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

Estimating the number of people with Tourette syndrome and persistent tic disorder in the United States

Estimates of the number of people in the U.S. with Tourette syndrome or other persistent tic disorders can inform service provision planning. Based on available prevalence estimates applied to 2020 population data from the U.S. Census, we estimated that 350,000-450,000 U.S. children and adults have Tourette syndrome and about one million have other persistent tic disorders. Variation across studies makes estimating the total number of people in the United States affected by these disorders challenging. More precise measurement could ensure that prevalence estimates accurately reflect all who are impacted by these disorders and who could benefit from evidence-based services.

Effects of Low-Frequency Repetitive Transcranial Magnetic Stimulation of the Bilateral Parietal Cortex in Patients With Tourette Syndrome

Background: Traditional medical treatments are not effective for some patients with Tourette syndrome (TS). According to the literature, repetitive transcranial magnetic stimulation (rTMS) may be effective for the treatment of TS; however, different targets show different results.

Objective: To assess the efficacy and safety of low-frequency rTMS in patients with TS, with the bilateral parietal cortex as the target.

Methods: Thirty patients with TS were divided into two groups: active and sham groups. The active group was subjected to 0.5-Hz rTMS at 90% of resting motor threshold (RMT) with 1,200 stimuli/day/side, whereas the sham group was subjected to 0.5-Hz rTMS at 10% of RMT with 1,200 stimuli/day/side with changes in the coil direction. Both groups were bilaterally stimulated over the parietal cortex (P3 and P4 electrode sites) for 10 consecutive days. The symptoms of tics and premonitory urges were evaluated using the Yale Global Tic Severity Scale (YGTSS), Modified Scoring Method for the Rush Video-based Tic Rating Scale (MRVBTS), and Premonitory Urge for Tics Scale (PUTS) scores at baseline, the end of the 10-day treatment, 1 week after treatment, and 1 month after treatment.

Results: At the end of the 10-day treatment, the YGTSS total, YGTSS motor tic, YGTSS phonic tic, MRVBTS, and PUTS scores in the active group significantly improved and improvements were maintained for at least 1 month.

Conclusions: Low-frequency bilateral rTMS of the parietal cortex can markedly alleviate motor tics, phonic tics, and premonitory urges in patients with TS.

Interventions for tic disorders: An updated overview of systematic reviews and meta analyses

To conduct an updated overview of systematic reviews (SRs) summarizing the efficacy and safety of various strategies used to treat tic disorders (TDs) in children. We searched the Cochrane Library, PubMed, EMBASE, and relevant reference lists for articles published between the search deadline from our last overview and April 2019 and included 16 SRs. The results presented that antipsychotics, a2-adrenergic receptor agonists, and HRT/CBIT still appeared to be the most robust evidence-based options for the treatment of TDs. Compared with our last overview, more robust evidence showed that aripiprazole and acupuncture was effective treatment in treating children TDs, and DBS for medication-refractory and severely affected patients. In addition, physical activity or exercise may be promising treatments, and the clonidine adhesive patch is an effective, safe, and convenient treatment option for TDs. Moreover, methylphenidate, guanfacine, and desipramine appeared to reduce ADHD symptoms in children with tics. However, no research studies have examined HRT/CBIT alone compared with HRT/CBIT in combination with medication. More high-quality clinical trials comparing different interventions for TDs including economic evaluations should be encouraged.

Pharmacotherapies to tics: a systematic review

The efficacy of all pharmacotherapies for patients suffering from tics were unclear. Literatures were searched from Medline, Embase, The Cochrane Library, and four Chinese databases. The primary efficacy outcome scale was defined as the Yale Global Tic Severity Scale (YGTSS). Overall estimates of pooled weighted mean difference (WMD) with 95% confidence interval (CI) were calculated for each outcome measure. A total of 53 trials were included. Meta-analysis suggested that alpha-2 adrenergic agonist agents and atypical antipsychotic agents were effective in improving tics, which included the maximum number of trials. Typical antipsychotic agents were associated with severer side-effects than alpha-2 adrenergic agonist agents. Besides, Traditional Chinese Medicine showed positive effects in YGTSS (NingDong Granule: WMD=-7.100, 95% CI, -10.430- -3.770; 5-Ling Granule: WMD=-11.300, 95% CI, -14.208- -8.392), while glutamate modulators (D-serine, N-Acetylcysteine and riluzole) might not be working. In summary, alpha-2 adrenergic agonist agents were associated with the optimal weigh between efficacy and safety. However, the significant factor of limited trials and sample sizes discounted these findings. Further better studies are necessary to ascertain them.

