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Consistent with international reports,1 this group of Tourette syndrome (TS) experts has noticed a recent increase in adolescents presenting with tic-like symptoms that show a markedly atypical onset and course. These sudden-onset motor movements and vocalizations are often associated with significant impairment and disability, resulting in emergency department visits and hospitalizations for some affected youths.

OBJECTIVE: Treatment guidelines for Tourette’s Disorder (TD) are based on patients’ degree of tic severity and impairment. However, clear benchmarks for determining tic severity and impairment have not been established. This study examined benchmarks of tic severity and tic impairment using the Yale Global Tic Severity Scale (YGTSS) and the Clinical Global Impression of Severity (CGI-S). METHOD: Individuals with TD or another Tic Disorder (N = 519) recruited across nine sites were administered a diagnostic interview, the YGTSS, and the CGI-S. Correlations and trend analyses contrasted YGTSS scores across CGI-S ratings. A logistic regression model examined predictive benchmarks for tic severity, tic impairment, and global severity. Model classifications were compared against CGI-S ratings, and agreement was examined using kappa. RESULTS: Spearman correlations between the CGI-S and YGTSS scores ranged from 0.54 to 0.63 (p < 0.001). Greater CGI-S ratings were associated with a linear stepwise increase in YGTSS Total Tic scores, Impairment scores, and Global Severity scores. Despite moderate-to-strong associations (ρ = 0.45–0.56, p < 0.001) between the CGI-S and predictive logistical regression models, only fair agreement was achieved when applying classification benchmarks (κ = 0.21–0.32, p < 0.001). CONCLUSIONS: CGI-S ratings are useful to characterize benchmarks for tic severity, tic impairment, and global severity on the YGTSS. Logistic regression model benchmarks had only fair agreement with the CGI-S and underscore the heterogeneity of TD symptoms. Collectively, findings offer guidance on the delineation of tic severity categorizations to apply evidence-based treatment recommendations.

Objectives Health care providers and educators play critical roles in supporting healthy sexuality development for youth with autism spectrum disorder. There is limited information about the sexual behavior of these youth, especially girls, and about their access to sexuality education or health care services. Methods This study addressed these gaps by surveying parents of youth with autism aged 12-18 years (N = 298, 52.7% boys) with a range of intellectual functioning. Results According to parent report, most youth experienced sexual attraction and were interested in relationships, including same-sex attraction or relationships (13.2%). Girls were more likely than boys to have had a romantic relationship and less likely to have experienced school or legal consequences for sexual behavior. Around one-fifth of youth had engaged in a socially inappropriate sexual behavior, whereas 6.4% had a known sexual abuse history and 14.5% were bullied by peers for lack of sexual knowledge. Almost 40% received no sex education in school or in the community, including 60.9% of youth with parent-reported intelligence quotient under 70. Some parents consulted with school personnel (36.4%) or health care providers (55.9%) about sexuality issues, whereas 19.5% reported taking no action aside from talking to their child about sexuality. Utilization models including predisposing, enabling, and needs-related factors were applied to parent consultation with providers and use of school-based sexuality education programming. Conclusion The results suggest unmet needs for sexual and reproductive health services, particularly among youth who are younger, those who have co-occurring intellectual disability, or those who are homeschooled or who attend private, charter, or therapeutic versus public schools.

Families are a critical context for healthy sexuality development. This study characterized family sexuality communication for autistic adults (age 18-30) without intellectual disability (n = 117) versus a neurotypical comparison group (n = 319). Parent-reported number of sexuality topics covered did not significantly differ by gender or autism/comparison group. Parents of autistic adults who covered few or no topics (31%) reported higher religiosity, lower comfort and self-efficacy, and were less likely to say that the adult expressed attraction or desire for relationships. Parents of autistic adults were more likely than comparison parents to perceive their young person as being uninterested or not ready to learn about sexuality topics. These results suggest that families of autistic people require support to convey sexuality-related knowledge and values.

Families are critical for supporting healthy sexuality and relationship development for youth with autism. The objective of this study was to describe family sexuality communication for adolescent girls with autism. Participants were 141 parents of autistic daughters who completed an online survey about sexuality development. Most parents relied on discussion alone rather than visual supports or skills-based teaching techniques. Intellectual functioning, child age, race/ethnicity, and whether youth expressed sexual interest in others affected family sexuality communication. We discuss how most parents covered important basics, but many did not cover more nuanced relationship or sexual health topics during family sexuality communication. Few used enhanced instructional techniques (e.g., visual supports, social stories), suggesting potential utilization barriers such as a lack of affordable and available resources. There is a need for research accounting for diverse racial/ethnic backgrounds, sexual orientations including asexuality/demisexuality, and for transgender and gender diverse youth.

