Contextual Triggers and Tic Severity Across Life Periods: A Retrospective Analysis in Adults with Tic Disorders.

In tic disorders (TD), tic expression varies across the lifespan and as a function of contextual factors. This study explored connections between tic expression and contextual triggers across life periods in 74 adults (Mage = 23.2) with TDs. The Tic History and Coping Strategies form assessed retrospective self-reports of contextual antecedents, consequences, and tic severity during four life periods (middle school; 9th/10th grade; 11th/12th grade; college/work) and past month. Tics reportedly worsened during and after school in school-aged years and worsened in the evening during college/work years. Stress and anxiety were reported to consistently trigger tics across time. The impact of activities, places, and emotions did not differ across life periods. Attention-based consequences, most prevalent during middle school, were more common than escape- or avoidance-related consequences across all periods. Findings illuminate how contextual factors may influence tics across life periods and underscore the consistent impact of tic-triggering emotions and attention-related consequences.

Perceived Negative Effects of Tic Management Strategies in Adults With Tic Disorders.

Behavior therapy is a well-established and empirically supported treatment for tic disorders (TDs). However, concerns have been expressed about the negative effects of behavioral interventions, such as tic worsening, tic substitution, and excessive effort. This study explored perceived negative effects of tic management strategies in adults with TDs and predictors of these experiences. Participants (N = 72) completed semi-structured interviews 11 years after receiving behavior therapy or supportive therapy in a randomized clinical trial. We examined responses to interview questions about managing tics and predictors of reported negative effects. Most participants did not experience tic worsening (84%) or tic substitution (75%) from tic management strategies. The majority felt they could manage tics while participating in their environment (87%) and did not report life interference from tic management (77%). About half (45%) felt less present when managing tics. Treatment non-responders in the original trial were more likely to report negative effects of tic management strategies. No differences in reported negative consequences were found between those who received behavior therapy versus supportive therapy, suggesting that behavior therapy specifically does not lead to such adverse effects. These findings could reduce misconceptions about behavior therapy for TDs and enhance its acceptability and utilization.

The Roles of Lifetime Enacted Stigma in Tic Symptoms among Young Adults with Tourette Syndrome.

Background: Although rarely framed as enacted stigma, adults with Tourette syndrome (ATS) have long suffered from discrimination associated with their tic symptoms. Given the high stress levels of enacted stigma that ATS experience, it is expected that their tic symptoms are profoundly impacted. However, the evidence linking enacted stigma to ATS's tic symptoms remains limited. Methods: This study used a secondary data-analysis approach to reanalyze the data from the follow-up phase of a multi-centered, randomized controlled trial in which a behavioral intervention was tested for its efficacy in managing tic symptoms. This study first conducted psychometric testing on a list of 16 enacted stigma events across five life stages and identified the underlying factor structure. The Yale Global Tic Severity Scale (YGTSS) was used to assess severity and impairment of current tic symptoms, whereas the Clinical Global Impression of Severity scale (CGI) was used to obtain the gestalt of clinical judgment on tic severity. A series of multivariate linear models were then fitted to test the relationships between different types of lifetime enacted stigma and current tic symptoms. Results: The analytic sample included 73 young ATS (average age of 23.2 [standard deviation = 2.5] years). The factor analysis identified three types of enacted stigmas: "traumatic events," "confrontations," and "subtle mistreatments." In multivariate models, traumatic events significantly associated with YGTSS-severity, whereas subtle mistreatments provided additional explanations for CGI. Conclusions: Enacted stigma may play important roles in shaping ATS's current tics symptom severity and, therefore, should be carefully considered in future intervention development.

Childhood Predictors of Long-Term Tic Severity and Tic Impairment in Tourette's Disorder.

Tics peak in late childhood and decline during adolescence. Yet, for some with Tourette's disorder, tics persist into adulthood. We evaluated childhood predictors of adult tic severity and tic impairment, and change over time. Eighty adolescents/adults were evaluated 11 years following a randomized-controlled trial of behavior therapy. An independent evaluator rated tic severity and tic impairment at baseline, posttreatment, and long-term follow-up. At baseline, parents completed demographics/medical history, and youth tic, internalizing, and externalizing symptom ratings. Youth rated premonitory urge severity and family functioning. After controlling for prior tic treatment effects, female sex and higher tic severity predicted higher tic severity in adulthood; and female sex, no stimulant medication use, higher tic severity, and poorer family functioning predicted higher tic impairment. Higher tic severity and premonitory urge severity predicted smaller reductions in tic severity, whereas higher externalizing symptoms predicted greater reduction in tic severity. Female sex predicted smaller reduction in tic impairment, and externalizing symptoms predicted greater reduction in tic impairment. Female sex and childhood tic severity are important predictors of tic severity and tic impairment in adulthood. Family functioning, premonitory urge severity, and tic severity are important modifiable targets for early or targeted intervention to improve long-term outcomes.

