Combined habit reversal training and exposure response prevention in a group setting compared to individual training: a randomized controlled clinical trial

Efficacy of cognitive-behavioral therapy combined with habit reversal training on anxiety disorders in children with Tourette's syndrome

BACKGROUND

Cognitive-behavioral therapy (CBT) and habit reversal training (HRT) have shown application potential in addressing tic symptoms and comorbid psychiatric conditions. Despite their theoretical potential, empirical evidence on their combined efficacy remains limited.

AIM

To evaluate the efficacy of CBT combined with HRT on anxiety disorders in children with Tourette's syndrome (TS).

METHODS

Clinical data of children with TS admitted to our hospital from January 2022 to June 2023 were collected, and the patients were grouped into the conventional therapy (control) group and the CBT combined with HRT group. Baseline characteristics, anxiety scores, tic severity scores, treatment adherence, and parental satisfaction were assessed. Statistical analysis was performed using t-tests, chi-square tests, and correlation analysis.

RESULTS

A total of 136 patients, including 65 patients in the control group and 71 patients in the CBT combined with HRT group, were included. The CBT combined with HRT group showed remarkable improvements compared with the control group. Post-intervention assessment revealed a decrease in anxiety scores from 63.52 ± 1.81 to 40.53 ± 1.64 (t = 2.022, P = 0.045), and the Yale Global Tic Severity Scale total score decreased from 22.14 ± 5.67 to 16.28 ± 4.91 (t = 2.288, P = 0.024). Treatment adherence was significantly higher in the CBT combined with HRT group (85.47 ± 7.62%) compared with the control group (82.32 ± 6.54%; t = 2.596, P = 0.010). Parental satisfaction scores were also higher in the CBT combined with HRT group (8.69 ± 1.77) compared with the control group (7.87 ± 1.92; t = 2.592, P = 0.011).

CONCLUSION

This study demonstrates that CBT combined with HRT significantly reduces anxiety symptoms and tic severity in children with TS, with higher treatment adherence and parental satisfaction. These findings support the potential application of this comprehensive therapeutic approach for TS treatment.

Tackle your Tics, a brief intensive group-based exposure treatment for young people with tics: results of a randomised controlled trial

Tics can have a serious impact on the quality of life of children and their families. Behavioural therapy is an evidence-based first line treatment for tic disorders. This randomised controlled trial studied the efficacy of a brief, condensed group-based programme for children with tics (Dutch Trial Registry NL8052, 27 September 2019). Tackle your Tics is a four-day group treatment, including exposure and response prevention and supporting components, delivered by therapists and 'experts by experience'. We collected outcome measures at baseline (T1), directly post-treatment (T2), and at three- and 6-months follow-up (T3, T4) including tic severity (primary outcome measure), tic-related impairment, quality of life, tic-related cognitions, emotional/behavioural functioning, family functioning, treatment satisfaction and adherence. Outcomes directly post-treatment improved in both the treatment group (n = 52) and waiting list (n = 54), but showed no statistically significant differences between the conditions (differential change over time T1-T2) on tic severity (Yale Global Tic Severity Scale), quality of life (Gilles de la Tourette Syndrome Quality of Life Scale), tic-related cognitions and family functioning. At longer term (T3), again no between-group difference was found on tic severity, but tic-related impairment, quality of life and emotional/behavioural functioning significantly improved in the treatment group compared to the waiting list. Mean treatment satisfaction scores were favourable for both children and parents. Directly posttreatment, Tackle your Tics showed no superior effect compared to waiting list. However, on longer term this brief four-day group treatment was effective in improving tic-related impairment, quality of life and emotional/behavioural functioning.

Exploring protocol development: Implementing systematic contextual memory to enhance real-time fMRI neurofeedback

Objective

The goal of this study was to explore the development and implementation of a protocol for real-time fMRI neurofeedback (rtfMRI-nf) and to assess the potential for enhancing the selective brain activation using stimuli from Virtual Reality (VR). In this study we focused on two specific brain regions, supplementary motor area (SMA) and right inferior frontal gyrus (rIFG). Publications by other study groups have suggested impaired function in these specific brain regions in patients with the diagnoses Attention Deficit Hyperactivity Disorder (ADHD) and Tourette's Syndrome (TS). This study explored the development of a protocol to investigate if attention and contextual memory may be used to systematically strengthen the procedure of rtfMRI-nf.

Methods

We used open-science software and platforms for rtfMRI-nf and for developing a simulated repetition of the rtfMRI-nf brain training in VR. We conducted seven exploratory tests in which we updated the protocol at each step. During rtfMRI-nf, MRI images are analyzed live while a person is undergoing an MRI scan, and the results are simultaneously shown to the person in the MRI-scanner. By focusing the analysis on specific regions of the brain, this procedure can be used to help the person strengthen conscious control of these regions. The VR simulation of the same experience involved a walk through the hospital toward the MRI scanner where the training sessions were conducted, as well as a subsequent simulated repetition of the MRI training. The VR simulation was a 2D projection of the experience.The seven exploratory tests involved 19 volunteers. Through this exploration, methods for aiming within the brain (e.g. masks/algorithms for coordinate-system control) and calculations for the analyses (e.g. calculations based on connectivity versus activity) were updated by the project team throughout the project. The final procedure involved three initial rounds of rtfMRI-nf for learning brain strategies. Then, the volunteers were provided with VR headsets and given instructions for one week of use. Afterward, a new session with three rounds of rtfMRI-nf was conducted.

Results

Through our exploration of the indirect effect parameters - brain region activity (directed oxygenated blood flow), connectivity (degree of correlated activity in different regions), and neurofeedback score - the volunteers tended to increase activity in the reinforced brain regions through our seven tests. Updates of procedures and analyses were always conducted between pilots, and never within. The VR simulated repetition was tested in pilot 7, but the role of the VR contribution in this setting is unclear due to underpowered testing.

Conclusion

This proof-of-concept protocol implies how rtfMRI-nf may be used to selectively train two brain regions (SMA and rIFG). The method may likely be adapted to train any given region in the brain, but readers are advised to update and adapt the procedure to experimental needs.

Applying an Established Exposure Response Prevention Protocol for Young People With Tourette Syndrome in an Intensive, Group Format: A Feasibility Study

BACKGROUND

The motor and vocal tics that characterise Tourette syndrome are stigmatizing and impact on quality of life. Behavioural interventions such as Exposure Response Prevention or Comprehensive Behavioural Interventions for Tics are first line treatment for Tourette syndrome, but availability is limited. This study is the first to explore the impact of an established manualised Exposure Response Prevention treatment protocol, developed for individual therapy, but here uniquely delivered intensively, to a group.

