CBIT: Journey to Tic Relief

Are tics impacting your life or someone you care about?

Discover the pinnacle of treatment for Tourette Syndrome & Tic Disorders during this FREE webinar where we uncover Comprehensive Behavioral Intervention for Tics (CBIT) and why it stands as the foremost choice for effectively managing tics.

Meir Flancbaum, PsyD, earned his doctorate in clinical psychology from Rutgers University with a specialization in CBT. He specializes in Tourette Syndrome, Trichotillomania, Skin Picking, and related conditions such as OCD, ADHD, and the range of anxiety disorders. He founded the Center for Cognitive Behavior Therapy and is a Clinical Assistant Professor and Coordinator of CBT Training for the Child Psychiatry Fellows at Rutgers Robert Wood Johnson Medical School.



0:03 Good evening, and welcome. Thank you so much for joining us tonight for tonight’s webinar, Comprehensive Behavioral Intervention for Ticks Journey to …, presented by doctor …. My name is Katie Delaney and I am the Family and Medical Outreach co-ordinator for the New Jersey Center for Tourette Syndrome and Associated Disorders. I will be your facilitator for this evening. Before I introduce our presenter, I wanted to go over some housekeeping notes. 0:32 The audience is muted if you are attending the live webinar, any questions you have can be submitted in the questions box located at the bottom of your screen. Throughout the presentation, if you have a question, please type it in the questions box and hit submit. 0:46 During the live Q&A, the audience will gain access to unmute themselves. We will first go through the submitted questions, and then open the floor for verbal questions. I will be ending the webinar right before we open the floor to verbal questions. 1:01 To the right of the React button, you will see an arrow. When you click the arrow, you will see a few emoji’s appear, such as heart, a thumbs, et cetera. Throughout the webinar, feel free to use this feature to let the presenter now how they’re doing. So if you guys want to test that out right now, just let me know that you’re able to find it. 1:20 Use the React button out parfait. Just give me a couple of thumbs up, maybe a heart. 1:26 Beautiful, OK, good. 1:29 So for those that are viewing the webinar recording, you will not have access to these features. However, you’ll be able to submit your questions for the presenter to answer. Your questions box is located to the left of your screen. Questions submitted during the presentation will be posted to our webinar blog for the presenter to answer. This block can be found on our website, WWW dot NJ CTAS dot org, under the Programs Tab. 1:55 This blog will be monitored until Wednesday, December 13th, 2023. Please note any personal information will not be posted. The New Jersey Center for Tourette Syndrome and Associated Disorders, its directors, and employees assume no responsibility for the accuracy, completeness, objectivity, or usefulness of information presented on our site. We do not endorse any recommendations or opinions made by any member or physician, Nor do we advocate any treatment. 2:24 You are responsible for your own medical decisions. Now, it’s my pleasure to introduce our speaker for this evening, doctor Maier …. Doctor … earned his doctorate in clinical psychology from Rutgers University with a specialization in CBT. He specializes in Tourette’s syndrome, trichotillomania, skin picking as and related conditions such as OCD, ADHD, and the range of anxiety disorders. He founded the Center for Cognitive Behavioral Therapy and as a clinical assistant professor and co-ordinator of CBT training for the Child Psychiatry Fellows at Wreckers, Robert Wood Johnson, Medical School, doctor Flan spam. 3:09 It is my pleasure to hand it over to you. By the way, did I pronounce your last name correctly? 3:16 It perfectly well, OK, the floor is all yours. 3:23 Awesome. Does it look like we’re in share mode. We’re all good to go. 3:28 Great, thank you so much Katie. I really appreciate the kind words and the introduction. 3:33 It’s always a pleasure to be able to present for N J CTAS, And I do a number of webinars on a variety of different topics, and the opportunity to talk about Comprehensive Behavior Intervention for ticks is a particular passion of mine, because I think kicks is an area where unlike ADHD and many other conditions within child psychology, there’s really a dearth of information about Tourette syndrome, and there are limited providers. 4:03 And so it’s a particular privilege to be able to talk to you about Tourette syndrome and and it’s treatment. 4:12 So, thank you very much, And I’m going to work my way through here. It doesn’t look like I’m able to see any of those share buttons, or anything on my screen. 4:22 So, I guess if there’s anything I should know, Katie, please feel free, or the emoji buttons. So Katy, please feel free to jump in. 4:31 Will do. 4:32 In terms of our time today, I’m going to start with a brief example about Tourette syndrome. Then we’re going to talk a little bit about what is habit reversal Training. Comprehensive behavioral intervention for ticks are defined both of those terms for you as we go along. 4:47 We’ll talk a little bit about: does it really work? In other words, what is the research behind this treatment? 4:54 And we’ll talk a little bit about the components. 4:56 What does it look like, were you or your child to be participating in, have a virtual training. 5:06 So, to begin, Marcos’s, an 11 year old boy, This is not one particular patient I’ve seen, but this is what many of them look like. 5:14 Yeah, he makes a powerful nek jerk. 5:17 Kinda like this. 5:19 You know, he may flail his arms to the side like pretty forcefully. 5:23 He also makes setting sweep noises. He makes a cough sound sometimes. 5:29 Marcus also frequently worries about germs. He worries about dirt. 5:34 So he’s very hesitant to be able to touch people to touch things even coming into my office. He doesn’t want to touch the doorknob. And he has difficulty in school. If someone touches his desk, it really frustrates him. 5:47 Marcus is also quite disorganized. He has trouble paying attention in. Class homework, is a disaster at home. 5:54 His parents are particularly complaining about that, to his teachers, trying to figure out what we can do to be able to help him focus, Pay attention, and not be so not be so impulsive. 6:06 Um, if I had the, if I was able to view your emojis, I would ask you have you seen somebody. How many of you have seen somebody like Markus. 6:20 I’m hoping, I’m hoping many of you. Margaret, yes. Marcus was diagnosed with Tourette syndrome when he was seven. 6:28 He was also diagnosed with OCD and ADHD. 6:31 This combination this, this combination of Tourette Syndrome, ADHD, and OCD, is often referred to as T S plus, or the Tourette Syndrome triad. 6:44 A substantial number of folks with tics in Tourette’s syndrome have ADHD. Oftentimes 50%, maybe even a little bit more, About 30 to 40% of them are going to have. 6:56 We’re going to have OCD and another chunk of them are going to have anxiety. And then of course, like any other child, they may struggle with learning difficulties or other challenges. 7:07 And so what do we do in order to best be able to help folks like Marcus? 7:14 Well, this really begins with an assessment. 7:17 Because there are ultimately a number of approaches for managing ticks and the related conditions. 7:22 And how to do that assessment is not going to be the topic of our talk today. 7:27 We’re really going to focus in on one particular area, but as overview, I did want to talk a little bit about the different approaches to managing ticks. 7:35 All the approaches for managing ticks as well as the related conditions do not have a cure. I share this pretty regularly on my first meeting with parents. I do talk pretty openly about it with kids as well. 7:47 There isn’t a cure for ticks. However, there are management strategies, things that we can do in order to be able to help manage the ticks. 