Non-Medical Treatment of Tics: An Overview of CBIT and the Rutgers Tourette Syndrome Clinic

Presented by Dr. Graham Hartke ##

This webinar will provide an overview of Comprehensive Behavioral Intervention for Tics (CBIT), a structured evidenced-based non-medical intervention for tics based on cognitive behavioral therapy. CBIT helps individuals of all ages learn tic management strategies and reduce tic symptoms. There will also be a discussion about how CBIT can be best integrated with other psychological, medical, and educational interventions. Finally, a brief overview of the Rutgers Tourette Syndrome Clinic will be provided.

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Thanks Kelly and good evening everyone. And welcome to tonight’s webinar, which as Kelly said, is non medical Treatment of Tics, an Overview of CB IT and the Rutgers Tourette Syndrome Clinic.


The webinar will provide an overview of Comprehensive behavioral interventions for tics which is a structured evidence based non medical intervention for tics which is based on cognitive behavioral therapy.


Our presenter for tonight is doctor Graham Hartke. Many of you may be familiar with doctor hierarchy as she’s presented several webinars for us over the past several years. Doctor Harkey is a licensed clinical psychologist.


Who practices has a private practice in roseland?


New Jersey specializing in cognitive behavioral treatment of anxiety, obsessive compulsive disorder, depression tics in Tourette’s Syndrome, ADHD, oppositional defiant disorder, and high functioning autism spectrum disorder.


He also specializes in the area of applied sport and performing arts psychology. 


Doctor Hartke works with children, adolescents and adults providing therapy, behavioral assessment, and psychological evaluations, is also New Jersey Certified School Psychologist, School Supervisor, and School Principal. Doctor Hierarchy became connected with NJ CTS, initially several years back when he was a student training CTS clinic that Rutgers, and today he currently serves as the Clinical Director of the Tourette Syndrome Clinic at the Graduate School of Applied Professional Psychology at Rutgers University.


So without further introduction, I’d like to turn the program over to you, Graham to begin the presentation.


Thank you, Barbara and Kelly.


And I would like to welcome everyone tonight to the webinar, Um, This time is the first webinar I’ve done for NGS and Jay CTS, where my video is on so I had that, I can’t see myself.


I took it off because it just takes up the whole screen so hopefully if there’s a southern that flies on my face or something like that, just Latino, all our brush off. But I’m not going to be looking at myself.


So today we’re going to be doing a webinar. I’m gonna give you an overview of save it.


And I’ll talk very little at the end about the Rutgers Tourette Syndrome clinic. I just want to say that, you know, this is an overview.


The webinar, it’s a short platform.


It’s not a training for someone to do see it, and it’s not also treatment for somebody who’s just going to give you an overview, But hopefully this could clarify and discuss, you know, we can discuss some issues related to it.


All right, let’s get on with it. So, today’s webinar, we’re going to do an overview of … and non medical treatment.


This will be not a really in-depth overview, just kind of covering some key areas, really, this event.


And also, I recognize that some people on here are experts and I know a lot about TS. Others might just be, this might be all new, so I want to provide some information, but I’m going to tailored towards how it’s relevant to see that.


Then we’re going to do a cebit overview, and then I want to talk at the end, are mostly about, a, lot, about the process of doing seabed, because I think this, a lot of people can describe it. They can read about it.


But since I’ve been doing this treatment for, no, over, maybe a decade and a half, and worked with many families and individuals of all ages.


I hope to, to share a little about the process of how it works and some things as we go. Also, at the end, we’ll talk about the Rutgers … clinic.


Um, OK. And I have some resources on here that we can talk about at the end. So let’s do a quick overview.


And let me just make sure had the time, OK. So, um, Tourette syndrome is a neurological disorder, OK. So we, we always that, is something that repeat very often but it’s neurologically based. And it’s characterized by tics. Tics are sudden rapid recurrent non redneck repetitive motor movements. And vocalizations there are two major categories of tics. We have motor.


Which are, you know, movements of different muscles in your body. And, we’re vocal tics, which are …, which are sounds.


We also categorize, tics as simple or complex.


Simple tics involve a few muscle groups, and complex tics involve multiple muscle groups.


As far as the official diagnosis is concerned, the latest diagnostic manual DSM five, we have these are the mean diagnoses for Tourette’s and tics.


So Tourette’s Disorder is really having multiple motor tics And at least one vocaltec present during you know, the course of having Tourette syndrome. So really it is just a way of describing that you have multiple motor tics and at least one vocaltec its historic name.


But it really describes having multiple motor tics and at least one vocaltec. And really one of the key things is you really, most people have symptoms and before age 18, usually way before that.


And the other diagnostic criteria is chronic motor or vocaltec.


So these are individuals that really just only have motor or vocal tics. And for both Tourette’s disorder and persistent or chronic motor vocal tics disorder, you need to have it for at least 12 months to have those diagnoses.


Otherwise, you get what we call the provisional … called transient Tic Disorder, which means you, your tic really, it lasts more than four weeks, but it’s no longer than 12 months.




So really, there’s a range of different presentations of tics.


And someone who might have a chronic motor tic no diagnoses, it might change to a Tourette diagnose, diagnose the diagnosis, when they started having a bulb will take at a later age.


Honestly, the diagnostic criteria is relatively no historical in that you don’t really need to distinguish between Tourette’s and Chronic or Motor Vocaltec because it really just describes tic disorders. So, I think the label Tourette has a lot of weight to it, sometimes, for some people. But really, it’s, it’s a, it’s a way, we describe, a tic disorder, where you have multiple motor tics in one book.


OK, so when we’re talking about the treatment today, see if it applies to to all of these tic disorders.


So key elements of tix perceive it.


So tics are usually preceded by a physical urge OK, um, Tics also, naturally, wax and wane.


So in the course of having tics, they just naturally will increase and decrease in different areas. Where we’ll talk about more about this in a second, tics can also be influenced by internal and external environments.


So it’s, it’s neurological, but how we feel and what’s going on around us can influence how tics are manifests it or how there basically really how someone’s experience them, Right? So if someone’s very stressed, or if you aren’t, you know, they’re feeling that they have a test that day in school they might have more text, right? So the environment can influence the texts.


Tics are also mostly involuntary, but there is often some temporary voluntary control with sustained effort.


So these are some key elements that are about tics that are important for C bit.


So let’s look at this a little more closely.


So we’re going to talk about the herbs. So the physical or just called the pre monetary urge, OK, so individuals can usually anticipate tics. A lot of times individuals are not aware of it, but with a little bit of training and practice and just education about it oftentimes for for many tics.


And I would say, most tics, and most cases, individuals can receive some kind of feeling right before the tic happens with kids and even adults, sometimes very different words. Instead of pre monetary sensory urge, we might say the tic signal or the tic urge.


And it’s often this is felt as a sensation occurring in the muscles expressing the tic.


But it doesn’t always happen exactly where the tic occurs. So one thing about the pretty monetary urge is that it’s usually around where the tic occurs. But not always, so, that’s one thing and save it that we want to be aware of.


Um, and it’s usually described as attention or other physical feeling so it could be an edge.


It could be a fresher, it could be just a feeling that something is not right, and the tic temporary relieves that feeling, right? So that’s kinda the process, is that usually individuals have some kind of physical urge and it’s relieved by the tic.


So the best analogy we have is usually it’s like having an itch, so imagine your arm is itchy and you scratch it, right? The it should be the physical urge and then scratching it would be taking that example, if that was, you know, to try to relate to it.


Let’s look at waxing and waning.


So tics wax and wane. They go up and down a change in very naturally over time, and contexts in multiple areas, in multiple ways. So they can change in the type of tics.


Lot of times the first six and will have will be around their head. So, oftentimes, for motor techs, it’s eye blinking. Vocal tics is some kind of sniffling or broke clearing and over time texts.


Can, you know, just change throughout their body?


