Tara Murphy

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

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

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.

Quality-of-life and psychosocial outcome following childhood arterial ischaemic stroke

Objectives: This study investigates psychosocial outcome and quality-of-life in children who have experienced arterial ischaemic stroke (AIS), using a multidimensional and multi-perspective approach. It also examines the predictors of quality-of-life following childhood AIS. Method: Forty-nine children between 6–18 years of age were recruited from a specialist childhood stroke clinic. Children, their parents and their teachers rated the childs quality-of-life. Questionnaires rating the childs self-esteem, behaviour and emotions were administered. Each child also underwent a neuropsychological assessment. Results: The findings show that child-, parent- and teacher-rated health-related quality-of-life (HRQoL) is significantly lower than comparative norms following childhood AIS, across all domains (physical, emotional, social, school and cognitive functioning). Predictors of HRQoL include neurological severity, executive function, self-esteem and family functioning. Conclusions: Improved screening, services and interventions are necessary to monitor longer-term outcome and provide support for children who have experienced AIS and their families.

Modified constraint-induced movement therapy after childhood stroke

The aim of this pilot study was to investigate feasibility, tolerability, and effect of modified constraint‐induced movement therapy (mCIT) in children with hemiparesis after arterial ischaemic stroke (AIS). Children with chronic hemiparesis and impaired hand function after AIS had mCIT for 2 hours a day, 5 days a week for 4 weeks. Pre‐ and post‐therapy assessments included indices of sensorimotor function, quality of upper limb movement, functional therapy goals, and child and parent interviews. Of eight participants initially recruited, six (one male, five females) completed mCIT (median age 12y 3mo; range 6y 10mo–15y 2mo). Hemiparesis was predominantly spastic in three participants and dystonic in the others; all had severely impaired hand function. After mCIT there were no significant improvements in sensorimotor function or quality of upper limb movement. However, all children improved in individual therapy goals related to functional performance. Children and parents were positive about mCIT. The use of mCIT is a promising intervention for children with chronic acquired hemiparesis. In this severely impaired group functional improvements were seen after therapy despite unchanged sensorimotor measures.

Neuropsychological and neurobehavioral outcome following childhood arterial ischemic stroke: Attention deficits, emotional dysregulation, and executive dysfunction

Objectives. To investigate neuropsychological and neurobehavioral outcome in children with arterial ischemic stroke (AIS). Background. Childhood stroke can have consequences on motor, cognitive, and behavioral development. We present a cross-sectional study of neuropsychological and neurobehavioral outcome at least one year poststroke in a uniquely homogeneous sample of children who had experienced AIS. Method. Forty-nine children with AIS aged 6 to 18 years were recruited from a specialist clinic. Neuropsychological measures of intelligence, reading comprehension, attention, and executive function were administered. A triangulation of data collection included questionnaires completed by the children, their parents, and teachers, rating behavior, executive functions, and emotions. Key Findings. Focal neuropsychological vulnerabilities in attention (response inhibition and dual attention) and executive function were found, beyond general intellectual functioning, irrespective of hemispheric side of stroke. Difficulties with emotional and behavioral regulation were also found. Consistent with an “early plasticity” hypothesis, earlier age of stroke was associated with better performance on measures of executive function. Conclusions. A significant proportion of children poststroke are at long-term risk of difficulties with emotional regulation, executive function, and attention. Data also suggest that executive functions are represented in widespread networks in the developing brain and are vulnerable to unilateral injury.

How does psychoeducation help? A review of the effects of providing information about Tourette syndrome and attention-deficit/hyperactivity disorder.

Tourette syndrome (TS) and attention-deficit/hyperactivity disorder (ADHD) are common neurodevelopmental disorders that often co-occur. They are both stigmatized and misunderstood conditions. This review critically appraises studies examining interventions using psychoeducational approaches in TS and ADHD. Studies examining the impact of providing educational information (or diagnostic label) about TS and ADHD to parents, teachers and peers (child and adult) were identified by searching relevant electronic databases, reference lists and citations, and consulting colleagues. Twenty-two studies were identified, 20 of which involved teachers or peers. The studies indicate that providing educational information increases knowledge, positive attitudes and behaviours towards individuals with TS and ADHD. Provision of a diagnostic label alone appears insufficient. Parental education may improve treatment enrolment and adherence. While the findings are encouraging, there are a number of gaps in the literature. These include the effects of giving information to parents, whether changes are maintained over time, or are generalizable to the population. Studies are needed to investigate the optimal way to present educational information in everyday contexts in order to improve the lives of those with TS and ADHD.