"I'm not being rude, I'd want somebody normal": Adolescents' Perception of their Peers with Tourette's Syndrome: an Exploratory Study

Tourette's syndrome (TS) is a highly stigmatised condition, and typically developing adolescents' motives and reasons for excluding individuals with TS have not been examined. The aim of the study was to understand how TS is conceptualised by adolescents and explore how individuals with TS are perceived by their typically developing peers. Free text writing and focus groups were used to elicit the views of twenty-two year ten students from a secondary school in South East England. Grounded theory was used to develop an analytical framework. Participants' understanding about the condition was construed from misconceptions, unfamiliarity and unanswered questions. Adolescents who conceived TS as a condition beyond the individual's control perceived their peers as being deprived of agency and strength and as straying from the boundaries of normalcy. People with TS were viewed as individuals deserving pity, and in need of support. Although participants maintained they had feelings of social politeness towards those with TS, they would avoid initiating meaningful social relationships with them due to fear of 'social contamination'. Intergroup anxiety would also inhibit a close degree of social contact. Participants that viewed those with TS as responsible for their condition expressed a plenary desire for social distance. However, these behavioural intentions were not limited to adolescents that elicited inferences of responsibility to people with TS, indicating that attributional models of stigmatisation may be of secondary importance in the case of TS. Implications for interventions to improve school belonging among youth with TS are discussed.

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.

The effectiveness and safety of plum-blossom needle therapy for Tourette syndrome: study protocol for a randomized controlled trial

Background

Previous studies have indicated that acupuncture can alleviate the symptoms of Tourette syndrome (TS), but the evidence is insufficient. So far, there have been no reports on plum-blossom needle therapy for TS. Here we present a protocol for a randomized controlled trial using plum-blossom needle therapy to treat TS.

Methods/design

Sixty patients will be randomly allocated into either the plum-blossom needle therapy group or the habit reversal training (HRT) group. All patients in each group will be given 12 weeks of treatment, with follow-up at the 24th week. The primary outcome measure will be the mean change from baseline in the total tic score on the Yale Global Tic Severity Scale (YGTSS) at the 12th week. Secondary outcome measures will include the scores on the TS Clinical Global Impression Scale (CGI) and the mean changes from baseline in the YGTSS score and the Children and Adolescents’ Quality of Life Scale (CAQOL) at other time points. Safety will also be evaluated.

Discussion

This trial will evaluate the effectiveness and safety of plum-blossom needle therapy for TS compared with HRT. A limitation of this trial is that patients and acupuncturists cannot be blinded.

Trial registration

ClinicalTrials.gov Identifier: NCT02403258 (Date of registration: March 31, 2015).

Sodium valproate for the treatment of Tourette׳s syndrome in children: a systematic review and meta-analysis

The aims are to evaluate the efficacy and safety of sodium valproate for children with Tourette׳s syndrome (TS). We searched PubMed, EMBASE, the Cochrane library, Cochrane Central, CBM, CNKI, VIP, WANG FANG database and relevant reference lists. Five RCTs (N=247) and five case series (N=163) studies were included. Only one RCT (93 patients) evaluated total YGTSS scores and there was significant difference in the reduction of total YGTSS scores between sodium valproate and the control group (3.50±4.59 vs 7.86±7.03, P<0.01). One RCT (30 patients) evaluated motor and vocal tics, and there was significant difference in the reduction of motor and vocal tics scores between sodium valproate and haloperidol (10.45±4.15 vs 14.92±3.01, P<0.01). Meta-analysis of three RCTs (N=124) showed there was no significant difference in the reduction of the number of tics between sodium valproate and the positive control group [Relative Risk (RR)=1.09, 95%CI (0.92, 1.30), P=0.30]. The pooled proportion in five case series studies which used tics symptom improvement self-defined by authors was 80.7% (95% CI: 73.7-86.2, I(2)=0). No fatal side effects were reported. In conclusion, based on the limited evidence, the routine use of sodium valproate for treatment of TS in children is not recommended. Further well-conducted trials that examine long-term outcomes are required.

