Aggressive symptoms in children with tic disorders

  • Noa Benaroya-MilshteinEmail author
  • Sharona Shmuel-Baruch
  • Alan Apter
  • Avi Valevski
  • Silvana Fenig
  • Tamar Steinberg
Original Contribution


Episodes of explosive anger and aggression are reported in patients with tic disorders and probably contribute to psychosocial stress and low quality of life. The source of these symptoms is controversial. The objective of the study was to study the relationship between tic disorders, their associated comorbidities, and aggressive behavior. The cohort included 47 children and adolescents (age 7–17 years) with Tourette syndrome or other chronic tic disorders attending a tertiary pediatric Tourette clinic. Associated psychopathology was assessed with the Yale Global Tic Severity Scale, Yale Brown Obsessive Compulsive Scale, Conners ADHD Rating Scale, Screen for Child Anxiety-Related Emotional Disorders, and Child Depression Inventory. Aggression was assessed with the Overt Aggression Scale and scores were compared with a group of 32 healthy age- and sex-matched children. There were no significant differences in aggression scores between the children with tic disorders and controls. Verbal aggression was the most prevalent type of aggression, found in 70% of the patients with tic disorders. The level of aggression was not correlated to tic severity. Comorbid attention-deficit hyperactivity disorder and obsessive–compulsive disorder increased the probability of aggressive behavior in patients with tic disorders. On regression analysis, the only significant predictor of aggression was the severity of attention-deficit hyperactivity disorder. This study suggests that there is no difference in aggressive behavior between children with tics without comorbidities and healthy children. It is possible that aggressive behavior in children with tic disorders is predominantly associated with comorbid attention-deficit hyperactivity disorder.


Aggression Tics Tourette syndrome Overt aggression scale ADHD OCD 



The authors thank Gloria Ginzah of the editorial board, Rabin Medical Centre, Belinson Campus, for her invaluable assistance.

Compliance with ethical standards

Conflict of interest

The authors have no financial disclosures or conflicts of interest.