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

Community stakeholders, researchers, and providers are increasingly focused on individual, family, and systemic factors that contribute to positive outcomes for adults on the autism spectrum. Parent expectations for their youth's future are associated with adult outcomes (e.g., employment, school success, independence), yet the mechanism for this effect remains unclear. This study investigated how expectations were related to parent transition-related activities in a sample of 298 parents of adolescents on the autism spectrum (48% female adolescents), stratified by parent-reported IQ (average or above, borderline, or below 70). Parent expectations for the future predicted engagement in some activities intended to enhance adult outcomes when controlling for IQ, gender, age, and household income. The results have implications for how providers discuss expectations and support families in preparing for adulthood.

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

Tourette Syndrome and other persistent tic disorders (TDs ) involve chronic, repetitive, unwanted movements and/or sounds (i.e., tics) that can cause substantial distress and disruption in everyday activities (American Psychiatric Association, 2013). Effective medications for treating TD exist, but, in many cases, they cause significant side effects that limit their usability. Comprehensive Behavioral Intervention for Tics (CBIT) is a therapy that teaches tic-management skills to reduce tic frequency and interference. Large, controlled research studies have shown that CBIT reduces tics in children and adults about as much as medications, but without significant side effects. However, at present, patient demand for CBIT exceeds availability, and many patients do not have access to a local CBIT provider. Also, a smaller percentage of patients perceive CBIT to be a poor fit for their specific situation. Researchers have been exploring options to make CBIT more available and to tailor it to different settings, but patient, family, and other stakeholder input is essential to understand how to do this most effectively. We established the “Treating Tourette Together” project to bring together patients, clinicians, researchers, and other stakeholders to develop an agenda for a new generation of patient-centered CBIT research. In this report, we describe the Treating Tourette Together project and present the resulting research agenda.

The past decade has realized substantial progress in understanding and treating Tourette disorder (TD). The goal of this review is to highlight recent research on behavioral approaches for treating TD and to identify limitations to this treatment approach and directions for future research. Two large randomized controlled trials provide the most compelling evidence to date of the efficacy of behavior therapy for reducing tic severity in both children and adults with TD. Historical concerns regarding adverse treatment side effects have been examined and are not supported. However, treatment response remains incomplete and studies have shown that access to trained providers and the burden associated with treatment are significant barriers to utilization. Abbreviated treatment protocols and remote delivery have been investigated and have shown promise for addressing these issues. Behavior therapy is an efficacious treatment for TD, a better understanding of the behavioral and biological mechanism(s) by which behavior therapy operates will likely lead to improved outcomes. Additionally, it is critical to continue to identify barriers to implementation and improve dissemination of this efficacious treatment option.

Background Premonitory urges are central to emerging behavioral models of chronic tic disorders (CTD). Urge reduction has been proposed as a behavioral explanation for tic maintenance and exacerbation as well as the efficacy of behavioral treatments. Prior investigations have produced inconsistent findings despite common methodologies. The current study evaluated the possibility that data aggregation obscures distinct and meaningful patterns of change in urge ratings when tics are freely expressed versus suppressed. Method Participants (n = 12) included children with moderate-to-marked tic severity and noticeable premonitory urges. Tic frequencies and urge ratings were obtained at 15 s and 10-s intervals, respectively, across an alternating sequence of 10-min tic freely and 40-min tic suppression conditions. Patterns were established using a two step approach. Results Five distinct patterns of urge rating change emerged, suggesting data aggregation may obscure meaningful patterns in the urge–tic relationship when tics are completed versus suppressed. Limitations Eligibility criteria may have unintentionally excluded younger affected children and included older participants with more severe tic disorders than commonly seen. Additional research with less stringent eligibility criteria and a larger sample size will help validate the results. Conclusions The relationship between urges and tics is much more complex than previously theorized. Investigations that rely on global assessments of urge and tic severity and/or assume uniformity when aggregating participant data may obscure meaningful differences in the urge–tic relationship. Future investigations should examine the possibility that individual differences and/or developmental considerations modulate the functional urge–tic relationship.

Background Parents of autistic youth are highly involved in the transition preparation process, yet the role and influence of parental factors and perceptions is underexplored. In the current study, we aimed to expand understanding of transition preparation and the role and influence of parental factors for autistic youth including perceptions of the likelihood (i.e., parent expectations), importance, and parental influence over postsecondary outcomes as well as parental self-efficacy, parent stress, and parent concerns for the future. Method We surveyed 269 parents of autistic youth (ages 14–21, 78.2 % male) who did not have co-occurring intellectual disability. We used linear regression analyses to examine youth and parent predictors of the frequency of transition preparation activities, parents’ overall sense of preparation, and parental worry about the future. We also qualitatively analyzed open-ended responses about parent concerns. Results The most frequently endorsed transition preparation activities were discussions about the future and chores. Parental factors were associated with greater frequency of transition preparation activities, greater overall sense of preparation for the transition, and less overall worry. Key areas of parent concern were related to youth independence, social life, employment/finances, autism features, safety, happiness, and health. Conclusions The results of this study have implications for education and interventions focused on supporting autistic youth and their parents for the transition to adulthood. There is a need for transition-related interventions that focus on parents and on particular instruction for raising expectations, enhancing parent self-efficacy, and increasing parental sense of control over outcomes.

