pmc10169726945955Evid Based Pract Child Adolesc Ment HealthEvid Based Pract Child Adolesc Ment HealthEvidence-based practice in child and adolescent mental health2379-49252379-4933388832301117759510.1080/23794925.2023.2263856HHSPA1977082ArticleA Population-Based Study of the Utility of Screening for Tics and the Relative Contribution of Tics and Psychiatric Comorbidity to Academic and Social Impairment in Adolescentshttp://orcid.org/0000-0002-3559-4895SmithJessica N.ahttp://orcid.org/0000-0002-3559-4895OwensJulie Sarnoahttp://orcid.org/0000-0002-3559-4895EvansSteven W.ahttp://orcid.org/0000-0002-3559-4895BitskoRebecca H.bhttp://orcid.org/0000-0003-1951-9809HolbrookJoseph R.bDepartment of Psychology, Ohio University, Athens, Ohio, USADivision of Human Development and Disability, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia, USACONTACT Julie Sarno Owens, owensj@ohio.edu, Department of Psychology, Ohio University, Porter Hall 200, Athens, OH 4570122320242023146202492192204

This study examined the performance of a brief screening tool for tics in adolescents. Academic and social impairment in students by tic screen status and emotional/behavioral problem status were examined. Data were collected as part of an epidemiologic study, the Project to Learn about Youth – Mental Health. Participants were 2,312 secondary school students at the Ohio site (47.4% female; 94.4% non-Hispanic white) and their teachers. Students completed 6 items from the Motor tic, Obsessions and compulsions, Vocal tic Evaluation Survey (MOVES-6) and the Strengths and Difficulties Questionnaire (SDQ). Teachers completed the Proxy Report Questionnaire for tics and SDQ. Based on responses to the MOVES-6, 11.1% of students screened positive for tics. Internal consistency was adequate (α = 0.76); inter-rater consistency between teachers and students was low (0.03). Based on student self-report, those who screened positive for tics self-reported more academic and social impairment than students who screened negative for tics; teacher-report of impairment was similar between those with a positive or negative tic screen. Students who screened positive for tics and reported internalizing difficulties reported more academic and social impairment than students with only a positive tic screen. Teachers perceived those screening positive for tics and externalizing difficulties as the most socially impaired. In conclusion, a positive self-reported tic screen was associated with self-reported academic and social impairment. Findings reveal the independent contribution of tics to impairment, even when internalizing and externalizing problems are present, and the potential utility of a school-based screening for tics in adolescents.

Tics, defined as “sudden, rapid, recurrent, non-rhythmic, stereotyped motor movements or vocalizations” (American Psychiatric Association, 2013), occur in up to 20% of children (Kurlan et al., 2001). Persistent tic disorders, which are characterized by the presence of tics for at least a year, are present in approximately 1 in 50 children aged 5–14 years (Tinker et al., 2022). Tics tend to first appear between the ages of 4 and 6 years, with peak severity often observed between the ages of 10 and 12 years (American Psychiatric Association, 2013). Tic disorders, including Tourette syndrome, are often associated with impairment in multiple domains, including social relationships, academics, and quality of life (Eapen et al., 2016; Evans et al., 2016; Franklin et al., 2012; Ricketts et al., 2022; Storch et al., 2007). For example, students with tic disorders report that attempting to control tics is distracting (Cutler et al., 2009) and tics can interfere with their ability to write, read, and complete homework (Franklin et al., 2012; Simpson et al., 2020). Further, students may face academic consequences if a teacher is unfamiliar with the condition and finds the tics disruptive (Zhu et al., 2006) and are more likely to experience ridicule from peers (Charania et al., 2022; Himle et al., 2007; Mingbunjerdsuk & Zinner, 2020; Zhu et al., 2006).

Comparing estimates of all children with Tourette syndrome to estimates of diagnosed Tourette syndrome suggests that approximately half of children with Tourette syndrome may be undiagnosed (Tinker et al., 2022); in addition, many families report consulting with several professionals before a tic disorder is diagnosed (Wolicki et al., 2019). One reason for the challenge in identifying tic disorders may be that tics can be interpreted as habits or medical problems (Hogan & Wilson, 1999; Jankovic et al., 1998; Kovacich, 2008).

