Effectiveness of a modified comprehensive behavioral intervention for tics for children and adolescents with tourette's syndrome: A randomized controlled trial

Treating Tourette Together: An Agenda for Patient-Centered Research Focused on Comprehensive Behavioral Intervention for Tics

To establish a patient-centered agenda for research that will lead to effective, widespread availability, adoption, and utilization of evidence-based behavioral treatment of Tourette syndrome and other tic disorders (TDs), we planned and executed a multistage, collaborative "Treating Tourette Together" research planning project with researchers, clinicians, patients, families, and other interested parties. Priorities for future behavioral treatment research were solicited from these parties via anonymous community surveys, a 2-day research planning summit with 46 individuals representing key stakeholder groups, and community response to summit reports. Four high-priority research domains were identified: (a) expanding treatment access, (b) improving treatment outcomes, (c) optimizing treatment within a broader care model, and (d) evaluating outcomes beyond tic severity. Community-engaged participatory research models can efficiently delineate clear and actionable priorities for clinical research. This approach holds promise for improving the impact of clinical research in TDs and other neuropsychiatric disorders.

Applying an Established Exposure Response Prevention Protocol for Young People With Tourette Syndrome in an Intensive, Group Format: A Feasibility Study

BACKGROUND

The motor and vocal tics that characterise Tourette syndrome are stigmatizing and impact on quality of life. Behavioural interventions such as Exposure Response Prevention or Comprehensive Behavioural Interventions for Tics are first line treatment for Tourette syndrome, but availability is limited. This study is the first to explore the impact of an established manualised Exposure Response Prevention treatment protocol, developed for individual therapy, but here uniquely delivered intensively, to a group.

METHODS

A naturalistic study comprised of a consecutive series of children (N = 20), aged 8-16 years (M = 12, SD = 2.17) were offered Exposure Response Prevention in one of two groups, delivered in series within a specialist clinic. Young people received the equivalent of 12 sessions (matching the manualised individual protocol).

RESULTS

The YGTSS and Giles de la Tourette Syndrome Quality of Life Scale for Children and Adolescents (Satisfaction Scale) showed significant improvement following treatment with moderate to large effect sizes. Thirty-five percent of children demonstrated a reliable improvement on the YGTSS Global Tic Severity score.

CONCLUSIONS

These data suggest an established Exposure Response Prevention protocol can be delivered in an intensive, group setting with a positive clinical outcome. Replication in a randomized controlled trial is an important next step.

Functional connectivity during tic suppression predicts reductions in vocal tics following behavior therapy in children with Tourette syndrome

BACKGROUND

Comprehensive Behavioral Intervention for Tics (CBIT) is recommended as a first-line treatment for Tourette syndrome in children and adults. While there is strong evidence proving its efficacy, the mechanisms of reduction in tic severity during CBIT are still poorly understood. In a recent study, our group identified a functional brain network involved in tic suppression in children with TS. We reasoned that voluntary tic suppression and CBIT may share some mechanisms and thus we wanted to assess whether functional connectivity during tic suppression was associated with CBIT outcome.

METHODS

Thirty-two children with TS, aged 8 to 13 years old, participated in a randomized controlled trial of CBIT v. a treatment-as-usual control condition. EEG was recorded during tic suppression in all participants at baseline and endpoint. We used a source-reconstructed EEG connectivity pipeline to assess functional connectivity during tic suppression.

RESULTS

Functional connectivity during tic suppression did not change from baseline to endpoint. However, baseline tic suppression-related functional connectivity specifically predicted the decrease in vocal tic severity from baseline to endpoint in the CBIT group. Supplementary analyses revealed that the functional connectivity between the right superior frontal gyrus and the right angular gyrus was mainly driving this effect.

CONCLUSIONS

This study revealed that functional connectivity during tic suppression at baseline predicted reduction in vocal tic severity. These results suggest probable overlap between the mechanisms of voluntary tic suppression and those of behavior therapy for tics.

