A randomized pilot trial comparing videoconference versus face-to-face delivery of behavior therapy for childhood tic disorders

Comprehensive Behavioral Intervention for Tics (CBIT) has been shown to be effective for reducing tics in children with chronic tic disorder. Unfortunately, there remain significant barriers to dissemination. The aim of the current study was to examine the effectiveness of CBIT delivered over videoconference. Twenty children were randomly assigned to receive CBIT over videoconference or via traditional face-to-face delivery. Results show that both treatment delivery modalities resulted in significant tic reduction with no between group differences. Furthermore, acceptability and therapist-client alliance ratings were strong for both groups. Together, these results suggest that videoconference is a viable option for disseminating CBIT.     

Habit reversal versus supportive psychotherapy in Tourette's disorder: a randomized controlled trial and predictors of treatment response

Tourette syndrome (TS) is characterized by chronic motor and vocal tics. Habit reversal therapy (HR) is a behavioral treatment for tics which has received recent empirical support. The present study compared the efficacy of HRT in reducing tics, improving life-satisfaction and psychosocial functioning in comparison with supportive psychotherapy (SP) in outpatients with TS. In addition, we investigated whether impairments in response inhibition in patients with TS predict response to HR treatment which specifically aims to inhibit tics. Thirty adult outpatients with DSM-IV TS were randomized to 14 individual sessions of HR (n = 15); or SP (n = 15). HR but not SP reduced tic severity over the course of the treatment. Both groups improved in life-satisfaction and psychosocial functioning during active treatment. Reductions in tic severity (HR) and improvements in life-satisfaction and psychosocial functioning (HR and SP) remained stable at the 6-month follow-up. The extent of pre-treatment response inhibition impairment in the HR group predicted reductions in tic-severity from pre- to post-treatment. Our results suggest that HR has specific tic-reducing effects although SP is effective in improving life-satisfaction and psychosocial functioning. Assessments of response inhibition may be of value for predicting treatment response to HR.     

Motor excitability is reduced prior to voluntary movements in children and adolescents with Tourette syndrome

Tourette syndrome (TS) is a neuro‐developmental disorder characterized by the occurrence of motor and vocal tics: involuntary, repetitive, stereotyped behaviours that occur with a limited duration, often typically many times in a single day. Previous studies suggest that children and adolescents with TS may undergo compensatory, neuroplastic changes in brain structure and function that help them gain control over their tics. In the current study we used single‐pulse and dual‐site paired‐pulse transcranial magnetic stimulation (TMS), in conjunction with a manual choice reaction time task that induces high levels of inter‐manual conflict, to investigate this conjecture in a group of children and adolescents with TS, but without co‐morbid Attention Deficit Hyperactivity Disorder (ADHD). We found that performance on the behavioural response‐conflict task did not differ between the adolescents with TS and a group of age‐matched typically developing individuals. By contrast, our study demonstrated that cortical excitability, as measured by TMS‐induced motor‐evoked potentials (MEPs), was significantly reduced in the TS group in the period immediately preceding a finger movement. This effect is interpreted as consistent with previous suggestions that the cortical hyper‐excitability that may give rise to tics in TS is actively suppressed by cognitive control mechanisms. Finally, we found no reliable evidence for altered patterns of functional inter‐hemispheric connectivity in TS. These results provide evidence for compensatory brain reorganization that may underlie the increased self‐regulation mechanisms that have been hypothesized to bring about the control of tics during adolescence.     