7:54 And so what does that look like? 7:56 So, Intervention hashtag one, Cognitive Behavior Therapy, hashtag two medications and hashtag three school based surfaces. 8:03 So, in terms of cognitive behavioral therapy, I often talk about with families, the idea that kicks are both a kicks need to be managed in two ways. I number one. We need to manage the ticks themselves. 8:18 Excuse me. 8:21 Battling a little bit over. 8:23 Month long class here, I apologize. 8:28 Number one, we need to manage the text themselves. And, number two, we need to learn how to live with tax. How do we live life with texts? In other words, how do we talk about tips with our peers? How do we respond to bullying? 8:40 What do you do when you’re online with the group at the grocery store, and somebody just asked you, like, What is that noise that you’re doing? 8:47 How is that response going to be different versus when a good friend asks, you know, can you tell me a little bit more about that, versus when you’re teased about it On the show, CBT helps in terms of managing ticks themselves, as well as kind of helping to navigate life with ticks. 9:05 In addition, like I mentioned earlier, kicks tend to have co-occurring conditions, we’re talking about things like anxiety, OCD, ADHD, phobias. 9:16 and those can also be managed using cognitive behavior therapy. 9:20 And many of them are managed, ADHD is manage usually through parent training, PMT, parent management training, and OCD through a treatment called exposure and response prevention. 9:33 An anxiety using exposure therapy medications. So, medications are both managing ticks themselves as well as the co-occurring conditions. 9:42 So, in terms of managing, takes themselves, the most common medications that you’re going to hear about are the alpha two agonists. So these are things like … 9:53 and clonidine and then we have the co-occurring disorders which would be addressed through a range of pharmacological interventions that would really depend upon the particular condition whether we’re talking about anxiety, depression, or any other condition. 10:08 So CBT is typically going to be conducted by a psychologist and occasionally social worker as well. And medications are typically going to be prescribed by a psychiatrist and I would add in the case of tics in Tourette’s syndrome it’s very common for us to work with Neurologist’s. 10:25 Yeah. 10:28 In terms of school based consultation services, this is a really important aspect of treatment, because as I often share with families, education, breed’s, acceptance, and teach students are often going to follow the lead of what teachers are doing in the classroom. 10:44 And so, in our practice, for example, we’ll often speak with teachers of students who have Tourette syndrome, who were seen. 10:50 And we’ll also occasionally do workshops for groups of teachers that are working with students. This is a good opportunity to just put in a quick plug for … CTS, if that’s OK. They have a pretty robust school based in service program, I believe, but, Katie, correct me, if I’m wrong, it’s free. 11:10 And so, you’re welcome to reach out to them if you want a little bit more information. 11:15 And those are really just educational webinars that we do in order or in person workshops that we do in order to be able to provide education to teachers who are learning how to navigate their students with, with Tourette syndrome. 11:31 Ciao. 11:33 The bulk of this talk is going to be on tick management. The cognitive behavioral intervention as to try to reduce ticks. 11:42 Now, determining where we’re going to focus in terms of our treatment, whether we’re going to be focusing on kicks themselves, we’re gonna be focusing on the associated conditions. Whether you’re going to be focusing on living with tax and kind of psychosocial challenges associated with it, that’s all going to be determined based on our assessment. 12:01 And so when are we going to focus on Kik stem cells? 12:04 I’ve outlined here a few areas that we look for. This is not a conclusive list, and there can be some flexibility with it. 12:12 In general, we’re going to focus on kix themselves when ticks are going to be a frequent or intense primary concern. 12:20 So what do I mean? By frequent, frequent, meaning the picture occurring pretty regularly? 12:26 They may be occurring multiple times, multiple times a minute, or sometimes, or certainly multiple times an hour. 12:33 And when ticks are going to be intense, that also increases the likelihood that we’re going to be able to focus on, we’re going to need to focus on ticks in terms of our primary intervention. 12:45 So just to give an example of intensity, I hope I’m in the camera here. 12:52 Sometimes we may flail our arm, right? A person may do it just like I’m doing right now. 12:57 I’m not doing it particularly hard. 12:59 So that would be low intensity versus other folks, other kids, when they tick and flail their arm. It looks like this, right, to the point where they’re experiencing a lot of pain up and down their arm. 13:10 And as one can imagine, we’re doing this, we’re doing this take over and over again, it becomes really uncomfortable, so when texts are either really free, really frequent, or really intense, that usually means that focusing on ticks themselves in some kind of tick reduction or kick management strategy is going to be important. 13:28 Sometimes people think that when you have lots of different tasks, that’s a reason to focus on ticks. Whereas, if you only have one, that may not be a reason to really develop treatment, specifically focused. The treatment we’re going to talk about today, comprehensive behavior intervention for text, is actually one that can fit really well. If you have a number of text, it certainly is also a very good fit, if you only have 1 or 2 gigs. 13:53 Frequency and intensity are things we look at, in addition, significant stressor interference as a result of ticks. 13:59 one of the questions that I always ask parents, and I also ask the kids when I meet with them, is, whose idea was it to come here today? 14:08 Because a lot of times, what happens is, kids are really bothered by their tecs. Kids are stressed by their kicks. 14:13 Kids are teased by their kickstand in those situations. Focusing on takes themselves make sense. 14:18 Other times, kids are totally comfortable with their texts, but parents are bothered by their texts. 14:23 And so, when something like that happens, that becomes a situation where it’s really important for us to be able to, to be able to not necessarily focus on reducing the kids tax but focus on educating parents. 14:39 Motivation to decrease kicks. Of course, this is a treatment that requires putting in a lot of time and effort. And I said, Of course, it requires time and effort. I would say that this treatment, while most treatment required, time, and effort, is really a treatment where the more you put in, the more you get out. I often say, when you put in five minutes of effort, in practice, you get five minutes worth of results, You put in an hour of practice, you get an hour’s worth of results. 15:03 And so a willingness to really put in that time is very important. 15:10 The more motivated kids are to reduce their kicks or any individual to reduce their kicks, the better the fit they’re going to be with treatment. 15:18 And the last thing I’ll note is it’s really important to be willing and able to tolerate discomfort. 15:24 This is a treatment where we are going to have to learn to experience short-term discomfort in the service of this long term benefit, and we’ll talk a little bit more about what that is, and how that, how that works in a moment. 15:39 So I guess, just quickly, give me the thumbs up in the With your With your emojis if we are on Target, if everything here makes sense so far, Can you relate to anything that we’re talking about? 