David Baxter PhD
Late Founder
Controlling the Uncontrollable
By Randi Hutter Epstein, M.D., Psychology Today
May 19, 2010
Upwards of 10 percent of school age children have had, at some time or another, sporadic, involuntary movements, such as eye-blinking, head-jerking or throat-clearing, to name a few. These so-called tics are not dangerous, and do not endure overtime in most in cases. A smaller percentage of these children will go onto have chronic motor tics. Tourette syndrome is defined by the presence of motor and vocal tics that persist for at least a year. Experts assume it has something to do with brain signals gone awry, but the precise cause is unknown.
For years, doctors had nothing to offer but comforting words that tics might fade with time. For severe cases, children have been put on antipsychotic medication, which often work but have side effects; or anti-hypertensive drugs, that are generally less effective. Now a new study suggests that it may be possible to teach children to manage what has appears to be an uncontrollable problem.
The multi-center study, published in the May 19th issue of the Journal of the American Medical Association, found that offering children a specific kind of behavioral therapy, called Comprehensive Behavioral Intervention, trained these youngsters to recognize the urge to move and replace it with a different movement. The goal is not to replace one tic with another, but rather to break the cycle between these urges and tics, explained Lawrence Scahill, MSN, PhD, one of the investigators and a professor of nursing and child psychiatry at Yale University. The key is finding an alternative movement that allows the urge to pass - rather than reinforce the tic.
As Dr. Scahill explained: "The basic idea of what we call CBIT (it builds on an old concept of habit reversal training) is if a person can become aware of an involuntary movement like a tic, such as a head jerking tic, they can mount an alternative response. It's a learning paradigm. Many people as young as 9 or 10 say they have a feeling or an urge before their tic and they describe it the way others may describe an itch or a sneeze. It doesn't mean that you have control over it, but you know it is coming. The urge is very compelling and when a person executes a tic, it relieves this urge temporarily. This is a model of negative reinforcement. Our model is based on early detection, awareness training and mounting an alternative response while there is still time."
For instance, he said children who may have an urge to jerk their head to the right, may learn to put their chin to their chest and wait for the tic urge to pass. When it works, the child learns that the tic is not the only way to get rid of the incessant urge. This instruction is more effective that strategies that children use to disguise their tics. "we've had kids in the clinic that try to cover a head-jerking tic by sweeping their hair back with a hand - but that only makes the tic more complicated."
The JAMA multi-center study, lead by UCLA's John Piacentini, included 126 children ages 9 to 17 randomized to receive behavioral training or counseling and support about Tourette sydrome. Researchers found that slightly more than half of the children in CBIT (52.5 percent) were rated as significantly improved compared with only 18 percent of those in the other group.
Dr. Scahill does not see CBIT as a cure, but a step in the right direction for children and families with Tourette syndrome to learn more about tics and their treatment. CBIT is helpful without medication related side effects. Future studies will evaluate the mechanism for these beneficial effects. In any event, CBIT offers hope for children who feel out of control and alone to manage their tics.
By Randi Hutter Epstein, M.D., Psychology Today
May 19, 2010
Upwards of 10 percent of school age children have had, at some time or another, sporadic, involuntary movements, such as eye-blinking, head-jerking or throat-clearing, to name a few. These so-called tics are not dangerous, and do not endure overtime in most in cases. A smaller percentage of these children will go onto have chronic motor tics. Tourette syndrome is defined by the presence of motor and vocal tics that persist for at least a year. Experts assume it has something to do with brain signals gone awry, but the precise cause is unknown.
For years, doctors had nothing to offer but comforting words that tics might fade with time. For severe cases, children have been put on antipsychotic medication, which often work but have side effects; or anti-hypertensive drugs, that are generally less effective. Now a new study suggests that it may be possible to teach children to manage what has appears to be an uncontrollable problem.
The multi-center study, published in the May 19th issue of the Journal of the American Medical Association, found that offering children a specific kind of behavioral therapy, called Comprehensive Behavioral Intervention, trained these youngsters to recognize the urge to move and replace it with a different movement. The goal is not to replace one tic with another, but rather to break the cycle between these urges and tics, explained Lawrence Scahill, MSN, PhD, one of the investigators and a professor of nursing and child psychiatry at Yale University. The key is finding an alternative movement that allows the urge to pass - rather than reinforce the tic.
As Dr. Scahill explained: "The basic idea of what we call CBIT (it builds on an old concept of habit reversal training) is if a person can become aware of an involuntary movement like a tic, such as a head jerking tic, they can mount an alternative response. It's a learning paradigm. Many people as young as 9 or 10 say they have a feeling or an urge before their tic and they describe it the way others may describe an itch or a sneeze. It doesn't mean that you have control over it, but you know it is coming. The urge is very compelling and when a person executes a tic, it relieves this urge temporarily. This is a model of negative reinforcement. Our model is based on early detection, awareness training and mounting an alternative response while there is still time."
For instance, he said children who may have an urge to jerk their head to the right, may learn to put their chin to their chest and wait for the tic urge to pass. When it works, the child learns that the tic is not the only way to get rid of the incessant urge. This instruction is more effective that strategies that children use to disguise their tics. "we've had kids in the clinic that try to cover a head-jerking tic by sweeping their hair back with a hand - but that only makes the tic more complicated."
The JAMA multi-center study, lead by UCLA's John Piacentini, included 126 children ages 9 to 17 randomized to receive behavioral training or counseling and support about Tourette sydrome. Researchers found that slightly more than half of the children in CBIT (52.5 percent) were rated as significantly improved compared with only 18 percent of those in the other group.
Dr. Scahill does not see CBIT as a cure, but a step in the right direction for children and families with Tourette syndrome to learn more about tics and their treatment. CBIT is helpful without medication related side effects. Future studies will evaluate the mechanism for these beneficial effects. In any event, CBIT offers hope for children who feel out of control and alone to manage their tics.
