new thoughts on the behavioral treatment of tourette syndrome john piacentini, ph.d., abpp child...
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New Thoughts on the New Thoughts on the Behavioral Treatment ofBehavioral Treatment of
Tourette Syndrome Tourette Syndrome
New Thoughts on the New Thoughts on the Behavioral Treatment ofBehavioral Treatment of
Tourette Syndrome Tourette Syndrome
John Piacentini, Ph.D., ABPPJohn Piacentini, Ph.D., ABPP
Child OCD, Anxiety, and Tic Disorders ProgramChild OCD, Anxiety, and Tic Disorders Program
Semel Institute for Neuroscience and Human BehaviorSemel Institute for Neuroscience and Human Behavior
UCLA School of MedicineUCLA School of Medicine
Advances in Tourette SyndromeFelsenstein Medical Research Center
Schneider Children’s Medical Center of IsraelTel Aviv, Israel - February 26, 2006
AcknowledgementsAcknowledgements
Some of the work described in this presentation was supported by grants from the:
TOURETTE SYNDROME ASSOCIATION
NATIONAL INSTITUTE OF HEALTH
NIMH / NINDS
KAREN MAYES GAMORAN FAMILY FOUNDATION
The Dr. David Feinberg Fellowship of the Semel Institute - UCLA and Schneider's Children's Medical Center – Israel
TSA Behavioral Sciences ConsortiumTSA Behavioral Sciences Consortium
Susanna Chang, PhD.Susanna Chang, PhD. UCLA Neuropsychiatric InstituteUCLA Neuropsychiatric Institute
Thilo Deckersbach, PhD.Thilo Deckersbach, PhD. Mass General Hospital/HarvardMass General Hospital/Harvard
Golda Ginsberg, PhD.Golda Ginsberg, PhD. Johns Hopkins UniversityJohns Hopkins University
Alan Peterson, PhD.Alan Peterson, PhD. Wilford Hall Medical CenterWilford Hall Medical Center
John Piacentini, PhD.John Piacentini, PhD. UCLA Neuropsychiatric InstituteUCLA Neuropsychiatric Institute
Lawrence Scahill, MSN, PhD.Lawrence Scahill, MSN, PhD. Yale Child Study CenterYale Child Study Center
John Walkup, MD.John Walkup, MD. Johns Hopkins UniversityJohns Hopkins University
Sabine Wilhelm, PhD.Sabine Wilhelm, PhD. Mass General Hospital/HarvardMass General Hospital/Harvard
Douglas Woods, PhD.Douglas Woods, PhD. University of Wisconsin-MilwaukeeUniversity of Wisconsin-Milwaukee
How can Behavioral Psychology How can Behavioral Psychology inform us about TSinform us about TS
The central tenet of Behavioral Psychology is that behavior is determined by a combination of forces comprised of biological - including genetic - and environmental factors.
Biology/GeneticsBiology/Genetics
Behavioral Psychology and TSBehavioral Psychology and TS
EnvironmentEnvironment
TicsTics
Behavioral Psychology primarily concerned with this relationship
Biological FactorsBiological Factors
GeneticsGenetics Twin StudiesTwin Studies
• MZ concordance 86%; DZ concordance 20% Family StudiesFamily Studies
• Risk of TS in relatives 10-15%
Perinatal/Postnatal InsultsPerinatal/Postnatal Insults• LBW, maternal stress, chemical exposure, placental insufficiency, gestational diabetes, PANDAS
NeurobiologyNeurobiology• Cortico-striato-thalamo-cortical (CSTC) circuits
Role of the EnvironmentRole of the Environment
Underlying biological abnormalities may explain broad consistency of symptom presentations seen in TS
Different experiences involving interactions with the environment may explain presentation differences.
