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This study measured therapist behaviors in relation to subsequent habituation within exposure tasks, and also tested their direct and indirect relationships (via habituation) with clinical outcomes of exposure therapy. We observed 459 videotaped exposure tasks with 111 participants in three clinical trials for pediatric obsessive-compulsive disorder (POTS trials). Within exposure tasks, therapist behaviors and patient fear were coded continuously. Outcomes were habituation and post-treatment change in symptom severity, global improvement, and treatment response. More therapist behaviors that encourage approach—and less use of accommodation, unrelated talk, and externalizing language—predicted greater subsequent habituation during individual exposure tasks (exposure-level), and also predicted improved patient clinical outcomes via higher ‘total dose’ of habituation across treatment (patient-level indirect effect). For six of seven therapist behaviors analyzed, the relationship with subsequent habituation within exposure differed by patient fear (low, moderate, or high) at the time the behavior was used. Two therapist behaviors had direct effects in the opposite direction expected; more unrelated talk and less intensifying were associated with greater patient symptom reduction. Results shed light on the “black box” of in-session exposure activities and point to specific therapist behaviors that may be important for clinical outcomes. These behaviors might be best understood in the context of changing patient fear during exposure tasks. Future studies should test whether therapist behaviors can be experimentally manipulated to produce improvement in clinical outcomes.

This study tested whether a new training tool, the Exposure Guide (EG), improved in-session therapist behaviors that have been associated with youth outcomes in prior clinical trials of exposure th...

Children with persistent (chronic) tic disorders (PTDs) experience impairment across multiple domains of functioning, but given high rates of other non-tic-related conditions, it is often difficult to differentiate the extent to which such impairment is related to tics or to other problems. The current study used the Child Tourette's Syndrome Impairment Scale - Parent Report (CTIM-P) to examine parents' attributions of their child's impairment in home, school, and social domains in a sample of 58 children with PTD. Each domain was rated on the extent to which the parents perceived that impairment was related to tics versus non-tic-related concerns. In addition, the Yale Global Tic Severity Scale (YGTSS) was used to explore the relationship between tic-related impairment and tic severity. Results showed impairment in school and social activities was not differentially attributed to tics versus non-tic-related impairment, but impairment in home activities was attributed more to non-tic-related concerns than tics themselves. Moreover, tic severity was significantly correlated with tic-related impairment in home, school, and social activities, and when the dimensions of tic severity were explored, impairment correlated most strongly with motor tic complexity. Results suggest that differentiating tic-related from non-tic-related impairment may be clinically beneficial and could lead to treatments that more effectively target problems experienced by children with PTDs. Keywords: Impairment, Tourette's disorder, Tic severity, Children

Future episodic thinking relies on the reconstruction of remembered experiences. Photographs provide one means of remembering, acting as a "cognitive springboard" for generating related memory qualities. We wondered whether photographs would also invite embellishment of future thought qualities, particularly in the presence (or absence) of associated memories. In two studies participants generated future events in familiar (associated memories) and novel (no associated memories) locations. Half of the participants viewed scene location photographs during event generation. All participants then imagined the events for one minute and completed a self-report measure of content qualities. Results of the current set of studies suggested that for novel locations, no differences in qualities emerged; however, for familiar locations, photographs did not enhance qualities and, in some cases, actually constrained perceptual (Experiments 1 and 2) and sensory (Experiment 1) detail ratings of future thoughts. Thus, photographs did not invite embellishment of future thought details.

In the case of Hiro, Dr. Jeremy Lichtman (2017, this issue) describes how he flexibly employed a manualized behavior therapy protocol to successfully treat a child’s involuntary motor and vocal tics. In doing so, he raises interesting observations and questions regarding manualized psychotherapy treatment protocols, including their intended role, the need for "flexibility with fidelity," and the strengths and limitations of following manuals in a step-by-step fashion. In our commentary, we draw upon Dr. Lichtman’s experience in treating Hiro to highlight what we see as the two most important factors in Hiro’s treatment: (1) the therapist’s firm grasp of the underlying theory behind behavior therapy for tics, which allowed for flexibility in treatment delivery without jeopardizing treatment fidelity, and (2) the importance of having a strong foundational clinical skill set prior to beginning treatment

Objective This study measured a variety of within-exposure fear changes and tested the relationship of each with treatment outcomes in exposure therapy. Method We coded 459 videotaped exposure tasks from 111 participants in 3 clinical trials for pediatric obsessive-compulsive disorder (OCD; POTS trials). Within exposures, fear level was observed continuously and alongside exposure process. Fear change metrics of interest were selected for relevance to mechanistic theory. Fear decreases were classified by function; nonhabituation decreases were associated with observed nonlearning processes (e.g., avoidance), whereas habituation decreases appeared to result from an internal and indirect process. Outcomes were posttreatment change in symptom severity, global improvement, and treatment response. Results Greater cumulative habituation across treatment was associated with larger reductions in symptom severity, greater global improvement, and increased odds of treatment response. Fear activation, fear variability, and nonhabituation fear decreases did not predict any outcomes. Exploratory analyses examined fear changes during habituation and nonhabituation exposures; higher peak fear during nonhabituation exposures was associated with attenuated global improvement. Conclusions Habituation is conceptually consistent with multiple mechanistic theories and should continue to be investigated as a practical marker of initial extinction learning and possible moderator of the relationship between fear activation and outcome. Results support the importance of functional and frequent fear measurement during exposures, and discussion considers implications of these findings for future studies aiming to understand learning during exposure and improve exposure delivery. (PsycINFO Database Record

Background: Tic suppression is the primary target of tic disorder treatment, but factors that influence voluntary tic inhibition are not well understood. Several studies using the Tic Suppression Task have demonstrated significant inter-individual variability in tic suppressibility but have individually been underpowered to address correlates of tic suppression. The present study explored patterns and clinical correlates of tic suppression in youth with tic disorders using a large, pooled dataset.Methods: Individual-level data from 9 studies using the Tic Suppression Task were pooled, yielding a sample of 99 youth with tic disorders. Analyses examined patterns of tic suppressibility and the relationship between tic suppressibility and demographic and clinical characteristics.Results: A large majority of youth demonstrated a high degree of tic suppression, but heterogeneous patterns of tic suppressibility were also observed. Better tic suppressibility was related to older age and more frequent tics but unrelated to other clinical variables, including presence of psychiatric comorbidity, psychotropic medication status, and tic and premonitory urge severity.Conclusions: The mechanisms underlying the observed heterogeneity in tic suppressibility warrant further investigation. The Tic Suppression Task is a promising method for testing mechanistic hypotheses related to tic suppression.

It is well established that persistent tic disorders (PTD) in youth can negatively affect the entire family system. Although efficacious interventions for reducing tics are available, interventions focused purely on reducing tic severity do not always fully address problems in family functioning. The aim of this chapter is to help clinicians to appreciate the importance of providing comprehensive, family-based clinical care when working with a child with PTD and to provide practical recommendations for how providers can intervene to reduce stress and burden on the family, improve resilience and family functioning, and increase treatment engagement.