1. Comprehensive Behavioral Intervention for Tics (CBIT) ADVANCES IN THE TREATMENT OF TIC DISORDERS PATRICIA CRAWFORD, PH.D. PATRICIA CRAWFORD, PH.D. ATLANTA CHILD THERAPY ATLANTA CHILD THERAPY

2. Underlying Assumptions of CBIT Functional Assessment of Behavior Systematic Modification of Tic Expression Maintenance of Adapted Functioning 2Patricia Crawford, Ph.D. (2016) Atlanta Child Therapy

3. CBIT: A Behavioral Approach Scientific study of antecedents, behavior, consequences Scientific study of antecedents, behavior, consequences Functional analysis of outcomes driving and maintaining the tic Functional analysis of outcomes driving and maintaining the tic Study of environmental, cognitive, and emotional triggers Study of environmental, cognitive, and emotional triggers Strategic implementation of modifications Strategic implementation of modifications Maintenance of Desired Changes Maintenance of Desired Changes 3 Every Behavior Expresses a Need… Patricia Crawford, Ph.D. (2016) Atlanta Child Therapy

4. The Behavior: Mapping Out Tics Motor Tics: Repeated Involuntary Movements Motor Tics: Repeated Involuntary Movements Neck Jerking Neck Jerking Eye Rolling Eye Rolling Blinking Blinking Passing Out Passing Out Shaking Shaking Flapping or Stiffening Flapping or Stiffening 4 Every Behavior Expresses a Need… Patricia Crawford, Ph.D. (2016) Atlanta Child Therapy

5. The Behavior: Mapping Out Tics Vocal Tics: Repeated Involuntary Noise Making Vocal Tics: Repeated Involuntary Noise Making Grunting Grunting Screeching Screeching Growling Growling Calling Out Calling Out Repeating Things Repeating Things 5 Every Behavior Expresses a Need… Patricia Crawford, Ph.D. (2016) Atlanta Child Therapy

6. Antecedents What Comes Just Before the Behavior Occurs Otherwise Known as “Triggers” Biology Biology Environment Environment Cognition Cognition 6 Every Behavior Expresses a Need… Patricia Crawford, Ph.D. (2016) Atlanta Child Therapy

7. Functional Assessment Biological Antecedents Internal Experiences Internal Experiences Predisposition Predisposition Illnesses Illnesses Family History Family History Every Behavior Communicates a Need… 7Patricia Crawford, Ph.D. (2016) Atlanta Child Therapy

8. Functional Assessment Environmental Antecedents Places & Situations Places & Situations Time Time Activities Activities Individuals Individuals Life Events Life Events 8 Every Behavior Expresses a Need… Patricia Crawford, Ph.D. (2016) Atlanta Child Therapy

9. Functional Assessment Cognitive Antecedents Negative Thought Patterns Negative Thought Patterns Expectations Expectations Anxiety Anxiety Obsessions Obsessions Beliefs Beliefs Every Behavior Communicates a Need… 9Patricia Crawford, Ph.D. (2016) Atlanta Child Therapy

10. The Premonitory Urge The Aversive Sensation that Frequently Precedes the Tic The Aversive Sensation that Frequently Precedes the Tic Nose, Eye, Facial Itch Nose, Eye, Facial Itch Neck Stiffness Neck Stiffness Electrical Surge Up the Back or Shoulders Electrical Surge Up the Back or Shoulders Twitching or Shaking of Hands, Fingers Twitching or Shaking of Hands, Fingers Pressure Pressure 10 Every Behavior Expresses a Need… Patricia Crawford, Ph.D. (2016) Atlanta Child Therapy

11. The Premonitory Urge T he Aversive Sensation that Frequently Precedes the Tic T he Aversive Sensation that Frequently Precedes the Tic Urge is relieved or reduces contingent on the tics Urge is relieved or reduces contingent on the tics Awareness of premonitions typically emerge around age 10 Awareness of premonitions typically emerge around age 10 Building awareness is crucial to the treatment of tics Building awareness is crucial to the treatment of tics 11 Every Behavior Expresses a Need… Patricia Crawford, Ph.D. (2016) Atlanta Child Therapy

