Joseph F. McGuire

A meta-analysis of behavior therapy for Tourette Syndrome

Individual randomized controlled trials (RCTs) of habit reversal training and a Comprehensive Behavioral Intervention for Tics (collectively referred to as behavior therapy, BT) have demonstrated efficacy in reducing tic severity for individuals with Tourette Syndrome and Chronic Tic Disorders (collectively referred to as TS), with no examination of treatment moderators. The present meta-analysis synthesized the treatment effect sizes (ES) of BT relative to comparison conditions, and examined moderators of treatment. A comprehensive literature search identified eight RCTs that met inclusion criteria, and produced a total sample of 438 participants. A random effects meta-analysis found a medium to large ES for BT relative to comparison conditions. Participant mean age, average number of therapy sessions, and the percentage of participants with co-occurring attention deficit hyperactivity disorder (ADHD) were found to moderate treatment effects. Participants receiving BT were more likely to exhibit a treatment response compared to control interventions, and identified a number needed to treat (NNT) of three. Sensitivity analyses failed to identify publication bias. Overall, BT trials yield medium to large effects for TS that are comparable to treatment effects identified by meta-analyses of antipsychotic medication RCTs. Larger treatment effects may be observed among BT trials with older participants, more therapeutic contact, and less co-occurring ADHD.

Treating trichotillomania: A meta-analysis of treatment effects and moderators for behavior therapy and serotonin reuptake inhibitors

Few randomized controlled trials (RCTs) exist examining the efficacy of behavior therapy (BT) or serotonin reuptake inhibitors (SRIs) for the treatment of trichotillomania (TTM), with no examination of treatment moderators. The present meta-analysis synthesized the treatment effect sizes (ES) of BT and SRI relative to comparison conditions, and examined moderators of treatment. A comprehensive literature search identified 11 RCTs that met inclusion criteria. Clinical characteristics (e.g., age, comorbidity, therapeutic contact hours), outcome measures, treatment subtypes (e.g., SRI subtype, BT subtype), and ES data were extracted. The standardized mean difference of change in hair pulling severity was the outcome measure. A random effects meta-analysis found a large pooled ES for BT (ES = 1.41, p < 0.001). BT trials with greater therapeutic contact hours exhibited larger ES (p = 0.009). Additionally, BT trials that used mood enhanced therapeutic techniques exhibited greater ES relative to trials including only traditional BT components (p = 0.004). For SRI trials, a random effects meta-analysis identified a moderate pooled ES (ES = 0.41, p = 0.02). Although clomipramine exhibited larger ES relative to selective serotonin reuptake inhibitors, the difference was not statistically significant. Publication bias was not identified for either treatment. BT yields large treatment effects for TTM, with further examination needed to disentangle confounded treatment moderators. SRI trials exhibited a moderate pooled ES, with no treatment moderators identified. Sensitivity analyses highlighted the need for further RCTs of SRIs, especially among youth with TTM.

Detecting a Clinically Meaningful Change in Tic Severity in Tourette Syndrome: A Comparison of Three Methods

OBJECTIVE To compare three statistical strategies for classifying positive treatment response based on a dimensional measure (Yale Global Tic Severity Scale [YGTSS]) and a categorical measure (Clinical Global Impression-Improvement [CGI-I] scale). METHOD Subjects (N=232; 69.4% male; ages 9-69years) with Tourette syndrome or chronic tic disorder participated in one of two 10-week, randomized controlled trials comparing behavioral treatment to supportive therapy. The YGTSS and CGI-I were rated by clinicians blind to treatment assignment. We examined the percent reduction in the YGTSS-Total Tic Score (TTS) against Much Improved or Very Much Improved on the CGI-I, computed a signal detection analysis (SDA) and built a mixture model to classify dimensional response based on the change in the YGTSS-TTS. RESULTS A 25% decrease on the YGTSS-TTS predicted positive response on the CGI-I during the trial. The SDA showed that a 25% reduction in the YGTSS-TTS provided optimal sensitivity (87%) and specificity (84%) for predicting positive response. Using a mixture model without consideration of the CGI-I, the dimensional response was defined by 23% (or greater) reduction on the YGTSS-TTS. The odds ratio (OR) of positive response (OR=5.68, 95% CI=[2.99, 10.78]) on the CGI-I for behavioral intervention was greater than the dimensional response (OR=2.86, 95% CI=[1.65, 4.99]). CONCLUSION A 25% reduction on the YGTSS-TTS is highly predictive of positive response by all three analytic methods. For trained raters, however, tic severity alone does not drive the classification of positive response. Clinicaltrials.gov identifiers: NCT00218777; NCT00231985.

