Sleep disorders in children with Tourette syndrome

Screening for Quality of Life in a Neurology Tic Clinic Using Quality Improvement Methodology

BACKGROUND

Tic disorders in children often co-occur with other disorders that can significantly impact functioning. Screening for quality of life (QoL) can help identify optimal treatment paths. This quality improvement (QI) study describes implementation of a QoL measure in a busy neurology clinic to help guide psychological intervention for patients with tics.

METHODS

Using QI methodology outlined by the Institute for Healthcare Improvement, this study implemented the PedsQL Generic Core (4.0) in an outpatient medical clinic specializing in the diagnosis and treatment of tic disorders. Assembling a research team to design process maps and key driver diagrams helped identify gaps in the screening process. Conducting several plan-do-study-act cycles refined identification of patients appropriate to receive the measure. Over the three-year study, electronic health record notification tools and data collection were increasingly utilized to capture patients' information during their visit.

RESULTS

Over 350 unique patients were screened during the assessment period. Electronic means replaced paper measures as time progressed. The percentage of patients completing the measure increased from 0% to 51.9% after the initial implementation of process improvement, advancing to 91.6% after the introduction of electronic measures. This average completion rate was sustained for 15 months.

CONCLUSIONS

Using QI methodology helped identify the pragmatics of implementing a QoL assessment to enhance screening practices in a busy medical clinic. Assessment review at the time of appointment helped inform treatment and referral decisions.

Sleep and circadian rhythm dysfunctions in movement disorders beyond Parkinson's disease and atypical parkinsonisms

PURPOSE OF REVIEW

This review aimed to comprehensively outline sleep and circadian rhythm abnormalities in hyperkinetic movement disorders beyond Parkinson's disease and atypical parkinsonisms, including tremor, dystonia, choreiform movements, tics, and ataxia disorders.

RECENT FINDINGS

Insomnia, poor sleep quality, and excessive daytime sleepiness (EDS) are commonly reported in essential tremor, Wilson's disease, tics or Tourette's syndrome, and spinocerebellar ataxia (SCA). REM sleep behavior disorder (RBD) have been observed in Wilson's disease and SCA. A combination of REM and non-REM parasomnias, along with nocturnal stridor with the initiation of sleep and re-entering after awakening, are characterized by undifferentiated Non-REM and poorly structured N2 in anti-IgLON5 disease. Restless legs syndrome (RLS) has been reported commonly in SCAs. Sleep-related dyskinesia has been reported in ADCY5-related disease and GNAO1-related movement disorder.

SUMMARY

Sleep problems can manifest as a result of movement disorders, either through direct motor disturbances or secondary nonmotor symptoms. Medication effects must be considered, as certain medications for movement disorders can exacerbate or alleviate sleep disturbances. Distinguishing sleep problems in some diseases might involve pathognomonic symptoms and signs, aiding in the diagnosis of movement disorders.

Prevalence and influencing factors of sleep problems in tic disorders: a meta-analysis

BACKGROUND

Sleep problems are commonly observed in patients with tic disorders. Nevertheless, studies have demonstrated a wide variation in the prevalence of sleep disturbances among this population. Consequently, it remains ambiguous whether sleep issues are inherently characteristic of tic disorders or are influenced by external factors.

METHODS

We conducted a comprehensive search across various databases and performed a meta-analysis to determine the prevalence of sleep problems in tic disorders. Additionally, we assessed pre-existing comorbidities and associated characteristics using meta-regression analysis.

RESULTS

After including 33 studies in the final meta-analysis, we found that the pooled prevalence of sleep problems in tic disorders was 34% (95%CI: 26% to 43%). Meta-regression analysis revealed that the presence of co-occurring symptoms of ADHD (p < 0.05), obsession compulsive disorder/behaviours (p < 0.05), anxiety (p < 0.001), and mood disorders (p < 0.001) was associated with an increased likelihood of experiencing sleep problems.

CONCLUSIONS

Our findings consistently indicate that individuals with tic disorders frequently encounter significant sleep problems. This underscores the importance of routinely screening for sleep problems during clinical assessments. Effectively managing sleep problems in patients with tic disorders is crucial not only for the well-being of the patients themselves but also for their families.

Parent-Report Sleep Disturbances and Everyday Executive Functioning Difficulties in Children with Tourette Syndrome

There is an increasing need to identify and treat sleep disturbances in Tourette syndrome (TS), a neurodevelopmental condition characterized by tics. This study explored sleep, tics, and executive functioning in children with TS (n=136) and neurotypical controls (n=101) through parent-report scales and open-ended questions. 85% of children with TS scored in the clinical range for a sleep disorder. Higher tic severity predicted increased sleep disturbances and executive difficulties. Qualitative insights indicated a bidirectional link between sleep and tics, which warrants consideration in clinical settings. Further research is needed to explore causal links.

The impact of the COVID-19 pandemic on sleep in children with Tourette syndrome in Ireland and the United Kingdom

STUDY OBJECTIVES

The aim of this mixed-methods study was to gain an insight through qualitative and quantitative means into the impact of the coronavirus disease 2019 (COVID-19) pandemic on children with and without Tourette syndrome (TS).

METHODS

Parents/guardians of children and adolescents with TS (n = 95; mean age = 11.2 years, standard deviation = 2.68 years) and typically developing controls (n = 86; mean age = 10.7 years, standard deviation = 2.8 years) in the United Kingdom and Ireland completed an online questionnaire examining sleep, with open-ended questions pertaining to their perceived impact of COVID-19 on the sleep of their children. Nine items from the Sleep Disturbance Scale for Children were used to supplement qualitative data.

RESULTS

A negative impact of the pandemic on the sleep of both groups was observed, including exacerbated tics, sleep deprivation, and anxiety, with particular disruption for children with TS. Parents of children with TS reported poorer sleep patterns than parents of typically developing children on the Sleep Disturbance Scale for Children. Analyses showed that group and age predicted 43.8% of variance in sleep duration: F (4, 176) = 34.2, P < .001.

CONCLUSIONS

Findings suggest that sleep patterns of children with TS may be more impacted by the pandemic than the average child. Given that there are generally more sleep issues reported in children with TS, further research is warranted in relation to the sleep health of children with TS in a postpandemic era. By identifying sleep issues potentially persisting after COVID-19, the true impact of the pandemic on the sleep of children and adolescents with Tourette syndrome may be ascertained.

CITATION

Colreavy E, Keenan L, Downes M. The impact of the COVID-19 pandemic on sleep in children with Tourette syndrome in Ireland and the United Kingdom. J Clin Sleep Med. 2023;19(8):1485-1493.

Clinical Characteristics of Children With Tourette Syndrome With and Without Sleep Disorder

BACKGROUND

Sleep problems are common in children with Tourette Syndrome (TS). However, research regarding their demographic and clinical profile is limited.

METHODS

We examined characteristics of 114 children aged five to 17 years with a lifetime diagnosis of TS and compared children with sleep disorder (n = 32) and without sleep disorder (n = 82). Parent report from the 2014 National Survey of the Diagnosis and Treatment of ADHD and Tourette Syndrome provided demographics and clinical information, other diagnosed disorders, medication use, TS severity, and impairment.