Working Mechanisms of Exposure and Response Prevention in the Treatment of Tourette Syndrome and Tic Disorders Revisited: No Evidence for within-Session Habituation to Premonitory Urges

BACKGROUND

Exposure and response prevention (ERP) has been shown to be an effective treatment for Tourette syndrome (TS) and chronic tic disorders (CTD). ERP is based on voluntary tic suppression in combination with prolonged exposure to premonitory urges preceding tics. A prevailing hypothesis of the working mechanism underlying ERP in tics is habituation to the premonitory urges as a result of prolonged exposure. However, results so far are equivocal. This study aims to further explore the relation between urges and ERP in tics, by investigating the course of premonitory urges during ERP sessions.

METHODS

Using a data-driven approach, within-session habituation to premonitory urge intensity was investigated. In total, 29 TS patients rated urge intensity at seven timepoints during ten 1 h ERP sessions.

RESULTS/CONCLUSIONS

Latent growth modeling showed an increase in urge intensity during the first 15 min of each session followed by a plateau in the remaining 45 min of the session. This does not support the idea of within-session habituation to premonitory urges as a working mechanism of ERP. Other potential underlying working mechanisms are discussed and should be tested in future research.

Online remote behavioural intervention for tics in 9- to 17-year-olds: the ORBIT RCT with embedded process and economic evaluation

Background

Behavioural therapy for tics is difficult to access, and little is known about its effectiveness when delivered online.

Objective

To investigate the clinical and cost-effectiveness of an online-delivered, therapist- and parent-supported therapy for young people with tic disorders.

Design

Single-blind, parallel-group, randomised controlled trial, with 3-month (primary end point) and 6-month post-randomisation follow-up. Participants were individually randomised (1 : 1), using on online system, with block randomisations, stratified by site. Naturalistic follow-up was conducted at 12 and 18 months post-randomisation when participants were free to access non-trial interventions. A subset of participants participated in a process evaluation.

Setting

Two hospitals (London and Nottingham) in England also accepting referrals from patient identification centres and online self-referrals.

Participants

Children aged 9-17 years (1) with Tourette syndrome or chronic tic disorder, (2) with a Yale Global Tic Severity Scale-total tic severity score of 15 or more (or > 10 with only motor or vocal tics) and (3) having not received behavioural therapy for tics in the past 12 months or started/stopped medication for tics within the past 2 months.

Interventions

Either 10 weeks of online, remotely delivered, therapist-supported exposure and response prevention therapy (intervention group) or online psychoeducation (control).

Outcome

Primary outcome: Yale Global Tic Severity Scale-total tic severity score 3 months post-randomisation; analysis done in all randomised patients for whom data were available. Secondary outcomes included low mood, anxiety, treatment satisfaction and health resource use. Quality-adjusted life-years are derived from parent-completed quality-of-life measures. All trial staff, statisticians and the chief investigator were masked to group allocation.

Results

Two hundred and twenty-four participants were randomised to the intervention (n = 112) or control (n = 112) group. Participants were mostly male (n = 177; 79%), with a mean age of 12 years. At 3 months the estimated mean difference in Yale Global Tic Severity Scale-total tic severity score between the groups adjusted for baseline and site was -2.29 points (95% confidence interval -3.86 to -0.71) in favour of therapy (effect size -0.31, 95% confidence interval -0.52 to -0.10). This effect was sustained throughout to the final follow-up at 18 months (-2.01 points, 95% confidence interval -3.86 to -0.15; effect size -0.27, 95% confidence interval -0.52 to -0.02). At 18 months the mean incremental cost per participant of the intervention compared to the control was £662 (95% confidence interval -£59 to £1384), with a mean incremental quality-adjusted life-year of 0.040 (95% confidence interval -0.004 to 0.083) per participant. The mean incremental cost per quality-adjusted life-year gained was £16,708. The intervention was acceptable and delivered with high fidelity. Parental engagement predicted child engagement and more positive clinical outcomes.

Harms

Two serious, unrelated adverse events occurred in the control group.

Limitations

We cannot separate the effects of digital online delivery and the therapy itself. The sample was predominately white and British, limiting generalisability. The design did not compare to face-to-face services.

Conclusion

Online, therapist-supported behavioural therapy for young people with tic disorders is clinically and cost-effective in reducing tics, with durable benefits extending up to 18 months.

Future work

Future work should compare online to face-to-face therapy and explore how to embed the intervention in clinical practice.

Trial registration

This trial is registered as ISRCTN70758207; ClinicalTrials.gov (NCT03483493). The trial is now complete.