Evidence-Based Assessment of Compulsive Skin Picking, Chronic Tic Disorders and Trichotillomania in Children

Body-focused repetitive behavior (BFRB) is an umbrella term for debilitating, repetitive behaviors that target one or more body regions. Despite regularly occurring in youth, there has been limited investigation of BFRBs in pediatric populations. One reason for this may be that there are few reliable and valid assessments available to evaluate the presence, severity and impairment of BFRBs in youth. Given the shift toward evidence-based assessment in mental health, the development and utilization of evidence-based measures of BFRBs warrants increasing attention. This paper examines the available evidence-base for assessments in youth across three BFRB-related disorders: compulsive skin picking, chronic tic disorders and trichotillomania. Based upon present empirical support in samples of youth, recommendations are made for an evidence-based assessment of each condition.

A Cluster Analysis of Tic Symptoms in Children and Adults with Tourette Syndrome: Clinical Correlates and Treatment Outcome

Cluster analytic methods have examined the symptom presentation of chronic tic disorders (CTDs), with limited agreement across studies. The present study investigated patterns, clinical correlates, and treatment outcome of tic symptoms. 239 youth and adults with CTDs completed a battery of assessments at baseline to determine diagnoses, tic severity, and clinical characteristics. Participants were randomly assigned to receive either a comprehensive behavioral intervention for tics (CBIT) or psychoeducation and supportive therapy (PST). A cluster analysis was conducted on the baseline Yale Global Tic Severity Scale (YGTSS) symptom checklist to identify the constellations of tic symptoms. Four tic clusters were identified: Impulse Control and Complex Phonic Tics; Complex Motor Tics; Simple Head Motor/Vocal Tics; and Primarily Simple Motor Tics. Frequencies of tic symptoms showed few differences across youth and adults. Tic clusters had small associations with clinical characteristics and showed no associations to the presence of coexisting psychiatric conditions. Cluster membership scores did not predict treatment response to CBIT or tic severity reductions. Tic symptoms distinctly cluster with little difference across youth and adults, or coexisting conditions. This study, which is the first to examine tic clusters and response to treatment, suggested that tic symptom profiles respond equally well to CBIT. Clinical trials.gov. identifiers: NCT00218777; NCT00231985.

Defining Treatment Response in Pediatric Tic Disorders: A Signal Detection Analysis of the Yale Global Tic Severity Scale

OBJECTIVE To examine the optimal Yale Global Tic Severity Scale (YGTSS) percent reduction and raw cutoffs for predicting treatment response among children and adolescents with tic disorders. METHOD Youth with a tic disorder (N=108; range=5-17 years) participated in several clinical trials involving varied medications or psychosocial treatment, or received naturalistic care. Assessments were conducted before and after treatment and included the YGTSS and response status on the Clinical Global Impressions-Improvement Scale (CGI-I). RESULTS A 35% reduction on the YGTSS total tic severity score or a YGTSS raw total tic severity score change of 6 or 7 points were the best indicators of clinical treatment response in youth with tic disorders. CONCLUSIONS A YGTSS total tic severity score reduction of 35% or a raw total tic severity score change of 6 or 7 appears optimal for determining treatment response. A consistent definition of treatment response on the YGTSS may facilitate cross-study comparability. Practitioners can use these values for treatment planning decisions (e.g., change medications, etc.).

