A Neuroplasticity-Based Approach to Tics

The New Jersey Center for Tourette Syndrome and Associated Disorders as Directors and employees, assume no responsibility for the accuracy, completeness, objectivity, usefulness, or usefulness of the information presented. We do not endorse any recommendation, or opinion, made, by any member or physician, nor do we advocate for any true. You are responsible for your own medical decisions. 1:53 Now, I’d like to introduce our speaker for this evening, Ms. Betsy Stoeber. Betsy Stober founded Brain Balance in New Jersey in 2010 following her own family’s participation in the program. She is proud to have played a role in moving the program’s core concepts the brain’s neuroplasticity. 2:16 can be leveraged to access the root development of developmental changes into the mainstream, their therapeutic approaches over the last decade. 2:28 Betsy has led her caring and dedicated team in the service of hundreds of families and is a tireless advocate strengthening rather than masking or accommodating when it comes to developmental issues. Betsy is a graduate of the University of Michigan and NY, use Stern School of Business and has a background in business, and has two nearly adult sons who are a great source of pride. 2:54 Betsy, I’m going to turn over the presentation to you now. 2:59 We’re so happy to have you. 3:02 Terrific. Thank you very much, I’m so happy to be here. Can you see my screen now? 3:10 Yes. Sorry, this, it says connect at the webinar. 3:16 OK, let me just There we go. 3:21 OK, so welcome to everyone. I’m thrilled to be here to talk to you about a topic that I am very passionate about. 3:33 As Kelley suggested that is looking at the symptoms of neuro developmental disorders as developmental immaturity. And issues that we can really address by driving development in the brain and helping kids and adults that struggle with these areas of dysfunction, to move forward and to kind of improve functionally. We’re, of course, going to be talking about this in the context of tic disorders tonight. And over on the left-hand side of this screen, you’ll see a child who is really making an effort. You can see that in his face, that he’s making an effort. 4:16 And we’re showing here of very simplified version of the brain system that he is activating and making that effort and that is to suppress undesirable, motor, impulses or tics. And that’s a real hint as to the topic of my talk tonight. And I want to tell you this is a very complex topic. And I’ve made a lot of effort myself to simplify it. And at the end of the talk, you will see a list of resources, and I think that the slides are going to be distributed to everybody who’s registered tonight. And so you’ll have an opportunity to go into greater detail and read some of the studies that I’m citing for yourself. But for the purposes of the discussion tonight, we’re going to keep things a little simple. 5:03 And yeah, so let me move to the next slide, which is an attempt. I know that I’m talking to an audience that probably knows more than the average person about text, but I want to start by kind of getting us on the same page. And I want to start by talking about how ticks feel to kids who are affected by them. And I went right to the source for this slide. I watched Rewatched, the HBO documentary I have Tourette’s but Tourette’s doesn’t have me, which is a very, very moving documentary, where kids talk about what it’s like to grow up with a tick disorder. 5:43 And these are the types, things that the kids say in that documentary. They wonder, you know, why they can’t stop there ticks. It feels bad to have something that’s out of their control, that’s affecting them every day. They talk about the fact that if they try to hold their ticks in, that it’s all they can do. It’s all they can think about. It’s really robbing. Them of a lot of the mental bandwidth that they need to just be a kid and learn at school and learn socially a tick can feel like a compulsion like it’s going to have to scratch this. It’s too much for me, it’s inevitable that I’m going to experience the tick, even if I’m holding it in, kids can feel embarrassed feel like it’s weird. Like, they’re disturbing people at school or elsewhere in their life by their ticks. And they just want kids to know that their normal. 6:36 They’re just a normal kid, like everybody else, with the same feelings and, you know, desires and dreams. So what happens when a child exhibits ticks is that they can be classified into patterns of ticks, can be classified into tic disorders. You all probably are familiar with that. And the classification is based on observed symptoms. And those have to do with everything from kind of the number and variety of different texts that an individual is experiencing, the age of onset the frequency of the ticks themselves. And then how long a person has experienced the symptoms. And down below on this slide are three tic disorders and kind of the criteria for diagnosing those tic disorders. 7:25 And if we’re asking what are ticks, they are defined as sudden twitches movements or sounds that are made repeatedly. And as you all probably know, there are both motor ticks, and verbal ticks. There are simple ticks that are kind of like one step ticks, and then there are more complex texts that kids and adults can exhibit. 7:48 And there, of course, has been a lot of thinking about where are these ticks come from what the source is. And we still don’t feel like we know definitively. I think, in general, out in the literature, but the current status of that thinking about the source of ticks is kind of moving away from the idea that there is a gene that is common to all Tourette’s sufferers are all take Disorder, Sufferers. And one of the studies that I’ve cited in this presentation has a quote Tourette Syndrome. Genetics Research has been frustrating despite an apparent high heritability meaning that people in the same family and different generations will all have issues with ticks, association studies in terms of finding something. That’s a problem at the chromosomal level, a tick that is related to, sorry, a gene that is related to tic disorders are largely Baron. There’s been a lot of looking into is this a … 8:48 problem with dopamine release, kind of a neuro chemistry problem in the brain, and again there’s little evidence of that. 8:55 And so now there has been a real shift in direction looking at functional connectivity in the brain as the potential source of tic disorders. And there is, as it says here, increasing evidence that circuitry, problems of brain systems associated with social decision making within the larger social behavior networks in the brain are behind ticks. 