Tourette Syndrome:Getting Started

John T. Walkup, MDDivision of Child and Adolescent

PsychiatryWeill Cornell Medical College

New York, NY

Part 3

Function-based Interventions Assess and address antecedents

and consequences Provoking experiences Social consequences

Positive reinforcement – active rewards Negative reinforcement – escape

consequences

Types of ReinforcementPositive Reinforcement Negative

Reinforcement

Internally Reinforcing

Provides gratification Relieves

distress

ExternallyReinforcing

Attention and support Avoidance

Depends on the audience Psychology Psychiatry Neurology Primary care doctors Other medical professionals Kids Families School personnel Advocacy organizations

Change In Advice Old - intuitive

Ignore tics Can’t be controlled Don’t punish Behavioral treatments

don’t work Don’t try to suppress Suppression worsens tics Suppression worsens

premonitory urges New tics develop when you

suppress

New - counterintuitive Become more aware Learn to manage Reward successful

management Use behavioral strategies Tics don’t get worse with

behavioral treatment Premonitory urge will fade

away New tics don’t develop

when you use behavioral strategies

Parent specific advice Old - intuitive

Advocacy Provide support Provide comfort Protect Don’t think about them Give time to tic Ignore tics Reduce stress Celebrate your specialness

New – counterintuitive Advocacy Take on challenges Comfort very carefully Expose Be mindful Take time to manage Understand their ABCs Stress proof tic

management skills Celebrate successes

New Treatment Paradigms Readiness for reducing tic severity

Comorbidity management Family and child intervention for “CBIT

Lifestyle” CBIT CBIT + Meds Meds + CBIT Meds + CBIT to CBIT only Training nurses in Neurology clinics Parent training for children under 9 yrs

What will assessment and treatment

look like in the future? Tics as a “marker” for neurodevelopmental disorders

Complete work up for co-morbidity Treat comorbidity aggressively with meds and behavioral

treatment Monitoring for development of new comorbid conditions

First contacted doc will know the new advice. First intervention would be to work with families to

provide a non-reinforcing environment for tics Parents would take what works to the school and

advocate for a non-reinforcing environment for tics Professionals’ (all types) offices would teach specific

interventions for a specific tic as tics develop. Kids would learn management strategies as they go

 

Not without controversy Neurological disorder What will teachers say? Tics get worse when you suppress If you suppress other tics will get

worse How can one focus on activities if

they are suppressing?

Himle & Woods (2006) Behaviour Research and

Therapy 7 children with TS Three conditions

• Baseline• Reinforced

suppression• Rebound evaluation

All conditions were 5 min

Tics were reduced in suppression condition

Rebound did not occur

05

101520253035404550

% intervals w

/ tics

Baseline

DRO

Rebound

DRO

Rebound

Does Symptom Substitution Occur?

Vocal tics decreased, untreated motor tics did not change or decreased

• 83% reduction in vocal tics • 26% reduction in motor tics

Suggests that untreated symptoms at the very least do not change, but may improve following nonpharmacological intervention

Other studies evaluating habit reversal have also not reported adverse symptom increases, nor have they reported excessively high dropout rates

Woods et al. (2003). Journal of Applied Behavior Analysis

What is the effect of stress? Stress makes tics worse How?

Mental stress – time math test Tic severity unchanged Stress impacts ability to suppress

Clinical Implications – Stress proof CBIT

And now for something completely different!!!

How about this?? Tourette syndrome Structural-reflex disorder Neurocranio Vertical Distractor

(NCVD) Brendan Stack DDS, MS Anthony Sims DDS

The Procedure Moving the mandible down and

forward Tongue depressors Construct an appliance Speech training etc Long term natural or surgical

restructuring of the TMJ joint