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(p. 55) Session 1 

(p. 55) Session 1
Chapter:
(p. 55) Session 1
Author(s):

Douglas W. Woods

, John C. Piacentini

, Susanna W. Chang

, Thilo Deckersbach

, Golda S. Ginsburg

, Alan L. Peterson

, Lawrence D. Scahill

, John T. Walkup

, and Sabine Wilhelm

DOI:
10.1093/med:psych/9780195341287.003.0005
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Subscriber: null; date: 10 December 2018

(Corresponds to chapters 1 and 2 of the workbook)

Outline

  • Establish rapport with patient and family

  • Review history of tic disorder and related problems

  • Introduce treatment rationale

  • Provide psychoeducation about TS

  • Work with patient to create tic hierarchy

  • Introduce concept of function-based interventions (see Chapter 3)

  • Present and discuss the behavioral reward program

  • Teach patient and family how to monitor tics

  • Assign homework

Working With Adults

When using the manual with adults, the following modifications are necessary in Session 1.

In-Session Activities

  • Unnoticed tics for adults: When a tic is observed in adult patients, the clinician immediately asks the patient about the severity and frequency of this particular tic. Then the clinician and patient jointly decide if and when the tic will be targeted in treatment.

  • No behavioral reward program or age-appropriately modified rewards.

  • Start discussing or identifying social support person in Session 1. Have the patient bring this person to the next session (when working with children, this is done in Session 2).

Rapport Building

The assessment described in Chapter 2 should be conducted before initiating treatment. Begin by welcoming patient and family to treatment. Briefly review social, developmental, and academic history of the patient.

History of Tic Disorder

Ascertain brief patient history and family knowledge of tic disorder. Review past mental health treatment history, especially for tic disorder but also attending to OCD and ADHD. Review impact of tic disorder on past and current functioning of patient.

Rationale for Comprehensive Behavioral Intervention for Tics

Explain the purpose of behavior therapy for tics. The following sample dialogue may be helpful:

(p. 57) We are going to do two things in therapy. First, we’re going to figure out when things happen in your life that make your tics worse and then see if we can keep these things from happening or at least make them have less of an impact on your tics. Second, we are going to teach you how to manage your tics better so they don’t bother you as much. Let’s say you have a tic that makes you shake your head. This can be embarrassing or annoying and maybe even a bother to other people who are around you. So what we’ll do is teach you to do something else that won’t be as noticeable. For example, instead of shaking your head, you could tense your neck muscles slightly. If you can learn to do things that are less noticeable than your tics, this may make things a lot easier for you.

Psychoeducation About Tic Disorderss

The goal of psychoeducation is to reduce blame, stigma, and negative feelings related to the patient’s symptoms. Although psychoeducation is covered in this session, you should feel free to distribute any additional information that may be helpful. When starting the psychoeducation component, the following rationale should be given to the parents and the patient:

When children and their parents come to us for help for their tics we find it useful if we go over what we know about tic disorders and give families a chance to ask any questions. For the next few minutes, we’re going to review some information about tic disorders. If you have any questions, please don’t hesitate to ask.

Diagnostic Criteria for Tic Disorders

Explain that there are three different types of tic disorders: Tourette syndrome (TS; called Tourette’s disorder in DSM-IV-TR), chronic tic disorder (CTD), and transient tic disorder (TTD). Review the DSM-IV-TR criteria for each (refer the family to the tables in Chapter 1 of the workbook). Because patients often have a catastrophic perception of a TS diagnosis, it can be helpful to point out the arbitrariness among the different tic disorders. Note that TS is not necessarily a much more problematic condition.

(p. 58) Review the list of tics from Chapter 1 and have the patient and the family follow along using the List of Simple and Complex Tics (Table 1.4) in Chapter 1 of the workbook. Note that not everything a child does is a tic and sometimes it can be difficult to tell them apart. You may want to use the following dialogue:

You can see from these criteria that motor and vocal tics are the main symptoms of tic disorders. On the list in your workbook, you can see that there are a number of different types of tics including simple tics (give examples) and complex tics (give examples).One type of complex vocal tic that many people associate with tic disorders is coprolalia, or swearing tics. Although the popular media likes to make this seem like a common symptom, it actually doesn’t happen for most people with tic disorders.

As you probably noticed, tics don’t occur in a steady way. Rather, they wax (get worse) and wane (get better) over the course of time.

Phenomenology

People with tic disorders not only have the tics themselves, but they often have what are called “premonitory urges.” These urges usually occur right before the tic. They feel similar to an urge to sneeze or scratch an itch. They are sometimes described as an “inner tension.” Urges usually go away or get less intense for a little while right after a tic. Not all tics have urges associated with them, and younger patients are less likely to have them than older patients.

