Diane Findley

Disruptive Behavior in Children With Tourette's Syndrome: Association With ADHD Comorbidity, Tic Severity, and Functional Impairment

OBJECTIVE To examine the association of disruptive behavior with social, adaptive, and family functioning in Tourettes syndrome (TS) with and without comorbid attention-deficit/hyperactivity disorder (ADHD). METHOD The sample included 207 children (144 boys and 63 girls) between the ages of 7 and 18 years. Forty-two children received a diagnosis of TS-only, 52 received a diagnosis of ADHD-only, 52 children had TS+ADHD, and there were 61 unaffected control children. Best-estimate DSM-IV diagnoses were assigned on the basis of structured interviews and clinical ratings. Dependent measures included parent and teacher ratings of disruptive behavior, parent ratings of social and family functioning, and the Vineland Adaptive Behavior Scales. RESULTS Children with TS-only did not differ from unaffected controls on the parent ratings of aggression and delinquent behavior or on the teacher ratings of conduct problems. By contrast, children with TS+ADHD were rated significantly above unaffected controls and similar to children with ADHD-only on these indices of disruptive behavior. Hierarchical regression analyses revealed that aggression and delinquency scores added unique contributions to impairment in social and family functioning, controlling for age, gender, and diagnostic status. CONCLUSIONS Comorbid ADHD is highly associated with disruptive behavior and functional impairment in children with TS. When disruptive behavior problems are present, there is an additional burden on childrens social and family functioning.

Assessment of symptom exacerbations in a longitudinal study of children with Tourette's syndrome or obsessive-compulsive disorder.

OBJECTIVES The severity of tic and obsessive-compulsive (OC) symptoms varies over time. Consequently, how do we, as clinicians, know when a change in symptom severity occurs that falls outside of the normal range of fluctuation? The goal of this study was to describe the level of symptom severity fluctuation over time and to establish an objective, prospective, and quantitative method for identifying symptom exacerbations in children with Tourettes syndrome, obsessive-compulsive disorder (OCD), or both. A second major aim was to assess whether fluctuations in tic and OC symptom severity covaried with one another. METHOD Monthly consecutive Yale Global Tic Severity Scale and Childrens Yale-Brown Obsessive Compulsive Scale scores were prospectively obtained in 64 children diagnosed with Tourettes syndrome and/or OCD for periods ranging from 3 to 39 months. Exacerbation thresholds were estimated by using state-of-the-art bootstrap methods. These thresholds were then independently evaluated by asking two expert clinicians to identify, retrospectively, clinically significant exacerbations based on a review of all available clinical and research records. RESULTS The severity of tic and OC symptoms displayed a high degree of intrasubject variability. Exacerbation thresholds, which incorporated the change score from the previous month and the current symptom score, provided the best agreement with those of expert clinicians. When both tic and OC symptoms were present, they showed a significant degree of covariation. CONCLUSIONS Evidence-based treatments are coming of age. The use of valid, clinician-rated severity scales will likely become a standard part of clinical practice. Bootstrapping methods may provide a quantitative and convenient way to obtain clinically valid thresholds to assess tic and OC symptom exacerbations. This method has the potential to be applied to other symptom domains where exacerbation thresholds are needed.

Development of the Yale Children's Global Stress Index (YCGSI) and Its Application in Children and Adolescents With Tourette's Syndrome and Obsessive-Compulsive Disorder

OBJECTIVE The Yale Childrens Global Stress Index (YCGSI) is a new clinical rating instrument designed to provide objective global clinician ratings of psychosocial stress in studies of children and adolescents. This study was designed to evaluate the psychometric properties of the YCGSI. METHOD Independent ratings of clinical severity and psychosocial stress were obtained at two time points separated by 4 months from 33 subjects with Tourettes syndrome (TS) and/or early-onset obsessive-compulsive disorder (OCD), aged 7 to 17 years, and 25 age-matched control subjects. Parents and children were interviewed separately. Multiple measures of stress were obtained including the YCGSI and the Daily Life Stressors Scale (DLSS). RESULTS Data support the interrater reliability and convergent and divergent validity of the YCGSI. At both time points, children and adolescents with TS and OCD had, on average, experienced significantly more psychosocial stress than did the controls. Cross-sectional ratings of tic and obsessive-compulsive symptom severity did not correlate with the YCGSI, but did correlate with self-report ratings of stress on the DLSS. In contrast, ratings on the YCGSI were associated with clinician ratings of depression. CONCLUSIONS The YCGSI has acceptable psychometric properties. Children and adolescents with TS and OCD appear to be at increased risk of experiencing higher levels of psychosocial stress and adversities compared with their peers in the community. Future studies need to examine the possible differential contributions of distinctive forms of stress on the intramorbid course of these disorders.

