1. New Thoughts on the Behavioral Treatment of Tourette Syndrome
Advances in Tourette Syndrome
Felsenstein Medical Research Center
Schneider Children’s Medical Center of Israel
Tel Aviv, Israel - February 26, 2006
New Thoughts on the Behavioral Treatment of Tourette Syndrome
John Piacentini, Ph.D., ABPP
Child OCD, Anxiety, and Tic Disorders Program
Semel Institute for Neuroscience and Human Behavior
UCLA School of Medicine

2. Acknowledgements
Some of the work described in this presentation was supported by grants from the:
TOURETTE SYNDROME ASSOCIATION
NATIONAL INSTITUTE OF HEALTH
NIMH / NINDS
KAREN MAYES GAMORAN FAMILY FOUNDATION
The Dr. David Feinberg Fellowship of the Semel Institute - UCLA and Schneider's Children's Medical Center – Israel

3. TSA Behavioral Sciences Consortium
Susanna Chang, PhD. UCLA Neuropsychiatric Institute
Thilo Deckersbach, PhD. Mass General Hospital/Harvard
Golda Ginsberg, PhD. Johns Hopkins University
Alan Peterson, PhD. Wilford Hall Medical Center
John Piacentini, PhD. UCLA Neuropsychiatric Institute
Lawrence Scahill, MSN, PhD. Yale Child Study Center
John Walkup, MD. Johns Hopkins University
Sabine Wilhelm, PhD. Mass General Hospital/Harvard
Douglas Woods, PhD. University of Wisconsin-Milwaukee

4. How can Behavioral Psychology inform us about TS
The central tenet of Behavioral Psychology is
that behavior is determined by a combination of forces comprised of biological - including genetic - and environmental factors.

5. Behavioral Psychology and TS
Behavioral Psychology primarily concerned with this relationship
Environment
Tics
Biology/Genetics

6. Biological Factors Genetics Perinatal/Postnatal Insults Neurobiology
Twin Studies
MZ concordance 86%; DZ concordance 20%
Family Studies
Risk of TS in relatives %
Perinatal/Postnatal Insults
LBW, maternal stress, chemical exposure, placental insufficiency, gestational diabetes, PANDAS
Neurobiology
Cortico-striato-thalamo-cortical (CSTC) circuits

7. Role of the Environment
Underlying biological abnormalities may explain broad consistency of symptom presentations seen in TS
Different experiences involving interactions with the environment may explain presentation differences.
Environmental Factors
Environmental antecedents and consequences
Environmental determinants of tic suppression
Role of Premonitory Urge
An individualized approach to understanding environment/behavior interaction is key

8. Environmental Factors
ANTECEDENTS
Being upset or anxious (Silva et al., 1995)
Watching TV (Silva et al., 1995)
Being Alone or with Others (Silva et al., 1995)
Stressful Life Events (Surwillo et al., 1978)
Hearing Others Tic or Talking about Tics
(Commander et al., 1991; Woods et al., 2000)
CONSEQUENCES
Being teased
TIC SUPRESSION
Ticcers can control tics under certain conditions
Woods, 2004; and others

9. A Neurobehavioral Model of Tourette Syndrome
Behavioral Sciences Consortium
of the Tourette Syndrome Association

10. Neurobehavioral Model of TS
Speculative at this point
Some data supporting certain aspects of the model
Other aspects are consistent with clinical observation
Useful as an aid to treatment development and planning
Identify specific individual and environmental targets for intervention
Identify specific techniques to use
Spur additional research to better understand TS
Environmental impacts on TS expression, suppression, etc.
Development of Premonitory Urge

11. Premonitory Urge Internal event Consequences
Sensation that precedes tics
Unpleasant itch, tension, tingle, pressure
Sometimes localized, sometimes general
Awareness begins around age 9-10
Very common: up to 90% of TS individuals describe urges
Urges more likely to precede complex tics than simple tics
Consequences
Urge is relieved or reduced contingent on tic

12. Premonitory Urge
Premonitory urge emerges over time (Leckman et al., 1993)
Descriptions of the urge become more internally consistent over time (Woods, Piacentini et al., 2005)