Funding

This project was funded by the National Institute for Health and Care Research (NIHR) Health and Technology Assessment programme (project number 16/19/02) and will be published in full in Health and Technology Assessment; Vol. 27, No. 18. See the NIHR Journals Library website for further project information.

Behavioral Interventions for Children and Adults with Tic Disorder

Over the past decade, behavioral interventions have become increasingly recognized and recommended as effective first-line therapies for treating individuals with tic disorders. In this article, we describe a basic theoretical and conceptual framework through which the reader can understand the application of these interventions for treating tics. The three primary behavioral interventions for tics with the strongest empirical support (habit reversal, Comprehensive Behavioral Intervention for Tics, and exposure and response prevention) are described. Research on the efficacy and effectiveness of these treatments is summarized along with a discussion of the research evaluating the delivery of these treatments in different formats and modalities. The article closes with a review of the possible mechanisms of change underlying behavioral interventions for tics and areas for future research.

Clinical Promotion of Comfort Nursing Combined with Comprehensive Nursing in the Treatment of Severe Stroke Patients with Diabetes in ICU

Objective

To investigate the application value of comprehensive nursing combined with comfort nursing for severe stroke patients with diabetes in the intensive care unit (ICU), as well as its effect on the incidence of pressure ulcers and aspiration.

Methods

Between March 2019 and March 2021, 123 severe stroke patients with diabetes who were treated at our hospital were randomly assigned to one of two groups: the control group (n = 61) or the study group (n = 62). The control group received normal care, but the research group received comprehensive nursing as well as comfort nursing. The two patient groups were compared in terms of the effects of the clinical application.

Results

The two groups did not differ significantly in general data (P > 0.05). The shorter ICU monitoring and extubation times, the lower incidence of pressure ulcers, aspiration, and nosocomial infections, and higher self-rating anxiety scale (SAS) and self-rating depression scale (SDS) scores and a lower MOS 36-item short-form health survey (SF-36) score were all observed in the research group when compared to the control group (P < 0.05).

Conclusion

For severe stroke patients with diabetes in the ICU, comprehensive nursing combined with comfort nursing has a promising effect, significantly, lowering the risk of pressure ulcers, aspiration, and nosocomial infections, accelerating physical recovery, enhancing mental state, and ensuring a better prognosis, deserving general clinical promotion.

Emerging therapies and recent advances for Tourette syndrome

Tourette syndrome is the most prevalent hyperkinetic movement disorder in children and can be highly disabling. While the pathomechanism of Tourette syndrome remains largely obscure, recent studies have greatly improved our knowledge about this disease, providing a new perspective in our understanding of this condition. Advances in electrophysiology and neuroimaging have elucidated that there is a reduction in frontal cortical volume and reduction of long rage connectivity to the frontal lobe from other parts of the brain. Several genes have also been identified to be associated with Tourette syndrome. Treatment of Tourette syndrome requires a multidisciplinary approach which includes behavioral and pharmacological therapy. In severe cases surgical therapy with deep brain stimulation may be warranted, though the optimal location for stimulation is still being investigated. Studies on alternative therapies including traditional Chinese medicine and neuromodulation, such as transcranial magnetic stimulation have shown promising results, but still are being used in an experimental basis. Several new therapies have also recently been tested in clinical trials. This review provides an overview of the latest findings with regards to genetics and neuroimaging for Tourette syndrome as well as an update on advanced therapeutics.

Prevalence of nail biting and its chronological relationship with tics in child and adolescent outpatients with Tourette syndrome: a single-centre, retrospective observational study

OBJECTIVE

To evaluate the prevalence of nail biting in child and adolescent outpatients at a single institution and the chronological relationship between nail biting and tics in patients with Tourette syndrome (TS) with or without attention-deficit hyperactivity disorder (ADHD).

DESIGN

Retrospective observational study.

SETTING

Teaching hospital in Taiwan.

PARTICIPANTS

All participants were aged 4-18 years, including 535 patients with TS, 230 patients with provisional tic disorder and 1460 patients without neurological or psychiatric disorders (controls).

OUTCOME MEASURES

Presence of nail biting, starting age for nail biting and starting age for motor and/or vocal tics.