15:53 And Katie, I guess, let me know their responses, because now we got a whole bunch a thumbs up, OK? 16:00 That is, That is awesome. So let’s talk a little bit about what this treatment is all about, Before we talk about what the treatment is all about, I do want to do, you want to do a short poll question. I don’t know how this is gonna go by Katie told me that it’s really important, that we have a couple of poll questions. 16:17 So one of the poll questions I have for you guys is, What is the way? How is it that this treatment is referred? 16:25 I often find when I’m talking to people that I hear this is called cebit, I also hear that this is called CB IT. 16:34 I have a view on this. And I don’t necessarily have a guaranteed right answer, but I am a little bit curious. 16:39 So, please go ahead and put your answers in the poll, and then we’ll talk a bit about the results. 16:56 Katie, how are we doing? 16:57 We’re doing good. I’m just gonna leave it on for another couple of seconds for any stragglers. 17:07 We close to 50 50, or even one extreme, or the other, we are, we’re very close, We have A, we have 48% for seabed, and 39% for C, B, I T, and then 17% for, I have no idea. 17:23 OK, so, we have a pretty smart group. I don’t know exactly what the answer is. I’ve never seen any formal publication describing what the answer is. What I can tell you is that, in the academic circles, that I am in, you know, where we kind of go to conferences, we talk a lot about Tourette syndrome and cebit, the terminology that is used 100% of the time is seated. 17:49 And so where I to come up with, when I tell you a little bit about, does seep it really work, which will be our next time. 17:57 There’s obviously a lot of questions, and we can talk a little bit about it at the end, if people have thoughts, questions, ideas, about how do you know who knows what they’re doing. It’s obviously more than knowing the name of the treatment. 18:07 That said, I think that it’s just no noteworthy that this is a treatment that we refer to as …, not typically C V I T, and it’s kind of like your first heuristic. When you call up the doctor, and you want to know, do they practice a specialized treatment for kicks, What treatment do they do? 18:29 Just listen for that name. And it’s a little bit of a shortcut to get a sense of, of what Circles they, what circles they travel in, and how closely linked they are to the Tourette Syndrome community. 18:39 So that said, take it or leave it. 18:43 See bit is a scientifically tested behavioral therapy. It’s based on a treatment called Habit Reversal Training, or HRT. And we’ll talk a little bit more about the components of sea bed a lot more about the components of Save it, and a little bit more about habit reversal training in a few slides. 18:58 She bet on Habit Reversal Training more broadly rather, is used to treat Tourette syndrome and tips and it’s a very, it’s also just about a very similar treatment that is used for treating a cluster of behaviors often referred to as …, body focused, repetitive behaviors. 19:17 So these are things like hair pulling, skin, picking, nail biting, and the light. 19:22 See if it has been tested in multiple controlled trials. 19:25 There’s not a huge literature on it, but there’s definitely, there have been dozens of trials, dozens of studies, and, you know, a handful of trials focusing on both children and adolescents, as well as adults. 19:38 In fact, a couple of years ago, they just received, they just put out a trial focused on cebit with, with the little guys they call that CPE junior. For kids ages 5 to 8. 19:50 Keep it as a goal oriented treatment, and it’s typically considered to be relatively time limited. 19:55 one sessions are approximately, approximately 10 sessions. Depending upon the practitioner, you go to, there may be a few less. There may be few more, in addition to the practitioner, or perhaps even more so. 20:06 It’s really going to be based on the child’s ability to be able to absorb the material, the degree of practice in between sessions, the severity of ticks, and other clinical variables, such as that. Most of the controlled trials, if not all of them, are 8 to 10 sessions, and sometimes they have a couple of booster ones as well. 20:28 OK, sorry, apologize. 20:33 So, let’s talk a little bit about the research. Does HRT and see if it really work. 20:38 As I mentioned, there have been a number of published studies. 20:41 Studies have mostly focused on adults, and there are a few on youth as well. 20:45 And, …, it is a first line recommendation from the American Academy of Neurology. 20:50 It is also a first line recommendation from the Journal, from the American Academy of Child and Adolescent Psychiatry, Psychiatry, or HCAAF. 20:58 So, it is a treatment that has gotten attention. 21:01 And is one that, I would say over the past 10 years or so, has also started to receive a lot of a lot of positive feedback within within mainstream medicine. 21:16 So, in terms of empirical support for cebit with youth, the study that I had here is not the most recent one. It’s actually the first one. And it’s, it’s really considered kind of a seminal study in the field. 21:27 This is a study with, I think, 126 kids. 21:29 It was a multi site study, and it essentially showed that Cebit, compared to just generic supportive counseling, was significantly more effective. 21:42 Over 50% of the folks who receive treatment had a, you know, where treatment responders were Either much improved or very much very much improved, and their tax rate, their kicks reduced by about, you know, their kicks reduce pretty substantially, as well. 22:00 So this is a study for youth ages 9 to 16. 22:05 As I mentioned earlier, there have been some studies done, and adults with Tourette syndrome, as well. 22:12 A number of those were done by Sabine Wilhelm, who is a researcher in Boston, and a number, and there was one study. 22:21 And that was done on Cebit junior, for 5 to 8 year old, with Alt, which also showed some preliminary positive support. So see if it is a Solid evidence based Treatment. 22:34 Post coven. We had a relatively new idea, or a new idea for many of us, Which is tele therapy. Now, it’s often referred to as Zoom treatment. 22:44 And I should I put this study on here, because, as you can see, this is a pilot trial, But it was dated from May 2012. 22:56 This particular study showed that tele therapy was about equally effective as face-to-face therapy. This was just a pilot study. They did do a slightly larger trial, which they had similar results as well. 23:11 That was done, now, is published a few years, I think, my 2016 or so. 23:16 So I think that this is really significant, because it over cov it and the period of time during coven, we all many of us, as practitioners, transfer to Zoom. 23:27 And there was a lot of discussion about whether Zoom therapy works, whether zoom therapy is kind of a necessary evil that we all have to endure, and then we pretend like it’s effective. This is a trial that was done in 20 12. 23:40 It certainly proceeded coven. 23:42 And what I suspect is, really, the difference between this trial, and the Trials Coming Post coven is that this was really video conferencing probably done. 23:50 I can’t remember, but over some platform, similar to Skype with lousy visibility and lousy quality, similar lag time, at least at times. It’s probably substantially, woops. 24:04 It’s probably substantially less, um, most technologically advanced than we are right now. Overall, and our experience at our practice, we find tele therapy to be incredibly effective for Tourette syndrome treatment, as well as various other factors, as well as various other conditions. 24:23 one of the things that we are mindful of though is just the age of the kid and the child’s ability to be able to maintain focus while on his screen. 24:32 And we tell all the families that we work with, as I’m sure many practitioners do, we’re happy to begin with telus therapy. However, if there are reasons to think that in person is really going to be more effective, we’re certainly going to let you know and encourage you to come into the office. 