attention-deficit/hyperactivity disorder (ADHD) compared with non-ADHD controls at ages 7 and 10; and (2) the additional psychiatric and functional burden of CTD in children with ADHD.

METHODS

Children aged 6-8 years with ADHD (n=179) and controls (n=212) were recruited through 43 Victorian schools using parent and teacher screening surveys (Conners 3 ADHD Index), followed by case confirmation (Diagnostic Interview Schedule for Children-IV (DISC-IV)). CTD was identified using the DISC-IV categories chronic motor tic disorder, chronic vocal tic disorder or Tourette syndrome at baseline and 36-month follow-up. Internalising and externalising disorders, social functioning, academic performance and quality of life were also measured. Tests of proportions and independent t-tests were used to compare the ADHD+CTD group with sex-matched ADHD alone children.

RESULTS

Compared with controls, children with ADHD were 4.1 (95% CI 1.1 to 14.1) times more likely to have CTD at age 7, and 5.9 (95% CI 1.6 to 17.9) times more likely at age 10. Children with ADHD+CTD experienced higher rates of internalising disorders and peer problems, and poorer quality of life than those with ADHD alone.

CONCLUSIONS

CTD prevalence is higher in children with ADHD compared with controls, and confers substantial additional psychiatric and functional burden. Clinicians need to consider CTD in both the initial assessment and ongoing management of children with ADHD, and address both the symptoms and the associated impairments.

Impact of Tourette Syndrome on School Measures in a Nationally Representative Sample

OBJECTIVE

Children with Tourette syndrome (TS) are at risk for a variety of co-occurring conditions and learning and school problems. The purpose of this study was to determine the impact of TS and co-occurring conditions on school measures.

METHODS

Parent-reported data from the 2007-2008 and 2011-2012 National Survey of Children's Health were combined (n = 129,353 children aged 6-17 yrs). Parent report of health care provider diagnosis of TS; co-occurring mental, emotional, and behavioral conditions; learning and language conditions; and school measures were assessed. School measures included type of school, individual education plan (IEP), number of school days missed, school problems, doing well in school, doing homework, and repeating a grade. Children with TS were compared with those who never had TS on school measures accounting for co-occurring conditions.

RESULTS

After adjusting for demographics, compared with children without TS, children currently with TS were more likely to have an IEP, have a parent contacted about school problems, and not complete homework. After further adjusting for co-occurring conditions, only IEP status remained statistically significant. Compared with children with mild TS, children with moderate or severe TS were more likely to have an IEP, repeat a grade, encounter school problems, and not care about doing well in school.

CONCLUSION

Tourette syndrome severity and co-occurring conditions are associated with school challenges and educational service needs. Awareness among health care providers, teachers and parents of the potential challenges related to both TS and co-occurring conditions would help to best support the child's education.

Tic Disorders and PANDAS

Tics are the most common movement disorder in childhood and are a frequent reason for referral to child neurology clinics. The purpose of this review is to examine the phenomenology of tics, discuss what is known regarding their genetic and pathophysiological causes and to evaluate current treatment options. The evidence for the evaluation and treatment of the controversial diagnosis of pediatric autoimmune neuropsychiatric disorders associated with group A streptococci (PANDAS) will also be reviewed. With improved understanding of tic disorders, their etiology and response to current treatment options, we may be able to more effectively diagnose them and identify novel treatment strategies.

Tourette syndrome and other neurodevelopmental disorders: a comprehensive review

Gilles de la Tourette syndrome (TS) is a complex developmental neuropsychiatric condition in which motor manifestations are often accompanied by comorbid conditions that impact the patient's quality of life. In the DSM-5, TS belongs to the "neurodevelopmental disorders" group, together with other neurodevelopmental conditions, frequently co-occurring. In this study, we searched the PubMed database using a combination of keywords associating TS and all neurodevelopmental diagnoses. From 1009 original reports, we identified 36 studies addressing TS and neurodevelopmental comorbidities. The available evidence suggests the following: (1) neurodevelopmental comorbidities in TS are the rule, rather than the exception; (2) attention deficit/hyperactivity disorder (ADHD) is the most frequent; (3) there is a continuum from a simple (TS + ADHD or/and learning disorder) to a more complex phenotype (TS + autism spectrum disorder). We conclude that a prompt diagnosis and a detailed description of TS comorbidities are necessary not only to understand the aetiological basis of neurodevelopmental disorders but also to address specific rehabilitative and therapeutic approaches.

