SCALES FOR TICS: CRITIQUE AND RECOMMENDATIONS

Systematic Review of Severity Scales and Screening ABSTRACT Background: Several clinician, informant, and self- Instruments for Tics: report instruments for tics and associated phenomena Critique and Recommendations have been developed that differ in construct, compre- hensiveness, and ease of administration. Objective: A Movement Disorders Society subcommit- Davide Martino, MD, PhD,1,2* tee aimed to rate psychometric quality of severity and Tamara M. Pringsheim, PhD,3 screening instruments for tics and related sensory Andrea E. Cavanna, MBChB, MD, PhD,4 phenomena. Carlo Colosimo, MD, PhD,5 Andreas Hartmann, MD,6 Methods: Following the methodology adopted by previ- James F. Leckman, MD,7 Sheng Luo, PhD,8 ous Movement Disorders Society subcommittee papers, a Alexander Munchau, MD,9 Christopher G. Goetz,10 review of severity and screening instruments for tics was Glenn T. Stebbins,10 Pablo Martinez-Martin,11 and completed, applying a classification as “recommended,” the Members of the MDS Committee on Rating Scales “suggested,” or “listed” to each instrument. Development Results: A total of 5 severity scales (Yale Global Tic Severity Scale, Tourette Syndrome Clinical Global 1International Parkinson’s Centre of Excellence, King’s College and Impression, Tourette’s Disorder Scale, Shapiro Tourette King’s College Hospital, London, UK 2Queen Elizabeth Hospital, syndrome Severity Scale, Premonitory Urges for Tics Woolwich, Lewisham & Greenwich NHS Trust, London, UK Scale) were “recommended,” and 6 (Rush Video-Based 3 Department of Clinical Neurosciences, Psychiatry, Pediatrics and Tic Rating Scale, Motor tic, Obsessions and compul- Community Health Sciences, University of Calgary, Calgary, sions, Vocal tic Evaluation Survey, Tourette Syndrome 4 Canada Birmingham and Solihull Mental Health National Health Global Scale, Global Tic Rating Scale, Parent Tic Ques- Service Foundation Trust, Department of Neuropsychiatry, The tionnaire, Tourette Syndrome Symptom List) were Barberry National Centre for Mental Health, Birmingham, UK 5Department of Neuroscience, University of Rome “La Sapienza,” “suggested.” A total of 2 screening instruments (Motor Rome, Italy 6Centre de Reference National Maladie Rare: tic, Obsession and compulsions, Vocal tic Evaluation “Syndrome Gilles de la Tourette,” Departement de Neurologie, Pole Survey and Autism-Tics, Attention Deficit/Hyperactivity des Maladies du Systeme Nerveux, Paris, France 7Child Study Disorder and Other Comorbidities Inventory) were Center, Yale University, New Haven, Connecticut, USA “recommended,” whereas 2 others (Apter 4-questions 8Department of Biostatistics, School of Public Health, The screening and Proxy Report Questionnaire for Parents University of Texas Health Science Center at Houston, Houston, and Teachers) were “suggested.” 9 Texas, USA Department of Paediatric and Adult Movement Conclusions: Our review does not support the need for Disorders and Neuropsychiatry, Institut of Neurogenetics, University developing new tic severity or screening instruments. of Lubeck,€ Lubeck,€ Germany 10Department of Neurological Potential objectives of future research include develop- Sciences, Rush University Medical Center, Chicago, Ilinois, USA 11National Center of Epidemiology and Centro Investigacion ing a rating instrument targeting the full spectrum of tic- Biomedica en Red Enfermedades Neurodegenerativas, Carlos III related abnormal behaviors, assessing/screening malig- Institute of Health, Madrid, Spain nant forms of tic disorders, and developing patient- reported outcome measures. VC 2017 International Par- kinson and Movement Disorder Society. Key Words: tics; urges; Tourette’s syndrome; rating scales; screening

Tics, the cardinal feature of Tourette syndrome (TS) ------and other primary tic disorders,1 are rapid, recurrent, *Corresponding author: Dr. Davide Martino, Department of Clinical Neuro- sciences, University of Calgary, Calgary, Canada; [email protected] nonrhythmic movements or vocalizations differing in Members of the MDS Committee on Rating Scales Development are complexity, frequency, and interference with normal listed in the acknowledgments. behavior.2,3 Individuals with tics report premonitory Davide Martino and Tamara M. Pringsheim contributed equally to this urges, unpleasant sensations preceding tics, and manuscript. momentarily relief after tics.4 They often have addi- Relevant conflicts of interests/financial disclosures: Nothing to report. tional complex repetitive behaviors (echo-, pali-, Received: 8 August 2016; Revised: 2 November 2016; Accepted: 9 copro-phenomena, or nonobscene socially inappropri- November 2016 ate behaviors).2,4 Attention deficit-hyperactivity disor- Published online 10 January 2017 in Wiley Online Library der, obsessive-compulsive disorder, and anxiety/mood (wileyonlinelibrary.com). DOI: 10.1002/mds.26891 disorders are commonly associated with TS, and these

Movement Disorders, Vol. 32, No. 3, 2017 467 468 TABLE 1. Summary of recommendations, structure, and clinical utility of recommended and suggested severity rating scales for tics and premonitory urges AL ET MARTINO

Features

Movement Panel Tic-related (other than tics) Time of Main advantages of its Instrument judgment Rater dimensions explored administration clinical application Main limitations

YGTSS Recommended Clinician - Number None 15-20 minutes - Comprehensiveness - Training for administration required iodr,Vl 2 o ,2017 3, No. 32, Vol. Disorders, - Frequency - Availability of a joint tic - Length of administration - Intensity checklist - Complexity - Availability of thresholds of - Interference score change indicating - Overall response to clinical impairment treatment STSS Recommended Clinician - Intensity None <5 minutes Brief and easy to administer - Does not assess frequency, complexity, - Interference or distribution - Uncertain time frame within which tic severity is measured TS-CGI Recommended Clinician Overall adverse None <2 minutes Brief and easy to administer Does not assess individual dimensions impact separately TODS Recommended Parent or Overall severity - Inattention >20 minutes Joint assessment of tics and - Does not assess individual dimensions of clinician - Hyperactivity main comorbid behavioral tics separately (2 versions) - Obsessions features - Length of administration - Compulsions - Aggression - Emotional symptoms PUTS Recommended in Patient Premonitory None 5-10 minutes - The only fully validated -Poor psychometric properties in youth patients older urges instrument to measure younger than 10 years than 10 years tic-related premonitory urges specifically - Brief and easy to administer RVBTRS Suggested Clinician - Number None >30 minutes - The only validated - Does not evaluate tics in the time period - Frequency (including set-up, instrument to measure prior to filming - Complexity filming, and current tics objectively - Does not assess interference and adverse video rating) through a videorecording impact of tics within a specified time - Requires audio-visual equipment window - Length of administration - The only instrument that - Divergent validity with instruments allows to measure the measuring other types of involuntary ability of patients to movements has not been assessed actively inhibit tics TSGS Suggested Clinician - Frequency - Behavioral problems 15-20 minutes Joint assessment of tics, - Length of administration - Disruption - Motor restlessness comorbid behavioral - Does not assess complexity or distribution level - School or occupational features and functioning - Internal consistency and divergent validity functioning have not been assessed GTRS Suggested Clinician or - Frequency None <2 minutes Brief and easy to administer - Does not assess individual tic dimensions caregiver - Overall severity - Internal consistency and divergent val