24:47 one of the amazing aspects of tele therapy that I want to add here is that it really has opened up access to treatment for Tourette syndrome, tic disorders. And there have been, you know, a couple of important papers published showing that tic disorders have a dearth of practitioners. 25:04 There are not enough clinicians, psychologists, social workers, neurologists, who are trained in Cebit, an able to effectively implement it. 25:13 And so, what the world of tele therapy has done is increased the access to treatment for children, adolescents, young, adults, and adults who are, struggling with Tourette syndrome. 25:28 So that’s it for the research. I do want to spend the bulk of our time talking a little, talking in more detail about each R T and C bit. 25:36 So what we’re gonna do is, we’re gonna run through the key components. 25:40 We’ll talk a little bit about some of these additional components, actually just did not function based assessment And then we will wrap up and I’d love to take some questions from anybody who, anybody who has. 25:52 So in terms of behavior therapy for text, what does it look like? 25:55 The core treatment components are going to be tick education, awareness training, competing response, training, and social support. 26:05 And you’ll notice over here, I have the words, H R T, next to awareness training, competing response, training, and social support. 26:11 Cebit is the term for these core treatment components, as well as the additional components function based assessment and intervention, or FBA, and relaxation training. 26:24 Cheap it is not a brand new treatment. 26:27 Originally, Tourette syndrome tic disorders and these other body focused repetitive behaviors were treated using a treatment called habit reversal training. 26:37 Have our virtual training, has been around for awhile in the late seventies. There was a book written on it. I actually, a few years ago, when I went, I kind of fell in love with treating Tourette syndrome. 26:47 I bought it for over slightly, Overprice, not so many people really wanted it slightly over priced on Amazon and no. So this is not a new treatment. That book was published in the late, in the late seventies, I’m almost certain. 27:03 And and that treatment HRT has really been expanded upon by Dogwoods and several of his colleagues to create Secret. 27:14 Shall we have Tick Education, awareness, training, competing, response, training, and social support. 27:19 And then oftentimes we either begin or we supplement one areas, no problem solving to do with relaxation training and function based assessment. 27:28 Just to give full credit and or full transparency in terms of the evidence base. Were you to read the Doug Woods Manual or speak to him? He places a tremendous emphasis on function based assessment. 27:41 So the fact that I wrote here it’s additional components, I don’t want to detract from that and he actually typically begins with it. 27:48 In our, in our work, we tend to use it as an important component. 27:52 However, we we see the crux of treatment being the HR key, the AHRQ components. 28:00 How are we doing so far? 28:04 Thumbs ups. 28:09 Yup, we’re getting a whole bunch of thumbs up. 28:12 OK, great. 28:14 So let’s get into the details. 28:17 Take education. 28:19 When families come in for cebit treatment, and we decide that, we’re going to talk about that, we’re going to focus on tick reduction. 28:27 The first thing we do is spend a few sessions on education. 28:31 Education really paves the way for successful treatment. 28:34 It’s not a waste of time. 28:36 It’s not extraneous information, even though sometimes we have to explain that to families, and families come in and they’re very eager to be able to, to get started with treatment. When you understand how tic disorders work, when you understand a little bit about the course of tix, when you understand how? 28:55 How habit reversal, how steep it works, and what realistic you’re at, how, what what realistic expectations from treatment look like? 29:03 That’s going to make you more informed? Knowledge is power, and you’re more likely to experience success once you get into the particular treatment procedures. 29:12 So I really conceptualize education as being a core component of treatment of this cebit package. 29:19 So we talked about the course of tic disorders. Typically ticks are going to have onset 5 to 7 years old, they’re going to peak around 12 to 14. 29:27 They’re going to have a slow regression, a slow decrease into early adulthood. And for many people, that’s where they end. 29:36 This is, of course, based on research and the aggregate. Everybody’s experience is going to be different. It is rare, though, that as kids get older into young adulthood, that their ticks are getting worse, however, it certainly can happen. 29:49 We talk about the benefits of Cebit HRT, some of the primary benefit, one of the primary benefits of HRT and save it is that with you attended 10 to 15 session treatment. 29:59 As soon as you wrap up that treatment, we hope that you’re going research indicates that it’s a durable therapy that gains or maintain multiple months later. 30:09 And so, you are no longer coming to treatment, however, you’ve maintained your game. 30:14 one of the big differences between skills and pills in terms of modes of intervention is going to be that when you’re done with behavior therapy, you have the skills, You have them for a lifetime, it’s a teach your kid to teach someone to fish kind of thing. 30:28 Versus medication. If you’re part of a trial, you take your medication, It works when you take it. And when you’re done taking the medication, oftentimes we see a relapse in symptoms. 30:40 That is not at all, This suggests that medication doesn’t have a very important place, intake treatment. 30:47 I encourage all of the clients that we see here to consider medication. 30:51 However, considering medication and taking medication are two different things. 30:56 And there are plenty of times and consistent with the American Academy of Neurology Guidelines where we recommend beginning with …, from mild to moderate ticks. We often begin with behavior therapy, receive it for very severe ticks, or severe ticks. 31:11 That’s where it may make more sense to potentially begin with medication. That would be a consultation that you would have to have with psychiatrists or neurologists in order to determine. 31:22 Medication could also be helpful for folks who A aren’t near a cebit provider and can’t do it via tele therapy, or, B, Art willink aren’t motivated to do treatment. They’re not going to engage in the process, or see they don’t have the ability. 31:35 It’s not feasible for them to be able to come on a weekly basis for therapy, realistic expectations for treatment. 31:43 This really is about recognizing that the intervention we’re doing here is a management strategy. 31:50 It’s not a cure. It’s not a silver bullet. But it is one that can be highly effective. And then we always take questions talking a little bit about myths and facts about ticks. Tourette syndrome, what does this mean? Most kids with ticks actually never actually seek treatment and met most and and the majority of kids with ticks. Ticks are not a life sentence. 32:10 They can go on to become young adults and adults, they can gain. They can finish their education. They can become doctors, lawyers, scientists, teachers. 32:19 You know, and virtually any profession, they, any profession they want, and they’re able to be successful. And so giving hope is a big part of, you know, kind of myths and facts. 32:32 So let’s talk a little bit about how it takes work, because this really gets us into the premise of HRT and all of the strategies that we’re going to talk about. 32:43 I think about it very much as being like a mosquito bite, where you have an itch. 32:47 And when you have an itch, of course, what you want to do is you want to scratch it. 32:51 Now, why does everybody scratch? Because they feel better, They experience relief. 