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PubMed2005

Tic-related school problems: impact on functioning, accommodations, and interventions.

Children with Tourette's syndrome (TS) are statistically overrepresented in special education classes; however, the extent to which tics contribute to such placement is unclear. In this article, the results of a survey of parents or guardians of 71 children and adolescents with TS are described within the broader context of discussing the impact of tics and educational practices. One half of the respondents reported moderate to significant tic-related academic impact, and 48% reported moderate to significant tic-related peer problems. Peer education and in-school counseling were generally not offered nor provided. In the minority of cases where behavioral interventions for tics were reported, contingent aversive consequences were reported to be ineffective or counterproductive, while positive reinforcement for modifying tics reportedly produced some successful results. The identification of research-validated academic accommodations and increased involvement of school psychologists are suggested as necessary and potentially helpful supports for students with TS and their teachers.

Achievement↗
PubMed2005

Habit reversal training for tic disorders in children and adolescents.

Chronic tic disorders, including Tourette's syndrome (TS), affect approximately .5% of children and adolescents. Although strong evidence exists supporting a neurobiological etiology, operant factors may play a role in the maintenance of tic behaviors. Pharmacological approaches remain the most commonly used intervention for chronic tic disorder in children and adults. Nevertheless, the unpredictable efficacy and serious side effects associated with medication along with parental concerns about long-term medication use in children underlie the need for nonpharmacological interventions for tics in this age group. This article reviews the rationale and evidence base for the use of habit reversal training (HRT), a multicomponent behavioral treatment package, as a treatment for childhood tics. Each of the primary treatment components of HRT is described and implementation is illustrated in case report format. A growing body of data suggests that HRT is a well-tolerated and efficacious intervention for tic disorders in this age group.

Adolescent↗
PubMed2000

New-onset tic disorder following acute hemorrhage of an arteriovenous malformation.

The etiology of tic disorder includes idiopathic, postencephalitic, head injury, carbon monoxide poisoning, stroke, and developmental syndromes. We report a case of new-onset complex motor and vocal tics that began after hemorrhage of an arteriovenous malformation located in the left frontal lobe. We have found no reported cases of new-onset tics related to arteriovenous malformations or hemorrhage into the frontal lobes. The patient is a 16-year-old right-hand-dominant boy who presented with generalized tonic-clonic seizures. Evaluation, including magnetic resonance imaging, revealed a left frontal arteriovenous malformation, confirmed by angiogram. Following resection, there was an intraparenchymal hemorrhage of the left frontal lobe with intraventricular hemorrhage, noted most prominently in the left lateral and IIIrd ventricles, and a subdural hematoma caudal to the craniotomy. The postoperative course was complicated by hemiparesis and global aphasia. During recovery, the patient developed what was thought to be a complex partial seizure evidenced by head turning to the right with vocalization and left upper extremity clonic jerks. These were brief and occurred multiple times per day. A trial of carbamazepine was given with no improvement. It was noted that the spells occurred more frequently under stress, as when the patient was frustrated with communication. The diagnosis was changed to complex motor tics and the therapy changed to clonidine. The tics subsequently improved by 80%, although they were still present. We believe the development of complex motor tics due to frontal hemorrhage represents a unique etiology and could complicate postsurgical recovery in similar cases.

Acute Disease↗
PubMed2006

Treatment of children and adolescents with tics and Tourette syndrome.

Tics, patterned movements distinct from stereotypies, myoclonus, and other hyperkinetic movements, are quite common in children, particularly among those with developmental and psychiatric disorders. Thus, tics can indicate the presence of atypical neurodevelopment or broader difficulties with cognition or mood. Tics are also the cardinal feature of Tourette syndrome, a childhood-onset neurobehavioral disorder characterized by a chronic inability to suppress or an urge to perform patterned, repetitive movements. Patients with Tourette syndrome most commonly have, in addition to tics, symptoms of inattention, hyperactivity, obsessiveness, or anxiety. Achieving the most effective treatment of a child with tics is contingent on proper diagnosis of the movement disorder and thorough assessment for other problems, followed by consideration of both nonpharmacologic and pharmacologic interventions for any and all symptoms interfering with the child's function and quality of life. This review focuses primarily on the diagnosis and medical treatment of tics in children and adolescents with Tourette syndrome.

Adolescent↗
PubMed1991

Patient perception of tics and other movement disorders.

