Behavior therapy in tic-disorders with co-existing ADHD

Evidence-based guidelines for the pharmacological management of attention deficit hyperactivity disorder: update on recommendations from the British Association for Psychopharmacology

Attention deficit hyperactivity disorder (ADHD) is a common condition with a high societal burden. The present guidelines summarise current literature, generating expert consensus recommendations for the treatment of ADHD in children and adults. These guidelines also provide a review of recent research in the fields of neuroimaging, neuropsychology and genetics of ADHD. Novel discoveries in these areas have informed physiological models for the disease. Since the publication of the previous British Association for Psychopharmacology guidelines in 2008, new drugs have been licensed and further compounds are being investigated. The publication of randomised controlled trials of psychological interventions has contributed to the range of treatment options for ADHD. As the disorder has been diagnosed more frequently there has been greater focus on comorbid conditions and how they impact treatment. Services have continued to develop for the treatment of ADHD in adults and care agreements have been introduced to facilitate access to treatment.

Updates on treatment of attention-deficit/hyperactivity disorder: facts, comments, and ethical considerations

OPINION STATEMENT

Within the last 2 years the bulk of information on evidence based treatments in ADHD was reviewed quite intensively and new empirical studies could be added. This update reports comprehensively about actual and essential facts in the field related to brain development and sensitive periods, predictors of treatment, safety of medication, value of naturalistic studies, new drugs and complementary medicine, behavioral interventions including neurofeedback and psychosocial treatment, treatment of comorbidity, and ethical considerations including preventive aspects. The updated combination of well selected evidence based treatments (ie, pharma plus non-pharma) seems to be clinically and ethically recommended as also suggested by the European and American guidelines on ADHD.

[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.

Attentional performance in children and adolescents with tic disorder and co-occurring attention-deficit/hyperactivity disorder: new insights from a 2 × 2 factorial design study

The aim of the present study was to investigate the effect of both tic disorder (TD) and attention-deficit/hyperactivity disorder (ADHD) on attentional functions. N=96 children and adolescents participated in the study, including n=21 subjects with TD, n=23 subjects with ADHD, n=25 subjects with TD+ADHD, and n=27 controls. Attentional performance was tested based on four computerized attention tasks (sustained attention, divided attention, go/nogo and set shifting). The effect of TD as well as ADHD on attentional performance was tested using a 2 × 2 factorial approach. A diagnosis of TD had no negative impact on attentional functions but was associated with improved performance in the set shifting task. By contrast, regardless of a diagnosis of TD, subjects with ADHD were found to perform worse in the sustained attention, divided attention and go/nogo task. No interaction effect between the factors TD and ADHD was revealed for any of the attention measures. Our results add to findings from other areas of research, showing that in subjects with TD and ADHD, ADHD psychopathology is often the main source of impairment, whereas a diagnosis of TD has little or no impact on neuropsychological performance in most cases and even seems to be associated with adaptive mechanisms.

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

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

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.

Voluntary motor drive: possible reduction in Tourette syndrome

Electrophysiologically, Tourette syndrome (TS) is characterized by shortened cortical silent period (CSP), reflecting decreased motor inhibition. However, voluntary versus involuntary aspects of inhibitory functions in TS are not well understood. Hence, investigating voluntary motor drive (VMD) could help to elucidate this issue. A group of 14 healthy adolescents was compared with subjects of same age suffering from TS with (N = 6) and without (N = 6) presence of distal tics. Basic resting and active motor thresholds (RMT and AMT, respectively) as well as suprathreshold transcranial magnetic stimulation-conditioned RMT and AMT were determined during the CSP. The difference between AMT and RMT was considered as VMD quantum. No group-differences were found in RMT or AMT. Subjects with distal tics showed reduced VMD compared to healthy controls while patients without distal tics did not differ from controls. In the second half of CSP, patients with distal tics showed also diminished VMD compared to tic-patients without distal tics. The findings support the notion, that TS shows possible reduction of VMD and is associated with central motor threshold alterations confined to the very motor networks related to the tics observed.

