Eur Child Adolesc Psychiatry [Suppl 1]
16:I/15–I/23 (2007) DOI 10.1007/s00787-007-1003-7
Roger D. Freeman
Tourette Syndrome
International Database
Consortium
R.D. Freeman, MD, FRCP(C) (&)
Neuropsychiatry Clinic
BC Children’s Hospital
Box 141
Vancouver, BC V6H 3V4, Canada
E-Mail: rfreeman@cw.bc.ca
Active members of the Tourette Syndrome
International Database Consortium (TIC)
are: Henrik Aabech (Norway), Javad
Allaghband-Rad (Iran), Cheston Berlin
(USA), Ruth Bruun (USA), Cathy Budman
(USA), Larry Burd (USA), Francesco Car-
dona (Italy), Francisco Cardoso (Brazil),
Jose Castillo (Brazil), Susan Chien (Brazil),
Sylvain Chouinard (Canada), Yves Dion
(Canada), Jacques Eisenberg (Israel), Nihal
Erfan (Saudi Arabia), Diane Fast (Canada),
John Fayyed (Lebanon), Emilio Fernandez-
Alvarez (Spain), Roger Freeman (Canada),
Ken Gadow (USA), Oscar Gershanik
(Argentina), Michel Gil (Canada), Don
Gilbert (USA), Helga Hannesdottir (Ice-
land), Don Higgins (USA), Piotr Janik
(Poland), Joseph Jankovic (USA), Bjorn
Kadesjo (Sweden), Yukiko Kano (Japan),
Jacob Kerbeshian (USA), Abraham Kessler
(Israel), U Finn Knudsen (Denmark), Anne
Korsgaard (Denmark), Anthony Lang
(Canada), David Lichter (USA), Trygve
Lindback (Norway), Zhisheng Liu (China),
Danielle Lobel (Israel), Alida Magor (Is-
rael), Euripides Miguel (Brazil), Kirsten
Mueller-Vahl (Germany), Kieran O’Connor
(Canada), Jessica Oesterheld (USA), Larry
Pancer (Canada), Hugh Rickards (UK),
Mary Robertson (UK), Veit Roessner
(Germany), Aribert Rothenberger (Ger-
many), Veit Roessner (Germany) Jeffrey
Rubin (Canada), Evzen Ruzicka (Czech
Republic), Kim St. John (Canada), Paul
ORIGINAL CONTRIBUTION
Tic disorders and ADHD: answers
from a world-wide clinical dataset on
Tourette syndrome
j Abstract Background Tourette
syndrome (TS) is a neurodevel-
opmental disorder with frequent
comorbidity with Attention-
deficit-Hyperactivity disorder
(ADHD). The impact of this
association is still a matter of
debate. Method Using the TIC
database containing 6,805 cases,
the clinical differences were
ascertained between subjects with
and without ADHD. Results The
reported prevalence of ADHD in
TS was 55%, within the range of
many other reports. If the pro-
band was diagnosed with ADHD,
a family history of ADHD was
much more likely. ADHD was
associated with earlier diagnosis
of TS and a much higher rate of
anger control problems, sleep
problems, specific learning dis-
ability, OCD, Oppositional-defiant
disorder, mood disorder, social
skill deficits, sexually inappropri-
Sandor (Canada), Anton Scamvougeras
(Canada), Gary Shady (Canada), Miriam
Spinner (Canada), Mara Stamenkovic
(Austria), Jeffrey Sverd (USA), Zsanett
Tarnok (Hungary), Chris Van der Linden
(Belgium), Arja Voutilainen (Finland),
Yanki Yazgan (Turkey), Zheng Yi (China),
Sam Zinner (USA)
ate behaviour, and self-injurious
behaviour. Subjects with seizures
and with Developmental Coordi-
nation Disorder also had high
rates of ADHD. Anxiety disorder,
however, was not more frequent.
Preliminary data suggest that
most behavioural difficulties in
ADHD are associated with the
Combined or Hyperactive-Impul-
sive Subtypes of ADHD. Every
large site (>200 cases) had a
significantly increased rate of
anger control problems in cases
with ADHD. Conclusion Subjects
with TS have high rates of ADHD
and complex associations with
other disorders. Clinically the
findings confirm other research
indicating the importance of
ADHD in understanding the
behavioural problems often asso-
ciated with the diagnosis of TS.
Additional ADHD comorbidity
should be taken into account in
diagnosis, management, and
training.
j Key words comorbidity –
attention-deficit/hyperactivity
disorder – obsessive-compulsive
disorder – oppositional-defiant
disorder – tourette syndrome
ECAP 1003
I/16 European Child & Adolescent Psychiatry, Vol. 16, Supplement 1 (2007)