METHODS

A naturalistic study comprised of a consecutive series of children (N = 20), aged 8-16 years (M = 12, SD = 2.17) were offered Exposure Response Prevention in one of two groups, delivered in series within a specialist clinic. Young people received the equivalent of 12 sessions (matching the manualised individual protocol).

RESULTS

The YGTSS and Giles de la Tourette Syndrome Quality of Life Scale for Children and Adolescents (Satisfaction Scale) showed significant improvement following treatment with moderate to large effect sizes. Thirty-five percent of children demonstrated a reliable improvement on the YGTSS Global Tic Severity score.

CONCLUSIONS

These data suggest an established Exposure Response Prevention protocol can be delivered in an intensive, group setting with a positive clinical outcome. Replication in a randomized controlled trial is an important next step.

Group-based comprehensive behavioral intervention for tics (CBIT) for adults with Tourette syndrome or chronic tic disorders: A pilot study

Comprehensive behavioral intervention for tics (CBIT) administered individually is an effective treatment for tics. However, the effectiveness of CBIT administered in groups for adults with Tourette syndrome and chronic tic disorders has not been investigated yet. This pilot study examined the effectiveness of group-based CBIT with respect to reduction of tic severity and tic-related impairment, as well as improvement of tic-related quality of life. Data from 26 patients were included in the intention-to-treat analyses. The Yale Global Tic Severity Scale was used to assess total tic severity and tic-related impairment. The Gilles de la Tourette - Quality of Life Scale was used to assess tic-related quality of life. These measures were administered at three points in time: at pretreatment, posttreatment, and 1-year follow-up. The results showed a significant reduction of total tic severity from pretreatment to 1-year follow-up, with larges effect sizes. Tic-related impairment and tic-related quality of life also improved significantly, although the effect sizes were smaller. Motor tics showed a stronger reduction than vocal tics. Additional analysis revealed that all change was achieved during treatment and that this effect was maintained from posttreatment to 1-year follow-up. The results of this study indicate that group-based CBIT is a promising treatment for tics.

Working Mechanisms of Exposure and Response Prevention in the Treatment of Tourette Syndrome and Tic Disorders Revisited: No Evidence for within-Session Habituation to Premonitory Urges

BACKGROUND

Exposure and response prevention (ERP) has been shown to be an effective treatment for Tourette syndrome (TS) and chronic tic disorders (CTD). ERP is based on voluntary tic suppression in combination with prolonged exposure to premonitory urges preceding tics. A prevailing hypothesis of the working mechanism underlying ERP in tics is habituation to the premonitory urges as a result of prolonged exposure. However, results so far are equivocal. This study aims to further explore the relation between urges and ERP in tics, by investigating the course of premonitory urges during ERP sessions.

METHODS

Using a data-driven approach, within-session habituation to premonitory urge intensity was investigated. In total, 29 TS patients rated urge intensity at seven timepoints during ten 1 h ERP sessions.

RESULTS/CONCLUSIONS

Latent growth modeling showed an increase in urge intensity during the first 15 min of each session followed by a plateau in the remaining 45 min of the session. This does not support the idea of within-session habituation to premonitory urges as a working mechanism of ERP. Other potential underlying working mechanisms are discussed and should be tested in future research.

An Update on the Diagnosis and Management of Tic Disorders

Tic disorders (TDs) are a group of common neuropsychiatric disorders of childhood and adolescence. TDs may impact the physical, emotional, and social well-being of the affected person. In this review, we present an update on the clinical manifestations, pathophysiology, diagnosis, and treatment of TDs. We searched the PubMed database for articles on tics and Tourette syndrome. More than 400 articles were reviewed, of which 141 are included in this review. TDs are more prevalent in children than in adults and in males than in females. It may result from a complex interaction between various genetic, environmental, and immunological factors. Dysregulation in the cortico-striato-pallido-thalamo-cortical network is the most plausible pathophysiology resulting in tics. TD is a clinical diagnosis based on clinical features and findings on neurological examination, especially the identification of tic phenomenology. In addition to tics, TD patients may have sensory features, including premonitory urge; enhanced and persistent sensitivity to non-noxious external or internal stimuli; and behavioral manifestations, including attention deficit hyperactivity disorders, obsessive-compulsive disorders, and autism spectrum disorders. Clinical findings of hyperkinetic movements that usually mimic tics have been compared and contrasted with those of TD. Patients with TD may not require specific treatment if tics are not distressing. Psychoeducation and supportive therapy can help reduce tics when combined with medication. Dispelling myths and promoting acceptance are important to improve patient outcomes. Using European, Canadian, and American guidelines, the treatment of TD, including behavioral therapy, medical therapy, and emerging/experimental therapy, has been discussed.

Online remote behavioural intervention for tics in 9- to 17-year-olds: the ORBIT RCT with embedded process and economic evaluation

Background

Behavioural therapy for tics is difficult to access, and little is known about its effectiveness when delivered online.

Objective

To investigate the clinical and cost-effectiveness of an online-delivered, therapist- and parent-supported therapy for young people with tic disorders.

Design

Single-blind, parallel-group, randomised controlled trial, with 3-month (primary end point) and 6-month post-randomisation follow-up. Participants were individually randomised (1 : 1), using on online system, with block randomisations, stratified by site. Naturalistic follow-up was conducted at 12 and 18 months post-randomisation when participants were free to access non-trial interventions. A subset of participants participated in a process evaluation.

Setting

Two hospitals (London and Nottingham) in England also accepting referrals from patient identification centres and online self-referrals.

Participants

Children aged 9-17 years (1) with Tourette syndrome or chronic tic disorder, (2) with a Yale Global Tic Severity Scale-total tic severity score of 15 or more (or > 10 with only motor or vocal tics) and (3) having not received behavioural therapy for tics in the past 12 months or started/stopped medication for tics within the past 2 months.

Interventions

Either 10 weeks of online, remotely delivered, therapist-supported exposure and response prevention therapy (intervention group) or online psychoeducation (control).

Outcome

Primary outcome: Yale Global Tic Severity Scale-total tic severity score 3 months post-randomisation; analysis done in all randomised patients for whom data were available. Secondary outcomes included low mood, anxiety, treatment satisfaction and health resource use. Quality-adjusted life-years are derived from parent-completed quality-of-life measures. All trial staff, statisticians and the chief investigator were masked to group allocation.