RESULTS

Nail biting was more commonly observed in patients with TS (56.6%) than in patients with provisional tic disorder (27.4%) or controls (15.0%), regardless of sex (all p<0.020). Nail biting was also more common in patients with TS with ADHD than in those without (75.0% vs 47.6%; p<0.001), but the starting age was significantly later in those with concomitant ADHD than without (5.3 vs 3.8 years; p<0.001). In patients with TS, the onset of nail biting occurred earlier than that of tics, regardless of ADHD status.

CONCLUSION

Nail biting was more prevalent and occurred earlier than tics in patients with TS, regardless of ADHD status, in the study population.

The Efficacy of Cognitive Behavioral Therapy for Tic Disorder: A Meta-Analysis and a Literature Review

Background

At present, tic disorder has attracted the attention of medical researchers in many countries. More clinicians choose non-drug therapy, especially cognitive-behavioral therapy (CBT) because of the cognitive side effects of drug therapy. However, few studies had assessed its efficacy. It is necessary to have a more comprehensive understanding of the literature quality of CBT and its intervention effect.

Methods

In this study, MEDLINE, Embase, and Cochrane were searched from the beginning to June 15, 2021 to study the efficacy of -CBT on tic disorder. Only studies using the Yale Global Tic Severity Scale (YGTSS) and the control group were included.

Results

A total of 12 randomized controlled trials (RCTs), including 536 patients with tic disorders, were identified. The results showed that the effect of CBT was better than that of the control group. The pooled standardized mean difference (SMD) was −0.34 (95% CI: −0.61, −0.07). The effect size of CBT differs from different intervention conditions. In seven studies, the subjects’ motor tic scores were counted. The sample size of the experimental group was 224 and that of the control group was 218. The pooled SMD was −0.43 (95% CI: −0.75, −0.11). Seven studies counted the vocal tic scores of subjects, 224 in the experimental group and 218 in the control group. The pooled SMD was −0.22 (95% CI: −0.54, −0.11). Seven studies counted the tic impairment scores of subjects, 220 in the experimental group and 214 in the control group. The pooled SMD was −0.48 (95% CI: −0.73, −0.23).

Conclusion

The literature shows that different CBTs can significantly reduce the total score of tic disorder and the score of motor tic, but cannot significantly reduce the score of vocal tic. In the future, more new interventions were needed to improve the symptoms of different patients, especially vocal tic.

Tourette Syndrome Treatment Updates: a Review and Discussion of the Current and Upcoming Literature

Purpose of Review

This study aims to examine the treatments currently available for Tourette syndrome (TS) and to discuss evolving therapies, spanning behavioral, pharmacologic, complementary and alternative medicine, and neuromodulation approaches.

Recent Findings

Behavioral therapies have undergone several modifications to improve accessibility, including transitioning to a virtual format which is particularly important in the current pandemic. There are several recent or ongoing pharmacologic studies that have shown promise including the selective D1 receptor antagonist ecopipam and various cannabinoid compounds. Adaptive DBS may enable the physiologic markers of tics to determine stimulation parameters and improve tic outcomes related to neuromodulation.

Summary

In recent years, there has been a wealth of research across multiple treatment domains in the TS field. This review highlights exciting and new potential options for the future treatment of patients with TS.

A preliminary study of comprehensive behavioral intervention for tics in Chinese children with chronic tic disorder or Tourette syndrome

OBJECTIVE

To investigate the adaptability of Comprehensive Behavioral Intervention for Tics (CBIT) for a Chinese population, and evaluate the efficacy of combined CBIT and pharmacotherapy (CBIT + PT) compared to CBIT or pharmacotherapy (PT) alone for reducing tics and for improving the quality of life (QoL) in a sample of Chinese children with chronic tic disorders (CTD) and Tourette syndrome (TS).

MATERIALS AND METHODS

In this 10-week randomized controlled pilot trial, 37 outpatients aged between 6 and 16 years affected by TS and CTD were randomly assigned to receive CBIT (n = 22) or PT alone (n = 15). Considering the feasibility, the patients allocated to the CBIT treatment group could further choose whether to simultaneously take medicine voluntarily, resulting in a CBIT alone group (n = 12) and a CBIT + PT group (n = 10).