Streptococcal Upper Respiratory Tract Infections and Psychosocial Stress Predict Future Tic and Obsessive-Compulsive Symptom Severity in Children and Adolescents with Tourette Syndrome and Obsessive-Compulsive Disorder

BACKGROUND One goal of this prospective longitudinal study was to identify new group A beta-hemolytic streptococcal infections (GABHS) in children and adolescents with Tourette syndrome (TS) and/or obsessive-compulsive disorder (OCD) compared with healthy control subjects. We then examined the power of GABHS infections and measures of psychosocial stress to predict future tic, obsessive-compulsive (OC), and depressive symptom severity. METHODS Consecutive ratings of tic, OC, and depressive symptom severity were obtained for 45 cases and 41 matched control subjects over a 2-year period. Clinical raters were blinded to the results of laboratory tests. Laboratory personnel were blinded to case or control status and clinical ratings. Structural equation modeling for unbalanced repeated measures was used to assess the sequence of new GABHS infections and psychosocial stress and their impact on future symptom severity. RESULTS Increases in tic and OC symptom severity did not occur after every new GABHS infection. However, the structural equation model found that these newly diagnosed infections were predictive of modest increases in future tic and OC symptom severity but did not predict future depressive symptom severity. In addition, the inclusion of new infections in the model greatly enhanced, by a factor of three, the power of psychosocial stress in predicting future tic and OC symptom severity. CONCLUSIONS Our data suggest that a minority of children with TS and early-onset OCD were sensitive to antecedent GABHS infections. These infections also enhanced the predictive power of current psychosocial stress on future tic and OC symptom severity.

Exposure and response prevention with or without parent management training for children with obsessive-compulsive disorder complicated by disruptive behavior: A multiple-baseline across-responses design study

Comorbidity with disruptive behavior disorders may have important implications for exposure-based cognitive behavioral treatments of children with OCD. Child noncompliance and parent-child conflict may interfere with performance of exposure activities and completion of therapeutic homework assignments, thus diminishing response to treatment. We investigated whether response to exposure and response prevention (ERP) can be enhanced if disruptive behavior is treated first with parent management training (PMT). A multiple-baseline across-responses design was used to investigate the effects of ERP with or without PMT in six children (age range 9-14 years) with OCD and disruptive behavior. Weekly ratings of OCD were conducted for four weeks to establish baseline. After that, children were randomly assigned to receive six weekly sessions of PMT and then twelve weekly sessions of ERP (ERP-plus-PMT condition) or to receive ERP after a six week waiting period (ERP-only condition). The outcome assessments were conducted weekly using the Child Yale-Brown Obsessive Compulsive Scale (CY-BOCS) administered by an experienced clinician, who was blind to treatment assignment. Three subjects in the ERP-plus-PMT condition evidenced a 39 percent reduction in the CY-BOCS score versus a 10 percent reduction in three subjects in the ERP-only condition. The results of our single-subject study suggest the feasibility and positive effects of combining ERP with PMT for children with OCD complicated by disruptive behavior.

Characteristics of Tic Disorders

Our understanding of tic disorders has increased significantly over the past twenty years through research that has focused on genetics, neurobiological substrates, environmental factors, and effective treatments. Through these empirical efforts as well as clinical experiences, the prevalence, natural course, and phenomenology of tic disorders have become clearer. High rates of comorbidity with ADHD and OCD have made it necessary to tease apart the biological and behavioral differences between individuals who have only tics (motor and/or vocal) and those who have these comorbidities, as well as the varying effects of these differences. These disorders provide a remarkable demonstration that behavior is the result of the on-going interaction of biology and environment and that simplistic approaches that consider only one without the other may prove insufficient to the understanding of tic disorders and to the development of effective treatments.