DEVELOPMENTAL MEDICINE & CHILD NEUROLOGY ORIGINAL ARTICLE

Influence of sex on tic severity and psychiatric comorbidity

profile in patients with pediatric tic disorder
JOSEPH GIRGIS 1 | DAVIDE MARTINO 2 | TAMARA PRINGSHEIM 2,3
1 Royal College of Surgeons in Ireland, Dublin, Ireland. 2 Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta; 3 Department of Psychiatry,
Pediatrics and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada.
Correspondence to Tamara Pringsheim at TRW4D65, 3280 Hospital Drive NW, Calgary, AB T2N 4Z6, Canada. E-mail: [email protected]

PUBLICATION DATA AIM To investigate sex-related differences in tic severity, tic-related impairments, and
Accepted for publication 17th September psychiatric comorbidities in childhood.
2021. METHOD In this cross-sectional study, tic severity/impairment and demographic factors were
Published online 21st October 2021. collected from 270 children and young people (aged 5–17y, mean 10y 6mo, SD 3y 4mo; 212
males and 58 females) with a tic disorder diagnosis at a specialty clinic. Psychiatric
ABBREVIATIONS diagnoses and corresponding screening questionnaire scores were collected for attention-
ASD Autism spectrum disorder deficit/hyperactivity disorder (ADHD), obsessive–compulsive disorder (OCD), major depressive
CDI-2 Children’s Depression Inventory, disorder, and anxiety disorders. Logistic regression was used to compare the effect of sex
Second Edition and age on psychiatric comorbid diagnoses. The Mann–Whitney U test and t-tests were used
CY-BOCS Children’s Yale-Brown to assess differences in questionnaire score distribution between sexes.
Obsessive Compulsive Scale RESULTS Females had more severe motor tics (12.55 vs 10.81, p=0.01) and higher global
EMTICS European Multicenter Tics in severity scores (38.79 vs 32.66, p=0.03) on the Yale Global Tic Severity Scale. Females were
Children Study less likely to be diagnosed with ADHD (odds ratio=0.48, 95% confidence interval=0.26–0.89).
MDD Major depressive disorder No significant sex difference was observed in diagnosis rates or symptom severity scores for
OCD Obsessive–compulsive disorder anxiety or OCD. Females had significantly higher scores than males on the Children’s
PTD Persistent tic disorder Depression Inventory, Second Edition.
YGTSS Yale Global Tic Severity Scale INTERPRETATION The higher level of motor tic severity and global severity in females further
supports the differential natural history of tic disorders in females. Females with tic disorders
may be underdiagnosed for ADHD.

Tourette syndrome is a neurodevelopmental disorder char- primary aim.6 This study involved children with Tourette
acterized by persistent vocal and motor tics lasting for syndrome and PTD recruited for the European Multicen-
longer than 1 year. A persistent tic disorder (PTD) is char- ter Tics in Children Study (EMTICS). This study found
acterized by the presence of either persistent vocal or motor that males had more severe tic symptoms than females but
tics. Tic disorders often begin in childhood, become more that there was a statistically significant interaction between
severe with age until early adolescence, and then regress in sex and age on the severity of tics, with females showing
adulthood.1 A meta-analysis of prevalence studies found the higher symptom severity with increasing age than males.
prevalence of Tourette syndrome in children to be 0.77%.2 This study also found that males had significantly greater
In childhood, it is estimated that Tourette syndrome in attention-deficit/hyperactivity disorder (ADHD) and aut-
males has a prevalence of 1.06%, compared to 0.25% in ism spectrum disorder (ASD) symptoms, while females had
females.2 Epidemiological studies found that this ratio nar- significantly greater emotional problems.
rows in adulthood. When comparing the childhood preva- The objective of this study was to examine potential dif-
lence of Tourette syndrome in males to females, Yang et al. ferences in both tic severity and comorbidity profiles
found a prevalence risk ratio of 5.31, which fell to 1.93 in between the sexes, using cross-sectional data collected at
adulthood.3 Narrowing of the sex ratio suggests that tics the first visit at a pediatric movement disorder specialty
may be resolving at a greater rate in males than females. clinic. Because relatively few studies have addressed this
This assumption has been supported by a study which topic, our findings may help establish the presence of
demonstrated that although tic severity decreases with age divergent natural histories of tic disorders in males and
in males, it is likely to increase with age in females.4 Addi- females. This study also compared the psychiatric comor-
tionally, adult females suffer from increased motor tic sever- bidity profile of male and female patients with Tourette
ity and increased levels of tic-related impairment.5 syndrome/PTD by comparing the levels of diagnosis and
To our knowledge, only one recently published study screening questionnaire scores, which serve to quantify
investigated sex differences in tic severity in children as the symptom severity. Our hypothesis, based on previously