Steinkopff Verlag 2007
What is the answer? [I was silent.] In that case, what is
the question?
Gertrude Stein [1963]
Background
Tourette syndrome (TS) is a usually complex neuro-
developmental disorder with onset of multiple tics in
childhood and gradual improvement in adolescence
and adult life [21]. Attention-deficit-Hyperactivity
disorder (ADHD) is generally acknowledged to be
common, important clinically, and often comorbid
with Tourette syndrome [4, 34], typically developing
before the onset of tics [31]. A high rate of comor-
bidity in TS was reported in a previous publication
[4]; ADHD was the most common [31], and may not
be due to referral bias alone. The consequences of
ADHD (especially with associated OCD and Specific
Learning Disability) may overshadow tics, whose
effect on impairment is frequently small [10, 36, 37].
As will be seen, the dataset from which the fol-
lowing findings are derived is very suitable for
approaching answers to a few questions, capable of
provoking useful questions about others, and inap-
propriate for others.
The ‘‘TIC’’ database stands for ‘‘Tourette syndrome
International database Consortium.’’ It was founded
in 1996 as the Canadian-American Tourette Syn-
drome database, but soon outgrew its North Ameri-
can origins and now contains data from 27 countries
and 81 sites, 67 of which are actively contributing at
present (see Table 1).
The project originated from a concern by several
clinician-researchers in Western Canada and North
Dakota, about reports with widely different results,
emanating from sites with relatively few cases, each of
which had its own unstated or unknown selection
biases. Since at that time the prevalence of TS was
thought to be quite uncommon (perhaps 1:10,000) it
seemed unreasonable to expect studies to be performed
on the general population; the next best approach
Table 1 Geographical distribution of cases (TOTAL: 6805)
Region n %
Africa 15
Asia 229
Australia 183
Europe 1,888
Middle East 273
North America 4,061
Canada (2,582)
United States (1,479)
South America 156
would be multiple series of consecutive cases from
many sites which could then be compared or aggre-
gated. A secondary goal was to be able to move toward
research projects on small subsets of patients with TS
who satisfied certain criteria: to locate them for more
in-depth research would be difficult or impossible
without collecting a very large series of patients. For
this secondary purpose it would not be necessary to
impose rigorous interrater reliability training and
procedures, because the selection of subsets for
research would incorporate those at a later stage.
We have found that this arrangement, which is
designed to allow sites to submit cases without any
funding or elaborate procedures, has been very suc-
cessful in recruiting a huge dataset, yet it can be
misunderstood. It is essential, in reading the presen-
tation of data that follows in this paper, to realize that
the figures represent clinical reports to a registry by
experienced clinicians, but with undetermined ascer-
tainment and referral biases. This enables us to make
some descriptive statements about clinical samples
with confidence, but others with less. We were not
able to detect diagnostic error, and by agreement we
do not identify specific sites. Nevertheless, if trends or
associations are found within the data from multiple
large sites, greater confidence may be extended to
those findings in clinical cases, and they might be a
stimulus for replication studies using different
methodologies. These findings cannot be extrapolated
to non-referred persons (community samples).
Appropriateness of questions
The questions that may be appropriately asked of this
dataset include:
(1) How common is the ADHD diagnosis in clinical
samples worldwide?
(2) With what other disorders, factors, and patterns
of behaviour is ADHD associated?
(3) Does the subtype of ADHD matter?
(4) Are there significant sex differences?
j ADHD in the literature
The ADHD prevalence in adults is about 4–8% in the
0.2 18–29-year age group [18, 19]. It was found to be
3.4 significantly associated with Intermittent Explosive
2.7
27.7
Disorder, anxiety disorders (29%), mood disorders
4.0 (21%), and impulse control disorders (25%), and in