To determine the subjective perception patients have of abnormal movements, 170 patients with various hyperkinesias were interviewed with questions directed at the "voluntary" or intentional versus "involuntary" aspects of their symptoms. One hundred and two of 110 patients with non-tic disorders thought that the abnormal movements were entirely involuntary. Forty-one of 60 tic disorder patients stated that all their motor and phonic tics were intentionally produced. Fifteen others had both voluntary and involuntary components, usually with the former predominating. A "voluntary" response could be used to predict the correct diagnostic category (tic versus non-tic) in 8 of 9 patients for whom the referral category was incorrect. These results suggest that a large proportion of the motor and phonic symptoms experienced by tic patients are irresistibly but purposefully executed, more akin to compulsions than to the other "involuntary" hyperkinesias with which they are commonly discussed.

Humans↗
PubMed1992

Adult tics in Gilles de la Tourette's syndrome: description and risk factors.

We studied 58 adults with Gilles de la Tourette's syndrome diagnosed during childhood. Tics persisted in all patients but were moderate/severe in only 24%, compared with 60% at the time of worst function. Coprolalia persisted in 4%, compared with 22% at the time of worst function. For most patients, worst function occurred in adolescence (mode = 13 years). In spite of a high frequency of school and behavioral problems during development, 98% graduated high school and 90% were full-time students or fully employed. Features predictive of mild tic severity in adulthood were mild tics during the patient's worst pre-adulthood function and mild tics during early and late adolescence. Childhood tic severity had no predictive value, and likewise, coprolalia during development did not increase the risk for adult moderate/severe tics.

Adult↗
PubMed2002

Treatment of ADHD in children with tics: a randomized controlled trial.

BACKGROUND: The treatment of children with attention deficit hyperactivity disorder (ADHD) and Tourette syndrome (TS) has been problematic because methylphenidate (MPH)--the most commonly used drug to treat ADHD--has been reported to worsen tics and because clonidine (CLON)--the most commonly prescribed alternative--has unproven efficacy. METHODS: The authors conducted a multicenter, randomized, double-blind clinical trial in which 136 children with ADHD and a chronic tic disorder were randomly administered CLON alone, MPH alone, combined CLON + MPH, or placebo (2 x 2 factorial design). Each subject participated for 16 weeks (weeks 1-4 CLON/placebo dose titration, weeks 5-8 added MPH/placebo dose titration, weeks 9-16 maintenance therapy). RESULTS: Thirty-seven children were administered MPH alone, 34 were administered CLON alone, 33 were administered CLON + MPH, and 32 were administered placebo. For our primary outcome measure of ADHD (Conners Abbreviated Symptom Questionnaire--Teacher), significant improvement occurred for subjects assigned to CLON (p < 0.002) and those assigned to MPH (p < 0.003). Compared with placebo, the greatest benefit occurred with combined CLON + MPH (p < 0.0001). CLON appeared to be most helpful for impulsivity and hyperactivity; MPH appeared to be most helpful for inattention. The proportion of individual subjects reporting a worsening of tics as an adverse effect was no higher in those treated with MPH (20%) than those being administered CLON alone (26%) or placebo (22%). Compared with placebo, measured tic severity lessened in all active treatment groups in the following order: CLON + MPH, CLON alone, MPH alone. Sedation was common with CLON treatment (28% reported moderate or severe sedation), but otherwise the drugs were tolerated well, including absence of any evident cardiac toxicity. CONCLUSIONS: Methylphenidate and clonidine (particularly in combination) are effective for ADHD in children with comorbid tics. Prior recommendations to avoid methylphenidate in these children because of concerns of worsening tics are unsupported by this trial.

Adolescent↗
PubMed2002

Tic disorders in the adolescent.

This chapter addresses the multidimensional nature of tic disorders. The several major dimensions include (1) duration of symptoms (from less than 1 year to lifelong); (2) intensity of symptoms (from mild to severe); (3) frequency of symptoms (from rare to constant); (4) variety of symptoms (from single motor group/single phonic tic to multiple occurrences of both types); (5) complexity of tics (from simple motor/phonic tics to tics involving multiple motor groups or the production of multiple sounds including involuntary phrases); (6) response to treatment (from good to minimal or no response); and (7) comorbid psychiatric disorders (from none to multiple). These dimensions and their relationship to a variety of tic disorder diagnoses are explored.

Adolescent↗
PubMed2002

Bereitschaftspotential in tic disorders: a preliminary observation.

Sensory phenomena in tic disorders such as Tourette's syndrome are known but are substantiated by only a handful of studies. In this preliminary report, we studied premonitory urge, a type of sensory phenomenon in three patients of tic disorders. Bereitschaftspotential, a movement-related cognitive potential indicative of motor preparation, was assessed in these patients. As bereitschaftspotential was observed in all our cases prior to occurrence of tics, it is speculated that tics are not entirely involuntary but are quasi-volitional in nature. Bereitschaftspotential may thus represent a neurophysiological marker of premonitory urge in tic disorders. Implications of exploring the voluntary nature of tics are discussed.