488 DOI: 10.1111/dmcn.15088 © 2021 Mac Keith Press

 14698749, 2022, 4, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/dmcn.15088 by Cochrane Romania, Wiley Online Library on [25/03/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
conducted research, was that females would have a more What this paper adds
severe disease phenotype in childhood/adolescence. • Females had higher motor tic and global severity than males.
• There was a positive association between age and tic severity, which was
METHOD more pronounced in females.
This study received ethical approval from the Conjoint • Despite similar symptoms of attention-deficit/hyperactivity disorder (ADHD)
at home, females with tics were less likely to be diagnosed with ADHD.
Health Research Ethics Board of the University of Calgary. • Females with tic disorders had more depressive symptoms than males.
Parents provided signed informed consent and children pro-
vided assent to study participation and publication of the OCD symptoms
study results. This study enrolled patients who were seen at The Children’s Yale-Brown Obsessive Compulsive Scale is
the Tourette Syndrome and Pediatric Movement Disorder a clinician-administered questionnaire that was used to
Clinic at the Alberta’s Children Hospital. Patients were screen for and quantify the severity of comorbid OCD.10,11
referred to the clinic by a primary care physician or other The Children’s Yale-Brown Obsessive Compulsive Scale is
healthcare practitioner. During the initial visit, a diagnosis the criterion standard for assessing OCD symptom severity
of a tic disorder was made. This was accompanied by and is both reliable and valid. A cutoff score of 8 was used
screening questionnaires for psychiatric comorbidities, to indicate that the individual had screened positive.
which are commonly present in Tourette syndrome/PTD,
including obsessive–compulsive disorder (OCD), ADHD, Anxiety symptoms
major depressive disorder (MDD), and anxiety disorders. The Multidimensional Anxiety Scale for Children, Second
Using medical records, screening questionaries, and struc- Edition is a self-report scale that was used to screen for
tured diagnostic interviews, the presence of psychiatric and quantify the severity of comorbid anxiety disorders.12
comorbidity was determined based on the DSM-5 criteria.7 It consists of anxiety scales (subscales include separation
Participants enrolled in the earlier stage of recruitment anxiety, generalized anxiety, social anxiety, humiliation/re-
(n=114) did not have their OCD, MDD, or anxiety disorder jection, and performance fears), physical symptom scales
symptom severity scores recorded in the database and were (subscales include tense/restlessness, panic, and total physi-
therefore excluded from these sections of the analysis. cal symptoms), an obsession/compulsion scale, and a harm
avoidance scale. T scores above 70 were used to indicate
Measures that the individual had screened positive.
Tics
The Yale Global Tic Severity Scale (YGTSS) was used to Depressive symptoms
elicit the history of tics and quantify current tic severity The Children’s Depression Inventory, Second Edition
and tic-related impairments. The scale has five subsections: (CDI-2) is a self-report scale used to screen for and quantify
motor tic severity; vocal tic severity; total tic severity (mo- the severity of comorbid depressive symptoms.13 The CDI-
tor + vocal); tic impairment score; and global severity score 2 measures both functional (consisting of subscales for inter-
(total tic severity + impairment score). The tic severity personal problems and ineffectiveness) and emotional prob-
scores are based on tic number, frequency, intensity, com- lems (consisting of subscales for negative mood/physical
plexity, and interference.8 The impairment scores are based symptoms and negative self-esteem). T scores above 70 were
on how the individual rates the impact of their tics on self- used to indicate that the individual had screened positive.
perception, self-esteem, personal relationships, and ability
to perform in an academic/occupational setting. The ASD
YGTSS has been demonstrated to be reliable and valid Medical records were used to determine if a diagnosis of
and is the criterion standard for quantifying tic severity ASD was present. If an individual was suspected of having
and impairment. Using the YGTSS scores and patient ASD but there was no prior diagnosis, they were referred
interview, a clinical diagnosis of a tic disorder was made for a formal diagnostic assessment.
based on the DSM-5 criteria. The diagnosis was classified
as Tourette syndrome, persistent motor tic disorder, per- Medication use and other variables
sistent vocal tic disorder, or provisional tic disorder. An individual’s medication use was recorded if the individ-
ual had been prescribed and was using an alpha agonist,
ADHD symptoms antipsychotic, psychostimulant, selective serotonin reuptake
The Conners 3 Parent Assessment Report was used to inhibitor, or topiramate. The medication may have been
screen for and quantify the severity of comorbid ADHD prescribed during the initial consult at the Tourette Syn-
symptoms. The scale’s subsections include inattention, drome and Pediatric Movement Disorder Clinic, or pre-
hyperactivity, learning problems, executive functioning, scribed previously. The participant’s age, age at onset of
aggression, and peer relations. T scores above 70 were tics, and sex were also recorded.
used to indicate that the individual had clinically relevant
symptoms in the home environment and prompted evalua- Statistical analysis
tion by teachers using the Conners 3 Teacher Assessment All statical analyses were conducted in Stata v16 (Stata-
Report.9 Corp, College Station, TX, USA). Histograms were used

