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ObjectiveTreatment 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).MethodIndividuals 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.ResultsSpearman correlations between the CGI-S and YGTSS scores ranged from 0.54 to 0.63 (p

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.

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 reward-enhanced tic suppression in youth with tic disorders using a large, pooled dataset. Individual-level data from nine 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. 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, tic and premonitory urge severity, and self-rated tic suppressibility. The mechanisms underlying the observed heterogeneity in reward-enhanced tic suppressibility warrant further investigation. The Tic Suppression Task is a promising method for testing mechanistic hypotheses related to tic suppression.

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.

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., Author(s): Laura Graham Holmes [sup.1] [sup.2] , Donald S. Strassberg [sup.1] [sup.3] , Michael B. Himle [sup.1] Author Affiliations: (1) grid.223827.e, 0000 0001 2193 0096, Department of Psychology, University of [...]

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.

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.

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.

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. (Contains 1 figure.)

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. (Contains 5 tables.)

Research has shown that children often engage in gun play when they find a firearm and that this behavior is often involved in unintentional firearm injuries. Previous research has shown existing programs to be ineffective for teaching children safety skills to reduce gun play. This study examined the effectiveness of a behavioral skills training (BST) program supplemented with in situ training for teaching children safety skills to use when they find a gun (i.e., don't touch, leave the area, tell an adult). Eight 4- to 5-year-old children were trained and assessed in a naturalistic setting and in a generalized setting in a multiple baseline across subjects design. Results showed that 3 of the children performed the skills after receiving BST, whereas 5 of the children required supplemental in situ training. All children in the study learned to perform the skills when assessed in a naturalistic setting and when assessed in a generalization setting. Performance was maintained at 2- to 8-week follow-up assessments.

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.

The purpose of this study was to compare two methods designed to produce tic reduction in 4 children with Tourette's syndrome. Specifically, a verbal instruction not to engage in tics was compared to a verbal instruction plus differential reinforcement of zero-rate behavior (DRO). Results showed that the DRO-enhanced procedure yielded greater reductions in tic frequency.

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.

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., Author(s): Laura Graham Holmes [sup.1] [sup.2] , Donald S. Strassberg [sup.1] , Michael B. Himle [sup.1] Author Affiliations: (Aff1) 0000 0001 2193 0096, grid.223827.e, Department of Psychology, University of Utah, [...]

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.

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., Author(s): Laura G. Holmes [sup.1] [sup.2] , Anne V. Kirby [sup.3] , Donald S. Strassberg [sup.1] , Michael B. Himle [sup.1] Author Affiliations: (Aff1) 0000 0001 2193 0096, grid.223827.e, Department [...]

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.

The risk for serious injury and death to children during motor vehicle accidents can be greatly reduced through the correct use of child passenger safety restraints (CPSRs). Unfortunately, most CPSRs are installed or used incorrectly. This study examined the effectiveness of behavioral skills training (BST) to teach 10 participants to install rear-facing CPSRs correctly using a multiple baseline design. Results show that installation errors were common for all participants during baseline. After BST, all 10 participants were able to install the rear-facing CPSR without error. An extension probe to assess whether the skills taught during BST extended to forward-facing installation showed that each participant made at least 1 critical error.

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. (Contains 1 figure.)

This manuscript is one in a series of invited papers to this journal. The purpose of the series is to highlight and discuss the similarities and differences between various behavioral and cognitive-behavioral approaches to the treatment of obsessive-compulsive disorder (OCD). The first article in this series (Twohig & Whittal) describes the case of "Caroline" upon which the current manuscript is based. We approach the case from a cognitive-behavioral orientation with exposure and ritual prevention (EX/RP) as the primary therapeutic approach. We highlight the use of EX/RP because of the considerable body of empirical evidence showing that EX/RP is an efficacious treatment for both adult and pediatric OCD. Using the provided case vignette, we outline a rationale for EX/RP and describe how EX/RP might be used to treat Caroline's OCD. We begin by discussing the theoretical underpinnings for EX/RP and providing a rationale for treatment. We then briefly discuss the rich extant literature supporting EX/RP as an effective treatment for OCD. We then provide a detailed case conceptualization and description of the treatment. We conclude with barriers commonly encountered during EX/RP. (Contains 4 tables.)

This article describes the development and initial psychometric properties of the Parent Tic Questionnaire (PTQ)--a new measure assessing the number, frequency, and intensity of motor and vocal tics in children and adolescents with Chronic Tic Disorder (CTD). Parents of 40 children with a CTD completed the PTQ as part of a larger assessment battery. Results show the PTQ to have excellent internal consistency and good to excellent 2-week test-retest reliability. The motor tic severity subscale, vocal tic severity subscale, and total severity score of the PTQ correlated highly with the corresponding scales of the gold-standard clinician-rated Yale Global Tic Severity Scale (YGTSS), indicating excellent convergent validity. Correlations between the YGTSS and PTQ remained strong after controlling for measures of obsessive-compulsive disorder and inattention, suggesting good discriminant validity. The PTQ is a promising supplement to current methods for assessing tic severity and further research on the validity, reliability, and clinical utility of the scale are warranted. (Contains 2 tables.)

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.