Environmental FactorsEnvironmental antecedents and consequencesEnvironmental determinants of tic suppressionRole of Premonitory Urge
An individualized approach to understanding environment/behavior interaction is key
Woods, 2004; and others
Environmental FactorsEnvironmental Factors
ANTECEDENTS Being upset or anxious (Silva et al., 1995)
Watching TV (Silva et al., 1995) Being Alone or with Others (Silva et al., 1995)
Stressful Life Events (Surwillo et al., 1978)
Hearing Others Tic or Talking about Tics (Commander et al., 1991; Woods et al., 2000)
CONSEQUENCES Being teased
TIC SUPRESSION Ticcers can control tics under certain conditions
A Neurobehavioral ModelA Neurobehavioral Model
of Tourette Syndromeof Tourette Syndrome
Behavioral Sciences Consortium of the Tourette Syndrome Association
Neurobehavioral Model of TSNeurobehavioral Model of TS
Speculative at this point • Some data supporting certain aspects of the model
• Other aspects are consistent with clinical observation
Useful as an aid to treatment development and planning • Identify specific individual and environmental targets for intervention
• Identify specific techniques to use
Spur additional research to better understand TS • Environmental impacts on TS expression, suppression, etc.
• Development of Premonitory Urge
Premonitory UrgePremonitory Urge
Internal event • Sensation that precedes tics
• Unpleasant itch, tension, tingle, pressure
• Sometimes localized, sometimes general
• Awareness begins around age 9-10
• Very common: up to 90% of TS individuals describe urges
• Urges more likely to precede complex tics than simple tics
Consequences • Urge is relieved or reduced contingent on tic
Premonitory UrgePremonitory Urge
• Premonitory urge emerges over time (Leckman et al., 1993)
• Descriptions of the urge become more internally consistent over time (Woods, Piacentini et al., 2005)
Premonitory UrgePremonitory UrgeDevelopmental FactorsDevelopmental Factors
Premonitory Urge for Tics Scale (PUTS)
• 9-item child self-report measure of premonitory urge severity
• Tested in 42 TS/CTD youngsters aged 8-16
• Total score did not differ between younger (8-10) and older (11-16) group
Woods, Piacentini, Himle, & Chang, 2005
Premonitory UrgePremonitory UrgeDevelopmental FactorsDevelopmental Factors
Premonitory Urge for Tics Scale (PUTS)
• PUTS score only correlated with tic severity in older group
• Sensations are present in younger children but perhaps in more diffuse form or association with tics not as easily recognized
Woods, Piacentini, Himle, & Chang, 2005
Neurobehavioral Model of TicsNeurobehavioral Model of Tics
Contemporary Behavioral Psychology assumes an underlying neurological deficiency/deficit for TS.
This deficit may reflect brain deficit in ability to inhibit competing motor patterns.
Initiation of Biological Process
EXPRESSION OF TIC
Termination of Biological Process
Biological Basis for Premonitory Urge
Biological basis for premonitory urge may or may not be present for different types of tics. Simple tics may not contain the biological basis for the premonitory urge.
Environment builds on this biologically derived sequence.
Behavioral Model of TicsBehavioral Model of Tics
Expression of TIC
Although the Biological Basis for the Premonitory Urge may be present, the “urge” itself may not exist at the very beginning of the disorder.
The underlying sensation may not be experienced as related to the tic.
Biological Basis for Premonitory Urge
Internal External
Consequences
Expression of tic leads to both internal and external consequences.
Discomfort
Teasing
?
Situational AntecedentsSituational Antecedents
As child starts to experience negative consequences of ticcing, he/she will begin to associate these negative consequences with the situationssituations in which the tics occurred.
Discomfort
Expression of TIC
Teasing
Consequences
Situational Antecedents School, Home, Social
Biological Basis for Premonitory Urge
Over time, these situational antecedentssituational antecedents become more salient and increasingly aversive to the child (e.g., classical conditioning).
Biological AntecedentsBiological Antecedents
Negative ConsequencesNegative Consequences
Discomfort
Expression of TIC
Teasing
Consequences
Situational Antecedents
Biological Basis for Premonitory Urge
The more salient the sensations become to the child, the more strongly he/she associates them with his/her tics.
and Situational AntecedentsSituational Antecedents
also impact internal cues, e.g., underlying sensations such that these sensations take on aversiveaversive qualities as well.
