Review of the evidence for the management of co-morbid Tic disorders in children and adolescents with attention deficit hyperactivity disorder

Attention deficit hyperactivity disorder(ADHD) is the most common neurodevelopmental disorder in children and adolescents, with prevalence ranging between 5% and 12% in the developed countries. Tic disorders(TD) are common co-morbidities in paediatric ADHD patients with or without pharmacotherapy treatment. There has been conflicting evidence of the role of psychostimulants in either precipitating or exacerbating TDs in ADHD patients. We carried out a literature review relating to the management of TDs in children and adolescents with ADHD through a comprehensive search of MEDLINE, EMBASE, CINAHL and Cochrane databases. No quantitative synthesis(meta-analysis) was deemed appropriate. Metaanalysis of controlled trials does not support an association between new onset or worsening of tics and normal doses of psychostimulant use. Supratherapeutic doses of dextroamphetamine have been shown to exacerbate TD. Most tics are mild or moderate and respond to psychoeducation and behavioural management. Level A evidence support the use of alpha adrenergic agonists, including Clonidine and Guanfacine, reuptake noradrenenaline inhibitors(Atomoxetine) and stimulants(Methylphenidate and Dexamphetamines) for the treatment of Tics and comorbid ADHD. Priority should be given to the management of co-morbid Tourette's syndrome(TS) or severely disabling tics in children and adolescents with ADHD. Severe TDs may require antipsychotic treatment. Antipsychotics, especially Aripiprazole, are safe and effective treatment for TS or severe Tics, but they only moderately control the co-occurring ADHD symptomatology. Short vignettes of different common clinical scenarios are presented to help clinicians determine the most appropriate treatment to consider in each patient presenting with ADHD and co-morbid TDs.

Adolescents’ perspectives on a school-based physical activity intervention:A mixed method study

Purpose'. To examine adolescent experiences and perspectives of the GoActive intervention (ISRCTN31583496) using mixed methods processevaluation to determine satisfaction with intervention components and interpret a*dolescents experiences of the intervention process in order toprovide insights for future intervention design.Methods'. Participants (n = 1542;13.2 土 0.4 years, mean 土 SD) provided questionnaire data at baseline (shyness, activity level) and post-intervention(intervention acceptability, satisfaction with components). Between-group differences (boys vs. girls and shy/inactive vs. others) weretested with linear regression models, accounting for school clustering. Data from 16 individual interviews (shy/inactive) and 11 focus groupswith 48 participants (mean = 4;range 2—7) were thematically coded. Qualitative and quantitative data were merged in an integrative mixedmethods convergence matrix, which denoted convergence and dissonance across datasets.Results'. Effect sizes for quantitative results were small and may not represent substantial between-group differences. Boys (vs. girls) preferredclass-based sessions (0 = 0.2, 95% confidence interval (CI): 0.1—0.3);qualitative data suggested that this was because boys preferred competition,which was supported quantitatively (0 = 0.2, 95%CI: 0.1-0.3). Shy/inactive students did not enjoy the competition (0 = -0.3, 95%CI:—0.5 to —0.1). Boys enjoyed trying new activities more (0 = 0.1, 95%CI: 0.1 -0.2);qualitative data indicated a desire to try new activities acrossall subgroups but identified barriers to choosing unfamiliar activities with self-imposed choice restriction leading to boredom. Qualitative datahighlighted critique of mentorship;adolescents liked the idea, but older mentors did not meet expectations.Conclusion. We interpreted adolescent perspectives of intervention components and implementation to provide insights into future complexinterventions aimed at increasing young people's physical activity in school-based settings. The intervention component mentorship was liked inprinciple, but implementation issues undesirably impacted satisfaction;competition was disliked by girls and shy/inactive students. The resultshighlight the importance of considering gender differences in preference of competition and extensive mentorship training.