Comprehensive treatment of three patients with comorbid OCPD and ADHD

Three patients were seen in an outpatient setting with work difficulties involving disorganization and task completion. They were evaluated and found to have significant symptoms of both attention-deficit/hyperactivity disorder, inattentive subtype and obsessive-compulsive personality disorder and were then treated with a creative combined behavioral and medication treatment, which emphasized the use of external aides (eg, paraprofessionals). Significant symptom reduction was observed as a result of this combined intervention.     

Self-regulation and inhibition in comorbid ADHD children: an evaluation of executive functions

The relationship between executive function and comorbid diagnoses in ADHD children is examined. One hundred six children between 7 and 15 years of age are assessed using the Tower of London (TOL), a test of executive function, and the Kiddie Schedule of Affective Disorders and Schizophrenia, Present and Lifetime Version, a diagnostic interview. All children met the diagnostic criteria for ADHD. A majority of the children had comorbid anxiety disorders, mood disorders, or oppositional defiant disorder. Measures on the TOL are total move score, total initiation time, and total rule violations. Age is predictive in all three measures of executive function as assessed by the TOL. Gender is predictive of total initiation time and total rule violations. Comorbid disorders are found to not have significance on executive function as measured by the TOL. This study concludes that comorbid disorders may not affect executive function.     

Timing recalibration in childhood Tourette syndrome associated with persistent pimozide treatment

In this study, we have tested the effects of the dopamine D₂ receptor blocker pimozide on timing performance in patients with Tourette syndrome (TS). Nine children with TS were tested off‐medication and following 3 months of daily treatment with pimozide. Subjects completed a time reproduction and a time production task using supra‐second temporal intervals. We show that pimozide improves motor timing performance by reducing the patients' variability in reproducing the duration of visual stimuli. On the other hand, this medication has no effect on the reproduction accuracy and on both variability and accuracy of the performance on the time production task. Our results suggest that pimozide might have improved motor timing variability as a result of its beneficial side effect on endogenous dopamine levels (i.e., normalization).     

Insights for treatment in Tourette syndrome from fMRI

In a recent American Journal of Psychiatry article, Wang and colleagues used functional MRI (fMRI) to examine cortico-striatal-thalamo-cortical circuitry in Tourette syndrome (TS), advancing the field's investigation of circuit level dysfunction in vivo in individuals with TS. Their results provide insight for interrogating neural mechanisms underlying different treatment methods.     

Prevalence of ADHD and comorbid disorders among elementary school children screened for disruptive behavior

In the context of a school-based prevention of conduct disorder program, 7,231 first- through fourth-grade children were screened for cross-setting disruptive behavior. Frequencies of DSM-III-R psychiatric disorders and patterns of comorbidity were assessed. We also examined the association of psychiatric diagnosis with child and parent characteristics to determine differential risk based on diagnostic subgroups. Attention deficit hyperactivity disorder (ADHD) and oppositional-defiant disorder (ODD) were the most frequent diagnoses. Mood and anxiety disorders were infrequent as single diagnoses. Patterns of comorbidity demonstrated that both externalizing and internalizing disorders commonly cooccurred with ADHD. More severe degrees of psychopathology and psychosocial risk accrued to the subgroup of youths with ADHD plus a comorbid externalizing disorder.This study was supported by grant MN-46584 from the National Institute of Mental Health.     

Examining the impact of distraction on tic suppression in children and adolescents with Tourette syndrome

Tourette syndrome (TS) is characterized by motor and/or vocal tics. Tics are thought to be temporarily suppressible, and it is believed that suppression requires significant attentional resources. The aim of the current study was to examine the impact of an attention-demanding distraction task on tic suppression. A secondary aim was to examine whether performance on that task decreased during concomitant periods of suppression. Nine children with TS, ages 9-15, participated in the study. An alternating treatment design was used to compare three conditions, free-to-tic baseline (BL), reinforced tic suppression (SUP) and reinforced tic suppression plus a distraction task (SUP + DIS). Tic frequencies were significantly higher during BL conditions than both SUP and SUP + DIS conditions, and tic frequencies during SUP and SUP + DIS did not differ. Accuracy on the distraction task decreased during SUP + DIS as compared to BL. Results suggest that contextual distractions may not negatively impact tic frequencies. In addition, accuracy on an attention-demanding task may be impacted if a child is simultaneously suppressing.     