13. Premonitory Urge Developmental Factors
Premonitory Urge for Tics Scale (PUTS)
9-item child self-report measure of premonitory urge severity
Tested in 42 TS/CTD youngsters aged 8-16
Total score did not differ between younger (8-10) and older (11-16) group
Woods, Piacentini, Himle, & Chang, 2005

14. Premonitory Urge Developmental Factors
Premonitory Urge for Tics Scale (PUTS)
PUTS score only correlated with tic severity in older group
Sensations are present in younger children but perhaps in more diffuse form or association with tics not as easily recognized
Woods, Piacentini, Himle, & Chang, 2005

15. Neurobehavioral Model of Tics
Contemporary Behavioral Psychology assumes an underlying neurological deficiency/deficit for TS.
This deficit may reflect brain deficit in ability to inhibit competing motor patterns.
Initiation of Biological Process
Biological Basis for Premonitory Urge
Biological basis for premonitory urge may or may not be present for different types of tics. Simple tics may not contain the biological basis for the premonitory urge.
EXPRESSION OF TIC
Termination of Biological Process
Environment builds on this biologically derived sequence.

16. Behavioral Model of Tics
Biological Basis for Premonitory Urge
Although the Biological Basis for the Premonitory Urge may be present, the “urge” itself may not exist at the very beginning of the disorder.
The underlying sensation may not be experienced as related to the tic. ?
Expression of TIC
Expression of tic leads to both internal and external consequences.
Internal
External
Consequences
Discomfort
Teasing

17. Situational Antecedents
School, Home, Social
As child starts to experience negative consequences of ticcing, he/she will begin to associate these negative consequences with the situations in which the tics occurred.
Biological Basis for Premonitory Urge
Expression of TIC
Over time, these situational antecedents become more salient and increasingly aversive to the child (e.g., classical conditioning).
Consequences
Discomfort
Teasing

18. Biological Antecedents
Situational Antecedents
Negative Consequences
Biological Basis for Premonitory Urge
and Situational Antecedents
also impact internal cues, e.g., underlying sensations such that these sensations take on aversive qualities as well.
Expression of TIC
The more salient the sensations become to the child, the more strongly he/she associates them with his/her tics.
Consequences
Discomfort
Teasing

19. Premonitory Urge
Premonitory urge severity becomes more related to behavior patterns suggestive of avoidance and social withdrawal as children get older (Woods, Piacentini et al., 2005)
Connection between premonitory urge and tics may be shaped by negative social response to tics

20. Development of Premonitory Urges
Situational Antecedents
As the child becomes more aware of these underlying sensations and they begin to predict specific consequences (e.g., tics), they begin to be experienced as “premonitory urges”.
Premonitory urges become aversive to the extent they predict aversive consequences.
PREMONITORY URGE (unpleasant)
Biological Basis for Premonitory Urge
Expression of TIC
Consequences
Discomfort
Teasing

21. Negative Reinforcement of Tics
Situational Antecedents
Relief from unpleasant premonitory urge serves to negatively reinforce tic expression.
Negative Reinforcement = any action reducing or eliminating an aversive stimulus will be more likely to occur upon subsequent presentation of that aversive stimulus.
If my child stops misbehaving when I shout at him, I’m more likely to use shouting as a disciplinary procedure in the future.
PREMONITORY URGE (unpleasant)
Expression of TIC + +
Termination of URGE

22. Positive Reinforcement of Tics
Expression of TIC
Positive Consequences also serve to reinforce tics and increase their frequency + +
Internal
External
Consequences
Relief
Avoidance

23. Support for the Neurobehavioral Model
Data examining impact of environmental factors on tic expression are very preliminary
Consequences of Tic expression
Antecedents of Tic expression
However, these data provide at least indirect support for Neurobehavioral Model

24. Antecedent Events that Impact Tics
Being upset or anxious (Silva et al., 1995)
Watching TV (Silva et al., 1995)
Being Alone (Silva et al., 1995)
Social Gatherings (Silva et al., 1995)
Stressful Life Events (Surwillo et al., 1978)
Hearing Others Cough (Commander et al., 1991)
Talking about tics (Woods et al., 2001)