Usually goes from head to torso kind of process, but it really can. It can be different ways for different people. So it also changed and how many tics someone has all might have three tics when there are five and then they kind of go away. And then when they’re 10, they have 14 tics. So the number can really change over time. The frequency intensity, So, how often they’re having a text, how strong they are, the complexity, so if they’re just simple text, or they involve multiple muscle groups and movements, and even how they present themselves. So some of my head, I have a local tech for shouting, and then they stop shouting and they start squeaking. It’s similar, but it just changes a little bit in the nature of it.


So, by nature, tics do this something that has come up and all.


And the precision I’ve done over the past decade or so in describing this and talking to parents and families, is that, know, what’s one thing you would say it takes is a really, anything goes that most movements you could think of could be a tic and probably have been a tic before. It doesn’t mean you’re going to have all the tics, but it’s possible and to almost expect the unexpected, it’s not to expect that, OK, something else different might happen in the future.


Why do we have waxing and waning? Really that the thinking on it is that there’s neurobiological factor responsible for tic initiation. So it’s neurologically base. And the urges or neurological.


And the general pattern of waxing and waning has neurological basis, but also there’s an interaction with the environment that may explain tic variability. So, you know, tics might waxed and waned throughout the course of the day.


For example, there are some kids who or adults but, you know, that will experience many, many tics when they are, know, on-screen so that they’re on their i-phone or iPad. They’re off the iPad not ticy as much.


So we can wax and wane within you know, a few hours and minutes based on the activity But also generally waxes and wanes over over months stays years, OK? So tics are influenced by into our internal and external environments.


This is important. This is kind of like a functional behavioral standpoint, but it’s important to kind of look at, you know, different types of antecedents and consequences. So there’s, the reason this is important is that the environment can be modified to promote some tic increase, you know, we can make people take more if we, if we, you know, have them in front of a microphone speaking in front of a large crowd, if that makes them nervous, maybe it’ll take more or we wouldn’t do that just to pick their tics more. Or we could reduce someone’s takes maybe by, you know, having someone in a quiet place or with someone who plays music, might play the piano and their tics decrease. So by adding things in environment, sometimes it can promote changes in tics. So, for example, if we look at internal, which means, you know, are how we feel our moods.


Where’s my mouse?


It’s not on the screen, OK? I can’t point to it.


There’s some reason.


But for internal, we might feel refer a tic occur. Someone will feel a pre monetary or tic urge. They also might feel stressed. They might be in a certain mood.


Then, after a tic happens, right? The ticer might reduce because the tic took away the urge temporarily, and there might be other emotional reactions. You know, someone could be relieved. They might also be more stress after check, because it doesn’t feel like if it was done the right way, or you urge is still there, or maybe the tic involve some kind of self injury. So there are different ways to look at it. Right? So external Before ticers, someone might be in a certain setting.


I knew some students, when I worked in a school who, particularly this one student, who started to tic only when he was around certain, a group of 1 or 2 students. Well, I guess there was about three soon, So a group of three students in this class was not taking as much or on other students. But when in that classroom, the students, the tic, started to really happen a lot. So, sometimes can be very specific and condition to certain situations, after a ticet occurs, we look at external consequences. So when a tic happens, let’s say a kid is shouting in class, maybe that he gets removed from the class or she gets removed from the class.


And, and, you know, when that happens, they get they don’t have to do their schoolwork for a half-hour, Right? And that might not be the kids, the goal of it.


But we wanna look at how these factors might be related to the tic.


The last area is the voluntary nature of tics.


So I had like six slides about this, but I cut it down to three because sometimes I go off on a a long talk about this, but I want to be clear that I’m not implying that tics are voluntary here. It takes for the most part are involuntary. There’s a neurological basis, OK. The urge to someone get is not made up are caused by individuals. So, you know, think about, if you could just make it, your arm, just H by thinking about it, you know, to do that, right? So, it’s not that these tics are people are doing these because they want to have these urges and and do this.


The thing is, though, that there is a slave voluntary component to tics, people can mostly hold back for short periods of time. But, they really can’t resist over a long period of time.


And really, only on some occasion with some tics, particularly when someone’s really upset or stressed, it’s really hard to do this on an, on off often. 


So one thing I want to point out here is that we say voluntary, It’s only a short-lived element of control that someone has to make a voluntary.


So the best example we have, because when someone’s doing this attention builds up and ultimately becomes almost unbearable, so imagine that you have a really bad mosquito bite is really itchy, and then you just could not touch it. Or you felt like you wanted to sneeze, and you just had to hold it back.


So, yes, you have some control over it, but it’s really, it’s, it’s not like total control where it’s just easy, only temporary control and only from the right mindset. Right. And you can really focus a lot of energy.


It’s energy consuming, so this is important.


I’m just gonna put this slide in for no dimension this year, that voluntary, you’re only means there’s an element of voluntary, not fully voluntary, right, but you can voluntarily breed.


But you can’t just tell yourself, I’m not going to read like you, your brain will this take over and you’ll breathe involuntarily.


It’s important, and this happens. This comes up a lot in schools and other contexts, even and families to resist being a tic detect. If you’re out someone that has text, right. There’s no way you get 100% know that someone has tics and that you hear very often that people feel like people, individual tics did it on purpose and they’re trying to, you know, cause problems or whatever the case.


But, bears in reality, all the factors that we talked about, our while, it’s tough to say someone did it on purpose, right? They have urges. And there’s also can be comorbidities. So what the, one of the best ways to kind of think about it is, you know, if you feel the pull to think this kid, definitely as text to remind yourself. We know this interval has tics, Right? Stop cyber herself from weren’t worrying if this is a tic in the moment and assume that the behavior is at least partially related to T S or associated other conditions, right?


So realize that even if this behavior maybe this time, was more of an impulse control in general that throwing a pencil across through Medicaid or doing something, you might not have been a tic. We don’t know.


But just know that this kid this individual does have no neurological difficulties, and whether it’s specifically a tic in this case, or more ADHD, or impulse control in general, it’s not worth being a detective about it, right? So, what this can cause, a lot of times, because a lot of misunderstanding, kids can feel really bad.


And, you know, there’s, there’s other things I could talk about this with, but I’m going to move on for now. So I think you get the point.


So really quick, overview of T S and non medical treatment.


like other conditions such as Autism we don’t have. We don’t know the, the cause, we know it’s neurobiological in nature.


The genetic studies, especially the Rutgers and X study, which is the national repository, actually International Repository of Genetic Information for Tourettes, you’re interested in getting involved that study. You know, we can give you information about that, But basically, it found that there’s, there’s over around 400 or so genes, maybe a little bit over 400 genes that they think are involved, So it’s not just one gene.


We do know brain areas that are related to motor and reward systems, such as the Bazel ganglia or the strain them are involved, Which stray and particularly with C, that, is important, because that is an area, what’s kind of a gatekeeper for for inhibitions and impulses.


There’s also some evidence that some prenatal factors, you know, as you know, during pregnancy, might be involved in this as well.


Epidemiology, you know, we say one out of one hundred children have this, but it’s a much higher percentage of people in the general population who have some kind of taken their life, even up to about 30%. That might have a tic for a short period of time, a transient tic.


But I want to add 1.01 is really what we say for people to have a diagnosable disorder And males are 3 to 4 times more likely. And it’s also reported widely across ethnic, cultural, racial groups, so it’s not like 100% population has tics.


This is important to perceive it, that this usually begins between the ages of 5 and 10, as we usually see the first central’s amine onset. It’s about 6 or 7 tend to be most severe between 9, 13 and takes usually diminished for most people in early adulthood. But not everybody, right? So, about a third of adults will have tics to, you know, basically the same degree of severity. They had it late adolescence, about a third have checks, But it’s a lot less and about a third really don’t report many tics.


But most of us that work with the individual to have tics or had in the past, you know, well, we’re working with an adult who had text, we might still observed some text that might, we might not pointed out.