Bilateral globus pallidus stimulation for severe Tourette's syndrome: a double-blind, randomised crossover trial

BACKGROUND

Deep brain stimulation (DBS) has been proposed as a treatment option for severe Tourette's syndrome on the basis of findings from open-label series and small double-blind trials. We aimed to further assess the safety and efficacy of bilateral globus pallidus internus (GPi) DBS in patient's with severe Tourette's syndrome.

METHODS

In a randomised, double-blind, crossover trial, we recruited eligible patients (severe medically refractory Tourette's syndrome, age ≥20 years) from two clinics for tertiary movement disorders in the UK. Enrolled patients received surgery for GPi DBS and then were randomly assigned in a 1:1 ratio (computer-generated pairwise randomisation according to order of enrolment) to receive either stimulation on-first or stimulation off-first for 3 months, followed by a switch to the opposite condition for a further 3 month period. Patients and rating clinicians were masked to treatment allocation; an unmasked clinician was responsible for programming the stimulation. The primary endpoint was difference in Yale Global Tic Severity Scale (YGTSS) total score between the two blinded conditions, assessed with repeated measures ANOVA, in all patients who completed assessments during both blinded periods. After the end of the blinded crossover phase, all patients were offered continued DBS and continued to have open-label stimulation adjustments and objective assessments of tic severity until database lock 1 month after the final patient's final trial-related visit. This trial is registered with ClinicalTrials.gov, number NCT01647269.

FINDINGS

Between Nov 5, 2009, and Oct 16, 2013, we enrolled 15 patients (11 men, four women; mean age 34·7 years [SD 10·0]). 14 patients were randomly assigned and 13 completed assessments in both blinded periods (seven in the on-first group, six in the off-first group). Mean YGTSS total score in these 13 patients was 87·9 (SD 9·2) at baseline, 80·7 (SD 12·0) for the off-stimulation period, and 68·3 (SD 18·6) for the on-stimulation period. Pairwise comparisons in YGTSS total scores after Bonferroni correction were significantly lower at the end of the on-stimulation period compared with the off-stimulation period, with a mean improvement of 12·4 points (95% CI 0·1-24·7, p=0·048), equivalent to a difference of 15·3% (95% CI 5·3-25·3). All 15 patients received stimulation in the open-label phase. Overall, three serious adverse events occurred (two infections in DBS hardware at 2 and 7 weeks postoperatively, and one episode of deep-brain-stimulation-induced hypomania during the blinded on-stimulation period); all three resolved with treatment.

INTERPRETATION

GPi stimulation led to a significant improvement in tic severity, with an overall acceptable safety profile. Future research should concentrate on identifying the most effective target for DBS to control both tics and associated comorbidities, and further clarify factors that predict individual patient response.

FUNDING

UK National Health Service.

Dual regulating effects of gastrodin on extracellular dopamine concentration in rats models of Tourette's syndrome

PURPOSE

Evaluate the dual regulating effects of gastrodin on striatal extracellular dopamine (DA) concentration in Tourette's syndrome (TS) rat models, and explore the underlying pharmacological mechanisms.

MATERIALS AND METHODS

Seventy Wistar rats were randomly divided into control group and TS model group. The former was intraperitoneally injected with saline (0.9%), while in the later, the rats were injected with Apomorphine (Apo) and 3,3'-iminodipropionitrile (IDPN) respectively to manipulate two kinds of TS rat models. Both Apo and IDPN induced rats were further assigned to three conditions, and the related rats were treated respectively by oral gavage with saline, gastrodin and Haloperidol (Hal). Data of stereotypy of the rats were collected. After 8 weeks, the extracellular content of DA and HVA in striatum were examined by intracerebral microdialysis and follow-up high-performance liquid chromatography (HPLC), and the expression of dopamine transporter (DAT) was probed by Western blot.

RESULTS

Gastrodin improved the stereotyped behaviors in TS rats. Furthermore, it down-regulated the elevated striatal extracellular DA concentration in Apo-induced rats and up-regulated the decreased DA content in the rats exposed to IDPN. Meanwhile, a dramatic down-regulation was detected in DAT protein expression in Apo + GAS group, while an opposite profile was showed in the IDPN + GAS group.