Influence of Sex on Tic Severity Joseph Girgis et al. 489

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to determine the normality of scale questionaires. Those severity but not vocal tics. Neither sex had a significantly
that met the assumptions of normality (YGTSS score and higher score for any ADHD, OCD, and anxiety scale or
subscales, age, age at onset of tics) were assessed for a dif- subscale, except for the Multidimensional Anxiety Scale for
ference in means between sexes using a t-test. For the Children, Second Edition humiliation/rejection subscale,
remaining scales that did not meet the assumption of nor- where females had significantly higher scores. Females had
mality (Conners 3 score and subscale scores, Children’s significantly higher scores for the CDI-2 total and all
Yale-Brown Obsessive Compulsive Scale scores, Multidi- CDI-2 subscales (with the exception of the negative self-
mensional Anxiety Scale for Children, Second Edition esteem subscale).
score and subscale scores, CDI-2 score and subscale Table 3 quantifies the relationship between age and sex
scores), a Mann–Whitney U test was conducted to assess (independent variables) and psychiatric comorbidities and
for a significant difference in the distribution of values medication use (dependent variables). Female sex was pro-
between the sexes. Logistic regression was used to assess tective for ADHD, while age had no association with
and quantify the relationship between sex/age and multiple ADHD. Sex did not have a significant association with
outcomes: ADHD diagnosis; OCD diagnosis; anxiety dis-
order diagnosis; MDD diagnosis; ASD diagnosis; alpha
agonist use; antipsychotic use; selective serotonin reuptake
inhibitor use; and stimulant use. A v2 test was used to anal-
Table 2: Average age, age at onset, and scale scores
yse if the proportions of tic disorder subtype or psychiatric
comorbidities varied between the sexes. The relationship Males (n=212) Females (n=58) t-test
Scale Mean (SD) Mean (SD) p
between age and tic severity was analysed using a linear
regression model, while controlling for sex as an indepen- Age at evaluation, y:mo 10:5 (2:10) 10:10 (3:7) 0.33
dent covariate. Since this was an exploratory study, we Age at tic onset, y:mo 6:6 (2:5) 6:4 (3:1) 0.78
YGTSS – total motor 10.81 (4.57) 12.55 (5.35) 0.01
used a p-value less than 0.05 to define a statistically signifi- YGTSS – total vocal 7.11 (5.50) 7.79 (5.29) 0.40
cant result. YGTSS – total tic 17.93 (8.36) 20.33 (9.10) 0.06
(motor + vocal)
YGTSS – impairment rating 15 (12.60) 18.47 (13.06) 0.07
RESULTS YGTSS – global 32.66 (18.15) 38.79 (20.49) 0.03
The sample included 270 participants, aged from 5 to 17 severity score
years (mean age at evaluation 10y 6mo, SD 3y 4mo), of