Results

Two hundred and twenty-four participants were randomised to the intervention (n = 112) or control (n = 112) group. Participants were mostly male (n = 177; 79%), with a mean age of 12 years. At 3 months the estimated mean difference in Yale Global Tic Severity Scale-total tic severity score between the groups adjusted for baseline and site was -2.29 points (95% confidence interval -3.86 to -0.71) in favour of therapy (effect size -0.31, 95% confidence interval -0.52 to -0.10). This effect was sustained throughout to the final follow-up at 18 months (-2.01 points, 95% confidence interval -3.86 to -0.15; effect size -0.27, 95% confidence interval -0.52 to -0.02). At 18 months the mean incremental cost per participant of the intervention compared to the control was £662 (95% confidence interval -£59 to £1384), with a mean incremental quality-adjusted life-year of 0.040 (95% confidence interval -0.004 to 0.083) per participant. The mean incremental cost per quality-adjusted life-year gained was £16,708. The intervention was acceptable and delivered with high fidelity. Parental engagement predicted child engagement and more positive clinical outcomes.

Harms

Two serious, unrelated adverse events occurred in the control group.

Limitations

We cannot separate the effects of digital online delivery and the therapy itself. The sample was predominately white and British, limiting generalisability. The design did not compare to face-to-face services.

Conclusion

Online, therapist-supported behavioural therapy for young people with tic disorders is clinically and cost-effective in reducing tics, with durable benefits extending up to 18 months.

Future work

Future work should compare online to face-to-face therapy and explore how to embed the intervention in clinical practice.

Trial registration

This trial is registered as ISRCTN70758207; ClinicalTrials.gov (NCT03483493). The trial is now complete.

Funding

This project was funded by the National Institute for Health and Care Research (NIHR) Health and Technology Assessment programme (project number 16/19/02) and will be published in full in Health and Technology Assessment; Vol. 27, No. 18. See the NIHR Journals Library website for further project information.

Group comprehensive behavioral intervention for tics contribution to broader cognitive and emotion regulation in children

There is increasing evidence for the effectiveness of behavioral techniques in managing tics in youth with Tourette syndrome and tics disorders (TDs). One such intervention is Comprehensive Behavioral Intervention for Tics (CBIT), which focuses on reducing tic severity by training control and regulation. In view of the regulation deficits characteristic to TDs, in the current study, we aimed to explore the contribution of CBIT beyond tic control, to a wider expression of regulation abilities-cognitive inhibition and emotion regulation. A total of 55 participants with TDs, aged 8-15, who were randomly assigned to group-CBIT or group-Educational Intervention for Tics, were compared on cognitive inhibition tests and use of emotion-regulation strategies, pre- and post-intervention. Whereas on none of the scales a significant interaction effect was found reflecting superiority of CBIT over EIT, repeated measures ANOVA revealed a significant time effect, with post hoc analyses indicating that cognitive inhibition and cognitive reappraisal significantly increased following CBIT intervention only. Within the group-CBIT, the increase in cognitive reappraisal was associated with higher intellectual ability. These findings may lead to a broader understanding of CBIT contribution to more than tic control, but rather to better cognitive and emotional regulation abilities.

[Metacognitions and interoceptive sensibility in the perception of premonitory urges in tic disorders across the lifespan]

Metacognitions and interoceptive sensibility in the perception of premonitory urges in tic disorders across the lifespan Abstract. Objective: Depending on contextual factors, the prevalence of premonitory urges (PU) in patients with tic disorders (TD) increases with age and varies both intra- and interindividually. In youth, PUs correlate with metacognitions. In both youth and adults, interoceptive sensibility is altered compared to healthy controls. We examined the relationship between PUs, tics, metacognitions, and interoceptive sensibility across the lifespan regarding tic severity. Method: In an online survey, 53 participants reported their PUs on the Premonitory Urge for Tics Scale (PUTS) and tic severity on the Symptom Checklist for Tic Disorders (SBB-TIC). We assessed interoceptive sensibility via the Body Perception Questionnaire (BPQ-A) and metacognitions regarding tics with the Belief About Tics Scale (BATS). Results: Adults scored higher on the PUTS than youth. In youth, interoceptive sensibility increased with age; interoceptive sensibility correlated with PUTS. Metacognitions and interoceptive sensibility explained a significant amount of variance in premonitory urges, even after controlling for tic severity and age. Conclusions: The presumed cause of age-dependent development of PUs in youth lies in their neurophysiological maturing processes. However, negative metacognitions and interoceptive abilities also play an important role in the development and maintenance of PU and might be of therapeutic use in the treatment of TD.

Behavioral Interventions for Children and Adults with Tic Disorder

Over the past decade, behavioral interventions have become increasingly recognized and recommended as effective first-line therapies for treating individuals with tic disorders. In this article, we describe a basic theoretical and conceptual framework through which the reader can understand the application of these interventions for treating tics. The three primary behavioral interventions for tics with the strongest empirical support (habit reversal, Comprehensive Behavioral Intervention for Tics, and exposure and response prevention) are described. Research on the efficacy and effectiveness of these treatments is summarized along with a discussion of the research evaluating the delivery of these treatments in different formats and modalities. The article closes with a review of the possible mechanisms of change underlying behavioral interventions for tics and areas for future research.

Exposure and Response Prevention: Evaluation of Tic Severity Over Time for Children and Adolescents with Tourette Syndrome and Chronic Tic Disorders

Tourette syndrome and chronic tic disorders are characterized by the presence of tics. Different behavioral therapies have shown to be efficacious for treating tics in children and adolescents, but Exposure and Response Prevention (ERP) is a less researched method. However, ERP is a method often used in the clinical setting. Therefore, the present study evaluated the severity of tics over time from beginning of ERP to follow-up approximately 1 year after last training session.In total, 116 patients treated with ERP face to face or ERP via web-based videoconferencing were included. The primary outcome measure was tic severity measured with the Danish version of the Yale Global Tic Severity Scale.The results showed that tic severity decreased during ERP and lasted in the follow-up period, with a statistically higher decrease in the group with patients who completed ERP as planned and the group that stopped earlier than planned because of reduction in tics, compared with those who dropped out due to lack of motivation (p < 0.001).The study concludes that ERP seems to have an immediate and a long-term effect on severity of tics, especially in those who complete the program or those who discontinue earlier due to good results.

Tourette syndrome: clinical features, pathophysiology, and treatment

Tourette syndrome is a chronic neurodevelopmental disorder characterised by motor and phonic tics that can substantially diminish the quality of life of affected individuals. Evaluating and treating Tourette syndrome is complex, in part due to the heterogeneity of symptoms and comorbidities between individuals. The underlying pathophysiology of Tourette syndrome is not fully understood, but recent research in the past 5 years has brought new insights into the genetic variations and the alterations in neurophysiology and brain networks contributing to its pathogenesis. Treatment options for Tourette syndrome are expanding with novel pharmacological therapies and increased use of deep brain stimulation for patients with symptoms that are refractory to pharmacological or behavioural treatments. Potential predictors of patient responses to therapies for Tourette syndrome, such as specific networks modulated during deep brain stimulation, can guide clinical decisions. Multicentre data sharing initiatives have enabled several advances in our understanding of the genetics and pathophysiology of Tourette syndrome and will be crucial for future large-scale research and in refining effective treatments.

