Behavioral therapy can help kids with Tourette disorder

An intensive course of behavioral therapy can limit the verbal and physical tics that plague some children with Tourette disorder, a new study finds. This form of therapy, in which a child learns simple ways to derail tics, led to improvement in more than half of children treated, scientists report in the May 19 Journal of the American Medical Association.

“I think this is groundbreaking,” says clinical psychologist Martin Franklin of the University of Pennsylvania in Philadelphia, who didn’t participate in the trial. “Clinically, we now have pretty powerful evidence of the efficacy of a behavioral treatment in this disorder.”

Tourette disorder is characterized by short, rapid physical or vocal tics that can take the form of jerking motions, blinking, grimacing, blurting out words or throat clearing. These tics are brought on by urges. And much as a cigarette satisfies a smoker’s need for nicotine, the tics seem to resolve these urges, but at a cost. People with Tourette disorder, which starts in childhood and affects about six in 1,000, can face isolation and social stigmatization.

“The urge-tic-relief cycle becomes automatic over time” in Tourette disorder, says study coauthor John Piacentini, a clinical psychologist at the University of California, Los Angeles. “We want to slow it down and make it less automatic.”

The behavioral intervention tested in the new study does that by teaching a child to recognize the onset of a tic, identify the body part involved and practice a behavior that competes with the tic, says study coauthor John Walkup, a psychiatrist at the Weill Cornell Medical College in New York City. “By doing this competing response, the connection between the urge and the tic can be disconnected,” he says. If the intervention is successful, the urge fades over time.

For example, a child whose tic involved habitually shouting a word or phrase might learn to concentrate on breathing in through the mouth and out through the nose, a pattern that makes it difficult to shout.

The researchers randomly assigned 61 children age 9 to 17 to get the behavioral training. Another 65 children with Tourette disorder were randomly assigned to get counseling and education about the condition. Roughly equal numbers in each group were taking medication for their tics.

After 10 weeks, 53 percent of the children getting behavioral training were judged as much improved or very much improved, according to a standard rating scale of tics. Among those getting counseling and education, 19 percent had improved this much. Questionnaires filled out by the children’s parents supported these scores.

Still, nearly half of the treated patients in this study didn’t show much improvement. Piacentini says some younger children might find it hard to focus on the intervention. And some Tourette kids have other issues, such as attention deficits, that would hinder concentration on the techniques, he says. Those issues are being studied, and another trial testing the intervention in adults with Tourette disorder is due out this year, Piacentini says.

The behavioral training used in this study is not a try-it-at-home matter in which kids can suppress tics on the first try, says Walkup. Rather, these techniques are taught by therapists and aimed at a specific tic. For example, Walkup, who worked on this study while at Johns Hopkins University in Baltimore, described a young child he treated whose tic was to stick out his tongue. The child was taught to identify the urge and to put a fist up to his mouth, as if covering a cough. Then he would just poke his tongue up against this hand, concealed. This subverted the tic, which ultimately faded, Walkup says.

Franklin says that patients must first predict a tic. “I get them to be really good at noticing the urge. Then I get them to use a physically incompatible response.” Uncontrolled blinking can be stymied by using slow, controlled blinks, he says.

When Tourette tics fade away with treatment, Franklin says, it’s like the dissipated urge an ex-smoker feels when getting a whiff of a cigarette. Whatever neurological pathway had once been hardwired to cause the tic — or to compel a smoker to reach for a cigarette — has been bypassed, he surmises.

Meanwhile, medication remains the first-line treatment for Tourette, the authors note, even though some drugs for the condition can cause weight gain and have a sedative effect.