Further, in the presence of additional learning difficulties or autism spectrum diagnosis it might be advisable to consult a clinical geneticist as well, as in some cases this high resolution array might reveal a rare genetic aetiology of these heterogeneous disorders. Although the majority of studies indicate that only TS patients with comorbid conditions exhibit cognitive dysfunction on standardised tests, the actual impact of having TS upon social and academic achievement, quality of life and the overall disability burden of the different subgroups of TS requires further study.
For this reason, the prognostic value, and, as a consequence, clinical usefulness of formal neuropsychological testing in children with TS has not been clearly established to date, and most neuropsychometric tools seem appropriate, at present, only in research settings.
However, it is useful to summarise the findings on cognitive performance in different subgroups of children with TS, and to identify tests that hold promise for standardised neuropsychometric assessment.
It should also be noted that no ecologically valid measure of manual speed or dexterity e. Authors suggest that this heightened ability to control inhibition may be a result of tic suppression over time. This finding needs confirmation in subsequent studies. The main negative impact on cognitive performance seems determined by ADHD, independent of the coexisting tic disorder [ ]. This might explain why comorbid ADHD is the main predictor of poorer psychosocial health [ , ] and the main determinant of the burden of disability [ ] in TS patients.
ADHD comorbidity seems to impact on the general intellectual function of children with TS, as the majority of reports suggest that a lower Full-Scale IQ is accounted for by the presence of the comorbidity [ — ]. Specifically, numerical skills [ ] and written language [ ] have been highlighted as prevalent in TS.
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The meaning of these cognitive impairments to predict outcome in children with TS remains inconclusive. It is unclear whether this comorbidity is associated with selective cognitive impairment in children with TS.
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The cognitive profile of OCD appears to be one of the primary executive dysfunctions, mainly affecting response inhibition and cognitive flexibility [ ]. Although memory may be affected as well, these deficits are thought to be secondary to a failure of organisational strategies during encoding [ ]. To conclude, in children who are diagnosed with TS in combination with comorbid ADHD or OCD should undergo neuropsychological evaluation encompassing intellectual function, academic attainments, motor skills, attention, executive function and memory. Neuropsychological tests of certain test-batteries with good psychometric properties for the country in question are suggested from published studies and more ecologically applicable screens.
Tic disorders represent a wide range of tics and co-existing symptoms with a varied and heterogeneous presentation. In our opinion, it is highly advisable to choose instruments that cover the whole age range between infancy and adulthood, so that the time course of symptoms across ages and life stages can adequately be captured.
In most situations, a standard interview with a few additional questionnaires and rating scales are sufficient to guide diagnosis and treatment. However, psychiatric comorbidity occurs in more than three quarters of cases that are referred for specialised care. Further, in a minority of cases a more extensive neurological and psychiatric screen is necessary to differentiate tics from other hyperkinetic disorders and from psychogenic disorders.
Finally, neuropsychological assessment can be useful because of the high concurrence of tics with learning disorders, especially in children who have not yet finished education or professional training. Commercial firms and governmental organisations did not play a role in, or fund, the development of these guidelines. Tammy Hedderly, Jeremy S. Danielle C. Open Access This article is distributed under the terms of the Creative Commons Attribution Noncommercial License which permits any noncommercial use, distribution, and reproduction in any medium, provided the original author s and source are credited.
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National Center for Biotechnology Information , U. Eur Child Adolesc Psychiatry. Published online Mar Cath , 1 Tammy Hedderly , 2 Andrea G. Ludolph , 3 Jeremy S. Munchau , 10 R. Andrea G. Jeremy S.
Author information Copyright and License information Disclaimer. Cath, Email: ln. Corresponding author. This article has been corrected. See Eur Child Adolesc Psychiatry. This article has been cited by other articles in PMC. Keywords: Tics, Tourette, Assessment, Guidelines. Introduction Tics are defined as sudden, rapid, recurrent, non-rhythmic motor movements or vocalizations usually appearing in bouts while waxing and waning in frequency, intensity and kind of tic [ 1 ]. Epidemiology of tics Prevalence TS affects between 0.
Pathogenesis Family studies of TS consistently show a to fold increase in the rates of tics and TS in first degree relatives of TS patients compared to control families, indicating a strong genetic component to be operant in the disease [ 31 — 33 ]. Open in a separate window. Tic disorders ADHD Fragments of normal movements Generally increased motor activity Circumscribed functional muscle groups General motor hyperactivity Suddenly occurring independent of waiting situation Slowly increasing intensified by waiting situation Fixed pattern of quick actions Disorganised, tempo change Badly modulated Badly modulated Uniformly repeated often in bouts Temporally irregular-intermittent changing intensity.
Types of tics Tics can be classified according to: type, complexity, whether they are isolated or multiple, and according to location, number, frequency and duration [ 6 ]. Type Tics can be motor, vocal, sensory or cognitive [ 60 ]. Motor tics Motor tics arise in the voluntary musculature and involve discrete muscles or muscle groups. Phonic or vocal tics Phonic or vocal tics can consist of any noise produced by movement of air through the nose, mouth or pharynx. Cognitive tics These tics have been described in adolescents and adults with TS and seem to occur predominantly in this age group [ 65 — 67 ].
Complexity Tics can be subdivided into simple and complex [ 62 ].
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Isolated or multiple One can have one tic that always originates from the same anatomical location isolated or many tics at multiple locations. Duration Tics are generally brief. Impairment In children and in adults, it is paramount to assess degree of impairment due to tics or comorbid conditions, although as described here above, in DSM-IV-TR [ 4 ] and in future DSM-V [ 49 ], the distress item has been omitted that was obligatory to establish a tic diagnosis in previous classifications.
Work up General evaluation A general evaluation of both children and adults includes assessment of the most debilitating complaints and symptoms, assesses how the symptoms developed and inquires about potential stressors and triggers. Parent- and patient rating scales to support the general evaluation In children, adolescents as well as adults, it is highly advisable to supplement clinical interviewing with screens that rate general psychopathology.
Specific evaluation Clinical interview Age of onset of first tics should be recorded, as well as tic history and course and age at worst tic severity. Assessment of tics A considerable difficulty in assessing and quantifying tics is caused by 1 the spontaneous variations of tics in an individual over time, 2 The large variability in impact of a given level of physical tic severity on an individual or their family and 3 the tendency of patients to suppress their tics, especially when in the office with the clinician. Assessment of comorbid conditions Recommendations are given to assess the most prevalent comorbid conditions, i.
Physical examination A general physical and a specialised neurological examination is mandatory to ensure correct diagnosis and exclude severe or progressive neurological disorders [ ]. Conclusion Tic disorders represent a wide range of tics and co-existing symptoms with a varied and heterogeneous presentation. Conflict of interest Commercial firms and governmental organisations did not play a role in, or fund, the development of these guidelines.
References 1. American Psychiatric association Diagnostic and statistical manual of mental disorder, 4th edn. Olson S. Neuner I, Ludolph A.
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Eur Psychiatry in press [ PubMed ]. VU University Press, Amsterdam, pp — Limited knowledge of Tourette Syndromecauses delay in diagnosis. Deutscher Artzeverlag, Bonn, pp — Thieme, Stuttgart, pp — Postgrad Med. The international prevalence, epidemiology, and clinical phenomenology of Tourette syndrome: a cross-cultural perspective.
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