Die Bedeutung des Vorgefühls bei Tic-Störungen

Zusammenfassung. Theoretischer Hintergrund: Die Funktion des Vorgefühls in der Pathogenese und Aufrechterhaltung von Tic-Störungen (TS) wird in den letzten Jahren verstärkt erforscht. Die mögliche funktionelle Bedeutung der Vorgefühle wird aber noch nicht ausreichend verstanden. Methode: Im vorliegenden Review wird der Kenntnisstand zu Vorgefühlen entlang eines integrativen funktionalen Störungsmodells zusammengefasst. Ergebnisse: Im Vergleich zum Jugendalter nehmen Tic-Symptome bei Tic-Störungen im Erwachsenenalter ab, während immer mehr Betroffene ein Vorgefühl berichten. Hierbei kann zwischen einem allgemeinen Vorgefühl (trait) und dem Drang, Tics auszuführen (state) unterschieden werden. Das Vorgefühl als trait ist abhängig von der Interozeptionsfähigkeit. An den Drang, Tics auszuführen, kann habituiert werden, moderiert von Aufmerksamkeits- und Attributionsprozessen. Durch das Auflösen des Vorgefühl-Tic-Reizreaktionsmusters reduzieren sich die Tic-Symptome. Schlussfolgerung: Für weitere Erkenntnisse in Bezug auf die Bedeutung von Vorgefühl und den Drang, Tics auszuführen, sollten zukünftige Forschungsansätze Drang und allgemeine Vorgefühle in therapeutischen Interventionsstudien berücksichtigen, weitere Interozeptionsparadigmen einbeziehen und die Entwicklung von allgemeinem Vorgefühl und Drang über die Lebensspanne hinweg untersuchen.

"Don't Touch Your Face!" The Contribution of Habit Reversal in the COVID-19 Pandemic

The Habit Reversal Training (HRT) is a behavioral procedure for treating the so-called nervous habits, such as nail biting, hair pulling and thumb sucking. In addition to being an established clinical procedure, HRT is also a strategy for behavioral change that can serve the entire community. For this reason, this review aims to explore the studies proposing the use of HRT for the reduction of hand-to-face habits in the context of COVID-19 pandemic. Touching one's nose, mouth and eyes, indeed, is one of the means of virus transmission that many awareness campaigns seek to highlight. After an overview of how HRT works and of the current epidemiological situation, studies supporting Habit Reversal Training for the reduction of risky hand-to-face habits are presented. The possible strategies are then exposed and critically discussed to identify their limitations and propose a new version according to the Relational Frame Theory.

Effectiveness of 'Tackle Your Tics', a brief, intensive group-based exposure therapy programme for children with tic disorders: study protocol of a randomised controlled trial

INTRODUCTION

This paper outlines the study protocol for the Dutch Tackle Your Tics study in youth with tic disorders. Tourette syndrome and chronic tic disorders are prevalent neurodevelopmental disorders, placing considerable burden on youth and their families. Behavioural treatment is the first-line, evidence-based intervention for tic disorders, but tic reduction and availability remain relatively low. Patient associations stress the need for more accessible high-quality treatments, also focusing on improving quality of life. Therefore, the brief, intensive group-based treatment Tackle Your Tics was developed.

METHODS AND ANALYSIS

Tackle Your Tics is a 4-day intensive and comprehensive group-based intervention for children and adolescents (9-17 years) with Tourette syndrome or a chronic tic disorder. The programme encompasses exposure and response prevention treatment and additional supporting components (coping strategies, relaxation exercises and parent support). To study the effectiveness of Tackle Your Tics and identify predictors/moderators at baseline, a single-blinded randomised controlled trial (n=104) is conducted, comparing Tackle Your Tics (n=52) with a waiting list condition lasting 3 months (n=52). Assessments are performed at similar time points for both groups: at baseline, after 4 weeks, and at 3 and 6 months of follow-up, on tic severity, quality of life and other psychosocial variables.

ETHICS AND DISSEMINATION

Ethics approval has been obtained from the medical ethical committee of the Amsterdam Medical Centre (METC nr NL66340.018.18, v3 June 2020). Findings will be presented on national and international conferences, peer-reviewed scientific journals, patient organisation meetings and public media. Patient representatives are fully integrated as part of the research team. If Tackle Your Tics proves to be effective, it can expand evidence-based treatment possibilities for children and adolescents with tic disorders. Identifying the psychosocial predictors/moderators for the effectiveness of this intervention can provide personalised treatment advice in the future.

TRIAL REGISTRATION NUMBER

NL8052.

Group behavioral interventions for tics and comorbid symptoms in children with chronic tic disorders

Exposure and Response Prevention (ERP), Habit Reversal Training (HRT) and Comprehensive Behavioral Intervention for Tics (CBIT) are effective in reducing tic severity. ERP and HRT have recently gained primary support in a group setting, while CBIT has not been examined similarly. We compared the efficacy of group-CBIT to group-Educational Intervention for Tics (group-EIT) for tics and comorbid symptoms. Children with Tourette Syndrome (TS) or Chronic Tic Disorder (CTD) were randomized to group-CBIT or group-EIT. Tics and comorbid symptoms were assessed in forty-six children pre- and postintervention, and 3-month later. Yale Global Tic Severity Scale (YGTSS) Motor tic severity decreased following both interventions, and was maintained at follow-up for group-CBIT only. The Parent Tic Questionnaire (PTQ) showed significant decrease in total and motor tic severity following group-CBIT only, a gain maintained three months later. YGTSS impairment score decreased following both interventions and was maintained at follow-up. YGTSS vocal tic severity score increased following both interventions, and then decreased significantly at follow up. Co-morbid symptoms including anxiety, behavioral problems, and aggressive behavior decreased following both interventions. Children with behavioral problems benefitted less while children with higher intellectual ability benefit more from intervention. Both group interventions showed efficacy in reducing tic impairment and comorbid symptoms. Group-CBIT was superior to group-EIT in reducing motor tic severity at 3-month follow-up, showing an advantage for tic-focused treatment. Based on the PTQ, group-CBIT was superior to group-EIT in reducing motor, vocal, and total tic scores, a gain maintained three months later. Clinical trial registry information-Group Intervention for Children with Chronic Tics Syndrome: CBIT vs Psychoeducational Intervention URL: http://clinicaltrials.gov , Identifier: NCT02407951, http://www.controlled-trials.com ).