RESULTS

More children with TS with sleep disorder were from households with lower parental education (P < 0.01) and poverty (P = 0.04); had other diagnoses (P = 0.03), including obsessive-compulsive disorder (P < 0.01), oppositional defiant disorder or conduct disorder (P < 0.01), attention-deficit/hyperactivity disorder (ADHD) (P = 0.02), and autism (P = 0.03); and had ever used TS medication (P = 0.01) than children with TS without sleep disorder. More children with TS with sleep disorder had severe TS symptoms (P <0.01), tic-related impairment (P<0.01), and severe ADHD symptoms (P < 0.01) compared with children with TS without sleep disorder.

CONCLUSIONS

Findings suggest greater parent-reported impact and tic-related interference in children with TS with sleep disorder compared with TS without sleep disorder. Results underscore the importance of monitoring and intervention for TS exacerbations, other diagnosed disorders, and medication use, and consideration of socioeconomic context in sleep disorder management and prevention in children with TS.

Sleep Disturbance in Tourette's Disorder: Potential Underlying Mechanisms

Purpose of review

Sleep disturbance is common in TD. However, our understanding of the pathophysiological mechanisms involved is preliminary. This review summarizes findings from neuroimaging, genetic, and animal studies to elucidate potential underlying mechanisms of sleep disruption in TD.

Recent findings

Preliminary neuroimaging research indicates increased activity in the premotor cortex, and decreased activity in the prefrontal cortex is associated with NREM sleep in TD. Striatal dopamine exhibits a circadian rhythm; and is influenced by the suprachiasmatic nucleus via multiple molecular mechanisms. Conversely, dopamine receptors regulate circadian function and striatal expression of circadian genes. The association of TD with restless legs syndrome and periodic limb movements indicates shared pathophysiology, including iron deficiency, and variants in the BTDB9 gene. A mutations in the L-Histidine Decarboxylase gene in TD, suggests the involvement of the histaminergic system, implicated in arousal, in TD.

Summary

These biological markers have implications for application of novel, targeted interventions, including noninvasive neuromodulation, iron supplementation, histamine receptor antagonists, and circadian-based therapies for tic symptoms and/or sleep and circadian rhythms in TD.

Sleep Disorders, Sleep Medication Use, and Predictors of Sleep Disturbance in Children with Persistent Tic Disorders

The present study examined rates of sleep disorders and sleep medication use, and predictors of sleep disturbance in children with persistent tic disorders (PTD). Sixty-three parents of children aged 10 to 17 years with PTDs completed an internet survey evaluating sleep patterns and clinical symptoms. Insomnia (19.4%), nightmares (16.1%), and bruxism (13.1%) were the most commonly reported lifetime sleep disorders. Fifty-two percent endorsed current sleep medication use. Higher ADHD severity, overall life impairment, and female sex predicted greater sleep disturbance. Findings suggest the utility of clinical management of co-occurring ADHD and impairment to mitigate sleep disturbance in children with PTDs.

Tourette syndrome and other tic disorders of childhood

Tics are repetitive, patterned, and nonrhythmic movements or vocalizations/audible sounds that are misplaced in context. Phenomenology and characteristics of tics (e.g., premonitory urge, suppressibility) differentiate them from compulsions, stereotypies, functional tic-like behaviors, and other types of hyperkinetic movement disorders. With a prevalence of approximately 1% in school-aged boys, Tourette syndrome (TS) is considered a common childhood-onset neurodevelopmental disorder, defined by the combination of at least two motor tics and at least one phonic tic lasting more than 1 year. TS is a highly heritable disorder, with a wide spectrum of severity. In some individuals, tics can cause pain, distress, functional impairment, or stigmatization. About 90% of individuals with TS have at least one mental health comorbidity (attention-deficit/hyperactivity disorder, obsessive-compulsive disorder, anxiety/depressive disorders). These comorbidities significantly impact patients' quality of life and must therefore be screened and managed accordingly in this population. Treatment of tics is based on behavioral therapies targeting tics (habit reversal training included in the comprehensive behavioral intervention for tics, and exposure and response prevention for tics), in association with medication if needed (e.g., alpha-2-agonists, second-generation antipsychotics). Deep brain stimulation is considered an experimental option in the most severe, treatment-resistant patients. In adulthood, less than 25% of individuals still have moderate or severe tics.

Children with neurodevelopmental disorders: how do they sleep?

PURPOSE OF REVIEW

In this review we summarized the available evidence on sleep disorders in children with neurodevelopmental disorders (NDDs) in particular: intellectual disability (including some genetic conditions such as Prader-Willi Syndrome, Smith-Magenis Syndrome), Autism spectrum disorder, attention-deficit/hyperactivity disorder (ADHD), Developmental Coordination Disorder, language disorders, and specific learning disorders.

RECENT FINDINGS

Children with NDDs frequently suffer from sleep disturbances, with a higher prevalence than that of the general pediatric population.

SUMMARY

These problems tend to be chronic and may cause additional cognitive and behavioral difficulties, often affecting the whole family's well-being. Sleep behaviors are also related to other important developmental skills, such as attention and listening. Investigating sleep disorders in children with NDDs is therefore crucial in clinical practice. For a systematic approach in clinical practice, we propose the use of a short and easy to remember sleep screening tool.

Sleep Dysfunction in Movement Disorders: a Window to the Disease Biology

PURPOSE OF REVIEW

To comprehensively summarize the sleep pathologies associated with movement disorders, focusing on neurodegenerative diseases.

RECENT FINDINGS

Mounting evidence has further implicated both sleep and circadian disruption in the pathophysiology of many movement disorders. In particular, recent data illuminate the mechanisms by which poor sleep quality and circadian dysfunction can exacerbate neurodegeneration. In addition, anti-IgLON5 disease is a recently described autoimmune disease with various symptoms that can feature prominent sleep disruption and parasomnia. Many movement disorders are associated with sleep and circadian rhythm disruption. Motor symptoms can cause sleep fragmentation, resulting in insomnia and excessive daytime sleepiness. Many neurodegenerative movement disorders involve brainstem pathology in regions close to or affecting nuclei that regulate sleep and wake. Further, commonly used movement medications may exacerbate sleep concerns. Providers should screen for and address these sleep symptoms to improve function and quality of life for patients and caregivers.

Sleep Disorders and Sleep Problems in Patients With Tourette Syndrome and Other Tic Disorders: Current Perspectives

Sleep disorders seem to be a frequent complaint of patients diagnosed with Tourette syndrome (TS) or chronic or persistent tic disorders (CTD or PTD). In this review, we expanded a previously used search using 4 well-known databases up to February 15, 2022, looking for the coexistence of global and/or specific sleep disorders and polysomnographic studies performed on patients with TS/CTD/PTD. The references of interest in the topic were selected by hand. Sleep disorders in general, insomnia, different arousal disorders, the persistence of tics during sleep, excessive daytime sleepiness, and periodic limb movements during sleep (PLMS) were very frequent in patients with TS, most of them being more frequent in patients with comorbid Attention Deficit Hyperactivity Disorder. The most frequent results from polysomnographic studies were decreased sleep efficiency and increased sleep onset latency. Many of these findings could be related to medication used for the treatment of tics and comorbid disorders.