59.6 general, ADHD is associated with comorbidity
(37.9) [3, 5, 15, 42]. In adolescence and adult life, ADHD
(21.7) symptoms persist in up to 65% [5, 22, 23, 43], but
2.3
the symptom pattern may change. A community
 R.D. Freeman et al.
World-wide clinical dataset
Table 2 Site size
a
Size of site
<50
50–99
100–199
200–299
300–399
‡400
Total
a
Number of cases
study by Kurlan et al. [20] found a rate of ADHD of
38.4% in those with tics. They reviewed previous
studies, which reported a range from 40% to 70% for
concurrent ADHD. Spencer et al. [36–38] showed
that the presence of tics did not influence the course
of ADHD, so that findings in ADHD samples might
be applicable to ADHD in a TS group. Other
researchers have come to the conclusion that TS-
Only cases are close to normal controls in most re-
spects, but that comorbid ADHD is associated with
high rates of psychopathology [6, 8, 9, 11, 13, 14, 17,
20, 30, 33, 35–37, 39, 40].
Methods
j Reporting sites
Of the 80 TIC sites, 34 are termed ‘‘large,’’ having
submitted over 50 cases; 16 have submitted over 100,
and of these eight have submitted over 200 (the
largest is over 700). Table 2 shows the distribution of
cases from these sites.
j Subject selection
The study population consisted of 6,805 cases entered
into the database since its inception. This includes the
3,500 cases reported in the first publication [13]. The
criteria of the Tourette Syndrome Classification Study
Group [41] were utilized, an elaboration of the DSM-
III-R criteria [1]. Each subject’s information was
submitted on a standard single-page form at the time
the patient was first seen, to assure maximum com-
parability of data. DSM-IV criteria [2] were used for
diagnosis of comorbid disorders. Clinicians submit-
ting were physicians (66% psychiatrists, 27% neurol-
ogists, 6% pediatricians, 2% medical geneticists) (See
Table 3). Local procedures were followed for human
subject approval. Each case submitted was reviewed
for errors or inconsistencies before data entry; those
identified as problematic were returned for correction
or e-mail verification was obtained. The results rep-
resent pooled data, except where otherwise stated. It
I/17
Table 3 Specialist distribution of cases
n Specialty n %
46 Neurology 1,839 27.0
19 Pediatrics 371 5.5
8 Psychiatry 4,485 65.9
4 Medical genetics 110 1.6
1 Total 6,805 100.0
3
81
is expected that this will reduce systematic error or
the unknown degree of referral bias at any one site.
Site differences, when significant, can be reported
separately, without identification.
Procedures
The eight very large sites with over 200 cases each
were subjected to separate analysis. This sub-sample
consisted of 3,065 cases. After results were obtained
on the pooled sample, the same procedures were run
on the sub-sample to see whether the trends found
were confirmed.
For the three ADHD Subtypes, only recent data on
153 consecutive cases was available. There were only
11 of the Hyperactive-Impulsive Subtype, thus too
small a number for meaningful analysis. The pre-
liminary comparisons made are therefore between the
Predominantly Inattentive Subtype (N = 64) and the
Combined Subtype (N = 78).
Statistical analysis
Statistical analyses were performed using SPSS (Sta-
tistical Package for the Social Sciences, version 15.0,
SPSS Corp., 2006). Groups were compared using
Pearson’s v2-test for categorical variables with Fish-
er’s Exact Test modification, one-way ANOVA, or
nonparametric correlations where appropriate. Vari-
ables with statistically significant differences between
groups in the bivariate analysis were then entered into
binary logistic regression analyses to control for the
effect of multiple variables. For these analyses, the
probability of F to enter the regression equations was
set at £0.05 and the probability of F to remove was set
at ‡0.10. Because of the very large dataset, differences
of small or trivial magnitude could acquire statistical
significance. The minimum p-value for serious con-
sideration was therefore set at 0.01, not the more
usual 0.05 level, except where specified.
Results
In the following, findings are reported on the total
dataset. Summary data on general characteristics are
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Steinkopff Verlag 2007