But really, it’s kind of about, if someone would perceive that don’t have any tics anymore, and that’s kind of fine with us, we’re not gonna, you know, say hey, that’s a tic or, and pointed out, but what I will say about course.


A lot of times, girls, and this is anecdotal evidence, and there’s some evidence and research about females, later in life, will tend to report symptoms a little bit later, whether it doesn’t get reports later, or they get symptoms showing up later. But I definitely see in my practice, a lot, over the last several years, a lot of girls coming in around age 13 or 14 for having either the first text or having tics get a lot worse during that time.


So I think there’s a little bit, it can be different on.


But there are girls that also have tics early at age five, but I will say that you often don’t get as many boys who have a sudden onset later as you do girls.


And to diagnosis, you really do need a physical exam and neurological exam to other conditions. So, typically, a pediatrician, well, recommendable, for, let’s say, watchful waiting, you know, keep an eye on it, you know, at first. And it’s, it’s going on for awhile, but, eventually, it’s important to go to a neurologist, particularly one that specializes in tics to kinda get an exam and rule out.


There, could be other conditions, neurologist usually won’t take very long, especially as a trained neurologists, and most, or all does a pretty good diagnosing tics, we’ll be able to pointed out.


Um, OK, so let’s talk about treatment guidelines, OK.


And, What I will say about this is really important.


Article came out in the American Academy of Neurologists last year, I think, in September.


Basically, having updated their guidelines for the treatment of tic disorders and why this is really important for our talk today is that Cebit, or the behavioral treatment a text was listed as a first line treatment, which we’ll talk about the history. that was kind of a big deal.


Um, so, their guidelines basically have that, you know, to educate families individuals about tic disorders.


As the first step, so if someone comes into a doctor’s office, a pediatrician’s office, they want to educate the individual and the family.


Talk to the parents about it, and usually what they’ll do if there’s not a lot of impairment. Tests aren’t really bothering Anyone. Let’s say, let’s keep an eye on it, because many tics are transient and will go away on their own, in many cases. So watchful waiting is just a way of describing doctoral. Say, Let’s just keep an eye on it.


It’s not a big deal. Sometimes doctors will give the impression, or say, like, don’t ever talk about it with your kid. If you do, it’s OK. It’s more that they’re saying that to say, let’s just kinda have almost calm the parents. Sounds like we don’t need to worry about right now. It’s just keep an eye on it. But talking about tech to a kid is not going to make it worse. They’ll, they’ll play off more of, if the parents are really anxious and it’s, like, they’re making a big deal about it. So it’s always important as a parent, it’s not a big deal, too.


If you tell kids a tic, it’s, it’s, or, say it’s the things that tic, it can be helpful. It’s more about how it’s presented to them.


In a way that’s that model says that it’s not that big of a deal, it’s OK. You know, if a kid gets the impression that’s really dangerous or scary, than they might, That might not be the best thing to do.


Um, but I do get a lot of families that tell me that they’re, they were under the impression that they should never bring it up ever with the kid.


That’s not really, it’s really more, a choice, the family, and if you do bring it up, it’s OK. It’s just, you can become about it. It’s not going to make the … worse, but authentic, if a young kid has a ticet, it’s better just to kind of keep an eye on it and let it be with the kid asked you about. I can say, I think that’s just like a tic movement.


Sometimes families that come up their own words like ticle or, You know, the twitch or something like that.


So, I put this simple.


the next area is cebit, OK, so besides educating families watchful waiting, keep an eye on it, They recommend, save it. So they have studies, and they did a meta analysis of many studies that show that … is more likely than supportive therapy and psychological education or reduce tics.


Any other areas, medication. So depending on the medication, they gave medication a low, or medium confidence that it was more likely than placebo to reduce text. Now, I’m not gonna go through that article with medications.


Have a link to it at the end, but, the main thing is that Steve, it was on there, So, let’s just go over the general tic treatments, and then we’ll get into C bit specifically.


So, really, when you’re going to treat tix right after getting a proper diagnosis, often you can consider a medication or a medical treatments, usually medications, such as anti hypertensive. So, the alpha two drugs, such as …


or quantity in the Senate release club scene is intuitive.


That’s usually one of the first blind medications, one of those vacations usually go off the scene.


But also, they can try neuroleptics.


You know, the anti-psychotics are atypical anti-psychotics, are are another class they might go to if if tics are worse. Sometimes medications will also be given for comorbid conditions where we’re not really getting into comorbid conditions too much today. But it’s it’s a route that that you know, a lot of families will take. Sometimes if tics are painful, Botox can be useful, especially in neck tics. And then, in severe cases, you know, they can use things such as deep brain stimulation has been tried know, in some cases, has been shown to be, effective, other cases, not as much for tics.


Then we have non medical treatment.


So, behavioral treatments cebit Alright, the hallmark of Steve it and the main part of secret that we know is haven’t reversal but it also includes a functional behavioral assessment relaxation and we’re going to talk all about that in a minute.


But also, supportive psychological treatment, Education, coping, strategies, social skills, and monitoring our partners, a medical treatment, and we’ll talk about that, too.


There’s also a bunch of alternative treatments, and I’m not gonna get into the, no, the pros and cons, that there’s, but I will say, there’s a lot, a lot of things, that people trapped. There is limited to, no research on it, and there’s some anecdotal evidence. But allow champion was to try it. because there’s no cure for Tourette syndrome, right? So loud sounds can go, so let’s just try it. Right. So there are a few limited studies. I think there’s like on my hand I can count how many studies there are, for THC and CBD there was a study recently of CBD and tics.


Jeremy I think involved like 1 or 2 subjects. So there are very small studies that showed some limited evidence.


I know there are some older teens and adults that try to self medicate and might have some handle on it.


So I’m not saying that any alternate treatments don’t work, but there’s just not as much evidence in them, OK, and then some people will use supplements and other.


There’s other alternate between its two, but we’re going to talk about sea bed.


So, this is the big picture, this is what in reality goes on for a lot of families when they work with tics. Besides, I didn’t have this on here.


But I do think it’s really important for for families to get a team together, you know, especially if you’re tics are going to be more than mile, that they’re causing some interference.


The team will really consist of having some allies in school, um, and also having like having a relationship with the school administration and counselors. 


Also, fining a medical professional that you feel comfortable, whether it’s your pediatrician or a neurologist that’s familiar with …, and then sometimes, you know, also maybe, having a psychologist or other mental health professional involved, Teams might involve other people with other conditions, as well. Sometimes, speech or OT might be involved as well, PT.


But just kinda get your team together, but overall for tics specifically, most individuals have a combination of just straight up coping strategies that work for them. And a lot of families that come to me, they already have some things that they, they used to get through the day. They might have a stress ball.


We might adjust the environment, like no screens as of this time, It might take breaks, chew, gum, some just some strategies that people have employed or schools use or they use at home.


Then we have standard treatments, whether it’s medical, psychological are just even supportive therapy. Sometimes then, educational accommodations is key for for a lot of kids making sure that the school understands that they have Nita accommodations, either true or 504, or through an IEP, is in place, and that we have some helpful activities, and alternative treatments, OK.


And these may change as kids change.


So, let’s talk about …, and I’m not this, just, you know, to, I’m not going to go over the assessment part too much, it takes, and I talk more about ….


So, survey is structured, and it’s evidenced based, OK?


It’s non medical, it’s for all ages, really, but mostly childrens starting around age, 8 or nine up that’s probably most appropriate for. I’ll talk a little about working with younger kids.


So cebit works one ticet a time, OK, we don’t. We don’t just treat eight tics at once. Medication would kind of be more of a global treatment. Where would you take the medication and might decrease your text globally, but see if it really works one at a time.


And really what we do is we, there’s three main components, right. We want to increase awareness, we want to use a competing response when the urge is felt, OK. And then we want to make adjustments to daily activities to help reduce tics.