Sleep disturbances and sleep patterns in children with tic disorder: A case-control study

STUDY OBJECTIVES

To characterize sleep disturbances and sleep patterns in children with Tic disorder (TD), and explore their association with TD severity and types.

METHODS

A case-control study was conducted in 271 children with TD recruited from a clinical setting and 271 non-TD children recruited from a primary school, matched by age (mean = 8.47 years, SD = 1.53 years) and gender (15.1% female). The Children's Sleep Habits Questionnaire (CSHQ) was used to assess sleep patterns and sleep disturbances. The TD types and severity were assessed with the Yale Global Tic Severity Scale (YGTSS).

RESULTS

The TD children scored higher on CSHQ total score than non-TD group (t = 29.50, p < 0.001) and demonstrated severer global sleep disturbance. Compared to non-TD children, TD children presented with increased risks for global sleep disturbance (aOR: 1.95; 95% CI = 1.20-3.06), and most specific sleep disturbances, including bedtime resistance (aOR: 3.15; 95% CI = 1.96-5.06), sleep onset delay (aOR: 3.43; 95% CI = 1.58-7.46), sleep anxiety (aOR: 2.83; 95%CI = 1.83-4.38), parasomnias (aOR: 3.68; 95% CI = 2.02-6.62), night waking (aOR: 9.29; 95% CI = 2.64-32.65), sleep disordered breathing (aOR: 1.72; 95% CI = 1.03-2.90) and daytime sleepiness (aOR: 1.72; 95% CI = 1.09-2.74). Children with mild and moderate tics, Provisional Tic Disorder (PTD), Chronic Tic Disorder (CTD) and Tourette Syndrome (TS) presented with more global and more specific sleep disturbances. In addition, combined ADHD, etc.

CONCLUSION

Children with TD are major risks for increased sleep disturbances, especially for those with severe and chronic symptoms. Furthermore, comorbid ADHD increases risk in certain areas of sleep. These findings highlight the importance to consider sleep outcomes in the assessment and treatment for children with TD.

Tourette Disorder and Sleep

Healthy sleep is of utmost importance for growth, development, and overall health. Strong evidence shows that sleep is affected negatively in patients and particularly children with Tourette Disorder (TD). There is also a frequent association of TD with Attention Deficit Hyperactivity Disorder (ADHD) which alone has negative effects on sleep and cumulatively worsens the associated sleep findings. The most consistent polysomnographic findings in patients with TD is decreased total sleep time, lower sleep efficiency and an elevated arousal index. Polysomnography studies have confirmed the presence of movements and persistence of tics during both Rapid Eye Movement (REM) and NREM sleep [1]. In general Patients with TD are found to have an increased incidence of sleep onset and sleep maintenance insomnia. Some studies have shown increased incidence of parasomnias (including sleepwalking, sleep talking and night terrors), but this may be confounded by the increased underlying sleep disruptions seen in TD. The hypersomnolence found in patients with TD is also suggested to be secondary to the underlying TD sleep disruption. There is not a significant association with sleep disordered breathing or circadian rhythm disorders and TD. Treatment of underlying TD is important for the improvement of sleep related TD manifestations and is outlined in this review.

Insomnia in Tourette Syndrome and Chronic Tic Disorder

BACKGROUND

Insomnia is common in Tourette syndrome (TS) and chronic tic disorder (CTD), but precise prevalence estimates are lacking.

OBJECTIVE

In this Swedish register-based cohort study, we estimated the prevalence of insomnia in TS/CTD and quantified the magnitude of this association, accounting for familial confounders and relevant somatic and psychiatric comorbidities.

METHODS

Of 10,444,702 individuals living in Sweden during the period from 1997 to 2013, 5877 had a diagnosis of TS/CTD and were compared to unexposed individuals from the general population on the presence of insomnia using logistic regression models.

RESULTS

Individuals with TS/CTD had a period prevalence of insomnia of 32.16%, compared to 13.70% of the unexposed population. This translated into a 6.7-fold increased likelihood of insomnia in TS/CTD (odds ratio adjusted [aOR] for sex, birth year, birth country, and somatic disorders = 6.74; 95% confidence interval [CI], 6.37-7.15). A full sibling comparison, designed to adjust for shared familial factors, attenuated the estimates (aOR = 5.41; 95% CI, 4.65-6.30). When individuals with attention-deficit/hyperactivity disorder (ADHD) and pervasive developmental disorders were excluded, the association was also attenuated, whereas exclusion of other psychiatric comorbidities had minimal impact. Having persistent TS/CTD, comorbid ADHD, and taking ADHD medication greatly increased the likelihood of insomnia.

CONCLUSIONS

Insomnia is significantly associated with TS/CTD, independently from somatic disorders, familial factors or psychiatric comorbidities, although familial factors, neurodevelopmental comorbidities, and ADHD/ADHD medication may explain part of the association. Insomnia should be routinely assessed and managed in TS/CTD, particularly in chronic patients and in those with comorbid ADHD. Other sleep disorders require further study. © 2021 The Authors. Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society.

A Comprehensive Review of Tic Disorders in Children

Tics are characterized by sudden, rapid, recurrent, nonrhythmic movement or vocalization, and are the most common movement disorders in children. Their onset is usually in childhood and tics often will diminish within one year. However, some of the tics can persist and cause various problems such as social embarrassment, physical discomfort, or emotional impairments, which could interfere with daily activities and school performance. Furthermore, tic disorders are frequently associated with comorbid neuropsychiatric symptoms, which can become more problematic than tic symptoms. Unfortunately, misunderstanding and misconceptions of tic disorders still exist among the general population. Understanding tic disorders and their comorbidities is important to deliver appropriate care to patients with tics. Several studies have been conducted to elucidate the clinical course, epidemiology, and pathophysiology of tics, but they are still not well understood. This article aims to provide an overview about tics and tic disorders, and recent findings on tic disorders including history, definition, diagnosis, epidemiology, etiology, diagnostic approach, comorbidities, treatment and management, and differential diagnosis.

Physical activity, sleep and neuropsychiatric symptom severity in children with tourette syndrome

The purpose of this study was to examine associations between physical activity, sleep and symptom severity in children with tic disorders. Children with tic disorders wore the GeneActiv device, a wrist-worn accelerometer that measures physical activity intensity and sleep/wake parameters continuously for seven days, and completed questionnaires on sleep quality, exercise and severity of tics, ADHD, obsessive-compulsive behaviours, anxiety and depression. 110 children participated in the study. Children with more severe tics had significantly more frequent comorbid diagnoses, greater impairment in subjective sleep measures, greater sedentary activity time and less light, moderate and vigorous activity time (all p < 0.05). There was a significant negative correlation between light, moderate and vigorous physical activity and the severity of tics (- 0.22, p = 0.04), obsessive compulsive behaviours (- 0.22, p = 0.03), anxiety (- 0.35, p = 0.0005) and depression (- 0.23, p = 0.03). There was no correlation between objective sleep time, sleep efficiency and symptom severity. Subjective sleep quality was positively correlated with all symptom severity measures, with the strongest correlation with ADHD severity (0.42, p < 0.00001). The results of this observational study indicate a small, but significant relationship between activity and sleep measures and the severity of the main symptom domains present in tic disorders.

