Emily J. Ricketts

An Open Trial of Intensive Family Based Cognitive-Behavioral Therapy in Youth With Obsessive-Compulsive Disorder Who Are Medication Partial Responders or Nonresponders

This study reports an open-trial of family-based cognitive-behavioral therapy (CBT) in children and adolescents with obsessive-compulsive disorder (OCD). Thirty primarily Caucasian youth with OCD (range = 7–19 years; 15 girls) who were partial responders or nonresponders to two or more medication trials that were delivered either serially or concomitantly received 14 sessions of intensive family-based CBT. Eighty percent of participants were considered improved at posttreatment and at 3-month follow-up, and symptom severity was reduced by 54% at both posttreatment and follow-up. Seventeen (56.6%) and 16 (53.3%) participants were classified as being in remission at posttreatment and follow-up, respectively. Significant reductions in OCD-related impairment, depressive symptoms, behavioral problems, and family accommodation were noted. No significant difference in youth-reported anxiety was found.

COMPARING THE EFFECTS OF DIFFERENTIAL REINFORCEMENT OF OTHER BEHAVIOR AND RESPONSE-COST CONTINGENCIES ON TICS IN YOUTH WITH TOURETTE SYNDROME

Tics are rapid, repetitive, stereotyped movements or vocalizations that arise from neurobiological dysfunction and are influenced by environmental factors. Although persons with tic disorders often experience aversive social reactions in response to tics, little is known about the behavioral effects of such consequences. Along several dimensions, the present study compared the effects of two treatments on tics: response cost (RC) and differential reinforcement of other behavior (DRO). Four children with Tourette syndrome were exposed to free-to-tic baseline, DRO, RC, and quasibaseline rebound evaluation conditions using an alternating treatments design. Both DRO and RC produced substantial decreases in tics from baseline levels. No differential effects of DRO and RC contingencies were seen on self-reported stress or in the strength of the reflexive motivating operation (i.e., premonitory urge) believed to trigger tics, and neither condition produced tic-rebound effects. Implications of these findings and directions for future research are discussed.

A Randomized Waitlist-controlled Pilot Trial of Voice Over Internet Protocol-delivered Behavior Therapy for Youth with Chronic Tic Disorders

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 < 0.05, partial η2 = 0.15), and parent-reported tic severity, (F(1,18) = 6.37, p < 0.05, partial η2 = 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.

Recent Advances in the Understanding and Treatment of Trichotillomania.

Trichotillomania (TTM), or chronic hair pulling, is associated with significant levels of distress and impairment. While research is in its infancy, more data are accumulating regarding the impact, phenomenology, maintaining variables, etiology, and treatment of TTM. Behavior therapy and clomipramine have been moderately effective in reducing TTM symptoms in clinical trials. Enhancing behavior therapy with techniques designed to address TTM patients’ emotional control tendencies (e.g., acceptance-based procedures) represents a promising direction in treating TTM.

A Comparison of Urge Intensity and the Probability of Tic Completion During Tic Freely and Tic Suppression Conditions.

Tic-suppression-based treatments (TSBTs) represent a safe and effective treatment option for Chronic Tic Disorders (CTDs). Prior research has demonstrated that treatment naive youths with CTDs have the capacity to safely and effectively suppress tics for prolonged periods. It remains unclear how tic suppression is achieved. The current study principally examines how effective suppression is achieved and preliminary correlates of the ability to suppress tics. Twelve youths, ages 10 to 17 years, with moderate-to-marked CTDs participated in an alternating sequence of tic freely and reinforced tic suppression conditions during which urge intensity and tic frequency were frequently assessed. Probability of tics occurring was half as likely following high-intensity urges during tic suppression (31%) in contrast to low-intensity urges during tic freely conditions (60%). Age was not associated with ability to suppress. Intelligence indices were associated with or trended toward greater ability to suppress tics. Attention difficulties were not associated with ability to suppress but were associated with tic severity. In contrast to our “selective suppression” hypothesis, we found participants equally capable of suppressing their tics regardless of urge intensity during reinforced tic suppression. Tic suppression was achieved with an “across-the-board” effort to resist urges. Preliminary data suggest that ability to suppress may be associated with general cognitive variables rather than age, tic severity, urge severity, and attention. Treatment naive youths appear to possess a capacity for robust tic suppression. TSBTs may bolster these capacities and/or enable their broader implementation, resulting in symptom improvement.

Behavior Therapy for Tic Disorders: An Evidenced-based Review and New Directions for Treatment Research.

Behavior therapy is an evidenced-based intervention with moderate-to-large treatment effects in reducing tic symptom severity among individuals with persistent tic disorders (PTDs) and Tourette’s disorder (TD). This review describes the behavioral treatment model for tics, delineates components of evidence-based behavior therapy for tics, and reviews the empirical support among randomized controlled trials for individuals with PTDs or TD. Additionally, this review discusses several challenges confronting the behavioral management of tics, highlights emerging solutions for these challenges, and outlines new directions for treatment research.

Cluster Analysis of the Yale Global Tic Severity Scale (YGTSS): Symptom Dimensions and Clinical Correlates in an Outpatient Youth Sample

Tic disorders are heterogeneous, with symptoms varying widely both within and across patients. Exploration of symptom clusters may aid in the identification of symptom dimensions of empirical and treatment import. This article presents the results of two studies investigating tic symptom clusters using a sample of 99 youth (M age = 10.7, 81% male, 77% Caucasian) diagnosed with a primary tic disorder (Tourette’s disorder or chronic tic disorder), across two university-based outpatient clinics specializing in tic and related disorders. In Study 1, a cluster analysis of the Yale Global Tic Severity Scale (YGTSS) identified four symptom dimensions: predominantly complex tics; simple head/face tics; simple body tics; and simple vocal/facial tics. In Study 2, these clusters were shown to be differentially associated with demographic and clinical characteristics. Findings lend support to prior research on tic phenomenology, help to organize treatment goals, and suggest symptom dimensions of tic disorders for further evaluation.

Pilot Testing Behavior Therapy for Chronic Tic Disorders in Neurology and Developmental Pediatrics Clinics

Comprehensive Behavioral Intervention for Tics (CBIT) is an efficacious treatment with limited regional availability. As neurology and pediatric clinics are often the first point of therapeutic contact for individuals with tics, the present study assessed preliminary treatment response, acceptability, and feasibility of an abbreviated version, modified for child neurology and developmental pediatrics clinics. Fourteen youth (9-17) with Tourette disorder across 2 child neurology clinics and one developmental pediatrics clinic participated in a small case series. Clinician-rated tic severity (Yale Global Tic Severity Scale) decreased from pre- to posttreatment, z = –2.0, P < .05, r = –.48, as did tic-related impairment, z = –2.4, P < .05, r = –.57. Five of the 9 completers (56%) were classified as treatment responders. Satisfaction ratings were high, and therapeutic alliance ratings were moderately high. Results provide guidance for refinement of this modified CBIT protocol.

Assessing Environmental Consequences of Ticcing in Youth With Chronic Tic Disorders: The Tic Accommodation and Reactions Scale

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.

Pilot Open Case Series of Voice over Internet Protocol-Delivered Assessment and Behavior Therapy for Chronic Tic Disorders ☆

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.