RESULTS

At baseline, no significant difference was found between the three groups in the demographic and clinical characteristics (p > 0.05). All three groups showed a significant reduction in tic severity after treatment assessed by the Yale Global Tic Severity Scale (YGTSS) severity score [F ₍₂,₃₃₎ = 35.05, p < 0.001, η _p ² = 0.51], the score of the Clinical Global Impression scale for Improvement (CGI-I) [F ₍₁,₃₄₎ = 13.87, p = 0.001, η _p ² = 0.29], and YGTSS impairment score [F ₍₂,₃₃₎ = 31.71, p < 0.001, η _p ² = 0.48]. Significant interactions were found between the time-point and group in emotional functioning [F ₍₂,₂₉₎ = 4.39, p = 0.02, η _p ² = 0.23], psychosocial functioning [F ₍₂,₂₉₎ = 5.93, p = 0.007, η _p ² = 0.29], and total QoL score [F ₍₁,₃₄₎ = 3.72, p = 0.04, η _p ² = 0.20] of Pediatric Quality of Life Inventory (PedsQL 4.0) for children suggesting a significantly larger improvement in emotional functioning, psychosocial functioning, and total QoL score of the life quality in the CBIT group for children self-report. PedsQL for proxy report only showed a significant main effect of time-point in physical functioning [F ₍₁,₃₃₎ = 8.35, p = 0.01, η _p ² = 0.2], emotional functioning [F ₍₁,₃₃₎ = 10.75, p = 0.002, η _p ² = 0.25], psychosocial functioning [F ₍₁,₃₄₎ = 11.38, p = 0.002, η _p ² = 0.26], and total Qol score [F ₍₁,₃₄₎ = 13.21, p = 0.001, η _p ² = 0.29].

CONCLUSION

CBIT is probably effective in reducing tic severity in Chinese children with tic disorders. CBIT + PT may not be superior to CBIT alone in reducing tic severity and improving quality of life. CBIT alone showed advantages in improving quality of life over CBIT + PT and PT alone. CBIT might be an appropriate treatment option for patients with tic disorder in Chinese mainland.

Open-case series of a remote administration and group setting comprehensive behavioral intervention for tics (RG-CBIT): A pilot trial

PURPOSE

The comprehensive behavioral intervention for tics (CBIT) is the first-line psychotherapeutic treatment for individuals with tic disorders. However, most patients with tic disorders do not have access to CBIT due to different factors including lack of trained therapists, treatment cost, and travel distance. Such barriers are more prominent in non-English speaking countries. Therefore, the current study assessed the preliminary efficacy, feasibility, and acceptability of remotely administered group CBIT (RG-CBIT) in Japan.

METHODS

This was an open-case series that adopted the AB design. Three Japanese children aged between 6 and 13 years who were diagnosed with TS were recruited. RG-CBIT was developed based on the published CBIT manual. Videoconference application, slide presentation software, and cloud learning platform were used as appropriate.

RESULTS

The Yale Global Tic Severity Scale scores of all participants decreased from baseline to post-treatment. That is, the score reduced by an average of 7.0. Regarding feasibility and acceptability, the attendance rate of participants was 100%, and the process measurement items had favorable scores.

CONCLUSIONS

RG-CBIT had satisfactory efficacy, feasibility, and acceptability. Hence, it could mitigate the barriers for treatment access.

European clinical guidelines for Tourette syndrome and other tic disorders-version 2.0. Part II: psychological interventions

Part II of the European clinical guidelines for Tourette syndrome and other tic disorders (ECAP journal, 2011) provides updated information and recommendations for psychological interventions for individuals with tic disorders, created by a working group of the European Society for the Study of Tourette Syndrome (ESSTS). A systematic literature search was conducted to obtain original studies of psychological interventions for tic disorders, published since the initial European clinical guidelines were issued. Relevant studies were identified using computerized searches of the MEDLINE and PsycINFO databases for the years 2011-2019 and a manual search for the years 2019-2021. Based on clinical consensus, psychoeducation is recommended as an initial intervention regardless of symptom severity. According to a systematic literature search, most evidence was found for Habit Reversal Training (HRT), primarily the expanded package Comprehensive Behavioral Intervention for Tics (CBIT). Evidence was also found for Exposure and Response Prevention (ERP), but to a lesser degree of certainty than HRT/CBIT due to fewer studies. Currently, cognitive interventions and third-wave interventions are not recommended as stand-alone treatments for tic disorders. Several novel treatment delivery formats are currently being evaluated, of which videoconference delivery of HRT/CBIT has the most evidence to date. To summarize, when psychoeducation alone is insufficient, both HRT/CBIT and ERP are recommended as first-line interventions for tic disorders. As part of the development of the clinical guidelines, a survey is reported from ESSTS members and other tic disorder experts on preference, use and availability of psychological interventions for tic disorders.