Table 4 General characteristics of dataset TS)ADHD (p < 0.001, SD 2.5, 3.2 respectively).
Item n %
Diagnosis was earlier in TS+ADHD: 11.6 years vs.
15.1 years (p < 0.001, SD 7.8 and 11.1). The patient
Females 1,259 18.5 was first seen by the TS specialist at 13 years in
Adopted 120 1.8 TS+ADHD, 17.0 years in TS-ADHD (p < 0.001, SD 8.7
Twins 106 1.6 and 12.1). The delay between tic onset and diagnosis
TS/tic family history 3,624 51.7
Tic severity mild 2,277 33.7
was 5.4 years in TS+ADHD, 7.8 years in TS-ADHD
Tic severity moderate 3,386 50.2 (p < 0.001, SD respectively 7.4 and 9.8 years). Cases
Tic severity severe 1,088 16.1 of the Combined Subtype were seen earlier by
Pre-/perinatal problems 1,102 19.0 reporting clinicians (9.4 years, SD 2.7) than Inatten-
TS-only (no comorbidity) 967 14.2 tive cases (11 years, SD 4.1).
ADHD comorbid 3,783 55.6
OCD comorbid 1,515 22.3
OCB comorbid 2,219 32.6 j Specialist differences
ODD/CD comorbid 840 12.3
LD comorbid 1,494 22.0
Mood disorder comorbid 1,152 16.9
Are there major differences in the rate of ADHD
Anxiety disorder comorbid 1,141 16.8 diagnosed by different specialists? Psychiatrists diag-
PDD comorbid 311 4.6 nose it in 62% of children and 42% of adults; neu-
Mental retardation comorbid 230 3.4 rologists diagnose it in 59% and 35% respectively, and
Anger control problems 1,813 27.6 pediatricians in 55% in children.
Sleep problems 1,182 17.8
Self-injurious behaviour (SIB) 1,006 14.8
Coprophenomena 885 13.0 j Subtypes of ADHD
Stuttering/speech dysfluency 485 7.1
Social skill deficits 1,268 18.6
Inappropriate sexual behaviour 257 4.3
This was not tracked until recently, so these findings
Trichotillomania 179 2.6 are preliminary. Of 153 sequential cases, 11 (7%) fit
Left-handed 349 9.5 the Hyperactive-Impulsive Subtype, 78 (51%) the
Ambidextrous 133 3.6 Combined Subtype, and 56 (37%) the Predominantly
Right-handed 3,186 86.9 Inattentive Subtype.
Child (<18 years) 5,108 75.1
Medication for tics (ever) 3,647 54.2
j Peak tic severity