Another challenge in the identification of tic disorders is the high prevalence of comorbid mental, behavioral, and developmental disorders, as over 80% of those with tic disorders have at least one comorbid disorder (Claussen et al., 2018; Khalifa & von Knorring, 2006). Many studies have documented that these comorbidities are largely responsible for functional impairment rather than the tics themselves (Claussen et al., 2018; Eddy et al., 2012; McGuire et al., 2013; Ricketts et al., 2022), and tic disorders may consequently receive less attention. Conversely, however, other studies have concluded that tic disorders contribute meaningful impairment, or at least comparable impairment, to that contributed by psychiatric comorbidity (see for example Bawden et al., 1998; Pierre et al., 1999; Pollak et al., 2009). The mixed findings across studies may be due to (a) the use of different informants, (b) small sample sizes, (c) small or nonexistent diagnostic subgroupings for comparison, and (d) clinic-based recruitment (Bawden et al., 1998; Eddy et al., 2012; McGuire et al., 2013; Pierre et al., 1999; Pollak et al., 2009). Further investigation with larger subgroups of children with co-occurring disorders could assist in understanding the relative contribution of each disorder.

There are several potential benefits of population-based screening for tics in adolescents in school settings. First, adolescents may be less likely than younger children to attend well-child visits (Black & Boersma, 2020). Second, the school setting may help to eliminate the “clinic effect” in which tics may reduce in severity or disappear in a clinical setting when being watched (Chang et al., 2009). In fact, tics may be more apparent at school compared to a clinical setting as tics are known to worsen during times of fatigue, social interaction, and stress (Franklin et al., 2012), all of which are likely to occur at school. Third, because many schools engage in universal mental health screenings, adding a few questions about tics to this process may be an efficient use of resources. Indeed, this process allows for identification of children at risk regardless of their access to healthcare (Siceloff et al., 2017). Following school-based screening, school professionals could assist families in pursuing further relevant evaluations for students detected by screening, which could also facilitate identification of comorbid problems as tics may indicate the presence of other psychiatric difficulties (Khalifa & von Knorring, 2006; Kurlan et al., 2001).

While teachers are unlikely to be as familiar with their students as parents are with their children, there are several potential benefits to teacher’s screening for tics in adolescence. Teachers may be useful informants of tics as they spend more time with students than healthcare providers, and disruptive behavior is likely to be noticed (Gadow et al., 2002). In addition, teachers have more opportunities for peer comparisons as references than parents (Evans et al., 2005). One study revealed that teacher report for identifying tic disorders using the proxy-report questionnaire (PRQ) had adequate specificity (74%) and negative predictive value (81%); however, sensitivity (40%) and positive predictive value (30%) were low (Cubo et al., 2011).

Although teacher-report may be helpful for identifying tics that are observable, self-report may offer incremental utility as for some youth the distress and impairment related to tics is often internal (e.g., premonitory urges; Franklin et al., 2012; Openneer et al., 2020). Self-report of symptoms in school-based screening might be especially beneficial in middle and high school settings when teachers spend less time with individual students (Margherio et al., 2019). Although few studies include self-report measures for the identification of tics (Martino et al., 2017), one study reported higher sensitivity by child report than teacher report on a tic screener when comparing to an expert clinical assessment as the gold standard (Adams et al., 2023). Thus, considering student report is important in the context of evaluating universal tic screening in schools.

The Motor tic, Obsessions and compulsions, Vocal tic Evaluation Survey (MOVES) is brief self-report measure that assesses for the presence of tics, obsessions, and compulsions (Gaffney et al., 1994). In the original study of the MOVES in a clinic sample including children as young as 7 years through adulthood and enriched for individuals with tic disorders, the measure had a sensitivity of 87% and specificity of 94% compared with expert clinical assessment, as well has a high correlation (r = 0.73) with the Yale Global Tic Severity Scale (YGTSS; Gaffney et al., 1994). In a second clinic-based study focused on the impact of tic disorders, which included 161 children aged 5 to 18 years with tic disorders and 74 community controls, the MOVES had high sensitivity (90%) and acceptable specificity (77%) compared to expert clinical assessment (Lewin et al., 2023). In this second study, six items were identified from the 20-item full version that were most highly associated with tic disorders and were less often endorsed for children without tic disorders (Lewin et al., 2023). A sub-analysis of the 6 items (“MOVES-6”) found that sensitivity (88%) and specificity (86%) were both good. Thus, the MOVES-6 could serve as a brief self-report measure for tics in school-based screening.

