Brief antecedent assessment and treatment of tics in the general education classroom: a preliminary investigation

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.

A Review on Functional Analyses of Tics

Tic disorders are characterized by a class of responses assumed to be neurobiological in origin. Still, several studies have shown that tic frequency can be influenced by antecedent environmental events and social consequences. Prior reviews have summarized the effects of environmental events but have not examined relations between tic diagnosis, behavioral deficits (e.g., intellectual disability), tic topography, and the consequences observed to maintain tics. These variables might be important when attempting to predict or identify relevant consequences. A more thorough understanding of the variables that maintain and give rise to tics might also be useful in predicting responsiveness to treatment and intervention refinement. We reviewed and summarized results from the 13 attempts to experimentally identify maintaining consequences for tics (i.e., functional analyses) that have been published to date. We examined patterns of functions across tic diagnoses (i.e., Tourette's syndrome or not), communication impairments (i.e., an intellectual disability or reported language difficulty), and tic topography. Results suggested that individuals with Tourette's syndrome and those without communication impairments are more likely to have functional analysis outcomes consistent with automatic reinforcement, but exceptions in both directions highlight the utility of functional analysis in treating tics.

Los tics y su relación con las dificultades de aprendizaje: estudio longitudinal de la prevalencia de los tics primarios y comorbilidad asociada en población escolar

Con el objetivo de estudiar la prevalencia de los trastornos con tics y la asociación con las dificultades de aprendizaje, se realizó un estudio epidemiológico en una muestra de 1.139 escolares. Los resultados señalaron una prevalencia del 16,86% (IC 95% del 14,10 – 19,63). Además se encontraron dificultades académicas en el 11,9% de los escolares, y la presencia de tics en el 8,6%. La presencia de trastornos de tics no se asoció con el bajo rendimiento académico en la cohorte. Los resultados obtenidos fueron contradictorios con relación a otros estudios publicados anteriormente. Como consecuencia de la divergencia en los resultados, se diseña un segundo estudio, que toma como punto de partida el seguimiento longitudinal de la cohorte de los escolares estudiados. En el análisis de regresión de Cox, durante el periodo de seguimiento de 4 años, la repetición de curso se asoció con una menor frecuencia de apoyo psicológico en el centro escolar (HR = 17,5; IC del 95% 5,7 a 53,9) y menor practica de deporte (HR = 4,02, 95% CI 01/03 a 11/08). No se encontró una asociación entre los tics y mayor riesgo de repetir curso.

Putting the Pieces Together in Gilles de la Tourette Syndrome: Exploring the Link Between Clinical Observations and the Biological Basis of Dysfunction

Gilles de la Tourette syndrome is a complex, idiopathic neuropsychiatric disorder whose pathophysiological mechanisms have yet to be elucidated. It is phenotypically heterogeneous and manifests more often than not with both motor and behavioral impairment, although tics are its clinical hallmark. Tics themselves present with a complex profile as they characteristically wax and wane and are often preceded by premonitory somatosensory sensations to which it is said a tic is the response. Highly comorbid with obsessive-compulsive disorder and attention deficit-hyperactivity disorder, it is purported to be an epigenetic, neurodevelopmental spectrum disorder with a complex genetic profile. It has a childhood onset, occurs disproportionately in males, and shows spontaneous symptomatic attenuation by adulthood in the majority of those afflicted. Although not fully understood, its neurobiological basis is linked to dysfunction in the cortico-basal ganglia-thalamo-cortical network. Treatment modalities for Tourette syndrome include behavioral, pharmacological and surgical interventions, but there is presently no cure for the disorder. For those severely affected, deep brain stimulation (DBS) has recently become a viable therapeutic option. A key factor to attaining optimal results from this surgery is target selection, a topic still under debate due to the complex clinical profile presented by GTS patients. Depending on its phenotypic expression and the most problematic aspect of the disorder for the individual, one of three brain regions is most commonly chosen for stimulation: the thalamus, globus pallidus, or nucleus accumbens. Neurophysiological analyses of intra- and post-operative human electrophysiological recordings from clinical DBS studies suggest a link between tic behavior and activity in both the thalamus and globus pallidus. In particular, chronic recordings from the thalamus have shown a correlation between symptomatology and (1) spectral activity in gamma band power and (2) theta/gamma cross frequency coherence. These results suggest gamma oscillations and theta/gamma cross correlation dynamics may serve as biomarkers for dysfunction. While acute and chronic recordings from human subjects undergoing DBS have provided better insight into tic genesis and the neuropathophysiological mechanisms underlying Tourette syndrome, these studies are still sparse and the field would greatly benefit from further investigations. This review reports data and discoveries of scientific and clinical relevance from a wide variety of methods and provides up-to-date information about our current understanding of the pathomechanisms underlying Tourette syndrome. It gives a comprehensive overview of the current state of knowledge and addresses open questions in the field.