9:24 So, you know, what are the circuitry problems? What does that actually mean? And again, here’s another quote, The circuitry problems are about the way different regions of the brain are creating neural pathway connections. So that they can work effectively together. And that’s something I’m going to talk a little bit more about this. But that’s something that is part of normal brain development throughout childhood and into young adulthood and into adulthood. 9:56 The brain is making these circuits between its regions, and here is another quote from the study that I talked about. On the last page, the emergence of involuntary movements, vocalizations and subsequent natural history of Tourette syndrome follows a predictable pattern in the first 2 to 3 decades of life suggesting that Tourette Syndrome results from altered brain development trajectories. And I want you to hold onto that, because I’m going to come back to that idea of the developmental trajectory of the brain and how that can be altered. 10:35 So first, a couple of additional truisms regarding ticks are things that people kind of generally accept to be true about tic disorders. The age of onset is really at this middle childhood period of time, 6 to 10 years old, that’s the most common age range for ticks to start make themselves a parent. They’re more frequent in boys than in girls. We know that most people experience intermittent symptoms, they can come and go, they can re-appear after a time that they don’t seem to be there anymore. one tick can start and kind of go through its life span, and remediate, and another can appear as that first is remediating. That’s kind of the nature of tic disorders. … can impede daily function. They can really get in the way of school and a job and social life. 11:29 And they can make people feel bad and embarrassed, and they can cause stress, antics can get worse when a person is stressed. 11:36 The act of trying to suppress text can be very tiring, and it can really eat up a lot of that mental bandwidth, like I said, on the the slide, with the child on it. And that can really get in the way of academic learning and social learning. And, you know, we’ve seen a lot of kids who are diagnosed with tic disorders and also learning disabilities Because it’s really hard to be at school and learning. When you’re working hard to suppress ticks. And, you know, in a worst-case scenario, ticks can be self interests, and they can cause pain or harm. 12:12 So these are serious issues. 12:14 And we really want to figure out how to help kids move past or overcome text because they are problematic. Another thing we know is that they are almost always comorbid with other neurodevelopmental issues, other issues that are about the timing of development of the brain. And some examples of neurodevelopmental disorders that you probably all familiar with, or ADHD and anxiety, OCD, autism, spectrum disorders, learning disabilities, sensory processing disorders, and, of course, they’re more. Medication and behavioral treatments do exist and have limited effectiveness. But it’s generally thought that there is no cure for tic disorders. And what we know about the course of tic disorders is that they most often decrease during adolescence and into early adulthood. And often, they disappear entirely. People grow out of tic disorders. 13:15 And, you know, what’s really happening is that compensatory neural plastic changes in the brain are allowing an individual’s brain to catch up developmentally, resulting in function that is more like the function in terms of suppressing undesirable impulses that we expect. 13:39 So we have to talk about that because that is really important, This idea that ticks are a developmental problem, and that the normal course of development in a human being, who is experiencing ticks, is for them to remediate over time. So, here we have this very clear statement: neuro plastic, changes in brain structure and connectivity, control ticks over time, and help move the brain onto a more typical developmental trajectory. So, you remember what we said on that earlier slide about an atypical developmental trajectory. 14:19 So, to understand this, we really have to talk about what is neuro plastic change. Neuro plastic change is the nature of the human brain and the human brain has been called an organ of surreal complexity. And it’s almost like a joke that human beings have to use their brains to try to understand their brains, but the brain is too complex for human beings to truly understand it. Although, we are making headway. There have been big advances in the understanding of the functioning of the brain in the last 10 to 15 years. 14:56 But generally, it’s considered the most complicated Oregon, known in nature, were born, and we have about somewhere in the ballpark of 100 billion specialized brain cells that are called neurons. 15:10 And over the course of life, with experience and stimulation, and practice, and action, and effort, those neurons, fire, and wire together to create in the ballpark of 100,000 billion neural pathway connections. And taken together, those neural pathway connections or functional connections in the brain are really the neurological equivalent of learning and skill mastery. There is a pretty good understanding at this point of what typical wiring of the human brain looks like, typical functional connectivity. And that’s referred to as the Human connectome. 15:51 And there was an article about a week or so ago in the New York Times about the mapping, the projective mapping, the fruit fly connectome, that a group of scientists are working hard at understanding all the connections in the brain of the fruit fly. And it’s not because they so desperately want to understand the fruit fly. It’s really kind of a precursor and an ability to look at a more simple brain in the process of really coming to understand the expected connectivity of the human brain. But, what we know is that typical wiring enables typical function, typical self regulation, typical physical co-ordination, skill, mastery, understanding of language, picking up on social cues, all of that typical function is dependent on typical wiring in the brain. 