The present study describes school-based screening for tics, internalizing symptoms, and externalizing symptoms by teachers and students in a population-based epidemiologic study of 2,312 middle- and high-school students. To address the above-described public health concerns and limitations in the literature, the study aims were to examine (a) several psychometric properties (i.e., internal consistency, student/teacher cross-informant consistency) of the self-report MOVES-6 in adolescents and (b) academic and social impairment in students (based on both teacher- and student- report) with and without a positive screen for tics (based on student-report) and with and without indication for internalizing and externalizing problems (based on student- and teacher-report, respectively). Although the present study was descriptive in nature, we had general hypotheses. Specifically, we expected that students would identify a higher rate of tics than teachers (e.g., Franklin et al., 2012). We also expected that students with internalizing problems would self-report more impairment than teachers, whereas students with externalizing problems would self-report less impairment than teachers (Aebi et al., 2017; Margherio et al., 2019; Smith, 2007). We also expected that youth with more comorbid symptoms would be more impaired overall than youth with less symptoms (e.g., those with tics, internalizing problems, and externalizing problems would be more impaired than youth with any one of these problems).

Materials and methodsParticipants

Screening data were collected at the Ohio site of an epidemiologic study, the Project to Learn about Youth-Mental Health (Danielson et al., 2021). In the district where data were collected, there were 1,374 middle school students and 1,729 high school students. Teacher ratings were completed for 1,302 (95%) middle school students, and 1,626 (94%) high school students. Student ratings were obtained from 1,268 (92%) middle school students and 1,266 (73%) high school students. Elementary students were not included in these analyses because they did not complete the MOVES-6 self-report measure. In most cases (69.1%), teachers reported knowing the student for at least 3 months; 30.5% reported knowing the students 1–2 months and 0.5% reported knowing the students for less than one month.

The current dataset includes the middle (n = 1,149; 84%) and high school students (n = 1,163; 67%) for whom there were complete teacher and student ratings on all measures described below. In this sample, 47.4% of students were female, 94.4% identified as White and non-Hispanic, and 43% were eligible for free or reduced lunch.

Reasons for missing teacher ratings included students who were attending an online academy, a post-secondary school, or were home-schooled, and students who moved out of the district between the start of the school year and the screening date. Reasons for missing student self-report ratings included parents who actively requested that their student not complete the student measures (6 in middle school; 29 high school); students who did not attend school on the day of screening, or the those who attended but actively declined to complete the surveys.

High school student data were not missing at random. Namely, missing student surveys were more common among students who were rated as high risk on the Strengths and Difficulties Questionnaire (SDQ) by teachers than among students who were rated low risk by teachers (risk status is defined below in Measures section). Stated differently, 35% of students rated as at-risk by the teachers did not complete self-ratings; in contrast, 21% of students rated as low-risk by the teachers did not complete the survey. Thus, the rates of risk status (for tic and internalizing and externalizing problems) may be under-represented in the high school population.

Procedures

The project was approved by Ohio University IRB (#14-F-49). We obtained a waiver of active informed consent from the Ohio University IRB and school district. Letters describing the screening were mailed to every household by the school district. Parents or guardians could contact the principals or the investigators if they wished to opt-out of the screening. Teachers of primary subjects rated 30 students or fewer. The teacher of a student’s first-occurring primary subject was invited first; if that teacher declined to participate in the study, the investigators invited the teacher of the next period to participate until there was a teacher match for every student. Once teachers agreed to participate, they were sent links for surveys to complete using the Research Electronic Data Capture system (REDCap; Harris et al., 2009). Teachers completed all assigned surveys at the same time (within the same month). Teachers were compensated $5 for every student for whom they completed the screening. Each school received a $500 participation stipend.

Student assent and self-ratings were obtained in a group format using paper surveys. If students were absent during the designated meeting, school counselors attempted to have them complete the survey another day. Students were not compensated for completing the survey. The lower response rate for high school students largely reflects student absence on the day of screening. High school ratings (teacher and student) were obtained in spring of 2015. Teacher and student ratings for middle school students were obtained midway through the Fall semester of 2015 and midway through the spring of 2016, respectively.