shown in Table 4. Differences between the TS+ADHD
and TS)ADHD groups are shown in Table 5, which
includes data on TS-Only cases so that the relation-
ship of symptoms to comorbidity is made clear.
Separate analysis of the eight large sites showed no
significant differences in patterns reported. (Details
are available upon request.)
Overall, ADHD was diagnosed in 61% of children
and 39% of adults. The range for large sites was 38–
91%.
j Sex
There were no significant differences in TS+ADHD vs.
TS)ADHD.
Family history
j Family history of tics and OCD
Rates did not differ because of the diagnosis of ADHD
(51% of TS+ADHD had a positive family history of
tics, and 53% in TS)ADHD); for OCD it was 21% in
TS+ADHD, 22% in TS)ADHD.

Male excess in TS was found at every site without

exception (regions vary from 15% to 26% female cases);
j Family history of ADHD
the mean for the full dataset is 19% female, or a 1:4 ratio.
Rates did differ: 34% had a positive family history of
59% of males and 40% of females were diagnosed with
ADHD if the patient had ADHD, but only 13% if he or
comorbid ADHD (55% and 36% in children, respec-
she did not. The Subtype of ADHD made no differ-
tively). There were no significant sex effects between
ence. In 4% bilineal ADHD was ascertained.
the Combined and Inattentive Subtypes.

j Age at onset, diagnosis, and when registered j ADHD comorbidity

These differ when ADHD has been diagnosed: age at Looking at Table 5, all categories are significantly
onset in TS+ADHD is 6.1 years, 6.8 years in increased in the TS+ADHD group on 2 · 2 cross-
 R.D. Freeman et al. I/19
World-wide clinical dataset

Table 5 Between-group
comparisons in 6,805 people with TS+ADHD TS)ADHD TS-only
Tourette syndrome and ADHD
(TS+ADHD) and without ADHD n= 3,783 2,055 967
(TS)ADHD)
N % n % p %

OCD (children) 662 21 308 16 <0.001 n/a

Adults 248 37 297 29 <0.001 n/a
ODD/CD (children) 652 21 87 4 <0.001 n/a
Adults 79 12 22 2 <0.001 n/a
Anxiety disorder 641 17 500 17 n.s. n/a
Mood disorder (children) 445 14 168 8 <0.001 n/a
Adults 232 35 307 30 0.037 n/a
Specific LD (children) 1,034 33 241 12 <0.001 n/a
Adults 145 22 74 7 <0.001 n/a
PDD 207 6 104 3 <0.001 n/a
MR (intellectual disability) 152 4 78 3 0.001 n/a
DCD in children 32 14 13 7 <0.001 n/a
Seizure disorder 51 21 19 9 <0.001 5.4
Sleep (now) (children) 654 22 119 15 <0.001 9.4
Adults 284 18 125 12 =0.001 7.5
Anger (now) (children) 1,148 39 320 16 <0.001 9.0
Adults 201 32 144 14 0.001 7.0
Coprophenomena (children) 408 13 168 8 <0.001 4.1
Adults 149 22 160 16 0.001 11.4
Self-injurious behaviour (children) 447 14 177 9 <0.001 3.5
Adults 180 27 202 20 0.001 6.9
Trichotillomania 115 3 64 2 0.018 1.0
Social skills deficits (children) 800 26 223 11 <0.001 3.9
Adults 129 19 116 11 <0.001 3.5
Stuttering/dysfluency 305 8 180 6 0.001 4.1
Sexually inappropriate behaviour (children) 172 6 39 2 <0.001 1.2
Adults 30 5 16 2 <0.001 0.6
Medication for tics (children) 1,672 54 837 43 <0.001 35
Adults 453 69 685 68 n.s. 71

Attention-deficit/hyperactivity disorder (ADHD)

Obsessive-compulsive disorder (OCD)
Developmental Coordination Disorder (DCD)
Mental retardation (MR)
Oppositional-defiant disorder (ODD)
Conduct disorder (CD)
Pervasive developmental disorder (PDD)
Specific learning disability (LD)
n.s. = not significant

