New Thoughts on the Behavioral Treatment of Tourette Syndrome

1. New Thoughts on the Behavioral Treatment ofTourette Syndrome John Piacentini, Ph.D., ABPP Child OCD, Anxiety, and Tic Disorders Program Semel Institute for Neuroscience and Human Behavior UCLA School of Medicine Advances in Tourette Syndrome Felsenstein Medical Research Center Schneider Children’s Medical Center of Israel Tel Aviv, Israel - February 26, 2006

2. Acknowledgements • Some of the work described in this presentation was supported by grants from the: • TOURETTE SYNDROME ASSOCIATION • NATIONAL INSTITUTE OF HEALTH • NIMH / NINDS • KAREN MAYES GAMORAN FAMILY FOUNDATION • The Dr. David Feinberg Fellowship of the Semel Institute - UCLA and Schneider's Children's Medical Center – Israel

3. TSA Behavioral Sciences Consortium Susanna Chang, PhD.UCLA Neuropsychiatric Institute Thilo Deckersbach, PhD.Mass General Hospital/Harvard Golda Ginsberg, PhD.Johns Hopkins University Alan Peterson, PhD.Wilford Hall Medical Center John Piacentini, PhD.UCLA Neuropsychiatric Institute Lawrence Scahill, MSN, PhD.Yale Child Study Center John Walkup, MD.Johns Hopkins University Sabine Wilhelm, PhD.Mass General Hospital/Harvard Douglas Woods, PhD.University of Wisconsin-Milwaukee

4. How can Behavioral Psychology inform us about TS The central tenet of Behavioral Psychology is that behavior is determined by a combination of forces comprised of biological- including genetic - and environmental factors.

5. Environment Biology/Genetics Behavioral Psychology and TS Behavioral Psychology primarily concerned with this relationship Tics

6. Biological Factors • Genetics • Twin Studies • MZ concordance 86%; DZ concordance 20% • Family Studies • Risk of TS in relatives 10-15% • Perinatal/Postnatal Insults • LBW, maternal stress, chemical exposure, placental insufficiency, gestational diabetes, PANDAS • Neurobiology • Cortico-striato-thalamo-cortical (CSTC) circuits

7. Role of the Environment • Underlying biological abnormalities may explain broad consistency of symptom presentations seen in TS • Different experiences involving interactions with the environment may explain presentation differences. • Environmental Factors • Environmental antecedents and consequences • Environmental determinants of tic suppression • Role of Premonitory Urge • An individualized approach to understanding environment/behavior interaction is key

8. Environmental Factors ANTECEDENTS Being upset or anxious (Silva et al., 1995) Watching TV (Silva et al., 1995) Being Alone or with Others (Silva et al., 1995) Stressful Life Events (Surwillo et al., 1978) Hearing Others Tic or Talking about Tics (Commander et al., 1991; Woods et al., 2000) CONSEQUENCES Being teased TIC SUPRESSION Ticcers can control tics under certain conditions Woods, 2004; and others

9. A Neurobehavioral Model of Tourette Syndrome Behavioral Sciences Consortium of the Tourette Syndrome Association

10. Speculative at this point Some data supporting certain aspects of the model Other aspects are consistent with clinical observation Useful as an aid to treatment development and planning Identify specific individual and environmental targets for intervention Identify specific techniques to use Spur additional research to better understand TS Environmental impacts on TS expression, suppression, etc. Development of Premonitory Urge Neurobehavioral Model of TS

11. Internal event Sensation that precedes tics Unpleasant itch, tension, tingle, pressure Sometimes localized, sometimes general Awareness begins around age 9-10 Very common: up to 90% of TS individuals describe urges Urges more likely to precede complex tics than simple tics Consequences Urge is relieved or reduced contingent on tic Premonitory Urge

12. Premonitory urge emerges over time (Leckman et al., 1993) Descriptions of the urge become more internally consistent over time (Woods, Piacentini et al., 2005) Premonitory Urge

13. Premonitory Urge for Tics Scale (PUTS) 9-item child self-report measure of premonitory urge severity Tested in 42 TS/CTD youngsters aged 8-16 Total score did not differ between younger (8-10) and older (11-16) group Premonitory UrgeDevelopmental Factors Woods, Piacentini, Himle, & Chang, 2005

14. Premonitory Urge for Tics Scale (PUTS) PUTS score only correlated with tic severity in older group Sensations are present in younger children but perhaps in more diffuse form or association with tics not as easily recognized Premonitory UrgeDevelopmental Factors Woods, Piacentini, Himle, & Chang, 2005

15. Contemporary Behavioral Psychology assumes an underlying neurological deficiency/deficit for TS. This deficit may reflect brain deficit in ability to inhibit competing motor patterns. Biological Basis for Premonitory Urge Initiation of Biological Process Biological basis for premonitory urge may or may not be present for different types of tics. Simple tics may not contain the biological basis for the premonitory urge. EXPRESSION OF TIC Termination of Biological Process Neurobehavioral Model of Tics Environment builds on this biologically derived sequence.