MeasuresMOVES-6

Students completed six items from the MOVES (Gaffney et al., 1994) (the “MOVES-6” (see Lewin et al., 2023) which includes the following items: At times I have the same jerk over and over; I can’t control all of my movements; I make noises (like grunts) that I can’t stop; Parts of my body jerk again and again, that I can’t control; I feel the pressure to talk, shout, or scream; I have habits or movements that come out more when I’m nervous. Items were rated on a 4-point scale: never (0), sometimes (1), often (2), and always (3). Total scores were created by summing the responses to the six items (i.e., scores range from 0 to 18). With no published study on the psychometric properties of the MOVES-6 at the time of this study, and differing optimal thresholds identified in previous studies of the full MOVES (Gaffney et al., 1994; Lewin et al., 2023), various thresholds for determining positive screen status were explored, as described below in the Data Analytic Plan.

Proxy report questionnaire (PRQ)

Teachers completed the PRQ (Linazasoro et al., 2006) which provides a description of the most common motor and vocal tics and then asks whether a child (1) has ever had tics, and (2) whether the child currently has tics.

Strengths and difficulties questionnaire (SDQ)

Students and teachers completed the SDQ (Goodman, 2001), a 25-item questionnaire comprised of five subscales (of five items each) assessing: emotional problems, conduct problems, hyperactivity/inattention, prosocial behavior, and peer relationship problems. Items are rated as not true (0), sometimes true (1), or certainly true (2). Subscale scores are derived by summing the five items on each subscale (subscale scores range from 0 to 10). Cutoff scores representing the 90th percentile for each subscale are published at www.sdqinfo.org. Symptom groups were formed using the 90th percentile cutoff scores for the student-rated emotion problem subscale score (alpha = 0.86) for internalizing problems (INT), the teacher-rated hyperactivity/inattention subscale score (alpha = 0.72) for externalizing problems (EXT), and the student-rated MOVES-6 for presence of potential tics (see Table 1). Different reporters (i.e., students, teachers) were used for internalizing and externalizing problems because student self-report has been shown to perform better at identifying internalizing problems, whereas teachers are likely more accurate raters of externalizing problems than students (Aebi et al., 2017; Margherio et al., 2019; Smith, 2007). In addition, an evidence of difficulties item inquires if the individual has difficulties in concentration, behavior, or getting along with others as a result of the symptoms reported in the five subscales. Response options are no difficulties (0), minor difficulties (1), definite difficulties (2), and severe difficulties (3). If the informant endorses the presence of difficulties (score of 1 or higher), the informant is asked to answer an impairment item in two domains (i.e., the extent to which the difficulties interfere with peer relationships and classroom learning). Items are rated as causing impairment not at all (0), only a little (1), a medium amount (2), or a great deal (3).

Data analytic plan

To determine the threshold representing a positive screen for tics, we examined the distribution of student MOVES-6 scores (summation across 6 items). We identified the score representing the 90th percentile (i.e., the score below which 90% of students’ scores fell), as this aligns with the categorical thresholds for SDQ risk status. Then, we examined the score above and below this threshold, considering prevalence rates, impairment scores, and cross-informant agreement. The MOVES-6 score at the 90th percentile is 5, identifying 11.1% percent of the sample who scored 5 or above. Regarding impairment, average impairment scores only decreased by 0.1 with a cutoff score of 4 and only increased by 0.1 with a cutoff score of 6. Thus, no single score was associated with a greater change in impairment than others. Similarly, no threshold was associated with greater student-teacher agreement than other thresholds (i.e., agreement on the positive risk status remained below 1% for all three cutoff scores). Thus, a threshold of 5 was retained. Lastly, these patterns and determinations did not differ between middle and high school scores.

Using the full sample, Cronbach’s alpha and item-total correlations were used to examine internal consistency. Kappa, McNemar, and Chi-square coefficients were used to examine cross-informant agreement between the student MOVES-6 and teacher PRQ. For the PRQ, the two items (present or past tics) were highly correlated (r = 0.90). Thus, a positive endorsement on either item was considered positive screen status.

To describe the degree of difficulties associated with tics, internalizing, and externalizing problems, two one-way Analysis of Variance tests (ANOVAs) were conducted on the difficulties item (separately for teacher and student report) in the seven mutually exclusive symptom groups (see Table 1). Post-hoc Games-Howell tests were conducted to assess differences between each symptom group. To determine the extent to which teacher- and student-reported impairment was associated with symptom groups among the sub-sample with endorsed difficulties (i.e., a score of 1 or higher on the difficulties item), two one-way Multivariate Analysis of Variance tests (MANOVAs) were conducted on the SDQ impairment items. The first MANOVA used teacher-reported peer and classroom impairment. The second MANOVA used student-reported peer and classroom impairment. Multivariate main effects were probed with follow-up univariate tests and post-hoc tests (Games-Howell procedure) to determine which groups differed significantly in impairment. See sample sizes for each analysis in Figure 1.