Examining the neural antecedents of tics in Tourette syndrome using electroencephalography

Tourette syndrome (TS) is a neurodevelopmental disorder characterized by the occurrence of motor and vocal tics. TS is associated with cortical–striatal–thalamic–cortical circuit dysfunction and hyper-excitability of cortical limbic and motor regions that lead to the occurrence of tics. Importantly, individuals with TS often report that their tics are preceded by premonitory sensory/urge phenomena (PU) that are described as uncomfortable bodily sensations that precede the execution of a tic and are experienced as an urge for motor discharge. While tics are most often referred to as involuntary movements, it has been argued by some that tics should be viewed as voluntary movements that are executed in response to the presence of PU. To investigate this issue further, we conducted a study using electroencephalography (EEG). We recorded movement-related EEG (mu- and beta-band oscillations) during (1) the immediate period leading up to the execution of voluntary movements by a group of individuals with TS and a group of matched healthy control participants, and (2) the immediate period leading up to the execution of a tic in a group of individuals with TS. We demonstrate that movement-related mu and beta oscillations are not reliably observed prior to tics in individuals with TS. We interpret this effect as reflecting the greater involvement of a network of brain areas, including the insular and cingulate cortices, the basal ganglia and the cerebellum, in the generation of tics in TS. We also show that beta-band desynchronization does occur when individuals with TS initiate voluntary movements, but, in contrast to healthy controls, desynchronization of mu-band oscillations is not observed during the execution of voluntary movements for individuals with TS. We interpret this finding as reflecting a dysfunction of physiological inhibition in TS, thereby contributing to an impaired ability to suppress neuronal populations that may compete with movement preparation processes.     

A double-blind,sham-controlled,trial of home-administered rhythmic 10-Hz median nerve stimulation for the reduction of tics,and suppression of the urge-to-tic,in individuals with Tourette syndrome and chronic tic disorder

Tourette syndrome (TS) and chronic tic disorder (CTD) are neurological disorders of childhood onset characterized by the occurrence of tics; repetitive, purposeless, movements or vocalizations of short duration which can occur many times throughout a day. Currently, effective treatment for tic disorders is an area of considerable unmet clinical need. We aimed to evaluate the efficacy of a home-administered neuromodulation treatment for tics involving the delivery of rhythmic pulse trains of median nerve stimulation (MNS) delivered via a wearable ‘watch-like’ device worn at the wrist. We conducted a UK-wide parallel double-blind sham-controlled trial for the reduction of tics in individuals with tic disorder. The device was programmed to deliver rhythmic (10 Hz) trains of low-intensity (1–19 mA) electrical stimulation to the median nerve for a pre-determined duration each day, and was intended to be used by each participant in their home once each day, 5 days each week, for a period of 4 weeks. Between 18th March 2022 and 26th September 2022, 135 participants (45 per group) were initially allocated, using stratified randomization, to one of the following groups; active stimulation; sham stimulation or to a waitlist (i.e. treatment as usual) control group. Recruited participants were individuals with confirmed or suspected TS/CTD aged 12 years of age or upward with moderate to severe tics. Researchers involved in the collection or processing of measurement outcomes and assessing the outcomes, as well as participants in the active and sham groups and their legal guardians were all blind to the group allocation. The primary outcome measure used to assess the ‘offline’ or treatment effect of stimulation was the Yale Global Tic Severity Scale–Total Tic Severity Score (YGTSS–TTSS) assessed at the conclusion of 4 weeks of stimulation. The primary outcome measure used to assess the ‘online’ effects of stimulation was tic frequency, measured as the number of tics per minute (TPM) observed, based upon blind analysis of daily video recordings obtained while stimulation was delivered. The results demonstrated that after 4-week stimulation, tic severity (YGTSS-TTSS) had reduced by 7.1 points (35 percentile reduction) for the active stimulation group compared to 2.13/2.11 points for the sham stimulation and waitlist control groups. The reduction in YGTSS–TTSS for the active stimulation group was substantially larger, clinically meaningful (effect size = .5) and statistically significant (p = .02) compared to both the sham stimulation and waitlist control groups, which did not differ from one another (effect size = −.03). Furthermore, blind analyses of video recordings demonstrated that tic frequency (tics per minute) reduced substantially (−15.6 TPM) during active stimulation compared to sham stimulation (−7.7 TPM). This difference represents a statistically significant (p < .03) and clinically meaningful reduction in tic frequency (>25 percentile reduction: effect size = .3). These findings indicate that home-administered rhythmic MNS delivered through a wearable wrist-worn device has the potential to be an effective community-based treatment for tic disorders.     

