Effects of methylphenidate and physiotherapeutic treatment on graphomotor movements in children with ADHD.

In addition to the core symptoms defining ADHD, affected children often experience motor problems; in particular, graphomotor movements including handwriting are affected. However, in clinical settings, there is little emphasis on standardized and objective diagnosing and treatment of those difficulties. The present study investigated for the first time the effects of methylphenidate as well as physiotherapeutic treatment on objectively assessed graphomotor movements compared to a control condition, i.e. parental psychoeducation, in 58 children (mean age: 9.52 ± 1.91 years) newly diagnosed with ADHD in an outpatient clinic for child and adolescent psychiatry. Families were invited to join one of the treatment groups. Before and after 8 weeks of treatment, children performed six different tasks on a digitizing tablet which allowed the objective analysis of three important kinematic parameters of graphomotor movements (fluency, velocity, and pen pressure) in different levels of visual control and automation. Graphomotor movement fluency and velocity improves over time across the groups, especially in tasks with eyes closed. We did not find clear evidence for beneficial effects of methylphenidate or physiotherapeutic treatment on children's overall graphomotor movements suggesting that treatments need to be better tailored towards specific and individual deficits in graphomotor movements.

WISC-IV performance of children with Chronic Tic Disorder, Obsessive-Compulsive Disorder and Attention-Deficit/Hyperactivity Disorder: results from a German clinical study.

BACKGROUND: Chronic Tic Disorder (CTD), Obsessive-Compulsive Disorder (OCD) and Attention-Deficit/Hyperactivity Disorder (ADHD) are complex neuropsychiatric disorders that frequently co-occur. The aim of this study was to examine WISC-IV performance of a clinical cohort of children with CTD, OCD and/or ADHD. METHODS: N = 185 children aged 6 to 17 years from Germany with CTD, OCD and/or ADHD were examined with the WISC-IV that comprises four index scores (VCI: Verbal Comprehension Index, PRI: Perceptual Reasoning Index, WMI: Working Memory Index, PSI: Processing Speed Index) and a Full Scale Intelligence Quotient (FSIQ). WISC-IV profiles of children with CTD-only, OCD-only, ADHD-only, CTD+ADHD, CTD+OCD and CTD+OCD+ADHD were compared with the WISC-IV norm (N = 1650, M = 100 and SD = 15) and among each other. RESULTS: Unpaired t-tests revealed that children with ADHD-only showed significant lower PSI scores, whereas children with CTD-only and OCD-only had significant higher VCI scores as compared to the German WISC-IV norm. One-way ANOVA revealed that children with ADHD-only showed significant lower WMI scores as compared to children with CTD+OCD. CONCLUSIONS: We were able to confirm previous evidence on WISC-IV profiles in ADHD in a German clinical sample and contribute new findings on cognitive performance in children with (non-)comorbid CTD and OCD that have to be seen in light of the study's limitations.

Come together: case specific cross-institutional cooperation of youth welfare services and child and adolescent psychiatry.

BACKGROUND: Due to the increasing rate of children and families who require support from both youth welfare services and from mental health services, a solid cross-institutional cooperation is needed to provide coordinated and integrated help. Studies involving not only qualitative, but also quantitative information from both services regarding not only general, but also case specific views on cross-institutional cooperation and psychosocial needs are lacking. METHODS: Hence, we collected data from n = 96 children and families who received support from youth welfare office (YWO) and child and adolescents psychiatry (CAP) simultaneously. In a longitudinal survey, we assessed the evaluation of case specific cross-institutional cooperation and psychosocial needs by employees of YWO and CAP as well as descriptive data (including psychopathology of children) over a 6-month period. Repeated-measures ANOVAs were conducted to assess the effects of time and institution (YWO/CAP) on employees' evaluation of case specific cross-institutional cooperation and psychosocial needs as well as children's psychopathology. RESULTS: The data showed that generally YWO employees rated the case specific communication better than CAP employees. Furthermore, CAP employees estimated psychosocial needs higher than YWO employees did. The employees' evaluation of total case specific cross-institutional cooperation did not differ between the employees of both institutions; it further did not change over time. The case specific evaluations did not correlate between the case responsible employees of YWO and CAP. CONCLUSION: The data showed satisfaction with the case specific cross-institutional cooperation in general, but meaningful differences in case specific ratings between both institutions indicate the possibility and need for improvement in daily work and cooperation as well as in regulations and contractual agreements. The implementation of more exchange of higher quality and transparency will ensure smoother cross-institutional cooperation. Future research should pursue this topic to convey the need for further improvement in cross-institutional cooperation into decision-making processes and to evaluate the success of innovative projects in this field.

Investigation of previously implicated genetic variants in chronic tic disorders: a transmission disequilibrium test approach.