ResultsPsychometric properties of the MOVES-6

The MOVES-6 (self-report) displayed an internal consistency of α = 0.76. Neither item removal, nor subgrouping items (e.g., vocal versus motor tics) improved internal consistency above 0.76. Using the threshold of 5, the MOVES-6 identified 11.1% (n = 257) of students screened positive for tics (n = 137). Prevalence was higher for middle school (14.5%) than high school students (7.7%). The average MOVES-6 score was 7.46 (SD = 2.84) for those above the threshold in middle school and 7.16 (SD = 2.93) for those above the threshold in high school. Although most students screening positive for tics had a score between 5 and 8, approximately 30% had a score of 9 or higher. The average MOVES-6 score was 1.10 (SD = 1.29) for children scoring below the threshold in middle school and 0.74 (SD = 1.13) in high school. Only 5% of students below the threshold scored close to the threshold (i.e., 4). By teacher report on the PRQ, 1.6% of students (n = 37) screened positive for tics. Teachers reported 1.3% and 1.9% of students had tics in middle school and high school, respectively.

A statistically significant association was observed between tic screen status by teacher report on the PRQ and student report on the MOVES-6 (χ2 (1, N = 2,312) = 4.20, p < .05); however, Kappa was low (0.03), indicating low agreement between teacher and student report of tics. McNemar’s test revealed that there were significantly (p < .001) more occasions in which the student-report resulted in a positive tic screen and the teacher-report did not (10.8%) than the converse (1.3%). Even among students with a positive tic screen per teacher report (n = 37), only 8 (21.6%) of these students screened positive for tics by self-report.

Perceived difficulties and impairment profilesDifficulty scores

For the one-item teacher-rated difficulty ratings, the main effect of symptom group was statistically significant (F(7,2304) = 133.56, p < .001). Games-Howell pairwise comparisons (see Table 2 for statistically significant effects) indicated that students in the tic-only group were rated as having significantly more difficulties (M = 0.60; SD = 0.82) than students in the negative screen group (M = 0.29; SD = 0.60; d = 0.44). Students in any group positive for EXT symptoms were rated as having significantly more difficulties than students in each group that was negative for EXT (i.e., negative screen, tic only, INT only, tic+INT). Students in the negative screen group were rated as having significantly less difficulty than students in all other groups except for students the INT group (see Table 2).

For the student-rated difficulties item, a statistically significant main effect of group was observed (F(7,2296) = 92.25, p < .001). Games-Howell comparisons indicated that students in the tic-only group reported significantly more difficulties (M = 1.05; SD = 0.85) than students in the negative screen group (M = 0.43; SD = 0.62) (d = .83). Students in the tic+INT group had the highest difficulties scores, significantly higher than most groups (except INT+EXT and tic+INT+EXT), highlighting the additional contribution of internalizing symptoms in student-perceived impairment (see Table 2).

Impairment

The first MANOVA was conducted on teacher-reported peer and classroom impairment. A statistically significant multivariate effect of group was observed (F(14,1382) = 7.77, p < .001; Wilk’s Λ = 0.89, partial η2 = 0.07). This effect was found for both impairment in peer relations (F(7, 2.59) = 3.98 p < .001) and classroom functioning (F (7, 7.95) = 13.17; p < .001). For peer impairment, students in the tic+EXT group were rated as more impaired than students in the negative screen/control group (see Table 2 and Figure 2); no other comparisons were statistically significant. For classroom impairment, students in any group that was positive for EXT symptoms were rated significantly more impaired than students in each group that was negative for EXT (i.e., negative screen, tic only, INT only, tic+INT); no statistically significant differences were found among groups positive for EXT.