Comprehensive Behavioral Intervention for Tics (CBIT) is an efficacious treatment for children with Chronic Tic Disorders (CTDs). Nevertheless, many families of children with CTDs are unable to access CBIT due to a lack of adequately trained treatment providers, time commitment, and travel distance. This study established the interrater reliability between in-person and VoIP administrations of the Yale Global Tic Severity Scale (YGTSS), and examined the preliminary efficacy, feasibility, and acceptability of Voice over Internet Protocol (VoIP)-delivered CBIT for reducing tics in children with CTDs in an open case series. Across in-person and VoIP administrations of the YGTSS, results showed mean agreement of 91%, 96%, and 95% for motor, phonic, and total tic severity subscales. In the pilot feasibility study, four children received 8-weekly sessions of CBIT via VoIP and were assessed at pre- and post-treatment by an independent evaluator. Results showed a 29.44% decrease in clinician-rated tic severity from pre to post-assessment on the YGTSS. Two of the four patients were considered treatment responders at post treatment, using Clinical Global Impressions-Improvement ratings. Therapeutic alliance, parent and child treatment satisfaction and videoconferencing satisfaction ratings were high. CBIT was considered feasible to implement via VoIP, although further testing is recommended.

Tourette syndrome (TS) is a neuropsychiatric condition associated with substantial distress and functional impairment. Pharmacotherapy has traditionally been considered the first-line intervention for this condition, but there is strong evidence that behavior therapy is a comparably effective treatment option. Here we review empirically supported behavior therapy protocols for treating TS and the evidence associated with each. Potential mechanisms through which behavior therapy operates and concerns surrounding the utilization of behavioral interventions are also discussed.

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.

This study examined the relationship between symptoms of autism spectrum disorder, parental sexuality-related concerns, and parent–child sexuality communication in a sample of 131 parents of youth with ASD (aged 12–18 years) and parent-reported average or above IQ. A principal component analysis was conducted on responses to the Parent Sexuality Concerns Inventory with four sexuality-related concern factors emerging. Parents of children with more severe autism spectrum disorder symptoms (e.g., deficits in social cognition, communication, motivation) had greater sexuality and relationship concerns for their child. Parental concerns were not associated with the number of sexuality topics parents reported having discussed with their child. However, some concerns were associated with parental preparedness to address sexual development and parent self-efficacy for communicating with youth about sexuality.

This study examined the relationship between core symptoms of autism spectrum disorder, parental romantic expectations, and parental provision of sexuality and relationship education in an online sample of 190 parents of youth 12–18 years of age with a parent-reported diagnosis of autism spectrum disorder. Regression analyses were conducted separately for youth with autism spectrum disorder + parent-reported average or above IQ and youth with autism spectrum disorder + parent-reported below average IQ. For youth with autism spectrum disorder + parent-reported average or above IQ, autism spectrum disorder severity predicted parental romantic expectations, but not parental provision of sexuality and relationship education. For youth with autism spectrum disorder + parent-reported below average IQ, parental romantic expectations mediated the relationship between autism spectrum disorder severity and parent provision of sexuality and relationship education. This supports the importance of carefully considering intellectual functioning in autism spectrum disorder sexuality research and suggests that acknowledging and addressing parent expectations may be important for parent-focused sexuality and relationship education interventions.

Introduction Comprehensive Behavioral Intervention for Tics (CBIT) has been shown to be efficacious for chronic tic disorders (CTDs), but utilization is limited by a lack of treatment providers and perceived financial and time burden of commuting to treatment. A promising alternative to in-person delivery is voice over Internet protocol (VoIP), allowing for remote, real-time treatment delivery to patients’ homes. However, little is known about the effectiveness of VoIP for CTDs. Therefore, the present study examined the preliminary efficacy, feasibility, and acceptability of VoIP-delivered CBIT (CBIT-VoIP). Methods Twenty youth (8–16 years) with CTDs participated in a randomized, waitlist-controlled pilot trial of CBIT-VoIP. The main outcome was pre- to post-treatment change in clinician-rated tic severity (Yale Global Tic Severity Scale). The secondary outcome was clinical responder rate (Clinical Global Impressions – Improvement Scale), assessed using ratings of ‘very much improved’ or ‘much improved’ indicating positive treatment response. Results Intention-to-treat analyses with the last observation carried forward were performed. At post-treatment (10-weeks), significantly greater reductions in clinician-rated, ( F(1,18) = 3.05, p 2 = 0.15), and parent-reported tic severity, ( F(1,18) = 6.37, p 2 = 0.26) were found in CBIT-VoIP relative to waitlist. One-third ( n = 4) of those in CBIT-VoIP were considered treatment responders. Treatment satisfaction and therapeutic alliance were high. Discussion CBIT can be delivered via VoIP with high patient satisfaction, using accessible, low-cost equipment. CBIT-VoIP was generally feasible to implement, with some audio and visual challenges. Modifications to enhance treatment delivery are suggested.