And … was really I’ll talk about the composite it but it was really put together by doctor Doug Woods, who’s psychologists think he’s at Marquette right now but he was out of University of Wisconsin for awhile.


So dogwoods is kind of a key name with Cebit, and the treatments based on an integrated model of T S, so looking at T S is having like, we discussed a neurological basis, right, occurs because of genetics neurological factor, and also that the environment influences it. So this treatment is possible because there’s that component where we can influence it through the environment.


Basically, the entire interaction, interacting with the tics, shapes tic expression.


So I’m not gonna go through all the research, but this, the main seminal study, the first big, random ice controlled study of …, published in 2010 and in JAMA, And it found that cebit compare with support therapy and education built into greater improvement. There’s also a study, a few years later showing that it also was a randomized control study, significantly decrease symptoms, and was safe and effective for adults. So we have for children and teens and adults, and there’s been a bunch of other studies since.


Um, But what we do here are the components. So, we always start with an assessment as part of a clinical intake, OK?


So, we will do it a standard interview of parent and child and family, often, will you use some standardized rating scales and observations for behavior and maybe more specific ones for ADHD, such as the vascular corners or the outcome box scales like Child Behavior checklist.


Then, what we do is we also do a, we call the Yale Global Tic Scale, which is an interview, semi structured interview we do with the family in part as part of the clinical intake.


This gives us a picture of the tics.


And we kind of assess that the individuals’ ready, willing and able for …. So, what I’m gonna do now is talk more, I guess I’m not going to folks NSS about the components of …. So, the main components are educating about tics and tic disorders.


Um, adding a function based assessment and intervention component to it.


And have a reversal training, which I said is a key part of this treatment is kind of the main part And relaxation training. So let’s go through these right now.


Well, first of all, over the coals the goal, the sea bed or such. And this is important because there is no cure for tics, OK? We do not have a cure.


So what we try to do if we want to reduce the symptoms of the ticing the ticers, that is the goal of Save it.


So reducing how much, how the frequency intensity and duration of the tic, and, in the ticers itself.


We also, especially in cases where it might not work so well for one tic or the other.


You know, at the very least, you want to develop and teach Tic Management strategies so on, so someone can, can work on managing in the moment.


And then we also want to boost boost.


So social confidence and self efficacy, we want the individual to feel more confident that there’s something they can do to help with the tics, and learn about T X be educated, right?


I put something I remember is a secret is not a cure.


Our main goal is to reduce tics, provide ways to kinda manager in the moment. If the tics are reduced overall, at least they have a way to manage it, They know more about it, and we boost confidence.


So, treatment is typically about 8 to 12 sessions. It can be as short as like four sessions. Sometimes it can go really fast, if you have just one, check the work on it, responds really quick.


Other people might do siva for a long time for, you know, several months or, you know, on and off for a few years depending on how the wax and wane.


It really depends on the person how many tics they have, and the waxing and waning. It’s appropriate for children and teens and adults. For younger children, it can work but it really depends on the child.


Kids are different, you know, developmentally some kids are, you know, at age five array to get up in front of a microphone and give like a, you know, a speech to a crowd of 400, you know, adults.


And, you know, other kids are just fine. They’re totally normal kids, they just, they just want to play their toys, and they’re not really interested, right?


So, it really depends on the child, And if they’re ready for, and also, if they’re motivated at all.


Though, in cases where you have a young child, they’re not super motivated. Oftentimes, parents will get a diagnosis between the ages of 5 to 8 or 9, and now that it is one of the top guidelines still get referred to Save it Right away. Which wasn’t the case years ago.


Which I’ll talk about as much and, know, but a lot of times, the child’s not really ready but the parents, you know, like, you know, understandably might be very nervous and want to know more about it and get, get the south of, I just wanna point out that … is a behavioral treatment. So it’s really important that the child is developmentally ready, and, and willing and able to work on it, right? So we might include a kid is on the fence. We might include reward systems and really work with them, and take a slightly slower approach to teach it.


But, um, no, I’ll talk more about this later, But I think with children, you really want to weigh the pros and cons of starting in certain age. Like, you might want to wait a year or two until they’re a little bit older, because you don’t want them to have a bad experience.


And then, never want to do it again, because I hated it when they are five.


So, if you, it’s, it’s, sometimes, it might not seem like you want to wait, but waiting could be the right thing to do, until a kid is ready.


So, one thing I wanna point out too, is receive it.


For those of us that do receive it, you know, the clinicians, I know that. You know, it’s a smaller group of us, a lot of us know each other.


I would say most of us agree that you can use all components of … or you know, you can pick and choose which one you want but there’s, you know there you can go through it through all of them. But often have a reversal on its own can be very effective.


I personally like to start with have a reversal, because if have a rustle works, you when that needs to do the other components as much.


Um, treatment is often delivered by psychologists or other mental health professional who’s trained involves family collaboration. So, we work with a child or teen or events, and it’s all we might work with a spouse or a parent of a young adult. As far as, you know, we want them involved in the assessment, having them kind of talk about the text, and then the education component, so they’re getting educated as well.


Also, on how we model and demonstrate, know, the tics, mala, demonstrate what we’re doing, the practice to save it.


And, for really, all components, we include the parents, especially if we’re doing function based interventions, will need parents to collect data and kind of help either, you know, implement interventions.


The other thing is, along with the individual therapy, cebit has been delivered, Yeah, an online training program.


So John Woods has developed an online way to do tics, and Steven at home, called a tic Helper.


Um, I believe he’s got, has some research supporting that.


You’d have to, I’d have to double check, and I don’t remember off the top of my head when the study was done. But I know that if you want to take help her dot com, you can see. I think, you think it might be three. Or, I don’t think the cost is too high.


There’s also some research recently where they, they had delivered Seba in groups, they had a group of, of kids, and they did it as a group. And it’s also also just, you know, a diverse group of people are trained to do cebit.


So, when, if you, if you’re a professional watching, and you do, as well, talking, know, there’s ways to get trained in doing cebit, particularly through the Threat Association of America, dogwoods kinda heads that up. There’s different training. Often. When you go those trainings, you’ll see people from different varied professional backgrounds, physical therapists, occupational therapists, social workers, autism, specialist. So just to know, it’s not just psychologist to do it.


Um, so let’s talk about the components of ….


Very important is to education. Right? To learn about tic disorders, and this is why it’s important to normalize and be OK with, you know, we’re we’re talking about a tic. It’s hard to treat tic disorders. If you can’t at least call it a tic. I don’t always caught Tourette’s to everybody. Especially young child.


Or if the family, if you prefer not to use a word, But I think the word tic is something I want them to at least know it, Or a word similar to it, to learn about the behavioral model of texts, which we’ll talk about in a minute.


How it works, and just answering questions, OK, The one thing that’s really important is to really know if the child is ready, willing, and able to get started.


So the functional assessment intervention, it usually involves identifying situations that proceed and responses to happen after tics happen They make them worse. So we start there. We want to know if there’s any antecedents.


So, we might ask, like, we have, We have different functional assessment, know, protocols and sheets. And we’ll kind of do interviews with families and find out, for example, if there’s a head tic that had to happen more when you’re watching TV, or to happen more when you’re in the car, Or less. And we’ll kinda get an idea that, and then we also find out what happens after ticet occurs. Maybe nothing happens. Maybe a teacher tells a kid or a parents, I was a kid to stop a lot, and that’s something that we want to know.


We basically use this information development strategies for modifying the environment. We might ask somebody to, you know, for example, into seen, intervention might be to educate others. You might really want to talk to teachers. Or, siblings: not to respond to a certain way, Or?


Well that we’re on consequences.


I mentioned, but we would really want to educate others, or we might prompt, practicing of have Russell before tics happens. So like we might remind a child, like, look, we’re going into the car. So where it happens remember to practice or establish routines. There’s lots of different ones we can come up with.