which 212 were male (mean age at evaluation 10y 5mo, Males Females Mann–
(n=212) (n=58) Whitney
SD 2y 10mo) and 58 were female (mean age at evaluation Scale Median Median U test p
10y 10mo, SD 3y 7mo). Table 1 describes the proportion
Conners 3 – inattention 65 59 0.06
of participants with each psychiatric comorbidity, as well
Conners 3 – hyperactivity 69 65 0.24
as the proportions of tic disorder diagnoses. Males had a Conners 3 – learning problems 56 54 0.50
significantly higher frequency of ADHD diagnosis than Conners 3 – executive function 60 59 0.71
Conners 3 – aggression 55 54 0.99
females (p=0.020).
Conners 3 – peer relations 67 59 0.09
Table 2 describes the mean and SD of age, age at onset Conners 3 – global 69 66 0.33
of tic disorder, YGTSS, and psychiatric comorbidity scales CY-BOCS – obsession severity 0 2 0.23
CY-BOCS – compulsion severity 0 4 0.28
in both males and females. Age and age at onset were not
CY-BOCS – total severity score 2 7 0.17
significantly different between males and females. Females MASC-2 – separation anxiety 57 53 0.32
had significantly higher scores for motor tics and global tic MASC-2 – general anxiety 57 59 0.29
MASC-2 – social anxiety 52 57 0.13
MASC-2 – humiliation/rejection 51 59 0.03
MASC-2 – performance/fears 56 54 0.59
Table 1: Prevalence of psychiatric comorbidities MASC-2 – obsession/compulsion 55 55 0.32
MASC-2 – physical symptoms 54 58 0.08
Males Females Overall MASC-2 – panic 55 57 0.10
Characteristic (n=212) (n=58) (n=270) v2 p MASC-2 – tense/restlessness 54 58 0.09
MASC-2 – harm avoidance 49 48 0.91
ADHD diagnosis 48 (41–55) 31 (20–44) 44 (39–50) 0.020 MASC-2 – total 55 56 0.27
OCD diagnosis 17 (13–23) 24 (15–37) 19 (15–24) 0.249 CDI-2 – emotional problems 53 57 0.02
Anxiety disorder 18 (14–24) 21 (12–33) 19 (15–24) 0.693 CDI-2 – negative mood/physical 54 57 0.01
diagnosis symptoms
MDD diagnosis 3 (2–7) 7 (3–17) 4 (2–7) 0.220 CDI-2 – negative self-esteem 49 53 0.14
Autism diagnosis 7 (4–11) 2 (0.2–12) 6 (4–9) 0.126 CDI-2 – functional problems 51 61 0.01
Tic disorder subset 100 100 100 0.702 CDI-2 – ineffectiveness 52 58 0.01
Tourette 79 (73–84) 83 (71–91) 80 (74–84) CDI-2 – interpersonal problems 51 58 0.03
Motor 10 (7–15) 10 (5–21) 10 (7–15) CDI-2 – total 52 58 <0.001
Vocal 2 (1–5) 0 (0) 1 (1–4)
Provisional 9 (6–14) 7 (3–17) 9 (6–13) Bold type indicates statistical significance (p<0.05). YGTSS, Yale
Global Tic Severity Scale; CY-BOCS, Children’s Yale-Brown Obses-
Data are % (95% confidence intervals) unless otherwise stated. sive Compulsive Scale; MASC-2, Multidimensional Anxiety Scale
ADHD, attention-deficit/hyperactivity disorder; OCD, obsessive– for Children, Second Edition; CDI-2, Children’s Depression Inven-
compulsive disorder; MDD, major depressive disorder. tory, Second Edition.