The second MANOVA was conducted on self-reported peer and classroom impairment, with a statistically significant multivariate effect of group, (F(14, 1890) = 14.14, p < .001; Wilk’s Λ = 0.82, partial η2 = 0.09). This effect was found for impairments in peer relations (F(7, 16.42) = 19.94 p < .001) and classroom functioning (F(7, 120.68) = 12.14; p < .001). For peer relations, students in the tic-only group (M = 1.20; SD = 1.01) reported significantly more impairment than students in the negative screen/control group (M = 0.76; SD = 0.85; d = 0.50). Students in the tic+EXT group did not differ from students in the tic-only group. Students in the tic+INT group reported the most peer impairment of any group (see Table 1 and Figure 2). Students in the EXT and EXT+INT groups reported the least impairment with peers and were not statistically different from students in the negative screen group. For classroom impairment, students in the tic-only group (M = 1.55; SD = 1.03) reported significantly more impairment than students in the negative screen/control group (M = 0.99; SD = 0.97) (d = 0.60). Students in the tic+INT group (M = 1.72; SD = 1.17) reported more severe classroom impairment than students in the negative screen/control and tic-only groups. Students in the tic+INT +EXT group had highest classroom impairment ratings (see Table 1 and Figure 2).

Discussion

This study advances the literature by assessing (a) several psychometric properties of the six items from the MOVES (referred to as MOVES-6) in a school-wide screening process of middle- and high-school students, (b) the relative utility of student and teacher report of tics in adolescents, and (c) the impairment profiles of those screening positive or negative for tics and internalizing and externalizing symptoms.

As expected, the prevalence of possible tics (11.1%) identified by student report on the MOVES-6 was higher than the prevalence of diagnosed tic disorders (Knight et al., 2012); however, this estimate is similar to or lower than population-based estimates of tics in other studies, where the range is 8–25% (Gadow et al., 2002; Kurlan et al., 2001; Snider et al., 2002). This lower prevalence is expected given that our sample was comprised of middle- and high- school students compared to studies that included younger children (Gadow et al., 2002; Kurlan et al., 2001; Snider et al., 2002). A recent study examined various MOVES-6 thresholds in identifying those with clinically diagnosed tic disorders (Lewin et al., 2023). In that study, 161 children with previously identified tic disorders and 74 children without tic disorders completed the full MOVES, and cutoffs that optimized sensitivity and specificity were calculated for the MOVES (5) and MOVES-6 (3). Using a cutoff of 3 for the MOVES-6, the sensitivity was 88% and the specificity was 86%, while a cutoff of 5 (as used in the current study) resulted in a sensitivity of 71% and a specificity of 96%. Thus, applying the cutoff of 5 to the current study represents high confidence that those identified as not having tics are true negatives, though we might have missed some students with tics. However, different studies have identified different optimal cutoffs for the full MOVES (Gaffney et al., 1994; Lewin et al., 2023) and only 5% of students in the current study scored a 4 on the MOVES-6, suggesting that a relatively small number of students might have been missed if the optimal cutoff is truly closer to 3.

The low agreement about mental health status between informants has been reported previously (Achenbach et al., 1987). This finding is consistent with a study that assessed the utility of the teacher-rated PRQ, where teacher and parent agreement was low (Cubo et al., 2011). Because there was no gold standard assessment of tics, the findings reported here cannot determine whether teachers or students are better reporters of tics, only that they were indeed discrepant. It is also noteworthy that teachers and students completed different tic screens, which may have contributed to discrepancy. Reporting of tics by teachers versus students may vary based on the noticeability of tics, and how much of the distress related to tics in adolescents is internal (e.g., premonitory urges; Franklin et al., 2012). Future investigations might consider these factors associated with teacher versus student report, as well as the utility of teachers conducting screening for tics among elementary school-aged students.

Regarding psychiatric comorbidity, 46% of students who screened positive for tics screened positive for a comorbid problem (35% for EXT; 33% for INT). All three rates were lower than that commonly reported for comorbid disorders among children with tic disorders (Chang et al., 2009; Hirschtritt et al., 2015). It may be that the MOVES-6 identified children with mild tics who do not (yet) meet criteria for a persistent tic disorder, and/or children with non-tic movements (e.g., stereotypy or hyperactivity) who may also be somewhat less likely to experience co-occurring problems. It has been found that community-samples of children with tic disorders tend to have lower rates of co-occurring disorders compared to studies based on clinic populations (Gaze et al., 2006). This finding may represent that those in clinic samples experience co-occurring problems with greater severity and that prompt the pursuit of treatment. The equal representation of internalizing and externalizing problems could also imply that internalizing comorbidity is as common as externalizing comorbidity and is more likely detected when youth self-report is included.