A Review of the Neuropsychological Dimensions of Tourette Syndrome

Neurocognitive functioning in Tourette syndrome (TS) has been the subject of intensive research in the past 30 years. A variety of impairments, presumably related to frontal and frontostriatal dysfunctions, have been observed. These impairments were found in various domains, such as attention, memory, executive functions, language, motor and visuomotor functions, among others. In line with contemporary research, other neurocognitive domains have recently been explored in TS, bringing evidence of altered social reasoning, for instance. Therefore, the aims of this review are to give an overview of the neuropsychological dimensions of TS, to report how neuropsychological functions evolve from childhood to adulthood, and to explain how various confounding factors can affect TS patients' performance in neuropsychological tasks. Finally, an important contribution of this review is to show how recent research has confirmed or changed our beliefs about neuropsychological functioning in TS.

The Association of Poor Academic Performance with Tic Disorders: A Longitudinal, Mainstream School-Based Population Study

BACKGROUND

Little is known about the academic performance of students with tic disorders (TD). Our aim was to investigate the association of TD and poor academic performance over time.

METHODS

Longitudinal, observational study of mainstream schoolchildren comparing grade retention (GR) and learning disorders (LD) in students with vs. without TD between 2010 and 2014. Students with vs. without TD based on DSM-IV-TR criteria, or with vs. without GR and LD were compared in terms of comorbidities, school, and environmental characteristics. The association of TD with GR was analyzed using hazard ratios (HRs) with 95% CIs, and with LD using logistic regression analysis [Odds ratio (OR)].

RESULTS

Two hundred fifty-eight students were included (mean age 14.0 ± 1.71 years, 143 [55.4%] males). The incident rate for TD and GR was 2.6 and 3.3 per 100 persons-year, respectively. LD found in 21 (9.9%) students was associated with TD (OR 11.62, 95% CI 2.21-60.90, p = 0.004), and attention deficit hyperactivity disorder (ADHD; OR 6.63, 95% CI 1.55-28.37, p = 0.01). Low psychological support (HRs 12.79, 95% CI 3.39-48.17) and low sport participation (HRs 6.41, 95% CI 1.54-26.78) were risk factors for GR.

CONCLUSIONS

TD was associated with academic difficulties, namely, LD in conjunction with ADHD but not GR. The diagnosis of TD and comorbidities, and the initiation of proper treatment could have a favorable impact on school performance, and consequently on social development.

Los tics y su relación con las dificultades de aprendizaje: estudio longitudinal de la prevalencia de los tics primarios y comorbilidad asociada en población escolar

Con el objetivo de estudiar la prevalencia de los trastornos con tics y la asociación con las dificultades de aprendizaje, se realizó un estudio epidemiológico en una muestra de 1.139 escolares. Los resultados señalaron una prevalencia del 16,86% (IC 95% del 14,10 – 19,63). Además se encontraron dificultades académicas en el 11,9% de los escolares, y la presencia de tics en el 8,6%. La presencia de trastornos de tics no se asoció con el bajo rendimiento académico en la cohorte. Los resultados obtenidos fueron contradictorios con relación a otros estudios publicados anteriormente. Como consecuencia de la divergencia en los resultados, se diseña un segundo estudio, que toma como punto de partida el seguimiento longitudinal de la cohorte de los escolares estudiados. En el análisis de regresión de Cox, durante el periodo de seguimiento de 4 años, la repetición de curso se asoció con una menor frecuencia de apoyo psicológico en el centro escolar (HR = 17,5; IC del 95% 5,7 a 53,9) y menor practica de deporte (HR = 4,02, 95% CI 01/03 a 11/08). No se encontró una asociación entre los tics y mayor riesgo de repetir curso.

A preliminary examination of self-concept in older adolescents and young adults with Gilles de la Tourette syndrome

INTRODUCTION

Gilles de la Tourette syndrome (GTS) is a childhood-onset neuropsychiatric disorder characterised by multiple tics and often associated with behavioural problems. Although there is evidence of significantly reduced self-esteem in children and adolescents with GTS, little is known about perceived self-concept and its clinical determinants at the transition age between adolescence and adulthood. We therefore set out to investigate self-concept in a clinical sample of young patients with GTS at this crucial age for personal development.