25. Consequences Impacting Tic Occurrence
Evidence for external consequences increasing tics…
Social reactions can result in a worsening of tics (e.g., Watson & Sterling, 1998)
Child may get out of a task because of his or her tics (e.g., getting out of math homework).
Evidence for external consequences decreasing tics
Real life negative consequences for tics (i.e., teasing, failure to participate in social activities, etc.)
Some children avoid these consequences through suppressing their tics

26. Environmental Control of Tic Expression Woods & Himle, Univ Wisconsin-Milwaukee
“TIC DETECTOR”
Remote controlled operant token dispenser
Inactive computer camera mounted on top of box
Tokens delivered by experimenter who observes from behind an observation mirror
Tokens delivered for every 10 sec. tic-free intervals
Interval resets if a tic occurs
Tokens later exchanged for small amount of money

27. Environmentally Mediated Tic Reduction Woods & Himle (2004)
Compared tic reduction with and without support of environmental consequences in 4 children with TS
Verbal Instructions to suppress produced a 10.3% reduction in tic occurrence from BL
Reinforcement-enhanced procedures produced a 76% decrease in tics
Results suggest that consequences to tics can impact tic frequency
BL (Baseline)
VI (Verbal Instructions)
DRO (Reinforcement for No Tics)

28. Funded by the Tourette Syndrome Association
Environmental Influences can be long lasting Woods, Himle, Miltenberger, & Carr, ongoing
Nine children with TS exposed to Rewards of 3 different durations (5 min, 25 min, 40 min) presented in a random order
Rewards interspersed with 5 min “rebound evaluation” phase
Rewards led to statistically significant tic reduction
No statistically significant rebound effects for any of the different durations
Funded by the Tourette Syndrome Association

29. Implications of Model for Treatment
Behavioral Intervention should address:
Antecedents and Consequences of Tics
Negative Reinforcement

30. Function-Based Interventions Identify “function” of enviromental factors on tic expression

31. Impact of Environment on Tics
Environmental Consequences
catch kids COMING or GOING
Positive consequences can increase ticcing
Tic
Positive Consequence
More Tics
Negative consequences can increase ticcing
Tic
Negative response
Distress
More Tics

32. Functional Analysis
Response to environment is typically not a conscious or voluntary process
Child/family/school often unaware this is happening
Environmental influence does not imply that tics are behaviorally caused or that child is manipulating the system

33. Functional Analysis Common Antecedents - What happens before the tic
Demand placed on child
Teasing
Anxiety
Stress

34. Functional Analysis Common Consequences - What happens after the tic
Comforting - extra attention
“Stop ticcing”
Teasing
Leave table, classroom, or other situation
Don’t finish meal, homework, or chores

35. Function-based Interventions
Does not imply that tics are behaviorally caused.
Despite the tics, the child is still expected to be treated as “normally” as possible
– both positive and negative consequences
Tics should not dictate what the child does or does not do, and the child does not receive any special treatment for his or her tics.
ENVIRONMENT SHOULD BE TIC NEUTRAL
Over 20 published studies of contingency management

36. Neutral Environment Situational Antecedents
PREMONITORY URGE (unpleasant)
Expression of TIC
Positive and Negative Consequences
Discomfort
Attention

37. Situational Antecedents PREMONITORY URGE (unpleasant)
Neutral Environment
Situational Antecedents
PREMONITORY URGE (unpleasant)
Expression of TIC
Consequences
Discomfort
Teasing

38. Situational Antecedents PREMONITORY URGE (unpleasant)
Neutral Environment
Situational Antecedents
PREMONITORY URGE (unpleasant)
Expression of TIC
Consequences
Discomfort
Teasing

39. Function-based Interventions What to do?
ADDRESS ANTECEDENTS
Provide child with 15 minutes warning and free time to calm
down prior to making specific requests (homework, chores)
ADDRESS SOCIAL CONSEQUENCES
Don’t respond to tics in the moment teasing, telling to stop,
comforting, etc.
This means parents, sibs, teachers, everyone

40. Function-based Interventions What to do?
ADDRESS ESCAPE CONSEQUENCES
(Negative Reinforcement)
If tics interfere, leave situation for 15 minutes then return BUT no escape from responsibilities
If leaves dinner table, must come back and finish meal
Needs to begin homework at set time regardless of tics – can take brief breaks according to set schedule
If tics still bothersome, encourage child to use HRT or other techniques to address them