Tourette Syndrome Treatment Updates: a Review and Discussion of the Current and Upcoming Literature

PURPOSE OF REVIEW

This study aims to examine the treatments currently available for Tourette syndrome (TS) and to discuss evolving therapies, spanning behavioral, pharmacologic, complementary and alternative medicine, and neuromodulation approaches.

RECENT FINDINGS

Behavioral therapies have undergone several modifications to improve accessibility, including transitioning to a virtual format which is particularly important in the current pandemic. There are several recent or ongoing pharmacologic studies that have shown promise including the selective D1 receptor antagonist ecopipam and various cannabinoid compounds. Adaptive DBS may enable the physiologic markers of tics to determine stimulation parameters and improve tic outcomes related to neuromodulation. In recent years, there has been a wealth of research across multiple treatment domains in the TS field. This review highlights exciting and new potential options for the future treatment of patients with TS.

Open-case series of a remote administration and group setting comprehensive behavioral intervention for tics (RG-CBIT): A pilot trial

PURPOSE

The comprehensive behavioral intervention for tics (CBIT) is the first-line psychotherapeutic treatment for individuals with tic disorders. However, most patients with tic disorders do not have access to CBIT due to different factors including lack of trained therapists, treatment cost, and travel distance. Such barriers are more prominent in non-English speaking countries. Therefore, the current study assessed the preliminary efficacy, feasibility, and acceptability of remotely administered group CBIT (RG-CBIT) in Japan.

METHODS

This was an open-case series that adopted the AB design. Three Japanese children aged between 6 and 13 years who were diagnosed with TS were recruited. RG-CBIT was developed based on the published CBIT manual. Videoconference application, slide presentation software, and cloud learning platform were used as appropriate.

RESULTS

The Yale Global Tic Severity Scale scores of all participants decreased from baseline to post-treatment. That is, the score reduced by an average of 7.0. Regarding feasibility and acceptability, the attendance rate of participants was 100%, and the process measurement items had favorable scores.

CONCLUSIONS

RG-CBIT had satisfactory efficacy, feasibility, and acceptability. Hence, it could mitigate the barriers for treatment access.

European clinical guidelines for Tourette syndrome and other tic disorders-version 2.0. Part II: psychological interventions

Part II of the European clinical guidelines for Tourette syndrome and other tic disorders (ECAP journal, 2011) provides updated information and recommendations for psychological interventions for individuals with tic disorders, created by a working group of the European Society for the Study of Tourette Syndrome (ESSTS). A systematic literature search was conducted to obtain original studies of psychological interventions for tic disorders, published since the initial European clinical guidelines were issued. Relevant studies were identified using computerized searches of the MEDLINE and PsycINFO databases for the years 2011-2019 and a manual search for the years 2019-2021. Based on clinical consensus, psychoeducation is recommended as an initial intervention regardless of symptom severity. According to a systematic literature search, most evidence was found for Habit Reversal Training (HRT), primarily the expanded package Comprehensive Behavioral Intervention for Tics (CBIT). Evidence was also found for Exposure and Response Prevention (ERP), but to a lesser degree of certainty than HRT/CBIT due to fewer studies. Currently, cognitive interventions and third-wave interventions are not recommended as stand-alone treatments for tic disorders. Several novel treatment delivery formats are currently being evaluated, of which videoconference delivery of HRT/CBIT has the most evidence to date. To summarize, when psychoeducation alone is insufficient, both HRT/CBIT and ERP are recommended as first-line interventions for tic disorders. As part of the development of the clinical guidelines, a survey is reported from ESSTS members and other tic disorder experts on preference, use and availability of psychological interventions for tic disorders.

Protocol of a randomized controlled trial to investigate the efficacy and neural correlates of mindfulness-based habit reversal training in children with Tourette syndrome

BACKGROUND

Tourette syndrome (TS) is a developmental neuropsychiatric disorder. Behavior therapy, especially habit reversal training (HRT), has gradually become regarded as one of the core therapies for TS. Mindfulness approaches can improve psychological adjustment and reduce stress and anxiety, suggesting potential benefits when incorporated into behavior therapy. To improve the efficacy of HRT, we combined it with mindfulness, an approach named mindfulness-based habitual reversal training (MHRT). The aim of this protocol is to investigate the efficacy and neural mechanisms of MHRT for TS.

METHODS/DESIGN

We will perform a randomized control trial (RCT) to evaluate the efficacy and neural mechanisms of MHRT. The sample will include 160 participants (including 120 patients with TS and 40 healthy controls). The patient sample will be randomly divided into three groups exposed to three different types of training: MHRT, HRT, and psychoeducation and supportive therapy (PST). Participants will be assessed and undergo resting-state fMRI scans at baseline and at the end of the 12-week training. The Yale Global Tic Severity Scale (YGTSS) and Premonitory Urge for Tic Scale (PUTS) will be used to assess the severity of tic symptoms and premonitory urges. The primary outcomes are change scores on the YGTSS and other assessments from baseline and the end of the training. The secondary outcomes are the neural correlates of these trainings among these groups based on graph theory, which is used to characterize brain functional connectivity networks. The default mode network (DMN) and the salience network (SN) will be assessed (which have been associated with mindfulness as well as the generation of tic symptoms) by network parameters, including clustering coefficients and shortest path lengths. Changes in these network parameters will be regarded as the neural correlates of the behavioral training.

DISCUSSION

MHRT was newly developed for the treatment of TS. MHRT may lead to greater reductions in tic severity than traditional HRT. Changes in the network parameters of the DMN and SN may show associations with the efficacy of MHRT.

CLINICAL TRIAL REGISTRATION

http://www.chictr.org.cn, ChiCTR2100053077, China.