tabulations, except anxiety disorder. TS-associated
‘‘pure’’ ADHD is uncommon, representing only 18%
of those diagnosed. One comorbid disorder was re-
ported in 34%, 2 in 28%, and 3 in 13%.
j Age relationship
Diagnosed ADHD gradually declines from 65% at age
4 through 48% at age 18 to 32% at age 28. Among the
TS+ADHD group, the following significantly decline
with age (percentages are, in order, children below 18,
then adults 18+): Sleep problems (22 fi 18%), anger
control problems (39 fi 32%), specific LD
(33 fi 22%), and ODD/CD (21 fi 12%). The fol-
lowing increase significantly with age: OCD
(21 fi 37%), Mood disorder (14 fi 35%), Anxiety
disorders (16 fi 21%), coprophenomena (13 fi
22%), SIB (14 fi 27%), and Mental Retardation
(3.2 fi 7.8%). PDD rates undergo no significant
changes with age.
Table 6 shows the prevalence and changes from
childhood to adulthood. In children, the most com-
mon categories were LD and OCB in both males and
females. More detailed information about differences
between age categories within childhood can be found
in the companion paper by Roessner et al. [32].
Diagnosed OCD and ODD/CD were less frequent. In
adults, OCD was most frequent in males, closely fol-
lowed by mood disorder and OCB, while in females,
mood disorders were most common, followed closely
by OCB and OCD. The large relative increase in mood
and anxiety disorders in adult females is evident. This
increase is considerably higher than for those in the
TS-ADHD group.
I/20 European Child & Adolescent Psychiatry, Vol. 16, Supplement 1 (2007)

Steinkopff Verlag 2007

Table 6 (a) Changes in prevalence with age in TS+ADHD (b) Changes in PDD: Although differences do not reach statistical
prevalence with age in TS)ADHD significance, rates of PDD were 13% in the
Children Adults Combined Subtype and 5% in the Inattentive
Subtype. About 67% of the PDD group were
Disorder Male Female Male Female also diagnosed with ADHD.
DCD: There are too few adults with this diagnosis
(a)
OCD 21 26 37 39 and too few among the Subtype subset to
OCB 33 35 33 40 report.
Combined OCD+OCB (54) (61) (70) (79)
Mood disorder 14 13 33 41
Anxiety disorder 16 16 18 33
Specific LD 34 28 23 17 Behaviour problems associated with ADHD
ODD/CD 21 21 13 9
(b)
OCD 16 15 28 31 j Anger control problems
OCB 31 32 36 29
Combined OCD+OCB (47) (47) (64) (60) For ADHD Subtypes, there is a predominance of sub-
Mood disorder 9 8 28 34
Anxiety disorder 14 14 20 24 jects in the Combined (33%) vs. Inattentive (15%)
Specific LD 13 9 8 6 Subtypes (p < 0.01). The 39% rate in TS+ADHD
ODD/CD 5 4 2 3 compared with 16% in TS)ADHD is highly significant.

j Comorbidity with OCD
It is of interest that OCD is more common in the
Combined Subtype (21%) than in the Inattentive
Subtype (11%), although this does not reach statistical
significance. For OCB (subclinical obsessive-compul-
sive symptoms), there are no differences between
Subtypes to report. About 60% of cases with OCD had
a diagnosis of ADHD.
j Comorbidity with ODD/CD
Of those diagnosed with ODD or CD, 87% were also
diagnosed with ADHD. The Combined Subtype was
much more frequent (16% vs. 3%) than the Inatten-
tive Subtype (p = 0.02).
j Comorbidity with anxiety disorder
There were no between-subtype differences. There
was no increase in the TS+ADHD group. About 56%
of anxiety disorder cases were diagnosed with ADHD.
j Sleeping problems
These problems are more frequent in the Combined
Subtype (37%) than in the Inattentive Subtype (24%).
About 65% of patients with sleep problems were
diagnosed with ADHD.
j Coprophenomena
ADHD Subtype makes no significant difference.
About 71% of children with coprophenomena have
ADHD, and 48% of adults.
j SIB
Age at onset of SIB in TS+ADHD is 7.4 years (SD 3.9)
compared with 10 years (SD 5.0) in TS)ADHD. In
OCD, by contrast, there is no difference. (These
numbers are still small, only 79 cases from our recent
and incomplete project.) SIB is somewhat increased in
the Combined Subtype (30%) vs. Inattentive (20%),
(p < 0.05). Overall, 62% of SIB cases had ADHD.
j Social skill deficits in children

j Comorbidity with mood disorder There was a significant and substantial increase in
TS+ADHD cases. Deficits were significantly more
There was a significant increase in children and a frequent in the Combined Subtype (47% vs. Pre-
lesser increase in adults. dominantly Inattentive Subtype (19%)) (p < 0.001).
About 78% of children with this problem have ADHD.

