Research paperSuicidal ideation in youth with tic disorders
Introduction
Chronic tic disorders and Tourette's syndrome (collectively referred to as TD herein) affect around .4–1.6% of youth (Knight et al., 2012, Scahill et al., 2014) and are characterized by sudden repetitive motor movements and/or vocalizations for more than a one year duration. Tic symptoms typically fluctuate over time, and subside in early adulthood in many cases (American Psychiatric Association, 2013, Bloch et al., 2006, Leckman et al., 1998). Despite this clinical course, when active, symptoms can be acutely impairing and distressing for both the young person and their family (Conelea et al., 2011, Storch et al., 2007a). Given the often involuntary and uncontrollable nature of their symptoms, many patients experience high levels of frustration and hopelessness surrounding their symptoms. Despite the common co-occurring of anxiety and mood disorders among youth with TD (Freeman et al., 2000, Specht et al., 2011), few studies have examined the phenomenology of suicidal ideation (SI) in this population. Given that suicide is one of the leading causes of death amongst youth (Bridge et al., 2006; Hawton et al., 2012), it is relevant to extend this body of literature to better understand the level of risk present amongst youth with TD, and the clinical features that characterize higher-risk patients.
There is an increasing recognition that TDs are associated with a range of negative outcomes, many of which also represent risk factors for suicidal thoughts and behaviors.
For example elevated levels of peer victimization, social deficits and psychiatric comorbidity including depressive symptoms, mood disorders, disruptive behavior disorders, and attention/hyperactivity problems have been documented in youth with TD (Kraft et al., 2012, McGuire et al., 2013, Robertson, 2006, Storch et al., 2007b, Sukhodolsky et al., 2003). In particular, depression, and (less consistently) anxiety, have been associated with increased risk of suicidal ideation and attempts in children and adolescents (Gould et al., 1998, O’Neil-Rodriguez and Kendall, 2014b, Reinherz et al., 1995). Despite these parallels, there remains a paucity of research examining the experience of SI in youth with TD.
Of the few studies that have examined SI in patients with TD, there has been some variability in incidence, likely due to differing age ranges, sampling methodology and measurement. For example, studies often utilize dichotomously coded measures of SI either derived from single-item responses to depressive symptom measures, clinical interview questions about depression, or clinician notes/ratings of SI as a construct that is present/absent. These formats may differ from a continuous measure of SI as a construct that varies in presence, frequency, and severity. Methodology also becomes more complex when considering informant issues, such as whether parents or youth provide the report. An archival review study examined clinical notes of patients with Tourette's disorder attending a specialist tic disorder clinic, and documented SI in .06% of cases with .05% having made a suicide attempt (Gharatya et al., 2014). This study found that patients with TD who endorsed SI experienced higher levels of tic severity, and had a greater prevalence of comorbid anxiety disorders, comorbid depressive disorders, and comorbid OCD in comparison to individuals with TD who did not endorse SI (Gharatya et al., 2014). Rates of SI may be even higher amongst severe cases, with an archival review study in a specialist clinic setting finding that around 5% of TD cases were classified as ‘malignant’ cases that were characterized by severe tics, rage episodes, and symptoms of SI or self-injurious behaviors (Cheung et al., 2007). Another study compared severe cases of ‘malignant’ TD, where symptoms had resulted in more than 2 emergency room visits or more than one hospitalizations, and documenting SI in 35.3% of these severe cases, compared to 7.6% in ‘nonmalignant’ cases (Cheung et al., 2007).