490 Developmental Medicine & Child Neurology 2022, 64: 488–494

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OCD, anxiety, MDD, or autism, while age had significant age was significantly positively associated with the use of
positive associations with all four disorders. Sex had no sig- selective serotonin reuptake inhibitors, antipsychotics, and
nificant association with taking any medication type, while alpha agonists.
A positive association was observed between age and
vocal tic severity (F[2,265]=6.86, p=0.001), motor tic severity
Table 3: Sex and age as independent variables in the logistic regression (F[2,265]=12.93, p<0.001), tic-related impairment
model (F[2,265]=5.27, p=0.006), and global severity (F[2,265]=9.85,
Female sex p=0.001) on the YGTSS. Increased symptom severity with
(adjusted for age) Agea (adjusted for sex)
increased age was more pronounced in females for all the
Outcome OR 95% CI p OR 95% CI p measurements except for tic-related impairments, where
the increase was more pronounced in males. Motor tic
ADHD 0.48 0.26–0.89 0.019 1.03 0.96–1.12 0.39
OCD 1.06 0.44–2.55 0.13 1.20 1.06–1.36 <0.001 severity (p=0.025), tic-related impairments (p=0.051), and
Anxiety 1.11 0.45–2.67 0.82 1.21 1.07–1.36 0.03 global severity (p=0.045) were higher in females at all ages,
disorder although the difference was not statistically significant for
MDD 2.2 0.56–8.8 0.25 1.30 1.04–1.63 0.02
Autism 0.17 0.02–1.42 0.10 1.27 1.07–1.52 0.01 tic-related impairment. Vocal tics were more severe in
No medication 1.34 0.60–3.01 0.48 0.82 0.73–0.91 0.001 males at a younger age (p=0.121) but were more severe in
Alpha agonist 1.43 0.72–2.86 0.31 1.11 1.00–1.22 0.04 females at an older age (p=0.077) (Fig. 1).
Antipsychotic 1.10 0.48–2.48 0.83 1.22 1.09–1.37 0.001
SSRI 1.48 0.69–3.18 0.32 1.25 1.12–1.40 0.001
Stimulant 0.43 0.18–1.01 0.06 1.07 0.97–1.18 0.17 DISCUSSION
a
Bold type indicates statistical significance (p<0.05). Continuous
Among participants, tic severity was significantly greater in
variable; the odds ratio represents the year-on-year increase in females compared to males, although the difference was
odds. OR, odds ratio; CI, confidence interval; ADHD, attention- small. Females had significantly higher scores for motor
deficit/hyperactivity disorder; OCD, obsessive–compulsive disorder;
MDD, major depressive disorder; SSRI, selective serotonin reuptake
tics and global tic severity. Our logistic regression analysis
inhibitor. found significantly higher motor and global tic severity in

Figure 1: Linear regression analyses. Age and motor tic severity, vocal tic severity, tic-related impairments, and global tic severity in males and
females.