You know, sometimes it might be to, you know, reduce screen time, you know, things like that and also that many times that’s a common one.


On these days, especially during Kobe, when a lot of kids are home, on the screens, for hours, consequence interventions. Ignoring Tix reinforcing the practice of have Russell.


And for example, let’s say kids get to leave the classroom every time. You know, when they’re taking we might say, you know what, why don’t you have them just bring their work so they can do their work in other room My down to this all the time.


but just an example of something that you might do an intervention.


OK, so have reversal trainings at the core of Seabed, See essential component, and this is not a new treatment unfortunately, this well, I don’t believe this was extremely widely disseminated for about, for many years. So as an none the psychologists study this and developed it nearly 50 years ago, it was shown to be effective for texts. They have a book.


It’s, there’s still some old copies on Amazon, it’s called Have A Control on the Day. If you feel like picking it up, you’ll see in that book, they, you know, they cite evidence that this worked, you know, back in the early seventies.


So it’s kind of surprising that, you know, for, for awhile until it got robust.


Rediscovered, kind of by doctor Woods and others in the 19 nineties and early two thousands and really researched and we had more funding on it that it wasn’t really at the core of treatment when I was in the the Rutgers Threats Clinic in the in the mid two thousands.


We didn’t do have a vessel or receive it protects because we didn’t think it was there was anything to treat any way to treat tics behaviorally. So, that was only 15 years ago, right? So, it, in that time, it’s now become the one of the first line recommendations for treatment. So, I always point this out, that it’s not anything new. And it’s rarely a great thing that it’s been brought back, because it’s helped many, people. So, there’s three main components this, we’re gonna go through. Awareness: training, competing response, and social support.


OK, so, this is kind of a key part, when I do have Russell, I’m very big on going over with people and talking about it, so.


So, basically, the model, the theory behind it, is a negative reinforcement model, with texts, and I kind of alluded to this before, but when you have negative report, reinforce, that means that by removing something, it increases the behavior from happening, right? So, by no taking something away, you know, then somebody will do something more, right? If they avoid something, then they’ll keep avoiding because they’re, they’re removing something. I’m usually unpleasant. So, in the tic and planets, that tics tics are negatively reinforced because they temporarily remove the unpleasant sensation from pre monetary century urges.


So, by doing the tic, the urge goes away temporarily. Just like if you scratch a mosquito bite, it might feel better for a few seconds, But then it comes back again. So the tics keep happening. The function they serve is to remove that unpleasant sensation.


Um, so they make it go away, but only temporarily and the cycle continues. It’s like scratching an itch.


So what have a vessel does if we want to break this cycle of reinforcement, OK? This is at the core of what happens. And sometimes I call it like retraining your brain, especially when I work with kids.


So basically, it starts with awareness training. So this is where we describe the tic in detail. We really want to know everything about. A lot of times, people just do the tech. They don’t think about it. So, for example, if you have a head tic, it’s your heads moving to the right, you might ask, Well, where does your head goes? Go to the right to the left.


And, you know, Oh, it goes to the right, OK, When you move your head, you also move your eyes and child might say, Oh, yeah, a little bit. I move them up.


So you might go through every part of the area around their tic, or even ask if there’s other parts of the body involved. Like, do you flip your stomach moving an ox? sometimes you might have another part of the body that’s not near the tic? That’s, you know, we’re an urge is happening before the tic happens, and you want to so sometimes you do. You just do a scan you really describe in detail the tic.


Next thing you want to become aware of is the pre monetary urge of the ticers, right? So, we want to get better at perceiving it, describing it and practicing it.


And this seeks training. Sometimes kids are not aware of it.


Sometimes they really don’t report having it.


But oftentimes, if I ask them that kind of let me know if they feel something, that area, they will start to notice it. And they’ll say, Oh, yeah, I am doing something. Or if I asked just kind of a general question, like, can you just tell when it’s gonna happen? Some, you know, Do you just know, and they’ll say, Oh, yeah, so I might ask for five minutes if they feel an urge, and they go, No, but I go, Well, you know when it’s going to happen in. Let’s say Oh, yeah. So sometimes we’ll just ask that question.


And that’s really what the point is, is to try to we want to eventually try to catch it before it happens. Right?


So what we will practice awareness training, sometimes for a whole session, Impression of the Week, if we need to. Or sometimes, kids will just know, they’re ticers really fast. Like, Oh, I feel it.


And so what it usually looks like as a kid will, we’ll have a conversation after we describe the tic. I’ll say, all right, now, we’re going to talk, we’ll talk about something.


You really like, let’s talk about football, you know how great the Jetsons giants are this year.


And we’ll talk about that. And while we’re talking about it, you know, just raise your hand when you feel the urge so we’ll talk and then cable. I feel like you pointed out some great that’s great, keep going. Oh so the Giants are great. They look like they go into the Super Bowl, You feel ready to hand. Oh, great, You notice it.


So, sometimes awareness training goes really fast, sometimes it takes a little bit longer. Every tic is different. I remember we work at one taking the time.


Then, once we noticed, the kid gets good at being aware of tic or adult two, we do this with adults.


Um, we will try to implement and go in and figure out a competing response, silica, … response is basically a incompatible behavior or opposite behavior.


And really, what we’re gonna do is we’re essentially want to, what we essentially want to do, is catch the tic before it happens, and then hold it.


and hold it for longer than anyone usually holds it until the urge that’s there. So imagine if you felt I feel a mosquito bite and you don’t, and you say I feel it, and I’m asking you to move your hand away from your arm and hold it. And sit with that uncomfortableness for one minute until the urge goes away.


When we do is we come up with a competing response. Some kind of incompatible behavior that makes it easier for you to hold your check back.


It’s not the competing response itself that that makes the change is the process of not satisfying the urge.


We want that urge to go away on its own, in a process we call …, We think, with tics might be something we call inhibitory learning. But right now are so saying habituation, which is basically, you know, over time, it’s unconscious learning. You’re, you’re, you just get used to it, right. So it’s like if you go into a cold pool, your body adjusts. There’s something about the process of not feeding. That urged by not, satisfying that eventually your brain almost. It just stopped seeing the signal as much. So we will develop companion responses unique, each tic.


For example, if someone has a neck tic, an opt in we want tics, we will we might ask them to just hold their neck straight in the middle and just call it. They’re in that position.


Right? If they have an arm tic where their arms flapping up, we might say, All right, I want to keep the arm down. It get it, has to get creative. There’s a little bit of finesse to this and working with the other person.


Um, I’m going to talk a little more active in response in a minute and in, but I will say that there are, the main thing I think is not talked about enough with this, is that we want to not do that tic. The appear response is not the thing that’s making the change on its own is helping us not do the tic. That’s what it does.


The last part if you want support from family, and we want to practice at home.


So let’s talk all about community swamps.


So we want to basically resist the urge and we want to hold the cupping response for a minute, or until the urge goes away. And this is often very difficult. Imagine if you could not scratch them as really itchy for over even NaN. It would be very hard.


So while this is easy to describe, it’s really not easy to do, it can be very hard to, or difficult to pursue, even perceive the text.


So, we might get stuck in awareness training for awhile because it’s hard to really knowing that takes going to happen. Or in practice, someone might not have the urge during a session. They might just have, say I don’t really urge, so it’s very hard to practice in session. So we might do things in sessions, are trying to get the urge to happen.


Um, the individual is asked to endure this naturally into, like what I said, we, the process of habituation happens. This is really the thing that really makes the biggest difference is that this process of actuation it’s similar to what we have with anxiety disorders. But instead of, you know, habituating are inhibitory learning, happen related to a fear or a mental aspect. It’s more of a physiological. So you feel the urge, you know, you’re not satisfying the urge.


So I sometimes tell kids. Yeah, we’re we’re going to retrain your brain. I think that’s a handy way to describe We’re going to train your brain. Doesn’t have to send the errors, Are not feeding it.


