Group comprehensive behavioral intervention for tics contribution to broader cognitive and emotion regulation in children

There is increasing evidence for the effectiveness of behavioral techniques in managing tics in youth with Tourette syndrome and tics disorders (TDs). One such intervention is Comprehensive Behavioral Intervention for Tics (CBIT), which focuses on reducing tic severity by training control and regulation. In view of the regulation deficits characteristic to TDs, in the current study, we aimed to explore the contribution of CBIT beyond tic control, to a wider expression of regulation abilities-cognitive inhibition and emotion regulation. A total of 55 participants with TDs, aged 8-15, who were randomly assigned to group-CBIT or group-Educational Intervention for Tics, were compared on cognitive inhibition tests and use of emotion-regulation strategies, pre- and post-intervention. Whereas on none of the scales a significant interaction effect was found reflecting superiority of CBIT over EIT, repeated measures ANOVA revealed a significant time effect, with post hoc analyses indicating that cognitive inhibition and cognitive reappraisal significantly increased following CBIT intervention only. Within the group-CBIT, the increase in cognitive reappraisal was associated with higher intellectual ability. These findings may lead to a broader understanding of CBIT contribution to more than tic control, but rather to better cognitive and emotional regulation abilities.

Relaxation training with and without Comprehensive Behavioral Intervention for Tics for Tourette's disorder: A multiple baseline across participants consecutive case series

BACKGROUND AND OBJECTIVES

Behavioral therapies such as the Comprehensive Behavioral Intervention for Tics (CBIT) are recommended as the first-line treatment for Tourette's Disorder. This treatment approach is comprised of three central components: habit reversal training, functional assessment/intervention, and relaxation training. Despite its combined efficacy, the contribution of each therapeutic component in CBIT for reducing tic severity remains undetermined. The study evaluated the efficacy of relaxation training alone or alongside other CBIT components for reducing tic severity.

METHODS

In this multiple-baseline study, participants completed a baseline assessment (A), 4 weekly sessions of relaxation training followed by a posttreatment assessment (B), 8 weekly sessions of CBIT followed by a posttreatment assessment (C), and a 1 month posttreatment follow up assessment (D). Six participants (83% male) aged 10-18 with Tourette's Disorder completed study procedures. Primary outcomes of tic severity was the Yale Global Tic Severity Scale (YGTSS).

RESULTS

A repeated measures ANOVA revealed a significance reduction in tic severity over time (p = .010). While post-hoc tests revealed a moderate non-significant reduction in tic severity after relaxation training (d =.23), large significant reductions in tic severity were observed after the combined treatment of relaxation training and CBIT (d = 1.17) that were maintained at a 1-month follow-up visit (d = 1.53).

LIMITATIONS

Findings are limited by the small sample size.

CONCLUSIONS

While relaxation training is effective when included in conjunction with CBIT, relaxation training alone is not effective in reducing tic severity in patients with Tourette's Disorder.

Internet-based guided self-help comprehensive behavioral intervention for tics (ICBIT) for youth with tic disorders: a feasibility and effectiveness study with 6 month-follow-up

Practice guidelines endorse comprehensive behavioral intervention for tics (CBIT) as first-line treatment for tic disorders (TD) in youth. Nevertheless, CBIT is rarely available due to various barriers. This study evaluated the feasibility and potential effectiveness of an Internet-based, self-help CBIT program (ICBIT) guided by parents with minimal therapist support delivered via telepsychotherapy. Forty-one youths, aged 7-18 years, were randomly assigned to receive either ICBIT (n = 25) or a wait-list (WL) condition (n = 16) in a crossover design. ICBIT was feasible to implement and at post-treatment, 64% of the participants have improved significantly. Results demonstrated clinically meaningful reductions in tic severity and improved youth global impairment and functioning. Gains were maintained over a 6-month follow-up period. The effect size for the primary outcome measure (Yale Global Tic Severity Scale) ranged between large effect size (Cohen"s d = 0.91) at post-intervention to very large effect size (Cohen's d = 2.25) 6 months after the end of the acute intervention. These were comparable to face-to-face delivery treatment trials for TD. Participants rated the intervention as highly acceptable and satisfactory. Youth receiving ICBIT experienced improvement in self-esteem and comorbidity. Finally, during the COVID-19 pandemic, the ICBIT program enabled the delivery of the intervention consecutively without interruption. The results observed provide preliminary evidence of the feasibility and effectiveness of this innovative modality to assist youth with TD and remove various barriers to treatment, including those during a public crisis, such as the COVID-19 pandemic. Larger studies with an active control group are warranted.Trial registration URL: http://clinicaltrials.gov, ClinicalTrials.gov Identifier: NCT04087616.

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.

