Cognitive Behavioral Therapy for Tourette Syndrome

CBIT puts teens and kids more in-control of their TS tics

In our last post, we presented some exciting new prospects for medicinal treatment of tics caused by Tourette’s Syndrome (TS). Today’s topic focuses on CBIT which is a behavioral therapy that is taught to the child or adult with TS to help him or her to have fewer tics with less severity.

What is a tic?

A tic is an uncontrolled sudden, repetitive movement or sound. There are several kinds of tic disorders- not all are caused by TS:

  • Provisional tic disorder — this is the most common type of tic disorder. With a provisional tic disorder, the tics have been happening for less than a year.
  • Chronic (persistent) tic disorder — this is a less common tic disorder. With chronic (persistent) tic disorder, tics have been happening for more than a year. The tics may be motor or vocal, but not both.
  • Tourette syndrome — TS is more common that you think. 1 out of 100 children has TS or another tic disorder and 50% of the population go undiagnosed. With Tourette syndrome, a person has multiple motor tics and at least one vocal tic happening for more than a year.

At certain times, like when someone is under stress, the tics can become more severe, happen more often, or last longer. Or the type of tic may change under stressful conditions.

How is Tourette Syndrome Treated

There are different treatments for the effects of TS. Currently, antipsychotic drugs and alpha-agonists are the most common treatment. As we discussed in our last article, the side effects of these traditional medications are often seen as worse than the tics themselves, especially for parents of children with TS. Side effects include weight gain, stiff muscles, tiredness, restlessness, and social withdrawal. New research provides hope for medicines with fewer side effects and positive results from behavioral interventions such as today’s blog topic: Comprehensive Behavioral Intervention for Tics (CBIT).

Before we go into the details of CBIT, take note of these six areas where you and your children can focus for better coping with the effects of TS:

  • Take control. Be open. Talk about the tics. Focus on mindfulness, environment, awareness of when, how and what types of tics occur. This deeper understanding combined with the practice of CBIT can help anyone coping with TS to feel more in control of their lives.
  • Stay informed. Research, ask questions, and listen to webinars such as the Wednesday Webinars at https://njcts.org/category/webinars/.
  • Stay busy and connected. Sports, exercise, or hobbies are great ways to focus mental and physical energy.
  • Help others. Dealing with Tourette syndrome often makes people more understanding of other people’s feelings, especially other teens living with a condition. Use that special sensitivity by volunteering to help others. NJCTS can always use help. Teens can also get involved and become a youth advocate or attend the Tim Howard Leadership Academy, August 4 – August 7, to learn more about TS and become an advocate for themselves and others
  • Embrace creativity. Creative activities such as writing, painting, or making music help focus the mind on other things.
  • Find support. NJ Center for Tourette Syndrome & Associated Disorders (NJCTS) offers a parent support group facilitated by Dr. Jeremy Lichtman an expert in the treatment of TS. The next support group will be announced.

What is Comprehensive Behavioral Intervention for Tics (CBIT)?

CBIT is an established therapy that teaches people to change their behavior over time and tic less. CBIT, which has evolved over the last decade or so, trains children to manage their tics while identifying and neutralizing the stressors that can exacerbate them. Practicing CBIT essentially adds an environmental component to habit-reversal therapy, which has been used to control behaviors, such as nail biting and thumb sucking, for roughly 40 years. The therapy has shown promising results both in clinical trials and in practice.

John Piacentini, PhD, a professor of psychology at the University of California, Los Angeles, and a co-developer of CBIT coauthored a study in the Journal of the American Medical Association in 2010 that found that children and adolescents who completed a 10-week course of CBIT showed a decrease in tic severity that was only slightly less than the decrease associated with antipsychotics- but with no side effects.

Since that time, leading minds in the TS Research space have come together, developed a TS-tailored behavioral therapy and piloted more research studies on the resulting treatment. And, in 2019, the American Academy of Neurology released its first ever Treatment Guidelines for Tourette Syndrome and Tic Disorders; the guidelines list CBIT as the recommended first line of treatment for TS. The recommendation reads in part: “If symptoms [of TS] affect a person’s daily life, the guideline recommends that doctors first consider prescribing a treatment called Comprehensive Behavioral Intervention for Tics (CBIT). CBIT combines relaxation training, habit-reversal training, and behavioral therapy to help reduce tic symptoms.” The guideline states that CBIT is effective in both children and adults and has no major side effects.
The full guideline can be found here.

How does CBIT work?

CBIT is a non-medicated treatment consisting of three important components:

(a) Training the patient to be more aware of his or her tics and the urge to tic.
(b) Training patients to do competing behavior when they feel the urge to tic.
(c) Making changes to day-to-day activities in ways that can be helpful in reducing tics.
While tics are neurological in nature, it is understood that tics are often also extremely sensitive to the environment in which they occur. When someone with TS is aware of their environment and their state of mind, they may begin to understand what makes his, her or their tics worse or better.

CBIT attempts to help children and adults familiarize themselves with and identify environmental factors that make their tics worse. CBIT also teaches skills on how to create environments that are more stable, predictable and easily manageable. Many of these strategies are already commonly used in the management of TS symptoms. Many adults with TS report that they have come up with strategies similar to CBIT to manage their tics. CBIT takes the most effective concepts and blends them with strategies that aid people in learning the techniques quickly.

Large, multi-site, National Institutes of Health-funded studies show that more than half of the people who undergo CBIT will have significant reductions in tic severity and improved ability to function. Complete elimination of all tics and other TS symptoms does happen occasionally in CBIT. CBIT is not a cure for TS but a tool that helps individuals better manage their tics and improves their quality of life.

Even CBIT’s proponents agree that the therapy isn’t for everyone — especially children with more disruptive co-occurring problems. Eighty-three percent of people with Tourette syndrome also have one additional mental health, behavioral or developmental disorder, such as attention-deficit hyperactivity disorder (ADHD), obsessive-compulsive disorder (OCD) and other anxiety disorders, according to the CDC.

“I think CBIT works best for kids and families who are motivated to practice new strategies for responding to the tics, and for kids who don’t have a lot of complicating co-morbidities,” says Piacentini. In particular, children with ADHD may have more difficulty succeeding at cognitive-behavioral therapy because they need to be able to pay attention to their anticipatory urges to employ their competing responses.

When the treatment works, it not only empowers the child to manage his or her tics, but boosts his or her self-esteem. If the child experienced anxiety and social issues related to the tics, then as the tics get better, these other areas improve, as well.

Says one mother of her adolescent who put CBIT into practice for the study: “Jill has come out of all this as a less anxious kid overall. She’s a totally different person.”

In February 2022, NJCTS hosted a webinar in its Tourette’s Talk series on this topic presented by Meir Flancbaum, PsyD, a licensed psychologist, who founded the Center for Cognitive Behavior Therapy with the goal of providing effective and efficient clinical care for children, adolescents, and their families.
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