j Comorbidity with LD, MR, PDD, and DCD j Sexually inappropriate behaviour

LD: There were no differences between subtypes. There was a significant increase in TS+ADHD. These
MR: There are no between-subtype differences. cases were mostly of the Combined Subtype (7 of 9).
About 66% have ADHD. About 82% of this group have ADHD.
 R.D. Freeman et al.
World-wide clinical dataset
In trichotillomania (TTM), comparison figures are
insignificant in children, and not convincingly dif-
ferent in adults (p < 0.05). However, of seven cases of
TTM among the 153 sub-sample, six were in the
Combined Subtype (p < 0.05). About 64% of this
group have ADHD.
In stuttering (or similar dysfluencies), ADHD
Subtype makes no significant difference. About 63%
of stutterers had ADHD. There is a modest increase in
the TS+ADHD group.
j Handedness
About 87% are right-handed, 10% are left-handed,
and 3% are ambidextrous. In TS+ADHD left-hand-
edness in 207 cases constitutes 11%, while in 142
cases of TS)ADHD 8% are left-handed (p < 0.01).
There were no significant ADHD Subtype differences.
Binary logistic regression with ADHD as the
dependent variable did not identify coprophenomena
as significantly increased in TS+ADHD, when con-
trolling for other factors, despite a significant 2 · 2
correlation. Variables retained in the equation were:
age at onset and diagnosis of tics (earlier), LD, ODD,
child, mood, anger control and social skill problems.
The variance explained was 22% and correct classifi-
cation was 68.0%. Specificity = 93.4%, sensitiv-
ity = 31.8%.
Discussion
The prevalence of ADHD in TS is in line with other
studies [20, 29]. Whether ADHD is in fact an ‘‘entity’’
and whether ADHD Subtypes are valid subcategories
are beyond the scope of this paper [12]. The relative
proportions of the three ADHD Subtypes is consistent
with other studies [26, 27]. The sex proportion (more
common in males) has been replicated here. The ex-
pected shift to more females in the Inattentive Sub-
type was not found. ADHD comorbidity of 82%
compares with 65% in the Goldman et al. [16] report.
The validity of the ADHD diagnosis was given
support in a prospective study of at-risk young chil-
dren with TS parents by McMahon et al. [24]; 29% of
the children developed a tic disorder, and 41% had
ADHD when followed up.
The presence of ADHD is associated with earlier
diagnosis of TS by 3.5 years. This may be assumed to
be due to the often-disruptive character of ADHD-
related symptoms, and seems supported by the earlier
diagnosis in the Combined Subtype than in the Inat-
tentive Subtype, in which it occurs fully 2 years earlier
(delay from onset of tics of 3.3 years vs. 5.3 years).
All comorbid disorders with the exception of
Anxiety Disorder (17% in both groups) were signifi-
I/21
cantly correlated with ADHD (there seems to be no
ready explanation for the latter, but Roessner et al.
[33] could show that emotional problems are present
in both chronic tic disorders and ADHD, while
externalizing behaviour is more closely related to
ADHD). Mennin et al. [25] cited rates of 8–43% in the
literature, and recommended using two or more
anxiety disorder subtypes for further study of the
relationship with ADHD. In particular, anger control
problems, sometimes referred to as ‘‘rage,’’ have been
shown to be related to comorbid ADHD, not to tics
alone [7, 13].
ODD comorbidity here reported to be 19% is low
compared with 40% reported by Goldman et al. [16].
The increase in OCD and mood disorders in adult life is
not unexpected; anxiety disorder also is substantially
increased in females. The decrease in specific LD and
ODD may be a function of subjects being out of school
or adult psychiatrists and neurologists being less
experienced with the diagnosis of these conditions.
Accumulation of additional cases over the next
year should provide sufficient data for more robust
information on ADHD Subtypes and for details of
coprophenomena, SIB and other repetitive behav-
iour.
Limitations
Due to lack of interrater reliability measures or oper-
ational definitions of behavioural categories and pos-
sible recall bias of parents and adult patients, the
findings deserve varying levels of confidence. Robust
findings are of associations with sex and age first seen.
At the time the project was conceived, diagnostic
categories were being used in a somewhat different
way. ADHD was included as a category without
breakdown into Subtypes. Oppositional-Defiant Dis-
order was thought to usually lead to Conduct Disor-
der in adult life, so the two were combined [28].
Anxiety Disorder was not subdivided. These subdi-
visions have now been added, but the additional
information applies to only a subset of the recent
data. Developmental Coordination Disorder as a
diagnostic category was added later.
Medication for tics and for ADHD cannot be ade-
quately addressed in this type of registry with one-
time entry. Comparisons of children and adults may
be confounded by the fact that different specialists
may be seeing children and adults, with different
training and experience.
Tic severity is another variable that has limited
utility in this study, probably because it is typically so
unstable in childhood, anchor points are not estab-
lished, and it is likely to be confounded with aware-
ness of behaviour problems and comorbid disorders.
I/22 European Child & Adolescent Psychiatry, Vol. 16, Supplement 1 (2007)