Is onset of Tourette syndrome influenced by life events?

The aim of this study is to investigate the possible relationship between stressful life events, personality, and onset of Tourette syndrome in children. The study group included 93 subjects aged 7-18 years: 41 with Tourette syndrome (TS), 28 with obsessive-compulsive disorder (OCD), and 24 healthy controls. Diagnoses were based on the Child Schedule for Schizophrenia and Affective Disorders (K-SADS). All children were tested with the Screen for Child Anxiety Related Emotional Disorders, Children's Yale Brown Obsessive Compulsive Scale, Beck Depression Inventory or Children's Depression Inventory, the Life Experience Survey, and the Junior Temperament and Character Inventory. The findings were compared among the groups. Subjects with Tourette syndrome and healthy controls had significantly less stressful life events than subjects with (OCD). There were no significant differences between the TS subjects and the healthy controls. This finding applied to total lifetime events, total lifetime negative events, and events in the year before and after illness onset. Subjects with TS and the healthy controls also showed a significantly lesser impact of life events than subjects with OCD. The Tourette syndrome group showed a significantly lesser impact of stressful life events than controls. Harm avoidance tended to be higher in the patients with Tourette syndrome and comorbid attention deficit hyperactivity disorder and obsessive-compulsive disorder than in patients with Tourette syndrome only. There seemed to be no association between life events, diagnosis, and personality. Although there is some research suggesting that tics can be influenced by the environment, the onset of Tourette syndrome does not seem to be related to stressful life events, nor to an interaction between stressful life events and personality.

Co-existence of tic disorders and attention-deficit/hyperactivity disorder-recent advances in understanding and treatment

In daily clinical practice of child psychiatry tic disorders (TD) and attention-deficit/hyperactivity disorder (ADHD) as well as their co-existence are common and need careful evidence-based approaches in differential diagnostics and treatment choice. Hence, their relationship at different levels (e.g., psychopathology, neuropsychology, neurobiology, treatment) needs to be elucidated in more detail. The articles of this supplement deal with this subject. It is unclear if TD + ADHD represents an own clinical entity and which component (TD vs. ADHD) is most important in case of co-existence with respect to accompanying problems like emotional or cognitive disturbances. This editorial gives a short overview of the essential research topics concerning TD + ADHD and shows where (in this ECAP supplement and other literature) empirically based answers can be found. Probably, the identification of separate or common "endophenotypes" for TD-only, ADHD-only and for TD + ADHD would help to sort out the complexities and this supplement may nurture such a perspective of future research for a better understanding and treatment of youths with TD + ADHD and their families.

Drug and non-drug treatments of children with ADHD and tic disorders

OBJECTIVE

To review the treatment of ADHD in children with chronic tic disorders.

BACKGROUND

Tic disorders are relatively common in school-age children and range from mild to severe. Children with mild tics may not require medication for the treatment of tics. The co-occurrence of attention deficit hyperactivity disorder (ADHD) and disruptive behavior are common in children with tic disorders and may be associated with significant morbidity.

METHODS

We conducted a literature search to identify reports of tics as an adverse effect to stimulant medication, the treatment of children with ADHD and tics as well as novel treatments that have been proposed for the treatment of ADHD in children with tic disorders.

RESULTS

The preponderance of evidence suggests that stimulant medications are safe and effective in the treatment of children with ADHD and tic disorders. A minority of children with tic disorders may show a worsening of tics or not tolerate stimulants for other reasons. The growing list of non-stimulants provides options for clinicians and parents of these children.

CONCLUSIONS

Treatment planning for children with ADHD and tic disorders involves careful discussion with parents on choosing the best course of action. Stimulants should be part of this discussion. More study is needed on non-pharmacological approaches to the treatment of tics and ADHD in this population.