Table 5.1 lists areas of the body where urges are commonly felt. Refer patient or parents to the same table in Chapter 1 of the workbook.

Table 5.1 Common Areas for Premonitory Urges

  • Left palm

  • Right shoulder blade

  • Right palm

  • Left shoulder

  • Left shoulder blade

  • Midline abdomen

  • Throat

  • Right shoulder

  • Back of right hand

  • Front of right thigh

  • Front of right foot

  • Back of left hand

  • Inside of right upper arm

  • Front of left thigh

  • Left eye

  • Right eye

People with tic disorders also sometimes are very sensitive to things going on around them. They may be bothered by particular sensory stimuli such as tags in clothing or textures of fabrics. Also, certain words or sounds may trigger tics. Some patients have urges to do dangerous or forbidden acts such as shouting in church or opening the door of a moving car. Other patients have what we call “just right” behavior, which is when the patient has to do something in a certain way until it is arranged properly or “evened up,” or until it feels “just (p. 59) right.” Sometimes these latter behaviors can be construed as symptoms of OCD. Refer to Chapter 2 for a discussion of the distinction between tic symptoms and OCD symptoms.

Natural History of Tics

Tics usually start around the age of 5–7 and usually increase in frequency and intensity up to around the age of 10–11 (refer to Tables 5.2 and 5.3 and the corresponding tables in Chapter 1 of the workbook). Tic disorders are more common in boys, and the severity of symptoms tends to decrease in adulthood.

Table 5.2 Age-of-Onset-Distribution for Tics

Age

Number of cases out of 221

1

 4

2

 7

3

22

4

22

5

32

6

28

7

24

8

21

9

22

10

15

11

 7

12

 6

13

 4

14

 2

15

 3

16

 2

Table 5.3 Percentage of Clients Stating the Age of Worst Ever Tic Severity

Age

% of clients

1

 0

2

 0

3

 0

4

 0

5

 0

6

 5

7

 7

8

 7

9

18

10

16

11

11

12

18

13

14

14

 5

15

 0

16

 2

17

 0

18

 0

Note. Note. Adapted from Bloch et al. (2006).

Social Difficulties and Comorbidities

Some patients with tic disorders experience social and academic difficulties, but these problems may be caused by other disorders that go (p. 60) (p. 61) along with tic disorders and not the tics themselves. In other words, if a patient has a tic disorder only, she is at a lower risk of experiencing social and academic difficulties when compared to those who also have ADHD, for example. In TS clinics, approximately 50% of people with TS have ADHD, and about 30% have OCD in addition to their tics.

Introduction to Causes

Begin by saying that you will be discussing the causes of tic disorder. The following dialogue may be helpful in your introduction to the topic:

I am sure you know other kids in your class with asthma or diabetes. Having tics is similar to that … you will always have your tics, just like asthma, but with medication, talking to people about it, and seeing doctors occasionally, you can learn to control it so that it doesn’t get in the way of you living your life and doing things you want to do.

Just like asthma or diabetes, tics are a medical illness with a genetic basis and are greatly affected by our lifestyle and what happens in our lives. Today we’re going to spend a few minutes talking about the causes of tics.

Genetics

Explain that although there is an inherited component to tic disorders, it is unlikely that one gene is responsible. It appears that a certain (p. 62) genetic makeup involving many genes puts patients at a greater risk of developing tic disorders.

Neurological Basis

Evidence suggests that specific circuits in the brain are responsible for many symptoms of tic disorders. These circuits are known as the cortico-striatal-thalamo-cortical (CSTC) circuits. Explain to the patient or parents using the following sample dialogue:

In all brains, signals from the cortex, or the part of the brain that plansmovements, get sent to the part of the brain that controlsmovements and then loops back into the front part of the brain. In patients with tic disorders, it may be that the part of the brain that inhibits movement is not working properly.

Explain that in addition to these brain structures, the chemical systems within these structures play a role in tic expression. For example, high levels of dopamine activity have been implicated in tics. Other neurotransmitters that may be involved in tics include glutamate, GABA, serotonin, and norepinephrine. Medications used to treat tics may alter these chemical systems. Although there isn’t direct evidence that the procedure described in this workbook actually affects brain chemistry, we do know that learning can produce changes in the way the brain works.

Other Risk or Protective Factors

Other events have also been found to worsen tics or put someone at greater risk of developing a tic disorder. For example, factors that influence the development and function of certain brain circuits include premature birth, maternal stress during pregnancy, prolonged labor, fetal distress, and use of forceps. It may also be the case that some patients develop tics in reaction to recurrent strep infections. It is important to note that although these factors may be related to tics, they do not necessarily cause tics.