METHODS

In addition to standard demographic and clinical data, we collected self-ratings using a standardised battery of psychometric instruments, as well as the Multidimensional Self Concept Scale, a comprehensive questionnaire developed to assess self-concept in subjects aged 9- to 19 years, tapping into the social, competence, affect, academic, family, and physical domains.

RESULTS

We found that patients diagnosed with at least one co-morbid psychiatric disorder ("GTS-plus" phenotype) reported significantly lower self-concept than patients with "pure GTS", whereas tic-related variables had no impact on self-concept. Anxiety symptoms were the main determinants of self-concept, especially trait anxiety with regard to social and affective domains. Affective symptoms could also have a negative impact on the physical, affective, competence, and social domains of self-concept.

CONCLUSION

Routine screening for anxiety and affective symptoms should be recommended in all patients with GTS seen at transition clinics from paediatric to adult care, in order to implement effective treatment interventions whenever possible.

The English Version of the Gilles de la Tourette Syndrome-Quality of Life Scale for Children and Adolescents (C&A-GTS-QOL)

Gilles de la Tourette syndrome is a chronic neuropsychiatric disorder that can have a detrimental impact on the health-related quality of life of children with the condition. To date no patient-reported health-related quality of life measures have been developed for children and adolescents in the English language. This study validated the first disease-specific scale for the quantitative assessment of health-related quality of life in 118 children and adolescents with Gilles de la Tourette syndrome (C&A-GTS-QOL) following language adaptation from Italian to English in the United Kingdom. Standard statistical methods were used to test the psychometric properties of the rating scale. Principal component factor analyses led to the identification of six health-related quality of life domains (cognitive, copro-phenomena, psychological, physical, obsessive-compulsive, and activities of daily living), explaining 66.7% of the overall variance. The C&A-GTS-QOL demonstrated satisfactory scaling assumptions and acceptability; validity was supported by interscale correlations (range 0.2-0.7), confirmatory factor analysis, and correlation patterns with other rating scales and clinical variables.

Treatment-refractory Tourette Syndrome

Tourette Syndrome (TS) is a complex neurodevelopmental condition marked by tics and frequently associated with psychiatric comorbidities. While most cases are mild and improve with age, some are treatment-refractory. Here, we review strategies for the management of this population. We begin by examining the diagnosis of TS and routine management strategies. We then consider emerging treatments for refractory cases, including deep brain stimulation (DBS), electroconvulsive therapy (ECT), repetitive transcranial magnetic stimulation (rTMS), and novel pharmacological approaches such as new vesicular monoamine transporter type 2 inhibitors, cannabinoids, and anti-glutamatergic drugs.

The Presentation Of Childhood Obsessive–Compulsive Disorder Across Home and School Settings

This study aimed to determine the exact pattern of obsessive–compulsive disorder (OCD) symptoms in children displayed across school and home settings. Twenty-six school children (aged 7 through 17) with OCD were tested using the Children's Yale-Brown Obsessive Compulsive Scale (CY-BOCS), the Clinical Global Impression (CGI) – severity subscale and a questionnaire which consists of items serving to compare the symptoms between home and school settings. The mean obsession and compulsion subscores on the CY-BOCS were found to be 10.73 ± 3.14 and 10.88 ± 3.17, respectively, both summing up a Total score of 21.61 ± 5.52. The mean CGI-severity scores, rated for home and school settings were 4.42 ± 0.90 and 2.42 ± 1.13 respectively, indicating a strong difference in the presentation of OCD between those settings ( t= 7.02, df = 50, p< 0.0001). No gender, diagnosis (pure versus comorbid) and age effect (7 to = 12 years versus > 12 to 17 years) was found on the CY-BOCS and CGI-severity subscale (Mann–Whitney U test, all p> 0.05). The presentation difference we have noted in this study is a significant finding. Further studies are needed to delineate the characteristics of this phenomenon with possible implications for diagnosis, management and treatment.

The Effectiveness of Aripiprazole for Tics, Social Adjustment, and Parental Stress in Children and Adolescents with Tourette's Disorder

OBJECTIVE

Tourette's syndrome (TS) frequently results in a negative impact on multiple functional domains. This prospective open-label study investigated the potential effectiveness of aripiprazole for tics, social adjustment, and parental stress in children and adolescents with TS.