The effects of co‐occurring ADHD symptoms on electrophysiological correlates of cognitive control in young people with Tourette syndrome

Efficient cognitive control is implicated in tic control in young people with Tourette syndrome (TS). Attention‐deficit/hyperactivity disorder (ADHD) frequently co‐occurs with TS and is associated with impaired cognitive control. Young people with TS and ADHD (TS+ADHD) show poorer cognitive control performance than those with TS, but how co‐occurring ADHD affects underlying neural activity is unknown. We investigated this issue by examining behavioural and event‐related potential (ERP) correlates of cognitive control in young people with these conditions. Participants aged 9–17 with TS (n = 17), TS+ADHD (n = 17), ADHD (n = 11), and unaffected controls (n = 20) performed a visual Go/Nogo task during electroencephalography (EEG) recording. Behavioural performance measures (D‐prime, RT, reaction time variability, post‐error slowing) and ERP measures (N2, P3, error‐related negativity (ERN), error positivity (Pe)) were analysed in a 2 (TS‐yes, TS‐no) × 2 (ADHD‐yes, ADHD‐no) factorial analysis to investigate the effects of TS, ADHD, and their interaction. The results of these analyses showed that ADHD was associated with poorer performance and reduced amplitude of all ERPs, reflecting widespread cognitive control impairments. Tourette syndrome was associated with slowed RTs, which might reflect a compensatory slowing of motor output to facilitate tic control. There was no interaction between the TS and ADHD factors for any behavioural or ERP measure, indicating the impairing effects of ADHD on behaviour and electrophysiological markers of cognitive control were present in TS+ADHD and that RT slowing associated with TS was unaffected by co‐occurring ADHD symptoms.     

Inhibition of Return in children with Tourette's syndrome and comorbid forms: A Preliminary Study

Background: This study investigated the nature and functioning of the visual-spatial inhibition of return (IOR) phenomenon in children with “pure” Tourette's syndrome (TS), and those with comorbid forms of TS. Method: Children with TS-only and “TS + comorbid” (TS + ADHD +/- OCD) and matched controls performed the inhibition of return (IOR) task, which involved responding to left and right visual targets appearing on a computer screen that were preceded by congruent or incongruent exogenous visual cues. Results: The TS-only group performed similarly on the IOR task to the controls. When the TS-only group was subdivided into children with mild and severe TS symptoms, a post hoc comparison between the controls and severe TS symptom children revealed that these TS children had a reduced magnitude of IOR for targets appearing in the right visual field. The comparison between the TS + comorbid and controls revealed an atypical IOR pattern for the TS + comorbid group. They displayed a loss of normal facilitatory and inhibitory effects for right visual field targets. Conclusions: The findings suggest abnormalities in attentional “disengage” and “move” mechanisms in TS when directing attention to the right visual field, which may reflect left posterior parietal, superior colliculus, and midbrain pathology.     

Motor excitability is reduced prior to voluntary movements in children and adolescents with Tourette syndrome

Tourette syndrome (TS) is a neuro‐developmental disorder characterized by the occurrence of motor and vocal tics: involuntary, repetitive, stereotyped behaviours that occur with a limited duration, often typically many times in a single day. Previous studies suggest that children and adolescents with TS may undergo compensatory, neuroplastic changes in brain structure and function that help them gain control over their tics. In the current study we used single‐pulse and dual‐site paired‐pulse transcranial magnetic stimulation (TMS), in conjunction with a manual choice reaction time task that induces high levels of inter‐manual conflict, to investigate this conjecture in a group of children and adolescents with TS, but without co‐morbid Attention Deficit Hyperactivity Disorder (ADHD). We found that performance on the behavioural response‐conflict task did not differ between the adolescents with TS and a group of age‐matched typically developing individuals. By contrast, our study demonstrated that cortical excitability, as measured by TMS‐induced motor‐evoked potentials (MEPs), was significantly reduced in the TS group in the period immediately preceding a finger movement. This effect is interpreted as consistent with previous suggestions that the cortical hyper‐excitability that may give rise to tics in TS is actively suppressed by cognitive control mechanisms. Finally, we found no reliable evidence for altered patterns of functional inter‐hemispheric connectivity in TS. These results provide evidence for compensatory brain reorganization that may underlie the increased self‐regulation mechanisms that have been hypothesized to bring about the control of tics during adolescence.     

Treatment of vocal tics in children with Tourette syndrome: investigating the efficacy of habit reversal

Habit reversal was used to treat vocal tics in 5 children with Tourette syndrome. Vocal tics were reduced in 4 of the 5 children, the untreated motor tics did not increase, and treatment was acceptable to the children's parents.     

Inhibition of return in children with Tourette's syndrome and comorbid forms: a preliminary study.

BACKGROUND: This study investigated the nature and functioning of the visual-spatial inhibition of return (IOR) phenomenon in children with "pure" Tourette's syndrome (TS), and those with comorbid forms of TS. METHOD: Children with TS-only and "TS + comorbid" (TS + ADHD +/- OCD) and matched controls performed the inhibition of return (IOR) task, which involved responding to left and right visual targets appearing on a computer screen that were preceded by congruent or incongruent exogenous visual cues. RESULTS: The TS-only group performed similarly on the IOR task to the controls. When the TS-only group was subdivided into children with mild and severe TS symptoms, a post hoc comparison between the controls and severe TS symptom children revealed that these TS children had a reduced magnitude of IOR for targets appearing in the right visual field. The comparison between the TS + comorbid and controls revealed an atypical IOR pattern for the TS + comorbid group. They displayed a loss of normal facilitatory and inhibitory effects for right visual field targets. CONCLUSIONS: The findings suggest abnormalities in attentional "disengage" and "move" mechanisms in TS when directing attention to the right visual field, which may reflect left posterior parietal, superior colliculus, and midbrain pathology.     