Urge intolerance predicts tic severity and impairment among adults with Tourette syndrome and chronic tic disorders.

Background: Individuals with Tourette Syndrome and Persistent Tic Disorders (collectively TS) often experience premonitory urges-aversive physical sensations that precede tics and are temporarily relieved by tic expression. The relationship between tics and premonitory urges plays a key role in the neurobehavioral treatment model of TS, which underlies first-line treatments such as the Comprehensive Behavioral Intervention for Tics (CBIT). Despite the efficacy of CBIT and related behavioral therapies, less than 40% of adults with TS respond to these treatments. Further examination of the relationship between premonitory urges, tic severity, and tic impairment can provide new insights into therapeutic targets to optimize behavioral treatment outcomes. This study examined whether urge intolerance-difficulty tolerating premonitory urges-predicted tic severity and tic-related impairment among adults with TS. Methods: Participants were 80 adults with TS. Assessments characterized premonitory urge, distress tolerance, tic severity, and tic impairment. We used structural equation modeling (SEM) to examine the construct of urge intolerance-comprised of premonitory urge ratings and distress tolerance ratings. We first evaluated a measurement model of urge intolerance through bifactor modeling, including tests of the incremental value of subfactors that reflect premonitory urge severity and distress tolerance within the model. We then evaluated a structural model where we predicted clinician-rated tic severity and tic impairment by the latent variable of urge intolerance established in our measurement model. Results: Analyses supported a bifactor measurement model of urge intolerance among adults with TS. Consistent with theoretical models, higher levels of urge intolerance predicted greater levels of clinician-rated tic severity and tic impairment. Conclusion: This investigation supports the construct of urge intolerance among adults with TS and distinguishes it from subcomponents of urge severity and distress tolerance. Given its predictive relationship with tic severity and tic impairment, urge intolerance represents a promising treatment target to improve therapeutic outcomes in adults with TS.

Proof of Concept Study of an Oral Orthotic in Reducing Tic Severity in Tourette Syndrome.

The use of an oral orthotic, called an occlusal splint, has gained recognition for the potential to reduce the frequency of tics for individuals with Persistent Tic Disorders. The purpose of this study was to assess the feasibility of a fully blinded, randomized controlled trial (RCT) to assess the safety, tolerability and initial efficacy of the oral orthotic in youth with chronic tics. Thirteen youth were randomly assigned to wear an active or sham orthotic in a two week double-blind RCT, with a 4-6 week unblinded follow up period. A statistically significant difference was found for change in tic severity between participants wearing the active and sham orthotic. However, this difference was not replicated during the follow up period. The oral orthotic is a promising intervention for the reduction of tics in youth with Tourette's Syndrome and is worthy of continued study to establish intervention efficacy and mechanism of action.

Long-term Outcomes of Behavior Therapy for Youth With Tourette Disorder.

OBJECTIVE: To determine the long-term durability of behavior therapy for tics among youth with Tourette disorder and persistent (chronic) motor or vocal tic disorders. METHOD: Of the 126 youth who participated in a randomized controlled trial of behavior therapy 11 years prior, 80 were recruited for this longitudinal follow-up. Consenting participants were interviewed in person or remotely (Web-based video) by trained evaluators to determine the course of tics, current tic severity, and tic-related impairment. Recruitment and data collection occurred between 2014 and 2019, with an average follow-up duration of 11.2 years. RESULTS: Treatment responders to both conditions in the original trial achieved partial, but not full, tic remission. Tic severity also decreased significantly across the sample, with 40% reporting partial remission. Behavior therapy responders (n = 21) in the original trial were more likely (67%) to achieve remission at follow-up (Total Tic Score = 12.52, SD = 10.75) compared to psychoeducation/supportive therapy responders (n = 6, 0%) at follow-up (Total Tic Score = 20.67, SD = 6.92) on the Yale Global Tic Severity Scale. Tic-related impairment decreased across the sample, with no significant differences between treatment groups or responders. CONCLUSION: Despite limitations of unmeasured variables and veracity of self-report at follow-up, this study supports guidelines recommending behavior therapy as the first-line intervention for tics. Further investigation of behavior therapy as an early preventive intervention also merits attention.