32:56 Yet, at the same time, there’s only one rule that all of us know about mosquito bites, which is when you have an itch you don’t scratch. 33:03 Right? Why don’t you scratch? Because it just makes it itch again. 33:06 Why do people scratch? 33:07 Of course, it makes sense because when something is aversive and uncomfortable, you end up scratching. You want to get rid of it. 33:13 And so people are living in the moment, they’re experiencing short-term relief, and they need to live in the moment. 33:20 And so what happens is you end up in this cycle. The same is true when it comes to ticks. 33:26 What happens is we initially have an urge. Most kids takes over 70% of them. They don’t exist in a vacuum. 33:33 What happens is they get a tingling, whether it’s in their throat, whether it’s in their arm, whether it’s in their stomach. And that results in them by their neck. And that results in them feeling discomfort. Just like with the mosquito bite when you feel the discomfort, you want to get rid of it. And so what do you do? 33:48 You engage in the tick, whether it’s jerking your neck, raising your shoulders, tinting your stomach, or something like that. 33:57 So how does treatment work? 33:59 What we’re trying to do in treatment is to help individuals recognize that they can experience an urge, and, at the same time, not engage in their tech. 34:10 In other words, they can learn to experience the short-term discomfort of having that urge in the service of the long term benefit, that they can have an urge, and they don’t necessarily need to tick. And over time, what happens is, our body can kind of learn it just because we have an urge, doesn’t mean that we have to engage in a tick. 34:32 So this is really the fundamental premise of how tix occur. 34:37 Based on that cycle that I was sharing with you, kicks occur, in order to alleviate the discomfort associated with the … urge That … 34:47 urge, sometimes referred to as a urge, sometimes referred to as a premonition, is that physiological sensation or that kind of quote unquote feeling that kids report, when they’re like, I just had to do it. 35:02 So tips occur in order to alleviate that discomfort. 35:06 Now, how exactly does that work? 35:09 It could be that the more the individual experiences and urge and doesn’t engage in the actual attack, the more the individual’s body habituates to it. 35:19 In other words, you learn to experience the urge, and not actually not actually need to think of habituation as like jumping into a swimming pool at first. The water is cold and over time you get used to it. 35:31 The water temperature didn’t change, but you do get used to it. It doesn’t feel as cold. 35:35 The urge didn’t necessarily disappear, but you get used to having the urge. So that’s one possible mechanism. 35:41 Another possible mechanism for what’s happening here and we’ll get into this and it will make more sense in a moment, is that an individual when they are in treatment is learning to experience the urge, but not engage in a tick, typically through us giving them something else to do. 35:56 So, for example, if someone has that urge to go like this and flail their arm out, right, then what happens is they may cross their arms when they have that urge. 36:05 And that crossing of their arms, that competing action, in essence, is sending a break a signal to your brain chain. 36:13 You can’t flail your arm out, because instead, you’re your arms are crossed here, right? That competing action, in a sense, prevents you from doing the tick up. What I’m sharing with you is theory. 36:25 This may or may not be accurate. We don’t really know. There’s a little more evidence to suggest. It’s not just habituation that the urge goes away. 36:37 However, I do find this to be a very helpful model for kids to just be able to recognize the idea that picture are occurring in order to alleviate the dysfunction this discomfort associated with the urge. 36:51 So let’s get into how we do that. How do we make all of this happen? 36:54 These are the core elements of CPE. 36:56 So number one is awareness training. 36:59 We want to really be setting the stage for treatment. 37:02 What is the rationale for awareness training? Think about all of the habits that any of us have ever had or if you need extreme examples. 37:09 think about, know, think about folks who have no smoking or other, you know, kind of more significant habits than just small annoyances, you know, or idiosyncrasies. 37:20 You know that your spouse or a friend has nobody has ever gotten rid of a habit. 37:27 They weren’t aware that they were doing. 37:31 And so, similarly, with techs, we need to help kids be able to understand that they are taking, we need to help them gain awareness to the fact that they’re ticking. 37:42 And so first, what we’re going to do is help kids in terms of describing the actual tick, Right? 37:48 And we have, we have a specific dif definition of a tick, with younger kids, with all kids, actually anecdotes. 37:55 I typically name the tick, And then after I name the tick, I will have the kid to find the tick. 38:02 And we’ll talk about it over and over again over the course of our session. 38:07 And I will prompt the kid, I’ll ask the child to demonstrate, I’ll ask the child to, you know, think about, Well, what would I be seen? You know where I looking in a camera? 38:19 What would I be noticing about what you’re doing? 38:24 Once a child gets good at describing the tick, then we want to help the child begin to understand the warning signs. 38:32 right? 38:32 Remember I mentioned earlier, we can’t really get rid of a habit unless we know that it’s going on. 38:38 Of course, we also can’t get rid of a habit unless we can preempt the habit from occurring. 38:45 And so, we want to help kids be able to recognize not only when their tick is occurring, which is a great first step, But then additionally, to be able to recognize when the physical sensations are happening. 38:57 That indicate, OK, my tick is about to occur now, because if we can capture in that space in that space between when the urge begins and when the tick occurs, is our room to be able to make a little bit of change. 39:14 So, our first step is awareness. We talk about awareness, and then we actually practice awareness in the session. 39:21 So, kids are learning to notice the arctic’s. We do this in a very simple way. I talk to the child. Kids often come in with other stuff going on, besides ticks. When we’re doing the awareness session, I say, I’m really excited to learn all about that. Or, I’m so sorry about the argument you had with your friend. I’m really no, no, I’m sad for you, and I really want to talk about it. So let me introduce an idea to you, related to awareness. And then we can talk while we’re practicing. 39:49 Once we’re practicing, what I’m doing is I’m coaching the child to be able to talk to me about whatever he would like to talk about. 39:56 Or she or they would like to talk about it. 39:59 Then we’re going to simply, whenever the child engages in a tick, have the child raise their hand. 40:09 Whenever the child engages in a tick and doesn’t notice it, I’ll simply raise my hand, right. 40:17 I praise the child when they notice their tick and I point out the tick whenever the child misses the tick. I don’t make a big scene, I simply pointed out. 40:27 And if the child isn’t engaging and … during the session, what we call the doctor’s office effect, we simply have a child simulate the text. 40:36 Over time the child is usually usually going to be engaging in those texts. 40:42 Once a child who’s good at noticing, when they picture happening in session, I’m going to give that as an assignment for the child to practice at home 30 minutes, or an hour a night with a family member. 40:53 The next week, the child comes in, we repeat the process. 