CONCLUSIONS

The dual regulating effects of gastrodin on extracellular DA level have been established, and the related mechanisms would be the dual regulating effects of gastrodin on the expression of DAT, a glycoprotein in the regulation of the extracellular DA concentration.

Health care needs of children with Tourette syndrome

To document the impact of Tourette syndrome on the health care needs of children and access to health care among youth with Tourette syndrome, parent-reported data from the 2007-2008 National Survey of Children's Health were analyzed. Children with Tourette syndrome had more co-occurring mental disorders than children with asthma or children without Tourette syndrome or asthma and had health care needs that were equal to or greater than children with asthma (no Tourette syndrome) or children with neither asthma nor Tourette syndrome. Health care needs were greatest among children with Tourette syndrome and co-occurring mental disorders, and these children were least likely to receive effective care coordination. Addressing co-occurring conditions may improve the health and well-being of children with Tourette syndrome. Strategies such as integration of behavioral health and primary care may be needed to improve care coordination.

Structural abnormalities in early Tourette syndrome children: a combined voxel-based morphometry and tract-based spatial statistics study

Tourette Syndrome (TS) is characterized with chronic motor and vocal tics beginning in childhood. Abnormality of both gray (GM) and white matter (WM) has been observed in cortico-striato-thalamo-cortical circuits and sensory-motor cortex of adult TS patient. It is not clear if these morphological changes are also present in TS children and if there are any microstructural changes of WM. To understand the developmental cause of such changes, we investigated volumetric changes of GM and WM using VBM and microstructural changes of WM using DTI, and correlated these changes with tic severity and duration. T1 images and Diffusion Tensor Images (DTI) from 21 TS children were compared with 20 age and gender matched health control children using a 1.5T Philips scanner. All of the 21 TS children met the DSM-IV-TR criteria. T1 images were analyzed using DARTEL-VBM in conjunction with statistical parametric mapping (SPM). Diffusion tensor imaging (DTI) analysis was performed using Tract-Based Spatial Statistics (TBSS). Brain volume changes were found in left superior temporal gyrus, left and right paracentral gyrus, right precuneous cortex, right pre- and post- central gyrus, left temporal occipital fusiform cortex, right frontal pole, and left lingual gyrus. Significant axial diffusivity (AD) and mean diffusivity (MD) increases were found in anterior thalamic radiation, right cingulum bundle projecting to the cingulate gurus and forceps minor. Decreases in white matter volume (WMV) in the right frontal pole were inversely related with tic severity (YGTSS), and increases in AD and MD were positively correlated with tic severity and duration, respectively. These changes in TS children can be interpreted as signs of neural plasticity in response to the experiential demand. Our findings may suggest that the morphological and microstructural measurements from structural MRI and DTI can potentially be used as a biomarker of the pathophysiologic pattern of early TS children.

Chinese Medicine Formula "Jian-Pi-Zhi-Dong Decoction" Attenuates Tourette Syndrome via Downregulating the Expression of Dopamine Transporter in Mice

Jian-Pi-Zhi-Dong Decoction (JPZDD) is dedicated to the treatment for Tourette syndrome (TS) with the guidance of the theories of Traditional Chinese Medicine (TCM). This study aims to investigate the expression of dopamine transporter (DAT) in the striatum and stereotyped behavior of TS mice model by intervention of JPZDD. Mice were induced by 3,3′-iminodipropionitrile (IDPN, 350 mg kg⁻¹ day⁻¹, i.p.) for 7 days and divided into 4 groups (n = 20, each): control and IDPN groups were gavaged with saline and the remaining 2 groups with Tiapride (Tia, 50 mg kg⁻¹ day⁻¹) and JPZDD (20 g kg⁻¹ day⁻¹), respectively. The results showed that the scores of stereotyped behavior in IDPN+JPZDD group were significantly reduced. A noticeably increased ¹¹C-β-CFT binding at bilateral striatum was observed after administration of JPZDD versus that of IDPN or Tia. Immunohistochemistry and in situ hybridization studies manifested higher levels of DAT protein and mRNA in IDPN+JPZDD group. These findings not only demonstrated that JPZDD could effectively inhibit the abnormal behaviors of TS mice model, but also increase the level of DAT in striatum. Therefore, JPZDD could be one of potential treatments of patients with TS.