16:40 We know that disorders in the observable developmental disorders involve predictable differences in the functional connectivity of the brain. The people, person, who is skilled at looking at brain scans can look at an atypical pattern of connectivity, and know what type of symptoms that person is going to have. 17:04 Just based on those atypical connections, and those wiring differences are very, very often detectable way ahead of symptoms. And that’s true in developmental issues, like autism. We can. We know that we can look at scans of six month old brains, if they are not making eye contact, or showing interest in other people. And we can see that important connections are not establishing themselves at six months old, and kind of say, we better step in and intervene because this is likely to result in the symptoms of autism by about two years old. I have a book over the cover of a book over on the right-hand side of this screen. Brain Scapes by neuroscientist named Rebecca …, it’s a book I’m reading right now, and it’s really, really interesting talking about the wiring of the brain. So, if you’re interested in you want some more kind of literature for regular people, that’s a great book to read. 18:09 But the important thing to know is that all through life, the brain can change people here. Sometimes that what you get in terms of development in your child by age five is what you’re going to get. 18:21 And after that, it’s not possible to change things anymore. That is really not true, Neuroplasticity changes and it changes for really good reasons. And the brain’s neuroplasticity at at six months old or two years old is quite different than the kind of responsiveness of neuroplasticity later in life. 18:43 But we remain people who can learn and master skills and get better at our golf swing or are, you know, ability to to throw a basketball all through our lives. And it’s important that we know that because that will help us in addressing these neurodevelopmental issues. 19:03 So how does this, the building of the human connectome start? It really starts in the womb experiences that we have in the womb, get that process started, and then we’re born. 19:16 And the, the stimulation of the world that we’re born into, is what drives brain development, being born with the right equipment, is not enough, and this is a wonderful article, Babies’ Brains, the first year, that was in National Geographic a number of years ago. And, this is also on the list of resources that you’ll see at the end of the presentation. And, it really makes the case that there is this lightening pace of development in the first year of life. You can see in this graph on the lower left, the the X axis is time with the shaded area being the first year of life. And the Y axis is the number of neural pathway connections. And you can see that at the time of birth, there are very limited number of neural pathway connections that are kind of all about the experience that a baby has in the womb. And the baby is born and all sorts of different types of connections just skyrocket and around six months old. The number of connections in the brain kind of peaks. 20:22 And they are not very sophisticated connections, but there are a lot of them. And that really makes such a difference in the way a six month old is functioning and connecting with the world versus a newborn. But then what you see happening is that neural pathway connections start refining through practice of different activities. And the brain really is great at pruning, or kind of getting rid of cleaning out obsolete connections that we don’t need. And so the rest of life is really about having neural pathway connections. Refined themselves gets stronger, get better and better what they’re supposed to be doing. As you see here, repeated activation strengthens and refine circuits and lack of using connections. 21:15 Know over time that that pruning process can do away with some of those obsolete connections. Dysfunction is observable when brain wiring is typical, like I said before. And the other thing that this article does really well is talk about how there is appropriate intervention to step in and influence the development of the brain, the wiring of the brain. And that can lead to strengthening of existing connections and the building of connections between regions that didn’t form previously based on the individual’s prior life experiences. And that this, this process of strengthening and building connections in the brain can really improve life. It can improve lots of different areas of function. 22:02 So how does neuroplasticity play a role in overcoming tix? Well, there is really ever growing body of research about this topic. 22:13 And increasingly, Tourette syndrome research is really focused on functional connectivity, you know, and how, as a certain system of brain regions is learning to work together over time to, know, build, typical, more typical function. And it’s really focusing on the idea that suppression of ticks is part of typical human development. It’s a lot like learning to read social cues and respond appropriately. It’s a lot like learning to not have a meltdown and control your emotional reactions and academic learning and learning different motor skills and more. 22:56 And here is a quote from this lower, right hand steady. Increased control over motor outputs, including suppression of ticks, may develop during adolescence in Tourette syndrome and be accompanied by compensatory, neuro, modular … alterations in brain structure and function. And that is the thesis of what is happening as people age out of ticks. 23:25 So, this system’s perspective, and again, this is very simplified way of looking at this very complex brain system. This neuro anatomical system is really made up of a part of the brain. It’s actually a collection of structures in the brain that we refer to, as the basal ganglia. Working together with the cortex and the cerebellum, those are the key parts of this, Tourette’s, or sorry, Tick suppressing System in the brain, and what they do is they work together to kind of select and maintain appropriate responses and generate behaviors according to what is thought of as appropriate and they inhibit inappropriate responses. I’m just going to show you this picture of the bouncer over on the right-hand side of the page. 24:18 The basal ganglia, are collectively, sometimes, referred to, as the bouncer of the brain because they play this really important role in deciding who gets, you know, what impulses get to come out, and kind of keeping the doors shut for undesirable impulses. 