An evaluation of behavioral treatments for Tourette syndrome.

The present study evaluated the effectiveness of self-monitoring, relaxation training and habit reversal in the treatment of 6 Tourette Syndrome (TS) subjects with multiple motor and vocal tics. A counterbalanced design was employed and tic frequencies were measured in the clinic setting using videotapes taken through a one-way mirror. Tics were reduced by an average of 55% with habit reversal, 44% with self-monitoring, and 32% with relaxation training and each behavioral procedure was the most effective treatment for at least one subject. All three treatment approaches may have some utility in the behavioral treatment of TS.     

A Web-based family problem-solving intervention for families of children with traumatic brain injury

We developed a Web-based intervention for pediatric traumatic brain injury (TBI) and examined its feasibility for participants with limited computer experience. Six families, including parents, siblings, and children with TBI, were given computers, Web cameras, and high-speed Internet access. Weekly videoconferences with the therapist were conducted after participants completed on-line interactive experiences on problem solving, communication, and TBI-specific behavior management. Families were assigned to videoconference with NetMeeting (iBOT cameras) or ViaVideo. Participants ranked the Web site and videoconferences as moderately to very easy to use. ViaVideo participants rated videoconferencing significantly more favorably relative to face-to-face meetings than did NetMeeting participants. Both the Web site and videoconferencing were rated as very helpful. All families demonstrated improved outcomes on one or more target behaviors, including increased understanding of the injury and improved parent-child relationships. All parents and siblings and all but 1 child with TBI said they would recommend the program to others. We conclude that a face-to-face intervention can be successfully adapted to the Web for families with varied computer experience.     

A web-based family problem-solving intervention for families of children with traumatic brain injury.

We developed a Web-based intervention for pediatric traumatic brain injury (TBI) and examined its feasibility for participants with limited computer experience. Six families, including parents, siblings, and children with TBI, were given computers, Web cameras, and high-speed Internet access. Weekly videoconferences with the therapist were conducted after participants completed on-line interactive experiences on problem solving, communication, and TBI-specific behavior management. Families were assigned to videoconference with NetMeeting (iBOT cameras) or ViaVideo. Participants ranked the Web site and videoconferences as moderately to very easy to use. ViaVideo participants rated videoconferencing significantly more favorably relative to face-to-face meetings than did NetMeeting participants. Both the Web site and videoconferencing were rated as very helpful. All families demonstrated improved outcomes on one or more target behaviors, including increased understanding of the injury and improved parent-child relationships. All parents and siblings and all but 1 child with TBI said they would recommend the program to others. We conclude that a face-to-face intervention can be successfully adapted to the Web for families with varied computer experience.     

Premonitory urges are associated with decreased grey matter thickness within the insula and sensorimotor cortex in young people with Tourette syndrome

Tourette syndrome (TS) is a neurological disorder characterized by vocal and motor tics and is associated with cortical–striatal–thalamic–cortical circuit (CSTC) dysfunction and hyperexcitability of cortical limbic and motor regions, which are thought to lead to the occurrence of tics. Importantly, individuals with TS often report that their tics are preceded by ‘premonitory sensory phenomena’ (PSP) that are described as uncomfortable cognitive or bodily sensations that precede the execution of a tic, and are experienced as a strong urge for motor discharge. While the precise role played by PSP in the occurrence of tics is controversial, PSP are nonetheless of considerable theoretical and clinical importance in TS, not least because they form the core component in many of the behavioural therapies that are currently used in the treatment of tic disorders. In this study, we investigated the brain structure correlates of PSP. Specifically, we conducted a whole‐brain analysis of cortical (grey matter) thickness in 29 children and young adults with TS and investigated the association between grey matter thickness and PSP. We demonstrate for the first time that PSP are inversely associated with grey matter thickness measurements within the insula and sensorimotor cortex. We also demonstrate that grey matter thickness is significantly reduced in these areas in individuals with TS relative to a closely age‐ and gender‐matched group of typically developing individuals and that PSP ratings are significantly correlated with tic severity.     