Quality of life in adults with Gilles de la Tourette Syndrome

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Tourette syndrome

Tourette syndrome (TS) is a neurodevelopmental disorder consisting of multiple motor and one or more vocal/phonic tics. TS is increasingly recognized as a common neuropsychiatric disorder usually diagnosed in early childhood and comorbid neuropsychiatric disorders occur in approximately 90% of patients, with attention deficit hyperactivity disorder (ADHD) and obsessive-compulsive disorder (OCD) being the most common ones. Moreover, a high prevalence of depression and personality disorders has been reported. Although the mainstream of tic management is represented by pharmacotherapy, different kinds of psychotherapy, along with neurosurgical interventions (especially deep brain stimulation, DBS) play a major role in the treatment of TS. The current diagnostic systems have dictated that TS is a unitary condition. However, recent studies have demonstrated that there may be more than one TS phenotype. In conclusion, it appears that TS probably should no longer be considered merely a motor disorder and, most importantly, that TS is no longer a unitary condition, as it was previously thought.

Genetic animal models of Tourette syndrome: The long and winding road from lab to clinic

Tourette syndrome (TS) is a disabling neuropsychiatric disorder characterised by persistent motor and vocal tics. TS is a highly comorbid state, hence, patients might experience anxiety, obsessions, compulsions, sleep abnormalities, depression, emotional liability, learning problems, and attention deficits in addition to tics. In spite of its complex heterogeneous genetic aetiology, recent studies highlighted a strong link between TS and genetic lesions in the HDC (L-histidine decarboxylase) gene, which encodes the enzyme that synthetises histamine, and the SLITRK1 (SLIT and TRK-like family member 1) gene, which encodes a transmembrane protein that was found to regulate neurite outgrowth. In addition to validating the contribution of a specific genetic aberration to the development of a particular pathology, animal models are crucial to dissect the function of disease-linked proteins, expose disease pathways through examination of genetic modifiers and discover as well as assess therapeutic strategies. Mice with a knockout of either Hdc or Slitrk1 exhibit anxiety and those lacking Hdc, display dopamine agonist-triggered stereotypic movements. However, the mouse knockouts do not spontaneously display tics, which are recognised as the hallmark of TS. In this review, we explore the features of the present genetic animal models of TS and identify reasons for their poor resemblance to the human condition. Importantly, we highlight ways forward aimed at developing a valuable genetic model of TS or a model that has good predictive validity in developing therapeutic drugs for the treatment of tics, hence potentially accelerating the arduous journey from lab to clinic.

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

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

Aripiprazole for the treatment of adolescent Tourette's syndrome: a case report

Gilles de la Tourette syndrome (GTS) is a neuropsychiatric, lifelong disorder with onset in childhood. The essential features of this disorder are multiple motor tics and one or more vocalizations. The neurochemical pathophysiology of GTS involves an unknown abnormality in the central dopaminergic system. Atypical antipsychotics, such as aripiprazole, serve as a new therapeutic option for GTS. The authors describe a unique case of Tourette's syndrome (TS) in an adolescent in which aripiprazole resolved the patient's symptoms. A 17-year-old, 5'11'' tall, African American male weighing 220 lbs was diagnosed with TS at 9 years old. By age 16, the patient developed prominent symptoms of intermitted eye blinking, forehead raising, finger snapping, heavy breathing, and head bobbing. Clonidine, in addition to homeopathic remedies (N-acetylcholine and alpha lipoic acid), was administered to the patient without significant diminution of symptoms. Later, aripiprazole was initiated at 5 mg/d. As a result, noticeable symptomatic improvement occurred within 48 hours. Aripiprazole was titrated over the next 4 weeks to 6.5 mg/d, with significant results. Over the next 6 months, aripiprazole was titrated again to 10 mg/d with additional symptom reduction. This case illustrates a patient who responded to aripiprazole with no reported adverse effects, when standard therapy failed to improve symptoms.

