title: Clinical effectiveness and patient perspectives of different treatment strategies for tics in children and adolescents with Tourette syndrome: a systematic review and qualitative analysis.
abstract: BACKGROUND
  Tourette syndrome (TS) is a neurodevelopmental condition characterised by chronic motor and vocal tics affecting up to 1% of school-age children and young people and is associated with significant distress and psychosocial impairment.
  
  
  OBJECTIVE
  To conduct a systematic review of the benefits and risks of pharmacological, behavioural and physical interventions for tics in children and young people with TS (part 1) and to explore the experience of treatment and services from the perspective of young people with TS and their parents (part 2).
  
  
  METHODS
  For the systematic reviews (parts 1 and 2), mainstream bibliographic databases, The Cochrane Library, education, social care and grey literature databases were searched using subject headings and text words for tic* and Tourette* from database inception to January 2013.
  For part 1, randomised controlled trials and controlled before-and-after studies of pharmacological, behavioural or physical interventions in children or young people (aged < 18 years) with TS or chronic tic disorder were included. Mixed studies and studies in adults were considered as supporting evidence. Risk of bias associated with each study was evaluated using the Cochrane tool. When there was sufficient data, random-effects meta-analysis was used to synthesize the evidence and the quality of evidence for each outcome was assessed using the Grading of Recommendations Assessment, Development and Evaluation approach. For part 2, qualitative studies and survey literature conducted in populations of children/young people with TS or their carers or in health professionals with experience of treating TS were included in the qualitative review. Results were synthesized narratively. In addition, a national parent/carer survey was conducted via the Tourettes Action website. Participants included parents of children and young people with TS aged under 18 years. Participants (young people with TS aged 10-17 years) for the in-depth interviews were recruited via a national survey and specialist Tourettes clinics in the UK.
  
  
  RESULTS
  For part 1, 70 studies were included in the quantitative systematic review. The evidence suggested that for treating tics in children and young people with TS, antipsychotic drugs [standardised mean difference (SMD) -0.74, 95% confidence interval (CI) -1.08 to -0.41; n = 75] and noradrenergic agents [clonidine (Dixarit(®), Boehringer Ingelheim) and guanfacine: SMD -0.72, 95% CI -1.03 to -0.40; n = 164] are effective in the short term. There was little difference among antipsychotics in terms of benefits, but adverse effect profiles do differ. Habit reversal training (HRT)/comprehensive behavioural intervention for tics (CBIT) was also shown to be effective (SMD -0.64, 95% CI -0.99 to -0.29; n = 133). For part 2, 295 parents/carers of children and young people with TS contributed useable survey data. Forty young people with TS participated in in-depth interviews. Four studies were in the qualitative review. Key themes were difficulties in accessing specialist care and behavioural interventions, delay in diagnosis, importance of anxiety and emotional symptoms, lack of provision of information to schools and inadequate information regarding medication and adverse effects.
  
  
  CONCLUSIONS
  The number and quality of clinical trials is low and this downgrades the strength of the evidence and conclusions.
  
  
  CONCLUSIONS
  Antipsychotics, noradrenergic agents and HRT/CBIT are effective in reducing tics in children and young people with TS. The balance of benefits and harms favours the most commonly used medications: risperidone (Risperdal(®), Janssen), clonidine and aripiprazole (Abilify(®), Otsuka). Larger and better-conducted trials addressing important clinical uncertainties are required. Further research is needed into widening access to behavioural interventions through use of technology including mobile applications ('apps') and video consultation.
  
  
  BACKGROUND
  This study is registered as PROSPERO CRD42012002059.
  