  1. 1.
    Mosby S (2009) Mosby's Medical Dictionary, 8th edn. Elsevier, PhildelphiaGoogle Scholar
  2. 2.
    Carlson GA, Potegal M, Margulies D, Gutkovich Z, Basile J (2009) Rages—what are they and who has them? J Child Adolesc Psychopharmacol 19(3):281–288. Google Scholar
  3. 3.
    Sukhodolsky DG, Scahill L, Zhang H, Peterson BS, King RA, Lombroso PJ, Katsovich L, Findley D, Leckman JF (2003) Disruptive behavior in children with Tourette's syndrome: association with ADHD comorbidity, tic severity, and functional impairment. J Am Acad Child Adolesc Psychiatry 42(1):98–105. Google Scholar
  4. 4.
    Leckman JF (2003) Phenomenology of tics and natural history of tic disorders. Brain Dev 25(Suppl 1):S24–S28Google Scholar
  5. 5.
    Perera H, Abayanayaka C (2012) Management of severe pediatric Tourette syndrome resistant to drug treatment. Case Rep Psychiatry 2012:497160. Google Scholar
  6. 6.
    Ghanizadeh A, Mosallaei S (2009) Psychiatric disorders and behavioral problems in children and adolescents with Tourette syndrome. Brain Dev 31(1):15–19. Google Scholar
  7. 7.
    Lebowitz ER, Motlagh MG, Katsovich L, King RA, Lombroso PJ, Grantz H, Lin H, Bentley MJ, Gilbert DL, Singer HS, Coffey BJ, Kurlan RM, Leckman JF (2012) Tourette syndrome in youth with and without obsessive compulsive disorder and attention deficit hyperactivity disorder. Eur Child Adolesc Psychiatry 21(8):451–457. Google Scholar
  8. 8.
    Pollak Y, Benarroch F, Kanengisser L, Shilon Y, Ben-Pazi H, Shalev RS, Gross-Tsur V (2009) Tourette syndrome-associated psychopathology: roles of comorbid attention-deficit hyperactivity disorder and obsessive-compulsive disorder. J Dev Behav Pediatr 30(5):413–419Google Scholar
  9. 9.
    Budman CL, Bruun RD, Park KS, Lesser M, Olson M (2000) Explosive outbursts in children with Tourette's disorder. J Am Acad Child Adolesc Psychiatry 39(10):1270–1276. Google Scholar
  10. 10.
    Budman CL, Bruun RD, Park KS, Olson ME (1998) Rage attacks in children and adolescents with Tourette's disorder: a pilot study. J Clin Psychiatry 59(11):576–580Google Scholar
  11. 11.
    Budman CL, Rockmore L, Stokes J, Sossin M (2003) Clinical phenomenology of episodic rage in children with Tourette syndrome. J Psychosom Res 55(1):59–65Google Scholar
  12. 12.
    Dehning S, Burger MB, Krause D, Jobst A, Yundina E, Muller N, Meyer S, Zill P, Buchheim A (2015) Tourette syndrome is associated with insecure attachment and higher aggression. Int J Neurosci 125(7):521–525. Google Scholar
  13. 13.
    Freeman RD, Fast DK, Burd L, Kerbeshian J, Robertson MM, Sandor P (2000) An international perspective on Tourette syndrome: selected findings from 3500 individuals in 22 countries. Dev Med Child Neurol 42(7):436–447Google Scholar
  14. 14.
    Santangelo SL, Pauls DL, Goldstein JM, Faraone SV, Tsuang MT, Leckman JF (1994) Tourette's syndrome: what are the influences of gender and comorbid obsessive-compulsive disorder? J Am Acad Child Adolesc Psychiatry 33(6):795–804. Google Scholar
  15. 15.
    Stefl ME (1984) Mental health needs associated with Tourette syndrome. Am J Public Health 74(12):1310–1313Google Scholar
  16. 16.
    Wand RR, Matazow GS, Shady GA, Furer P, Staley D (1993) Tourette syndrome: associated symptoms and most disabling features. Neurosci Biobehav Rev 17(3):271–275Google Scholar
  17. 17.
    Liu S, Zheng L, Zheng X, Zhang X, Yi M, Ma X (2017) The subjective quality of life in young people with Tourette syndrome in China. J Atten Disord 21(5):426–432. Google Scholar
  18. 18.
    Eddy CM, Rizzo R, Gulisano M, Agodi A, Barchitta M, Cali P, Robertson MM, Cavanna AE (2011) Quality of life in young people with Tourette syndrome: a controlled study. J Neurol 258(2):291–301. Google Scholar
  19. 19.
    Cutler D, Murphy T, Gilmour J, Heyman I (2009) The quality of life of young people with Tourette syndrome. Child Care Health Dev 35(4):496–504. Google Scholar
  20. 20.
    Kano Y, Ohta M, Nagai Y, Spector I, Budman C (2008) Rage attacks and aggressive symptoms in Japanese adolescents with Tourette syndrome. CNS Spectr 13(4):325–332Google Scholar
  21. 21.