Premonitory UrgePremonitory Urge
Premonitory urge severity becomes more related to behavior patterns suggestive of avoidance and social withdrawal as children get older (Woods, Piacentini et al., 2005)
Connection between premonitory urge and tics may be shaped by negative social response to tics
Development of Premonitory UrgesDevelopment of Premonitory Urges
Discomfort
PREMONITORY URGEPREMONITORY URGE(unpleasant)(unpleasant)
Expression of TIC
Teasing
Consequences
Situational Antecedents
As the child becomes more aware of these underlying sensations and they begin to predict specific consequences (e.g., tics), they begin to be experienced as “premonitory urges”.“premonitory urges”.
Premonitory urges become aversive to the extent they predict aversive consequences.
Biological Basis for Premonitory Urge
Negative Reinforcement of TicsNegative Reinforcement of Tics
PREMONITORY URGE(unpleasant)
Expression of TIC
Termination of URGE
Situational Antecedents
++
Relief from unpleasant premonitory urge serves to negatively reinforcenegatively reinforce tic expression.
Negative ReinforcementNegative Reinforcement = any action reducing or eliminating an aversive stimulus will be more likely to occur upon subsequent presentation of that aversive stimulus.
If my child stops misbehaving when I shout at him, I’m more likely to use shouting as a disciplinary procedure in the future.
Positive Reinforcement of TicsPositive Reinforcement of Tics
Expression of TIC
Internal External
Consequences
Positive Consequences also serve to reinforce tics and increase their frequency
Relief Avoidance
++
Support for the Neurobehavioral Support for the Neurobehavioral ModelModel
Data examining impact of environmental factors on tic expression are very preliminary
• Consequences of Tic expression
• Antecedents of Tic expression
However, these data provide at least indirect support for Neurobehavioral Model
Antecedent Events that Impact TicsAntecedent Events that Impact Tics
• Being upset or anxious (Silva et al., 1995)
• Watching TV (Silva et al., 1995)
• Being Alone (Silva et al., 1995)
• Social Gatherings (Silva et al., 1995)
• Stressful Life Events (Surwillo et al., 1978)
• Hearing Others Cough (Commander et al., 1991)
• Talking about tics (Woods et al., 2001)
Consequences Impacting Tic Consequences Impacting Tic OccurrenceOccurrence
Evidence for external consequences increasing tics…• Social reactions can result in a worsening of tics (e.g., Watson & Sterling, 1998)
• Child may get out of a task because of his or her tics (e.g., getting out of math homework).
Evidence for external consequences decreasing tics• Real life negative consequences for tics (i.e., teasing, failure to
participate in social activities, etc.)• Some children avoid these consequences through suppressing their tics
Environmental Control of Tic Environmental Control of Tic ExpressionExpression
Woods & Himle, Univ Wisconsin-MilwaukeeWoods & Himle, Univ Wisconsin-Milwaukee
“TIC DETECTOR”• Remote controlled operant token
dispenser
• Inactive computer camera mounted on top of box
• Tokens delivered by experimenter who observes from behind an observation mirror
• Tokens delivered for every 10 sec. tic-free intervals
• Interval resets if a tic occurs
• Tokens later exchanged for small amount of money
0
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Billy
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Nick
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101214161820
BL VI DRO VI DROF
req
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Tic
s)
Mary
BL (Baseline)VI (Verbal Instructions)DRO (Reinforcement for No Tics)
• Compared tic reduction with and without support of environmental consequences in 4 children with TS
• Verbal Instructions to suppress produced a 10.3% reduction in tic occurrence from BL
• Reinforcement-enhanced procedures produced a 76% decrease in tics
• Results suggest that consequences to tics can impact tic frequency