Features Resembling Tourette''s Syndrome in Developmental Stutterers

Developmental stuttering (DS) may be related to the extrapyramidal motor system and shares many clinical similarities with Tourette's syndrome (TS), which is widely believed to be associated with extrapyramidal dysfunction. Twenty-two stutterers were examined for neuropsychiatric features commonly seen in TS, including tics, obsessive-compulsive behaviors (OCB), and attention deficit disorders. Eleven stutterers displayed motor tics, and symptoms of OCB were observed at rates similar to those seen in persons with TS. Few stutterers demonstrated significant attentional deficits. Findings are consistent with models suggesting extrapyramidal involvement in DS and raise the possibility that DS and TS are pathogenetically related.     

Executive and Attention Functioning Among Children in the PANDAS Subgroup

Evidence from past studies indicates that adults and children with Obsessive-Compulsive Disorder (OCD) and Tourette syndrome (TS) experience subtle neuropsychological deficits. Less is known about neuropsychological functioning of children and adolescents with a symptom course consistent with the PANDAS (Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal infection) subgroup of OCD and tics. To provide such information, we administered three tests of attention control and two of executive function to 67 children and adolescents (ages 5–16) diagnosed with OCD and/or tics and a symptom course consistent with the PANDAS subgroup and 98 healthy volunteers (HV) matched by age, sex, and IQ. In a paired comparison of the two groups, the PANDAS subjects were less accurate than HV in a test of response suppression. Further, in a two-step linear regression analysis of the PANDAS group in which clinical variables were added stepwise into the model and in the second step matching variables (age, sex, and IQ) were added, IQ emerged as a predictor of performance on this task. In the same analysis, ADHD diagnosis and age emerged as predictors of response time in a continuous performance task. Subdividing the PANDAS group by primary psychiatric diagnosis revealed that subjects with TS or OCD with tics exhibited a longer response time compared to controls than subjects with OCD only, replicating previous findings within TS and OCD. This study demonstrates that children with PANDAS exhibit neuropsychological profiles similar to those of their primary psychiatric diagnosis.     

Reliability and validity of the Yale Global Tic Severity Scale

To investigate the reliability and validity of the Yale Global Tic Severity Scale (YGTSS), 28 youth aged 6 to 17 years with Tourette's syndrome (TS) participated in the study. Data included clinician reports of tics and obsessive-compulsive disorder (OCD) severity, parent reports of tics, internalizing and externalizing problems, and child reports of depression and anxiety. All children participated in a 2nd YGTSS administration by the same rater 48 days later. Good internal consistency and stability were found for the YGTSS scores. YGTSS scores demonstrated strong correlations with parent-rated tic severity (r = .58-.68). YGTSS scores were not significantly related to measures of clinician ratings of OCD severity (r = .01-.15), parent ratings of externalizing and internalizing behavior (r = -.07-.20), and child ratings of depression (r = .02-.26) and anxiety (r = -.06 -.28). Findings suggest that the YGTSS is a reliable and valid instrument for the assessment of pediatric TS.     

The role of the cingulate cortex in the generation of motor tics and the experience of the premonitory urge-to-tic in Tourette syndrome

Tourette syndrome (TS) is a neurological disorder of childhood onset that is characterized by the occurrence of motor and vocal tics. TS is associated with cortical-striatal-thalamic-cortical circuit [CSTC] dysfunction and hyper-excitability of cortical limbic and motor regions that are thought to lead to the occurrence of tics. Individuals with TS often report that their tics are preceded by ‘premonitory sensory/urge phenomena’ (PU) that are described as uncomfortable bodily sensations that precede the execution of a tic and are experienced as a strong urge for motor discharge. While the precise role played by PU in the occurrence of tics is largely unknown, they are nonetheless of considerable theoretical and clinical importance as they form a core component of many behavioural therapies used in the treatment of tic disorders. Recent evidence indicates that the cingulate cortex may play an important role in the generation of PU in TS, and in ‘urges-for-action’ more generally. In the current study, we utilized voxel-based morphometry (VBM) techniques, together with ‘seed-to-voxel’ structural covariance network (SCN) mapping, to investigate the putative role played by the cingulate cortex in the generation of motor tics and the experience of PU in a relatively large group of young people with TS. Whole-brain VBM analysis revealed that TS was associated with clusters of significantly reduced grey matter volumes bilaterally within: the orbito-frontal cortex; the cerebellum; and the anterior and mid-cingulate cortex. Similarly, analysis of SCNs associated with bilateral mid- and anterior cingulate ‘seed’ regions demonstrated that TS is associated with increased structural covariance primarily with the bilateral motor cerebellum; the inferior frontal cortex; and the posterior cingulate cortex.     