Family and Maternal Characteristics of Children With Co-Occurring ADHD and Depression.

Objective: This study examined differences between children with ADHD and comorbid depression (n = 26), ADHD only (n = 111), and a community control group (n = 130) on measures of family and maternal characteristics. Method: The present study utilized a large, community sample. Diagnoses required positive endorsements from multiple sources. ANOVAs and chi-square tests were conducted to determine group differences. Results: Compared with children with ADHD alone and community controls, mothers of depressed ADHD children reported decreased family cohesion, limited participation in social/recreational activities, increased maternal depressive symptoms, difficulty coping with parenting roles, and higher rates of bipolar and anxiety disorders. Mothers of children with ADHD (with or without comorbid depression) reported increased conflict, decreased cohesion, and poor maternal coping compared with community controls. Conclusion: Findings are consistent with prior literature suggesting that families of children with ADHD and depression demonstrate both similar and unique characteristics. Clinical implications are discussed.

Patterns and Predictors of Tic Suppressibility in Youth With Tic Disorders.

Tic suppression is the primary target of tic disorder treatment, but factors that influence voluntary tic inhibition are not well understood. Several studies using the Tic Suppression Task have demonstrated significant inter-individual variability in tic suppressibility but have individually been underpowered to address correlates of tic suppression. The present study explored patterns and clinical correlates of reward-enhanced tic suppression in youth with tic disorders using a large, pooled dataset. Individual-level data from nine studies using the Tic Suppression Task were pooled, yielding a sample of 99 youth with tic disorders. Analyses examined patterns of tic suppressibility and the relationship between tic suppressibility and demographic and clinical characteristics. A large majority of youth demonstrated a high degree of tic suppression, but heterogeneous patterns of tic suppressibility were also observed. Better tic suppressibility was related to older age and more frequent tics but unrelated to other clinical variables, including presence of psychiatric comorbidity, psychotropic medication status, tic and premonitory urge severity, and self-rated tic suppressibility. The mechanisms underlying the observed heterogeneity in reward-enhanced tic suppressibility warrant further investigation. The Tic Suppression Task is a promising method for testing mechanistic hypotheses related to tic suppression.

Benchmarking Treatment Response in Tourette's Disorder: A Psychometric Evaluation and Signal Detection Analysis of the Parent Tic Questionnaire.

This study assessed the psychometric properties of a parent-reported tic severity measure, the Parent Tic Questionnaire (PTQ), and used the scale to establish guidelines for delineating clinically significant tic treatment response. Participants were 126 children ages 9 to 17 who participated in a randomized controlled trial of Comprehensive Behavioral Intervention for Tics (CBIT). Tic severity was assessed using the Yale Global Tic Severity Scale (YGTSS), Hopkins Motor/Vocal Tic Scale (HMVTS) and PTQ; positive treatment response was defined by a score of 1 (very much improved) or 2 (much improved) on the Clinical Global Impressions - Improvement (CGI-I) scale. Cronbach's alpha and intraclass correlations (ICC) assessed internal consistency and test-retest reliability, with correlations evaluating validity. Receiver- and Quality-Receiver Operating Characteristic analyses assessed the efficiency of percent and raw-reduction cutoffs associated with positive treatment response. The PTQ demonstrated good internal consistency (α = 0.80 to 0.86), excellent test-retest reliability (ICC = .84 to .89), good convergent validity with the YGTSS and HM/VTS, and good discriminant validity from hyperactive, obsessive-compulsive, and externalizing (i.e., aggression and rule-breaking) symptoms. A 55% reduction and 10-point decrease in PTQ Total score were optimal for defining positive treatment response. Findings help standardize tic assessment and provide clinicians with greater clarity in determining clinically meaningful tic symptom change during treatment.

Premonitory Urge for Tics Scale (PUTS): replication and extension of psychometric properties in youth with chronic tic disorders (CTDs).

