Beyond tics: executive functioning and psychopathological comorbidities in children and adolescents with Tourette syndrome. A systematic review

Pediatric Tourette syndrome (TS) is heterogeneous, and functional outcomes are associated not only with tic severity but also with comorbid psychopathology and self-regulatory difficulties. We systematically reviewed (i) psychiatric/psychosocial comorbidities and their links to functioning and (ii) executive functioning (EF), explicitly contrasting performance-based and ecological measures. The protocol was preregistered on OSF and reported according to PRISMA. PubMed, PsycINFO, and Web of Science were searched from inception to 30 March 2025. Eligible studies included participants ≤18 years with TS and outcomes on psychiatric/psychosocial features and/or EF. Risk of bias was assessed using the Newcastle-Ottawa Scale. Thirty studies from 12 countries were included; 22 were rated low risk of bias. Given heterogeneity, findings were synthesized narratively. Comorbidity was common and ADHD-related symptoms were the most consistent correlates of externalizing problems, school difficulties, and poorer psychosocial functioning. Anxiety and obsessive-compulsive symptoms were frequent and associated with greater clinical complexity, while depressive symptoms tended to co-occur with broader psychosocial impairment. EF difficulties were more evident in TS with comorbidities, particularly ADHD, but groups with TS-only were not uniformly free of selective or context-dependent vulnerabilities. While performance-based tasks often indicated relatively preserved executive control in groups with TS-only, ecological/parent-report measures more consistently captured everyday difficulties (especially inhibition/behavioral regulation and working memory). A multidimensional view of pediatric TS highlights the importance of assessing tic severity together with psychiatric comorbidities, psychosocial functioning, and both performance-based and ecological EF measures.