Genetic studies in Tourette syndrome (TS) are characterized by scattered and poorly replicated findings. We aimed to replicate findings from candidate gene and genome-wide association studies (GWAS). Our cohort included 465 probands with chronic tic disorder (93% TS) and both parents from 412 families (some probands were siblings). We assessed 75 single nucleotide polymorphisms (SNPs) in 465 parent-child trios; 117 additional SNPs in 211 trios; and 4 additional SNPs in 254 trios. We performed SNP and gene-based transmission disequilibrium tests and compared nominally significant SNP results with those from a large independent case-control cohort. After quality control 71 SNPs were available in 371 trios; 112 SNPs in 179 trios; and 3 SNPs in 192 trios. 17 were candidate SNPs implicated in TS and 2 were implicated in obsessive-compulsive disorder (OCD) or autism spectrum disorder (ASD); 142 were tagging SNPs from eight monoamine neurotransmitter-related genes (including dopamine and serotonin); 10 were top SNPs from TS GWAS; and 13 top SNPs from attention-deficit/hyperactivity disorder, OCD, or ASD GWAS. None of the SNPs or genes reached significance after adjustment for multiple testing. We observed nominal significance for the candidate SNPs rs3744161 (TBCD) and rs4565946 (TPH2) and for five tagging SNPs; none of these showed significance in the independent cohort. Also, SLC1A1 in our gene-based analysis and two TS GWAS SNPs showed nominal significance, rs11603305 (intergenic) and rs621942 (PICALM). We found no convincing support for previously implicated genetic polymorphisms. Targeted re-sequencing should fully appreciate the relevance of candidate genes.

Familiality of Co-existing ADHD and Tic Disorders: Evidence from a Large Sibling Study.

BACKGROUND: The association of attention-deficit/hyperactivity disorder (ADHD) and tic disorder (TD) is frequent and clinically important. Very few and inconclusive attempts have been made to clarify if and how the combination of ADHD+TD runs in families. AIM: To determine the first time in a large-scale ADHD sample whether ADHD+TD increases the risk of ADHD+TD in siblings and, also the first time, if this is independent of their psychopathological vulnerability in general. METHODS: The study is based on the International Multicenter ADHD Genetics (IMAGE) study. The present sub-sample of 2815 individuals included ADHD-index patients with co-existing TD (ADHD+TD, n = 262) and without TD (ADHD-TD, n = 947) as well as their 1606 full siblings (n = 358 of the ADHD+TD index patients and n = 1248 of the ADHD-TD index patients). We assessed psychopathological symptoms in index patients and siblings by using the Strength and Difficulties Questionnaire (SDQ) and the parent and teacher Conners' long version Rating Scales (CRS). For disorder classification the Parental Account of Childhood Symptoms (PACS-Interview) was applied in n = 271 children. Odds ratio with the GENMOD procedure (PROCGENMOD) was used to test if the risk for ADHD, TD, and ADHD+TD in siblings was associated with the related index patients' diagnoses. In order to get an estimate for specificity we compared the four groups for general psychopathological symptoms. RESULTS: Co-existing ADHD+TD in index patients increased the risk of both comorbid ADHD+TD and TD in the siblings of these index patients. These effects did not extend to general psychopathology. INTERPRETATION: Co-existence of ADHD+TD may segregate in families. The same holds true for TD (without ADHD). Hence, the segregation of TD (included in both groups) seems to be the determining factor, independent of further behavioral problems. This close relationship between ADHD and TD supports the clinical approach to carefully assess ADHD in any case of TD.

Pre- and perinatal complications in relation to Tourette syndrome and co-occurring obsessive-compulsive disorder and attention-deficit/hyperactivity disorder.

Pre- and perinatal complications have been implicated in the onset and clinical expression of Tourette syndrome albeit with considerable inconsistencies across studies. Also, little is known about their role in co-occurring obsessive-compulsive disorder (OCD) and attention-deficit/hyperactivity disorder (ADHD) in individuals with a tic disorder. Therefore, we aimed to investigate the role of pre- and perinatal complications in relation to the presence and symptom severity of chronic tic disorder and co-occurring OCD and ADHD using data of 1113 participants from the Tourette International Collaborative Genetics study. This study included 586 participants with a chronic tic disorder and 527 unaffected family controls. We controlled for age and sex differences by creating propensity score matched subsamples for both case-control and within-case analyses. We found that premature birth (OR = 1.72) and morning sickness requiring medical attention (OR = 2.57) were associated with the presence of a chronic tic disorder. Also, the total number of pre- and perinatal complications was higher in those with a tic disorder (OR = 1.07). Furthermore, neonatal complications were related to the presence (OR = 1.46) and severity (b = 2.27) of co-occurring OCD and also to ADHD severity (b = 1.09). Delivery complications were only related to co-occurring OCD (OR = 1.49). We conclude that early exposure to adverse situations during pregnancy is related to the presence of chronic tic disorders. Exposure at a later stage, at birth or during the first weeks of life, appears to be associated with co-occurring OCD and ADHD.

German Validation of the Conners 3® Rating Scales for Parents, Teachers, and Children.