A meta-analysis of executive functioning in dyslexia with consideration of the impact of comorbid ADHD

Grapheme coding was examined in French Grade 6 and Grade 8 children and adults who learned English as a second language (L2). In Experiments 1 and 2, three conditions were compared in a letter detection task in L2: (1) simple grapheme (i.e., detect “a” in black); (2) complex language-shared grapheme (i.e., “a” in brain) and (3) complex L2-specific grapheme (i.e., “a” in beach). The data indicated that graphemes in L2 words were functional sub-lexical orthographic units for these L2 learners. Moreover, L2-specific graphemes took longer to process than language-shared complex graphemes. Using the same task, Experiment 3 examined phonological influences by manipulating the cross-language congruency of grapheme-to-phoneme mappings (detect “a” in have [congruent] vs. take [incongruent]). The outcome of this study offers preliminary evidence of graphemic coding during L2 word recognition both at the orthographic and the orthography-to-phonology mapping levels.     

Dilemmas in diagnosis and treatment of Gilles de la Tourette syndrome.

Gilles de la Tourette syndrome (TS) is a neurological disorder which has an inordinate risk of being diagnosed as psychogenic in nature because of commonly shared behavioral symptomes with syndromes of psychological origin. An overview of TS is presented including its history, symptomatology, and treatment of choice. The problems and pitfalls inherent in the diagnostic process which lead to psychogenic misconceptions are discussed. Treatment considerations include the secondary emotional problems and the negative consequences of the medication for TS. The implications for training professionals are discussed, but the essential point is that without an adequate history of the onset of symptoms, the potential for misdiagnosis is dramatically increased.     

Assessing ADHD and comorbid disorders in children: the Child Behavior Checklist and the Devereux Scales of Mental Disorders

Evaluated discriminant validity and clinical utility of selected subscales of the Devereux Scales of Mental Disorders (DSMD; Naglieri, LeBuffe, & Pfeiffer, 1994) and the Child Behavior Checklist (CBCL; Achenbach, 1991a) in 228 children referred to a clinic for the evaluation and treatment of attention deficit hyperactivity disorder (ADHD). The DSMD is a multiaxial behavior rating scale that measures symptomatology for a broad range of child psychopathology as described in the Diagnostic and Statistical Manual of Mental Disorders (3rd ed., rev. [DSM-R-III] and 4th ed. [DSM-IV]; American Psychiatric Association, 1987, 1994). Discriminant function analyses as well as sensitivity, specificity, and predictive power analyses were computed to evaluate the discriminant validity and clinical utility of selected DSMD and CBCL subscales for assessing ADHD, oppositional defiant disorder (ODD), and anxiety disorders. Results indicated that the DSMD compared very favorably with the CBCL in the ability to discriminate between children with ADHD and those without ADHD and between children with comorbid ODD and anxiety disorders and children who did not meet criteria for these disorders. The DSMD Attention subscale may be somewhat better at ruling in ADHD combined subtype (ADHD-C) and ADHD inattentive subtype (ADHD-I) than the CBCL Attention Problems subscale, but the CBCL Attention Problems subscale may have slightly better utility than the DSMD Attention subscale in ruling out these subtypes. Both the CBCL and DSMD were more useful for ruling out than for ruling in ODD and anxiety disorders.     

Evaluation of sensorimotor training in children with ADHD

Reduced ability to regulate motor behavior seems to be an essential aspect of Attention-Deficit Hyperactivity Disorder (ADHD) and may reflect deficits in behavioral response inhibition. In this respect, pragmatic clinical experience over the last two decades, in daily practice, training of motor control has played an important role within multimodal treatment approaches, although an adequate proof of its efficacy is still lacking. Therefore, to examine the efficacy of sensorimotor training, 12 children with ADHD (two groups of six) were treated with both sensorimotor training and (as control) cognitive behavioral training using a within-subject cross-over design. Each treatment had a duration of 4 months (20 sessions), yielding a total of 40 sessions for the completed cross-over design. Results showed that Sensorimotor Training improved sensorimotor coordination slightly, while Cognitive Behavioral Training ameliorated cognitive impulse control. Hyperactivity and anxious-depressive/aggressive behavior were markedly reduced by Sensorimotor Training but not by Cognitive Behavioral Training. In conclusion, a combined treatment may be recommended since compensation and regulation of inhibitory deficits in ADHD come into play within the framework of both kinds of training.