METHODS

Study participants consisted of 26 patients (mean age 10.4 ± 3.0 years; 22 boys and 4 girls) who were prescribed aripiprazole, with each dose ranging from 2.5 to 15 mg/day. At baseline and 2, 4, and 8 weeks from baseline, tic symptoms, social adjustment, and parenting stress were assessed using the Yale Global Tic Severity Scale (YGTSS), the Social Adjustment Inventory for Children and Adolescents (SAICA), and the Parenting Stress Index (PSI). Aripiprazole could be optionally titrated from 2.5 to 30 mg/day at each visit.

RESULTS

Of the 26 patients at the initial visit, 22 (84.6%) completed the study. The mean dose of aripiprazole at the endpoint was 8.0 ± 4.0 mg/day. During the 8-week aripiprazole treatment period, motor tics, phonic tics, and impairment on the YGTSS all showed significant improvement. Home behaviors on the SAICA and child domain on the PSI also showed significant improvement. Patients' phonic tics, but not motor tics, showed a positive correlation with their school function and peer relationships. The child domain on the PSI was positively correlated with motor tics, phonic tics, and impairment, as measured by the YGTSS.

CONCLUSIONS

An 8-week aripiprazole treatment program for children and adolescents with TS was beneficial to their tic symptoms, behaviors at home, and caregivers' stress with regard to fulfilling parenting roles. A long-term placebo-controlled trial with larger samples is warranted to confirm the effectiveness of aripiprazole for social adjustment and parental stress.

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.

Tourette Syndrome: a general pediatrician's 35-year experience at a single center with follow-up in adulthood

A retrospective analysis of a 35-year single-center experience with pediatric tics and Tourette syndrome was conducted. 482 charts from 1972 to 2007 were reviewed. Follow-up surveys were mailed to last known address and 83 patients responded (17%). Response rate was affected by long interval from last visit; contact information was often incorrect as it was the address of the patient as a child. Males constituted 84%. Mean tic onset was 6.6 years. At first visit, 83% had multiple motor tics and >50% had comorbidities. 44% required only 1 visit and 90% less than 12 visits. Follow-up showed positive clinical and social outcomes in 73/83 survey responses. Of those indicating a poor outcome, mean educational level was lower and attention deficit/hyperactivity disorder and learning disabilities were significantly higher. Access to knowledgeable caregivers was a problem for adult patients. A shortage of specialists may in part be addressed by interested general pediatricians.

Practice parameter for the assessment and treatment of children and adolescents with tic disorders

Tic disorders, including Tourette's disorder, present with a wide range of symptom severity and associated comorbidity. This Practice Parameter reviews the evidence from research and clinical experience in the evaluation and treatment of pediatric tic disorders. Recommendations are provided for a comprehensive evaluation to include common comorbid disorders and for a hierarchical approach to multimodal interventions.

Tic Disorders and Learning Disability: Clinical Characteristics, Cognitive Performance and Comorbidity

Tics are involuntary movements or sounds. Tourette syndrome is one of a family of tic disorders that affect around 1% of the population but which remains underrecognised in the community. In paediatric special education learning disability classes, the prevalence of individuals with tic disorders is around 20–45% — higher still in special education emotional/behavioural classes. Given the high rates of individuals with tic disorders in special education settings, as well as the unique challenges of working in an educational setting with a person with a tic disorder, it is incumbent upon professionals working in these settings to be cognisant of the possibility of tic disorders in this population. This review seeks to provide an overview of tic disorders and their association with learning and mental health difficulties. The review focuses on an exploration of factors underpinning the association between tic disorders and learning disabilities, including neurocognitive corollaries of tic disorders and the influence of common comorbidities, such as ADHD, as well as upon strategies to support individuals with tic disorders in the classroom.

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.

Update on attention-deficit/hyperactivity disorder and tic disorders: a review of the current literature

Tic disorders impact quality of life, but when they are co-occurring with attention-deficit/hyperactivity disorder, the combined impact takes a toll on psychosocial functioning and adds another layer of complexity to treatment approaches. A review of the current literature supports evidence of a unique relationship between comorbid attention-deficit/hyperactivity disorder and tic disorders, emphasizing the intricate phenotype and impairment associated with these co-occurring conditions. The complexity of these symptoms requires careful diagnosis and appropriate treatment as determined by the level of impairment and can include pharmacotherapy, behavioral interventions, or a combination of therapies. To achieve the greatest benefits in improving quality of life and eliminating further comorbidity, an ideal treatment plan would include a comprehensive evaluation as well as a hierarchical treatment approach involving education of the child, family, and teachers; careful medication management; and cognitive and behavioral training.