16. Biological Basis for Premonitory Urge ? Expression of TIC Consequences Teasing Discomfort Internal External Behavioral Model of Tics Although the Biological Basis for the Premonitory Urge may be present, the “urge” itself may not exist at the very beginning of the disorder. The underlying sensation may not be experienced as related to the tic. Expression of tic leads to both internal and external consequences.

17. School, Home, Social Situational Antecedents Discomfort Teasing Situational Antecedents As child starts to experience negative consequences of ticcing, he/she will begin to associate these negative consequences with the situations in which the tics occurred. Biological Basis for Premonitory Urge Expression of TIC Over time, these situational antecedents become more salient and increasingly aversive to the child (e.g., classical conditioning). Consequences

18. Discomfort Teasing Biological Antecedents Situational Antecedents Negative Consequences Biological Basis for Premonitory Urge and Situational Antecedents also impact internal cues, e.g., underlying sensations such that these sensations take on aversive qualities as well. Expression of TIC The more salient the sensations become to the child, the more strongly he/she associates them with his/her tics. Consequences

19. Premonitory urge severity becomes more related to behavior patterns suggestive of avoidance and social withdrawal as children get older (Woods, Piacentini et al., 2005) Connection between premonitory urge and tics may be shaped by negative social response to tics Premonitory Urge

20. Discomfort Teasing Development of Premonitory Urges Situational Antecedents As the child becomes more aware of these underlying sensations and they begin to predict specific consequences (e.g., tics), they begin to be experienced as “premonitory urges”. Premonitory urges become aversive to the extent they predict aversive consequences. PREMONITORY URGE(unpleasant) Biological Basis for Premonitory Urge Expression of TIC Consequences

21. Situational Antecedents PREMONITORY URGE(unpleasant) Expression of TIC + + Termination of URGE Negative Reinforcement of Tics Relief from unpleasant premonitory urge serves to negatively reinforce tic expression. Negative Reinforcement = any action reducing or eliminating an aversive stimulus will be more likely to occur upon subsequent presentation of that aversive stimulus. If my child stops misbehaving when I shout at him, I’m more likely to use shouting as a disciplinary procedure in the future.

22. Expression of TIC + + Consequences Avoidance Relief Internal External Positive Reinforcement of Tics Positive Consequences also serve to reinforce tics and increase their frequency

23. Data examining impact of environmental factors on tic expression are very preliminary Consequences of Tic expression Antecedents of Tic expression However, these data provide at least indirect support for Neurobehavioral Model Support for the Neurobehavioral Model

24. Being upset or anxious (Silva et al., 1995) Watching TV (Silva et al., 1995) Being Alone (Silva et al., 1995) Social Gatherings (Silva et al., 1995) Stressful Life Events (Surwillo et al., 1978) Hearing Others Cough (Commander et al., 1991) Talking about tics (Woods et al., 2001) Antecedent Events that Impact Tics

25. Evidence for external consequences increasing tics… Social reactions can result in a worsening of tics (e.g., Watson & Sterling, 1998) Child may get out of a task because of his or her tics (e.g., getting out of math homework). Evidence for external consequences decreasing tics Real life negative consequences for tics (i.e., teasing, failure to participate in social activities, etc.) Some children avoid these consequences through suppressing their tics Consequences Impacting Tic Occurrence

26. Environmental Control of Tic ExpressionWoods & Himle, Univ Wisconsin-Milwaukee “TIC DETECTOR” • Remote controlled operant token dispenser • Inactive computer camera mounted on top of box • Tokens delivered by experimenter who observes from behind an observation mirror • Tokens delivered for every 10 sec. tic-free intervals • Interval resets if a tic occurs • Tokens later exchanged for small amount of money

27. Environmentally Mediated Tic ReductionWoods & Himle (2004) • Compared tic reduction with and without support of environmental consequences in 4 children with TS • Verbal Instructions to suppress produced a 10.3% reduction in tic occurrence from BL • Reinforcement-enhanced procedures produced a 76% decrease in tics • Results suggest that consequences to tics can impact tic frequency BL (Baseline) VI (Verbal Instructions) DRO (Reinforcement for No Tics)

28. Environmental Influences can be long lastingWoods, Himle, Miltenberger, & Carr, ongoing • Nine children with TS exposed to Rewards of 3 different durations (5 min, 25 min, 40 min) presented in a random order • Rewards interspersed with 5 min “rebound evaluation” phase • Rewards led to statistically significant tic reduction • No statistically significant rebound effects for any of the different durations Funded by the Tourette Syndrome Association

29. Implications of Model for Treatment • Behavioral Intervention should address: • Antecedents and Consequences of Tics • Negative Reinforcement