Role of psychotherapy strategy for the management of patients with Tourette syndrome - A Bayesian network meta-analysis

Tourette's syndrome (TS) is a complex neurodevelopmental disorder characterized by high comorbidity. Treatment with psychotherapy is highly recommended, however, there exists limited available evidence on the use and the optimal psychotherapeutic outcome is debatable. We performed a systematic search on several bibliographic databases for randomized controlled trials (RCTs) reporting the use of psychotherapy treatment in TS patients, from inception to August 1st, 2020, and without language restrictions. Outcome measures were measured by the Yale global tic severity scale (YGTSS) to determine the efficacy of psychotherapy. Data were pooled as Standard mean difference (SMD) in the Bayesian analysis of the random effect model. A total of 17 RCTs with 9 treatments and 1042 participants were included from an initial 4901 records. The primary outcome including, Comprehensive behavioral intervention (CBIT) [SMD = -1.43, 95%Credible interval (CrI): -2.39, -0.44], Exposure with response prevention (ERP) [SMD = -1.37, 95%CrI: -2.62, -0.13], Habit reversal therapy (HRT) [SMD = -0.93, 95%CrI: 1.83, -0.05], and Behavior therapy (BT) [SMD = -0.85, 95%CrI: 1.51, -0.18], were found to be significantly lower in the TS group compared with the control group (including wait-list, treatment-as-usual or other named control group). Based on the Surface under the cumulative ranking curve (SUCRA), CBIT (SUCRA value = 86.97%, 95%CrI: 44%, 100%) was found to be a suitable psychotherapeutic treatment for TS patients. High-quality RCTs on psychotherapy are needed to perform for establishing the foundation of the generation of evidence-based guidelines.

Psychometric Properties of the Chinese Version of the Premonitory Urge for Tics Scale: A Preliminary Report

Premonitory urges (PUs) are sensory phenomena that immediately precede tics. The Premonitory Urge for Tics Scale (PUTS) is widely used to assess the severity of PUs, but the psychometric properties of PUTS and clinical features of PU in Chinese patients with tic disorders are still unclear. In this study, we examined the psychometric properties of the Chinese version of the PUTS in a large sample (including 367 Chinese pediatric patients with tic disorders). We found no difference in PU in different age groups. The exploratory factor analysis (EFA) of PUTS showed the emergence of four primary factors. The results of reliability and validity analyses indicated that the Chinese version showed good psychometric properties. It seemed that PU was associated with the severity of obsession symptoms in patients with tic disorders. Network analysis showed that Item 7 is a critical node for the PU, in addition to Items 1 and 4. Overall, the Chinese version of PUTS can be used in Chinese child and adolescent patients with tic disorders, particularly for patients with Tourette syndrome.

Recent progress on Tourette syndrome

Tic disorders and Tourette syndrome are the most common movement disorders in children and are characterized by movements or vocalizations. Clinically, Tourette syndrome is frequently associated with comorbid psychiatric symptoms. Although dysfunction of cortical–striatal–thalamic–cortical circuits with aberrant neurotransmitter function has been considered the proximate cause of tics, the mechanism underlying this association is unclear. Recently, many studies have been conducted to elucidate the epidemiology, clinical course, comorbid symptoms, and pathophysiology of tic disorders by using laboratory studies, neuroimaging, electrophysiological testing, environmental exposure, and genetic testing. In addition, many researchers have focused on treatment for tics, including behavioral therapy, pharmacological treatment, and surgical treatment. Here, we provide an overview of recent progress on Tourette syndrome.

Using brief habit reversal and an interdependent group contingency to reduce public-speaking speech disfluencies

This study replicated and extended previous research on the effectiveness of brief habit reversal, consisting of awareness training and competing response training (silent pause) in reducing the rate of speech disfluencies during public speaking. Nine university students, divided into 3 groups, delivered short speeches on a novel topic. Brief habit reversal combined with an interdependent group contingency resulted in a meaningful reduction in speech disfluencies with only 1 group requiring booster sessions. Relative to baseline, competing responses increased for all participants but only remained high for 1 participant following training. Reductions in speech disfluencies maintained during follow-up when participants presented in front of a small audience.

A Comprehensive Review of Tic Disorders in Children

Tics are characterized by sudden, rapid, recurrent, nonrhythmic movement or vocalization, and are the most common movement disorders in children. Their onset is usually in childhood and tics often will diminish within one year. However, some of the tics can persist and cause various problems such as social embarrassment, physical discomfort, or emotional impairments, which could interfere with daily activities and school performance. Furthermore, tic disorders are frequently associated with comorbid neuropsychiatric symptoms, which can become more problematic than tic symptoms. Unfortunately, misunderstanding and misconceptions of tic disorders still exist among the general population. Understanding tic disorders and their comorbidities is important to deliver appropriate care to patients with tics. Several studies have been conducted to elucidate the clinical course, epidemiology, and pathophysiology of tics, but they are still not well understood. This article aims to provide an overview about tics and tic disorders, and recent findings on tic disorders including history, definition, diagnosis, epidemiology, etiology, diagnostic approach, comorbidities, treatment and management, and differential diagnosis.

A Review of Cognitive and Behavioral Interventions for Tic Disorder

OBJECTIVES

Tic disorder is a neurodevelopmental disorder characterized by multiple involuntary movements of muscles or vocalization. Although tic symptoms subside as the patient ages, some patients suffer from significant functional impairments related to severe tic symptoms. This manuscript aimed to review the latest scientific evidences for the effect of cognitive-behavioral interventions on tic disorder.

METHODS

The relevant studies were identified by searching medical research databases. We focused our search on studies published between 2000 and 2020 in order to reflect the latest scientific evidence. A total of 821 articles were identified in the initial database search and 27 articles were finally included for the review after the exclusion of duplicated and irrelevant articles.

RESULTS

Behavioral therapies including habit reversal training, Comprehensive Behavioral Intervention for Tics, and exposure and response prevention were the most widely studied interventions for tic disorder and are recommended as first-line treatments for tic disorders with high confidence. Cognitive psychophysiologic approaches were also reported to be effective.

CONCLUSION

Further studies are needed to support the future treatment of tics with low-cost and more widely available treatments, in order to ensure better treatment outcomes.

One-year outcome of manualised behavior therapy of chronic tic disorders in children and adolescents

BACKGROUND

Chronic tic disorders are neurodevelopmental disorders that can be treated with Habit Reversal Training (HRT) and Exposure Response Prevention (ERP). Intermediate and long-term effects have been examined after individual treatment with HRT, whereas evaluation of long-term outcome after an initial treatment with ERP, or a combination of HRT and ERP is lacking. The present study examines the long-term effect after a combined treatment with HRT and ERP delivered in an individual or a group setting METHODS: Fifty-nine children and adolescents diagnosed with a chronic tic disorder were randomised to manualised treatment combining HRT and ERP as individual or group training. Forty-seven were re-examined 1 year after acute outcome. Outcome measures included Total Tic Severity score (TTS) measured by the Yale Global Tic Severity Scale (YGTSS) and Beliefs About Tics Scale (BATS) RESULTS: In a mixed model, it was shown that the initial improvement with both individual and group treatment was maintained throughout the follow-up period. There were no significant differences between the two methods of treatment delivery. Of all participants completing the 12 months evaluation, 74.4% were considered responders. There was a significant positive association between the reduction of TTS and the reduction in BATS. In a latent class post-treatment trajectory analysis, two classes were identified, where high baseline severity increased the likelihood of being in the lesser responder class. Similar, but only as a trend, having ADHD, planning difficulties or hypersensitivity increased the risk of a lesser response.