The presence of attention-deficit hyperactivity disorder (ADHD) and obsessive-compulsive disorder worsen psychosocial and educational problems in Tourette syndrome

We assessed the psychosocial and educational consequences of Tourette syndrome using a structured interview and child behavior checklist in 314 children with Tourette syndrome and 81 healthy controls. Of the children with Tourette syndrome, 59.0% needed some kind of educational support, 44.7% had been teased, and 61.8% withheld themselves from taking part in social activities because of Tourette syndrome-related problems. There were significantly more psychosocial and educational problems in children with Tourette syndrome compared with healthy controls. A higher rate of these problems was also seen if the comorbidities attention-deficit hyperactivity disorder (ADHD) and/or obsessive compulsive disorder were present. It is very important for the physicians, teachers, and other professionals to be aware of the high prevalence of these social and educational problems to be able to deal with them and to teach the families to cope with them.

Tourette syndrome in children and adolescents: special considerations

Tourette syndrome (TS) affects people of all ages, with onset in early childhood and continuing through the different stages of the life cycle into adolescence and adults. This review focuses on barriers to diagnosis and challenges in the management of young patients with TS. Barriers to identification occur at multiple levels, including detection in the community setting (including schools), parents' help-seeking behavior, and cultural influences on such behavior, as well as diagnosis by the medical provider. Challenges to management include unfamiliarity of primary care providers, inconsistencies in the diagnosis and management plan, and failure to recognize comorbid conditions, as well as inadequate knowledge and lack of resources to effectively deal with comorbidities. In addition to the complexities posed by pharmacological interactions, there are unique psychosocial challenges experienced by young people with TS and their families. Effective communication and collaboration between families, health care providers, and school personnel, as well as supportive communities, are essential components of comprehensive management.

Arithmetic performance in children with Tourette syndrome: relative contribution of cognitive and attentional factors

The study addressed the issue of arithmetic deficiencies in children with Tourette syndrome (TS) as well as explanations for such deficiencies. A total of 47 children with TS were assigned to three subgroups based on a composite attention score from the Test of Variables of Attention (TOVA). These children, along with 17 normal controls between 8 and 16 years of age, were tested on standardized measures of IQ, attention, visuospatial ability, and arithmetic achievement. The children also were administered an experimental calculation task with two levels of structure. Children with TS scored below controls on tests of IQ, attention, and arithmetic achievement but not visuospatial ability. The TS subgroup with the greatest impairment of attention accounted for most of the differences in arithmetic achievement. Regression analysis, based on the 47 children with TS, indicated that IQ and TOVA scores were the best predictors of arithmetic achievement. Likewise, the experimental calculation task indicated that the poor performance of some children with TS could be attributed to deficient attention. Irrespective of structure, children in the TS subgroup with the greatest attentional impairment made more attention (but not visuospatial) errors than did controls on the experimental task. Thus, on both the standardized and the experimental tasks, poor arithmetic skill was found only in children with TS who had significant attentional deficits.

The diagnosis of Tourette's Syndrome: communication and impact

No study to date has investigated differences in perception regarding the manner in which a diagnosis of Tourette's Syndrome (TS) is communicated and the impact that this diagnosis can have on patients, as well as their relatives and physicians. The main objective was to explore the personal experiences regarding the communication and impact of a TS diagnosis on those who receive the diagnosis, their caregivers and physicians. A qualitative research methodology was used in this study, based on the use of focus groups (FGs). All health professionals, persons with TS and their relatives said that TS was difficult to diagnose. However, each group perceived different causes for the difficulty. Physicians cited the complexity of the symptoms, while the patients themselves noted the general lack of knowledge regarding the disease. In adittion, the physicians and the relatives both noted that the symptoms of TS were often hidden behind family guilt. The communication of the diagnosis to relatives of children with TS was not adequate because of poor understanding and interpretation of the clinical terminology. The most important conclusion was that the current method for communicating the diagnosis of TS to patients and relatives should be improved to facilitate better understanding and interpretation.