    Lewin AB, Chang S, McCracken J, McQueen M, Piacentini J (2010) Comparison of clinical features among youth with tic disorders, obsessive-compulsive disorder (OCD), and both conditions. Psychiatry Res 178(2):317–322. Google Scholar
  22. 22.
    Chang HL, Liang HY, Wang HS, Li CS, Ko NC, Hsu YP (2008) Behavioral and emotional problems in adolescents with Tourette syndrome. Chang Gung Med J 31(2):145–152Google Scholar
  23. 23.
    Zhu Y, Leung KM, Liu PZ, Zhou M, Su LY (2006) Comorbid behavioural problems in Tourette's syndrome are positively correlated with the severity of tic symptoms. Aust N Z J Psychiatry 40(1):67–73. Google Scholar
  24. 24.
    Carter AS, O'Donnell DA, Schultz RT, Scahill L, Leckman JF, Pauls DL (2000) Social and emotional adjustment in children affected with Gilles de la Tourette's syndrome: associations with ADHD and family functioning. Attention Deficit Hyperactivity Disorder. J Child Psychol Psychiatry 41(2):215–223Google Scholar
  25. 25.
    Stephens RJ, Sandor P (1999) Aggressive behaviour in children with Tourette syndrome and comorbid attention-deficit hyperactivity disorder and obsessive-compulsive disorder. Can J Psychiatry 44(10):1036–1042. Google Scholar
  26. 26.
    Cavanna AE, Servo S, Monaco F, Robertson MM (2009) The behavioral spectrum of Gilles de la Tourette syndrome. J Neuropsychiatry Clin Neurosci 21(1):13–23. Google Scholar
  27. 27.
    Storch EA, Murphy TK, Geffken GR, Soto O, Sajid M, Allen P, Roberti JW, Killiany EM, Goodman WK (2004) Further psychometric properties of the Tourette's Disorder Scale-Parent Rated version (TODS-PR). Child Psychiatry Hum Dev 35(2):107–120. Google Scholar
  28. 28.
    Leckman JF, Riddle MA, Hardin MT, Ort SI, Swartz KL, Stevenson J, Cohen DJ (1989) The Yale Global Tic Severity Scale: initial testing of a clinician-rated scale of tic severity. J Am Acad Child Adolesc Psychiatry 28(4):566–573. Google Scholar
  29. 29.
    Scahill L, Riddle MA, McSwiggin-Hardin M, Ort SI, King RA, Goodman WK, Cicchetti D, Leckman JF (1997) Children's Yale-Brown Obsessive Compulsive Scale: reliability and validity. J Am Acad Child Adolesc Psychiatry 36(6):844–852. Google Scholar
  30. 30.
    Kovacs M (1981) Rating scales to assess depression in school-aged children. Acta Paedopsychiatr 46(5–6):305–315Google Scholar
  31. 31.
    Kovacs M, Beck AT (1977) An empirical clinical approach towards a definition of childhood depression. In: Schultebrant JG, Raskin A (eds) Depression in Children. Raven Press, New York, pp l–25Google Scholar
  32. 32.
    Steer RA, Ball R, Ranieri WF, Beck AT (1997) Further evidence for the construct validity of the Beck Depression Inventory-II with psychiatric outpatients. Psychol Rep 80(2):443–446Google Scholar
  33. 33.
    Birmaher B, Khetarpal S, Brent D, Cully M, Balach L, Kaufman J, Neer SM (1997) The Screen for child anxiety related emotional disorders (SCARED): scale construction and psychometric characteristics. J Am Acad Child Adolesc Psychiatry 36(4):545–553. Google Scholar
  34. 34.
    Conners CK (1997) Conners Rating Scales—revised: technical manual. Multi-Health Systems, North TonawandaGoogle Scholar
  35. 35.
    Yudofsky SC, Silver JM, Jackson W, Endicott J, Williams D (1986) The Overt Aggression Scale for the objective rating of verbal and physical aggression. Am J Psychiatry 143(1):35–39. Google Scholar
  36. 36.
    Malone RP, Delaney MA, Luebbert JF, Cater J, Campbell M (2000) A double-blind placebo-controlled study of lithium in hospitalized aggressive children and adolescents with conduct disorder. Arch Gen Psychiatry 57(7):649–654Google Scholar
  37. 37.
    Stewart SE, Ceranoglu TA, O'Hanley T, Geller DA (2005) Performance of clinician versus self-report measures to identify obsessive-compulsive disorder in children and adolescents. J Child Adolesc Psychopharmacol 15(6):956–963. Google Scholar
  38. 38.
    Landgren M, Pettersson R, Kjellman B, Gillberg C (1996) ADHD, DAMP and other neurodevelopmental/psychiatric disorders in 6-year-old children: epidemiology and co-morbidity. Dev Med Child Neurol 38(10):891–906Google Scholar
  39. 39.
    Birmaher B, Brent DA, Chiappetta L, Bridge J, Monga S, Baugher M (1999) Psychometric properties of the screen for child anxiety related emotional disorders (SCARED): a replication study. J Am Acad Child Adolesc Psychiatry 38(10):1230–1236. Google Scholar