Compulsive Personality Disorder↗
PubMed2004

Colour Doppler echocardiography in children with group A streptococcal infection related tic disorders.

BACKGROUND & OBJECTIVES: A possible relationship has been suggested between tic disorders and streptococcal infections. To understand the complex relationship between streptococcal infections and neuropsychiatric disorders in children the present study was done on colour Doppler echocardiography of patients with possible post-streptococcal tic disorders. METHODS: The patients were 23 children (22 males, 1 female) affected by tic disorders, who at the time of the observation presented (or had presented in the past) signs of streptococcal infections temporally related to the onset or recrudescence of tic disorders. Echocardiographic examination and laboratory tests were performed on these children. RESULTS: In 4 cases a mild mitral insufficiency and in 8 cases a minimal mitral insufficiency was seen, all haemodynamically not significant. Follow up studies (up to 1 yr) showed the consistency and persistence of these findings. Of the 12 patients with echocardiographic abnormalities, 10 displayed very high anti streptolysin O (ASO) titres, 5 showed positive cultures for GAS and 9 had abnormal ESR, even if no significant differences were found in respect to patients with tics and normal echocardiography. INTERPRETATION & CONCLUSION: With the caution due to the design of study and to low number of patients, our data seem to indicate that the pathophysiology of GAS-infection related tic disorders is similar to that SC, at least in some cases.

Child↗
PubMed2005

Olanzapine in Gilles de la Tourette syndrome: beyond tics.

UNLABELLED: Although there only have been a limited number of double-blind, placebo controlled trials, antipsychotics are considered to be effective drugs for the treatment of tics in Gilles de la Tourette syndrome (GTS). Evidence concerning the efficacy of olanzapine and other atypical antipsychotics in the treatment of tics in GTS is growing, but still limited. Little is known about the use of olanzapine in adult GTS patients and about its effect on comorbid behavioural problems. We report on the use of olanzapine in a 25-year old male GTS patient with comorbid obsessive-compulsive behaviours, who was treated with olanzapine. Tic severity was rated using the Yale Global Tic Severity Scale (Y-GTSS). Comorbid obsessive-compulsive symptoms were assessed with the Yale-Brown Obsessive Compulsive Scale (Y-BOCS). Both scales were performed at admission and after 4 weeks of treatment with olanzapine. Treatment with olanzapine (20 mg) resulted not only in a fast reduction of tic severity and frequency, but also in a reduction of obsessive-compulsive behaviours. CONCLUSIONS: This case report further supports the available literature on the use of olanzapine as a therapeutic strategy for tics in GTS and draws attention to its possible use for comorbid behavioural disorders. Further research of antipsychotics in GTS should include measurements of comorbid behavioural symptom clusters.

Adult↗
PubMed1976

Results of a randomized study comparing DTIC with TIC mustard in malignant melanoma.

This prospective randomized Eastern Cooperative Oncology Group (ECOG) study (1071) was designed to compare a new and promising cytotoxic agent TIC Mustard (triazeno imidazole carboxamide mustard, NSC 82196) with DTIC (dimethyl triazeno imidazole carboxamide, NSC 45388) in the treatment of inoperable melanoma. One hundred and seventy-eight patients were randomized to receive either DTIC (150 mg/m2/day X 5) or TIC Mustard (800 mg/m2/day X 5). Of this group 145 patients were evaluable for tumor response at the completion of the study. Objective responses were seen in 15/79 (19.0%) DTIC patients and 4/66 (6.1%) TIC Mustard patients. Adjustment of crude response rates yielded final response rates of 18.2% for DTIC patients and 5.8% for TIC Mustard. These differences were significant at the p less than or equal to .03 level. Median response duration was 15 weeks for the DTIC responders and 4 weeks for the TIC Mustard responders. Responders and nonresponders did not differ significantly in any of the standard prognostic categories. However, responders had a significantly longer median survival (47.5 weeks) compared to that for nonresponders (17.8 weeks). Toxicity was tolerable for either drug and no deaths were ascribed to either. We conclude that TIC Mustard has limited usefulness in the treatment of malignant melanoma and is less effective than DTIC.

Clinical Trials as Topic↗
PubMed1995

Influence of sample pH on the conformational backbone dynamics of a pseudotripeptide (H-Tyr-Tic psi [CH2-NH]Phe-OH) incorporating a reduced peptide bond: an NMR investigation.