Environmentally Mediated Tic Environmentally Mediated Tic ReductionReduction
Woods & Himle (2004)Woods & Himle (2004)
Environmental Influences can be long lastingEnvironmental Influences can be long lasting Woods, Himle, Miltenberger, & Carr, ongoingWoods, Himle, Miltenberger, & Carr, ongoing
• Nine children with TS exposed to Rewards of 3 different durations (5 min, 25 min, 40 min) presented in a random order
• Rewards interspersed with 5 min “rebound evaluation” phase
• Rewards led to statistically significant tic reduction
• No statistically significant rebound effects for any of the different durations
0
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40
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R+
Re
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dFunded by the Tourette Syndrome Association
Behavioral Intervention should address:
• Antecedents and Consequences of Tics
• Negative Reinforcement
Implications of Model for Implications of Model for TreatmentTreatment
Function-BasedFunction-Based
InterventionsInterventionsIdentify “function” of enviromental factors on tic Identify “function” of enviromental factors on tic
expressionexpression
Impact of Environment on TicsImpact of Environment on Tics
Environmental Consequences catch kids COMING or GOING
Tic
Positive consequences can increase ticcing
Tic Positive Consequence More Tics
Negative consequences can increase ticcing
Negative response Distress More Tics
Response to environment is typically not a conscious or voluntary process
• Child/family/school often unaware this is happening
• Environmental influence does not imply that tics are behaviorally caused or that child is manipulating the system
Functional AnalysisFunctional Analysis
Common Antecedents
- What happens before the tic
• Demand placed on child
• Teasing
• Anxiety
• Stress
Functional AnalysisFunctional Analysis
Functional AnalysisFunctional Analysis
Common Consequences
- What happens after the tic
• Comforting - extra attention
• “Stop ticcing”
• Teasing
• Leave table, classroom, or other situation
• Don’t finish meal, homework, or chores
Function-based InterventionsFunction-based Interventions
• Does not imply that tics are behaviorally caused.
• Despite the tics, the child is still expected to be treated as “normally” as possible
– both positive and negative consequences
• Tics should not dictate what the child does or does not do, and the child does not receive any special treatment for his or her tics.
• ENVIRONMENT SHOULD BE TIC NEUTRAL
• Over 20 published studies of contingency management
Neutral EnvironmentNeutral Environment
Discomfort
PREMONITORY URGEPREMONITORY URGE(unpleasant)(unpleasant)
Expression of TIC
Attention
Positive and Negative Consequences
Situational Antecedents
Neutral EnvironmentNeutral Environment
Discomfort
PREMONITORY URGEPREMONITORY URGE(unpleasant)(unpleasant)
Expression of TIC
Teasing
Consequences
Situational Antecedents
Neutral EnvironmentNeutral Environment
Discomfort
PREMONITORY URGEPREMONITORY URGE(unpleasant)(unpleasant)
Expression of TIC
Teasing
Consequences
Situational Antecedents
ADDRESS ANTECEDENTS
• Provide child with 15 minutes warning and free time to calm down prior to making specific requests (homework, chores)
ADDRESS SOCIAL CONSEQUENCES
• Don’t respond to tics in the moment teasing, telling to stop, comforting, etc.
This means parents, sibs, teachers, everyone
Function-based InterventionsFunction-based Interventions What to do? What to do?
ADDRESS ESCAPE CONSEQUENCES (Negative Reinforcement)
• If tics interfere, leave situation for 15 minutes then return - BUT no escape from responsibilities
• If leaves dinner table, must come back and finish meal
• Needs to begin homework at set time regardless of tics – can take brief breaks according to set schedule
• If tics still bothersome, encourage child to use HRT or other techniques to address them
Function-based InterventionsFunction-based Interventions What to do?What to do?
