Developmental psychopathology of children and adolescents with Tourette syndrome – impact of ADHD

  • Veit RoessnerEmail author
  • Andreas Becker
  • Tobias Banaschewski
  • Roger D. Freeman
  • Aribert Rothenberger
  • Tourette Syndrome International Database Consortium



In Tourette syndrome (TS) as a neurodevelopmental disorder not only the tics but also the comorbid conditions change with increasing age. ADHD is highly comorbid with TS and usually impairs psychosocial functioning more than the tics. Its impact on further comorbidity during development is important for clinical practice and still a matter of debate.


Aspects of developmental psychopathology considering the impact of ADHD were examined by logistic regression (year wisely) in a cross-sectional sample of children and adolescents (n = 5060) from the TIC database.


In TS+ADHD (compared to TS−ADHD) higher rates of comorbid conditions like OCD, anxiety disorders, CD/ODD and mood disorders were found in children (5–10 years). In adolescents (11–17 years) higher comorbidity rates in TS+ADHD remained only for CD/ODD and mood disorders. Accordingly, for OCD and anxiety disorders there was a steeper year wise increase of these comorbidities in TS−ADHD while it was a similar for CD/ODD and mood disorders in TS−ADHD as well as TS+ADHD.


Children with TS+ADHD have more comorbidities than the TS−ADHD group, whereas in both adolescent groups this did no longer hold for OCD and anxiety disorders. These findings indicate that in TS comorbid ADHD is associated with high rates of externalizing and internalizing problems, whereas TS without ADHD is associated only with internalizing problems in adolescence.