Individuals with chronic tic disorders (CTDs) frequently describe aversive subjective sensory sensations that precede their tics. The first aim of the present study was to explore the psychometric properties of a standardized self-report measure to assess premonitory urges in CTDs, The Premonitory Urge for Tics Scale (PUTS), by replicating the analyses of Woods et al. (J Dev Behav Pediatr 26:397-403, 2005) using a sample twice the size of theirs. The second aim was to conduct an exploratory factor analysis of the PUTS. Eighty-four youth with CTDs, recruited from a pediatric OCD and tic specialty clinic, completed the PUTS while their caregivers completed The Parent Tic Questionnaire (PTQ) and a demographic measure. Consistent with (Woods et al. J Dev Behav Pediatr 26:397-403, 2005), the PUTS was found to be internally consistent (α = 0.82) and significantly correlated with overall tic severity as measured by the PTQ (r = 0.24, p < 0.05) as well as the PTQ number (r = 0.34, p < 0.01) and intensity (r = 0.24, p < 0.05) subscales. A factor-analysis of the PUTS revealed a two-factor solution with one factor capturing the quality of premonitory sensations while the other factor assessed the overall intensity of the urges. These results support the use of the PUTS in reliably measuring premonitory urges, particularly in children over the age of 10 years. Additionally, these findings highlight that urges are uniformly reported across gender and age and are more closely associated with number of tics than the frequency or intensity of tics.

Efficacy of parent-delivered behavioral therapy for primary complex motor stereotypies.

AIM: Primary complex motor stereotypies (CMS) are persistent, patterned, repetitive, rhythmic movements in young people with typical development. This study evaluated the efficacy of an instructional DVD as a home-based, parent-administered, behavioral therapy for primary CMS. METHOD: Eighty-one children with primary CMS were enrolled. Primary outcome measures included the Stereotypy Severity Scale (SSS) - Motor and Impairment scores, and Stereotypy Linear Analog Scale (SLAS). Mean CMS onset was 13.4 months (SD 13.1). Eligibility required observed CMS. Psychiatric disorders were not exclusionary and a stable medication regimen was required. Intellectual disability, neurological disorder, autism spectrum disorder, and tics were exclusionary. Initial assessments were completed via REDCap before receipt of the DVD. Fifty-four of the 81 children (34 male, 20 female; mean age 8y 2mo, SD 1.42, range 7-14y) completed assessments at 1, 2, or 3 months after receiving the DVD. RESULTS: Reductions (baseline to last assessment) in SSS Motor, SSS Impairment, and SLAS scores (all p<0.001) represented change ratios of -15%, -24%, and a -20% respectively. Greatest relative treatment benefit was observed by younger children (ages 7-8y), and by 1 month after receipt of DVD, while a parent global assessment scale showed progressive improvement throughout the study. INTERPRETATION: An instructional DVD for parent-delivered behavioral therapy was a safe, effective intervention for primary CMS.

Use of Modified Positive Behavioral Interventions and Supports in a Psychiatric Inpatient Unit for High-Risk Youths.

OBJECTIVE: Despite a call for the reduction and ultimate elimination of the use of seclusion and restraint, research on reduction of these practices in behavioral programs has been limited. This study sought to examine the effectiveness of a modified version of the Positive Behavioral Interventions and Supports (M-PBIS) implemented in a youth psychiatric inpatient unit to reduce use of seclusion and restraint. METHODS: This naturalistic, prospective study covered a four-year period (1,485 admissions). RESULTS: The number of seclusion and restraint events, mean duration of events, and percentage of patients placed in seclusion or restraint were reduced, as was the overall seclusion rate for the unit. Furthermore, there was a significant reduction in the use of pro re nata (PRN) medications for agitation. CONCLUSIONS: These findings suggest that M-PBIS is a promising intervention to use in youth psychiatric inpatient units to reduce seclusion and restraint and PRNs.

Risk Factors for Seclusion and Restraint in a Pediatric Psychiatry Day Hospital.

The use of seclusion and restraints (SR) in acute hospital settings remains a controversial practice. Despite the focus on SR in the psychiatric services literature, data on SR use in pediatric day hospital settings is lacking. A case-control retrospective analysis for children admitted into a pediatric psychiatry day hospital in a 2-year span examined predictors of SR use. Demographic and clinical descriptors were examined in relation to SR events using univariate and multivariate regression models. Significant univariate risk factors for SR use were psychiatric morbidity, history of physical abuse, post-traumatic stress disorder, having any anxiety disorder, and younger age. Knowledge of risk factors for SR use in pediatric psychiatric day hospitals can avert use of SR and lead to improved safety in a trauma-informed care model.

Continuous performance test in pediatric obsessive-compulsive disorder and tic disorders: the role of sustained attention.