Overlapping sleep disturbances in persistent tic disorders and attention-deficit hyperactivity disorder: A systematic review and meta-analysis of polysomnographic findings

INTRODUCTION

Persistent tic disorders (PTDs) and attention-deficit hyperactivity disorder (ADHD) are common neurodevelopmental conditions which tend to co-occur. Both diagnoses are associated with sleep problems. This systematic review and meta-analysis investigates overlaps and distinctions in objective sleep parameters based on diagnosis (PTD-only, PTD + ADHD, and ADHD-only).

METHODS

Databases were searched to identify studies with objective sleep measures in each population. Meta-analyses were conducted using a random effects model.

RESULTS

Polysomnography was the only measure included in all three groups. Twenty studies met final inclusion criteria, combining PTD-only (N = 108), PTD + ADHD (N = 79), and ADHD-only (N = 316). Compared to controls (N = 336), PTD-only and PTD + ADHD groups had significantly lower sleep efficiency and higher sleep onset latency. PTD + ADHD also had significantly increased time in bed and total sleep time. No significant differences were observed between ADHD-only groups and controls.

DISCUSSION

Different sleep profiles appear to characterise each population. PTD + ADHD was associated with more pronounced differences. Further research is required to elucidate disorder-specific sleep problems, ensuring appropriate identification and monitoring of sleep in clinical settings.

Postural Control in Childhood: Investigating the Neurodevelopmental Gradient Hypothesis

Neurodevelopmental disorders (NDDs) have been suggested to lie on a gradient continuum, all resulting from common brain disturbances, but with different degrees of impairment severity. This case-control study aimed to assess postural stability against such hypothesis in 104 children/adolescents aged 5–17, of whom 81 had NDDs and 23 were healthy controls. Compared to healthy controls, Autism Spectrum Disorder (ASD) resulted in the most severely impaired neurodevelopmental condition, followed by Attention Deficit Hyperactive Disorder (ADHD) and Tourette Syndrome (TS). In particular, while ASD children/adolescents performed worse than healthy controls in a number of sensory conditions across all parameters, ADHD children/adolescents performed worse than healthy controls only in the sway area for the most complex sensory conditions, when their vision and somatosensory functions were both compromised, and performance in Tourette Syndrome (TS) was roughly indistinguishable from that of healthy controls. Finally, differences were also observed between clinical groups, with ASD children/adolescents, and to a much lesser extent ADHD children/adolescents, performing worse than TS children/adolescents, especially when sensory systems were not operationally accurate. Evidence from this study indicates that poor postural control may be a useful biomarker for risk assessment during neurodevelopment, in line with predictions from the gradient hypothesis.

General health and mortality in Tourette syndrome and chronic tic disorder: A mini-review

Current knowledge on the general somatic health and causes of death in Tourette syndrome and chronic tic disorder is very limited. Here, we review the available literature on the topic, while highlighting strengths and weaknesses of the studies conducted to date. These previous works have suggested associations between Tourette syndrome and chronic tic disorder and a range of health conditions, including autoimmune disorders, common allergies and respiratory diseases, sleep difficulties, and metabolic and cardiovascular outcomes. Additionally, the risk of mortality in tic disorders might be higher than that of the general population, but specific causes of death have rarely been studied, except for substance use-related deaths and suicide, which are significantly higher in individuals with Tourette syndrome and chronic tic disorder. Many of these emerging findings require replication and extension but, taken together, they suggest that that it might be sensible to monitor the general health and suicide risk of individuals with Tourette syndrome or chronic tic disorder across the lifespan. We suggest further avenues for research on this topic.

Investigating Gait, Movement, and Coordination in Children with Neurodevelopmental Disorders: Is There a Role for Motor Abnormalities in Atypical Neurodevelopment?

Motor abnormalities have been suggested to play a role in most neuropsychiatric disorders, as a potential generic neurodevelopmental vulnerability. However, they still represent a neglected area, with a paucity of empirical studies, especially in pediatric populations. This case-control study aimed to comprehensively assess motor functioning in children with atypical neurodevelopment and investigate whether any socio-demographic or clinical characteristics would concur with motor difficulties to distinguish children with neurodevelopmental disorders (NDD) from healthy controls. Socio-demographic (age and gender) and clinical (intelligence quotient, gait, movement, and coordination) data were collected on 114 children aged 5-15 (83 with NDD, 31 healthy controls). Male children were at significantly higher risk for NDD (OR: 13.023, p < 0.001). Furthermore, there was a statistically significant interaction between the total intelligence quotient and overall coordination such that increasing levels of total intelligence quotient appeared to protect against the likelihood of being diagnosed with an NDD, but only in the context of a preserved coordination (OR: 0.964, p = 0.038). Collectively, results may have important public health implications, as they point towards the development of new approaches to establish an early prognosis in neurodevelopment, including assessing motor difficulties and mitigating their impact on children's quality of life.

Assessment and Management of Tic Disorders in Pediatric Primary Care Settings

Purpose of Review

Pediatricians and other primary care providers are often the first and sole healthcare clinicians of patients who present with tics. However, limited primary care pediatric training in neuropsychiatric concerns, as well as perceived lack of comfort and preparation, make it challenging for these clinicians to confidently identify and manage tic disorders.

Recent Findings

Current empirical findings of tic disorder management relevant to pediatric physicians, including assessment, psychoeducation, behavioral interventions, psychotropic medications, and alternative treatments are reviewed.

Summary

This article discusses neuropsychiatric and medical complexities of tic disorder assessment, with particular emphasis on differential and comorbid diagnoses. Tiered referral recommendations, based on symptom severity, impairment, and consideration of comorbid conditions, are provided. Future directions for tic management, including dissemination of evidence-based treatments of tic disorders and multidisciplinary teams within pediatric primary care settings, are included.

Sleep disorders in tourette syndrome

Sleep disorders are very common in patients diagnosed with Tourette syndrome (TS). The present review focuses on sleep disorders and the results of polysomnographic studies performed in patients with TS. We made a search using the PubMed, Embase, MedLine, and Web of Science Databases, from 1966 until November 14, 2019, crossing the search term "Tourette syndrome" with "sleep", "sleep disorders", "sleep disturbances", and "polysomnography", and with each of the specific sleep disorders listed according to the International Classification of the Sleep Disorders-Third Edition. Then we identified the references of interest for the topic. Insomnia, excessive daytime sleepiness, disorders of arousal (sleepwalking, sleeptalking, sleep terrors, and enuresis), the persistence of tics during sleep, and presence of periodic limb movements during sleep (PLMS) were very frequent in patients with TS. These disturbances were more frequent in children and in patients with comorbid Attention Deficit Hyperactivity Disorder. Decreased sleep efficiency, decreased percentage of delta sleep, increased nocturnal awakenings and increased PLMS were the most consistent findings in the polysomnographic studies.