40:56 But this time, assuming everything went well, we’re not focusing on acknowledging just to teach themselves, but I want to actually have the child raise their hand and catch themselves before they engage in the actual tick, I’m sorry, in, before they engage in the actual tick. 41:12 In other words, as soon as the urge happens, I want them to be engaging, and I want them to be raising their hand. 41:20 So, this is awareness training. 41:22 Once a child has solid awareness, I actually tally it retargeting about 85, 90% awareness. Once a child has solid awareness, then we can go on to our blocking strategy, our competing response. 41:36 So, competing response is a structure treatment, similar to awareness training. We have a rationale, we have a specific procedure, and then we’re going to practice. 41:45 So, what is the rationale for a competing response? 41:47 Well, our theory goes when it comes to behavior intervention for text when it comes to cebit that if we provide a child with a behavior that is incompatible with the actual tick, that the child is not going to tick. 42:01 So, when we introduce the competing response, what I share with the child is that for this competing response, I often call it a blocking tracker, blackening strategy. We need to make sure we follow three rules. 42:12 We need to fight, we need to come up with a strategy where you can’t do the tick and the strategy at the same time. In other words, is incompatible with the tech. We need a strategy that’s easy to do in different situations, and we need a strategy to do that is socially acceptable. In other words, it needs to be discrete. 42:30 At the beginning, I’m going to take a more active role in coming up with the competing response for the first ticker … and as we expanded into other ticks and gradually going to be pushing the child to think through well, so what are the rules? So, what do you think would be a good strategy? 42:47 The reason that I do this and I place this I place a big emphasis on not really kind of giving kids too much is because my goal is not to be their clinician forever. 42:58 I want kids to be able to gain life skills for managing their tics and then, you know, go off on their way feeling empowered and I believe, even at 9 10, 11 years old, kids can learn those in support with their parents and not be reliant on no consistent, revolving door, cognitive behavior therapy. 43:18 Of course, I do help kids, I don’t want that to come out wrong. You know, it is a collaborative process. Part of that collaboration is me being involved. 43:26 However, I wanna really emphasize that teaching kids how to think about their text and how to think about their strategies, in my, in my opinion, is a really important part of doing good cebit. 43:38 So, let’s just give a quick example of this. 43:42 Excuse me. 43:51 A child has an attic, child as an attic, where they may flail their neck out to the side like this. 43:57 If a child is flailing out there next to the side, we may want to think of a strategy that they can do. That is incompatible, easy to do and socially acceptable. In the interest of time, I’m gonna give away the answer here and I chose this simple case, they’re not all this simple, but it’s great for teaching. 44:14 We may have a child simply learned to tense their neck and turn their neck a tiny bit down. 44:20 Right, So right now, I’m in this strategy, and I intend to my neck. I’m looking at a tiny bit down just to kinda block me from going like this. 44:29 But as you’ll notice, and I’m going to talk in this strategy for the next few seconds, you’ll notice that I’m continually in this strategy, but I don’t necessarily look like it. 44:38 I’m not necessarily looking any different. 44:41 If you have really closely at me, and now, I’m out of it, if you were to look really closely at me, you may have noticed something different. But, it still looks socially acceptable, It’s still easy to do. You can do the strategy and class, you can do the strategy at home. 44:56 You can even do the strategy to a certain extent if you’re playing Ball, and you may not always be able to do that, though. 45:03 So, we have our awareness training, we have our competing response training, And then, following that, we’re going to move into social support. 45:10 Here’s just a couple of quick examples of a competing response. 45:14 These are common ones. We do change these around for kids, depending upon what’s going on. 45:20 Eye blinking. I’ll just discuss for a moment. The control blinking strategy is one that can be really effective. 45:26 I’m thinking is also one that, A is often mistreated. A lot of times people use a strategy like holding your eyes open for as long as you can, which I do not recommend as a competing response. I don’t think it’s a sustainable strategy. Try it, and you’ll understand. 45:45 No, just hold your eyes open, hold it open for about five, NaN, and as soon as you feel like closing them, just hold them open again. I think you’ll realize it’s hard to make it 1 or 2 minutes like that. 45:55 So I think that’s a misapplication of competing response training. Control blinking, Just blinking slowly and a particular pace, the rate that your child is typically blinking at is going to be a more effective approach. 46:10 The other thing I would share is that a lot of clinicians shy away from treating eye blinking, because it is a very automatic behavior. It can be really challenging. 46:19 one of the things though, that we know is that ticks while they are very automatic feeling, there’s an element of … to them. 46:28 Right, this is not to be confused with teachers telling kids, control, your kicks. Of course, they should not be in kids shouldn’t be punished for ticks. It’ll probably make them worse because it increases stress. And stress will increase the likelihood of ticking. 46:42 However, it is important to be able to. 46:48 I lost my train of thought, and. 46:55 So I can just pick up here. So, it is important, though, to be able to utilize a controlled linking strategy so that we are able to, we are able to be effective. And we’ll we’ll leave it at that. 47:10 Mouse movements, gently parsing your lips, NEF jerk, tensing your neck and holding it down. 47:16 And we can kind of work our way down the list here, finger movements and making fish. 47:21 Like Tenting, tenting your attention, your, Your touch, your **** muscles a little bit, flailing your arms out. Oftentimes, we focus on just kind of crossing your arms and unnatural position. 47:32 And a vocaltec will often talk a little bit about using a controlled breathing, a controlled breathing strategy. 47:42 OK, so moving on from competing response. Well, let’s talk a little bit about when do we use a competing response, and then I apologize, and then we’ll jump into social support. 47:51 So competing responses. when and how? 47:53 Number one, when do we use our competing response? We’re going to coach kids to use their competing response at the onset of the urge, or as soon as awareness of the tick occurs. 48:05 Show. 48:06 it’s OK if kids are going to recognize their tick, only when they tick. 48:12 That’s fine, let them notice then. 48:14 And let them get into their strategy that. 48:17 Ideally, though, what happens is, as soon as you notice and urge, you, kinda raise your hand, and you go into your strategy. As soon as you notice, you have an urge to flow your arm forward, rather than do your actual tech. 48:28 We want you to go into your strategy at that moment. 48:31 If a tick sneaks in there, that’s OK. I still coach a kid to simply get into his strategy, because it can be really good practice. 48:40 And once we’re in our strategy, we want to engage in our strategy for one minute, or until the urge goes away, whichever one is longer. 48:48 We don’t want to engage in a strategy for less than a minute. Number one, when you engage in the strategy for a minute, it gives you some consistency and some practice in being. 48:57 Number two, a lot of times with kids, they go into their strategy and they’re, like, Oh, my urge is gone, and they get out of their strategy, NaN, NaN later. 49:06 And then what happens is, the urge kind of comes back with a vengeance and sneaks in there and then the tic occurs. 