Practitioner review: Treatments for Tourette syndrome in children and young people: a systematic review

Whittington, Craig; Pennant, Mary; Kendall, Tim; Glazebrook, Cris; Trayner, Penny; Groom, Madeleine J.; Hedderly, Tammy; Heyman, Isobel; Jackson, Georgina M.; Jackson, Stephen; Murphy, Tara; Rickards, Hugh; Robertson, Mary; Stern, Jeremy; Hollis, Chris

Abstract

Background:
Tourette syndrome (TS) and chronic tic disorder (CTD) affect 1–2% of children and young people, but the most effective treatment is unclear. To establish the current evidence base, we conducted a systematic review of interventions for children and young people.

Methods:
Databases were searched from inception to 1 October 2014 for placebo-controlled trials of pharmacological, behavioural, physical or alternative interventions for tics in children and young people with TS or CTD. Certainty in the evidence was assessed with the GRADE approach.

Results:
Forty trials were included [pharmacological (32), behavioural (5), physical (2), dietary (1)]. For tics/global score there was evidence favouring the intervention from four trials of a2-adrenergic receptor agonists [clonidine and guanfacine, standardised mean difference (SMD) = -0.71; 95% CI -1.03, -0.40; N = 164] and two trials of habit reversal training (HRT)/comprehensive behavioural intervention (CBIT) (SMD = -0.64; 95% CI -0.99, -0.29; N = 133). Certainty in the effect estimates was moderate. A post hoc analysis combining oral clonidine/guanfacine trials with a clonidine patch trial continued to demonstrate benefit (SMD = -0.54; 95% CI -0.92, -0.16), but statistical heterogeneity was high. Evidence from four trials suggested that antipsychotic drugs improved tic scores (SMD = -0.74; 95% CI -1.08, -0.40; N = 76), but certainty in the effect estimate was low. The evidence for other interventions was categorised as low or very low quality, or showed no conclusive benefit.

Conclusions:
When medication is considered appropriate for the treatment of tics, the balance of clinical benefits to harm favours a2-adrenergic receptor agonists (clonidine and guanfacine) as first-line agents. Antipsychotics are likely to be useful but carry the risk of harm and so should be reserved for when a2-adrenergic receptor agonists are either ineffective or poorly tolerated. There is evidence that HRT/CBIT is effective, but there is no evidence for HRT/CBIT alone relative to combining medication and HRT/CBIT. There is currently no evidence to suggest that the physical and dietary interventions reviewed are sufficiently effective and safe to be considered as treatments.

Citation

Whittington, C., Pennant, M., Kendall, T., Glazebrook, C., Trayner, P., Groom, M. J., Hedderly, T., Heyman, I., Jackson, G. M., Jackson, S., Murphy, T., Rickards, H., Robertson, M., Stern, J., & Hollis, C. (in press). Practitioner review: Treatments for Tourette syndrome in children and young people: a systematic review. Journal of Child Psychology and Psychiatry, 57(9), 988-1004. https://doi.org/10.1111/jcpp.12556

• Journal Article Type: Article
• Acceptance Date: Jan 22, 2016
• Online Publication Date: May 2, 2016
• Deposit Date: May 3, 2016
• Publicly Available Date: May 3, 2016
• Journal: Journal of Child Psychology and Psychiatry
• Print ISSN: 0021-9630
• Electronic ISSN: 1469-7610
• Publisher: Wiley
• Peer Reviewed: Peer Reviewed
• Volume: 57
• Issue: 9
• Pages: 988-1004
• DOI: https://doi.org/10.1111/jcpp.12556
• Keywords: Paediatrics; Tourette syndrome; therapy; tics
• Public URL: https://nottingham-repository.worktribe.com/output/791762
• Publisher URL: http://onlinelibrary.wiley.com/doi/10.1111/jcpp.12556/abstract
• Additional Information: This is the peer reviewed version of the following article: Whittington, C., Pennant, M., Kendall, T., Glazebrook, C., Trayner, P., Groom, M., Hedderly, T., Heyman, I., Jackson, G., Jackson, S., Murphy, T., Rickards, H., Robertson, M., Stern, J. and Hollis, C. (2016), Practitioner Review: Treatments for Tourette syndrome in children and young people – a systematic review. Journal of Child Psychology and Psychiatry. doi: 10.1111/jcpp.12556, which has been published in final form at: http://onlinelibrary.wiley.com/doi/10.1111/jcpp.12556/epdf. This article may be used for non-commercial purposes in accordance with Wiley Terms and Conditions for Self-Archiving
• Contract Date: May 3, 2016