Few studies have focused on SI exclusively on pediatric TD samples, with most studies using a wide age-range (Cheung et al., 2007, Davila et al., 2010, Gharatya et al., 2014). In the only study of SI in children and adolescents with TD to date, around 10% of children had experienced SI over the past year, significantly higher than rates endorsed by community controls (Storch et al., 2015). Suicidal ideation was associated with higher tic severity, impairment, depressive symptoms, anxiety symptoms, hyperactivity/impulsivity, and oppositional behaviors (Storch et al., 2015). Importantly, anxiety and depressive symptoms (collectively) fully mediated the relationship between tic severity and SI, theoretically suggesting that it is the presence of these symptoms that increases youth risk rather than their TD per se. This study combined single-item ratings from multiple informants (parent, child, and clinician) on symptoms measures (e.g., depression) to identify SI. While there are some strengths to this method, specific continuous measure of SI presence and severity have been developed for youth (Reynolds, 1988) that may allow for a more nuanced examination about not only the clinical features associated with the presence/absence of SI, but the severity of these symptoms as well. Overall, there appears to be a general consensus in the literature that there is a relationship between tic severity, psychiatric comorbidity and SI (Davila et al., 2010). In particular, anxiety and depressive symptoms may increase the risk of SI; however the differential impact of these symptoms has not been fully elucidated. There is evidence to suggest an independent relationship between anxiety symptoms and SI (Carter et al., 2008, Gould et al., 1998, Hawgood and De Leo, 2008, Hill et al., 2011, O’Neil-Rodriguez and Kendall, 2014b, O’Neil et al., 2012a, Sareen et al., 2005), depressive symptoms and SI (Carlson and Cantwell, 1982, Gould et al., 1998, O’Neil-Rodriguez and Kendall, 2014b, O’Neil et al., 2012a), and externalizing symptoms and SI (Kumar and Steer, 1995, Lewinsohn et al., 1993, Sourander et al., 2009), however it is unclear whether these have a differential impact on SI in pediatric TD populations.
Given the lack of studies assessing the relationship between TD and SI in youth, and the limitations in current assessment methods of SI, this study is novel in examining the presence and severity of SI in a pediatric TD sample, using a specific measure of SI in children and adolescents with CTD. This study had three aims. Firstly, this study aimed to examine the incidence of suicidal ideation in treatment-seeking youth with TD, and to examine the agreement between parent and child reports. We expected that, similar to Storch et al. (2015), around 10% of youth with TD would experience SI as endorsed by either parent or child report. Given existing findings suggesting limitations to parental insight into these symptoms (e.g., Achenbach, 2011, Breton et al., 2002, Klaus et al., 2009, Walker et al., 1990), we anticipated higher rates of SI to be endorsed by youth than their parents. Secondly, this study aimed to assess demographic and clinical correlates of SI in youth with TD. We hypothesized that SI would be positively associated with tic severity, anxiety symptoms, depressive symptoms, and affective lability, and negatively associated with distress tolerance and global functioning. Third, we aimed to extend the model proposed by Storch et al. (2015) to examine whether tics impacted SI by increasing anxiety, depressive and/or externalizing symptoms. Our hypothesis was that tics would have no direct impact on SI, but would indirectly influence SI severity by increasing anxiety, depressive and externalizing symptoms. To enhance previous study designs, we included a specific and empirically validated measure of SI, as well as a separate measures of anxiety and depressive symptoms. Finally, we examined whether the above relationships differed in pre-pubertal and post-pubertal youth, given increased risk of suicide in older youth (Shaffer and Fisher, 1981, Tishler et al., 2007).
Section snippets
Participants
Participants were 75 treatment-seeking youth aged 6–18 (M=10.68, SD=2.82) who were diagnosed with a tic disorder and their parent or primary caregiver. Participants were recruited from two specialty programs for OCD and tic disorders in Florida, United States. To be included, youth were required to meet DSM-IV criteria for a tic disorder with current tic symptoms present. Participants were excluded if they experienced active psychosis, mania, active suicidality, intellectual disability, or a
Phenomenology
On the SIQ-JR, 61.33% (n=46) of youth endorsed at least some symptoms of SI. Based on a cut-off score of 31 on the SIQ-JR, 8% (n=6) of youth with CTD endorsed clinically significant levels of SI. Parents reported SI in 10.7% (n=8) of cases. Although parent and child-report was consistent in 86.7% of cases (n=65), there were 10 cases where parent- and child report varied. In 8% of cases (n=6) parents reported symptoms of SI while their child did not. In 5.3% of cases (n=4), children reported
Discussion
The rate of parent-reported SI (11%) was similar to rates of overall SI reported by parents on in the previous child-focused study of SI in TD (9.7%; Storch et al., 2015). Overall, 61% of youth with TD endorsed at least some level of SI. Using a clinical cut-off on the SIQ-JR, rates of clinically significant SI reported by youth (8%) were similar to that of parents, however our findings suggested poor agreement between parent and child reports of SI. This finding may reflect the differing
Acknowledgements
The contributions of Elysse Arnold, Erika Crawford, Amanda Collier, Brittney Dane, and Morgan King at University of South Florida with data collection are gratefully acknowledged.
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