49:12 And so that’s why whenever we’re engaging in it in a competing response, certainly at the beginning, I always have coaching kids to be able to talk a bit to be able to stay in their strategy for a minute. 49:26 This is our primary way. 49:28 This is our primary way of being able to, of being able to reduce kicks using …. 49:35 So how do we bring this into practice? 49:37 The same way with awareness training. We’re going to come into session. We’re going to practice. The client is going to talk about whatever they want to talk about. We check in about school, we check a bit about their friends. We check in about the latest disagreement with their siblings. That’s usually a hot topic. 49:53 And then when the client ticks when the client is when the client is about to tick rather. 50:01 The client engages in the competing response, and when the child engages in the competing response, I simply praise the child if the child, if the client ticks, and then doesn’t acknowledge meaning he actually ticks. Then what I’m going to do is I’m going to prompt the child. 50:18 And similar to before, there’s no criticism here when the child engages experiences, in urging, goes into his competing response, we give an awesome job paying attention. And when the child mrs. attack, we simply go, hey, you know, did you notice that? 50:33 Sometimes what I’ll do over time is how begin to talk a little bit more about, did the child recognize that he had an urge, And that can be really important and helpful. 50:45 We’re basically doing some of that, some of that, some of that processing. 50:52 Social support, the last, the last arm of our habit reversal training. 50:58 So the rationale for social support, it’s really important to be able to prompt kids, remind them to practice, prompt them to be able to use their strategies, will have a social support person at home. Occasionally, we’ll do it at school, most commonly, by most commonly, I mean, the vast majority of the time, well, over 90%. This person is going to be a parent. 51:22 The job of the social support person, the job of the parent, I introduce, is really being like a coach, and I shape it as a coach for the child as well. 51:30 because even the greatest basketball players, even the Lebron James is of the world. They all have coaches, because even when they’re great, they can still do a little better. 51:39 They can still learn and benefit from somebody else. 51:42 And so that’s the role of the social support person. 51:45 I then meet with the social support person together with the child to talk about how would you like, know, Marcus, right, our client the other day? Marcus, how would you like Mom to be able to support you? 51:57 What would you like data to be able to tell you, when you engage in a tech, how would you like to raise his hand, you wanted to give you the thumbs up versus the thumbs down, do you want a verbal prompt from them? So, we talk about this so that there are no surprises. The last thing we want is kids going home and getting into an argument with their parents about text because that’s only going to a decrease motivation and be unfortunately increase the likelihood of the ticks being exacerbated. 52:26 So we’re going to teach parents how to praise the use of the of the Competing Response Strategy. We’re going to teach parents how to be encouraging when kids need to use their competing response. And then we’re focusing very much on praising kids effort and use of the exercises, not necessarily, the reduction of tax reduction of ticks will happen. But we are focusing on effort in using the exercises. 52:52 So, naturally, the role of the social support person person Chow before we jump into SBA quickly and then wrap up with some questions, this makes sense, thumbs up, are we? 53:05 Are you with me? 53:12 We have a whole bunch of thumbs up, and we’ve got a couple of people that have a question at 753. 53:19 OK, so let’s talk briefly about function based intervention, and with that, we are going to, we’re going to wrap up. 53:28 Function based intervention is essentially the idea that by understanding what occurs before and after ticks, we can minimize or prevent the occurrence of situations where we are likely to engage in texts. 53:44 In other words, if we know that, um, a child is going to, a child has a math test coming up, right? We need to be able to eye. Or child has homework coming up. Rather, we need to be able to minimize the impact of that homework, right? 54:04 Now, what’s important to recognize is, this is where kids get all excited and say, you know, I realized, whenever I have a math test coming up, then that actually means that I’m going to, know, whenever I have a math test, it means that I really, I really shouldn’t take them. Or, I should take them at a different time because of my tics. No. 54:21 We want to minimize, or prevent, not, automatically prevent the occurrence of stressful situations. 54:27 Most of the time, we are understanding, well, if I have a math test coming up and that’s really stressful, I need to be prepared for that inevitable, take exacerbating situation, Right? So, we talk about how are we going to practice our strategies right before? 54:43 What kind of break could we take over the course of our study? How could we study in advance? Because then we’re going to be ready to take our tests. We’re going to do well. And we’re less likely to be stressed about it were more likely to do well because we’ve studied in advance. 54:57 What kind of relaxation strategies could I implement? 55:00 So this is the main aim of SBA, the main aim of the function based intervention. Right? Be prepared for that, take exacerbating situation so that we can attack it full force with our competing response. 55:14 And we also want to be able to remove negative consequences that result from ticks. So, just as one quick example here, we want to understand the places and situations who understand the people that trigger texts. We want to understand the activities they trigger ticks. And we want to understand when those internal sensations are happening when those urges are popping up. 55:37 And then on the back end, we want to be be very mindful of what kind of positive reinforcement folks are getting and what kind of negative reinforcement are getting. 55:46 We want to make sure that kids are not getting a lot of positive attention for their text, because it increases the likelihood they’re occurring. We want people to be ignoring them. 55:55 And certainly want to make sure that we’re not punishing folks for ticks because that’s actually going to increase the likelihood of them happening because it generates so much stress. 56:04 So, that’s a little bit of an overview of siebeck. Obviously, there’s a lot that goes into it. 56:11 However, if anybody does have any questions, please feel free to reach out to me. Please feel free to reach out to NGOs CTS both providers as well as families who are struggling. 56:22 And I’d be glad to talk about it. 56:23 It’s a topic that is very, very much a passion of mine. 56:28 Thank you all for listening. 56:30 OK, thank you so much, Mary. Greatly appreciate your presentation, as I know everybody else does. OK, so, for the Q and A, I will be stopping the recording, for those watching the recorded webinar, thank you so much for attending. There will be an exit survey, which we appreciate you completing. An archive recording of this webinar will be posted to our website and … dot org, under the Programs tab. All questions submitted during the recorded webinar. 56:57 It will be posted to our website blog. 57:00 Art will be posted to our webinar blog for the presenter to answer. This can be found on our website under the Programs tab. This blog will be open and monitored through Wednesday, December 13th. Our next presentation will be in January, on Dyslexia, presented by doctor Eric …. Stay up to date with all of our upcoming events on our website at … dot org slash events. And with that, I’m now going to stop the recording. 57:27 And I’m going to.