24:36 And what we know is that there are systemic differences in this brain system in people who have the symptoms of Tourette syndrome. Some of the brain structures in that system are known to be immature. And there will be atypical interactions between the brain regions in this system and atypical functional connectivity or neural pathway connections between those regions. And what’s really interesting is that same dysfunction is implicated in other neurodevelopmental disorders like OCD, obsessive compulsive disorder, and ADHD attention deficit hyperactivity disorder. And here’s a quote from that study. ADHD is common in Tourette’s as our anxiety disorders and OCD, often arising to, oh, sorry, obsessive compulsive behaviors often a rising to the level of OCD. 25:33 And here is a really interesting idea, you know, that look at autism as a spectrum of disorders. We look at anxiety disorders as being a spectrum, attention deficit issues as being kind of on the spectrum with different types of ADHD. 25:48 And this researcher says it is plausible to view simple tics and complex obsessions as the poles on a spectrum of compulsive behaviors with kind of more simple compulsive behaviors like needing to know, move a curtain so that it’s even occupying the middle of that spectrum. So I think that’s a really kind of different way of looking at text than than many people have been led to in the past. This is a graphic that we use a lot at brain bear balance, where I work to kind of get this idea across, of simple connections being important in more complex neural pathway networks. 26:36 Sticking up above the surface of the water are lots of different areas of complex skill mastery, where you have to use lots of brain regions together as networks. Things like being able to direct your focus and attention to things that you need to. Even if they’re not super interesting to you, the ability to pick up on social cues and respond appropriately, the ability to control your behaviors and kind of not explode over something small, the ability to learn academically and control, repetitive anxious thoughts or to work in ways that are goal oriented, like what we consider executive function. All of those abilities are based on many more foundational areas of function. Coming together, creating neural pathway connections and operating in these synchronized ways. 27:31 So, what is the promise of plasticity based interventions for neurodevelopmental issues? I’m going to turn to doctor Michael …, who was on the neuroscience faculty at UC San Francisco, which is very well known for its neuroscience department. He’s an author. He is really considered the father of neuroplasticity. You see on the lower right-hand side of this page, a book that he wrote called Soft Wired, which is all about the brain’s ability to grow and change. 28:04 And then, at the, the, the research paper that I’ve copied shot of is really a wonderful research paper, blank brain plasticity based therapeutics. I encourage you to take a look at that if you find this interesting, but he says, brain plasticity based therapeutics can be expected to drive fundamental re normalizing corrections for distorted brain systems that’s really what he sees as the future. He calls neurodevelopmental disorders. Failure modes of the self organizing brain, that’s the idea from that National Geographic article that the brain is organizing itself. Starting with birth, and moving into childhood. The brain is going through a well understood process of organizing itself. 28:53 If only it is, you know, staying on that typical path and and responding to experience and the way that we expect. He says, We have very clear insight into brain changing processes, both in the directions that we don’t want the brain to be changing. Kind of degrading directions, losing function, having compulsion to become more and more set and stronger. But also in the strengthening rejuvenating and corrective direction, which is what we’re talking about. The ability to use that neuroplasticity, to strengthen an individual and help them function better. 29:32 And he is a real believer that the future will involve brain remodeling That’s induced on a large scale can really help with lots of different symptoms and truly at any age. 29:47 How do we do that, in my program, brain balance program, I work for, Well, we, you know, use this idea that we have to stimulate the brain and provide experience in a lot of different modalities, integrated into one approach and practiced frequently and intensively. We’re combining a lot of different modalities. And you see over on the right-hand side of the page, you see kids who are working in our centers and using lots of modalities together. And we do this, strengthening work in a progressive, really challenging way that requires that participants are really having active, purposeful, intentional control over the systems that their body and directing those systems of their body using their brains. 30:34 Doing this all together, many modalities in an integrated way reflects the complexity of the real-world, that, as we’ve talked about before, is what jumpstarts neuro plastic change in the brain, and causes the brain to be on that typical path of development. And by making a plan that is targeted based on what we know about the individual and sticking with it and supporting a family to kind of get across the finish line, we can really move the needle developmentally for kids. We can improve the speed and efficiency of the neural pathways in the brain, help out with that firing together and then we see with practice, the wiring together that results in stronger, more synchronized skill mastery. As brain connections become more typical, that leads to more typical function across the board. And that’s really, you know, I think what we would hope for any kid who was struggling with a developmental issue. 