41. Habit Reversal Training (HRT)

42. Habit Reversal Training
Multicomponent Behavioral Treatment Package
developed by Azrin & Nunn (1973)
Targeted tics and other habit disorders, including
trich, nailbiting, thumbsucking, skin picking
Originally consisted of 14 techniques aimed at:
increasing tic (habit) awareness
developing competing responses to tics (habits)
building and sustaining motivation and compliance

43. Habit Reversal Training
TWO PRIMARY COMPONENTS
Awareness Training
Competing Response

44. Habit Reversal Training
ANCILLARY COMPONENTS
- Addressing tic antecedents
Psychoeducation
Reduce family anxiety/stress and negative reactions to child’s tics
Relaxation Training
Reduce child anxiety/stress

45. Habit Reversal Training
ANCILLARY COMPONENTS
- Addressing motivation/compliance
Social Support
Enhance use of HRT
Behavioral Reward System
Enhance treatment motivation and compliance
Inconvenience Review
Identify functional impairments and enhance motivation

46. Habit Reversal Training Awareness Training
Response Description and Detection
Describe details of tic and re-enact under therapist supervision
Early Warning Procedure
Practice detecting earliest sign of movement or tic urge
Situation Awareness Training
Recall high-risk situations and describe tic in these settings
Ancillary Procedures
Use videotape or enlist support persons
Necessary level of awareness is unclear

47. Premonitory Urge Relationship of HRT to Premonitory Urge Simple tics
Less likely to experience premonitory urge
HRT focused on other early warning signs or initial aspects of tic expression
Complex tics
Typically preceded by premonitory urge
HRT focused on detecting and intervening at premonitory urge stage

48. Habit Reversal Training Competing Response
Incompatible physical behavior performed in response to:
Urge to tic
Initial expression of tic itself
CR Should be:
Opposite to the tic behavior
Capable of being maintained for at least one minute
Socially inconspicuous - compatible with normal activity
Necessary level of compliance is unclear

49. Habit Reversal Training
Treatment Tips
Start with a relatively “big” and noticeable tic first
Simple eyeblinks often not targeted by HRT
Shaping procedure often used for motor tics
Slow, rhythymic breathing used as CR for vocal tics
Developmentally sensitive implementation (“tic-buster”)

50. Habit Reversal Training Social Support/Reward System
Goal is to reinforce and prompt use of competing response
Significant others prompt use of CR
Significant others praise correct use of CR
Necessity of social support is unclear, but probably required for most children
Rewards offered for compliance with treatment assignments (effort not outcome)

51. Impact of TS on Family Family confusion, upset, blame
Due to inaccurate, inconsistent information about TS
Due to improper and/or failed treatment attempts
Due to reaction of others in the environment
Disruption caused by excessive attention, energy focused on the problem
Other family needs remain unaddressed
Other family members (sibs) may become jealous
Relaxation of regular family rules or roles

52. Family Involvement in Treatment
Family plays crucial role in treatment and recovery
Provide support and encouragement to child
Exact role depends on age/developmental level of child
For younger children
Parents may need to be directly involved in implementation of treatment techniques
For older children and adolescents
Parent typically needs to accept a less direct role
Primary task is to provide support

53. Empirical Support for HRT

54. Empirical Support for HRT
Over 25 published studies of HRT for TS or Chronic Tic Disorder
Most single case or small case series reports
At least 6 published randomized, between group studies of HRT for TS/CTD
Only two included children (most subjects were adults)
One unpublished trial solely of children

55. Empirical Support for HRT
Azrin & Nunn (1973): 12 individuals with habits or tics
90% symptom reduction after 1 session
99% symptom reduction at 3 month follow-up
Tourette’s Syndrome
More effective than relaxation training or self-monitoring (Peterson & Azrin, 1992)
More effective than wait-list control (Azrin & Peterson, 1990)

56. Habit Reversal for Adult TS
Sabine Wilhelm, PhD.
Thilo Deckersbach, PhD.
Barbara Coffey, MD.
Antje Bohne, MS.
Alan Peterson, Ph.D.
Lee Baer, PhD.
Massachusetts General Hospital
Harvard Medical School
Suppported by a grant from the TSA Permanent Research Fund
Am J Psychiatry, 160, (2003)