  1. Terrence says:

    are there special driving instructors trained in CBIT? not sure if that’s a thing.. but just wondering since tics can affect driving automobiles sometimes..

    • NJCTS staff says:

      That is a very interesting question. I haven’t heard of anyone. In general, thinking through how one’s tics impact their driving is something important to consider. For example, eye blinking or head turning tics compromise safety. While I don’t think a driving instructor needs to be trained in CBIT, it is important to be seeing a psychologist or other allied health professional with expertise in CBIT to ensure that one has strategies in place to manage tics that occur when driving.

  2. Susan says:

    How would CBIT works for someone with Coprolalia? Would they use the same technique as vocal tics?

    • NJCTS staff says:

      Yes, the strategy coprolalia would similar to that of other vocal tics!

  3. Heather says:

    My son’s tic are only present when he’s talking. Have you seen this before and how would you treat this?

    • NJCTS staff says:

      How to manage vocal tics while talking would depend on the particular tics and some unique child characteristics. Therefore, it’s a bit tricky to respond to in this forum though you are welcome to reach out to me directly. In general, awareness training and competing response training can still possible, and some modifications may need to be made and some problem solving may be needed. The way to manage motor tics while talking would include standard awareness and competing response training, of course being sure to practice while the child is talking.

  4. Jessica says:

    Can you clarify the competing response or blocking strategy you often suggest for blinking?

    • NJCTS staff says:

      A common competing response strategy for eye blinking would be controlled blinking. Though there can be some variations, I typically implement this by helping the child blink with intentionality at their natural blinking rate. They would enter the strategy at the onset of their urge and remain in it for a minute or until the urge goes away, whichever is longer. Eye blinking tics can be quite difficult, though with practice and persistence one can have really great results. As eye tics can vary greatly, it’s important to carefully understand the tic in order to determine if what I outlined is actually the most appropriate strategy.

  5. Miranda says:

    Does someone always have an urge prior to a tic?

    • NJCTS staff says:

      The majority of individuals with tics experience an urge, though not everyone. A treatment like CBIT is predicated on the identification of the urge. Therefore, if an individual doesn’t recognize or seem to experience an urge, we would work with them on learning to do so. Some people who don’t initially report an “urge,” but do in fact identify particular experiences that occur prior to their tic occurring. In those cases, our role as clinicians is helping people to recognize that experience they are having as actually the urge.

  6. Dina says:

    Can a child work on several tics with CBIT at the same time?

    • NJCTS staff says:

      Typically, we begin with one tic. Once the child can manage that one tic, we add on a second tic. The child would then practice strategies for both tics in session and during between session practice. There are occasionally different tics that involve either the same urge, or a similar body movement or vocalization. In that case, we can sometimes target two at once.

  7. Sarah says:

    Is CBIT video-conferencing covered by insurance? Generally speaking.

    • NJCTS staff says:

      While I am not at all proficient in insurance, I would assume CBIT — in person and video conferencing — is covered by insurance similar to any other outpatient mental health care on a particular plan. This question may be better directed to an insurance advocate. In our experience, the challenge for families is finding in-network providers who are experts in CBIT. Since TS is a condition which lacks a lot of specialists who are in-network, families can sometimes secure a single case agreement (SCA) with their insruance company to cover their out-of-network care as if it was in-network. This is not as easy as it used to be, but it is possible.

  8. Katie says:

    It seems like HRT focuses on addressing one tic at a time. So when you work on one tic, does another one just get worse?

    • NJCTS staff says:

      Good question! There was a study done several years ago that indicated when Tic 1 was untreated Tic 2 actually also decreased. I often quote that study since it puts parents at ease. Anecdotally (which I also share!), I see varied responses. Sometimes when Tic 1 is treated, Tic 2 also decreases. There are other occasions when clients seem to increase the frequency of another tic. Most commonly – at least in the early stages of treatment – I see that when Tic 1 is treated, Tic 2 simply stays the same. The frequency of Tic 2 then changes once we begin to target it in treatment.