31:34 How do we know that this works well? There’s a lot of research that supports using brain plasticity based approaches. We are just coming to the end and in our program of an independent study of our program by a researcher at Harvard Medical School and McLean Hospital in Boston, And we’re thrilled because he has really taken a look at these multimodal activities and seen profound effects in the group of kids who participated in his study, in terms of observable improvement in their symptoms. Measurable performance, in this case, it’s looking at focus and attention. And using brain scanning equipment, he has seen real improvement in functional connections in the brain. 32:25 Those are more consistent and stronger. This study we love because E used multiple assessments in all three of those areas. The first one prior to kids doing any kind of integrative activity and then providing them with what they needed to do 16 weeks of this activity and then doing a second test right at the end and seeing improvement on all three of those measures. But then sending them home to lead their lives for half a year and bringing them back in, and doing those, start doing those tests again. And this is really what is so exciting, is that doctor … 33:05 and his team saw persistence of benefits of doing this work that half year down the road after not being involved in daily exercise. Seeing that kids have improved on all of those fronts, and that’s what we call true neuro plastic change, and really helping a brain to be moving forward on a typical and positive trajectory. 33:28 The other way? the way that we know that the approach works is from the replicable results that we achieve for families that come and do this work with us, and parent reported success and that is what’s truly exciting. And here are some quotes from parents of kids who came to us with tic disorders. You know, talking about how taking a neural plasticity based approach is life-changing that their child, they feel that their child has accomplished a lot move forward. I love this. 34:00 This report from a mom that her son has been on the news at school and done weather reports and news reports, things that really put him out there in front of his peers and that he’s not shy or not embarrassed to do that. And then, finally, this quote from a mom who says that a year and a half later, although they hear an occasional snorting noise, that their child really has a normal social life, and, again, that is the kind of outcome that is wonderful, and that we want to achieve. 34:30 So, in summary, we know the course of tic disorders. 34:35 And we know that the fact that many, many of them remediate fully by early adulthood is about development and growth and aging out of the problem. 34:47 And in promoting beneficial neural plastic change, and putting effort into that kind of work, we can help people get to that point of being able to suppress, ticks, and control them sooner. And that is the message I hope that you leave this talk with. And there’s so much more to know about this and talk about. I’d love to take some questions if you have them. And I’ve also included my contact information. And then here is the list of resources that I have mentioned during the course of the talk. 35:23 Betsy, thank you very much for all that information or really do appreciate it. 35:32 So we’ve had several questions come. First, I thought it was a myth that people with six or … have their ticks go away. Inbuilt hood in adulthood. I know there was a study that discussed, even the people who thought their chicks are gone away, experienced ticks, when watched on video, but didn’t even pay attention to them anymore. 35:59 So I think I understand all the parts of that question or statement. And it is considered the typical course of having tic disorders that they kind of go in an arc. We see the onset of in that middle childhood range 6 to 10, and then we usually see them be at their most intense kind of in the 10 to 14 year old range. And then typically see not in everybody, there are definitely adults with Tourette’s adults, with tic disorders. But in the majority of cases, you see those … start to remediate in terms of the second part of your question. I’m sorry, Kelly, can you repeat the end of that question? 36:51 Sure. 36:54 There was something Oh, I know I think it was, there was a study that discussed the people who thought their tickets and garner were experienced six when they were watched. 37:06 Oh, that’s interesting. So, I don’t know about that study. 37:09 but what I do know is a lot of taking a look at how when people are distracted when they’re really like mentally engaged in something that they love or that interests them that they aren’t experiencing tics, and so that’s interesting to, you know, what is it about a very engaged brain that enables the person not to have ticks. 37:35 So, you know, I think these are all really good questions, and I think that there’s still research to be done about, you know, all of the, the dynamics of the experience of ticks. 37:51 So, what are your thoughts on the recent increase in individuals? Mostly teen girls. 37:58 Seeking assessment for you or late onset tics. 38:03 Do you use all the same modalities for functional tics, OTS or they’re treated differently? 38:11 So I would treat them the same. I mean, I think so, and, and, and I’m not an expert on this system in tic disorders. You know, we use neuroplasticity based approach to address lots of silicones developmental disorders. 38:31 But this idea of like leader onset of tics can, Absolutely, if this is a problem of the social decision making networks in the brain. 38:44 It can follow that a person who is increasingly stressed about social shoemaking and has some weakness and the connectivity in the brain can go through, the brain is constantly, um, shifting the focus of development throughout childhood and into early adulthood. So, we kind of think of adulthood as being reached neurologically by about 25. And it’s interesting because car rental companies, for example, won’t rent to people who are under 25 and that’s for a reason. You really haven’t reached adulthood and decision making ability of an adult until you’re 25. 39:32 And so, you know, the emphasis of development shifts two different regions during the course of teenage years, young adulthood. 39:43 And we can see people move into a time where the parts of the brain that are performing that that motor impulse suppressing function are overwhelmed or stressed. They are in social situations that are too much for them to just handle easily and we can see ticks as a result of that. 40:08 So I hope that that makes sense what I’m saying. 