CONCLUSIONS

The present study compares the efficacy in individualised and group treatment of providing manualised therapy for child and adolescent tic disorders using two behavioural methods (combined HRT and ERP) both of which have been shown to have acute benefits but only one of which has been validated for longer term effectiveness. In the present study, both individualised and group treatments showed benefit throughout a 1-year follow-up period with several potential confounds affecting outcomes, while the relative benefits of either HRT and ERP were not addressed. Trial registration NCT04594044, 1-10-72-216-15, registered 19th October 2020, retrospectively registered, https://register.clinicaltrials.gov/prs/app/template/Home.vm?uid=U0005BW2&ts=9&sid=S000ABEY&cx=-wlx7vb The study is approved by the National Ethical Committee (1-10-72-216-15) and the Danish Data Protection Agency (1-16-02-490-15), registered 12 October 2015.

Effectiveness of Behaviour Therapy for Children and Adolescents with Tourette Syndrome and Chronic Tic Disorder in a Naturalistic Setting

It is unclear if the results of randomised controlled trials (RCTs) of behaviour therapy (BT) for Tourette syndrome (TS) and chronic tic disorder (CTD) can be generalised to naturalistic clinical settings and are durable long-term. In this naturalistic study, 74 young people with TS/CTD received BT at a specialist clinic. Data were collected at baseline, post-treatment, and at 3-, 6-, and 12-month follow-ups. Measures included the Yale Global Tic Severity Scale (YGTSS) and the Clinical Global Impression-Improvement scale (CGI-I), amongst others. Tic severity and tic-related impairment improved after treatment, with large within-group effect sizes. At post-treatment, 57% of the participants were classified as treatment responders according to the CGI-I. Tic severity and tic-related impairment improved further through the follow-up, with 75% treatment responders at the 12-month follow-up. BT is an effective and durable treatment for young people with TS/CTD in a naturalistic specialist clinical setting, with comparable effects to RCTs.

Tackle your Tics: pilot findings of a brief, intensive group-based exposure therapy program for children with tic disorders

Tourette syndrome (TS) and other chronic tic disorders (CTD) are prevalent neurodevelopmental disorders, which can have a huge burden on families and society. Behavioral treatment is a first-line intervention for tic disorders. Despite demonstrated efficacy, tic reduction and utilization rates of behavioral treatment remain relatively low. Patient associations point to an urgent need for easy-to-undergo treatments that focus both on tic reduction and improvement of quality of life. To enhance treatment outcome and overcome treatment barriers, this pilot study's aim was to investigate the feasibility and preliminary results of a brief, intensive group-based treatment. Tackle your Tics is a 4-day intensive and comprehensive group-based program for children and adolescents (9-17 years) with a tic disorder, consisting of exposure and response prevention (ERP) treatment and additional supporting components, such as coping strategies, relaxing activities and parent support. Assessments were performed pre- and post-treatment and at 2 months follow-up, to test outcomes on tic severity and quality of life, and explore premonitory urges, emotional and behavioral functioning and treatment satisfaction (N = 14, of whom 13 completed the treatment). Parents and children rated this treatment positive on a treatment satisfaction questionnaire. On tic severity (Yale Global Tic Severity Scale) and quality of life (Gilles de la Tourette Syndrome Quality of Life Scale for children and adolescents), improvements between pre-treatment and follow-up were found. Intensive ERP in group format is promising as a feasible treatment to improve both tic severity as well as quality of life. Larger controlled trials are needed to establish its effectiveness.

Tourette syndrome research highlights from 2019

This is the sixth yearly article in the Tourette Syndrome Research Highlights series, summarizing research from 2019 relevant to Tourette syndrome and other tic disorders. The highlights from 2020 is being drafted on the Authorea online authoring platform; readers are encouraged to add references or give feedback on our selections comments feature on this page. After the calendar year ends, this article is submitted as the annual update for the Tics collection F1000Research.

Using Online Support Communities for Tourette Syndrome and Tic Disorders: Online Survey of Users' Experiences

Background

People living with a tic disorder (TD)—such as Tourette syndrome (TS)—experience many negative psychological and social challenges arising from chronic tics, such as stigmatization from peers and poorer quality of life, and these can impact upon their families too. It can be difficult for this population to access face-to-face support for tics, and so online support communities offer one avenue for support from peers facing similar experiences. However, little is known about how online support communities may be used by people with TS and other TDs, and by others (eg, parents, caregivers) supporting a person with TS/TD.

Objective

This study aimed to explore users’ experiences of participation in online support communities for TS and TDs.

Methods

In total, 90 respondents (aged 13-62 years; 62% [56/90] female) from 13 countries completed an online survey exploring their experiences of using online support communities for TS and TDs. Respondents were people living with TS/TD themselves (n=68) or supportive others of someone with TS/TD (eg, parent, sibling, spouse; n=14), or both (n=8). The online survey contained open-ended questions eliciting their self-reported motivations for using online communities, their benefits and drawbacks of participation, and whether online support communities affected offline management of tics. Responses were analyzed using thematic analysis.

Results

Seven overarching themes captured experiences of using online support communities for TS/TDs. The overwhelming reason for their use was to find accessible support due to a lack of offline face-to-face support. Online support communities were valued sources of informational and emotional support, and also had a positive impact upon helping users’ psychological well-being. Online communities helped provide a space where people with TS/TDs could feel accepted and reduce the social isolation they felt offline. The suggestible nature of tics and being reminded of the challenging nature of TDs were main disadvantages arising from using online support communities, alongside conflict arising within online communities.

Conclusions

The findings suggest that online support communities appear to offer valuable informational and emotional support to those living with TS/TD and their families too, especially given the lack of locally available support. This facilitates a sense of community online, which can help users in overcoming long-standing social isolation and aid self-reported improvements in psychosocial well-being. Users reported some drawbacks in engaging with online support communities, such as conflict between different types of users and triggering content, which negatively affected experiences of community participation.

The therapeutic effect of habit reversal training for Tourette syndrome: a meta-analysis of randomized control trials

OBJECTIVES

Comprehensive behavioral intervention for tics (CBIT) and habit reversal training (HRT) are forms of cognitive behavioral therapy that can effectively reduce tic symptoms in patients with tic disorders, but their efficacies and potential moderators were needed to be clarified.