Tourette tic ADHD psychopathology – children adolescents development 


  1. 1.
    American-Psychiatric-Association (1994) Diagnostic and statistical manual of mental disorders. American Psychiatric Association, WashingtonGoogle Scholar
  2. 2.
    American Psychiatric Association (1987) Diagnostic and Statistical Manual of Mental Disorders - DSM-III-R. APA, Washington, DCGoogle Scholar
  3. 3.
    Banaschewski T, Neale BM, Rothenberger A, Roessner V (2007) Comorbidity of ADHD & Tic Disorder – Conceptual and methodological considerations. Eur Child Adolesc Psychiatry 16(Suppl 1):I/5–I/14Google Scholar
  4. 4.
    Bawden HN, Stokes A, Camfield CS, Camfield PR, Salisbury S (1998) Peer relationship problems in children with Tourette’s disorder or diabetes mellitus. J Child Psychol Psychiatry 39:663–668PubMedCrossRefGoogle Scholar
  5. 5.
    Biederman J, Faraone SV, Keenan K (1992) Further evidence for family-genetic risk factors in attention deficit hyperactivity disorder (ADHD): Patterns of comorbidity in probands and relatives in psychiatrically and pediatrically referred samples. Arch Gen Psychiatry 49:728–738PubMedGoogle Scholar
  6. 6.
    Biederman J, Kwon A, Aleardi M, Chouinard VA, Marino T, Cole H, Mick E, Faraone SV (2005) Absence of gender effects on attention deficit hyperactivity disorder: findings in nonreferred subjects. Am J Psychiatry 162:1083–1089PubMedCrossRefGoogle Scholar
  7. 7.
    Bloch MH, Peterson BS, Scahill L (2006) Adulthood outcome of tic and obsessive-compulsive symptom severity in children with Tourette syndrome. Arch Pediatr Adolesc Med 160:65–69PubMedCrossRefGoogle Scholar
  8. 8.
    Bruun RD, Budman CL (1997) The course and prognosis of Tourette syndrome. Neurol Clin 15:291–298PubMedCrossRefGoogle Scholar
  9. 9.
    Bruun RD, Budman CL (2005) The natural history of Gilles de la Tourette Syndrome. In: Kurlan R (ed) Handbook of Tourette’s Syndrome and related tic and behavioral disorders. Marcel Decker, New York, pp 23–38Google 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 59:576–580PubMedGoogle 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 55:59–65PubMedCrossRefGoogle Scholar
  12. 12.
    Burd L, Freeman RD, Klug MG, Kerbeshian J (2005) Tourette Syndrome and learning disabilities. BMC Pediatr 5:34PubMedCrossRefGoogle Scholar
  13. 13.
    Burd L, Kerbeshian PJ, Barth A, Klug MG, Avery PK, Benz B (2001) Long-term follow-up of an epidemiologically defined cohort of patients with Tourette syndrome. J Child Neurol 16:431–437PubMedCrossRefGoogle Scholar
  14. 14.
    Caine ED, McBride MC, Chiverton P, Bamford KA, Rediess S, Shiao J (1988) Tourette’s syndrome in Monroe County school children. Neurology 38:472–475PubMedGoogle Scholar
  15. 15.
    Cardona F, Romano A, Bollea L, Chiarotti F (2004) Psychopathological problems in children affected by tic disorders - study on a large Italian population. Eur Child Adolesc Psychiatry 13:166–171PubMedCrossRefGoogle Scholar
  16. 16.
    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 41:215–223PubMedCrossRefGoogle Scholar
  17. 17.
    Carter AS, Pauls DL, Leckman JF, Cohen DJ (1994) A prospective longitudinal study of Gilles de la Tourette’s syndrome. J Am Acad Child Adolesc Psychiatry 33:377–385PubMedCrossRefGoogle Scholar
  18. 18.
    Casey MB, Cohen M, Schuerholz LJ, Singer HS, Denckla MB (2000) Language-based cognitive functioning in parents of offspring with ADHD comorbid for Tourette syndrome or learning disabilities. Dev Neuropsychol 17:85–110PubMedCrossRefGoogle Scholar
  19. 19.
    Coffey B, Frazier J, Chen S (1992) Comorbidity, Tourette syndrome, and anxiety disorders. In: Chase TN, Friedhoff AJ, Cohen DJ (eds) Advances in neurology, Tourette Syndrome: Genetics, neurobiology, and treatment. Raven, New York, pp 95–104Google Scholar
  20. 20.
    Coffey BJ, Biederman J, Geller DA, Spencer TJ, Kim GS, Bellordre CA, Frazier JA, Cradock K, Magovcevic M (2000) Distinguishing illness severity from tic severity in children and adolescents with Tourette’s disorder. J Am Acad Child Adolesc Psychiatry 39:556–561PubMedCrossRefGoogle Scholar
  21. 21.
    Coffey BJ, Biederman J, Smoller JW, Geller DA, Sarin P, Schwartz S, Kim GS (2000) Anxiety disorders and tic severity in juveniles with Tourette’s disorder. J Am Acad Child Adolesc Psychiatry 39:562–568PubMedCrossRefGoogle Scholar
  22. 22.