A large Italian family with Gilles de la Tourette syndrome: Clinical study and analysis of theSLITRK1 gene

Our objective was to report the clinical characteristics and to investigate the role of SLITRK1 gene in a large Italian family with Tourette syndrome (TS). The diagnosis of TS and chronic motor tics (CMT) was made according to "The Tourette Syndrome Classification Study Group" (1993). Psychiatric diagnoses were made by administering the Structured Clinical Interview for DSM and the Yale-Brown Obsessive Compulsive Scale. Genetic study included direct sequencing and copy number analysis of the SLITRK1 gene, and haplotype analysis. We found tics or other behavioral manifestations in 15 subjects. Of these, 5 received a diagnosis of definite TS, 5 were classified as having definite CMT, 2 had definite nonspecific tic disorder, and 3 patients had obsessive-compulsive disorder without motor or phonic tics. Tics mainly involved the craniocervical district. Many patients with tics had coexisting psychiatric disorders, especially obsessive-compulsive disorder, performed poorly at school and had social problems. Direct sequencing and copy number analysis of the SLITRK1 gene, and haplotype analysis suggested that the SLITRK1 locus was not involved in this family. In conclusion, the distinctive clinical features in this family are the motor tics mainly involving the face and the neck and the severe coexisting psychiatric disorders. The negative results of the SLITRK1 analysis point to genetic heterogeneity in TS.

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.

Reduced white matter connectivity in the corpus callosum of children with Tourette syndrome

BACKGROUND

Brain imaging studies have revealed anatomical anomalies in the brains of individuals with Tourette syndrome (TS). Prefrontal regions have been found to be larger and the corpus callosum (CC) area smaller in children and young adults with TS compared with healthy control subjects, and these anatomical features have been understood to reflect neural plasticity that helps to attenuate the severity of tics.

METHOD

CC white matter connectivity, as measured by the Fractional Anisotropy (FA) index from diffusion tensor images, was assessed in 20 clinically well-defined boys with Tourette syndrome and 20 age- and gender-matched controls.

RESULTS

The hypothesis that children with TS would show reduced measures of connectivity in CC fibers was confirmed for all subregions of the CC. There was no significant interaction of TS and region. Reductions in FA in CC regions may reflect either fewer interhemispheric fibers or reduced axonal myelination. FA values did not correlate significantly with the severity of tic symptoms. Group differences in measures of connectivity did not seem to be attributable to the presence of comorbid ADHD or OCD, to medication exposure, or group differences in IQ.

CONCLUSION

Our findings of a reduced interhemispheral white matter connectivity add to the understanding of neural connectivity and plasticity in the brains of children who have TS.

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.

Gilles de la Tourette's syndrome and its impact in the UK

Gilles de la Tourette's syndrome of chronic multiple motor and vocal tics is now acknowledged to be far more common than once thought, affecting up to 1% of schoolchildren with a wide range of severity. At the milder end of the spectrum the associated psychopathologies can in themselves impair social and educational functioning, in particular obsessive compulsive disorder and attention deficit hyperactivity disorder. Many patients with this condition are not being adequately served by health and education services in the UK. The epidemiology, clinical features, aetiological factors, and management of the syndrome are reviewed.

Movement disorders

Movement disorders are commonly encountered in clinical practice. The diagnosis of movement disorders relies on a focused history and neurologic examination. Diagnostic steps include (1) identification of the phenomenology of the movements (eg, tremor); (2) characterization of appropriate clinical syndromes; and (3) differential diagnosis of specific disease entities. Accurate diagnosis is essential because symptomatic treatment exists for most movement disorders.

Gilles de la Tourette's syndrome

Tourette's syndrome (TS) is a childhood onset neurological disorder characterized by motor and vocal tics. It may be associated with a number of co-morbidities including attention deficit hyperactivity disorder, obsessive compulsive symptomatology, and behaviour disorders. Prevalence of TS is higher than previously thought, and may be present in up to 2% of the population. Tourette's syndrome has a significant genetic component. Inheritance may involve several mechanisms including autosomal dominant, bilinear, or polygenic mechanisms. Pathophysiology is still unknown, although is thought to involve striatocortical circuits. Treatment begins with modification of the work and home environment. For more severe cases, medications such as tetrabenazine and neuroleptics may be helpful. Treatment of co-morbidities needs to be considered, as these may result in moredisability than the tics themselves.