Um, and then what happens is oftentimes, with less of the tic signal happens less, you don’t see the text so we can decrease. The amount particular company will have less tics.


And I will say this again. This is way easier to describe it, is to do.


This is, this is something that’s important.


Um, And I’ll also say, it’s not just learning a skill. So a lot of people say, I just want to learn the skills of how to deceive it. It’s, it’s learning the skills as part of it, but you need to experience it.


So for the treatment to really work, it’s not just learning how it works. You need to go through it oftentimes having some six several or a few successful trials of doing the awareness, training, configure spots and holding that computer spots for long enough for the urge to at least decrease.


That’s it.


That’s what makes a difference. Usually the most, the skills are really there for after the main trials to help, you know, keep that in so the kids know how to apply it later.


Um, so some elements of companion response. Right. And then a point this out for those of you who work in behavioral fields, this is not a replacement behavior. It’s the opposite of a replacement behavior. Replaces behavior. Satisfies the urge.


Another way we do not want to satisfy the air, is another way we want to do, an office of behavior that basically Does not satisfy the air, so it’s, it’s the X absolute opposite of the computer response. So sometimes people come in, like, I have this, tic, this, this stic, I do maybe, with, where, I, like, touch my cheek, And so instead of touching my cheek, I just like, put something else. I use my arm to hold my cheek or something. And that’s, that’s basically the urge is not going to go away that way.


So must be incompatible the tic here thing is we want is not to be obvious to others. So if someone’s head tic goes to the right, I’m not going to have their, their community wants to go to the left. Because if they’re sitting in class the friends, it’s gonna be obvious what they’re doing.


So we really try to make a few responses that are, you know, look as casual and unusual as possible. Sometimes it’s impossible to make it totally look inconspicuous.


But we try.


the other thing is, unlike have reversal for some other things like bike focused, repetitive behaviors and we use other things, like for stimulus control, for those of you familiar with that, with tics, we usually don’t want to use any other external objects.


So Dogwoods says, you want you want to be able to do this naked in the desert. you know, so you have nothing else with you. And it’s unique for each tic And each individual. I will say that on rare occasions, I will sometimes add another object to help someone who’s sick opinion response for a long period of time, particularly with vocal tics at their mouth, getting really dry or something. We might have water if you’re holding it for a very long period of time. But generally speaking, I don’t like to use any extra objects.


The social support, we want parents and guardians to be there supporting.


We definitely want to reinforce the effort.


And we want to give some prompts reminders on when they forget to engage, but not all the time. So I will, I’ll talk about some of that. We want to make sure that we don’t stress kids out because it’s very hard to practice.


So just practice as much as your therapist tells you to do not no anymore unless the kid wants to the focus should be on the competing responses, not the text and sometimes extra reinforcements, like, rewards, are helpful for kids, for their effort, because it’s very hard to do this.


Um, OK, so, one reward that I remember this, this one young child was really into a toy, but the toy seem to change like every three weeks. So, every time I go to Target and get this little toy, after, you know, the next week, I’d see this, this child, they want it, they didn’t like that so anymore. So, game rewards. You gotta make sure something that will stay in fashion to, but, but the rewards really motivated this child to practice.


So the other component of …, which is not a core component, I mean you can do, you can successfully treat checks without doing this but it’s helpful is some kind of helps manage sixth Amendment is relaxation training.


So the former ones are some slow deep breathing might do belly breathing, we call it or progressive muscle relaxation where we kind of tense and relax muscle groups.


I’ve had I’ve had an integral individuals often where they’re not ready for cebit or they don’t They don’t want or not ready for have a reversal. Or when they’re practicing at home, we might incorporate relaxation in.




But, but really, it depends on the individual how much you’re going to do.


But this can be very helpful to temporarily reduce tics and to make it easier easier, especially at times we need to relax, like falling asleep and things like that. It’s not going to work as long term as the have versus up on it, though.


So a little bit about the process of conducting it, and then I know I’m going along. So I’ll try and wrap it up.


Um, OK.


So, this is typically short-term, right, But like I said, it can go on longer. So, someone might be a clue sessions, or they might be a long time And then come back for booster sessions. I might see someone when they’re there eight years old, and then worked for awhile, and then I’ll see him again when they’re 14.


And then, then maybe when they’re in college, right.


So, sometimes there’s is, there’s, it’s not uncommon to, you know, come back to see that every once in awhile to get a refresher or to work on it for long term. 


But the goal, one of the goal to see, but it’s really have the individual be able to do it on their own, and they finished. We really want you to learn how to do it, and then kinda be able to come up with something that’s on your own.


And it really has to go with the faces, right, for the individual.


So having a rustle often focuses on weekly review, homework, and so I have people basically practice what we do in session for homework, for a week.


I, there, the, and I’ll talk about practice in a second, so I know it’s on the next slide, But one thing I’ll point out is that, on the bottom here of this, it can be fun to practice.


So, this is a ton of treatment where while we’re practicing holding computer spots, we could play games, we can talk, I don’t have to just, it’s OK if I distract them mentally, because we’re focusing on the physical urge. And so, we can make it fun even though it’s unpleasant. So, sometimes, you know, since I learned how good kids aren’t chess, sometimes when we do see that and how bad I am at chess, you know, sometimes for kids like to do that.


So here’s an example of a have a Rustle session.


This is kind of an agenda you might have. So, he might start with a, usually, a check in with the parent and client together about, you know, what they did over the last week, You know, that they practice their practice awareness training. Usually, I will ask people to practice, to start one time a day for like, it’s 10 to 15 minute period. If you notice the tics, you know, either practice being aware of it, you know, noticing when it happens, or practice computer response. So the homework that’s official, I usually give a one time a day.


Others might do more.


Um, as a kid would like to practice more, I always say you can’t, I just don’t want to make them overwhelmed, because you usually kids have a lot of other activities going on. Then after doing the homework, I usually will always do a tic hierarchy, so we will review and rate all texts. We get a number on 0 to 10 scale for suds.


Will select the Ticet to Work on that day, often one that’s bothering them the most.


Then we’ll work on for that tic on practicing, being aware of the tic and then doing a cupping response and holding it.


The process of doing a ping response, while they are holding it, I usually will ask them for a rating of 0 to 10 scale, to tell me how uncomfortable the urge is.


Um, if the earth goes away in NaN, right, I want them to hold it for at least a minute. So I’ll say keep holding it for a minute because sometimes it tics will come back.


If the urge goes on, oftentimes kids will have to hold it for like 12 minutes, 30 minutes, it can go very long. So, we will check in with their Suds ratings, but every minute, and I’ll kind of graph it out for them as they go at the end. I’ll show them, just so they could see how their progress, how it went up and down.


Takes somebody to go down to zero. And, and just doing a little bit of, of … response times can make a big difference.


But we know that it’s an It is good, I like to see it when it goes down. But, it doesn’t always have to go all the way down the ratings.


Um, so then we review of the parent at the end and say, Here’s what we did today. Let’s practice in front of the parent.


Here’s what I want you to practice is for homework, and then they go home.


So this is kind of a, CERA an example.


Some key points, and we’re almost done. Motivation for treatment is essential.


If kids are not motivated, I don’t really want to treat them right now. That’s kinda where I, we can try to see if they can be motivated. And sometimes, you know, some rewards, you could teach them and show them what that is, and they’ll get on board.


But if someone really does not think it’s a problem and they don’t want to work on it, you know, it’s important to kind of address that and see it. And not just force it.


Um, oftentimes in my ***, like who’s more biotechs, the parents of the kids often, it’s the parents. And I understand that parents are concerned and the kids might just not even notice it too much.


But if kids are not ready, willing and able, we can kind of put it off later or we could do some rewards.


I also strongly encourage, while kids are practicing parents, that’s why I only give a few homework assignments.