Évaluation de l’effet d’un programme d’entraînement à l’autogestion des épisodes explosifs chez des enfants atteints du syndrome de Gilles de la Tourette

For children with Tourette syndrome (TS), explosive outbursts (EO) can be more disruptive than tics to the child's functioning. This study evaluated the effectiveness of an innovative cognitive-behavioral intervention for decreasing frequency and intensity of EO. Five boys and one girl ranging in age from 9 to 12 years took part in the study. EO frequency and intensity were measured by systematic observation of events and by questionnaire, while tics and child's psychosocial functioning were measured by questionnaires. The children showed trends towards decreased EO frequency post treatment but no changes in EO intensity. Statistical analysis and questionnaires results revealed no significant change. Qualitative information indicated a benefit to the families following therapy.     

A Meta-Analysis on the Efficacy of Technology Mediated CBT for Anxious Children and Adolescents

Several meta-analyses indicate that cognitive-behavioral therapy (CBT) via electronic/technological devices or applications (i.e., eCBT) is an effective alternative to standard therapist-delivered CBT for anxious adults. However, we know little about the efficacy of eCBT interventions for anxious children and adolescents. The present meta-analysis set out to investigate the efficacy of eCBT in comparison to standard CBT or waitlist control for anxious children and adolescents. Eight randomized controlled studies (N = 404 participants) that targeted anxiety at post-intervention and follow-up were included in the analysis. The results indicated that eCBT was as effective as standard CBT (g = .295) and more effective than waitlist (g = 1.410) in reducing anxiety symptoms. Moderation analyses revealed that anxious children and adolescents benefited the most from eCBT in the minimal therapist involvement condition (g = 2.682) in contrast to the significant therapist involvement group (g = .326). Furthermore, older participants seemed to extract greater clinical benefits from eCBT in contrast to younger participants (slope = .514). Current eCBT interventions for anxious children and adolescents appear to be promising, but require further investigation.     

The impact of a stress induction task on tic frequencies in youth with Tourette Syndrome

Tourette Syndrome (TS) is a neuropsychiatric disorder characterized by motor and vocal tics. Tic fluctuations are common and thought to be attributable in part, to contextual variables. Stress is one such variable, but its effects and mechanism of action are poorly understood. The current study measured the effects of a stress induction task on tic frequencies during periods of suppression and non-suppression of tics. Ten youth with TS between the ages of 9 and 17 were exposed to four conditions in random sequence: free-to-tic baseline (BL), reinforced tic suppression (SUP), reinforced tic suppression plus a stress induction task (SUP + STRESS), and a stress induction task alone (STRESS). Tic frequencies did not differ during STRESS and BL. Tic frequencies were greater in SUP + STRESS than SUP. Stress may impact tics through disrupting suppression efforts. Clinically, results suggest that interventions designed to improve tic inhibition in the presence of acute stressors may be beneficial.     

A comparison of problem identification interviews conducted face-to-face and via videoconferencing using the consultation analysis record

School psychologists who experience challenges delivering face-to-face consultation may utilize videoconferencing to facilitate their consultation activities. Videoconferencing has been found to be an effective method of service delivery in related fields and emerging research suggests that it may be effective for providing teacher training and support in school settings. In this exploratory investigation, we used the Consultation Analysis Record (Bergan & Tombari, 1975) and its four indices to assess the effectiveness of conducting problem identification interviews via videoconferencing versus face-to-face. Overall, findings indicated significant differences across these two conditions, with videoconference interviews coded as having higher indices of content relevance, process effectiveness, and message control, but lower content focus, compared to face-to-face interviews. As these indices have been positively associated with favorable consultation outcomes, the results provide initial support for the effectiveness of consultation delivered via videoconferencing.     

