Psychiatry Research (xxxx) xxxx–xxxx

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Psychiatry Research
journal homepage: www.elsevier.com/locate/psychres

Letter to the editor

Do ADHD subtypes related to specific impairment of cognitive functions in boys with TS?

To the editors,
We read with great interest the article by Termine et al. (Termine et al., 2016) published in the Journal recently. The authors carried out a
controlled study to examine the impact of comorbid attention deficit hyperactivity disorder (ADHD) on cognitive function in boys with Tourette
syndrome (TS). The results showed that in neuropsychological tests the TS+ADHD group was the most severely affected, followed by the ADHD
group, and then the TS group, which suggested that deficits of cognitive function in children with TS appeared to be more strongly related to the
presence of comorbid ADHD symptoms than core TS symptoms. This report is a significant attempt to determine the possible contributions of tic
symptoms and ADHD symptoms in cognitive deficits in patients with TS. It is well designed; however, there are several concerns when interpreting
the results.
First, the present report did not provide the information of specified ADHD subtypes for children with TS, and therefore the reader would not be
able to link one certain ADHD subtype to a specific cognitive deficit. As is well known, ADHD is a highly neuropsychologically heterogeneous
condition, with different individuals being associated with different patterns of pathophysiological and neuropsychological processes (Castellanos
and Tannock, 2002). Subgroups of children with particular neuropsychological profiles have been identified (Castellanos and Tannock, 2002; Fair
et al., 2012; Sonuga-Barke et al., 2010), suggesting the possible relationship of ADHD subtypes and neuropsychological deficits (Nigg et al., 2005a,
2005b). A study by Barkley (Barkley, 1991) has indicated that the inattentive subtype is qualitatively different, with ADHD-C representing impaired
goal-directed persistence arising from poor inhibition and ADHD-I reflecting impaired speed of processing. In addition, children with ADHD-C
compared with those with ADHD-I have more difficulties inhibiting inadequate responses (Geurts et al., 2005; Huang-Pollock et al., 2005). There is
also another study showing that children with ADHD-I display a slower tempo for information processing than children with ADHD-C (Nigg et al.,
2002). However, these findings did not establish the definite link between one particular ADHD subtype and specific cognitive deficits, since the
current evidence is inconsistent and needs to be confirmed. If the association is proved in the future, it may be able to replace the monolithic
category of ADHD and provide more insight into the spectrum of possible distinct and neurobiologically defined entities (Koziol and Budding,
2012). Therefore, the authors are strongly encouraged to undertake this work, which would expand on the results reported in the present study.
Second, a description of the severity of ADHD symptoms was absent in the report, which limits the exploration of possible relationships between
the severity of ADHD clinical symptoms and neuropsychological functional impairments in children with TS. Neurocognitive functioning may act as
a predictor of symptom severity and overall functioning of ADHD (Willcutt et al., 2005), and it plays a key role in several models of ADHD (Barkley,
1997; Sergeant, 2000; Sonuga-Barke et al., 2010). The study (Halperin and Schulz, 2006) on relevance of neurocognitive functioning for the course
of ADHD showed that better functions of inhibition and working memory may contribute to better ADHD outcomes. However, it remains unknown
whether there is an association of ADHD symptom severity and impairments of neurocognitive function in children with both ADHD and TS.
To our knowledge, there have been no systematic studies aimed at these two mentioned concerns. It is therefore necessary to consider them in
designing future studies.

Sources of financial assistance

None.

Potential conflicts of interest

None.

References

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Castellanos, F.X., Tannock, R., 2002. Neuroscience of attention-deficit/hyperactivity disorder: the search for endophenotypes. Nat. Rev. Neurosci. 3 (8), 617–628.
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http://dx.doi.org/10.1016/j.psychres.2016.12.047
Received 21 August 2016Received in revised form 5 November 2016Accepted 29 December 2016
0165-1781/ © 2017 Elsevier B.V. All rights reserved.
Letter to the editor Psychiatry Research (xxxx) xxxx–xxxx

Nigg, J.T., Blaskey, L.G., Huang-Pollock, C.L., Rappley, M.D., 2002. Neuropsychological executive functions and DSM-IV ADHD subtypes. J. Am. Acad. Child Adolesc. Psychiatry 41 (1),
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Termine, C., Luoni, C., Fontolan, S., Selvini, C., Perego, L., Pavone, F., Rossi, G., Balottin, U., Cavanna, A.E., 2016. Impact of co-morbid attention-deficit and hyperactivity disorder on
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Willcutt, E.G., Doyle, A.E., Nigg, J.T., Faraone, S.V., Pennington, B.F., 2005. Validity of the executive function theory of attention-deficit/hyperactivity disorder: a meta-analytic review.
Biol. Psychiatry 57 (11), 1336–1346.

Shujiong Mao,, Rongwang Yang

Department of Pediatrics, Hangzhou First People's Hospital, Hangzhou, Zhejiang Province, China
Department of Child Psychology, The Children's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China
E-mail address: maoshujiong@126.com

⁎
Correspondence to: No. 261 Huansha Road, Hangzhou, Zhejiang Province, China.