Habit ReversalHabit Reversal TrainingTraining
(HRT)(HRT)
Habit Reversal TrainingHabit Reversal Training
Multicomponent Behavioral Treatment Package
developed by Azrin & Nunn (1973)
Targeted tics and other habit disorders, including
trich, nailbiting, thumbsucking, skin picking
Originally consisted of 14 techniques aimed at:• increasing tic (habit) awareness• developing competing responses to tics (habits)• building and sustaining motivation and compliance
TWO PRIMARY COMPONENTS
Awareness Training
Competing Response
TWO PRIMARY COMPONENTS
Awareness Training
Competing Response
Habit Reversal TrainingHabit Reversal Training
ANCILLARY COMPONENTS - Addressing tic antecedents
Psychoeducation• Reduce family anxiety/stress and negative reactions
to child’s tics
Relaxation Training• Reduce child anxiety/stress
Habit Reversal TrainingHabit Reversal Training
ANCILLARY COMPONENTS - Addressing motivation/compliance
Social Support• Enhance use of HRT
Behavioral Reward System• Enhance treatment motivation and compliance
Inconvenience Review• Identify functional impairments and enhance
motivation
Habit Reversal TrainingHabit Reversal Training
Habit Reversal TrainingHabit Reversal TrainingAwareness TrainingAwareness Training
Response Description and Detection• Describe details of tic and re-enact under therapist supervision
Early Warning Procedure• Practice detecting earliest sign of movement or tic urge
Situation Awareness Training• Recall high-risk situations and describe tic in these settings
Ancillary Procedures• Use videotape or enlist support persons
Necessary level of awareness is unclear
Premonitory UrgePremonitory Urge
Relationship of HRT to Premonitory Urge
Simple tics
• Less likely to experience premonitory urge
• HRT focused on other early warning signs or initial aspects of tic expression
Complex tics
• Typically preceded by premonitory urge
• HRT focused on detecting and intervening at premonitory urge stage
Incompatible physical behavior performed in response to:• Urge to tic
• Initial expression of tic itself
CR Should be:• Opposite to the tic behavior
• Capable of being maintained for at least one minute
• Socially inconspicuous - compatible with normal activity
Habit Reversal TrainingHabit Reversal TrainingCompeting ResponseCompeting Response
Necessary level of compliance is unclear
• Start with a relatively “big” and noticeable tic first
• Simple eyeblinks often not targeted by HRT
• Shaping procedure often used for motor tics
• Slow, rhythymic breathing used as CR for vocal tics
• Developmentally sensitive implementation (“tic-buster”)
Habit Reversal TrainingHabit Reversal Training
Treatment Tips
Habit Reversal TrainingHabit Reversal TrainingSocial Support/Reward SystemSocial Support/Reward System
Goal is to reinforce and prompt use of competing response
• Significant others prompt use of CR
• Significant others praise correct use of CR
• Necessity of social support is unclear, but probably required for most children
• Rewards offered for compliance with treatment assignments (effort not outcome)
Family confusion, upset, blame • Due to inaccurate, inconsistent information about TS
• Due to improper and/or failed treatment attempts
• Due to reaction of others in the environment
Disruption caused by excessive attention, energy focused on the problem
• Other family needs remain unaddressed
• Other family members (sibs) may become jealous
• Relaxation of regular family rules or roles
Family confusion, upset, blame • Due to inaccurate, inconsistent information about TS
• Due to improper and/or failed treatment attempts
• Due to reaction of others in the environment
Disruption caused by excessive attention, energy focused on the problem
• Other family needs remain unaddressed
• Other family members (sibs) may become jealous
• Relaxation of regular family rules or roles
Impact of TS on FamilyImpact of TS on Family
Family plays crucial role in treatment and recovery
• Provide support and encouragement to child
• Exact role depends on age/developmental level of child
For younger children• Parents may need to be directly involved in implementation
of treatment techniques
For older children and adolescents
• Parent typically needs to accept a less direct role
• Primary task is to provide support
Family plays crucial role in treatment and recovery
• Provide support and encouragement to child
• Exact role depends on age/developmental level of child
For younger children• Parents may need to be directly involved in implementation
of treatment techniques
For older children and adolescents
• Parent typically needs to accept a less direct role
• Primary task is to provide support
Family Involvement in TreatmentFamily Involvement in Treatment
EmpiricalEmpirical SupportSupport
for HRTfor HRT
Empirical Support for HRTEmpirical Support for HRT
Over 25 published studies of HRT for TS or Chronic Tic Disorder
• Most single case or small case series reports
At least 6 published randomized, between group studies of HRT for TS/CTD
• Only two included children (most subjects were adults)
• One unpublished trial solely of children
Azrin & Nunn (1973): 12 individuals with habits or tics• 90% symptom reduction after 1 session• 99% symptom reduction at 3 month follow-up
Tourette’s Syndrome• More effective than relaxation training or self-monitoring
(Peterson & Azrin, 1992)
• More effective than wait-list control (Azrin & Peterson, 1990)
Empirical Support for HRTEmpirical Support for HRT
Habit Reversal for Adult TSHabit Reversal for Adult TS
Sabine Wilhelm, PhD.Sabine Wilhelm, PhD.Thilo Deckersbach, PhD.Thilo Deckersbach, PhD.
