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Over the past decade, behavioral interventions have become increasingly recognized and recommended as effective first-line therapies for treating individuals with tic disorders. In this article, we describe a basic theoretical and conceptual framework through which the reader can understand the application of these interventions for treating tics. The three primary behavioral interventions for tics with the strongest empirical support (habit reversal, Comprehensive Behavioral Intervention for Tics, and exposure and response prevention) are described. Research on the efficacy and effectiveness of these treatments is summarized along with a discussion of the research evaluating the delivery of these treatments in different formats and modalities. The article closes with a review of the possible mechanisms of change underlying behavioral interventions for tics and areas for future research.

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.

Importance: Parents play an essential role in the transition to adulthood for autistic youth, yet often feel they do not have adequate training and resources. Objective: To evaluate data on the preliminary efficacy of and collect participant feedback about the Maximizing Adolescent Post-Secondary Success (MAPSS) intervention. Design: Single-group, pretest–posttest pilot study. Setting: Clinic. Participants: Twenty-two families of autistic youth (ages 13–19 yr, 72.7% male). Intervention: MAPSS is a group intervention for parent–youth dyads that is designed to guide parents in facilitating the development of independent skills for adulthood. Outcomes and Measures: Measures included the Transition Preparation Activities Measure (T-PAM), Family Empowerment Scale (FES), 10-item Perceived Stress Scale (PSS–10), Adulthood Expectations Questionnaire (AEQ), Adaptive Behavior Assessment System–Third Edition (ABAS–3), and a study-specific participant feedback survey. Results: Frequency of transition preparation activities (T-PAM) significantly increased from before to after the intervention, and although the frequency of preparation activities decreased by 1-mo follow-up, it remained significantly higher than at baseline. Parent self-efficacy (FES), parent expectations (AEQ), and parent sense of control over outcomes (AEQ) also significantly increased from preintervention to follow-up; however, parent coping (PSS–10) was unchanged. Youth self-care skills (ABAS–3) demonstrated improvements 6 mo after the completion of the intervention, although other areas of adaptive behavior did not significantly change. Feedback from parents suggested they had positive experiences and felt the intervention was beneficial. Conclusions and Relevance: Our data suggest that the MAPSS intervention is an appropriate candidate for larger, controlled clinical trials. What This Article Adds: With additional evidence, this intervention can offer guidelines for occupational therapists to work with autistic youth and their parents to prepare for adulthood.

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.

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.

The successful application of cognitive-behavior therapy (CBT) to treat obsessive-compulsive disorder (OCD) and other anxiety problems is arguably one of the greatest recent success stories in psychotherapy research and practice. Several large clinical trials, multiple meta-analyses, and several effectiveness studies have shown variations of CBT to be effective for treating OCD in both children and adults. Unfortunately, there is also evidence that many individuals who receive the recommended “dose” of CBT experience significant and problematic residual symptoms and relapse after treatment. So it is important that we also make efforts to improve treatment engagement, response, and maintenance. This timely series brought together leading authorities on CBT for OCD to begin to explore whether a better understanding of how exposure-based techniques are incorporated into treatment might provide valuable insights into how to improve outcomes.

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.

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.

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 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 validit...

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.

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.