57. HRT for Adults - Symptoms*
35% decrease
in tic severity
Wilhelm et al. (2003)

58. HRT for Adults - Interference* *
55% decrease
in tic interference
Wilhelm et al. (2003)

59. Comparison of HRT and Awareness Training for Children with TS
John Piacentini, Ph.D.
Susanna Chang, Ph.D.
Velma Barrios
James McCracken, M.D.
UCLA - Neuropsychiatric Institute
Suppported by a grant from the
TSA Permanent Research Fund

60. Treatment Response Rates
INTENT TO TREAT ANALYSES
Condition Responder Rate
HRT: 6/13 46%
AT: 3/12 25%
TREATMENT COMPLETERS
HRT: 6/11 55%
AT: 3/9 33%

61. Habit Reversal Efficacy
HRT: 30%
decrease in tic severity;
55% decrease in tic-related impairment

62. Durability of HRT (3 Month FU)
response
rate at 3 mos

63. Exposure plus Response Prevention
Some evidence that ERP effective for tic reduction
Verdellen et al., 2004; Woods et al., 2000
Consistent with neurobehavioral model
- negative reinforcement of tics by urge reduction

64. Comprehensive Behavioral Intervention for Tics Studies
CBITS Studies
Comprehensive Behavioral Intervention for Tics Studies

65. TSA Behavioral Sciences Consortium
Susanna Chang, PhD. UCLA Neuropsychiatric Institute
Thilo Deckersbach, PhD. Mass General Hospital/Harvard
Golda Ginsberg, PhD. Johns Hopkins University
Alan Peterson, PhD. Wilford Hall Medical Center
John Piacentini, PhD. UCLA Neuropsychiatric Institute
Lawrence Scahill, MSN, PhD. Yale Child Study Center
John Walkup, MD. Johns Hopkins University
Sabine Wilhelm, PhD. Mass General Hospital/Harvard
Douglas Woods, PhD. University of Wisconsin-Milwaukee

66. Child Behavioral Intervention for Tics Study (CBITS-C)
120 children (aged 9-17) with TS/CTD (40 at each of 3 sites)
UCLA
Johns Hopkins University
University of Wisconsin - Milwaukee
Three supporting sites
Mass General Hospital/Harvard
Yale Child Study Center
Wilford Hall Medical Center (Texas)
Comparison of two psychosocial treatments
Comprehensive Behavioral Intervention for TS (CBIT)
- HRT + Function-based Intervention
Psychoeducation/Supportive Therapy (PST)
Funded by NIMH (R ) through the Tourette Syndrome Association

67. CBITS Treatments CBIT Components Psychoed/Support Components
Psychoeducation
Habit Reversal Therapy
Functional Intervention
Reward System
Relaxation Training
Psychoed/Support
Components
Phenomenology of TS
Prevalence of TS
Natural History of TS
Common Comorbidities
Causes of TS
Psychosocial Impairments
Nonspecific Support

68. Adult Behavioral Intervention for Tics Study (CBITS-A)
120 adults (aged 16-60) with TS/CTD (40 at each of 3 sites)
Mass General Hospital/Harvard
Yale Child Study Center
Wilford Hall Medical Center (Texas)
Three supporting sites
UCLA
Johns Hopkins University
University of Wisconsin- Milwaukee
Comparison of two psychosocial treatments
Comprehensive Behavioral Intervention for TS (CBIT)
- HRT + Function-based Intervention
Psychoeducation/Supportive Therapy (PST)
Funded by NIMH through Collaborative R01s to MGH, Yale, and WHMC

69. Behavioral Interventions for Tics
SUMMARY
Although tics are biologically-based, environmental factors can be important determinants of tic expression and maintenance
Integrative neurobehavioral models provide theoretical basis for psychosocial treatment of TS
Best approach may be combination of Function-based and Tic-specific intervention
Good supportive data from numerous small open and pilot controlled trials
CBITS & ABITS Multisite Trials will provide large-scale efficacy data
Future trials need to examine comparative efficacy of HRT and medication and mechanisms of action