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.

Research on adolescents and young adults with autism spectrum disorders (ASDs) has focused on promoting independence and optimizing quality of life, yet the areas of sexual development and sexuality has been largely neglected. The American Academy of Pediatrics encourages pediatricians to address sexuality issues in youth with disabilities to foster healthy development and minimize negative consequences. However, it is unclear to what extent pediatricians address sexuality issues in this population.Two hundred three pediatricians who regularly care for youth with ASD completed an online survey about their experiences in providing sexuality-related care to families and youth with ASD.Respondents discussed an average of 10.9 of 26 sexuality topics with all families at least once during routine visits. Experience in caring for youth with ASD correlated positively with the number of sexuality-related topics discussed and with self-reported comfort discussing sexuality with parents of youth with ASD. The most common barriers to providing comprehensive sexuality-related care to youth with ASD included logistical barriers, pediatrician and parent discomfort, lack of training, and absence of information and materials to help pediatricians address sexuality in this population.Although most pediatricians acknowledged the importance of addressing sexuality-related issues with youth with ASD and their families, several important sexuality-related topics were rarely discussed due to a variety of perceived barriers. Implications and recommendations are discussed.

We analyzed data from 74 male collegiate hockey players. Each athlete’s season began with a baseline administration of the Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) neuropsychology test battery. Fourteen athletes sustained a sport-related head injury and were readministered the test to assess the impact of the injury. A significant decrease in performance (compared to baseline) on immediate and delayed word recall and designs followed the first concussion. Following a second sport-related concussion, the 4 affected athletes showed significant decrease in visual motor speed. Performance improved on 2 response speed measures ( Ps < .01). More errors occurred during a visual processing/discrimination task and immediate recall of designs declined ( Ps < .05). We discuss the results in light of recent work related to the impact of early-life concussions and head injury on late-life consequences, such as chronic traumatic encephalopathy, and more immediate issues such as return-to-play decisions for athletes.

Comprehensive behavioral intervention for tics (CBIT) is a safe and effective treatment for managing the tics of Tourette syndrome (TS). In contrast to most current medications used for the treatment of tics, the efficacy of CBIT has been demonstrated in 2 relatively large, multisite trials. It also shows durability of benefit over time. Similar to psychopharmacological intervention, skilled practitioners are required to implement the intervention. Despite concerns about the effort required to participate in CBIT, patients with TS and parents of children with TS appear willing to meet the requirements of the CBIT program. Efforts are under way to increase the number of trained CBIT providers in the United States. Based on available evidence, recent published guidelines suggest that CBIT can be considered a first-line treatment for persons with tic disorders. © 2013 Movement Disorder Society.

Research has shown that both education about Tourette Syndrome (TS) and self-disclosure have a positive impact on how peers rate the social acceptability of an individual with TS. However, no studies have directly compared generic TS education and personally delivered self-disclosure on how they impact attitudes towards an individual with TS. In the current study, 197 participants viewed a short videotape of a male actor displaying tics, after which they were assigned to one of three groups. One group received no education, one group viewed a commercially available video in which several individuals with TS provided education about TS and discussed their personal experiences with the syndrome, and one group viewed a content-matched video of an actor displaying tics, providing TS education, and personally self-disclosing about his experience having TS. Results indicate that participants in both video conditions rated themselves as more knowledgeable about tics than those in the control condition. More importantly, results also show that participants who viewed the actor personally self-disclose about TS rated him as more socially acceptable than did individuals who either viewed the content-matched generic TS education video or who did not receive education.

Tourette’s Syndrome (TS) is a complex neurobiological disorder that typicallybegins in early childhood. Once thought to be extremely rare, recent estimates haveshown it to be more common in school-aged children than was previously thought(Scahill et al. 2005). Although the range in severity is considerable, TS is asignificant source of impairment for many afflicted children and families (Storch etal. 2007; Woods and Himle 2005).Over the course of the disorder, the involuntary tics that characterize TS change inpresentation and fluctuate in topography, number, frequency, and complexity acrossdays, weeks, and months (Leckman et al. 1998). In addition to tics, most childrenwith TS struggle with one or more comorbid condition, most commonly attentiondeficit hyperactivity disorder (ADHD), obsessive-compulsive disorder (OCD),oppositional-defiant disorder (ODD), conduct disorder (CD), explosive outbursts(“rage attacks”), and/or a learning disorder (Freeman et al. 2007). The complexcombination of tics, internalizing problems, and externalizing problems results insignificant interpersonal, family, and academic impairment and creates challenges foreffective clinical care.The past two decades have witnessed a surge in empirical research aimed atenhancing clinical care for TS. Advances in genetic and brain imaging techniqueshave shed light on the underlying phathophysiology which has in turn led to thedevelopment and testing of more effective pharmacotherapeutics. Refined assess-ment techniques have allowed for reliable diagnosis, more precise prevalenceestimates, and a better understanding of the TS phenotype. Psychosocial research hasled to the development and testing of exciting new nonpharmacological treatmentsfor tics and associated symptoms. This is perhaps best exemplified in the recentlypublished Comprehensive Behavioral Treatment for Tics (CBIT) treatment trial