Comparative study of the behavioral and neuropsychologic characteristics of tic disorder with or without attention-deficit hyperactivity disorder (ADHD)

To study the nature of the comorbidity of tic disorder and attention-deficit hyperactivity disorder (ADHD), patients with tic disorder with or without ADHD were compared on the basis of clinical ratings and neuropsychologic tests. Seventy-eight children were involved in this study: 16 with tic disorder, 19 with comorbid tic disorder and ADHD, 21 with ADHD, and 22 normal controls. Rating scales for ADHD, the Child Behavior Checklist and the Yale Global Tic Severity Scale, were completed in clinical groups. To identify differences in neuropsychologic function among the four groups, the results of seven neuropsychologic tests of global cognitive abilities, attention, information-processing capacity, and fine motor skill were compared. On most behavioral and neuropsychologic tests, the tic disorder with ADHD and the ADHD groups demonstrated similar performance patterns and marked deficits compared with the tic disorder and the control groups, whereas in most of the attention tests, the ADHD group made more commission errors than the tic disorder with ADHD group. These findings suggest that the tic disorder with ADHD group has marked cognitive deficits and behavioral disturbance similar to the ADHD group, whereas the tic disorder group is more similar to the controls. The tic disorder with ADHD group might represent a true comorbidity of the two disorders.

Tics and its disorders

Tourette syndrome (TS) is familial neuropsychiatric disorder that is characterized by motor and phonic tics that begin in childhood. Once thought of as a rare and debilitating disorder, in the last decade new scientific knowledge suggests that TS and related tic disorders are more common and less debilitating for the majority of individuals. Evidence points toward a spectrum of TS symptomatology that extends beyond the tics disorder to probably include obsessive-compulsive disorder, attention deficit hyperactivity disorder, and mood disorders. Tourette syndrome and its differential diagnosis are discussed in this article with a focus on new developments in classification, etiology, epidemiology, genetics, pathophysiology, and clinical management.

Gilles de la Tourette syndrome: symptomatic treatment based on evidence

The treatment of the Gilles de la Tourette syndrome has evolved from case reports, clinical experience and more recently blinded trials usually in small numbers of patients. We have reviewed the evidence available to clinicians. The oldest and still most widely prescribed drug, haloperidol, should now not be considered the first-line agent in children as other agents have superior adverse effects profiles. Symptomatic treatment should be targeted to the specific additional psychopathologies seen in the syndrome. For the treatment of tics, sulpiride, tiapride, possibly pimozide and in some cases clonidine may be considered first-line agents. Although a body of data supports pimozide, caution has to be exercised in relation to possible cardiac effects. Antidepressants and stimulants have an important place in the management of depression, obsessionality and attention deficit hyperactivity disorder. The latter also responds to clonidine making it a rational first choice where ADHD coexists with GTS. There are a multitude of other drugs advocated in the literature in addition to reports of neurosurgery and the novel use of immune modulation. Therapeutic trials for GTS are challenging. However, further data from blinded trials are required before many of these treatments can be considered to be mainstream treatment options.

Parent perceptions of symptom severity in Tourette's syndrome

The families of 66 consecutive children with Tourette's syndrome were surveyed for their perception of symptom significance using a questionnaire. Families considered attention deficit and learning difficulties to be most significant, while motor and vocal tics were least important. When present, episodic rage was the most impairing symptom. Physicians must be aware of the significance of these comorbid symptoms for patients with Tourette's syndrome.

Tic disorders: new developments in Tourette syndrome and related disorders

The constellation of motor and vocal tics and certain of the other neuropsychiatric symptoms seen in Tourette syndrome are thought to have an organic basis, although the nature of the neurobiological lesion is uncertain. The syndrome is usually familial but the presumed genetic substrate has not been identified. A number of models currently under debate include a proposed autoimmune contribution.

Tourette syndrome. Neuropsychological tests for obsessive-compulsive disorder and attention deficit hyperactivity disorder

Recent evidence has suggested that the commonly observed comorbid behavioral disorders of Tourette syndrome, including attention deficit hyperactivity disorder and obsessive-compulsive disorder clearly have an impact on cognitive, educational, and psychosocial function. These behavioral features of Tourette syndrome can be more debilitating than the cardinal motor features of the disorder and they require careful clinical assessment so that appropriate treatment intervention can be offered to patients and their families. This article focuses on objective neuropsychological and behavioral assessment of obsessive-compulsive disorder and attention deficit hyperactivity disorder which have proven useful for both the clinical evaluation and treatment of obsessive-compulsive disorder and attention deficit hyperactivity disorder associated with Tourette syndrome and in the research setting. Instruments with proven psychometric reliability and validity for assessing obsessive-compulsive disorder and attention deficit hyperactivity disorder which also have been useful in Tourette syndrome populations are discussed. Objective and quantitative assessment of these comorbid behavioral conditions greatly enhance our ability to treat the full neurobehavioral spectrum of Tourette syndrome.