key: cord-0979620-1576bk2q
authors: Graziola, Federica; Garone, Giacomo; Di Criscio, Lorena; Grasso, Melissa; Curatolo, Paolo; Vigevano, Federico; Capuano, Alessandro
title: Impact of Italian lockdown on Tourette syndrome at the time of the COVID‐19 pandemic
date: 2020-08-14
journal: Psychiatry Clin Neurosci
DOI: 10.1111/pcn.13131
sha: c8908c2091b7e244846ccde5b5f6e83171cad0b7
doc_id: 979620
cord_uid: 1576bk2q

nan

In early 2020, the rapid spread of SARS-CoV-2 from China to the rest of the world produced a global pandemic affecting over 100 countries 1 . To limit viral transmission and mitigate the disease burden, most countries adopted lockdown measures. Italian outbreak emerged in the North of the country (Lombardy, Veneto and Emilia-Romagna regions) in late February 2020, and later spread to the rest of the peninsula 2 . Nationwide school closedown was ordered on March 5 th , and students and teachers have been required to switch to distance-learning programs. Disruption of daily routines and social isolation may have deleterious effects on children's health, especially for those with mental health needs and pre-existing chronic diseases 3 .

Chronic Tic Disorders (CTD) and Tourette Syndrome (TS) are childhood-onset neurodevelopmental disorders often associated with neuropsychiatric comorbidities, especially attention deficithyperactivity disorder (ADHD) and obsessive-compulsive disorder (OCD) 4, 5 . Children with TS and CTD could be at high risk for lockdown-related worsening of their condition.

Patients with TS (N= 58) and CTD (N=22) were recruited from the Movement Disorders Outpatient Clinic of Bambino Gesù Children's Hospital. Sixteen patients met diagnostic criteria for ADHD (ADHD+), 18 for OCD (OCD+), 12 for both (ADHD+-OCD+). The remaining 34 were classified as Isolated Tic disorder (ITD) subgroup. Other comorbidities encountered included anxiety, oppositional-defiant disorder, academic difficulties and explosive outbursts (for details of the study design and the cohort description see figure S1 and Table S1 in Supporting Info).

Parents and/or children were interviewed by structured telephone questionnaires. The study was approved by local Ethical Committee and parents gave their informed consent; when directly involved in the interview, children gave their own assent.

Tic severity (YGTSS) 6 , OCD symptoms (CY-BOCS) 7 and new onset symptoms were assessed during the fourth and fifth week of nationwide lockdown. Furthermore, we rated the guardian's impression of the worsening during the lockdown using a simplified 5-grade scale from "improved or unchanged" to "extreme worsening" (see Methods in Supporting Info).

We found a significant reduction of overall YGTSS scores ( Figure 1A ) in the entire cohort with no difference among groups, comparing pre-and post-lockdown. Considering the two components of YGTSS, we found that the overall reduction was significantly due to the tic-related impairment score (-23.45%) of YGTSS, while motor and vocal tic severity subscales (number, frequency, intensity, complexity and interference of tics) was stable or reduced in a lesser extent.

The severity of obsessive-compulsive symptoms resulted stable before and during the lockdown (Table S2 in Supporting Info for a detailed description).

New symptoms during lockdown, particularly anxiety and irregular sleep patterns were reported in about half of the patients. Sleep disturbances, especially in those with comorbid ADHD and OCD subgroups, affected both sleep length and sleep patterns, with difficulties in falling asleep, higher rate of co-sleeping and frequent awakenings and can be related both to the lack of daily routine 8 and to the co-occurring anxiety (anxiety-induced insomnia) 9 . Less frequently, previously unnoticed ADHD symptoms, explosive outbursts or mood deflection were reported. The occurrence of explosive outbursts during school closedown raises serious concerns about their management by the guardians, because of the prohibition of outdoor activity and the difficulties to deal with the rage attacks domestically. A new onset of eating disorders (restricted and increased eating habits or avoidant/restrictive food intake) was reported in ADHD+OCD+ group (Table S3 in Supporting Info) .

Finally, interestingly, contribution of tic and OCD severity to parents' impression was more evident in those patients rated by most severe degrees of worsening ( figure 1C and D) .The mismatch between parental impression and tic and OCD severity measures suggests that lockdown may exert different This article is protected by copyright. All rights reserved. effects on tics and behavioral symptoms, and global worsening could be related to other neuropsychiatric comorbidities.

In conclusion, TS and CTD patients experienced a significant reduction of tic severity, mainly due to the decrease in tic-related impairment, likely reducing the burden of tic in social context (school, playful activities). Nevertheless, prolonged social distancing led to the appearance of novel neuropsychiatric symptoms, especially in children with pre-existing comorbidities.

Although with limitations as the use of a retrospective evaluation for pre-lockdown severity of tics and OCD and the cross-sectional nature of the study, our data shed a light on the need to assess the mental health burden of this unprecedented situation in vulnerable groups of children.

Disclosure Statement: nothing to declare 

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