    Coffey BJ, Biederman J, Spencer T, Geller D, Faraone S, Bellordre C (2000) Informativeness of structured diagnostic interviews in the identification of Tourette’s disorder in referred youth. J Nerv Ment Disord 188:583–588CrossRefGoogle Scholar
  23. 23.
    Comings BG, Comings DE (1987) A controlled study of Tourette syndrome. V. Depression and mania. Am J Hum Genet 41:804–821PubMedGoogle Scholar
  24. 24.
    Comings DE (1995) Role of genetic factors in depression based on studies of Tourette syndrome and ADHD probands and their relatives. Am J Med Genet 60:111–121PubMedCrossRefGoogle Scholar
  25. 25.
    Comings DE, Comings BG (1990) A controlled family history study of Tourette’s syndrome III, Affective and other disorders. J Clin Psychiatry 51:288–291PubMedGoogle Scholar
  26. 26.
    Comings DE, Comings BG (1987) A controlled study of Tourette syndrome, I-VII. Am J Hum Genet 41:701–866PubMedGoogle Scholar
  27. 27.
    Comings DE, Comings BG (1987b) A controlled study of Tourette syndrome. II. Conduct disorder. Am J Hum Genet 41:742–760Google Scholar
  28. 28.
    Comings DE, Comings BG (1987) A controlled study of Tourette syndrome. III. Phobias and panic attacks. Am J Hum Genet 41:761–781PubMedGoogle Scholar
  29. 29.
    de Groot CM, Janus MD, Bornstein RA (1995) Clinical predictors of psychopathology in children and adolescents with Tourette Syndrome. J Psychiatr Res 29:59–70PubMedCrossRefGoogle Scholar
  30. 30.
    Douglas (1972) VI. Stop, look and listen: The problem of sustained attention and impulse control in hyperactive and normal children. Can J Behav Sci 4:259–282Google Scholar
  31. 31.
    Eapen V, Fox-Hiley P, Banerjee S, Robertson M (2004) Clinical features and associated psychopathology in a Tourette syndrome cohort. Acta Neurol Scand 109:255–260PubMedCrossRefGoogle Scholar
  32. 32.
    Edell-Fisher BH, Motta RW (1990) Tourette syndrome: relation to children’s and parents’ self-concepts. Psychol Rep 66:539–545PubMedCrossRefGoogle Scholar
  33. 33.
    Elwood RW (1993) Clinical discriminations and neuropsychological tests: an appeal to Bayes’ theorem. Clin Neuropsychol 7:224–233CrossRefGoogle Scholar
  34. 34.
    Erenberg G, Cruse RP, Rothner AD (1987) The natural history of Tourette syndrome: A follow-up study. Annals of Neurology 22:383–385PubMedCrossRefGoogle Scholar
  35. 35.
    Erenberg G, Cruse RP, Rothner AD (1986) Tourette syndrome: an analysis of 200 pediatric and adolescent cases. Cleve Clin Q 53:127–131PubMedGoogle Scholar
  36. 36.
    Freeman RD, The Tourette Syndrome International Database Consortium (2007) Answers from a World-wide Clinical Dataset on Tourette Syndrome. Eur Child Adolesc Psychiatry 16(Suppl 1):I/15–I/23Google Scholar
  37. 37.
    Freeman RD, Fast DK, Burd L, Kerbeshian J, Robertson MM, Sandor P (2000) An international perspective on Tourette syndrome: selected findings from 3,500 individuals in 22 countries. Dev Med Child Neurol 42:436–447PubMedCrossRefGoogle Scholar
  38. 38.
    Gadow KD, Nolan EE, Sprafkin J, Schwartz J (2002) Tics and psychiatric comorbidity in children and adolescents. Dev Med Child Neurol 44:330–338PubMedCrossRefGoogle Scholar
  39. 39.
    Gaze C, Kepley HO, Walkup JT (2006) Co-occurring psychiatric disorders in children and adolescents with Tourette syndrome. J Child Neurol 21:657–664PubMedCrossRefGoogle Scholar
  40. 40.
    Hoekstra PJ, Steenhuis MP, Troost PW, Korf J, Kallenberg CG, Minderaa RB (2004) Relative contribution of attention-deficit hyperactivity disorder, obsessive-compulsive disorder, and tic severity to social and behavioral problems in tic disorders. J Dev Behav Pediatr 25:272–279PubMedCrossRefGoogle Scholar
  41. 41.
    Kadesjo B, Gillberg C (2000) Tourette’s disorder: epidemiology and comorbidity in primary school children. J Am Acad Child Adolesc Psychiatry 39:548–555PubMedCrossRefGoogle Scholar
  42. 42.
    Kerbeshian J, Burd L, Klug MG (1995) Comorbid Tourette’s disorder and bipolar disorder: an etiologic perspective. Am J Psychiatry 152:1646–1651PubMedGoogle Scholar
  43. 43.
    Khalifa N, von Knorring AL (2006) Psychopathology in a Swedish population of school children with tic disorders. J Am Acad Child Adolesc Psychiatry 45:1346–1353PubMedCrossRefGoogle Scholar
  44. 44.
    Kirov R, Kinkelbur J, Banaschewski T, Rothenberger A (2007) Sleep patterns in children with attention-deficit/hyperactivity disorder, tic disorder and comorbidity. J Child Psychol Psychiatry 48:561–570PubMedCrossRefGoogle Scholar