Protocol of a randomized controlled trial to investigate the efficacy and neural correlates of mindfulness-based habit reversal training in children with Tourette syndrome

BACKGROUND

Tourette syndrome (TS) is a developmental neuropsychiatric disorder. Behavior therapy, especially habit reversal training (HRT), has gradually become regarded as one of the core therapies for TS. Mindfulness approaches can improve psychological adjustment and reduce stress and anxiety, suggesting potential benefits when incorporated into behavior therapy. To improve the efficacy of HRT, we combined it with mindfulness, an approach named mindfulness-based habitual reversal training (MHRT). The aim of this protocol is to investigate the efficacy and neural mechanisms of MHRT for TS.

METHODS/DESIGN

We will perform a randomized control trial (RCT) to evaluate the efficacy and neural mechanisms of MHRT. The sample will include 160 participants (including 120 patients with TS and 40 healthy controls). The patient sample will be randomly divided into three groups exposed to three different types of training: MHRT, HRT, and psychoeducation and supportive therapy (PST). Participants will be assessed and undergo resting-state fMRI scans at baseline and at the end of the 12-week training. The Yale Global Tic Severity Scale (YGTSS) and Premonitory Urge for Tic Scale (PUTS) will be used to assess the severity of tic symptoms and premonitory urges. The primary outcomes are change scores on the YGTSS and other assessments from baseline and the end of the training. The secondary outcomes are the neural correlates of these trainings among these groups based on graph theory, which is used to characterize brain functional connectivity networks. The default mode network (DMN) and the salience network (SN) will be assessed (which have been associated with mindfulness as well as the generation of tic symptoms) by network parameters, including clustering coefficients and shortest path lengths. Changes in these network parameters will be regarded as the neural correlates of the behavioral training.

DISCUSSION

MHRT was newly developed for the treatment of TS. MHRT may lead to greater reductions in tic severity than traditional HRT. Changes in the network parameters of the DMN and SN may show associations with the efficacy of MHRT.

CLINICAL TRIAL REGISTRATION

http://www.chictr.org.cn, ChiCTR2100053077, China.

Role of psychotherapy strategy for the management of patients with Tourette syndrome - A Bayesian network meta-analysis

Tourette's syndrome (TS) is a complex neurodevelopmental disorder characterized by high comorbidity. Treatment with psychotherapy is highly recommended, however, there exists limited available evidence on the use and the optimal psychotherapeutic outcome is debatable. We performed a systematic search on several bibliographic databases for randomized controlled trials (RCTs) reporting the use of psychotherapy treatment in TS patients, from inception to August 1st, 2020, and without language restrictions. Outcome measures were measured by the Yale global tic severity scale (YGTSS) to determine the efficacy of psychotherapy. Data were pooled as Standard mean difference (SMD) in the Bayesian analysis of the random effect model. A total of 17 RCTs with 9 treatments and 1042 participants were included from an initial 4901 records. The primary outcome including, Comprehensive behavioral intervention (CBIT) [SMD = -1.43, 95%Credible interval (CrI): -2.39, -0.44], Exposure with response prevention (ERP) [SMD = -1.37, 95%CrI: -2.62, -0.13], Habit reversal therapy (HRT) [SMD = -0.93, 95%CrI: 1.83, -0.05], and Behavior therapy (BT) [SMD = -0.85, 95%CrI: 1.51, -0.18], were found to be significantly lower in the TS group compared with the control group (including wait-list, treatment-as-usual or other named control group). Based on the Surface under the cumulative ranking curve (SUCRA), CBIT (SUCRA value = 86.97%, 95%CrI: 44%, 100%) was found to be a suitable psychotherapeutic treatment for TS patients. High-quality RCTs on psychotherapy are needed to perform for establishing the foundation of the generation of evidence-based guidelines.