Sleep and Sleep Disorders in Tourette Syndrome: What is Known and What is Still Unknown

Background:

Most of the patients with Tourette Syndrome (TS) present additional comorbidities. Attention Deficit Hyperactivity Disorder (ADHD) and Obsessive-Compulsive Disorder (OCD) are the most common. Sleep Disorder has been suggested also as common comorbidity.

Objective:

To review the literature on sleep characteristics and sleep disorder in patients with Tourette Syndrome (TS), with emphasis on the contribution of specific co-morbidities to the severity of impaired sleep and life quality of the patients.

Results:

In general, sleep problems are not frequent at the age when tics appear which are estimated to affect about 10 % of these children. In severe cases, tics appear in all sleep stages. In a large study, the prevalence of sleep problems was 17.8% but was 12 % in “TS-only” (9.4% in children and 7.5 in adults) compared to 22% in children and 18% in adults with TS+ADHD. Unfortunately, in most of the studies, the characteristics of these “sleep problems” are not defined. In spite of the scarcity of data, the two main sleep disorders in TS patients are insomnia and parasomnias. Although much more data is needed, many TS subjects are sleep deprived (which exacerbate the tics) and may suffer from excessive daytime sleepiness, which negatively affects normal functioning.

Conclusions:

Although the literature is not conclusive, children and adolescents with TS appear to suffer more from sleep disturbances and sleep disorders than age-matched controls. Not all patients have tics during sleep, but in severe cases, tics may appear in all sleep stages. It is clear that when patients present both TS and ADHD, (a very common condition), the sleep difficulties are related mainly to ADHD. Much more research is warranted in all aspects of sleep and sleep disorders in TS.

Tics and Tourette Syndrome

PURPOSE OF REVIEW

The purpose of this article is to present current information on the phenomenology, epidemiology, comorbidities, and pathophysiology of tic disorders and discuss therapy options. It is hoped that a greater understanding of each of these components will provide clinicians with the necessary information to deliver thoughtful and optimal care to affected individuals.

RECENT FINDINGS

Recent advances include the finding that Tourette syndrome is likely due to a combination of several different genes, both low-effect and larger-effect variants, plus environmental factors. Pathophysiologically, increasing evidence supports involvement of the cortical-basal ganglia-thalamocortical circuit; however, the primary location and neurotransmitter remain controversial. Behavioral therapy is first-line treatment, and pharmacotherapy is based on tic severity. Several newer therapeutic agents are under investigation (eg, valbenazine, deutetrabenazine, cannabinoids), and deep brain stimulation is a promising therapy.

SUMMARY

Tics, defined as sudden, rapid, recurrent, nonrhythmic motor movements or vocalizations, are essential components of Tourette syndrome. Although some tics may be mild, others can cause significant psychosocial, physical, and functional difficulties that affect daily activities. In addition to tics, most affected individuals have coexisting neuropsychological difficulties (attention deficit hyperactivity disorder, obsessive-compulsive disorder, anxiety, mood disorder, disruptive behaviors, schizotypal traits, suicidal behavior, personality disorder, antisocial activities, and sleep disorders) that can further impact social and academic activities or employment.

Neurobehavioural complications of sleep deprivation: Shedding light on the emerging role of neuroactive steroids

Sleep deprivation (SD) is associated with a broad spectrum of cognitive and behavioural complications, including emotional lability and enhanced stress reactivity, as well as deficits in executive functions, decision making and impulse control. These impairments, which have profound negative consequences on the health and productivity of many individuals, reflect alterations of the prefrontal cortex (PFC) and its connectivity with subcortical regions. However, the molecular underpinnings of these alterations remain elusive. Our group and others have begun examining how the neurobehavioural outcomes of SD may be influenced by neuroactive steroids, a family of molecules deeply implicated in sleep regulation and the stress response. These studies have revealed that, similar to other stressors, acute SD leads to increased synthesis of the neurosteroid allopregnanolone in the PFC. Whereas this up-regulation is likely aimed at counterbalancing the detrimental impact of oxidative stress induced by SD, the increase in prefrontal allopregnanolone levels contributes to deficits in sensorimotor gating and impulse control, signalling a functional impairment of PFC. This scenario suggests that the synthesis of neuroactive steroids during acute SD may be enacted as a neuroprotective response in the PFC; however, such compensation may in turn set off neurobehavioural complications by interfering with the corticolimbic connections responsible for executive functions and emotional regulation.

Sleep difficulties in children with Tourette syndrome and chronic tic disorders: a systematic review of characteristics and associated factors

Sleep difficulties are common in children and young people with Tourette syndrome and chronic tic disorders (TS/CTD). However, it is unclear whether sleep problems can be considered typical of the TS/CTD phenotype or whether they reflect concomitant factors such as individual patient characteristics (e.g. medication use), underlying neurodevelopmental disorders and/or co-occurring psychiatric symptoms. To help address this question, this review systematically explored types and frequency of sleep problems in children and young people with TS/CTD, while also examining the heterogeneity and methodological quality of studies. Psycinfo, Ovid Medline, Embase, and Web of Science databases were searched using a range of terms relating to tics, sleep and co-occurring psychopathology. Studies were considered that included a sample of children with TS/CTD (n &gt; 5) for whom sleep difficulties were measured. Eighteen studies met criteria for inclusion in the review. Findings supported the high prevalence of sleep difficulties in children with TS/CTD, though estimates of sleep difficulties ranged from 9.7% to 80.4%. Twelve studies reported on other factors affecting sleep in this patient group including tic severity, comorbid psychopathological or neurodevelopmental disorders and medication use. Studies varied in terms of methodology, sample characteristics and research quality, but most concluded that children with TS/CTD experienced high levels of sleep difficulties with children with co-occurring anxiety most at risk. The current review highlights the need for further empirical investigation of sleep in children with TS/CTS, with a view to informing understanding and clinical management.

The Blood Levels of Trace Elements Are Lower in Children With Tic Disorder: Results From a Retrospective Study

Background: Tic disorders (TD) are common neuropsychiatric disorders among children and adolescents. It is controversial that trace elements may participate in the pathogenesis of TD. Our study aimed to investigate the trace elements status of zinc (Zn), copper (Cu), iron (Fe), and magnesium (Mg) in children with TD, in comparison to healthy controls.

Methods: The medical records of eligible TD children and normal healthy children from January 1 to December 31, 2018 in the outpatient clinic were retrospectively reviewed. The clinical information of all subjects were collected including age, gender, diagnosis, previous health records, and serum trace elements level (Cu, Zn, Fe, Mg) at the time of diagnosis before initiating treatment.

Results: In total, 1204 TD children (7.63 ± 2.45 years) and 1,220 healthy children (7.27 ± 3.15 years) who were divided into two gender and three age groups (2–4years, 5–9years, ≥10 years) were reviewed in our study. Our study showed that TD children generally had lower whole blood levels of Zn, Cu, Fe than the normal controls (P < 0.01). No significant difference was observed in whole blood levels of Mg. After adjusting for gender, the trends still remained. Further analysis was performed according to age, the trends still remained in Zn and Fe in all age groups (P < 0.05). However, we observed an almost significantly (P = 0.055) lower level of Cu in TD of 2–4 years group while significant differences in other two groups (P < 0.01). Further multiple linear regression and point biserial correlation showed that the lower blood levels of Zn, Cu, and Fe were correlated with the incidence of TD.