Like one day, not to over hover or push kid the practice and less the kids on board because kids could even start out really gung ho about it. And then it’s hard to do. And the parents are always pointing out, like, Hey, you’re practicing. I just saw ticer, you’re practicing. Remember, practice, Hey, I’m paying for this treatment, why aren’t practicing those kind of things? Which I totally understand, that parents say it, But sometimes I’ve had kids where, after a couple of sessions are doing well, next Appointment Kids crying in my office.


Because they’re very stressed, because they feel like it’s too hard, they can’t do it.


So, the thing with Seba is you don’t have to rush, we do at one ticet at a time, and sometimes a little practice goes a long way and the goal is the motivation piece is key.


Like if we lose that part with kids, and we, the treatment is not very effective, or someone’s gotta want to work on this, OK, also, I don’t want kids to hate it and not want to work on it, later on their life, right.


If they’re, it’s important how they feel about it, silver practice.


We practice in session, and they ask you to do it at home.


The ideal, and even Duguid said, this would be the practice as much as you can, So, with tech stops. But this isn’t huge.


Icons isn’t usually practical, for most people, because kids play sports or they’re in school day, and they have dance class, or they want to, they’re not paying attention.


So, I will often tell kids, like, if they feel like working on it, they can.


When, you know, the practice, know, at least one practice today, I will say, as a coach effects, that oftentimes, I’ll hear, and students I work with will tell me that their clients have said, or my colleagues, that people often do their best job during competing response with the therapist, is like, the coach effects. So, it’s, you know, so sometimes, you know, that, and we work on it, but we want to really get the parents and the kids to be able to do it, as best it can At home.


What to expect?


So this, I, I would, I would argue with any psychologists that, I think that this could be the fastest treatment.


And the most affected tree we have is in psychology sometimes, in that, like sometimes, one trial of a green response can can cause a tic to really stop happening.


That’s not every case, but wanted. sometimes it works really fast. Sometimes it doesn’t work as fast with different texts. So every tic is different, every person is different. So someone might have a tic that responded really well, and there might be some tricky texts, right? They don’t respond as well. They’re really tough to catch eye. Blinking sometimes can be really tricky one, because we blink your eyes naturally anyway.


Um, We often get some reduction. But we might want to come back and assess it later, if it’s too tough.


So once some concern to you will have about event, I only have a few more slides, almost done.


Is that research is not supported. That, suppressing your checks will backfire. So by doing cebit it’s gonna make it way worse. There’s, this has been studied, all these have been studied, that treating one take will make untreated tics were, sometimes people report this, and it might be the case temporarily, but overall it’s, it’s not. Like some people may experience that sometimes it’s more relative.


They might notice the other checks more takes all saline. Also naturally, wax and wane. It also can replace the old tic for a new tic, that’s not true. We don’t, it’s, that has not been found, and paying attention, that takes a therapy. Makes them worse it just by talking about tax. People might take more in that moment, but it’s not going to make them worse in the long run.


Limits a C, but it’s not a cure.


Does not always work well for every person, right? Some people respond well, some people don’t.


It can be difficult to practice.


You need to be ready, willing, able, and motivated on one ticet at a time.


So it’s if you want to, if you have 10 tics, you want to work on it in a day. It’s not going to work that way.


And it doesn’t address co-occurring conditions itself.


No. So, you know, if you’re going to work on some other conditions, you might want to add other treatments into it.


It’s not always great with young children, or the individuals with intellectual disabilities.


Because it takes some awareness and, and motivation.


And also can be very difficult to find people that do this work on. There aren’t a lot of people out there.


I mean, a lot of people will have a tough time finding practitioners.


So real quick, the Rutgers University Tourette Syndrome Clinic. We are in partnership with the Dirty Center for Tourette Syndrome and Rutgers Graduate School of Applying professional psychology. We’re approaching our 20th anniversary. I’m not sure there’s I think it’s 2000. So maybe it was 2001, we started. So of course, 20th anniversary.


We have a specialty clinic at Rutgers, it’s run by. I’m the supervisor and director I supervise graduate students who are trained to do Cebit and also other cognitive behavioral treatments for OCD, anxiety, ADHD, depression. So we treat, you know, we’re a fully functional clinic, are run by graduate students. 


And we utilize evidence based treatments.


So the, the therapists there are doctoral students. They’re not licensed professionals yet. But they, they hopefully will be in the future, and I supervise them.


We work with children, teens, adults. We have groups, and we work individually. Our groups are social skills groups that we do in the spring. So we have kids and teens, they’re going to be remote this year, they were remote last year.


We’re also getting together to do a virtual Group for college students, a young adult college in psychology and graduate students.


And, just as important, we don’t take insurance, because we are, We are training clinics, so we can’t, couldn’t pass.


We’ve access insurance, but, you know, we do have lower scale of use often than what you have in the general community.


This is last year students. I don’t think they know I’m using their picture right now, so hopefully they’ll get mad at me, but it’s on our website. We couldn’t take a picture this year because we are remote, because it …. So I don’t have a group shot this year.


But the lady over here on the left is Emily. She’s our clinic co-ordinator, actually, this year, the one in the white shirt on the left.


Our information, if you if you just do a Google search, Rutgers, Tourette’s, you’ll find our information. And this is our e-mail, so resources for tics. So if you’re interested in fine tic treatment, you can obviously contact New Jersey Center for Tourette Syndrome for providers in New Jersey.


Or, you can contact our clinic, um, if you’re national, cause I know there’s a bunch of people on here.


Nationally, the Trade Association of America has, not only do they have ally information and see what they have brochures on it, But they also do use …, certification training. Dogwoods, it’s not always there, but he’s, I think he’s there most of the time involved in that training. And so you can look up certified providers throughout America. You know, people that are in your area. With virtual now, you might have more access to people, even if they’re not live exactly close to you.


I know, for example, someone in Pennsylvania live far away from where the nearest provider was, but now with virtual, they can see them and there’s online cebit.


Kelly was telling me, there’s also a program, a dog, runs for training people for C But out of Marquette University I couldn’t find their website though.


OK, so, I know I went long, but this is an important topic, so, I just wanted to make sure I covered it.


And, does anyone have any questions?


Does anyone still there can hear you answer? Still, plenty of people here.


Thank you very much, doctor Hierarchy for that informative presentation on TS symptoms and save it as a treatment. We do have a few questions. First, I just wanted to say as someone did ask about where they can find a CIT therapist. So, I do want to let people know that … has a list of practicing CD IT therapists in New Jersey. There are several of them. So, you can call our office at (908) 575-7350 or e-mail our info box info I N F O at … dot org and we’ll be happy to get you. A list or a few, you know, referrals for CPIC therapists in is close to your geographic region as possible.


So, a couple of questions for you, doctor Hierarchy, are tics that occur because of a trigger specific words, still tourettes?


Um, Yeah, I mean, tics, tics can occur after a trigger some tics.


Or, some tics are almost, like, we would call classically conditioned, to occur after certain, um, they do it, certain triggers in the environment, so yes, that, that, that doesn’t disqualify him from being a tic at all.


Sometimes, people will hear things like, a lot of times with vocal tics, they will it was just pal EYLEA we repeat yourself or echolalia or repeat others.


So sometimes people will hear a word and the, or they’ll say a word and then they will trigger other tics while they’re talking, so it’s that stuff that’s, yeah, that’s, that does not disqualify, a tic from being a tic that often is the case with texts.


Not always, but, but it’s it’s not uncommon OK, next question, Is CBOT effective and those that aren’t naturally aware, they tic.


Yes, because most people aren’t naturally OK naturally where they tic or, well it can be if someone is able to become aware of it, right, it depends on the person.


If it, if someone has no idea they’re ticing and you, you know, talk to them about it and they’re still saying they don’t tech then it wouldn’t be there. They’re not, if they have no ability to have insight. You’re not going to really be able to do you see it too much.