In the present paper we investigate the influence of sample pH on the conformational and dynamical properties of the pseudotripeptide H-Tyr-Tic psi [CH2-NH]Phe-OH (TIP[psi]; Tic: 1,2,3,4,-tetrahydroisoquinoline-3-carboxylic acid) using various one- and two-dimensional nmr techniques in conjunction with molecular modeling. Studies were conducted at three different pH levels corresponding to the zwitterionic peptide containing a formal positive charge (pH 3.1), the deprotonated molecule (pH 9.1), and a situation at neutral pH (pH 7.2) involving both protonated and deprotonated states of the reduced peptide bond. Analysis of the one-dimensional1H-nmr spectra reveals that in solution TIP[psi] is in slow dynamic exchange between conformations containing cis and trans configurations of the Tyr-Tic bond. An nmr pH dependence study of the cis:trans ratio indicated that the exchange process was governed by the protonation state of the reduced bone amine. From the nmr data, reduced peptide bond pK alpha values of 6.5 and 7.5 were determined for the cis and trans conformers, respectively. It was concluded that conformations containing a trans Tyr-Tic bond are stabilized at low pH by an intramolecular hydrogen bond between the Tyr carbonyl and the reduced peptide bond protonated amine. This observation was corroborated by molecular mechanics investigations that revealed low energy trans structures compatible with nmr structural data, and furthermore, were consistently characterized by the existence of a strong N+ H ... O = C interaction closing a seven-membered cycle. The dynamics of cis-trans isomerization about the Tyr-Tic peptide bond were probed by nmr exchange experiments. The selective presaturation of exchanging resonances carried out at several temperatures between 50 and 70 degrees C allowed the determination of isomerization rate constants as well as thermodynamic activation parameters. delta G not equal to values were in close agreement with the cis-->trans energy barrier found in X-Pro peptide fragments (approximately 83 kJ/mol). A large entropic barrier determined for the trans-->cis conversion of TIP[psi] (5.7 JK-1 mol-1 at pH 3.1;6.5 J K-1 mol-1 at pH 9.1) is discussed in terms of decreased solvent molecular ordering around the conformers possessing a trans Tyr-Tic bond. Evidence that the neutral form of the reduced peptide bond gains rigidity upon protonation was obtained from relaxation measurements in the rotating frame. T1 rho measurements of several protons in the vicinity of the reduced peptide bond were made as a function of spin-lock field.(ABSTRACT TRUNCATED AT 400 WORDS)

Amino Acid Sequence↗
PubMed2004

Validity of the Telephone Interview for Cognitive Status (TICS) in post-stroke subjects.

BACKGROUND: Cognitive impairment and dementia are very common after stroke. Telephone screening has potential advantages for clinical follow-up and population-based research in this group. We wished to test the validity of the Telephone Interview for Cognitive Status (TICS) for cognitive testing in post-stroke subjects. METHODS: Cognitive function in stroke outpatients was assessed using the R-CAMCOG (a modification of the cognitive part of the Cambridge Examination for Mental Disorders of the Elderly, for use in stroke subjects) along with the TICS and a modified version, the TICSm. The tests were administered in random order. A cut-off point of 33 on the R-CAMCOG was used to define post-stroke dementia. RESULTS: Sixty-four patients with a median age of 72 years were assessed. The Pearson correlation coefficients between the R-CAMCOG and the TICS and TICSm were 0.833 and 0.855 (both p <0.001) respectively. Twenty-four (38%) patients met R-CAMCOG criteria for post-stroke dementia. The area under the ROC curve for both the TICS and TICSm was 0.94. Using a cut-off of 28 or less on the TICS produced a sensitivity of 88% and a specificity of 85% for the diagnosis of post-stroke dementia. For the TICSm a cut-off of 20 or lower produced a sensitivity of 92% and a specificity of 80%. CONCLUSIONS: The TICS and TICSm telephone questionnaires are practicable and valid methods of assessing cognitive function in community outpatients following stroke. Scores of < or =28 and < or =20 respectively carry good sensitivity and specificity for the diagnosis of post-stroke dementia.

Aged↗
PubMedDate not supplied

Menstrual cycle-related fluctuations of tics in Tourette syndrome.

In a survey of 47 women of all ages with Tourette syndrome, 26% had a premenstrual increase in tics (P less than .001) when various hormonal states were examined. An increase in tics at menarche predicted the premenstrual tic exacerbation (P less than .001). In contrast, other hormonally influenced conditions, such as premenstrual syndrome, oral contraceptive use, pregnancy, and menopause were not associated with a change in tic frequency. The finding of an increase in tic frequency during the estrogenic phase of the menstrual cycle provides additional insight into an important control mechanism for tic expression and suggests possible therapeutic options.

