Therapist-supported online remote behavioural intervention for tics in children and adolescents in England (ORBIT): a multicentre, parallel group, single-blind, randomised controlled trial

Abstract

Background Exposure and Response Prevention (ERP) is a form of behavioural therapy for tics; however, its effectiveness remains uncertain. We aimed to evaluate the effectiveness of internet-delivered, therapist-supported, and parent-assisted ERP for treatment of tics in children and young people with Tourette syndrome or chronic tic disorder.Methods This multicentre, parallel group, single-blind, randomised controlled trial was conducted across two study sites in England. Participants were recruited via 16 patient identification centres, two study sites in England (Nottingham and London), or online self-referral. Eligible participants were aged 9-17 years, had Tourette syndrome or chronic tic disorder, had not received behavioural therapy for tics in the past 12 months or were about to start, and had a Yale Global Tic Severity Scale (YGTSS) Total Tic Severity Score (TTSS) of more than 15 or more than 10 if they had only motor or vocal tics. Patients were excluded if they had started or stopped medication for tics within the past 2 months; had current alcohol or substance dependence, psychosis, suicidality, anorexia nervosa, or suspected moderate to severe intellectual disability; or presented an immediate risk to self or others; or the parent or carer was unable to speak, read, or write in English. Eligible patients were randomly assigned (1:1) by masked outcome assessors to receive 10 weeks of online, remotely delivered, therapist-supported ERP or psychoeducation (active control). Outcome assessors, statisticians, health economists, the trial manager, and the chief investigator were masked to group allocation. Patients were not directly informed of their allocation, but this could be established from the content once treatment commenced and the patients were not, therefore, considered masked to treatment. The primary outcome was YGTSS-TTSS 3 months after randomisation, and analysis was done in all randomised patients for whom data were available for each timepoint and outcome. Safety analysis was by intention to treat. Longer term follow-up is ongoing. This trial is registered with ISRCTN (ISRCTN70758207) and ClinicalTrials.gov (NCT03483493).

Acute and Long-Term Effects of an Internet-Based, Self-Help Comprehensive Behavioral Intervention for Children and Teens with Tic Disorders with Comorbid Attention Deficit Hyperactivity Disorder, or Obsessive Compulsive Disorder: A Reanalysis of Data from a Randomized Controlled Trial

“…The results showed that ICBIT had a comparable effect on tic reduction in participants with ADHD. These data are consistent with studies indicating that children and teens with ADHD can benefit comparably from CBIT as was found in previous studies [ 10 , 21 ]. However, the current study showed that although both tics and functional impairment of the participants with co-occurring ADHD improved, they had lower CGAS scores, indicating greater impairment, compared to the participants without ADHD.…”

“…However, other studies have reported that children and adolescents with TD and ADHD were able to suppress tics, and that tic suppressibility did not differ as a function of the presence or absence of ADHD comorbidity [ 19 , 20 ]. Yet, other studies have indicated that ADHD did not impede the effects of behavioral treatment [ 10 , 21 ]. Hence, further research is needed to clarify whether comorbid ADHD influences the response outcomes of behavioral treatment in children and teens.…”

“…Despite the efficacy of CBIT, the vast majority of children and teens with TD do not receive evidence-based interventions for tics [ 27 , 28 ], and COVID-19 has created additional obstacles to implementing psychotherapy. Computerized-based administrations can help overcome hurdles to the greater accessibility of BT [ 5 , 21 ] as well as CBIT in the routine care of patients at this age range with TD. A recent RCT showed that internet-based self-help CBIT (ICBIT) for children and teens supported by their parents and with minimal remote therapist intervention was also effective, with a significant improvement in comorbid symptoms six months after treatment [ 25 ].…”

ONLINE-TICS: Internet-Delivered Behavioral Treatment for Patients with Chronic Tic Disorders

“…Compared to our results at 3 months after end of treatment, they observed a nearly identical estimated mean difference in tic reduction between ERP and placebo (−2.29 [−3.86; 0.71] vs. −2.25 [−3.75; −0.75]). Despite several differences between the study of Hollis et al [ 37 ] and our study (e.g., length of treatment period, participants’ age), the nearly identical tic reduction after iCBIT and ERP, respectively, further supports the hypothesis that both behavioral interventions, HRT/CBIT and ERP, are comparably effective [ 38 ].…”

“…Interestingly, only recently, Hollis et al [ 37 ] reported the results of a randomized controlled study investigating a therapist-supported online remote exposure and response prevention training (ERP) in n = 224 children and adolescents with CTD/TS and examined effects on tics compared to psychoeducation after a 3 month treatment period using the YGTSS-TTS. Compared to our results at 3 months after end of treatment, they observed a nearly identical estimated mean difference in tic reduction between ERP and placebo (−2.29 [−3.86; 0.71] vs. −2.25 [−3.75; −0.75]).…”