OBJECTIVE: Pediatric obsessive-compulsive disorder (OCD) and tic disorders (TD) are often associated with attention-deficit hyperactivity disorder (ADHD). In order to clarify the role of attention and inhibitory control in pediatric OCD and TD, a continuous performance test (CPT) was administered to a cohort of children and adolescents with OCD alone, TD alone, and OCD+TD. METHODS: A clinical cohort of 48 children and adolescents with OCD alone (n=20), TD alone (n=15), or OCD+TD (n=13) was interviewed clinically and administered the Conners Continuous Performance Test II (CPT-II). The Conners CPT-II is a 14-minute normed computerized test consisting of 6 blocks. It taps into attention, inhibitory control, and sustained attention cognitive domains. Key parameters include errors of omission (distractability), commission (inhibitory control), and variable responding over time (sustained attention). Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) criteria were applied in a best-estimate process to diagnose OCD, TD, ADHD, and anxiety disorders. RESULTS: Children with OCD+TD had more errors of omission (p=0.03), and more hit RT block change (p=0.003) and hit SE block change (p=0.02) than subjects with OCD alone and TD alone. These deficits in sustained attention were associated with younger age and hoarding tendencies. A clinical diagnosis of ADHD in the OCD+TD group also determined worse sustained attention. CONCLUSIONS: A deficit in sustained attention, a core marker of ADHD, is also a marker of OCD+TD, compared to OCD alone and TD alone. Biological correlates of sustained attention may serve to uncover the pathophysiology of OCD and TD through genetic and imaging studies.

The Prevalence of Tic Disorders and Clinical Characteristics in Children.

BACKGROUND: Prevalence is a simple statement about the frequency of a disease in the population. For many medical conditions, including Tourette syndrome, there are true cases that have not been previously diagnosed due to problems of access to appropriate clinical services. Therefore, to obtain a trustworthy estimate of prevalence, it is necessary to go beyond cases identified in clinical settings and evaluate community samples. METHOD: We reviewed 11 community surveys in children with Tourette syndrome (TS) published since 2000. We also examined the frequency of co-occurring psychiatric conditions in community samples and large clinically-ascertained samples. RESULTS: Transient tics are relatively common affecting as many as 20% of school-age children. The 11 studies reviewed here offer a wide range of estimates from 2.6 to 38 per 1000 children for TS. Six studies provide estimates in a narrower range from 4.3 to 7.6 per 1000, but the confidence interval around this narrower range remains wide. Six studies provided results on chronic tic disorders ranging from 3 to 50 per 1000 for Chronic Motor Tic Disorder and 2.5 to 9.4 per 1000 for Chronic Vocal Tic Disorder. Community samples and large clinically-ascertained samples consistently show high rates of ADHD, disruptive behavior and anxiety disorders in children with TS. CONCLUSIONS: The wide range of prevalence estimates for TS and chronic tic disorders is likely due to differences in sample size and assessment methods. The best estimate of prevalence for TS in school-age children is likely to fall between 4 and 8 cases per 1000. Clinical assessment of children with chronic tic disorders warrants examination of other problems such as ADHD, disruptive behavior and anxiety.

Factors associated with suicide attempts in female inmates: the hegemony of hopelessness.

In this study factors associated with past suicide attempts in female inmates were examined. Female inmate participants (N = 105) were given structured diagnostic assessments of antisocial and borderline personality disorders and substance dependence, as well as measures of depression, hopelessness, problem-focused coping styles, and reasons for living. There was a high lifetime prevalence of past suicide attempts (38.1%). Suicide attempts were positively associated with personality disorders, hopelessness, depression, childhood physical/emotional abuse, and family history of suicide and mood disorders, and negatively associated with income, reasons for living, and problem-focused coping. Controlling for hopelessness, borderline personality disorder and family history of suicide attempts were the only variables that remained uniquely associated with suicide attempts.

Borderline personality disorder and deliberate self-harm: does experiential avoidance play a role?

The theory that borderline personality disorder (BPD) is associated with experiential avoidance, and that experiential avoidance mediates the association between BPD and deliberate, nonsuicidal self-harm was examined. Female inmate participants (N = 105) were given structured diagnostic assessments of BPD, as well as several measures of experiential avoidance. There was a high lifetime prevalence of past self-harm (47.6%). Higher dimensional scores representing BPD severity were associated with higher self-harm frequency and greater experiential avoidance. Structural equation modeling analyses indicated that experiential avoidance did not mediate the association between BPD and self-harm, although thought suppression was associated with self-harm frequency.