Flint M. Espil

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.

The Role of Parental Perceptions of Tic Frequency and Intensity in Predicting Tic-Related Functional Impairment in Youth with Chronic Tic Disorders

Tic severity is composed of several dimensions. Tic frequency and intensity are two such dimensions, but little empirical data exist regarding their relative contributions to functional impairment in those with chronic tic disorders (CTD). The present study examined the relative contributions of these dimensions in predicting tic-related impairment across several psychosocial domains. Using data collected from parents of youth with CTD, multivariate regression analyses revealed that both tic frequency and intensity predicted tic-related impairment in several areas; including family and peer relationships, school interference, and social endeavors, even when controlling for the presence of comorbid anxiety symptoms and Attention Deficit Hyperactivity Disorder diagnostic status. Results showed that tic intensity predicted more variance across more domains than tic frequency.

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.

Manualized and Modular Behavior Therapy for a Child With Tourette’s Disorder, Inattention, and Disruptive Behavior A Case Example

Persistent tic disorders (PTDs), including Tourette’s Disorder (TD), involve motor and/or vocal tics and often cause significant impairment and distress for affected individuals and families. Functional impairment is typically greater among individuals with PTDs and comorbid disorders. The current gold standard behavioral intervention for tic disorders, Comprehensive Behavioral Intervention for Tics (CBIT), has demonstrated efficacy in randomized clinical trials. Complications introduced by comorbidities, however, potentially facilitate less optimal long-term outcomes using this treatment approach. This case study describes the implementation of CBIT and subsequent modularized parent training for an 8-year-old boy diagnosed with TD who also exhibited comorbid symptoms of inattention, hyperactivity, and oppositional behavior. Emphasis is placed on delineating treatment decisions, including the sequencing of specific techniques, in accord with algorithms for complicated PTD presentations discussed in the literature.

Associations Between Anxiety Symptoms and Child and Family Factors in Pediatric Obesity.

Objective: This study compared child weight status, social skills, body dissatisfaction, and health-related quality of life (HRQOL), as well as parent distress and family functioning in youth who are overweight or obese (OV/OB) with versus without clinical anxiety symptoms. Method: Participants included 199 children 7 to 12 years of age (mean age = 9.88 years) who were OV/OB, and their parents. Children completed social skills, body dissatisfaction, and HRQOL questionnaires. Parents completed the Child Behavior Checklist (CBCL) and child HRQOL, parent distress, family functioning, and demographic questionnaires. Children were placed in 2 groups based on CBCL anxiety problems scale scores: the OV/OB + clinical anxiety group included children with T scores ≥65 (n = 23) and children with T scores ⩽59 comprised the OV/OB group (n = 176). Results: After controlling for covariates, children in the OV/OB + clinical anxiety group reported more body dissatisfaction (F[1,198] = 5.26, p = .023, partial &eegr;2 = .027) and lower total HRQOL (F[1,198] = 8.12, p = .005, &eegr;2 = .041) and had parents who reported higher psychological distress (F[1,198] = 5.48, p = .020, &eegr;2 = .028) and lower child total HRQOL (F[1,198] = 28.23, p < .001, &eegr;2 = .128) compared with children in the OV/OB group. Group differences were not significant for child weight status, social skills, or family functioning. Conclusion: Clinically significant anxiety among children who are OV/OB is associated with increased body dissatisfaction and parent psychological distress, as well as decreased HRQOL. Findings have implications for the assessment and treatment of anxiety symptoms in pediatric obesity.

Comparing fixed-amount and progressive-amount DRO Schedules for tic suppression in youth with chronic tic disorders.

Chronic tic disorders (CTDs) involve motor and/or vocal tics that often cause substantial distress and impairment. Differential reinforcement of other behavior (DRO) schedules of reinforcement produce robust, but incomplete, reductions in tic frequency in youth with CTDs; however, a more robust reduction may be needed to affect durable clinical change. Standard, fixed-amount DRO schedules have not commonly yielded such reductions, so we evaluated a novel, progressive-amount DRO schedule, based on its ability to facilitate sustained abstinence from functionally similar behaviors. Five youth with CTDs were exposed to periods of baseline, fixed-amount DRO (DRO-F), and progressive-amount DRO (DRO-P). Both DRO schedules produced decreases in tic rate and increases in intertic interval duration, but no systematic differences were seen between the two schedules on any dimension of tic occurrence. The DRO-F schedule was generally preferred to the DRO-P schedule. Possible procedural improvements and other future directions are discussed.

Computerized response inhibition training for children with trichotillomania

Evidence suggests that trichotillomania is characterized by impairment in response inhibition, which is the ability to suppress pre-potent/dominant but inappropriate responses. This study sought to test the feasibility of computerized response inhibition training for children with trichotillomania. Twenty-two children were randomized to the 8-session response inhibition training (RIT; n = 12) or a waitlisted control (WLT; n = 10). Primary outcomes were assessed by an independent evaluator, using the Clinical Global Impression-Improvement (CGI-I), and the NIMH Trichotillomania Severity (NIMH-TSS) and Impairment scales (NIMH-TIS) at pre, post-training/waiting, and 1-month follow-up. Relative to the WLT group, the RIT group showed a higher response rate (55% vs. 11%) on the CGI-I and a lower level of impairment on the NIMH-TIS, at post-training. Overall symptom reductions rates on the NIMH-TSS were 34% (RIT) vs. 21% (WLT) at post-training. The RITs therapeutic gains were maintained at 1-month follow-up, as indicated by the CGI-I responder status (= 66%), and a continuing reduction in symptom on the NIMH-TSS. This pattern of findings was also replicated by the 6 waitlisted children who received the same RIT intervention after post-waiting assessment. Results suggest that computerized RIT may be a potentially useful intervention for trichotillomania.

Cognitive Restructuring About Tics

Abstract Tics are often stigmatized by peers, which in some cases can cause affected youth to develop problematic beliefs about themselves and their tics. These negative beliefs can then engender poor self-esteem and avoidance of valued life activities. Clinicians who seek to provide comprehensive care of youth with tics should be attentive to these potential problems and prepared to confront them effectively. This chapter aims to briefly describe the stigma associated with tics and introduce a cognitive-behavioral technique—cognitive restructuring (CR)—that the authors have found useful in addressing maladaptive cognitions related to tics. A series of case examples are also provided to illustrate the use of CR during treatment sessions.