Habit reversal training (HRT) has been proven effective for reducing tics in children with Tourette's syndrome (TS). However, the availability of the intervention is limited. Videoconference technology represents a promising mode through which HRT may be disseminated to underserved areas. Using a multiple-baseline across participants design, the current study tested the effectiveness of videoconference-delivered HRT for 3 children with TS. Similar to results from randomized controlled trials studying face-to-face delivered HRT, videoconference-delivered HRT was effective for reducing tics. All three children demonstrated significant tic reduction following videoconference HRT delivery. All participants and their families rated the delivery modality as acceptable and the therapeutic relationship as strong. These results suggest that videoconference delivery may be a promising method for disseminating behavior therapy for tics.

This paper describes the phenomenological features of early childhood onset obsessive compulsive disorder (OCD; defined as children meeting DSM-IV criteria for OCD with age of onset

The current study evaluated the effects of tokens delivered on differential reinforcement of zero-rate behavior (DRO) schedules or noncontingently on tic suppression in 4 children with tics. Tic frequency was lower in 3 of 4 children when tokens were delivered contingent on the absence of tics than when tokens were delivered noncontingently.

“Evidence-Based Psychosocial Treatments for Tic Disorders” (Cook & Blacher, 2007) provided a current and comprehensive summary of the evidence base for psychosocial approaches to these conditions, and concluded that habit reversal training meets established criteria as an empirically supported treatment. This commentary delves further into the theoretical implications of the treatment outcome findings for chronic tic disorders (CTDs), and highlights the importance of conducting studies that better elucidate the mechanism underlying symptom reduction. We maintain that significant advances in our understanding of these mechanisms will improve our understanding of the causal and maintaining factors in CTDs, which in turn will inform treatment refinements. We also believe that this line of research will improve the acceptability of these psychosocial approaches among all of those who encounter CTDs in clinical practice.

Chronic tic disorders are characterized by involuntary motor and vocal tics, which are influenced by contextual factors. Recent research has shown that (a) children can suppress tics for brief periods of time, (b) suppression is enhanced when programmed reinforcement is provided for tic-free intervals, and (c) short periods of suppression do not result in a paradoxical "rebound" in tic frequency when active suppression has ceased. The current study extended existing research in three important ways. First, we examined whether tic suppression ability decreased as suppression duration increased from 5 to 25 to 40 min. Second, we examined post-suppression tic frequency to test whether longer periods of suppression were more likely to be associated with a rebound effect. Finally, we explored neuropsychological predictors of tic suppression. Thirteen children with Tourette syndrome or a chronic tic disorder completed the study. Results showed that (a) tic suppression was sustained for all of the suppression durations, (b) rebound effects were not observed following any of the suppression durations, and (c) ability to suppress was correlated with omission, but not commission errors on a continuous performance task. Implications of these findings are discussed.

Children with chronic tic disorders (CTD), including Tourette’s Disorder (TD), demonstrate a higher incidence of comorbid conditions, including attention-deficit hyperactivity disorder (ADHD) and obsessive–compulsive disorder (OCD). The relative contributions of tics versus ADHD and OCD symptoms for predicting impaired functioning in children with TD is unknown and existing studies on the topic are inconsistent. This study evaluated the unique contributions of tic severity, ADHD diagnostic status, and OCD symptom severity in predicting competence scores on the Child Behavior Checklist (CBCL) in a sample of children with CTD. Results of a hierarchical regression analysis show that both ADHD and OCD symptoms predicted decreased CBCL competence scores. When tic complexity was added, however, only ADHD and tic complexity continued to predict CBCL competence scores. These findings begin to resolve inconsistencies in existing literature and have important implications for understanding and treating children with CTD.

In this chapter, we provide a brief overview of Tourette syndrome (TS) and tic disorders, including diagnostic information, prevalence, course, and associated features. We then provide a brief summary of evidence-based treatment with a focus on comprehensive behavioral intervention for tics (CBIT). Following this background overview, we then describe the use of CBIT to treat tics in an 11-year-old boy with TS and attention-deficit/hyperactivity disorder (ADHD). We describe, in detail, evidence-based assessment, case conceptualization, and detailed information on intervention techniques. Specifically, we discuss managing comorbidity in CBIT, implementation, and relevant modification of interventions and patient clinical response. Complicating factors and their impact on treatment are discussed. Conclusions and a brief list of key practice points are provided.