Perceptions of treatment for tics among young people with Tourette syndrome and their parents: a mixed methods study

BackgroundTourette syndrome (TS) among young people is associated with psychosocial difficulties and parents play an important role in the management of the condition. Clinical guidelines have been developed for the treatment of TS and tics, but little is known about how young people and their parents perceive their treatment options or their desired outcomes of treatment. The aim of this study is to explore perceptions of treatments for tics among young people with TS and their parents.MethodsIn-depth interviews with 42 young people with TS and a mixed-methods, online survey of 295 parents of young people with TS. Participant recruitment was conducted through Tourettes Action (TA): a non-profit UK organisation for the support of people with TS. Interview transcripts were analysed using thematic analysis and responses to survey open-ended questions were analysed using content analysis. Triangulation of qualitative and quantitative data from the parents’ survey and qualitative data from the interviews with young people was used to increase the validity and depth of the findings.ResultsA strong theme was the perception that health professionals have limited knowledge of TS and its treatment. Medication was a common treatment for tics and both young people and parents described benefits of medication. However, adverse effects were frequently described and these were a common reason for stopping medication among young people. Aripiprazole was viewed most positively. Access to behavioural interventions for tics was limited and 76% of parents wanted this treatment to be available for their child. Some young people had reservations about the effectiveness or practicality of behavioural interventions. Reduction and abolition of tics were desired outcomes of treatment, but both parents and young people also identified the importance of increasing control over tics and reducing anxiety-related symptoms. For young people, managing the urge to tic was an important outcome of treatment.ConclusionsThe results suggest a need for more training in the identification and management of TS and wider availability of behavioural treatments. Clinical trials could explore the effectiveness of Aripiprazole used in combination with psycho-educational interventions to reduce anxiety and promote a sense of control.

Computerized Working-Memory Training for Children Following Arterial Ischemic Stroke: A Pilot Study With Long-Term Follow-Up

Cognitive deficits in the domains of working memory (WM) and executive function are well documented following childhood arterial ischemic stroke (AIS). However, there are currently no evidence-based cognitive interventions for this population. Computerized, implicit WM training has been demonstrated to generate generalized cognitive gains for children with WM and attention deficits and for adults following brain injury. This study used a pilot design to investigate the efficacy and feasibility of such an intervention program (Cogmed WM Training) for a childhood AIS population. Outcomes were measured via psychometric assessment at preintervention and postintervention and again at 1-year follow-up. At longitudinal follow-up, participants were found to have significant and persistent cognitive difficulties, particularly with attention and response inhibition. Following the computerized, implicit WM intervention, a significant improvement in phonological-loop WM was seen; however, this improvement was not maintained after 12 months. No additional significant improvements on standardized psychometric outcome measures were seen either immediately or at 12-month follow-up. Findings of this pilot study therefore do not currently support Cogmed as an effective intervention for children with AIS but highlight the need for further research, including randomized, controlled trials, to investigate cognitive interventions for the childhood AIS population.

Habit reversal training and educational group treatments for children with tourette syndrome: A preliminary randomised controlled trial.

Quality of life of children with Tourette Syndrome (TS) is impacted greatly by its symptoms and their social consequences. Habit Reversal Training (HRT) is effective but has not, until now, been empirically evaluated in groups. This randomised controlled trial evaluated feasibility and preliminary efficacy of eight HRT group sessions compared to eight Education group sessions. Thirty-three children aged 9-13 years with TS or Chronic Tic Disorder took part. Outcomes evaluated were tic severity and quality of life (QoL). Tic severity improvements were found in both groups. Motor tic severity (Yale Global Tic Severity Scale) showed greatest improvements in the HRT group. Both groups showed a strong tendency toward improvements in patient reported QoL. In conclusion, group-based treatments for TS are feasible and exposure to other children with tics did not increase tic expression. HRT led to greater reductions in tic severity than Education. Implications, such as cost-effectiveness of treatment delivery, are discussed.

Risk factors for comorbidity in ADHD and GTS: looking beyond a single-deficit model.

Attention-deficit hyperactivity disorder (ADHD) and Gilles de la Tourette syndrome (GTS) are commonly co-occurring neurodevelopmental conditions. This article explores the mechanism of co-occurrence by describing shared biogenetic, neural, and cognitive risk factors between the two disorders. Neuroanatomical risk factors underlie atypical neuropsychological profiles of motor control and inhibition. Features of inhibition (impulsivity in ADHD and tics in GTS) may be a disadvantage in ADHD but may present as a protective factor in GTS. The application of cognitive manifestations for assessment and behavioral management in GTS is considered.