New Thoughts on the Behavioral Treatment of Tourette Syndrome John Piacentini, Ph.D., ABPP Child...

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 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.


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


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


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 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


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.


Negative Reinforcement of TicsNegative Reinforcement of Tics

PREMONITORY URGE(unpleasant)

Expression of TIC

Termination of URGE


++

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

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101214161820

BL VI DRO VI DROF

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Tic

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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

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40

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R+

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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



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


Expression of TIC

Attention

Positive and Negative Consequences


Neutral EnvironmentNeutral Environment

Discomfort


Expression of TIC

Teasing

Consequences


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


ANCILLARY COMPONENTS - Addressing tic antecedents

Psychoeducation• Reduce family anxiety/stress and negative reactions

to child’s tics

Relaxation Training• Reduce child anxiety/stress


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 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


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”)


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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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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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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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)



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



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



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

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