Homework adherence predicts therapeutic improvement from behavior therapy in Tourette's disorder

Behavior therapy is a first-line intervention for Tourette's Disorder (TD), and a key component is the practice of therapeutic skills between treatment visits (i.e., homework). This study examined the relationship between homework adherence during behavior therapy for TD and therapeutic outcomes, and explored baseline predictors of homework adherence during treatment. Participants included 119 individuals with TD (70 youth, 49 adults) who received behavior therapy in a clinical trial. After a baseline assessment of tic severity and clinical characteristics, participants received 8 sessions of behavior therapy. Therapists recorded homework adherence at each therapy session. After treatment, tic severity was re-assessed by independent evaluators masked to treatment condition. Greater overall homework adherence predicted tic severity reductions and treatment response across participants. Early homework adherence predicted therapeutic improvement in youth, whereas late adherence predicted improvement in adults. Baseline predictors of greater homework adherence in youth included lower hyperactivity/impulsivity and caregiver strain. Meanwhile in adults, baseline predictors of increased homework adherence included younger age, lower hyperactivity/impulsivity, obsessive-compulsive severity, anger, and greater work-related disability. Homework adherence is an integral component of behavior therapy and linked to therapeutic improvement. Strategies that improve homework adherence may optimize the efficacy of behavioral treatments and improve treatment outcomes.

Review of habit reversal training for tic disorders

Tic disorders (TD) is a neurodevelopmental disorder that is often first recognized in children and adolescents and is characterized mainly by motor and phonic tics. Drug treatment of TD has been criticized because of serious side effects, and TD treatment emphasizes behavioral psychotherapy. This study reviewed the most common behavioral psychotherapy for TD: habit reversal training (HRT). We examined the contents, variation, curative effects, and premonitory urge control of HRT and other behavioral psychotherapies. The findings suggest that current understanding of HRT is insufficient and further studies are needed. First, studies of online guidance training are needed to implement technology that can help more patients. Second, the future integration of HRT and other technologies is important. Third, imaging techniques could be used to further explore the brain mechanisms underlying HRT. Research on HRT for TD in China is insufficient. We call on more Chinese researchers to study, investigate, and develop technology to promote the development of behavioral psychotherapy for TD in China.

Bothersome tics in patients with chronic tic disorders: Characteristics and individualized treatment response to behavior therapy. Behav Res Ther. 2015;70:56-63. [PMID: 25988365 DOI: 10.1016/j.brat.2015.05.006]

This report examined the most frequently reported bothersome tics among individuals with chronic tic disorders and evaluated the improvement and remission of tics and their associated characteristics. Youths and adults (N = 240) were randomly assigned to receive the comprehensive behavioral intervention for tics (CBIT) or psychoeducation and supportive therapy (PST). At baseline, motor tics and tics with an urge were rated as more bothersome relative to vocal tics and tics without premonitory urges. The five most common bothersome tics included eye blinking, head jerks, sniffing, throat clearing, and other complex motor tics. While CBIT outperformed PST across tic type and urge presence, tics preceded by premonitory urges at baseline had higher severity at posttreatment across treatment condition. Six individual tic types had lower severity at posttreatment following CBIT relative to PST. Baseline urge presence was associated with tic remission for CBIT but not PST. Specific bothersome tics were more likely to remit with CBIT relative to PST. Findings suggest that individual tics respond and remit differently to CBIT relative to PST, with implications highlighting the negative reinforcement hypothesis in tic symptom maintenance. CLINICALTRIALS.

GOV IDENTIFIERS

NCT00218777; NCT00231985.

A cluster analysis of tic symptoms in children and adults with Tourette syndrome: clinical correlates and treatment outcome

Cluster analytic methods have examined the symptom presentation of chronic tic disorders (CTDs), with limited agreement across studies. The present study investigated patterns, clinical correlates, and treatment outcome of tic symptoms. 239 youth and adults with CTDs completed a battery of assessments at baseline to determine diagnoses, tic severity, and clinical characteristics. Participants were randomly assigned to receive either a comprehensive behavioral intervention for tics (CBIT) or psychoeducation and supportive therapy (PST). A cluster analysis was conducted on the baseline Yale Global Tic Severity Scale (YGTSS) symptom checklist to identify the constellations of tic symptoms. Four tic clusters were identified: Impulse Control and Complex Phonic Tics; Complex Motor Tics; Simple Head Motor/Vocal Tics; and Primarily Simple Motor Tics. Frequencies of tic symptoms showed few differences across youth and adults. Tic clusters had small associations with clinical characteristics and showed no associations to the presence of coexisting psychiatric conditions. Cluster membership scores did not predict treatment response to CBIT or tic severity reductions. Tic symptoms distinctly cluster with little difference across youth and adults, or coexisting conditions. This study, which is the first to examine tic clusters and response to treatment, suggested that tic symptom profiles respond equally well to CBIT. Clinical trials.gov. identifiers: NCT00218777; NCT00231985.