Youths with ADHD with and without tic disorders: Comorbid psychopathology, executive function and social adjustment
Highlights
► We investigated tic disorders and attention deficit/hyperactivity disorder (ADHD). ► We compared psychopathologies, executive functions (EF) and social adjustment. ► The presence of tic disorders in ADHD was associated with more anxiety disorders. ► Tic disorders add no more EF impairments and social difficulties on ADHD.
Introduction
Attention-deficit/hyperactivity disorder (ADHD) is a common developmental neuropsychiatric disorder of childhood, with a world-wide pool prevalence of 5.29% (Polanczyk, de Lima, Horta, Biederman, & Rohde, 2007) and a prevalence rate of 7.5% in the Taiwanese child and adolescent population (Gau, Chong, Chen, & Cheng, 2005). ADHD is characterized by early-onset functionally impairing attention deficits, hyperactivity and impulsivity. Commonly occurring together with ADHD, tic disorder (TD) is also an early-onset neuropsychiatric condition, characterized by episodic motor or/and vocal tics. According to the presentation and course of symptoms, it is further classified into Tourette's disorder, chronic tic disorder, transient tic disorder and tic disorder, not otherwise specified. Tourette's disorder shows persistent motor tics and at least one kind of vocal tics persisting for more than one year, with a symptom-free period less than three consecutive months. Chronic tic disorder, a milder form of Tourette's disorder (Leckman et al., 1998), is defined by either motor and/or vocal tics lasting more than one year. Transient tic disorder is defined as having motor and/or vocal tics with a duration of at least four weeks but less than one year. The prevalence is around 5–23% for all tic disorders (Khalifa and von Knorring, 2003, Kurlan et al., 2001, Wang and Kuo, 2003) and 0.6–3.8% for Tourette's disorder (Hornsey et al., 2001, Khalifa and von Knorring, 2003, Wang and Kuo, 2003).
ADHD and TD commonly co-occur. Children with ADHD have high rate (8–14%) of concurrent TD (Biederman et al., 2005) and around 35–50% of children with TD also meet the diagnosis of ADHD (Freeman, 2007, Kurlan et al., 2002, Wang and Kuo, 2003). The high co-occurrence of these two disorders has raised significant clinical attention (Carter et al., 2000, Erenberg, 2005, Khalifa and von Knorring, 2003, Kurlan et al., 2002, Nijmeijer et al., 2008). Although many studies have tried to clarify the overlap of these two disorders with regard to psychopathological, psychophysiological (Rothenberger et al., 2000, Yordanova et al., 1996, Yordanova et al., 1997) and neuropsychological (Brand et al., 2002, Harris et al., 1995, Roessner et al., 2007a, Sherman et al., 1998, Shin et al., 2001) aspects, the pathophysiological mechanism underlying this comorbidity is still unclear (Roessner, Becker, Banaschewski, & Rothenberger, 2007b).
Nevertheless, the relationship between comorbid psychopathology and social function in the two disorders are rather commonly acknowledged. ADHD, with or without Tourette's disorder, is associated with higher rates of other psychopathology than Tourette's disorder-alone (Brand et al., 2002, Carter et al., 2000, Sukhodolsky et al., 2003). Furthermore, ADHD is associated with disruptive behaviors, but TD (including Tourette's disorder) is with anxious or depressive symptoms (Freeman, 2007, Roessner et al., 2007b, Spencer et al., 2001). Children with Tourette's disorder co-occurring with ADHD present worse psychosocial outcome than with those without (Carter et al., 2000, Spencer et al., 1998). Interestingly, co-occurring Tourette's disorder has little impact on the psychosocial outcomes of children with ADHD (Spencer et al., 1999). Taken together, it seems that ADHD contributes most to the social and behavioral impairments for children with co-occurring ADHD and TD (Robertson, 2006).