Behavior analysis has been at the forefront in establishing effective treatments for children and adults with chronic tic disorders. As is customary in behavior analysis, the efficacy of these treatments has been established using direct-observation assessment methods. Although behavior-analytic treatments have enjoyed acceptance and integration into mainstream health care practices for tic disorders (e.g., psychiatry and neurology), the use of direct observation as a primary assessment tool has been neglected in favor of less objective methods. Hesitation to use direct observation appears to stem largely from concerns about the generalizability of clinic observations to other settings (e.g., home) and a lack of consensus regarding the most appropriate and feasible techniques for conducting and scoring direct observation. The purpose of the current study was to evaluate and establish a reliable, valid, and feasible direct-observation protocol capable of being transported to research and clinical settings. A total of 43 children with tic disorders, collected from two outpatient specialty clinics, were assessed using direct (videotape samples) and indirect (Yale Global Tic Severity Scale; YGTSS) methods. Videotaped observation samples were collected across 3 consecutive weeks and two different settings (clinic and home), were scored using both exact frequency counts and partial-interval coding, and were compared to data from a common indirect measure of tic severity (the YGTSS). In addition, various lengths of videotaped segments were scored to determine the optimal observation length. Results show that (a) clinic-based observations correspond well to home-based observations, (b) brief direct-observation segments scored with time-sampling methods reliably quantified tics, and (c) indirect methods did not consistently correspond with the direct methods.

Tic frequency was assessed and compared across home and clinic as well as three experimentally-manipulated situations in order to assess the phenomenon of tic reactivity. Forty-three youngsters with chronic tic disorder recruited from two geographically-distinct sites were videotaped over three weekly laboratory visits under each of the following conditions: (1) alone/camera present, (2) other present/camera present, and (3) alone/camera hidden. Contrary to expectation, more tics were observed during overt as compared to covert observation, while the presence of another person had no overall impact on tic expression. Mean tic counts obtained from clinic observation did not significantly differ from those obtained at home collected either one day before or after. Tic frequency counts were remarkably stable over the three weekly assessments both at home and clinic. Study findings are consistent with past observations that tic expression can be influenced by environmental factors and suggest the stability of tic frequency may exhibit greater temporal and setting stability than previously thought. The clinical and research implications of these results are discussed.

Tourette's syndrome (TS) is a neurobiological disorder consisting of motor and vocal tics that are thought to be temporarily suppressible. Many professionals, however, believe that a paradoxical increase in tic frequency (above baseline levels) occurs when efforts to suppress have ceased (i.e., a rebound effect). To date, little research has investigated tic suppression or its effects. This study examined tic frequency during baseline, suppression, and post-suppression conditions using an experimental preparation reported to reliably produce tic suppression in children. Six children with TS and one with chronic tic disorder (CTD) were recorded during baseline and repeated suppression and post-suppression conditions. Tic frequency was significantly lower during suppression as compared to baseline. Although tic frequency during post-suppression was higher than during suppression, it was lower than baseline levels, arguing against a "rebound" effect of tic suppression. Exploratory analyses revealed that scores on the attention problems subscale of the Child Behavior Checklist significantly predicted tic suppressibility. The relationships between age, tic severity, and tic suppressibility were also explored.

Many patients, parents of children with Tourette’s disorder, and professionals have suggested that following a period of suppression, tics will rebound to a rate that will exceed the average rate of occurrence. At present, there are no empirical data to support or refute such an effect. This experiment utilized an A-B-A design with replication to test this hypothesized effect. Following baseline observation, participants were instructed to refrain from exhibiting tics while watching videotapes, engaging in conversation, or while alone in a room with no activity. Observation continued following the suppression phase. Results of this experiment showed suppression of tics in almost one half of all sessions, with adults demonstrating suppression more frequently. Furthermore, results of this experiment failed to support a commonly held perception that following a period of voluntary suppression tics will rebound to a rate that will exceed the average rate of occurrence.

Individuals with tic disorders are at risk for experiencing functional impairment in a variety of domains. However, the impact of tic disorders on family functioning remains unclear partly because psychometrically sound assessment instruments with normative data from a tic disorder population do not exist. The current study provides preliminary normative, descriptive, and internal consistency data for the Impact on Family Scale (IFS): an instrument designed to measure the impact of children's chronic illness on family functioning. Parents of 45 children diagnosed with a tic disorder completed the IFS. The relationship between IFS scores, tic severity, and measures of comorbid symptomology was also investigated. Significant correlations were found between the IFS Total score and measures of ADHD symptomology, tic severity, depressive symptoms, and internalizing and externalizing symptoms. Regression analyses show that tic severity did not significantly predict family impact after accounting for va...