Cognitive behavior therapy for obsessive-compulsive and related disorders

Cognitive behavior therapy (CBT) is considered a first-line intervention for obsessive-compulsive disorder (OCD) across the lifespan. Efficacy studies of CBT with exposure and response prevention suggest robust symptom reduction, often with sustained remission. Acceptability of CBT is high, and the treatment is devoid of adverse side effects. The primary mechanism of CBT is based on operant principles, specifically extinction learning. The efficacy of extinction-based treatments such as CBT is being shown for other obsessive-compulsive spectrum disorders. This article reviews the theoretic basis, clinical application, and relevant treatment outcome research for CBT and related therapies for several obsessive-compulsive spectrum disorders.

Social deficits in children with chronic tic disorders: Phenomenology, clinical correlates and quality of life

Youth with chronic tic disorders (CTD) experience social problems that have been associated with functional impairment and a diminished quality of life. Previous examinations have attributed social difficulties to either tic severity or the symptom severity of coexisting conditions, but have not directly explored performance deficits in social functioning. This report examined the presence and characteristics of social deficits in youth with CTD and explored the relationship between social deficits, social problems, and quality of life. Ninety-nine youth (8-17years) and their parents completed a battery of assessments to determine diagnoses, tic severity, severity of coexisting conditions, social responsiveness, and quality of life. Parents reported that youth with CTD had increased social deficits, with 19% reported to have severe social deficits. The magnitude of social deficits was more strongly associated with inattention, hyperactivity, and oppositionality than with tic severity. Social deficits predicted internalizing and social problems, and quality of life above and beyond tic severity. Social deficits partially mediated the relationship between tic severity and social problems, as well as tic severity and quality of life. Findings suggest that youth with CTD have social deficits, which are greater in the presence of attention-deficit hyperactivity disorder and obsessive compulsive disorder. These social deficits play an influential role in social problems and quality of life. Future research is needed to develop interventions to address social performance deficits among youth with CTD.

Psychometric Properties of the Obsessive Compulsive Inventory: Child Version in Children and Adolescents with Obsessive–Compulsive Disorder

The psychometric properties of the Obsessive Compulsive Inventory–Child Version (OCI-CV) were examined in ninety-six youth with a primary/co-primary diagnosis of obsessive–compulsive disorder (OCD). A confirmatory factor analysis revealed an acceptable model of fit with factors consisting of doubting/checking, obsessing, hoarding, washing, ordering, and neutralizing. The internal consistency of the OCI-CV total score was good, while internal consistency for subscale scores ranged from poor to good. The OCI-CV was modestly correlated with obsessive–compulsive symptom severity on the Children’s Yale-Brown Obsessive Compulsive Scale (CY-BOCS) Severity Scale, as well as with clinician-reported OCD severity. All OCI-CV subscales significantly correlated with the corresponding CY-BOCS Symptom Checklist dimension. The OCI-CV significantly correlated with child-reported depressive symptoms and OCD-related functional impairment, but was not significantly correlated with parent-reported irritability or clinician-reported overall functioning. Taken together, these data suggest the psychometric properties of the OCI-CV are adequate for assessing obsessive–compulsive symptom presence among youth with OCD.

Neuropsychological functioning in youth with obsessive compulsive disorder: an examination of executive function and memory impairment.

Preliminary research suggests neuropsychological deficits in youth with obsessive-compulsive disorder (OCD) similar to those in adults; however, small samples and methodological confounds limit interpretation. We aimed to examine the rates and clinical correlates of cognitive sequelae in youth with OCD, focusing on executive functioning and memory abilities. Youth ages 7-17 years with OCD (N=96) completed a hypothesis-driven neuropsychological battery (including the Rey-Osterreith Complex Figure, California Verbal Learning Test, and subtests of the Delis-Kaplan Executive Function System and Wide Range Assessment of Memory and Learning) that primarily assessed executive functioning, memory and processing speed. Cognitive sequelae were identified in 65% of youth (37% using a more stringent definition of impairment). Magnitude of cognitive sequelae was not associated with OCD severity or age; however, greater neuropsychological impairments were found amongst youth prescribed atypical neuroleptics and those diagnosed with comorbid tic disorders. Comorbidity burden was associated with presence of neuropsychological impairment, but was not specific to any single test. Findings suggest that the presence of cognitive sequelae is prevalent amongst treatment-seeking youth with OCD. Deficits were found in executive functioning and non-verbal memory performance but these impairments were not associated with OCD severity.