Barbara Coffey, MD.Barbara Coffey, MD.Antje Bohne, MS.Antje Bohne, MS.
Alan Peterson, Ph.D.Alan Peterson, Ph.D.Lee Baer, PhD.Lee Baer, PhD.
Massachusetts General HospitalMassachusetts General Hospital
Harvard Medical SchoolHarvard Medical School
Suppported by a grant from the TSA Permanent Research FundSuppported by a grant from the TSA Permanent Research FundSuppported by a grant from the TSA Permanent Research FundSuppported by a grant from the TSA Permanent Research Fund
Am J Psychiatry, 160, 1175-1177 (2003)Am J Psychiatry, 160, 1175-1177 (2003)
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SESSION
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S T
ota
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Supp Tx
**
HRT for Adults - SymptomsHRT for Adults - Symptoms
35% decrease 35% decrease in tic severityin tic severity
Wilhelm et al. (2003)Wilhelm et al. (2003)
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HRT for Adults - InterferenceHRT for Adults - Interference
**
55% decrease 55% decrease in tic interferencein tic interference
Wilhelm et al. (2003)Wilhelm et al. (2003)
Comparison of HRT and Awareness Comparison of HRT and Awareness Training for Children with TSTraining for Children with TS
Suppported by a grant from the Suppported by a grant from the TSA Permanent Research FundTSA Permanent Research FundSuppported by a grant from the Suppported by a grant from the TSA Permanent Research FundTSA Permanent Research Fund
John Piacentini, Ph.D.John Piacentini, Ph.D.Susanna Chang, Ph.D.Susanna Chang, Ph.D.
Velma BarriosVelma BarriosJames McCracken, M.D.James McCracken, M.D.
UCLA - Neuropsychiatric InstituteUCLA - Neuropsychiatric Institute
John Piacentini, Ph.D.John Piacentini, Ph.D.Susanna Chang, Ph.D.Susanna Chang, Ph.D.
Velma BarriosVelma BarriosJames McCracken, M.D.James McCracken, M.D.
UCLA - Neuropsychiatric InstituteUCLA - Neuropsychiatric Institute
Treatment Response RatesTreatment Response Rates
INTENT TO TREAT ANALYSESINTENT TO TREAT ANALYSES Condition Responder Rate
HRT: 6/13 46% AT: 3/12 25%
TREATMENT COMPLETERSTREATMENT COMPLETERS Condition Responder Rate
HRT: 6/11 55% AT: 3/9 33%
Habit Reversal EfficacyHabit Reversal Efficacy
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Baseline
Post-Tx
HRT: 30% HRT: 30% decrease in decrease in
tic severity; tic severity;
55% decrease 55% decrease in tic-related in tic-related impairmentimpairment
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Post-Tx
3 Mo FU
Durability of HRT Durability of HRT (3 Month FU)(3 Month FU)
HRT: 80% HRT: 80% response response
rate at 3 mosrate at 3 mos
Exposure plus Response PreventionExposure plus Response Prevention
Some evidence that ERP effective for tic reduction
• Verdellen et al., 2004; Woods et al., 2000
• Consistent with neurobehavioral model- negative reinforcement of tics by urge reduction
Comprehensive Comprehensive
Behavioral Behavioral
Intervention for Tics Intervention for Tics
StudiesStudies
CBITS StudiesCBITS Studies
TSA Behavioral Sciences ConsortiumTSA Behavioral Sciences Consortium
Susanna Chang, PhD.Susanna Chang, PhD. UCLA Neuropsychiatric InstituteUCLA Neuropsychiatric Institute
Thilo Deckersbach, PhD.Thilo Deckersbach, PhD. Mass General Hospital/HarvardMass General Hospital/Harvard
Golda Ginsberg, PhD.Golda Ginsberg, PhD. Johns Hopkins UniversityJohns Hopkins University
Alan Peterson, PhD.Alan Peterson, PhD. Wilford Hall Medical CenterWilford Hall Medical Center