Tourette's Syndrome (TS) and Trichotillomania (TTM) are both subsumed under a larger category of repetitive behavior disorders. The purpose of this paper is to provide an overview of the most recent behavioral research on TS and TTM. A description of both disorders is provided along with the most recent research on their etiology and maintenance. Behavioral treatments are then discussed with an emphasis on habit reversal--a multi-component procedure shown to be effective for treating repetitive behavior disorders. In addition, research analyzing the relative efficacy and importance of each habit reversal component is discussed. The review then concludes with treatment considerations ADVANCES IN THE BEHAVIOR ANALYTIC TREATMENT OF TRICHOTILLOMANIA AND TOURETTE'S SYNDROME Over the past 30 years, behavior analysts have been at the forefront in developing nonpharmacological treatment options for persons with repetitive behavior problems such as tic disorders, chronic hair pulling, and chronic skin picking. The current paper briefly describes these repetitive behavior disorders, presents recent behavioral research on their etiology and maintenance, and describes habit reversal--an effective behavioral treatment for these problems. After this review, the most recent research on the efficacy of habit reversal and its components is discussed. Describing Tourette's Syndrome and Trichotillomania All tic disorders involve the presence of one or more motor and/or vocal tics (i.e., sudden, rapid, recurrent, nonrhythmic motor movements or sounds). Perhaps the most representative of the tic disorders is Tourette's Syndrome (TS) which is characterized by multiple motor tics and one or more vocal tic(s) that have been present for at least one year. Other tic disorder diagnoses include chronic tic disorder and transient tic disorder (American Psychiatric Association, 1994). Tics can vary in location, topography and frequency (i.e., waxing and waning) and can be either simple or complex. Examples of simple tics include facial grimacing, head and shoulder jerking, arm and hand movements, leg kicking, stomach tensing, noises, grunting, coughing, and throat clearing. Examples of complex tics include touching objects or other people, difficulty starting actions, hurting oneself, hopping, picking at objects (e.g., clothing), tapping or straightening objects, obscene gestures (copropraxia), spontaneously saying words or parts of words, echolalia and palalalia, and shouting insults or obscenities. According to the American Psychiatric Association (APA, 1994), TS is diagnosed in four to five of every 10,000 individuals. Other reports have found TS to be as prevalent as 3% in certain populations. TS has been reported across a variety of cultures and ethnicities and is more common in males than females (APA, 1994; Kadesjo & Gillberg, 2000). The average age of onset of TS is approximately 7 years and it has been reported in children as young as two years of age (APA, 1994). Trichotillomania (TTM) is listed as an impulse control disorder in the Diagnostic and Statistic Manual of Mental Disorders (DSM-IV). The essential feature of TTM is the recurrent pulling of one's hair resulting in noticeable hair loss. To receive a diagnosis of TTM, the individual must report an increased sense of tension prior to pulling out his/her hair and pleasure/gratification after pulling. Common sites of pulling include the scalp, eyebrows, eyelashes, and pubic regions, but hair may be pulled from other locations as well (Christenson, Mackenzie, & Mitchell, 1991). A related behavior problem, chronic skin picking, has a substantially smaller body of research than TTM, but is generally considered a similar problem (Woods, 2002). Prevalence estimates of TTM in adults range from 3.2% to 22.4% (Hansen, Tishelman, Hawkins, & Doepke, 1990; Woods, Miltenberger, & Flach, 1996a), however most prevalence studies have not strictly adhered to DSM-IV diagnostic criteria (e. …

Tics associated with Tourette syndrome and other chronic tic disorders (CTDs) often draw social reactions and disrupt ongoing behavior. In some cases, such tic-related consequences may function to alter moment-to-moment and future tic severity. These observations have been incorporated into contemporary biopsychosocial models of CTD phenomenology, but systematic research detailing the nature of the relationship between environmental consequences and ticcing remains scarce. This study describes the development of the Tic Accommodation and Reactions Scale (TARS), a measure of the number and frequency of immediate consequences for ticcing experienced by youth with CTDs. Thirty eight youth with CTDs and their parents completed the TARS as part of a broader assessment of CTD symptoms and psychosocial functioning. The TARS demonstrated good psychometric properties (i.e., internal consistency, parent-child agreement, convergent validity, discriminant validity). Differences between parent-reported and child-reported data indicated that children may provide more valid reports of tic-contingent consequences than parents. Although preliminary, results of this study suggest that the TARS is a psychometrically sound measure of tic-related consequences suited for future research in youth with CTDs.

Although tics are the defining feature of chronic tic disorders (CTD), many children experience comorbid internalizing and externalizing problems that contribute to impairment across several domains, including family functioning. The current study examined clinical correlates and predictors of caregiver strain in parents of children with CTD. Participants were 123 children and adolescents diagnosed with a CTD who participated in a randomized-controlled trial of behavior therapy for reducing tics. Results showed that a combination of disruptive behavior, inattention/hyperactivity, and tic intensity best explained objective strain and a combination of inattention/hyperactivity and tic intensity were the best predictors of subjective caregiver strain. Implications of these findings for care providers are discussed.

While considerable research has focused on promoting independence and optimizing quality of life for adolescents and young adult with autism spectrum disorder (ASD), sexual development and sexuality education have been largely neglected. Experts recommend that parents be the primary source of sex education for adolescents with ASD, and that sex education be tailored to a child's developmental level. Prior studies show that parents of youth with ASD are uncertain about how to best communicate about sex and which topics to discuss with their children. In the current study we administered an online survey to 190 parents of adolescents with ASD in order to better understand sexuality communication patterns between parents and adolescents with both low and high functioning ASD.