In children with ADHD, TD, and ADHD plus TD, the neuropsychological functions, rather than the motor symptoms, contribute most to their functional impairments (Cohen et al., 1992, Dykens et al., 1990). Tourette's disorder is characterized by impairments in visuomotor integration (Schultz et al., 1998), sustained attention (Harris et al., 1995, Sherman et al., 1998, Shucard et al., 1997), inhibition (Channon et al., 2003a, Muller et al., 2003), reaction time and verbal fluency (Schuerholz, Baumgardner, Singer, Reiss, & Denckla, 1996) and real-life problem-solving (Channon, Crawford, Vakili, & Robertson, 2003). Nevertheless, these studies seldom controlled for comorbid conditions (Shin et al., 2001). The deficits are often associated with comorbid ADHD, which typically presents deficits in inhibition, sustained attention, self-control, time perception and other executive functions (Barkley, 1997, Berlin et al., 2003, Coffey et al., 2004, Gau and Shang, 2010, Hwang et al., 2010, Nigg, 2005). Studies accounting for the presence of ADHD often report no differences on general intelligent ability between children with and without TD (Roessner et al., 2007a). In a few studies investigating executive functions, ADHD is suggested to be the main impairing factor on neuropsychological performance for children with concurrent ADHD and Tourette's disorder (Banaschewski, Neale, Rothenberger, & Roessner, 2007). Paradoxically, some studies reported a better performance of children with ADHD co-occurring with Tourette's disorder than those with ADHD alone, indicating plausible protective or compensatory mechanisms (Greimel et al., 2008, Sherman et al., 1998). Studies are required to disentangle the relationship between these two disorders in terms of executive functions.
Most studies to date investigated the relationship between ADHD and Tourette's disorder (and/or chronic tic disorder), but rarely included transient tic disorder. However, transient tic disorder is even more prevalent and commonly associated with ADHD (Khalifa & von Knorring, 2005). In addition, two community-based studies showed that children with tic symptoms had similar psychopathology as those with Tourette's disorder (Gadow et al., 2002, Kurlan et al., 2002). Investigating how TD in general (i.e., including transient tic disorder, chronic tic disorder and Tourette's disorder altogether) has an impact on ADHD better reflects the actual clinical complexity of ADHD and provides more ecologically valid inferences. Therefore, this study aims to compare children and adolescents with ADHD with and without co-occurring TD on aspects of comorbid psychopathology, executive functions and social adjustments. Based on findings reviewed earlier, we hypothesized that (1) for comorbid psychopathology, children and adolescents with ADHD and co-occurring TD (ADHD + TD group) are more likely to have comorbid anxiety disorders than those without TD (ADHD − TD group); furthermore, both ADHD + TD and ADHD − TD groups have more disruptive behaviors than the control group; and (2) the ADHD + TD group has similar or better executive function and social adjustment compared to ADHD − TD group, and both ADHD +/− TD groups have poorer executive and social functions than the control group.
Section snippets
Participants
Participants included three age-, sex- and IQ-matched groups of children and adolescents aged between 8 and 16. The ADHD + TD group included 40 participants diagnosed with both ADHD and TD at the child neurology and child psychiatry clinics of the National Taiwan University Hospital. The ADHD − TD group included 40 participants diagnosed with ADHD alone, at the child psychiatry clinic of the same hospital. The control group included 40 typically developing participants without either TD or ADHD,
Sample characteristics
Table 1 summarizes the demographic characteristics of the ADHD + TD, ADHD − TD and the control groups. The three groups were well matched in terms of chronological age, sex and IQ. There were no group differences in parental age, educational level and occupation for the whole sample and for the subsample with complete SAICA data either (data not shown). There was no significant difference in the number of inattentive symptoms assessed by the CK-SADS-E between the ADHD + TD and ADHD − TD groups, but the
Discussion
This study discovered interesting similarities and differences between ADHD youths with and without co-occurring TD. Consistent with our prediction, ADHD itself was associated with more disruptive behavioral disorders, and co-occurring TD brought in a higher association with anxiety disorders. Neuropsychologically, ADHD youths with or without TD both showed faster movement in 5-choice reaction and poor spatial working memory. Similar to previous reports (Channon et al., 2003a, Roessner et al.,
Conclusions
TD (including transient/chronic tic disorders and Tourette's disorder) does not add additional executive dysfunctions or social adjustment problems to youths with ADHD, yet the presence of TD is associated with higher co-occurrence of anxiety disorders and less interpersonal relationship difficulties at school. The finer differential patterns of comorbidity, executive functions and social adjustment between ADHD youths with and without TD may imply partially divergent developmental
Acknowledgements
This study was supported by grants from National Health Research Institute (NHRI-EX98-9407PC) and National Taiwan University Hospital, Taipei, Taiwan (NTUH96-S558).
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