The ability to orient attention in Gilles de la Tourette syndrome

Gilles de la Tourette syndrome is characterised by tics, although patients also commonly present with attentional problems. This experiment aimed to ascertain whether TS patients have problems in orienting attention, via the use of a vibrotactile choice reaction time task. Participants were required to push a button in response to a faint vibration delivered to the index finger. Prior to each stimulus vibration, a pre-cue (valid, neutral or invalid) was administered to the finger. The performance benefits and costs participants gained from valid and invalid precues were calculated. Contrary to our prediction TS patients did not show significantly different costs or benefits. Furthermore, both patients and controls showed an equal and increased benefit in the crossed arm posture, compared to the uncrossed. These results suggest TS patients do not generally have problems in orienting attention. In addition, in the tactile modality, both patients and controls may benefit from directed attention when difficulty levels are maximal.     

Motor excitability during movement preparation in Tourette syndrome

Tourette syndrome (TS) is a neurodevelopmental disorder characterized by the occurrence of motor and vocal tics. TS has been linked to the impaired operation of cortical‐striatal‐thalamic‐cortical circuits that give rise to hyper‐excitability of cortical motor areas, which may be exacerbated by dysfunctional intra‐cortical inhibitory mechanisms. That said, many individuals gain control over their tics during adolescence and it has been suggested that this increased control arises as a result of the development of mechanisms that operate to suppress corticospinal excitability (CSE) ahead of volitional movements. Here we used single‐pulse transcranial magnetic stimulation (TMS) in conjunction with a manual Go/NoGo task to investigate alterations in CSE ahead of volitional movements in a group of adolescents with TS (N = 10). Our study demonstrated that CSE, as measured by TMS‐induced motor‐evoked potentials (MEPs), was significantly reduced in the TS group in the period immediately preceding a finger movement. More specifically, we show that individuals with TS, unlike their age‐matched controls, do not exhibit the predicted increase in mean MEP amplitude and decrease in MEP variability that immediately precede the execution of volitional movements in typically developing young adults. Finally, we report that the magnitude of the rise in MEP amplitude across the movement preparation period in TS is significantly negatively correlated with clinical measures of motor tic severity, suggesting that individuals with severe motor tics are least able to modulate motor cortical excitability.     

Lessons learned: the effect of prior technology use on Web-based interventions.

This study examined the role of regular prior technology use in treatment response to an online family problem-solving (OFPS) intervention and an Internet resource intervention (IRI) for pediatric traumatic brain injury (TBI). Participants were 150 individuals in 40 families of children with TBI randomly assigned to OFPS intervention or an IRI. All families received free computers and Internet access to TBI resources. OFPS families received Web-based sessions and therapist-guided synchronous videoconferences focusing on problem solving, communication skills, and behavior management. All participants completed measures of depression, anxiety, and computer usage. OFPS participants rated treatment satisfaction, therapeutic alliance, and Web site and technology comfort. With the OFPS intervention, depression and anxiety improved significantly more among technology using parents (n = 14) than nontechnology users (n = 6). Technology users reported increasing comfort with technology over time, and this change was predictive of depression at followup. Satisfaction and ease-of-use ratings did not differ by technology usage. Lack of regular prior home computer usage and nonadherence were predictive of anxiety at followup. The IRI was not globally effective. However, controlling for prior depression, age, and technology at work, there was a significant effect of technology at home for depression. Families with technology experience at home (n = 11) reported significantly greater improvements in depression than families without prior technology experience at home (n = 8). Although Web-based OFPS was effective in improving caregiver functioning, individuals with limited computer experience may benefit less from an online intervention due to increased nonadherence.