30. Function-BasedInterventionsIdentify “function” of enviromental factors on tic expression

31. Impact of Environment on Tics Environmental Consequences catch kids COMING or GOING Positive consequences can increase ticcing Tic Positive Consequence More Tics Negative consequences can increase ticcing Negative response Distress Tic More Tics

32. Functional Analysis • Response to environment is typically not a conscious or voluntary process • Child/family/school often unaware this is happening • Environmental influence does not imply that tics are behaviorally caused or that child is manipulating the system

33. Functional Analysis • Common Antecedents • - What happens before the tic • Demand placed on child • Teasing • Anxiety • Stress

34. Functional Analysis • Common Consequences • - What happens after the tic • Comforting - extra attention • “Stop ticcing” • Teasing • Leave table, classroom, or other situation • Don’t finish meal, homework, or chores

35. Function-based Interventions • Does not imply that tics are behaviorally caused. • Despite the tics, the child is still expected to be treated as “normally” as possible • – both positive and negative consequences • Tics should not dictate what the child does or does not do, and the child does not receive any special treatment for his or her tics. • ENVIRONMENT SHOULD BE TIC NEUTRAL • Over 20 published studies of contingency management

36. Discomfort Attention Neutral Environment Situational Antecedents PREMONITORY URGE(unpleasant) Expression of TIC Positive and Negative Consequences

37. Discomfort Teasing Neutral Environment Situational Antecedents PREMONITORY URGE(unpleasant) Expression of TIC Consequences

38. Discomfort Teasing Neutral Environment Situational Antecedents PREMONITORY URGE(unpleasant) Expression of TIC Consequences

39. Function-based Interventions What to do? • ADDRESS ANTECEDENTS • Provide child with 15 minutes warning and free time to calm • down prior to making specific requests (homework, chores) • ADDRESS SOCIAL CONSEQUENCES • Don’t respond to tics in the momentteasing, telling to stop, • comforting, etc. • This means parents, sibs, teachers, everyone

40. Function-based InterventionsWhat to do? • ADDRESS ESCAPE CONSEQUENCES • (Negative Reinforcement) • If tics interfere, leave situation for 15 minutes then return - BUTno escape from responsibilities • If leaves dinner table, must come back and finish meal • Needs to begin homework at set time regardless of tics – can take brief breaks according to set schedule • If tics still bothersome, encourage child to use HRT or other techniques to address them

41. Habit ReversalTraining(HRT)

42. Habit Reversal Training Multicomponent Behavioral Treatment Package developed by Azrin & Nunn (1973) Targeted tics and other habit disorders, including trich, nailbiting, thumbsucking, skin picking Originally consisted of 14 techniques aimed at: • increasing tic (habit) awareness • developing competing responses to tics (habits) • building and sustaining motivation and compliance

43. Habit Reversal Training • TWO PRIMARY COMPONENTS • Awareness Training • Competing Response

44. Habit Reversal Training • ANCILLARY COMPONENTS • - Addressing tic antecedents Psychoeducation • Reduce family anxiety/stress and negative reactions to child’s tics Relaxation Training • Reduce child anxiety/stress

45. Habit Reversal Training • ANCILLARY COMPONENTS • - Addressing motivation/compliance Social Support • Enhance use of HRT Behavioral Reward System • Enhance treatment motivation and compliance Inconvenience Review • Identify functional impairments and enhance motivation

46. Habit Reversal TrainingAwareness Training • Response Description and Detection • Describe details of tic and re-enact under therapist supervision • Early Warning Procedure • Practice detecting earliest sign of movement or tic urge • Situation Awareness Training • Recall high-risk situations and describe tic in these settings • Ancillary Procedures • Use videotape or enlist support persons Necessary level of awareness is unclear

47. Relationship of HRT to Premonitory Urge Simple tics Less likely to experience premonitory urge HRT focused on other early warning signs or initial aspects of tic expression Complex tics Typically preceded by premonitory urge HRT focused on detecting and intervening at premonitory urge stage Premonitory Urge

48. Habit Reversal TrainingCompeting Response Incompatible physical behavior performed in response to: • Urge to tic • Initial expression of tic itself CR Should be: • Opposite to the tic behavior • Capable of being maintained for at least one minute • Socially inconspicuous - compatible with normal activity Necessary level of compliance is unclear

49. Habit Reversal Training Treatment Tips • Start with a relatively “big” and noticeable tic first • Simple eyeblinks often not targeted by HRT • Shaping procedure often used for motor tics • Slow, rhythymic breathing used as CR for vocal tics • Developmentally sensitive implementation(“tic-buster”)

50. Habit Reversal TrainingSocial Support/Reward System • Goal is to reinforce and prompt use of competing response • Significant others prompt use of CR • Significant others praise correct use of CR • Necessity of social support is unclear, but probably required for most children • Rewards offered for compliance with treatment assignments (effort not outcome)