  45. 45.
    Kurlan R, Como PG, Miller B, Palumbo D, Deeley C, Andresen EM, Eapen S, McDermott MP (2002) The behavioral spectrum of tic disorders: a community-based study. Neurology 59:414–420PubMedGoogle Scholar
  46. 46.
    Leckman JF (2003) Phenomenology of tics and natural history of tic disorders. Brain Dev 25 Suppl 1:S24–S28PubMedCrossRefGoogle Scholar
  47. 47.
    Leckman JF (2002) Tourette’s syndrome. Lancet 360:1577–1586PubMedCrossRefGoogle Scholar
  48. 48.
    Mahone EM, Cirino PT, Cutting LE, Cerrone PM, Hagelthorn KM, Hiemenz JR, Singer HS, Denckla MB (2002) Validity of the behavior rating inventory of executive function in children with ADHD and/or Tourette syndrome. Arch Clin Neuropsychol 17:643–662PubMedCrossRefGoogle Scholar
  49. 49.
    Milberger S, Biederman J, Faraone S (1997) Pregnancy delivery and infancy complications and ADHD: Issues of gene-environment interactions. Biol Psychiatry 41:65–75PubMedCrossRefGoogle Scholar
  50. 50.
    Moll GH, Heinrich H, Trott GE, Wirth S, Bock N, Rothenberger A (2001) Children with comorbid attention-deficit-hyperactivity disorder and tic disorder: evidence for additive inhibitory deficits within the motor system. Ann Neurol 49:393–396PubMedCrossRefGoogle Scholar
  51. 51.
    Pappert EJ, Goetz CG, Louis ED, Blasucci L, Leurgans S (2003) Objective assessments of longitudinal outcome in Gilles de la Tourette’s syndrome. Neurology 61:936–940PubMedGoogle Scholar
  52. 52.
    Pauls DL, Leckman JF, Cohen DJ (1994) Evidence against a genetic relationship between Tourette’s syndrome and anxiety, depression, panic and phobic disorders. Br J Psychiatry 164:215–221PubMedCrossRefGoogle Scholar
  53. 53.
    Pauls DL, Leckman JF, Cohen DJ (1993) Familial relationship between Gilles de la Tourette’s syndrome, attention deficit disorder, learning disabilities, speech disorders, and stuttering. J Am Acad Child Adolesc Psychiatry 32:1044–1050PubMedCrossRefGoogle Scholar
  54. 54.
    Peterson BS, Pine DS, Cohen P, Brook JS (2001) Prospective, longitudinal study of tic, obsessive-compulsive, and attention-deficit/hyperactivity disorders in an epidemiological sample. J Am Acad Child Adolesc Psychiatry 40:685–695PubMedCrossRefGoogle Scholar
  55. 55.
    Randolph C, Hyde TM, Gold JM, Goldberg TE, Weinberger DR (1993) Tourette’s syndrome in monozygotic twins. Relationship of tic severity to neuropsychological function. Arch Neurol 50:725–728PubMedGoogle Scholar
  56. 56.
    Rasmussen SA, Tsuang MT (1986) Clinical characteristics and family history in DSM-III obsessive-compulsive disorder. Am J Psychiatry 143:317–322PubMedGoogle Scholar
  57. 57.
    Robertson MM (2006) Attention deficit hyperactivity disorder, tics and Tourette’s syndrome: the relationship and treatment implications. A commentary. Eur Child Adolesc Psychiatry 15:1–11PubMedCrossRefGoogle Scholar
  58. 58.
    Robertson MM, Banerjee S, Eapen V (2002) Obsessive compulsive behaviour and depressive symptoms in young people with Tourette syndrome. Eur Child Adolesc Psychiatry 11:261–265PubMedCrossRefGoogle Scholar
  59. 59.
    Robertson MM, Stern JS (2000) Gilles de la Tourette syndrome: symptomatic treatment based on evidence. Eur Child Adolesc Psychiatry 9 Suppl 1:I60–75PubMedCrossRefGoogle Scholar
  60. 60.
    Robertson MM, Trimble MR, Lees AJ (1988) The psychopathology of the Gilles de la Tourette syndrome. A phenomenological analysis. Br J Psychiatry 152:383–390PubMedGoogle Scholar
  61. 61.
    Roessner V, Becker A, Banaschewski T, Rothenberger A (2006) Executive functions in children with chronic tic disorders with/without ADHD: new insights. Eur Child Adolesc Psychiatry 16(Suppl 1):I/36–I/44Google Scholar
  62. 62.
    Roessner V, Becker A, Banaschewski T, Rothenberger A (2007) Psychopathological profile in children with chronic tic disorder and co-existing ADHD: additive Effects. J Abnorm Child Psychol 35:79–85PubMedCrossRefGoogle Scholar
  63. 63.
    Rosenberg LA, Brown J, Singer HS (1995) Behavioral problems and severity of tics. J Clin Psychol 51:760–767PubMedCrossRefGoogle Scholar
  64. 64.
    Rosenberg LA, C. HJ, Singer HS (1984) Relationship of the child behavior checklist to an independent measure of psychopathology. Psychol reps 54:427–430Google Scholar
  65. 65.
    Rothenberger A, Banaschewski T (2006) Tic-Disorders. In: Gillberg C, Harrington R, Steinhausen H-C (eds) A clinician’s handbook of child and adolsecent psychiatry. Cambridge University Press, Cambridge, pp 598–624Google Scholar