40:14 Um, the next question starts off this presentation has was, has been lovely to questions, however, Kenya, re-exported Spectrum Issue you included on one of the slides issue of mind in the middle was confusing? 40:31 Sure. 40:32 So this is a researcher looking at the nature of simple ticks and looking at the nature of complex compulsion. So, you know the the really complex things that people who get an OCD diagnosis, for example, can sometimes experience needing to take a certain number of breaths before they walk through a door. 40:58 Feeling like the world is going to come to an end if they don’t do that and having these complex compulsion that they feel a need to follow. And that researcher, is saying that all of those are kind of uncontrolled impulses. Going from very simple to very complex. And he’s saying that at the middle of that spectrum, from one pole, simple pole to complex pole are kind of the more simple compulsions. 41:32 That we know people have the compulsion to set something straight. Or to have both light switches be up or down and not one up and one down. 41:45 These things that we hear about regularly as kind of simple compulsion, that don’t always rise to the level of an obsessive compulsive disorder, diagnosis, OK. and part of the question, have there been benefits of the other big benefits of the kind of exercise you discussed? 42:08 What about the children who demonstrate ticks? 42:12 Are they just more confident or do they actually have fewer symptoms due to the exercises or to target and password? 42:22 So, I love this question, and, you know, let me tell you that I, after over 10 years, I kind of feel like I know when a child comes to us and has, is experiencing tix, I kind of know what things are likely to look. Like. 42:42 Not every kid responds to this strengthening process in the same way, but I most often tell parents that when they’re coming to us and their child starts in our program, that whatever they’ve experienced in the past in terms of a tick, like the onset of a tick. 43:01 And then it becoming more prevalent, You know, parents will describe to me that they’ll see their child do something new and they’ll think, oh, is that a new tick? And then over time, they will say, yes, that’s absolutely a new tickets. We’re seeing it now pretty frequently, and up, this is the next tech that’s coming. And maybe concurrently, they’ll see that an older check goes away, and they’re not seeing it anymore. So that tick is remediated. This new tech has become kind of the primary tick that is being experienced, and then over time, they’ll start a little less frequently. So I’m calling that kind of the lifespan of the tick, and then eventually it remediate fully. What we see in our program is kids are doing this work to strengthen connections in the brain. It very often the life cycle will shorten dramatically, kind of intensify. Families will see a new tick. And within a day or so they’re seeing a logical. 43:57 And within a relatively short period of time compared to the past, that tick is like, worked out of the system and they don’t see it anymore, but maybe another tick happens, like right away. So that compression of the timeline of ticks is something that we see as kids go through this process. And then, little by little, by little, you know what parents report. I have a wonderful mom who was one of the first 10 parents to enroll her child with us back in 2010. And she for years wrote to us with an annual update on how her son was doing. And you know what I know from talking to her is that by about six months from the end of her son’s six months with us and the program, so about a year after the first came to us. They really didn’t see anything anymore, no tax anymore. Occasionally he would do something a little bit repetitively. And they would think, is that a tick? 44:54 But, you know, and along with that remediation of the ticks and him not having to put so much effort into suppression anymore. He started to blossom Academically And he ended up moving out of a learning, disabled classroom and becoming a mainstream student. He’s now, I think, a junior in college. And, you know, that kind of process, it doesn’t happen overnight, it’s not waving a magic wand. And the process of strengthening parts of the brain and putting effort can be fatiguing to some individuals and so for a period of time, we can see that the ticks are more intense. 45:35 But generally, we see the individual kind of work their way out of, of experiencing tix. 45:44 I hope that answered the question, OK. Oh, you asked about self confidence. So what I wanted to say is that if not, having text leads a child to feel more confident and to be able to go out and put themselves out in front of other kids and have the spotlight shined on them a little bit more. And then success leads to more confidence than that competence is absolutely driving their experience and driving new connections. And so, you know, I don’t want to say that confidence isn’t an important part of this. Of course, it is. But it’s all kind of part of that, becoming more typical and how you’re functioning. 46:32 What are the multiple modalities you’re referred to? 46:37 So we are the doctor who created our program, really worked to include ways of working on developing regions of the brain as many different modalities as he could. 46:53 So, first of all, sensory systems. We are working on strengthening and individuals’ ability to do auditory processing, have the brain really be able to make sense of what they’re hearing, and improving visual function in lots of different ways. Right. There’s there’s basic I reflexes. There is ocular motor co-ordination, how the two eyes work together, Convergence and divergence. There is visual processing, and how the brain makes sense of what a person is seeing. There is the kind of movement involved in eye tracking, when your eyes reach the end of a line of text, their ability to jump to the beginning of the next line of text. 47:38 So those are all visual system modalities, that there is Carolyn and timing and core muscles strengthen engagement, And there are cognitive qualities, the ability to make inferences or think about cause and effect relationships, or comprehend what you’re reading or hearing. And so, our program strives to incorporate as many scientifically validated tools that are known to improve function in as wide, a range of modalities, as we can, into that single program, and have them all be moving forward. And increasingly, as kids move up levels, they’re using all of those areas of function together in more and more synchronized ways. So, you can think about from what I’ve said during the talk that that is putting some real, concerted effort into building the brain’s ability to use all of these foundational systems in more and more complex combinations. I hope that’s helpful. 