Behavior Therapy for Children With Tourette Disorder

Abstract

Context Tourette disorder is a chronic and typically impairing childhood-onset neurological condition. Antipsychotic medications, the first-line treatments for moderate to severe tics, are often associated with adverse effects. Behavioral interventions, although promising, have not been evaluated in large-scale controlled trials. Objective To determine the efficacy of a comprehensive behavioral intervention for reducing tic severity in children and adolescents. Design, Setting, Participants Randomized, observer-blind, controlled trial of 126 youngsters recruited from December, 2004 through May, 2007 and aged 9–17 years with impairing Tourette or chronic tic disorder as primary diagnosis randomized to 8 sessions over 10 weeks of behavior therapy (n=61) or a control treatment consisting of supportive therapy and education (n=65). Responders received 3 monthly treatment booster sessions and were reassessed at 3- and 6-months post-treatment. Intervention Comprehensive behavioral intervention. Main Outcome Measures Yale Global Tic Severity Scale (range 0–40, score >15 indicating clinically significant tics), Clinical Global Impression-Improvement Scale (range 1-very much improved to 8-very much worse). Results Behavioral intervention led to a significantly greater decrease on the Yale Global Tic Severity Scale (24.7; CI:23.1,26.3) to 17.1 CI:15.1,19.1) from baseline to endpoint compared to the control treatment (24.6 CI:23.2,26.0) to 21.1 CI:19.2,23.0) (P<.001; 95% CI for difference between groups: 6.2, 2.0); (effect size=0.68). Compared to children in control treatment, significantly more children receiving behavioral intervention were rated as “very much” or “much improved” on the Clinical Global Impression-Improvement scale (52.5% to 18.5%, respectively; P<0.001; number-needed-to-treat=3). Attrition was low (12/126 or 9.5%); tic worsening was reported by 4% of children (5/126). Treatment gains were durable with 87% of available responders to behavior therapy showing continued benefit 6 months post-treatment. Conclusions A comprehensive behavioral intervention, compared with supportive therapy and education, resulted in greater improvement in symptom severity among children with Tourette and chronic tic disorder.

Reporting of harms in randomized controlled trials of psychological interventions for mental and behavioral disorders: A review of current practice

“…A checklist of adverse events was developed for one of the trials [20]. In another trial the therapists asked about adverse events each session [21]. The participants in yet another trial, spanning over two years, were assessed for relapse and major incidents every month [23].…”

“…Four reports provided a complete report of occurring adverse events as well as the methods used for collecting these data [20][21][22][23]. In a trial of cognitivebehavioral therapy for posttraumatic stress disorder (PTSD) in children [20], an 8-item checklist was designed to measure adverse events.…”

“…The checklist included items for "suicidality", "homicidality", "grave disability", "hallucinations", "worsening of any old symptom", "appearance of any new symptom", "exposure to new domestic violence", and "a category for other". In a trial of behaviour therapy for children with Tourette disorder [21], the therapists asked the participants each session about recent health complaints, behavioral changes, visits for medical/mental health care, need for concomitant medications, change in on-going medications, and hospitalizations, and offered the opportunity for spontaneous report of any other problem. One trial aimed to systematically assess adverse effects in exposure treatment of PTSD related to chronic and early-life trauma [22].…”

Treatment of Tourette Syndrome

“…Clinical trials have demonstrated tic-suppressing efficacy as a form of cognitive behavioral therapy called "habit reversal", which involves training patients to self-monitor their tics and premonitory sensations, and to respond to them by performing a voluntary behavior that is physically incompatible with the tic [9]. Potential shortcomings of habit reversal therapy are that it must be administered by a specially trained therapist so it is not widely available, it is time-consuming, and its longterm benefits have not been examined.…”

Tourette and tic disorders in ICD-11: standing at the diagnostic crossroads

“…In more recent years, the conceptualization of Tourette disorder as a biologically based condition that is highly influenced by psychocontextual factors has emerged, given the growing research demonstrating the efficacy of behavioral approaches for the treatment of tics. 11 Of course, the efficacy of a particular mode of treatment should not be viewed as evidence of a disorder's cause, but with the discovery that different modalities of treatment could be effective, the broad factors seen as impacting symptoms have changed, and this has resulted in various approaches to classification. Diagnostically, tics were included in the first version of the DSM, though they were categorized as ''neurotic traits'' and viewed as a symptom of an underlying neurosis.…”