Conclusion: The present results indicated that lower blood levels of zinc, iron, copper were associated with TD. Trace elements may be used as an auxiliary treatment for TD and need to be further explored.

Rating Scales for Movement Disorders With Sleep Disturbances: A Narrative Review

Introduction: In recent years, a wide variety of rating scales and questionnaires for movement disorders have been developed and published, making reviews on their contents, and attributes convenient for the potential users. Sleep disorders are frequently present in movement disorders, and some movement disorders are accompanied by specific sleep difficulties. Aim: The aim of this study is to perform a narrative review of the most frequently used rating scales for movement disorders with sleep problems, with special attention to those recommended by the International Parkinson and Movement Disorders Society. Methods: Online databases (PubMed, SCOPUS, Web of Science, Google Scholar), related references from papers and websites and personal files were searched for information on comprehensive or global rating scales which assessed sleep disturbances in the following movement disorders: akathisia, chorea, dystonia, essential tremor, myoclonus, multiple system atrophy, Parkinson's disease, progressive supranuclear palsy, and tics and Tourette syndrome. For each rating scale, its objective and characteristics, as well as a summary of its psychometric properties and recommendations of use are described. Results: From 22 rating scales identified for the selected movement disorders, only 5 included specific questions on sleep problems. Movement Disorders Society-Unified Parkinson's Disease Rating scale (MDS-UPDRS), Non-Motor Symptoms Scale and Questionnaire (NMSS and NMSQuest), Scales for Outcomes in Parkinson's Disease (SCOPA)-Autonomic and Progressive Supranuclear Palsy Rating Scale (PSPRS) were the only rating scales that included items for assessing sleep disturbances. Conclusions: Despite sleep problems are frequent in movement disorders, very few of the rating scales addresses these specific symptoms. This may contribute to an infra diagnosis and mistreatment of the sleep problems in patients with movement disorders.

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.

Sleep Sufficiency in Pediatric and Adolescent Tourette's Disorder: National Survey of Children's Health

OBJECTIVE

The present study compared sleep sufficiency in youth with current Tourette's disorder (TD), history of TD and matched case controls, and examined predictors of sufficient sleep using a large US population-based survey.

METHOD

Participants were 673 caregivers of youth aged 6 to 17 years (298 with current TD, 122 with a history of TD with no endorsement of current diagnosis, and 254 matched case controls) from the 2007 and 2011-2012 versions of the National Survey of Children's Health. History and current TD status, current comorbidity (attention deficit/hyperactivity disorder, anxiety, and depression) and psychiatric medication status were assessed by yes/no items. Current TD severity was dichotomized into mild or moderate/severe symptoms. Sleep was assessed by parent-reported number of sufficient nights their child slept in the past week.

RESULTS

Univariate analysis of variance yielded significant group differences in nights of sufficient sleep (F[2,369.70] = 71.53, p < .001), with controls having 1.5 more nights per week relative to both TD groups (p < .001). With respect to predictors of sufficient sleep, the analysis of covariance yielded a significant age × sex × TD severity interaction (F[1,15.84] = 4.28, p = .04) such that older adolescent males with mild TD had significantly fewer nights of sufficient sleep than children (p = .004) and early adolescents (p = .002; F[2,54.93] = 7.45, p = .001). Early adolescent females with moderate/severe TD had fewer nights of sufficient sleep relative to males (p = .008). Comorbidity type and psychiatric medication status did not significantly predict sleep.

CONCLUSION

Findings suggest that insufficient sleep in youth with TD persists independently of comorbidity or psychiatric medication status. Findings highlight the importance of clinical sleep monitoring in this population.

Tourette syndrome and other chronic tic disorders: an update on clinical management

INTRODUCTION

The management of Tourette syndrome (TS) and other chronic tic disorders occurs in multiple stages and begins with comprehensive assessment and complex psychoeducation. Behavioral and pharmacological interventions (second stage) are needed when tics cause physical or psychosocial impairment. Deep brain stimulation surgery or experimental therapies represent the third stage. Areas covered: Discussed are recent advances in assessment and therapy of chronic tic disorders, encompassing the three stages of intervention, with the addition of experimental, non-invasive brain stimulation strategies. A PubMed search was performed using as keywords: 'tic disorders', 'Tourette syndrome', 'assessment', 'rating scales', 'behavioral treatment', 'pharmacological treatment', 'deep brain stimulation', 'transcranial magnetic (or current) stimulation', and 'transcranial current stimulation'. More than 300 peer-reviewed articles were evaluated. The studies discussed have been selected on the basis of novelty and impact. Expert commentary: Comprehensive assessment of tic disorders and psychoeducation are crucial to a correct active management approach. Behavioral treatments represent first line of active interventions, with increasing potential offered by telehealth. Antipsychotics and alpha agonists remain first line pharmacological interventions for tics, although VMAT-2 inhibitors appear promising. Deep brain stimulation is a potential option for medically refractory, severely disabled patients with tics, but age and target selection require further investigation.

Relationship of serum ferritin level and tic severity in children with Tourette syndrome

PURPOSE

Tics can be considered hyperkinetic movements akin to restless leg syndrome (RLS). Drawing the analogy of iron deficiency as an etiology of RLS, it is conceivable that iron deficiency may underlie or worsen tics in Tourette syndrome (TS). The purpose of this study was to evaluate the relationship between serum ferritin levels and tic severity, as well as consequent impact on life, in children with TS.

METHODS

Children <18 years, diagnosed with TS during 2009-2015, were reviewed. Only those with serum ferritin testing were included. The following data were collected: tic severity, impact on life, medication, comorbidities, blood count, and serum ferritin at diagnosis and follow-up.

RESULTS

In fifty-seven patients, M:F = 2:1, serum ferritin was 48.0 ± 33.28 ng/mL, tic severity score 2.3 ± 0.80, impact on life score 2.2 ± 0.93, and composite score 4.57 ± 1.6. Serum ferritin was not influenced by comorbid obsessive compulsive disorder (OCD), attention deficit hyperactive disorder (ADHD), or anxiety (P > 0.16). Thirty-eight percent with low serum ferritin (≤50 ng/mL) (n = 37) had severe tics (>5 composite score), compared with 25% in normal ferritin group (n = 20). Over 6-12 months, tic severity score improved in both iron treated groups, deficient (2.70 to 1.90) and sufficient (2.40 to 1.95), whereas tics worsened or remained the same when not treated with iron.

CONCLUSIONS

Our data suggest iron deficiency may be associated with more severe tics with higher impact on TS children, independent of the presence of OCD, ADHD, or anxiety. Iron supplementation showed a trend towards improvement of tic severity upon follow-up. We suggest a double-blind, placebo-controlled prospective study to reach a definite conclusion.