You could try to shape the behavior, sometimes, almost like you would do in with no more ABA, you can sometimes, you know, depends on the individual, to do an opposite and try it that way. But it’s, it’s often more difficult.


So I would say usually the person having some awareness of the tic is most of the time required, but there’s maybe been a few cases where we’ve attempted it.


You know.


And also I want to point out that have a reversal has there are people that study and there are, there are there’s a guy, Harvey, Harvey Singer. Who is he? Who is researching using? You know, have a wrestle with …, a piece with autism.


And in those cases, people aren’t, as NGOs might not be as aware, so it can be done, but you sometimes need to do other kind of shaping behaviors, or ways to kind of gradually get to the point where they’re holding back.


But I find in most people, it takes you really, you really want to have some kind of awareness.


OK, great. I have another question here in your presentation you referenced in terms of sort of contributing factors that can cause or contribute to T S: you referenced potentially prenatal factors. We have a couple inquiries here as to where they can learn more information about that. So, I don’t know if you can say a few more words about that or provide a source for people to go to for that.


Yeah, so I’m basing that on the some of the research out of the Rutgers Genetic Studies. From Gary Hyman.


So, I can get more, you know, I can, I can put you in touch with with him to talk about, you know, he’s, if you look up, let’s see if I get on the screen.


Websites, let’s see, I don’t know if you could still see my screen.


Well, let me let you know what I mean. I don’t think I have it on here, but I’ll get it for you.


Basically, it’s not that they know that there’s they don’t have any not like, oh, there’s a toxin and the environment that, you know, or something you do well, and prenatal environments that causes tics, they’re just looking at development, and it might be genetically related.


That something happens while a fetus is developing with the way the neurons develop, around the basal ganglia.


He, they know a little bit more about that than me but it’s not exactly, It’s not like there’s evidence that, oh, you know, if you eat foo that had roundup in it that this is going to cause, it’s nothing like that. It’s, it’s what I’m talking about is referring to as a research and nginx studies. I believe they’re doing studies with animal models to kind of look at how the genes that they think are related to Tourette’s or are influencing prenatal development and that there aren’t the connections aren’t being made. That normally are made in the area of the brain. So, it’s more related to that.


So, I don’t have the article and to give to you, but I think I can think Gary Hyman, another partner of ours works with NGA CTS at Rutgers Genetics. If you wanted to contact them for more, information, may be happy.


Talk to you about that, OK, thank you for that, and we can, we can probably provide people with the content. I don’t want to just do a Web search when I’m out with those people right now, so, I’ll get it. So, that’s, that’s fine. So, there’s one last question that will pose right now, and that is that someone says it there. There’s 15 year old isn’t CIT training for a few weeks? Tics have been going on for several months sidelines.


And there is some, culturally, it sounds like, some some offensive words, which are hard to ignore, and she does not want to do the therapy. So are there any suggestions for how to deal with that?


Well, I mean, it’s a It depends on the individual, right?


But when someone’s 15, and it’s a little trickier, if they’re not motivated, you would really, I really would talk to the individual and find out what their concerns are.


And you can see if there’s some kind of middle ground, you know. And maybe they’d be willing to try for a short period of time. You could try some reinforcements or rewards like look if you if you just give it a shot, you know. But, I think it was a teenager. You really have to have a discussion with them and find out what’s going on.


Honestly, there’s been I’ve had those cases it’s, it’s tough, I mean, you can’t force someone to do behavioral training but you can educate them and see if there’s a way to kind of motivate them to try and part of that process of finding out what their, his or her or their reservations are, um, or for doing the treatment. That’s a good question.


OK, so, at this point, we’ve gone over a bit, and it’s getting a bit late, so I do want to wrap it up. I want to thank you very much, doctor Harkey, for the informative presentation. And any questions that we didn’t get to tonight, we will try to have doctor Harkey answer on our blog. And I’m going to turn it over now to Kelly, who will just wrap things up for the evening.


Thank you for joining our webinar on non-medical Treatment of Tics, an Overview of … in the rutgers Tourette Syndrome Clinic. There is an Exit survey, which we need everyone attending to fill out. The webinar blog is open now and available for the next seven days on the NJ CTAS website, for any additional questions that were not covered in tonight’s presentation.


  1. Jerome Keeler says:

    My son has a vocal tic that involves a snort/sniffle. Our biggest problem has been physical factors that influence the tic – mainly sneezing but also crying. Whenever he sneezes (and it always seems to happen at the worst possible time, like when he is about to lie down for bed), the tic is exacerbated for a solid 30 minutes or more. He can be having a great day with the tic control and then some sneeze comes along or he stubs his toe and starts crying and it’s right back to the drawing board. Do you have any advice about this situation from your experience working with nasal-related tics? Note – he has no allergies. These are just occasional sneezes.

  2. TJune says:

    My 15 year old is in cbit training for three weeks now. Tics have been going on for 5 months and words are very offensive. Very hard to ignore. He does not want to do the therapy either. Any suggestions

    • Graham Hartke says:

      Thanks for your question TJune. Generally speaking, I would work with the teen on their motivation to work on tics. Every individual is unique in their awareness of and concern with tics. Parents are often more concerned than their children. Sometimes rewards to encourage participation can help. I would continue to speak with your teen and therapist about this. Sometimes contracting with your teen, and seeing if they will at least give it a try for a short period of time can help. If a teen does not want to, and is unwilling to try therapy I will not/cannot force them too. Instead we might work on other concerns, build up to readiness to work on CBIT, or decide to revisit treatment at a later time.

  3. MMiller says:

    My son’s tics have greatly increased during the covid situation and going to school. I continue to receive comments from teachers such as, “It’s a shame that he continues to choose these behaviors.” Do you have a suggestion to a way of responding to teachers?

    • Graham Hartke says:

      Thanks for your question MMiller. This can be a frustrating situation. Education is recommended here. Specifically speaking with the teachers/school admin/support staff about your son’s tics, possibly having a NJCTS inservice for the school, and or considering a 504 or other accommodations to address these concerns. As discussed in the webinar this is a very common issue, it can be helpful to let the school know that his tics are for all intensive purposes, involuntary.

  4. CGuiterman says:

    My son is currently school is remote learning. When he is having a tic episode, blinking, making loud noises at the lap top does anything happen to his brain? How many seconds does he lose focusing? Does anything happen to the brain in general?

    • Graham Hartke says:

      Thanks for your question CGuiterman. It is very difficult to know how long your child is losing focus for while ticing. Not every individual reports being distracted by tics. The amount of time an individual might be distracted by tics for can vary greatly from not at all to several minutes+ Some individuals report an increase of tics when on electronics and the reasons for this can vary. For instance some individuals are more frustrated while working on a laptop doing school work and some are more excited., both of these internal states can increase tic expression. Not sure what you mean by the brain part of your question.

  5. NChavez says:

    For children that are in the 5-8 age range, do you find the only option is to ignore or medication? Do you know of any plans of more research for children in this age range for treatment options.

    • Graham Hartke says:

      Thanks for your question. As discussed in the webinar, we do treat younger children with CBIT, and there is ongoing research in this area. For most of these children we can at least work on the functional behavioral assessment/intervention component. Also, there are often other behavioral challenges that parent management training can address. The habit reversal component can be effective with younger children, if the child is developmentally ready for it. This really depends on the individual child. So it is worth looking into. An experienced CBIT therapist would be able to assess your child and determine appropriate behavioral-psychological treatment options. Also along with watchful waiting, medication and behavioral treatment, it can be helpful to have school accommodations (504, IEP) in place if needed.

  6. Graham Hartke says:

    Hi Jerome, thanks for your question. It is not uncommon for internal and external triggers to lead to an increase in tic expression. Without having more information, I would think CBIT could address these concerns. Practicing habit reversal when tics are triggered, utilizing relaxation to help keep him calm during those tough moments, and developing a plan for when these tic episodes happen.