48:45 Kids were part of the study with Harvard and McLane. 48:51 So, OK, and there is a link on our website. I failed to put the link in the list of resources, but if you go to our website, you can follow the link to scientific research, and that will take you to a summary and the preliminary write up of the research done at Harvard. Initially, it was something like 60 children, and they ended up losing in the formal conclusions. 49:20 They ended up using a smaller group than that, because not everyone, people were given these exercises to do. And they were asked to report on how frequently they were doing them. Because there was a kind of floor that they wanted to reach, to create the statistics for the study, and not every family, get logged in, and do these exercises frequently enough to be included in the results of the study. I think it was about half the families reached the number of times the character headset, but the really interesting thing when talking to him and hearing from him is that the people who didn’t do enough of the exercise to be included in the study results still recording improvements in the way their children were functioning. So, you know, what does that say? It says doing more of this work is even more effective than doing less of it, but even doing some of it can be very helpful. 50:20 How do you compare this therapeutic approach to say CBR? 50:27 Um, so, I am really not familiar enough to comment on that. Um, but what I will say is that people recognize aspects of other therapies in brain balance. 50:44 And that is because really, what makes me bounce different is pulling together many proven approaches that have been shown to strengthen individual areas of function. It’s pulling lots of honing those proven approaches into a single multimodal integrated program. So I am sorry that I can’t comment on how that compares to the the therapy that you mentioned. 51:16 But, you know, feel free to call me and talk to me about the therapy that you’re talking about. And I’m very happy to comment further, and to help you think through how what we’re doing is different. 51:30 I’m sorry, CPI T stands for Comprehensive Behavioral Intervention for Ticks. 51:39 It is a per something that was developed and psychologists are usually psychologists and licensed. 51:48 Clinical social workers usually implement it. 51:52 So what I would, Yes, and this is just my guess, not knowing at therapy. Well, what I would guess is that it is kind of like Maybe a BA where you are repeating something many times. 52:08 And you know, what I just said to you tonight in this presentation is that practice and repetition, you know, does change the brain over time. 52:20 And the difference in the approach of really getting to the brain’s neuroplasticity and jump starting a change in this general way is that you are not just working on repeating one behavior or one action, you’re strengthening really the broad foundation of human function. 52:47 I hope that makes sense instead of looking at a specific behavior and looking to address that one behavior, You’re strengthening the whole foundation of the brain and so that has the potential to strengthen the regions that aren’t associated with disorders but are associated with other issues that are so often comorbid as we discussed. 53:12 Can you do your program via Telehealth? 53:17 So before … we are you know I’m sure you’ve heard many stories of people becoming more flexible in their delivery of their service or product. Since covert before Kobi we were really a very much in person program and very quickly we had to continue to work with our enrolled families when we had to shut down back in March of 2020. And we it was really interesting because we had the program that doctor … in the study in Boston to kind of work off of and give us confidence. And we really much enhanced the program that was used in the Harvard study and created our remote program and sense, kind of June of 2020. We have had many families enroll with us remotely. 54:08 No, there’s no one way to do this integrated multimodal work. It just is about consistency, frequency, and intentional effort. 54:21 And so, we can really work with families to help them do the lion’s share of this work at home, through that virtual approach, OK. 54:33 About programs, like Attentive Brain Training Program, using video game with headsets as a way to reach or break. 54:44 Um, so, I know that there are many video, game based, Gamified, gamification based brain training tools. There’s certainly in my line of work, I hear about a lot of them and see them. And I have no doubt that, you know. Those are things that the nature of video games are very engaging to children’s brains. It’s really a way to stimulate the brain through the visual system and activate lots of regions. 55:20 But I truly believe that in order to create this step by step progressive strengthening of all of the systems of the body, we have to be using motor movement. We have to be using sensory systems. We have to kind of get back to the basics and use simple methods or strengthening systems of the body. the way they evolved to work. And we certainly didn’t evolve to receive so much of our stimulation through looking at moving light pixels. And you know, I could be proven wrong through a study that shows that there are ways to use screen based activities to really excite and stimulate and activate all of the regions of the brain. 56:13 But my question is really when we can use the systems of the body to engage with the world, and to build muscle. Why wouldn’t we do that? 56:23 So, that’s my opinion. 56:25 And I, you know, that’s something I would love, continue to talk about and read about. 56:32 Very six year old son started accessibly, blinking about a month ago. I was worried and was told by his pediatrician that it was a habitual patterns. 56:44 What is the timeframe or when should I be concerned? 