Research has shown that motor and vocal tics fluctuate in frequency, intensity, and form in response to environmental and contextual cues. Behavioral models have proposed that some of the variation in tics may reflect context-dependent interactive learning processes such that once tics are performed, they are influenced by environmental contingencies. The current study describes the results of a function-based assessment of tics (FBAT) from a recently completed study comparing Comprehensive Behavioral Intervention for Tics (CBIT) with supportive psychotherapy. The current study describes the frequency with which antecedent and consequence variables were reported to exacerbate tics and the relationships between these functional variables and sample baseline characteristics, comorbidities, and measures of tic severity. Results showed that tic-exacerbating antecedents and consequences were nearly ubiquitous in a sample of children with chronic tic disorder. In addition, functional variables were related to baseline measures of comorbid internalizing symptoms and specific measures of tic severity.

Comprehensive Behavioral Intervention for Tics (CBIT) has been shown to be effective for reducing tics in children with chronic tic disorder. Unfortunately, there remain significant barriers to dissemination. The aim of the current study was to examine the effectiveness of CBIT delivered over videoconference. Twenty children were randomly assigned to receive CBIT over videoconference or via traditional face-to-face delivery. Results show that both treatment delivery modalities resulted in significant tic reduction with no between group differences. Furthermore, acceptability and therapist-client alliance ratings were strong for both groups. Together, these results suggest that videoconference is a viable option for disseminating CBIT.

To examine the relative efficacy of family-based cognitive-behavioral therapy (CBT) versus family-based relaxation treatment (RT) for young children ages 5 to 8 years with obsessive-compulsive disorder (OCD).Forty-two young children with primary OCD were randomized to receive 12 sessions of family-based CBT or family-based RT. Assessments were conducted before and after treatment by independent raters blind to treatment assignment. Primary outcomes included scores on the Children's Yale-Brown Obsessive Compulsive Scale and Clinical Global Impressions-Improvement.For the intent-to-treat sample, CBT was associated with a moderate treatment effect (d = 0.53), although there was not a significant difference between the groups at conventional levels. For the completer sample, CBT had a large effect (d = 0.85), and there was a significant group difference favoring CBT. In the intent-to-treat sample, 50% of children in the CBT group achieved remission as compared to 20% in the RT group. In the completer sample, 69% of children in the CBT group achieved a clinical remission compared to 20% in the RT group.Results indicate that children with early-onset OCD benefit from a treatment approach tailored to their developmental needs and family context. CBT was effective in reducing OCD symptoms and in helping a large number of children achieve a clinical remission.

It is well established that Tourette syndrome has a neurobiologic origin. Although pharmacotherapy is the most commonly prescribed intervention, there is considerable evidence to support the use of behavior therapy, specifically habit reversal training, as an alternative or adjunct treatment for some individuals with Tourette syndrome. Unfortunately, many professionals are unfamiliar with habit reversal training. The purpose of this review is to provide readers with a brief review of empiric studies on habit reversal training, update readers on the current state and future of behavior therapy for Tourette syndrome, and provide resources for those readers interested in additional information. (J Child Neurol 2006;21:719—725; DOI 10.2310/7010.2006.00158).

Although motor tics and/or vocal tics are the defining features of chronic tic disorder (CTD) and Tourette syndrome (TS), older youths and adults often report their tics to be preceded by an unpleasant sensation or "premonitory urge." While premonitory urge phenomena may play an important role in behavioral interventions for CTD/TS, standardized assessments for premonitory urges do not exist. The current study of 42 youths with TS or CTD presents initial psychometric data for a new, brief self-report scale designed to measure tic-related premonitory urges. Results showed that the Premonitory Urge for Tics Scale (PUTS) was internally consistent (alpha = .81) and temporally stable at 1 (r = 0.79, p < .01) and 2 (r = 0.86, p < .01) weeks. PUTS scores were also correlated with overall tic severity as measured by the Yale Global Tic Severity Scale (YGTSS; r = 0.31, p < .05) and the YGTSS number (r = 0.35, p < .05), complexity (r = 0.49, p < .01), and interference (r = 0.36, p < .05) subscales. Finally, an examination of the psychiatric correlates of the premonitory urge phenomenon yielded significant correlations between the PUTS and the Child Behavior Checklist (CBCL) anxiety/depression (r = 0.33, p < .05), and withdrawal (r = 0.38, p < .05) subscales as well as the Children's Yale-Brown Obsessive Compulsive Scale (CYBOCS; r = 0.31, p < .05). However, a cross-sectional examination of the data showed that the psychometric properties of the PUTS were not acceptable for youths 10 years of age and younger. Likewise, significant correlations found between the YGTSS subscales, CBCL subscales, CYBOCS, and the PUTS did not emerge in this younger age group. The clinical and theoretical implications of these findings are discussed.