Of note, students with tics only self-reported having more difficulties than those without tics, highlighting the independent contribution of tics to impairment (d = 0.83). Average scores on the difficulties item indicate that while students in the negative screen group reported no difficulties, students with tics reported at least some difficulties (scores >1). Within the subsample with difficulties, students with tics reported on average between a little and a medium amount of peer and classroom impairment, and students without tics experienced minimal such impairment (ds ranged from 0.50 to 0.60). These findings are consistent with studies that suggest tics can contribute to poor academic performance and social impairment (Eapen et al., 2016; Evans et al., 2016; Himle et al., 2007; Ricketts et al., 2022; Zhu et al., 2006). Interestingly, this pattern was not observed with teacher-rated impairment (i.e., teachers did not report that youth with self-identified tics only were more impaired than youth without).

The presence of comorbid internalizing problems was associated with elevated student-rated peer impairment relative to that observed in the tic only group. For student-rated classroom impairment, students with both externalizing and internalizing problems, regardless of the presence of tics, reported the most severe impairment. These data highlight why impairment associated with comorbid problems might be given priority when students present to clinics for treatment and why tic-related impairment, although meaningful, might be overlooked relative to other problems.

The presence of comorbid externalizing symptoms was associated with significantly greater teacher-rated impairment. This finding is consistent with studies reporting that teachers under-identify internalizing concerns, but are adept at identifying externalizing behaviors; alternatively, adolescents are often thought to be poor informants of their own externalizing behaviors (Achenbach et al., 1987). Indeed, the presence of tics or internalizing symptoms alone may not be sufficient for the teacher to detect impairment. However, externalizing symptomatology significantly impacts teacher perceptions of impairment. Notably, although we attempted to use the most ideal informant possible for each presentation, associations between symptoms and impairment may be due in part to shared informant (i.e., student-report of internalizing problems and student-reported impairment; teacher-report of externalizing problems and teacher-reported impairment).

The current study is limited in that there was no gold standard clinical assessment for determination of tics, psychiatric comorbidities, or functional impairment. To document the accuracy of the MOVES-6 in identifying specific symptomatology, future studies could compare the MOVES-6 to clinical identification of tics, tic disorders, and comorbidities (see Lewin et al., 2023). Second, missing data from the high school sample were disproportionately associated with risk status on the SDQ; thus, tic risk in this sample may be under-represented. Third, the use of different measures to identify tics (MOVES-6 was only completed by students and the PRQ was only completed by teachers) may have contributed to discrepancy in reporting of tics between students and teachers. Fourth, the present study leveraged a large, epidemiological dataset on middle- and high-school students who completed the MOVES-6, an age at which tics may be near-peak severity and yet still undiagnosed. However, this age range may be late for universal screening of tics, as those still without diagnoses would have gone undetected for already many years and may have benefited from earlier screening. Last, the sample was not racially or ethnically diverse; thus, generalization to diverse student populations may be limited. Future studies with more diverse populations of students should explore determine whether the MOVES-6 performs differently in identifying status of tics and tic disorders.

Despite these limitations, this study documents several psychometric properties of the MOVES-6 and suggests that adolescents may be useful informants of their own tic experiences. The MOVES-6 holds promise as a brief screening tool to improve identification of possible tics, which could lead to referral for a diagnostic assessment of tics themselves, which contributed meaningfully to impairment in this study, as well as any co-occurring psychiatric symptoms.

Funding

The data presented in this article were obtained in a project supported by the Disability Research and Dissemination Center (DRDC) through its Grant Number [5U01DD001007-03] from the Centers for Disease Control and Prevention (CDC). The contents of the article are solely the responsibility of the authors and do not necessarily represent the official views of the DRDC or the CDC.

Disclosure statement

No potential conflict of interest was reported by the author(s).

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Sample sizes in the present study. Symptom groups defined by the presence of tics, externalizing difficulties (EXT), internalizing difficulties (INT) based on screening instruments (student report on MOVES-6 for tics, teacher report on Strengths and Difficulties Questionnaire (SDQ) for EXT, and student report on SDQ for INT). Numbers may not sum exactly to 100% due to rounding. Data collected in 2015–2016 as part of the Ohio site of the Project to Learn about Youth Mental Health (PLAY-MH).