56:49 So, I’m really glad that you asked that question, because one of the things that I say all the time to families, is that development, although we have developmental milestones and pediatricians, can ask a question at the six month appointment and then one year appointments on about whether a child is meeting those milestones. Like it said on the page about the National Geographic article. 57:18 Having, being born with the right equipment isn’t enough. 57:21 Development is about experiences stimulation. 57:27 Having that, those experiences and stimulation be very diverse, lots of different sources of stimulation, driving development and it’s about how responsive a specific individuals brain is. The genes that drive brain development. How responsive they are to that multimodal experience and stimulation. 57:51 And so, what you do as a parent, the actions you take to engage your child in that really wide range of experiences and sources of stimulation, will influence your child’s development. So, although, like I said before, I can tell parents what we typically see with a child with texts who comes and participates in our program. And parents can talk to me about, you, know, the extent to which their child’s experience, with ticks mirrors what they were told to Be typical. No one can tell you exactly. when it’s going to happen with your child, Your child is on a path of development that is influenced by their life. We call these issues epigenetic issues, instead of genetic issues because it’s really how an individual’s genes respond to environmental and experiential factors. 58:48 And, you know, what I would say to you is, um, if you feel that the tick that you are seeing is joined by another tick. You know you’re starting to see moving towards the criteria for a disorder diagnosis that I showed you on that earlier page. 59:14 You know, that’s a sign, that, that the issue is going in that, know, as Emerson, to put it a kind of degrading or detrimental direction instead of your signs green strengthening and moving in a corrective direction and so I would watch very carefully. 59:35 I would make a real effort cap your son have lots of physical activity and lots of mixed experiences and to, you know, try things and use his muscles and not spend all his time, you know, doing sedentary activities. Things like that. 59:53 And then I would watch for the symptoms of other usually comorbid neurodevelopmental issues if it seems like he has a hard time directing his attention towards things that the teacher is asking him to do, he’s not really kind of able to shift his attention. It stay stuck on something that he kind of intensely focuses on, like Minecraft or Pokemon or trains are dinosaurs, and that’s all he really wants to talk about and think about we call that per separation. So that’s a kind of symptom of neurodevelopmental issues, or if he has things that he’s anxious about, and you reason with him, and you try to explain to him, why those things aren’t dangerous for him. But his mind kinda stay stuck on those things, And that might be moving in the direction of more anxious thinking, or anxiety. 1:00:41 If you see some sensory issues, you know, if you start to see other issues, then I would definitely be more concerned. So hopefully, that’s helpful. 1:00:54 But if you just see one tick, your pediatrician isn’t concerned, you know, I don’t think that you should be tremendously worried. 1:01:08 Last question for the evening, could you please give an example of what the program for a child with tix might look like? 1:01:19 Sure. And this is the really interesting thing about neuroplasticity based approach. The program for a child who comes to us and experiencing is experiencing ticks, is actually really similar to the program for a child who comes to us and is experiencing anxiety or trichotillomania, you know, pulling out patches of their hair. Or a child who just was having trouble reading social cues and is having trouble making friends or child who might be considered twice exceptional. You know, really strong academically, but but but immature in terms of their self regulation and their ability to connect with other people. 1:02:07 Everybody, it’s going to go through our multimodal intensive program made up of beneficial strengthening activities that are targeted to the degree that we can target them based on what we know about the child and what that means in terms of the regions of their brain that are underdeveloped. So parent observations are really the most important part of our assessment process with us getting to know a family. But a family will come in and we’ll work with the child for about an hour. 1:02:44 And what the motor testing will do, some cognitive testing, are, are program director, will make some observations of the child. And then we’ll kind of pull that all together into a report and meet with the parent and talk about how we would design a program. 1:02:59 But the difference between programs is about the starting points in this progressively challenging program more than it is about only including certain activities. 1:03:11 Because what we want to see is that the brain is responding to this intensified. 1:03:20 Frequent exercise that is being done over a concerted, you know, of a period of time, of like 3 to six months, depending on what we see in the assessment. And I will tell you that kids with tic disorders, typically they’re more in the, you know, six month range than shorter because it just takes a little bit more of this work to strengthen those parts of the brain that suppress ticks. 1:03:49 But everybody is going to be doing a program that is that multimodal approach to get lots of regions of the brain activated and lots of regions of the brain better and better at making connections together. 1:04:05 Terrific. 1:04:06 Thank you all for joining us. 1:04:09 Tonight, on our web webinar, a neuroplasticity based Approach to Ticks, there is an exit survey, which we need everyone attending to fill out. 1:04:19 The webinar blog is open now and available for the next seven days for any additional questions that were not covered tonight. 1:04:27 That website is WWW dot NJCTS. org. Also, an archived recording of tonight’s webinar will be posted to the site. 1:04:39 Our next presentation presentation, IEP in 504 plans there, Are you Eligible, and How to Begin will be presented by Andrew Meltzer, a score. 1:04:51 Scheduled for December 8, 2000, and this ends tonight’s Webinar. Thank you, Ms. Stoeber, for your presentation, and thank you, everyone, for attending tonight. 1:05:02 Good Night.