John Piacentini, PhD.John Piacentini, PhD. UCLA Neuropsychiatric InstituteUCLA Neuropsychiatric Institute
Lawrence Scahill, MSN, PhD.Lawrence Scahill, MSN, PhD. Yale Child Study CenterYale Child Study Center
John Walkup, MD.John Walkup, MD. Johns Hopkins UniversityJohns Hopkins University
Sabine Wilhelm, PhD.Sabine Wilhelm, PhD. Mass General Hospital/HarvardMass General Hospital/Harvard
Douglas Woods, PhD.Douglas Woods, PhD. University of Wisconsin-MilwaukeeUniversity of Wisconsin-Milwaukee
Child Behavioral Intervention for Tics Child Behavioral Intervention for Tics Study Study (CBITS-C)(CBITS-C)
120 children (aged 9-17) with TS/CTD (40 at each of 3 sites) UCLA Johns Hopkins University University of Wisconsin - Milwaukee
Three supporting sites Mass General Hospital/Harvard Yale Child Study Center Wilford Hall Medical Center (Texas)
Comparison of two psychosocial treatments Comprehensive Behavioral Intervention for TS (CBIT)
- HRT + Function-based Intervention Psychoeducation/Supportive Therapy (PST)
Funded by NIMH (R01 70802) through the Tourette Syndrome Association
120 children (aged 9-17) with TS/CTD (40 at each of 3 sites) UCLA Johns Hopkins University University of Wisconsin - Milwaukee
Three supporting sites Mass General Hospital/Harvard Yale Child Study Center Wilford Hall Medical Center (Texas)
Comparison of two psychosocial treatments Comprehensive Behavioral Intervention for TS (CBIT)
- HRT + Function-based Intervention Psychoeducation/Supportive Therapy (PST)
Funded by NIMH (R01 70802) through the Tourette Syndrome Association
CBITS Treatments
CBIT Components
• Psychoeducation• Habit Reversal Therapy• Functional Intervention• Reward System • Relaxation Training
Psychoed/Support Components
• Phenomenology of TS• Prevalence of TS• Natural History of TS• Common Comorbidities• Causes of TS• Psychosocial Impairments• Nonspecific Support
Adult Behavioral Intervention for Adult Behavioral Intervention for Tics Study Tics Study (CBITS-A)(CBITS-A)
120 adults (aged 16-60) with TS/CTD (40 at each of 3 sites) Mass General Hospital/Harvard Yale Child Study Center Wilford Hall Medical Center (Texas)
Three supporting sites UCLA Johns Hopkins University University of Wisconsin- Milwaukee
Comparison of two psychosocial treatments Comprehensive Behavioral Intervention for TS (CBIT)
- HRT + Function-based Intervention Psychoeducation/Supportive Therapy (PST)
Funded by NIMH through Collaborative R01s to MGH, Yale, and WHMC
120 adults (aged 16-60) with TS/CTD (40 at each of 3 sites) Mass General Hospital/Harvard Yale Child Study Center Wilford Hall Medical Center (Texas)
Three supporting sites UCLA Johns Hopkins University University of Wisconsin- Milwaukee
Comparison of two psychosocial treatments Comprehensive Behavioral Intervention for TS (CBIT)
- HRT + Function-based Intervention Psychoeducation/Supportive Therapy (PST)
Funded by NIMH through Collaborative R01s to MGH, Yale, and WHMC
Behavioral Interventions for TicsBehavioral Interventions for Tics
SUMMARYSUMMARY• Although tics are biologically-based, environmental factors can be important
determinants of tic expression and maintenance
• Integrative neurobehavioral models provide theoretical basis for psychosocial treatment of TS
• Best approach may be combination of Function-based and Tic-specific intervention
• Good supportive data from numerous small open and pilot controlled trials
• CBITS & ABITS Multisite Trials will provide large-scale efficacy data
• Future trials need to examine comparative efficacy of HRT and medication and mechanisms of action