Behavior Therapy for Tic Disorders: an Evidenced-Based Review and New Directions for Treatment Research

Curr Dev Disord Rep Behavior Therapy for Tic Disorders: an Evidenced-Based Review and New Directions for Treatment Research Joseph F. McGuire 0 1 2 4 5 6 7 Emily J. Ricketts 0 1 2 4 5 6 7 John Piacentini 0 1 2 4 5 6 7 Tanya K. Murphy 0 1 2 4 5 6 7 A. Stor 0 1 2 4 5 6 7 m B. L 0 1 2 4 5 6 7 0 Departments of Psychiatry and Behavioral Neurosciences, University of South Florida , Tampa, FL , USA 1 Department of Pediatrics, University of South Florida , Tampa, FL , USA 2 Semel Institute of Neuroscience and Human Behavior, University of California Los Angeles , 760 Westwood Plaza, 48-228B, Los Angeles, CA 90095 , USA 3 Joseph F. McGuire 4 All Children's Hospital , Johns Hopkins Medicine, St. Petersburg, FL , USA 5 Rogers Behavioral Health-Tampa Bay , Tampa, FL , USA 6 Department of Psychology, University of South Florida , Tampa, FL , USA 7 Department of Health Policy and Management, University of South Florida , Tampa, FL , USA Behavior therapy is an evidenced-based intervention with moderate-to-large treatment effects in reducing tic symptom severity among individuals with persistent tic disorders (PTDs) and Tourette's disorder (TD). This review describes the behavioral treatment model for tics, delineates components of evidence-based behavior therapy for tics, and reviews the empirical support among randomized controlled trials for individuals with PTDs or TD. Additionally, this review discusses several challenges confronting the behavioral management of tics, highlights emerging solutions for these challenges, and outlines new directions for treatment research. Tourette's disorder; Persistent tic disorder; Treatment outcome; Comprehensive Behavioral Intervention Introduction Tics are sudden rapid non-rhythmic motor movements or vocalizations that can be simple (rapid, meaningless) or complex (purposeful, orchestrated) in nature [ 1 ]. Tics are relatively common among school-aged youth for brief periods of time but often do not continue beyond 6 months [ 2 ]. A chronic or persistent tic disorder (PTD) is characterized by the presence of either a single or multiple motor or vocal tic(s), but not both, that persisted longer than a year, with a diagnosis of Tourette’s disorder being conferred when both motor and phonic tics are present (although not necessarily concurrently) for longer than a year [ 1 ]. Persistent tic disorders and Tourette’s disorder (collectively referred to as PTDs henceforth) affect approximately 0.4–1.6 % of youth [ 3, 4 ]. For youth with PTD, symptoms typically onset around 6 years of age [5] and exhibit a fluctuating course with peaks in symptom severity that stabilize over a period of weeks [ 6 ]. For the majority of youth, tics reach their greatest severity in adolescence—increasing in number, type, and frequency—but subside in early adulthood in many cases [ 5, 7 ]. Tic symptoms show minimal difference between youth and adults with PTD [8], with the most common bothersome tics including eye blinking, head jerks, sniffing, throat clearing, and other complex motor tics [ 9 ]. In addition to tics, individuals with PTD typically present with co-occurring psychiatric disorders [e.g., anxiety disorders, attention deficit-hyperactivity disorder (ADHD), obsessivecompulsive disorder (OCD)] [ 10–13 ], mood and behavioral problems (e.g., disruptive behaviors, rage attacks, anger problems, suicidal thoughts, and/or behaviors) [ 14–16 ], and social difficulties (e.g., peer victimization, social deficits, low selfconcept) [ 17–22 ] (also, see Hanks et al. [ 22 ] in this issue). Tics and co-occurring problems can cause individuals with PTD to experience significant impairment [ 21, 23, 24 ] and a poor quality of life [ 25, 26 ]. Thus, effective treatments are needed for individuals with PTD to efficiently manage their tics and co-occurring symptoms. Historically, tic symptom severity has been managed using psychotropic medications, such as antipsychotic agents and/or alpha-2 agonists [ 27 ]. A meta-analysis of five randomized controlled trials (RCTs) of antipsychotic medications identified a significant but moderate reduction in tic severity relative to placebo [effect size=0.58], with no significant difference between medication types [ 28 ]. Additionally, a meta-analysis of six RCTs of alpha-2 agonist medications identified a statistically significant albeit small reduction in tic severity relative to placebo (effect size=0.31) that was moderate when limited to RCTs in which individuals had both PTD and ADHD (effect size=0.68) [ 28 ]. Despite their efficacy, these medications are often accompanied by side effects that can limit long-term use [ 27 ]. Moreover, while medication management significantly reduces tic severity, some troublesome tics may remain. Thus, individuals with PTD have to confront and cope with tics even when receiving evidence-based pharmacotherapy. In addition to pharmacotherapy, behavior therapy has demonstrated success in reducing tic (...truncated)