What makes you tic? Translational approaches to study the role of stress and contextual triggers in Tourette syndrome

Tourette syndrome (TS) is a neurodevelopmental condition characterized by multiple, recurring motor and phonic tics. Rich empirical evidence shows that the severity of tics and associated manifestations is increased by several stressors and contextual triggers; however, the neurobiological mechanisms responsible for symptom exacerbation in TS remain poorly understood. This conceptual gap partially reflects the high phenotypic variability in tics, as well as the existing difficulties in operationalizing and standardizing stress and its effects in a clinical setting. Animal models of TS may be highly informative tools to overcome some of these limitations; these experimental preparations have already provided critical insights on key aspects of TS pathophysiology, and may prove useful to identify the neurochemical alterations induced by different stressful contingencies. In particular, emerging knowledge on the role of contextual triggers in animal models of TS may inform the development of novel pharmacological interventions to reduce tic fluctuations in this disorder.

Efficacy and safety of acupuncture treatment on primary insomnia: a randomized controlled trial

OBJECTIVE

The objective of this study was to evaluate the efficacy and safety of acupuncture treatment for primary insomnia.

METHODS

We conducted a single-center, single-blinded, and randomized controlled clinical trial. Seventy-two patients with primary insomnia were randomly assigned into two groups - the acupuncture group, who received acupuncture treatment, and the control group, who received sham acupuncture treatment. The treatment was given three times a week for four weeks. Patients were asked to wear sleep monitors and complete questionnaires every two weeks for a total of eight weeks. The primary outcome was the Insomnia Severity Index (ISI). The secondary outcomes were sleep parameters including sleep efficiency (SE), sleep awakenings (SA) and total sleep time (TST) recorded by the Actigraphy, as well as scores of the Self-Rating Anxiety Scale (SAS) and the Self-Rating Depression Scale (SDS).

RESULTS

Compared with pretreatment baseline, patients in both groups had varying degrees of improvements in their sleep conditions. Paired t-test showed that there was a significant difference in all indicators in the acupuncture group before and after acupuncture treatment. One-way analysis of covariance adjusted for baseline scores indicated that the ISI improved dramatically in the acupuncture group at two weeks post-treatment (F = 11.3, p = 0.001), four weeks post-treatment (F = 33.6, p < 0.001), 2 weeks follow-up (F = 39.4, p < 0.001) and four weeks follow-up (F = 34.1, p < 0.001). Similar significant improvements can also be observed in the SE, TST and SDS scores. Although no differences in SA and SAS were shown between the two groups until the end of the treatment, remarkable decrements in SA and SAS were found in the acupuncture treatment group after the two-week and four-week follow-ups.

CONCLUSION

Acupuncture treatment is more effective than sham acupuncture treatment in increasing insomnia patients' sleep quality and improving their psychological health.

TRIAL REGISTRATION

Chinese Clinical Trial Registry: Chi CTR-TRC-14004859.

Developmental Trajectories of Sleep Problems from Childhood to Adolescence Both Predict and Are Predicted by Emotional and Behavioral Problems

Although the prevalence rates of sleep disorders at different stages of childhood and adolescence have been well established, little is known about the developmental course of general sleep problems. This also holds true for the bidirectional relationship between sleep problems and emotional as well as behavioral difficulties. This longitudinal study investigated the general pattern and the latent trajectory classes of general sleep problems from a large community sample aged 5–14 years. In addition, this study examined the predictive value of emotional/behavioral difficulties (i.e., anxiety/depression, attention problems, and aggressive behavior) on sleep problems latent trajectory classes, and vice-versa. Participants (N = 1993) were drawn from a birth cohort of Western Australian children born between 1989 and 1991 who were followed until 14 years of age. Sleep problems were assessed at ages 5, 8, 10, and 14, respectively, whereas anxiety/depression, attention problems, and aggressive behavior were assessed at ages 5 and 17 years. Latent growth curve modeling revealed a decline in an overall pattern of sleep problems during the observed 10-year period. Anxiety/depression was the only baseline factor that predicted the longitudinal course of sleep problems from ages 5 to 14 years, with anxious and depressed participants showing faster decreasing patterns of sleep problems over time than those without anxiety or depression. Growth mixture modeling identified two classes of sleep problem trajectories: Normal Sleepers (89.4%) and Troubled Sleepers (10.6%). Gender was randomly distributed between these groups. Childhood attention problems, aggressive behavior, and the interaction between gender and anxiety/depression were significantly predictive of membership in the group of Troubled Sleepers. Group membership in Troubled Sleepers was associated with higher probability of having attention problems and aggressive behavior in mid-adolescence. Boys and girls with behavioral difficulties, and girls with emotional difficulties were at increased risk of having sleep problems during later childhood and adolescence. Developmental trajectories of sleep problems were also predictive of behavioral difficulties in later life. Findings from this study provide empirical evidence for the heterogeneity of sleep problems and their development, and emphasize the importance of understanding sleep problems and their relationship to children and adolescents’ mental health.

Sleep, anxiety and psychiatric symptoms in children with Tourette syndrome and tic disorders

OBJECTIVE

The current study evaluated the relationship between tic, sleep disorders and specific psychiatric symptoms (anxiety, depression, obsessive compulsive symptoms).

METHODS

Assessment of 36 consecutive children and adolescents with tic disorders included: the Yale Global Tic Severity Scale (YGTSS) to assess the severity of tic symptoms; the Self-administered scale for children and adolescents (SAFA) to evaluate the psychopathological profile; a specific sleep questionnaire consisting of 45 items to assess the presence of sleep disorders. An age and sex-matched control group was used for comparisons.

RESULTS

Sleep was significantly more disturbed in patients with tic disorders than in controls. Difficulties in initiating sleep and increased motor activity during sleep were the most frequent sleep disturbances found in our sample. Patients showed also symptoms of anxiety (SAFA A), depressed mood (SAFA D) and doubt-indecision (SAFA O). Additionally, difficulties in initiating sleep resulted associated with other SAFA subscales relative to obsessive-compulsive symptoms and depression symptoms. Furthermore, anxiety symptoms (SAFA A) resulted associated with increased motor activity during sleep.

CONCLUSIONS

Findings confirm literature studies reporting high frequency of sleep problems, anxiety and other psychopathological symptoms in patients with tic disorders, and support the hypothesis that intrusive thoughts and other emotional disturbances might disrupt the sleep onset of these patients. These results suggest the importance of a thorough assessment of sleep and psychiatric disturbances in patients with tic disorders.

The Fallacy of Univariate Solutions to Complex Systems Problems

Complex biological systems, by definition, are composed of multiple components that interact non-linearly. The human brain constitutes, arguably, the most complex biological system known. Yet most investigation of the brain and its function is carried out using assumptions appropriate for simple systems—univariate design and linear statistical approaches. This heuristic must change before we can hope to discover and test interventions to improve the lives of individuals with complex disorders of brain development and function. Indeed, a movement away from simplistic models of biological systems will benefit essentially all domains of biology and medicine. The present brief essay lays the foundation for this argument.