Objective: Attention-deficit/hyperactivity disorder (ADHD) rating scales such as the Conners' Rating Scales (CRS) are valuable adjuncts for diagnosis, since they offer parent, teacher, and self-ratings of children susceptible for ADHD. Even though the scales are widely used internationally, cross-cultural comparability has rarely been verified, and culture and language invariance have only been presumed. The Conners 3(®) rating scales are the updated version of the CRS, though hardly any studies report the psychometric properties apart from the results published in the test edition itself. To our knowledge there are no studies on the various adaptations of the Conners 3(®) in other languages. Method: The German translations of the Conners 3(®) were completed by 745 children, 953 parents, and 741 teachers (children's age range: 6­18 years, mean: 11.74 years of age). Exploratory and confirmatory factor analyses on content scale items were conducted to obtain the factor structure for the German version and to replicate the factor structure of the original American models. Cronbach's α was calculated to establish internal consistency. Results: The exploratory analyses for the German model resulted in factor structures globally different from the American model, though confirmatory analyses revealed very good model fi ts with highly satisfying Cronbach's αs. We were able to provide empirical evidence for the subscale Inattention which had only hypothetically been derived by Conners (2008). Conclusions: Even though the exploratory analyses resulted in different factor structures, the confirmatory analyses have such excellent psychometric properties that use of the German adaptation of the Conners 3(®) is justifi ed in international multicenter studies.

[Therapy of tic disorders]. / Therapie der Tic-Störungen.

Tremendous progress has taken place in the last 8 years since the publication of our review on «Therapy of Tic Disorders¼ in the Zeitschrift für Kinder- und Jugendpsychiatrie. Several steps in treatment have been specified. For example, consensus-based indications for treatment have been published, and a detailed manual for a so-called habit-reversal training program has been developed and evaluated. In addition, new treatment options such as aripiprazole and deep-brain stimulation have been implemented. Increasing attention is being given to the disabling consequences of the commonly co-occurring psychiatric conditions known as ADHD or OCD. Nevertheless, there is still much to be learned about the treatment of tic disorders; standardized and sufficiently large drug trials in patients with tic disorders fulfilling evidence-based medicine standards are still scarce. The same is true for direct comparisons of different agents as well as of medication versus behavioral treatment. Finally, the question of how to predict the individual course of tics and how best to deal with the problems of waxing and waning of tics in this context still limits evidence base for treatment decisions. Large clinical experience is still a pre-requisite for making optimal decisions for the treatment of individual patients suffering from a tic disorder.

Relationship of obsessive-compulsive disorder to age-related comorbidity in children and adolescents with Tourette syndrome.

OBJECTIVE: Attention-deficit/hyperactivity disorder (ADHD) and obsessive-compulsive disorder (OCD) are the 2 most frequent psychiatric disorders co-occurring with Tourette syndrome (TS). Both usually cause greater impairment in psychosocial functioning than the tics themselves. In a previous study, we examined the relationship of attention-deficit/hyperactivity disorder to other comorbid conditions in TS. The relationship of OCD to other comorbidities in TS still remains unclear and is the focus of the present study. METHODS: Pearson's χ tests and logistic regressions (year-wise) were used to examine a cross-sectional sample of children and adolescents (n = 5060) diagnosed with TS, taken from the Tourette Syndrome International Database Consortium. We explored the relationship of OCD to other comorbid conditions in TS across different age groups. RESULTS: In children (ages 5-10 y) with TS, higher rates of comorbidities were found in the presence compared with the absence of OCD. Adolescents (ages 11-17 y) with TS + OCD showed higher rates of internalizing (i.e., anxiety and mood) disorders when compared with those with TS - OCD. A year-wise increase of coexisting mood disorders was found for subjects with TS with and without OCD. CONCLUSIONS: Overall, children and adolescents with TS + OCD showed higher rates of comorbid disorders compared with those with TS - OCD. This underlines the necessity for a comprehensive assessment of additional comorbidities even if the 2 disorders (TS + OCD) have already been diagnosed.

Attentional performance in children and adolescents with tic disorder and co-occurring attention-deficit/hyperactivity disorder: new insights from a 2 × 2 factorial design study.

The aim of the present study was to investigate the effect of both tic disorder (TD) and attention-deficit/hyperactivity disorder (ADHD) on attentional functions. N=96 children and adolescents participated in the study, including n=21 subjects with TD, n=23 subjects with ADHD, n=25 subjects with TD+ADHD, and n=27 controls. Attentional performance was tested based on four computerized attention tasks (sustained attention, divided attention, go/nogo and set shifting). The effect of TD as well as ADHD on attentional performance was tested using a 2 × 2 factorial approach. A diagnosis of TD had no negative impact on attentional functions but was associated with improved performance in the set shifting task. By contrast, regardless of a diagnosis of TD, subjects with ADHD were found to perform worse in the sustained attention, divided attention and go/nogo task. No interaction effect between the factors TD and ADHD was revealed for any of the attention measures. Our results add to findings from other areas of research, showing that in subjects with TD and ADHD, ADHD psychopathology is often the main source of impairment, whereas a diagnosis of TD has little or no impact on neuropsychological performance in most cases and even seems to be associated with adaptive mechanisms.