12. Common Triggers Watching TV Watching TV Computer Time Computer Time Boredom Boredom Test Taking Test Taking Car Rides Car Rides Socializing Socializing Every Behavior Communicates a Need… 12Patricia Crawford, Ph.D. (2016) Atlanta Child Therapy

13. The Function of Tics What Drives and Maintains Tics? What Drives and Maintains Tics? Anxiety Reduction Anxiety Reduction Relieve Premonitory Urge Relieve Premonitory Urge Neurobiological Activity Neurobiological Activity Reinforcement of Tic Expression Reinforcement of Tic Expression Avoidance of Aversive Response Avoidance of Aversive Response 13 Every Behavior Expresses a Need… Patricia Crawford, Ph.D. (2016) Atlanta Child Therapy

14. Systematic Modification Start by identifying and prioritizing the individual’s tic(s) Start by identifying and prioritizing the individual’s tic(s) List each of the tics past and present. List each of the tics past and present. Prioritize the tics Prioritize the tics Start with the most invasive tic first. Start with the most invasive tic first. Prioritize those that cause pain. Prioritize those that cause pain. Target only 2-3 tics at a time. Target only 2-3 tics at a time. 14 Every Behavior Expresses a Need… Patricia Crawford, Ph.D. (2016) Atlanta Child Therapy

15. Contributing Factors Biology can maintain tics. Biology can maintain tics. Life events push and pull tics expressions. Life events push and pull tics expressions. Emotions and Cognition drive tics expressions. Emotions and Cognition drive tics expressions. Consequences may either reduce or maintain tic expressions. Consequences may either reduce or maintain tic expressions. Therapy is the most successful way to treat tics. Therapy is the most successful way to treat tics. Tics are not always anxiety related. Tics are not always anxiety related. Tics can by modified by altering consequences. Tics can by modified by altering consequences. 15Patricia Crawford, Ph.D. (2016) Atlanta Child Therapy Every Behavior Expresses a Need…

16. Maintaining & Reducing Behavior Patricia Crawford, Ph.D. (2016) Atlanta Child Therapy16 Antecedent Comes About Urge Goes Unrecognized Tic Expression Occurs Urge is Reduced Positive Reinforcement has Transpired Tic Expression is More Likely to Occur Again Antecendent Comes About Urge is Recognized Intervention Happens Urge is Reduced Negative Reinforcement has Transpired Tic Expression is Less Likely to Occur Again Tic Expression is Maintained Tic Expression is Extinguished

17. Intervention Alter circumstances that are positively related to the tic expression Alter circumstances that are positively related to the tic expression Reduce time in highly related situations Reduce time in highly related situations Teach stress reduction techniques Teach stress reduction techniques Provide training in self-monitoring strategies Provide training in self-monitoring strategies Provide instruction in self-regulation techniques Provide instruction in self-regulation techniques 17Patricia Crawford, Ph.D. (2016) Atlanta Child Therapy

18. Systematic Modification Shaping Behavior Shaping Behavior Developing new topographies of behavior Developing new topographies of behavior Reinforcement of successive approximations of a target behavior Reinforcement of successive approximations of a target behavior A form of existing response is gradually changed A form of existing response is gradually changed 18Patricia Crawford, Ph.D. (2016) Atlanta Child Therapy

19. Tips for Parenting Tracking the Tic Expression The Tic Tracker The Tic Tracker Make note of what happened before the tic Make note of what happened before the tic Situation, individuals, location, time of day Situation, individuals, location, time of day Describe the topography of the tic Describe the topography of the tic Severity, duration, form, frequency Severity, duration, form, frequency Define the consequence that follows the tic Define the consequence that follows the tic Relief, disappointment, frustration, fatigue Relief, disappointment, frustration, fatigue 19Patricia Crawford, Ph.D. (2016) Atlanta Child Therapy

20. The Tic Tracker Patricia Crawford, Ph.D. (2016) Atlanta Child Therapy20