Adolescent↗
PubMed2006

Botulinum toxin in the management of laryngeal tics.

SUMMARY: The objective of the study was to demonstrate the utility of botulinum toxin (BTX; Botox: Allergan Pharmaceuticals, Irvine, CA) type A injections for symptom reduction in laryngeal tics. The study consisted of case studies and literature review. Case histories of two patients with laryngeal tics are presented. Treatment was administered using BTX type A injected into the thyroarytenoid muscles using electromyographic guidance or via direct laryngoscopy. Treatment outcomes were measured using clinical rating scales with a range from 0 (no response) to 4 (maximal response). A subjective assessment of reduction in premonitory sensations was recorded. Subject 1 was a 49-year-old female with onset of laryngeal tic (throat clearing) at 46 years. She received six injections over 24 months. The lowest effective dose was 1.25 units bilaterally, producing complete resolution of the tic behavior (peak effect of 4/4) and reduction of the premonitory sensations. The median duration of benefit was 13 weeks. Subject 2 was a 14-year-old male with Gilles de la Tourette syndrome with laryngeal symptoms including throat clearing, barking, and crowing. He received three injections, with the lowest effective dose of 0.625 units bilaterally. He achieved marked reduction (peak effect of 3/4) of the throat clearing, barking, and crowing behaviors. There was also substantial reduction of the premonitory sensations. The median duration of benefit was 10 weeks. The cases presented herein are examples of successful treatment with low-dose BTX type A to reduce the symptoms of laryngeal tics, leading to improved quality of life. These cases add to the relatively small number of similar patients reported in the literature, and support the use of chemical neuromuscular blockade for treatment of laryngeal tic symptoms.

Adolescent↗
PubMedDate not supplied

Rates for tic disorders and obsessive compulsive symptomatology in families of children and adolescents with Gilles de la Tourette syndrome.

The aim of this study was to assess rates for tic disorders and obsessive compulsive psychopathology in families of children and adolescents with Gilles de la Tourette syndrome (TS). Diagnoses were based on the DSM III-R criteria. Obsessive compulsive psychopathology, that did not fulfill the criteria for obsessive compulsive disorder (OCD) was additionally assessed and termed obsessive compulsive symptoms (OCS). The authors hypothesized that comorbid OCD or OCS in TS patients predicts a higher familial loading with obsessive compulsive symptomatology. The study cohort included 87 patients with TS who were evaluated clinically and with the use of a structured psychiatric interview. All available parents (152/174; 87%), several sibs (49/93; 53%) and some second degree relatives (27/659; 4.1%) were also interviewed. For other first and second degree relatives the family history method was used. Familial rates for TS were clearly elevated. Rates for chronic tic disorders (CT) were considerably lower than in previous studies. Additionally, tic disorders not otherwise specified (TDNOS) were diagnosed in a substantial number of first degree (15/267; 5.6%) and second degree relatives (36/659; 5.5%). OCD in parents (4/174; 2.3%) did not occur in an above baseline rate. However, both OCD (14/87; 16.1%) and OCS (15/87; 17.2%) were frequently associated with TS in index patients. Interestingly, 10 of 16 fathers with OCS also had a tic disorder. Obsessive compulsive psychopathology clustered in families. It is concluded that genetic studies in TS could profit from adhering to a conservative diagnostic approach to both tic disorders and OCD. The familial clustering of OCS/OCD in conjunction with the elevated paternal rate for the co-occurrence of tic disorders and OCS might indicate heterogeneity of TS.

Adolescent↗
PubMed2004

Testing the prenatal hormone hypothesis of tic-related disorders: gender identity and gender role behavior.

The hypothesis that prenatal masculinization of the brain increases risk of tic disorders in postnatal life was tested by measuring gender and gender role behavior in 89 children and adults with a clinical diagnosis of Tourette syndrome or obsessive compulsive disorder and 67 healthy, unaffected children and adults. Consistent with this hypothesis, a tic disorder in females was associated with more gender dysphoria, increased masculine play preferences, and a more typically "masculine" pattern of performance on two sex-typed spatial tasks. Males with tic disorders reported increased masculine play preferences, and the strength of these preferences was positively associated with the severity of tic symptoms. In addition, unlike their female counterparts, males with tic disorders showed a relative impairment in mental rotation ability. These behavioral profiles are consistent with those of children who have verifiable elevations in prenatal androgen levels. These findings therefore support the hypothesis that an altered androgen-dependent process of sexual differentiation during prenatal life may contribute to the development of tic-related disorders.

Adolescent↗