The international prevalence, epidemiology, and clinical phenomenology of Tourette syndrome: a cross-cultural perspective

The overall international prevalence of Tourette syndrome (TS) is 1% in the majority of cultures of the world. Both TS and tics are certainly more obvious and may be more common in younger people. Moreover, TS is seen less frequently in some cultures. However, in all cultures where it has been reported, the phenomenology is similar, highlighting the biological underpinnings of the disorder. This article reviews the international prevalence, epidemiology, and clinical phenomenology of TS, from a cross-cultural perspective.

Tics en niños y adolescentes: análisis retrospectivo de 78 casos

INTRODUCTION

Tics are the most frequent abnormal movement in children. A familial history of tics and a personal and familial history of neurobehavioral disturbances are common in children with this abnormality. Tics may seriously compromise daily activities in affected individuals.

OBJECTIVE

To identify the characteristics of tics in children and adolescents followed-up in the Neuropediatric Unit of the Hospital Geral de Santo António.

MATERIALS AND METHODS

We performed a retrospective analysis of patients with tics based on information collected from medical records. The diagnostic criteria of the DSM IV-TR 2000 of the American Psychiatric Association were used.

RESULTS

The medical records of 78 children were analyzed, 84.6 % of whom were boys. More than one third of the patients were aged 4 to 8 years old. In 5.1 % of the patients tics developed before the age of 2 years. A familial history of tics, depression and obsessive disorder traits was found in approximately 30 % of patients. The most frequent comorbidity was attention deficit hyperactivity disorder (67.9 %). The occurrence of pediatric autoimmune neuropsychiatric disorders associated with streptococcus infection (PANDAS) was suggested in five patients. In all patients, motor tics occurred before vocal tics. In more than two thirds of the patients, tics were simple. In 59.0 % of the patients, tics were chronic, and in 45.7 % of these met the criteria for Tourette's syndrome. A total of 43.1 % of the patients with chronic tics received pharmacotherapy, risperidone being the most frequently used drug.

CONCLUSIONS

In general the results of the present study are in agreement with those of previous studies, underlining the need to consider a diagnosis of tics in young children and highlighting the importance of identification and appropriate treatment of comorbidities.

Prevalence of tic disorder in two schools in the Basque country: Results and methodological caveats

Different studies have shown that the prevalence of tic disorder is highly variable, depending on the methodology employed. The aim of this study was to determine the prevalence of tic disorder among children of two schools. The study was conducted in three successive steps: information to parents and teachers by way of speeches and projection of videotapes; anonymous fulfilling of an ad hoc questionnaire by teachers and parents and identification of children as "possible tic disorder" according to the questionnaire; and confirmation of the presence of tics by direct observation of children at school (20 minutes in each classroom). Eight hundred sixty-seven children were included. Age ranged from 4 to 16 years. Ninety percent of parents and 99% of teachers fulfilled the questionnaire. Seventy-one children had tics according to parents' and 50 according to teachers' opinion (both coincided in 23 cases). Fifty-seven cases were identified after direct observation in the classroom (prevalence of 6.5%). The vast majority of tics were mild in severity and duration. Prevalence obtained in this study was comparable with data reported in studies using a similar methodology, which is higher than results shown in early studies addressed with less rigid methodology. Most of identified cases were quite mild, not leading to major functional disability. In spite of the methodology employed, it is possible that some cases were lost.

Tic disorders: from pathophysiology to treatment

Tic disorders are stereotypic behaviours,more frequent than once believed, and therefore likely to be encountered by primary care physicians. Tics usually begin in childhood and are the clinical hallmark of Tourette Syndrome (TS), the most common cause of tics. TS is a relatively common neurobehavioural disorder with a spectrum of manifestations that wax and wane during its natural course. The pathophysiology of tics, at molecular and cellular level, is still unknown,whereas structural and functional neuroimaging studies have shown the involvement of the basal ganglia and related cortico-striato-thalamo-cortical circuits, and the dopaminergic neuronal system. Moreover, TS has a strong genetic background. The management of TS is often complicated by the presence of attention-deficit/hyperactivity disorder, obsessive-compulsive disorder, and other behaviour disorders. The correct diagnosis is a fundamental step for a proper management of these disorders, and a multimodal treatment is usually indicated. This approach includes educational and supportive interventions, as well as pharmacological treatments when tics are at their worst.