Influence of Sex on Tic Severity Joseph Girgis et al. 491

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females at all ages. These findings are partly in keeping increased premature mortality, including suicide, within
with the EMTICS, which demonstrated greater tic severity cohorts of individuals with Tourette syndrome. The persis-
in males but higher tic severity in females with increasing tence of tics into adulthood was a significant risk factor for
age. The cause for the divergence of our findings from the suicide. Given that females are more likely to have tics that
EMTICS data is unclear. Our study had a similar mean persist into adulthood, this highlights females with Tour-
age, sex distribution, and mean tic severity to the EMTICS ette syndrome as a potential at-risk group that may require
participants. Because the EMTICS involved 16 different additional preventative measures and attention from heath-
study centers, the number of tic severity raters was higher care providers.22,23
compared to our study, which involved only four clinicians In this study, female sex was a protective factor for
scoring tic severity. ADHD, with the rate of diagnosis being significantly lower
One potential explanation for the greater tic severity in in females. This is in keeping with a broader trend of
females may be differences between the sexes in tic aware- higher rates of ADHD diagnosis in males, both among
ness and self-report of tics. The YGTSS has several ele- those with Tourette syndrome/chronic tic disorder24 and
ments that rely heavily on patient report, including review in the general population.25 However, when comparing the
of the tic inventory with the patient and estimation of fre- Conners 3 global scores, males did not score significantly
quency, interference, and impairment. Females report higher. Higher rates of ADHD diagnosis among males,
somatic symptoms more frequently than males14 and this despite similar scale scores, indicate that ADHD may be
may be true also for tics. underdiagnosed in females; this is supported by recent
The role and effect of psychosocial stress may also influ- studies, which indicate a wider pattern of ADHD under-
ence tic severity in females to a greater extent than in diagnosis in females. One population-based study, which
males. A prospective longitudinal study of young people did not rely on a previous diagnosis to establish the pres-
with Tourette syndrome and/or OCD compared to typi- ence of ADHD, found that among those found to have
cally developing controls found that current levels of psy- ADHD, 51% were male and 49% were female.26 The
chosocial stress and depression were independent study also found that, among those with ADHD, females
predictors of future tic severity.15 Sex differences have been were significantly more likely to be undiagnosed at the
demonstrated in the experience of psychosocial stress in time of the study (odds ratio=0.3).
adolescents, with females reporting higher frequencies of One potential explanation for the bias toward ADHD
perceived stress,16 distress, anxiety, and depression17 than diagnosis in males may have to do with the behavior of
males and demonstrating greater cortisol output in the females with ADHD in the classroom.27 In our study, if
morning.16 Our sample also demonstrated significantly participants screened positive for ADHD in the Conners 3
higher depressive symptoms in females than males. Parent Assessment Report, then a Conners 3 Teacher
The greater tic severity in females in our study suggests Assessment Report was conducted. If participants did not
that Tourette syndrome in females may follow a distinct screen positive in the Conners 3 Teacher Assessment
natural history in comparison to males and may partly Report, then ADHD was not diagnosed since symptoms
explain why the sex ratio of Tourette syndrome, which is must be present in more than one setting (home and
heavily biased toward males in childhood and adolescence, school). If females are less symptomatic in the classroom,
is closer to 1 in adulthood. This may be related to the they would be less likely to fulfil this requirement for
explanations provided earlier, sexual dimorphism in the ADHD diagnosis. One study found that although parents
maturation of neural networks, or the effects of the X rated disruptive behavior as equal between males and
chromosome on inflammatory phenotypes, which may females, teachers found males to be significantly more dis-
affect neurological outcomes.18–20 ruptive.28 Development plays a role in ADHD diagnosis.29
Many individuals with Tourette syndrome see their tic Since females have earlier development of self-control
severity decline as they enter young adulthood, with some skills, it is possible that females control their symptoms in
going into full remission.1,5 If females experience a more socially demanding settings, such as the classroom, to a
severe phenotype, then a reduction in symptoms entering greater extent than males.30
adulthood may be less likely to fully put them into remis- Another potential explanation for the bias toward
sion.21 Previous studies that followed the disease progres- ADHD diagnosis in males relates to bias in healthcare.
sion of patients with Tourette syndrome into adulthood One study presented therapists with clinical vignettes of
found that symptoms and tic-related impairments may individuals with ADHD symptoms but not meeting the
worsen with age in females. In a sample of 75 patients with DSM-IV criteria. The therapists were twice as likely to
Tourette syndrome, males and females followed divergent diagnose ADHD in the male version of the vignettes com-
paths after adolescence.4 Females were more likely to expe- pared to the female one.31
rience more severe motor tics and tic worsening and We observed a trend indicating that females were more
expansion (rather than contraction) in adulthood. The likely to have a diagnosis of depression than males,
inverse was found among males, who were more likely to although this did not reach statistical significance. Females
experience tic improvement and tic contraction. Two also scored higher on the CDI-2. Given that the average
recent Scandinavian longitudinal studies identified age of participants was young (10y 6mo) and that MDD