METHODS

In the present study, a meta-analysis was performed to identify the efficacy of HRT and CBIT for individuals with tic disorders. The standard mean difference (SMD) was calculated to assess the effect size of the efficacy of HRT. Subgroup analysis and meta-regression analysis were performed to identify the potential heterogeneity of the SMD of HRT.

RESULTS

A total of 10 randomized controlled trials (RCTs) including 586 patients with tic disorders were identified. The pooled SMD was -0.43 (95% CI: -0.71, -0.16). The effect size of HRT was moderated by different 'Comparison Conditions' (it means the different behavioral therapies in the control group).

CONCLUSION

Overall, the authors found a small to medium effect size for the efficacy of HRT. As the most promising behavioral therapy, they conclude that HRT is effective for the treatment of patients with tic disorders. Further high-quality RCTs are needed to determine the efficacy of HRT compared with that of medications.

Review of habit reversal training for tic disorders

Tic disorders (TD) is a neurodevelopmental disorder that is often first recognized in children and adolescents and is characterized mainly by motor and phonic tics. Drug treatment of TD has been criticized because of serious side effects, and TD treatment emphasizes behavioral psychotherapy. This study reviewed the most common behavioral psychotherapy for TD: habit reversal training (HRT). We examined the contents, variation, curative effects, and premonitory urge control of HRT and other behavioral psychotherapies. The findings suggest that current understanding of HRT is insufficient and further studies are needed. First, studies of online guidance training are needed to implement technology that can help more patients. Second, the future integration of HRT and other technologies is important. Third, imaging techniques could be used to further explore the brain mechanisms underlying HRT. Research on HRT for TD in China is insufficient. We call on more Chinese researchers to study, investigate, and develop technology to promote the development of behavioral psychotherapy for TD in China.

Efficacy of Parent-Delivered, Home-Based Therapy for Tics

BACKGROUND

Although behavioral therapy is an effective approach to reduce tics in children and adults, there is an insufficient availability and accessibility of behavioral therapy in the community.

OBJECTIVE

The goal of the study was to test the clinical efficacy of home-based, parent-provided behavioral therapy in children with Tourette syndrome aged seven to 13 years.

METHOD

An instructional habit reversal training-based video and guide was developed for use by parents. Eligible families, in this 10-week study, were enrolled in either a home-based therapy (DVD) group (received disk and written instructions) or an in-person therapist group (had scheduled visits with the therapist). Outcome scales included the Yale Global Tic Severity Scale, both the total Tic Severity Score and total Global Severity Score, and the parent report of Clinical Global Impressions of Improvement.

RESULTS

Forty-four children (mean age = 10.21 ± 1.69 years) were enrolled into either the DVD (n = 33) or in-person therapist (n = 11) groups. Eighteen completed the study-eight in the DVD and 10 in the in-person therapist group. Outcome measures showed significant reductions in Yale Global Tic Severity Scale change ratios: mean improvement on the Tic Severity Score was DVD 32.4% (P < 0.001) and in-person therapist 26.6% (P = 0.01); and for the Global Severity Score, DVD 33.7% (P < 0.001) and in-person therapist 26.7% (P < 0.001).

CONCLUSIONS

Home-based, parent-administered habit reversal training behavioral therapy is efficacious for reducing tics in children. Telephone contacts early in the DVD treatment course might reduce the number of dropouts.

Predictors of therapeutic treatment outcome in adolescent chronic tic disorders

BACKGROUND

Chronic tic disorders may have a major impact on a child's function. A significant effect has been shown for combined habit reversal training (HRT) and exposure response prevention (ERP) treatment delivered in an individual and group setting.

AIMS

The present study examines predictors and moderators of treatment outcome after an acute therapeutic intervention.

METHOD

Fifty-nine children and adolescents were randomised to manualised treatment combining HRT and ERP as individual or group training. Age, gender, baseline tic severity, Premonitory Urge for Tics Scale (PUTS) scores, Beliefs about Tic Scale (BATS) scores, hypersensitivity and comorbid psychiatric symptoms were analysed as predictors of outcome. The same characteristics were examined as moderators for individual versus group treatment. Outcome measures included the change in total tic severity (TTS) score and functional impairment score (as measured by the Yale Global Tic Severity Scale (YGTSS)).

RESULTS

Internalising symptoms predicted a lesser decrease in functional impairment. The occurrence of obsessive-compulsive symptoms predicted a larger decrease in TTS. Baseline hypersensitivity and high scores on depressive symptoms favoured individual treatment. High baseline PUTS scores favoured group therapy.

CONCLUSIONS

This is the first study examining factors predicting and moderating perceived functional impairment following a therapeutic intervention. The study adds to the knowledge on predictors and moderators of TTS. Furthermore, this is the first study examining the effect of the BATS score. The study points towards factors that may influence treatment outcome and that require consideration when choosing supplemental treatment. This applies to comorbid anxiety and depressive symptoms, and to the child's belief about their tics and premonitory urge.

DECLARATION OF INTEREST

None.

Evidence-based treatment of Tourette's disorder and chronic tic disorders

Introduction: Chronic Tic Disorders and Tourette's Disorder (collectively referred to as TD) are characterized by sudden, rapid, and repetitive motor movements or vocalizations called tics. Children, adolescents, and adults with TD often experience co-occurring psychiatric symptoms and impairments in multiple domains. As a result of tics and other symptoms, patients with TD can develop negative self-views, require considerable accommodations, and experience a poor quality of life. Therefore, the efficient and effective management of TD bears considerable importance. Areas covered: This expert review evaluated the empirical support for behavioral and pharmacological interventions based on the results of randomized controlled trials (RCTs). Behavioral interventions evaluated include habit reversal training (HRT), comprehensive behavioral intervention for tics (CBIT), and exposure response prevention (ERP). Reviewed pharmacological interventions included alpha-2 agonists, antipsychotics, and anticonvulsants. Expert opinion: This review identified several efficacious behavioral and pharmacological interventions for TD. However, several gaps in the management of TD include: (1) the access/availability of behavioral interventions, (2) novel and more efficacious treatment approaches, and (3) the development of more comprehensive interventions to manage TD. In order to advance the treatment of TD, additional research is necessary to efficiently, effectively, and comprehensively develop and evaluate new treatments for patients with TD.

Tourette syndrome research highlights from 2018

This is the fifth yearly article in the Tourette Syndrome Research Highlights series, summarizing research from 2018 relevant to Tourette syndrome and other tic disorders. The authors briefly summarize reports they consider most important or interesting. The  highlights from 2019 article is being drafted on the Authorea online authoring platform, and readers are encouraged to add references or give feedback on our selections using the comments feature on that page. After the calendar year ends, the article is submitted as the annual update for the  Tics collection on F1000Research.