Steinkopff Verlag 2007

As a registry, the database provides a snapshot Conclusions

view of persons with TS coming to specialist-clini-
cians, at varying ages. The figures cited in this paper
are not lifetime diagnoses. Their absolute levels may
not be dependable, but it is felt that patterns within
the data, despite differences in sensitivity, may be
useful for stimulating further research.
Clinical implications
The diagnosis of ADHD is the most commonly made
of all. It is significantly more likely in males and in
this dataset accounts for much of the sleep and anger
control problems that are often described as charac-
teristic of TS. Disruptive behaviour is more common
in the Combined Subtype. Coprophenomena, when
controlled for other significant variables, are not
associated with ADHD.
The lack of significant difference between psychi-
atrist and neurologist reporting of ADHD at least
indicates comparable levels of awareness, though
relative sensitivity of the diagnostic threshold cannot
be determined from this data. The high comorbidity
rate of ADHD (with the exception of anxiety disor-
ders) is a strong indicator that training in recognition
and management of these syndromes is essential for
all clinicians coming into contact with them. For
example, one-third of TS+ADHD cases were given a
diagnosis of Learning Disability, 26% had social skill
deficits, and 39% presented with problems controlling
anger. All three of these should be seen clinically as
markers for ADHD investigation. Overall, findings
may be seen as providing a strong recommendation
for clinicians to develop, or have available, psycho-
educational as well as psychopharmacologic skills,
and adequate assessment resources.
Reports from clinicians in 27 countries confirm that
ADHD is the most common comorbidity in TS,
approximating 60%. The expected male excess is also
found beyond that already in TS itself. ADHD is itself
comorbid. The reported presence of comorbid ADHD
accounts for most of the sleep, anger control prob-
lems, and SIB that are often reported, other comor-
bidities adding little. However, this study is the first to
report that, when controlled for other factors, ADHD
is not a significant factor for coprophenomena, and
for social skill deficits, ADHD is only one of several
factors. High ODD/CD and LD rates in the TS+ADHD
group corroborate previous reports. The ADHD
Subtype data is preliminary, but as expected is
indicative that the Combined Subtype is associated
with more behavioural problems in the areas of anger
management and social skills, yet not in sleep prob-
lems. Overall, the diagnosis of ADHD is significantly
associated with a wide variety of other diagnoses and
symptoms, only 18% not having further comorbidity.
It is therefore very clear that the recognition and
management of ADHD and related symptoms are
essential features of the overall management of TS
[15]. The world-wide patterns represented here for
the most part confirm previous findings with different
methodologies at single sites.
j Acknowledgements I wish to thank Larry Burd, Ph.D., for his
frequent inspiration, and Boris Kuzeljevic (Statistician/Data Man-
ager, BC Research Institute) for helping with logistic regression
procedures and their interpretation.

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