Thirty years of research on the functional analysis of problem behavior

Hanley, Iwata, and McCord (2003) reviewed studies published through 2000 on the functional analysis (FA) of problem behavior. We update that review for 2001 through 2012, including 158 more recent studies that reported data from 445 FAs. Combined with data obtained from Hanley et al., 435 FA studies, with line graphs for 981 FAs, have been published since 1961. We comment on recent trends in FA research and introduce the studies in the 2013 special issue of the Journal of Applied Behavior Analysis.

Clinical assessment of Tourette syndrome and tic disorders

Tourette syndrome (TS) is a neuropsychiatric disorder involving multiple motor and phonic tics. Tics, which usually begin between the ages of 6 and 8, are sudden, rapid, stereotyped, and apparently purposeless movements or sounds that involve discrete muscle groups. Individuals with TS experience a variety of different sensory phenomena, including premonitory urges prior to tics and somatic hypersensitivity due to impaired sensorimotor gating. In addition to other conditions, stress, anxiety, fatigue, or other heightened emotional states tend to exacerbate tics, while relaxation, playing sports, and focused concentration on a specific task tend to alleviate tic symptoms. Ninety percent of children with TS also have comorbid conditions, such as attention deficit hyperactivity disorder (ADHD), obsessive-compulsive disorder (OCD), or an impulse control disorder. These disorders often cause more problems for the child both at home and at school than tics do alone. Proper diagnosis and treatment of TS involves appropriate evaluation and recognition, not only of tics, but also of these associated conditions.

Behavior therapy for children with Tourette disorder: a randomized controlled trial

CONTEXT

Tourette disorder is a chronic and typically impairing childhood-onset neurologic condition. Antipsychotic medications, the first-line treatments for moderate to severe tics, are often associated with adverse effects. Behavioral interventions, although promising, have not been evaluated in large-scale controlled trials.

OBJECTIVE

To determine the efficacy of a comprehensive behavioral intervention for reducing tic severity in children and adolescents.

DESIGN, SETTING, AND PARTICIPANTS

Randomized, observer-blind, controlled trial of 126 children recruited from December 2004 through May 2007 and aged 9 through 17 years, with impairing Tourette or chronic tic disorder as a primary diagnosis, randomly assigned to 8 sessions during 10 weeks of behavior therapy (n = 61) or a control treatment consisting of supportive therapy and education (n = 65). Responders received 3 monthly booster treatment sessions and were reassessed at 3 and 6 months following treatment.

INTERVENTION

Comprehensive behavioral intervention.

MAIN OUTCOME MEASURES

Yale Global Tic Severity Scale (range 0-50, score >15 indicating clinically significant tics) and Clinical Global Impressions-Improvement Scale (range 1 [very much improved] to 8 [very much worse]).

RESULTS

Behavioral intervention led to a significantly greater decrease on the Yale Global Tic Severity Scale (24.7 [95% confidence interval {CI}, 23.1-26.3] to 17.1 [95% CI, 15.1-19.1]) from baseline to end point compared with the control treatment (24.6 [95% CI, 23.2-26.0] to 21.1 [95% CI, 19.2-23.0]) (P < .001; difference between groups, 4.1; 95% CI, 2.0-6.2) (effect size = 0.68). Significantly more children receiving behavioral intervention compared with those in the control group were rated as being very much improved or much improved on the Clinical Global Impressions-Improvement scale (52.5% vs 18.5%, respectively; P < .001; number needed to treat = 3). Attrition was low (12/126, or 9.5%); tic worsening was reported by 4% of children (5/126). Treatment gains were durable, with 87% of available responders to behavior therapy exhibiting continued benefit 6 months following treatment.

CONCLUSION

A comprehensive behavioral intervention, compared with supportive therapy and education, resulted in greater improvement in symptom severity among children with Tourette and chronic tic disorder.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00218777.

The influence of contextual factors on tic expression in Tourette's syndrome: a review

Symptoms of Tourette's syndrome vary in frequency and intensity. Although such variability may be the result of deficits in the underlying neurological system, tic expression can also be systematically impacted by contextual factors. This article reviews research on the impact of several contextual factors on tic expression and discusses implications for future research and treatment development.

Functional Analysis and Treatment of Nail Biting

This study applied functional analysis methodology to nail biting exhibited by a 24-year-old female graduate student. Results from the brief functional analysis indicated variability in nail biting across assessment conditions. Functional analysis data were then used to guide treatment development and implementation. Treatment included a simplified habit reversal package that was modified based on results of the functional analysis. Following treatment implementation, nail biting decreased as evidenced by consistent nail growth and participant self-recorded data. Results are discussed in terms of treatment utility of functional analysis methodology for novel populations and response topographies.