  66. 66.
    Saccomani L, Fabiana V, Manuela B, Giambattista R (2005) Tourette syndrome and chronic tics in a sample of children and adolescents. Brain Dev 27:349–352PubMedCrossRefGoogle Scholar
  67. 67.
    Shapiro AK, Shapiro ES, Young JG, Feinberg TE (1988) Gilles de la Tourette Syndrome. Raven Press, New YorkGoogle Scholar
  68. 68.
    Sherman EM, Shepard L, Joschko M, Freeman RD (1998) Sustained attention and impulsivity in children with Tourette syndrome: comorbidity and confounds. J Clin Exp Neuropsychol 20:644–657PubMedCrossRefGoogle Scholar
  69. 69.
    Shin MS, Chung SJ, Hong KE (2001) Comparative study of the behavioral and neuropsychologic characteristics of tic disorder with or without attention-deficit hyperactivity disorder (ADHD). J Child Neurol 16:719–726PubMedGoogle Scholar
  70. 70.
    Singer HS, Rosenberg LA (1989) Development of behavioral and emotional problems in Tourette syndrome. Pediatr Neurol 5:41–44PubMedCrossRefGoogle Scholar
  71. 71.
    Spencer T, Biederman J, Coffey B, Geller D, Faraone S, Wilens T (2001) Tourette disorder and ADHD. Adv Neurol 85:57–77PubMedGoogle Scholar
  72. 72.
    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 39:1037–1044PubMedCrossRefGoogle Scholar
  73. 73.
    Spencer T, Biederman J, Harding M, Wilens T, Faraone S (1995) The relationship between tic disorders and Tourette’s syndrome revisited. J Am Acad Child Adolesc Psychiatry 34:1133–1139PubMedCrossRefGoogle Scholar
  74. 74.
    Spencer T, Biederman M, Coffey B, Geller D, Wilens T, Faraone S (1999) The 4–year course of tic disorders in boys with attention-deficit/hyperactivity disorder. Arch Gen Psychiatry 56:842–847PubMedCrossRefGoogle Scholar
  75. 75.
    Spencer TJ, Biederman J, Faraone S, Mick E, Coffey B, Geller D, Kagan J, Bearman SK, Wilens T (2001) Impact of tic disorders on ADHD outcome across the life cycle: findings from a large group of adults with and without ADHD. Am J Psychiatry 158:611–617PubMedCrossRefGoogle Scholar
  76. 76.
    Stephens RJ, Sandor P (1999) Aggressive behaviour in children with Tourette and comorbid attention-deficit hyperactivity disorder obsessive–compulsive disorder. Can J Psychiatry 44:1036–1042PubMedGoogle Scholar
  77. 77.
    Stokes A, Bawden HN, Camfield PR, Backman JE, Dooley JM (1991) Peer problems in Tourette’s disorder. Pediatrics 87:936–942PubMedGoogle Scholar
  78. 78.
    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 42:98–105PubMedCrossRefGoogle Scholar
  79. 79.
    The Tourette Syndrome Classification Study Group (1993) Definitions and classification of tic disorders. Arch Neurol 50:1013–1016Google Scholar
  80. 80.
    Wilson RS, Garron DC, Tanner CM, Kawans HL (1982) Behavior disturbance in children with Tourette syndrome. Adv Neurol 35:329–333PubMedGoogle Scholar
  81. 81.
    Wilson RS, Garron DC, Tanner CM, Klawans HL (1982) Behavior disturbance in children with Tourette syndrome. In: Friedhoff JJ, Chase TN (eds) Gilles de la Tourette syndrome. Raven Press, New York, pp 329–333Google Scholar
  82. 82.
    Wodrich DL, Benjamin E, Lachar D (1997) Tourette’s syndrome and psychopathology in a child psychiatry setting. J Am Acad Child Adolesc Psychiatry 36:1618–1624PubMedCrossRefGoogle Scholar
  83. 83.
    Yordanova J, Dumais-Huber C, Rothenberger A (1996) Coexistence of tics and hyperactivity in children: no additive effect at the psychophysiological level. Int J Psychophysiol 21:121–133PubMedCrossRefGoogle Scholar
  84. 84.
    Yordanova J, Dumais-Huber C, Rothenberger A, Woerner W (1997) Frontocortical activity in children with comorbidity of tic disorder and attention-deficit hyperactivity disorder. Biol Psychiatry 41:585–594PubMedCrossRefGoogle Scholar

Copyright information

© Steinkopff Verlag Darmstadt 2007

Authors and Affiliations

  • Veit Roessner
    • 1
    Email author
  • Andreas Becker
    • 1
  • Tobias Banaschewski
    • 1
    • 2
  • Roger D. Freeman
    • 3
  • Aribert Rothenberger
    • 1
  • Tourette Syndrome International Database Consortium
  1. 1.Dept. of Child and Adolescent Psychiatry/PsychotherapyUniversity of GoettingenGöttingenGermany
  2. 2.Dept. of Child and Adolescent Psychiatry and PsychotherapyCentral Institute of Mental HealthMannheimGermany
  3. 3.Neuropsychiatry Clinic, BC Children’s HospitalVancouverCanada

Personalised recommendations