  40. 40.
    Beck AT, Steer RA, Ball R, Ranieri W, Ranieri WF (1996) Comparison of Beck depression inventories-IA and -II in psychiatric outpatients. J Pers Assess 67(3):588–597Google Scholar
  41. 41.
    Beck AT, Steer RA, Garbin MG (1988) Psychometric properties of the Beck depression inventory; 25 years of evaluation. Clin Psychol Rev 8(1):77–100Google Scholar
  42. 42.
    Budman CL, Rosen M, Shad S (2015) Fits, tantrums, and rages in TS and related disorders. Curr Dev Dis Rep 2(4):273–284. Google Scholar
  43. 43.
    American Psychiatric Association (2013) Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition: DSM-5. American Psychiatric Publishing, ArlingtonGoogle Scholar
  44. 44.
    Lebowitz ER, Vitulano LA, Omer H (2011) Coercive and disruptive behaviors in pediatric obsessive compulsive disorder: a qualitative analysis. Psychiatry 74(4):362–371. Google Scholar
  45. 45.
    Apter A, van Praag HM, Plutchik R, Sevy S, Korn M, Brown SL (1990) Interrelationships among anxiety, aggression, impulsivity, and mood: a serotonergically linked cluster? Psychiatry Res 32(2):191–199Google Scholar
  46. 46.
    Sheppard B, Chavira D, Azzam A, Grados MA, Umana P, Garrido H, Mathews CA (2010) ADHD prevalence and association with hoarding behaviors in childhood-onset OCD. Depress Anxiety 27(7):667–674. Google Scholar
  47. 47.
    Van Ameringen M, Mancini C, Simpson W, Patterson B (2011) Adult attention deficit hyperactivity disorder in an anxiety disorders population. CNS Neurosci Ther 17(4):221–226. Google Scholar
  48. 48.
    Robertson MM (2000) Tourette syndrome, associated conditions and the complexities of treatment. Brain 123(3):425–462. Google Scholar
  49. 49.
    Dykens E, Leckman J, Riddle M, Hardin M, Schwartz S, Cohen D (1990) Intellectual, academic, and adaptive functioning of Tourette syndrome children with and without attention deficit disorder. J Abnorm Child Psychol 18(6):607–615Google Scholar
  50. 50.
    Nolan EE, Sverd J, Gadow KD, Sprafkin J, Ezor SN (1996) Associated psychopathology in children with both ADHD and chronic tic disorder. J Am Acad Child Adolesc Psychiatry 35(12):1622–1630. Google Scholar
  51. 51.
    Pierre CB, Nolan EE, Gadow KD, Sverd J, Sprafkin J (1999) Comparison of internalizing and externalizing symptoms in children with attention-deficit hyperactivity disorder with and without comorbid tic disorder. J Dev Behav Pediatr 20(3):170–176Google Scholar
  52. 52.
    Spencer T, Biederman J, Coffey B, Geller D, Faraone S, Wilens T (2001) Tourette disorder and ADHD. Adv Neurol 85:57–77Google Scholar
  53. 53.
    Spencer T, Biederman J, Harding M, O'Donnell D, Wilens T, Faraone S, Coffey B, Geller D (1998) Disentangling the overlap between Tourette's disorder and ADHD. J Child Psychol Psychiatry 39(7):1037–1044Google Scholar
  54. 54.
    Gillberg C (1998) Neuropsychiatric disorders. Curr Opin Neurol 11(2):109–114Google Scholar
  55. 55.
    Robertson MM, Cavanna AE (2007) The Gilles de la Tourette syndrome: a principal component factor analytic study of a large pedigree. Psychiatr Genet 17(3):143–152. Google Scholar
  56. 56.
    Yordanova J, Heinrich H, Kolev V, Rothenberger A (2006) Increased event-related theta activity as a psychophysiological marker of comorbidity in children with tics and attention-deficit/hyperactivity disorders. Neuroimage32 (2):940–955. doi: 10.1016/j.neuroimage.2006.03.056Google Scholar
  57. 57.
    Apter A, Pauls DL, Bleich A, Zohar AH, Kron S, Ratzoni G, Dycian A, Kotler M, Weizman A, Gadot N et al (1993) An epidemiologic study of Gilles de la Tourette's syndrome in Israel. Arch Gen Psychiatry 50(9):734–738Google Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  1. 1.The Matta and Harry Freund Neuropsychiatric Tourette Clinic, Department of Child and Adolescent PsychiatrySchneider Children’s Medical Center of IsraelPetach TikvaIsrael
  2. 2.Sackler Faculty of MedicineTel Aviv UniversityTel AvivIsrael
  3. 3.Department of PsychologyBar Ilan UniversityRamat GanIsrael
  4. 4.Geha Mental Health CenterPetach TikvaIsrael

Personalised recommendations