(p. 63) Prevalence

Finally, discuss the prevalence of Tourette syndrome and CTDs. You may use the following sample dialogue:

One last thing I wanted to discuss with you is how many people actually have tics. The best available evidence from the most recent studies indicates that 3–8 school-age children per 1000 have TS. The prevalence of CTDs or TTDs is less certain—but altogether, the prevalence of tic disorders may be as high as 4% in children. From these numbers, you can tell that tic disorders are not “rare” in school-age children. Given what we know about the natural history of TS, the prevalence of TS and tic disorders are likely to be lower in adulthood.

At this point, ask the patient and/or parents whether they have any questions.

Normalize the disorder and reduce stigma and anxiety about “being crazy.” Stress that while tic disorders can run in families, neither the patient nor their parents caused it. Recommend bibliotherapy (e.g., “What Makes Ryan Tick”; Hughes, 1996) to show that others kids have the same problem and that they are not alone, or “crazy.” Note the list of resources provided in the appendix at the end of this book. The same appendix appears in the corresponding workbook as well.

Creating a Tic Hierarchy

Using the Tic Symptom Hierarchy Tracker in Chapter 2 of the workbook, help the patient develop a comprehensive list of her current tics. The symptom checklist portion of the Yale Global Tic Severity Scale (YGTSS) can be used to facilitate this procedure. A parent(s) can also aid in listing the tics. All current tics noted by the parents and the patient should be listed.

After the tics have been identified, work with the patient to create operational definitions for each tic she currently exhibits. For example, if the patient has a neck shaking tic, you may agree on the following definition, “A neck shaking tic is when your head departs from midline, moves (p. 64) left, and then returns to midline.” Obtaining operational definitions for all current tics allows you to communicate effectively with the patient and allows you to accurately count tics during assessment.

After the tics have been identified and operationally defined, ask the patient to rate how bothersome each tic is on a scale of 0–10 and record the Subjective Units of Discomfort (SUDS) rating on the Tic Symptom Hierarchy Tracker. A rating of 0 indicates that a tic either is not occurring or produces absolutely no distress/discomfort. A score of 10 indicates that the tic is creating significant amounts of distress or discomfort. See the sample, completed hierarchy shown in Figure 5.1. This completed form shows a child with five tics.

Figure 5.1 Example of a Completed Tic Symptom Hierarchy Tracker

Figure 5.1
Example of a Completed Tic Symptom Hierarchy Tracker

Treatment is based on the tics identified in this hierarchy. Generally, we start with the most bothersome tic that the clinician. patient and her parents or significant others feel is most likely to meet with success. For example, our clinical experience suggests that tics involving the eyes (e.g., eye rolling and eye blinking) are more difficult to treat, so if these are rated as most troubling, we typically start with a different tic. Addressing an easier-to-treat tic first will allow the patient to meet with early success that may facilitate motivation in later therapy sessions.

If you notice a tic in session that the patient and parents do not note, then you should gently state that you noticed the tic and ask the patient (p. 65) or parents whether they have ever noticed it themselves. Tics noted only by you should not be put on the hierarchy immediately, but in subsequent weeks you should again bring up the tic and ask whether the patient or parents would like to rate the severity of that tic and put it on the hierarchy.

Sometimes confusion is created by determining whether a complex tic should be listed as one tic, or as a series of individual tics. Our general rule is that if any component of a complex tic occurs separately from the complex tic, then it should be listed as its own tic in addition to being included in the description of the complex tic. If components of the complex tic do not occur separately, we recommend that the complex tic be defined as a single tic with multiple components.

Introduce Concept of Function-Based Intervention

Review the material in Chapter 3. Introduce the concept of function-based interventions to the parents and child by describing the rationale and how the factors that influence tics for that child are determined. Discuss also how interventions are chosen. Beginning in Session 2, each tic being addressed in HRT will also be functionally assessed and a function-based treatment implemented.

Rationale

Point out to the parent that research clearly shows that various factors in the child’s life can make tics better or worse. These factors can come before tics occur or right after, and they can affect children in different ways.

Discuss with the parent that even though some of the interventions can make it seem like the child has been doing the tics intentionally, this is not the case. Even though getting out of activities or receiving attention for tics can make them happen more, tics are not intentional things children do to avoid certain activities or to get attention.