Teacher-rated (Panel 2a) and student-rated (Panel 2b) peer and classroom mean impairment on the Strengths and Difficulties Questionnaire (SDQ) by symptom group. Symptom groups defined by the presence of tics, externalizing difficulties (EXT), internalizing difficulties (INT) based on screening instruments (student report on MOVES-6 for tics, teacher report on Strengths and Difficulties Questionnaire (SDQ) for EXT, and student report on SDQ for INT). SDQ evidence of difficulties item ranges from not at all (0) to a great deal (3). Error bars represent standard errors. Data collected in 2015–2016 as part of the Ohio site of the Project to Learn about Youth Mental Health (PLAY-MH).

Formation of mutually exclusive symptom groups using the MOVES-6 and subscale scores of the Strengths and Difficulties Questionnaire (SDQ).

MeasureGroupMOVES-6Score ≥ 5Self-Report SDQEmotion Problems Score ≥ 7Teacher Report SDQHyperactive/Inattention Score ≥ 7
Negative Screen
Tic OnlyX
Tic+INTXX
Tic+EXTXX
EXT onlyX
INT onlyX
EXT+INTXX
Tic+EXT+INTXXX

The Negative Screen group includes students whose scores on the above measures were below the above-described thresholds. The presence of tics (Tic) is based on the student-rated MOVES-6 summed score, internalizing problems (INT) are based on using the 90th percentile cutoff scores for the student-rated emotion problem subscale score on the SDQ, and externalizing problems (EXT) are based on the 90th percentile cutoff scores for the teacher-rated hyperactivity/inattention subscale score on the SDQ.

Descriptive Statistics for the Strength and Difficulties Quesionnaire (SDQ) Teacher and Student difficulty and impairment ratings by symptom group.

Symptom GroupTeacher Difficulty Score M(SD)Teacher Peer Impairment M(SD)Teacher Class Impairment M(SD)Student Difficulty Score M(SD)Student Peer Impairment M(SD)Student Class Impairment M(SD)
Negative Screen0.29 (.60)a0.87 (.79)a1.49 (.82)a0.45(.63)a0.76 (.85)a0.99 (.97)a
Tic only0.60 (.82)b0.93 (.78)a,b1.64 (.76)a1.05 (.85)b1.29 (1.01)b1.55 (1.02)b
Tic+EXT2.06 (.91)c1.50 (.97)b,c2.37 (.72)b1.13 (.92)b,d1.14 (.77)ab1.64 (.95)a,c
Tic+INT0.56 (.67)b,d0.88 (.61)a,b,c1.31 (.82)a,c1.87 (.84)c1.90 (1.02)c1.72 (1.17)b,c
EXT only1.58 (.88)c1.14 (.87)b,c2.02 (.70)b0.56 (.71)a,d0.63 (.84)a1.33 (1.00)a
INT only0.31 (.58)a1.14 (.74)a,b,c1.45 (.89)a,c1.24 (.80)b1.38 (1.03)b1.38 (.92)b
EXT+INT1.89 (.78)c0.89 (1.17)a,b,c2.00 (.71)a,b,c0.89 (.93)a,b,c,d0.60 (.55)a,b1.80 (1.30)a,b,c
Tic+EXT+INT2.00 (.68)c,d1.00 (.78)a,b,c2.21 (.80)a,b1.64 (1.08)b1.58 (1.08)a,b,c2.50 (.80)c

Symptom groups were defined by the presence of tics, externalizing difficulties (EXT), internalizing difficulties (INT) based on screening instruments (student report on MOVES-6 for tics, teacher report on Strengths and Difficulties Questionnaire (SDQ) for EXT, and student report on SDQ for INT). One-way Analysis of Variance (ANOVA) tests with Games-Howell pairwise comparison tests were conducted to assess differences between each symptom group on each difficulties score. One-way Multivariate ANOVA tests with Games-Howell pairwise comparison tests were conducted to assess differences between each symptom group on the impairment scores. Within each column (for each measure) subscripts (a-d) indicate results of statistical comparisons, such that estimates with the same subscript are not statistically different (p ≥ .05) from each other (e.g., in the first column, teacher difficulty score, the negative screen group is not statistically different from INT only, but is significantly different from all other groups).

See Figure 1 for sample sizes for difficulties scores (total sample) and impairment scores (subsamples).

Data collected in 2015–2016 as part of the Ohio site of the Project to Learn about Youth Mental Health (PLAY-MH).