Annual Research Review: Sleep problems in childhood psychiatric disorders--a review of the latest science

BACKGROUND

Hippocrates flagged the value of sleep for good health. Nonetheless, historically, researchers with an interest in developmental psychopathology have largely ignored a possible role for atypical sleep. Recently, however, there has been a surge of interest in this area, perhaps reflecting increased evidence that disturbed or insufficient sleep can result in poor functioning in numerous domains. This review outlines what is known about sleep in the psychiatric diagnoses most relevant to children and for which associations with sleep are beginning to be understood. While based on a comprehensive survey of the literature, the focus of the current review is on the latest science (largely from 2010). There is a description of both concurrent and longitudinal links as well as possible mechanisms underlying associations. Preliminary treatment research is also considered which suggests that treating sleep difficulties may result in improvements in behavioural areas beyond sleep quality.

FINDINGS

To maximise progress in this field, there now needs to be: (a) greater attention to the assessment of sleep in children; (b) sleep research on a wider range of psychiatric disorders; (c) a greater focus on and examination of mechanisms underlying associations; (d) a clearer consideration of developmental questions and (e) large-scale well-designed treatment studies.

CONCLUSIONS

While sleep problems may sometimes be missed by parents and healthcare providers; hence constituting a hidden risk for other psychopathologies - knowing about these difficulties creates unique opportunities. The current excitement in this field from experts in diverse areas including developmental psychology, clinical psychology, genetics and neuropsychology should make these opportunities a reality.

Insomnia in childhood and adolescence: clinical aspects, diagnosis, and therapeutic approach

OBJECTIVES

To review the clinical characteristics, comorbidities, and management of insomnia in childhood and adolescence.

SOURCES

This was a non-systematic literature review carried out in the PubMed database, from where articles published in the last five years were selected, using the key word "insomnia" and the pediatric age group filter. Additionally, the study also included articles and classic textbooks of the literature on the subject.

DATA SYNTHESIS

During childhood, there is a predominance of behavioral insomnia as a form of sleep-onset association disorder (SOAD) and/or limit-setting sleep disorder. Adolescent insomnia is more associated with sleep hygiene problems and delayed sleep phase. Psychiatric (anxiety, depression) or neurodevelopmental disorders (attention deficit disorder, autism, epilepsy) frequently occur in association with or as a comorbidity of insomnia.

CONCLUSIONS

Insomnia complaints in children and adolescents should be taken into account and appropriately investigated by the pediatrician, considering the association with several comorbidities, which must also be diagnosed. The main causes of insomnia and triggering factors vary according to age and development level. The therapeutic approach must include sleep hygiene and behavioral techniques and, in individual cases, pharmacological treatment.

Neurexin-1 regulates sleep and synaptic plasticity in Drosophila melanogaster

Neurexins are cell adhesion molecules that are important for synaptic plasticity and homeostasis, although links to sleep have not yet been investigated. We examined the effects of neurexin-1 perturbation on sleep in Drosophila, showing that neurexin-1 nulls displayed fragmented sleep and altered circadian rhythm. Conversely, the over-expression of neurexin-1 could increase and consolidate night-time sleep. This was not solely due to developmental effects as it could be induced acutely in adulthood, and was coupled with evidence of synaptic growth. The timing of over-expression could differentially impact sleep patterns, with specific night-time effects. These results show that neurexin-1 was dynamically involved in synaptic plasticity and sleep in Drosophila. Neurexin-1 and a number of its binding partners have been repeatedly associated with mental health disorders, including autism spectrum disorders, schizophrenia and Tourette syndrome, all of which are also linked to altered sleep patterns. How and when plasticity-related proteins such as neurexin-1 function during sleep can provide vital information on the interaction between synaptic homeostasis and sleep, paving the way for more informed treatments of human disorders.

Interactions of the histamine and hypocretin systems in CNS disorders

Histamine and hypocretin neurons are localized to the hypothalamus, a brain area critical to autonomic function and sleep. Narcolepsy type 1, also known as narcolepsy with cataplexy, is a neurological disorder characterized by excessive daytime sleepiness, impaired night-time sleep, cataplexy, sleep paralysis and short latency to rapid eye movement (REM) sleep after sleep onset. In narcolepsy, 90% of hypocretin neurons are lost; in addition, two groups reported in 2014 that the number of histamine neurons is increased by 64% or more in human patients with narcolepsy, suggesting involvement of histamine in the aetiology of this disorder. Here, we review the role of the histamine and hypocretin systems in sleep-wake modulation. Furthermore, we summarize the neuropathological changes to these two systems in narcolepsy and discuss the possibility that narcolepsy-associated histamine abnormalities could mediate or result from the same processes that cause the hypocretin cell loss. We also review the changes in the hypocretin and histamine systems, and the associated sleep disruptions, in Parkinson disease, Alzheimer disease, Huntington disease and Tourette syndrome. Finally, we discuss novel therapeutic approaches for manipulation of the histamine system.

Advances in Tourette syndrome: diagnoses and treatment

Tourette syndrome (TS) is a childhood-onset neurodevelopmental disorder characterized by multiple motor tics and at least one vocal or phonic tic, and often one or more comorbid psychiatric disorders. Premonitory sensory urges before tic execution and desire for "just-right" perception are central features. The pathophysiology involves cortico-striato-thalamo-cortical circuits and possibly dopaminergic system. TS is considered a genetic disorder but the genetics is complex and likely involves rare mutations, common variants, and environmental and epigenetic factors. Treatment is multimodal and includes education and reassurance, behavioral interventions, pharmacologic, and rarely, surgical interventions.

Shared Brain Connectivity Issues, Symptoms, and Comorbidities in Autism Spectrum Disorder, Attention Deficit/Hyperactivity Disorder, and Tourette Syndrome

The prevalence of neurodevelopmental disorders, including autism spectrum disorder (ASD), attention deficit/hyperactivity disorder (ADHD), and Tourette syndrome (TS), has increased over the past two decades. Currently, about one in six children in the United States is diagnosed as having a neurodevelopmental disorder. Evidence suggests that ASD, ADHD, and TS have similar neuropathology, which includes long-range underconnectivity and short-range overconnectivity. They also share similar symptomatology with considerable overlap in their core and associated symptoms and a frequent overlap in their comorbid conditions. Consequently, it is apparent that ASD, ADHD, and TS diagnoses belong to a broader spectrum of neurodevelopmental illness. Biologically, long-range underconnectivity and short-range overconnectivity are plausibly related to neuronal insult (e.g., neurotoxicity, neuroinflammation, excitotoxicity, sustained microglial activation, proinflammatory cytokines, toxic exposure, and oxidative stress). Therefore, these disorders may a share a similar etiology. The main purpose of this review is to critically examine the evidence that ASD, ADHD, and TS belong to a broader spectrum of neurodevelopmental illness, an abnormal connectivity spectrum disorder, which results from neural long-range underconnectivity and short-range overconnectivity. The review also discusses the possible reasons for these neuropathological connectivity findings. In addition, this review examines the role and issue of axonal injury and regeneration in order to better understand the neuropathophysiological interplay between short- and long-range axons in connectivity issues.