  
  BACKGROUND
  The National Institute for Health Research Health Technology Assessment programme.
authors.affiliation: Division of Psychiatry and Applied Psychology, Institute of Mental Health, University of Nottingham Innovation Park, University of Nottingham, Nottingham, UK.
authors.forename: Chris
authors.initials: C
authors.lastname: Hollis
authors.affiliation: National Collaborating Centre for Mental Health, Royal College of Psychiatrists, London, UK.
authors.forename: Mary
authors.initials: M
authors.lastname: Pennant
authors.affiliation: Division of Psychiatry and Applied Psychology, Institute of Mental Health, University of Nottingham Innovation Park, University of Nottingham, Nottingham, UK.
authors.forename: José
authors.initials: J
authors.lastname: Cuenca
authors.affiliation: Division of Psychiatry and Applied Psychology, Institute of Mental Health, University of Nottingham Innovation Park, University of Nottingham, Nottingham, UK.
authors.forename: Cris
authors.initials: C
authors.lastname: Glazebrook
authors.affiliation: National Collaborating Centre for Mental Health, Royal College of Psychiatrists, London, UK.
authors.forename: Tim
authors.initials: T
authors.lastname: Kendall
authors.affiliation: National Collaborating Centre for Mental Health, Royal College of Psychiatrists, London, UK.
authors.forename: Craig
authors.initials: C
authors.lastname: Whittington
authors.affiliation: National Collaborating Centre for Mental Health, Royal College of Psychiatrists, London, UK.
authors.forename: Sarah
authors.initials: S
authors.lastname: Stockton
authors.affiliation: National Collaborating Centre for Mental Health, Royal College of Psychiatrists, London, UK.
authors.forename: Linnéa
authors.initials: L
authors.lastname: Larsson
authors.affiliation: School of Psychological Sciences, University of Manchester, Manchester, UK.
authors.forename: Penny
authors.initials: P
authors.lastname: Bunton
authors.affiliation: Tourettes Action, The Meads Business Centre, Farnborough, Hampshire, UK.
authors.forename: Suzanne
authors.initials: S
authors.lastname: Dobson
authors.affiliation: Division of Psychiatry and Applied Psychology, Institute of Mental Health, University of Nottingham Innovation Park, University of Nottingham, Nottingham, UK.
authors.forename: Madeleine
authors.initials: M
authors.lastname: Groom
authors.affiliation: Paediatric Neurology Department, Kings College Hospital NHS Foundation Trust, London, UK.
authors.forename: Tammy
authors.initials: T
authors.lastname: Hedderly
authors.affiliation: Department of Child and Adolescent Mental Health, Great Ormond Street Hospital for Children, London, UK.
authors.forename: Isobel
authors.initials: I
authors.lastname: Heyman
authors.affiliation: Division of Psychiatry and Applied Psychology, Institute of Mental Health, University of Nottingham Innovation Park, University of Nottingham, Nottingham, UK.
authors.forename: Georgina M
authors.initials: GM
authors.lastname: Jackson
authors.affiliation: School of Psychology, University of Nottingham, Nottingham, UK.
authors.forename: Stephen
authors.initials: S
authors.lastname: Jackson
authors.affiliation: Institute of Neurology, University College London, London, UK.
authors.forename: Tara
authors.initials: T
authors.lastname: Murphy
authors.affiliation: National Centre for Mental Health, Birmingham, UK.
authors.forename: Hugh
authors.initials: H
authors.lastname: Rickards
authors.affiliation: Department of Neurology, St George's University Hospitals NHS Foundation Trust, London, UK.
authors.forename: Mary
authors.initials: M
authors.lastname: Robertson
authors.affiliation: Tourettes Action, The Meads Business Centre, Farnborough, Hampshire, UK.
authors.forename: Jeremy
authors.initials: J
authors.lastname: Stern
mesh_terms: D000293:Adolescent; D014150:Antipsychotic Agents / Q000008:administration & dosage / Q000009:adverse effects / Q000627:therapeutic use*; D001521:Behavior Therapy / Q000379:methods*; D002648:Child; D000529:Complementary Therapies; D003362:Cost-Benefit Analysis; D006801:Humans; D010290:Parents / Q000523:psychology*; D020323:Tics / Q000628:therapy*; D005879:Tourette Syndrome / Q000628:therapy*
chemical_list: D014150:Antipsychotic Agents