(p. 66) Events That Affect Tics

Explain to the parents that you will use two methods for determining what events affect their child’s tics. First, in each session, a functional assessment interview will be conducted for the tic being addressed in that session. This will involve you, the patient, and parents discussing different events that may make tics more likely to happen (see Chapter 3). Explain to the parents that it will be important to provide as much detail about those situations as possible.

Second, the patient and the parents will be given homework assignments, starting today, to observe the tics at home. Using the Functional Assessment Self-Report Form in the workbook, the patient or the parents will record occurrences of tics, including when and in what situations they seem to be worse. Such information will be helpful in developing the treatments specifically for the patient.

Behavioral Reward Program

The purpose of the behavioral reward system is to motivate the patient to attend sessions, participate in session activities, complete homework assignments, and increase general compliance with therapy. One of the primary reasons behavior therapy fails to produce behavior change involves poor treatment compliance (Carr, Bailey, Carr, & Coggin, 1996). Thus, the focus is on rewarding compliance and attendance. It is important to note that the behavioral reward program is not designed to reward tic reduction, only efforts in management.

Rationale

The first step in any behavioral reward system is to provide a rationale. The parents and the patient should be reassured that you understand that therapy is hard work and that the patient should be rewarded for doing this work. To do so, you, the patient, and the parents are going to work together to decide upon a fair and feasible reward system. The following rationale should be given to the parents and the patient.

(p. 67) Coming to session and doing the homework assignments is hard work, so we’d like to come up with a system to reward (patient) for his/her hard work. For the next few minutes we are going to come up with a few things or activities that (patient) can earn for coming to sessions, doing homework, and working hard in session. These rewards are given for trying hard, not for reducing tics. Although we hope the tics will get better, we’re really interested in having (patient) work hard and give treatment his/her best shot.

Explain that the reinforcement program involves the delivery of points or stickers contingent on specific behaviors. These include attending sessions, attempting or completing in-session tasks, and completing homework assignments. When explaining the program, emphasize that points are given for doing these behaviors, but not for reporting reductions in tic occurrence. Points or stickers are exchangeable for tangible rewards which will be predetermined by the patient and the therapist at an exchange rate also negotiated by the therapist between the patient and the parents.

After explaining the aforementioned rationale and general layout of the reinforcement program, you should negotiate the tangible rewards that can be earned for the specified behaviors and set the exchange rate.

Identify Rewards

Identify several small and inexpensive items and/or activities that the patient finds rewarding. Allow the patient to respond first, but follow-up with the parents to identify activities and items that the parents have found useful in the past. After several items and activities have been identified, have the patient rank them in order of most to least rewarding. Next, ask the parents to remove any items/activities that are not feasible (i.e., too expensive, difficult to obtain, forbidden, etc.)

Therapist Note

We recommend providing these rewards yourself, so don’t agree to anything that you cannot provide.

(p. 68) Set Exchange

Next, inform the patient what she must do to obtain the reward. The exchange should be decided upon by you and is nonnegotiable once established. For example, the patient may get one point for attending each session, one point for doing all homework assigned in previous sessions, and one point for participating in the previous session. When the patient earns the predetermined number of points (e.g., 21 of 24 possible points), then she receives the chosen reward.

Review Date

Establish a time during the session in which performance will be evaluated for reinforcer exchange. For example, at the end of a session, you can tell the patient and the parents that the patient earned a reward for attending the day’s session and another reward for making an effort during the session. Likewise, if the patient complied with the homework during the prior week, the patient could earn the reward attached to homework compliance, which could be noted during the session. Each week, the behavioral reward program is revisited and points earned are recorded and progress toward the final goal praised. When the plan is complete, have the patient fill out the Behavioral Reward Form in the workbook. See Figure 5.2 for a sample, completed Behavioral Reward Form.

Figure 5.2 Example of Behavioral Reward Program

Figure 5.2
Example of Behavioral Reward Program

Self-Monitoring Training

Direct the family to the tic self-monitoring forms provided in the workbook. Have the parents use the Tic Monitoring Sheet for Parents to monitor the first tic, chosen in this session, a minimum of 3–4 times over the next week. Both the patient and the parents will be involved in keeping tally marks that record each occurrence of the first tic during an agreed-upon time interval (15–30 min). Ask patient and parents to choose a period of time for monitoring tics (e.g., when patient is sitting down watching TV or doing homework) when parents will be (p. 69) (p. 70) available to monitor the patient carefully. Choose a time period when tic occurrence is likely.

In addition to these structured monitoring times, encourage the patient to use the My Tic Sheet to self-monitor the first tic on the hierarchy whenever she can (e.g., when alone, at school, and around bedtime) and do something unnoticeable to others like saying “T” under her breath each time the tic occurs.

Homework