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more often begins to present in late adolescence and adult- comorbidities. OCD, anxiety disorders, and MDD have an
hood, few patients in the sample were diagnosed with average age at onset that is later than Tourette syndrome.
MDD.32 The small number of diagnosed cases of depression The cross-sectional nature of this study may mean that
is the most likely reason that a statistically significant rela- psychiatric disorders that had not yet presented were not
tionship between sex and a diagnosis of MDD was not accounted for. A longitudinal study analysing lifetime
observed, given that population-based studies consistently prevalence may present a more complete picture pertaining
indicate a strong female preponderance.33 Clinical studies to these disorders. There are limitations in the current
examining patients with Tourette syndrome/PTD also estab- assessment methods of tic severity. Tic severity fluctuates
lished a significant relationship between sex and MDD.24 over periods of days, weeks, months, or years. We docu-
In this study, females had slightly higher scores in the mented tic severity at the time of the first assessment;
Multidimensional Anxiety Scale for Children, Second Edi- YGTSS scores may be both higher or lower at other time
tion scale and were more likely to be diagnosed with an points.
anxiety disorder; however, neither trend was statistically
significant. In the general population, females are at signif- CONCLUSIONS
icantly higher risk of developing an anxiety disorder.34 In The greater tic severity and tic-related impairments
Tourette syndrome, the same association has been found.24 observed in females suggest a unique natural history of
Females also had slightly higher rates of OCD and higher Tourette syndrome/PTD in these patients compared to
Children’s Yale-Brown Obsessive Compulsive Scale scores, their male counterparts. More research in the nature of the
although this did not translate to a significant relationship differential natural history may reveal more about the eti-
between sex and OCD. Studies in the general population ology of Tourette syndrome. The increased prevalence of
found OCD prevalence to be higher in males during child- ADHD diagnosis in males despite similar scale scores
hood and higher in females in adolescence/adulthood. The highlights potential systemic underdiagnosis of ADHD in
age at onset of symptoms in females is generally during or females. Additional training and health resources may be
after puberty, although studies examining sex differences in required to recognize the differential expression of ADHD
OCD prevalence reported mixed findings.35 Studies among and Tourette syndrome/chronic tic disorder in females.
those with Tourette syndrome/chronic tic disorder have
also been inconsistent.24 A CK N O W L E D G E M E N T S
This study was funded by the Owerko Centre of Alberta Chil-
Study limitations dren’s Hospital Research Institute. The authors have stated they
The main limitation of this study was its clinic-based study had no interest that might be perceived as posing a conflict or
design. Participants who are referred to a specialty clinic bias.
are more likely to have greater disease severity, which may
limit the generalizability of results to those with Tourette DATA AVAILABILITY STATEMENT
syndrome/PTD in the general population. This study was The data that support the findings of this study are avail-
cross-sectional, which may have limited the extent to which able from the corresponding author upon reasonable
conclusions could be drawn concerning certain psychiatric request.

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