Behavioral therapy is effective for reducing tics in children with Tourette syndrome
SAN ANTONIO (May 18, 2010) — Parents and clinicians now have an effective non-medication treatment option for children with Tourette syndrome and related tic disorders, according to a study published in the May 19 issue of the Journal of the American Medical Association (JAMA).
The study, conducted by researchers from several leading American universities including The University of Texas Health Science Center at San Antonio, found that a specialized form of behavioral therapy called “Comprehensive Behavioral Intervention for Tics” (or CBIT) significantly reduced chronic tics and tic-related problems in children and adolescents with the chronic neurological condition Tourette syndrome.
Alan L. Peterson, Ph.D., professor of psychiatry at the UT Health Science Center, helped design both the behavioral therapy and the CBIT study. He and his graduate school mentor, Nathan Azrin, Ph.D., of Nova Southeastern University in Fort Lauderdale-Davie, Fla., were instrumental in conducting the first studies of this behavior therapy treatment approach in the late 1980s.
Tourette syndrome, which affects approximately 6 per 1,000 children and adolescents, is a chronic neurological disorder characterized by motor and vocal tics. Common tics include eye blinking, facial grimacing, head jerking, throat clearing, sniffing and grunting. Although the repetition of curse words is often portrayed as the characteristic feature of the syndrome, cursing is an uncommon symptom and not required for diagnosis of the disorder.
“The behavioral therapy employed in CBIT is built on the observation that tics are preceded by unwanted feelings or sensations,” Dr. Peterson said. “These unwanted sensations are temporarily relieved by the performance of the tics. In CBIT, children learn to recognize when a tic is about to occur and to engage in an alternative voluntary action until the unwanted sensation passes. In addition, parents were taught how to promote these management strategies in the children.”
Historically, Tourette syndrome has been treated with antipsychotic medications that reduce tics but are associated with side effects that often limit their usefulness in children. These include inability to remain still, slowed thinking and short-term memory loss. “It is significant that we have shown this form of behavioral therapy to be effective in children, providing them relief without the negative effects of medication,” Dr. Peterson said.
“This study makes a strong case for a specialized behavioral therapy, either as a stand-alone treatment or as an adjunct to medication” said Thomas Insel, M.D., director of the National Institute of Mental Health, which funded the CBIT program.
This multisite study included 126 children ages 9 to 17 with moderate to severe Tourette syndrome or chronic tic disorder who were randomly assigned to CBIT or supportive counseling and education about Tourette syndrome. Approximately one-third of children entered the study on a stable dose of anti-tic medication.
Findings and implications
The study showed that CBIT resulted in a greater reduction of tic severity and tic-related problems compared to the supportive therapy. Almost 53 percent of children receiving CBIT were rated as significantly improved, compared to 19 percent of those receiving the comparison treatment.
The degree of improvement with CBIT was similar to that found in recent anti-tic medication studies. Benefits were observed in children who were on a tic medication and children not on medication. Adverse treatment effects, including tic worsening, were rare in both CBIT and supportive counseling.
Treatment gains for CBIT were maintained over time. Children who showed a positive response to CBIT were invited to return six months after treatment ended. Most of these children did return, and 87 percent of those who returned continued to show benefit.
CBIT is the largest study to date designed to test an intervention for tics in children with Tourette syndrome. Previous medication studies were much smaller. The CBIT findings expand the range of clinicians who can treat this condition, Dr. Peterson said.
The investigators are working with the Tourette Syndrome Association and the Centers for Disease Control and Prevention to teach CBIT to clinicians who treat children with tic disorders. Studies using neuroimaging and related techniques are under way at various centers to examine how CBIT works.
“Understandably, parents and adult patients in San Antonio and South Texas will want to begin this behavioral therapy now that it has been shown to be effective,” Dr. Peterson said. “Psychologists, behavioral therapists and others need to be trained in it so they can start delivering it to patients; that could take some time.”
The research was conducted by a team of investigators from the UT Health Science Center (Dr. Peterson); University of California, Los Angeles (John Piacentini, Ph.D.); University of Wisconsin-Milwaukee (Douglas Woods, Ph.D.); Yale University (Lawrence Scahill, M.S.N., Ph.D.); Massachusetts General Hospital/Harvard Medical School (Sabine Wilhelm, Ph.D.); Johns Hopkins Medical Institutions and Weill Cornell Medical College (John Walkup, M.D.); and the Tourette Syndrome Association (Sue Levi-Pearl, M.A.).
The University of Texas Health Science Center at San Antonio, one of the country’s leading health sciences universities, ranks in the top 2 percent of all U.S. institutions receiving federal funding. Research and other sponsored program activity totaled a record $259 million in fiscal year 2009. The university’s schools of medicine, nursing, dentistry, health professions and graduate biomedical sciences have produced 27,000 graduates. The $753 million operating budget supports six campuses in San Antonio, Laredo, Harlingen and Edinburg. For more information on the many ways “We make lives better®,” visit www.uthscsa.edu.