Behavior therapy is an evidenced-based intervention with moderate-to-large treatment effects in r... more Behavior therapy is an evidenced-based intervention with moderate-to-large treatment effects in reducing tic symptom severity among individuals with Persistent Tic Disorders (PTDs) and Tourette's Disorder (TD). This review describes the behavioral treatment model for tics, delineates components of evidence-based behavior therapy for tics, and reviews the empirical support among randomized controlled trials for individuals with PTDs or TD. Additionally, this review discusses several challenges confronting the behavioral management of tics, highlights emerging solutions for these challenges, and outlines new directions for treatment research.
Journal of telemedicine and telecare, Jan 13, 2015
Comprehensive Behavioral Intervention for Tics (CBIT) has been shown to be efficacious for chroni... more Comprehensive Behavioral Intervention for Tics (CBIT) has been shown to be efficacious for chronic tic disorders (CTDs), but utilization is limited by a lack of treatment providers and perceived financial and time burden of commuting to treatment. A promising alternative to in-person delivery is voice over Internet protocol (VoIP), allowing for remote, real-time treatment delivery to patients' homes. However, little is known about the effectiveness of VoIP for CTDs. Therefore, the present study examined the preliminary efficacy, feasibility, and acceptability of VoIP-delivered CBIT (CBIT-VoIP). Twenty youth (8-16 years) with CTDs participated in a randomized, waitlist-controlled pilot trial of CBIT-VoIP. The main outcome was pre- to post-treatment change in clinician-rated tic severity (Yale Global Tic Severity Scale). The secondary outcome was clinical responder rate (Clinical Global Impressions - Improvement Scale), assessed using ratings of 'very much improved' or ...
ABSTRACT Comprehensive Behavioral Intervention for Tics (CBIT) is an efficacious treatment for ch... more ABSTRACT Comprehensive Behavioral Intervention for Tics (CBIT) is an efficacious treatment for children with chronic tic disorders (CTDs). Nevertheless, many families of children with CTDs are unable to access CBIT due to a lack of adequately trained treatment providers, time commitment, and travel distance. This study established the interrater reliability between in-person and Voice over Internet Protocol (VoIP) administrations of the Yale Global Tic Severity Scale (YGTSS), and examined the preliminary efficacy, feasibility, and acceptability of VoIP-delivered CBIT for reducing tics in children with CTDs in an open case series. Across in-person and VoIP administrations of the YGTSS, results showed mean agreement of 91%, 96%, and 95% for motor, phonic, and total tic severity subscales. In the pilot feasibility study, 4 children received 8 weekly sessions of CBIT via VoIP and were assessed at pre- and posttreatment by an independent evaluator. Results showed a 29.44% decrease in clinician-rated tic severity from pre- to postassessment on the YGTSS. Two of the 4 patients were considered treatment responders at posttreatment, using Clinical Global Impressions–Improvement ratings. Therapeutic alliance, parent and child treatment satisfaction, and videoconferencing satisfaction ratings were high. CBIT was considered feasible to implement via VoIP, although further testing is recommended.
Tics associated with Tourette syndrome and other chronic tic disorders (CTDs) often draw social r... more Tics associated with Tourette syndrome and other chronic tic disorders (CTDs) often draw social reactions and disrupt ongoing behavior. In some cases, such tic-related consequences may function to alter moment-to-moment and future tic severity. These observations have been incorporated into contemporary biopsychosocial models of CTD phenomenology, but systematic research detailing the nature of the relationship between environmental consequences and ticcing remains scarce. This study describes the development of the Tic Accommodation and Reactions Scale (TARS), a measure of the number and frequency of immediate consequences for ticcing experienced by youth with CTDs. Thirty eight youth with CTDs and their parents completed the TARS as part of a broader assessment of CTD symptoms and psychosocial functioning. The TARS demonstrated good psychometric properties (i.e., internal consistency, parent-child agreement, convergent validity, discriminant validity). Differences between parent-reported and child-reported data indicated that children may provide more valid reports of tic-contingent consequences than parents. Although preliminary, results of this study suggest that the TARS is a psychometrically sound measure of tic-related consequences suited for future research in youth with CTDs.
Annals of clinical psychiatry : official journal of the American Academy of Clinical Psychiatrists, 2012
There is a lack of consensus on how to conceptualize skin picking disorder (SPD). It has been pro... more There is a lack of consensus on how to conceptualize skin picking disorder (SPD). It has been proposed that SPD is related to other problematic body-focused repetitive behaviors (BFRBs), such as hair pulling disorder (HPD) and problematic nail biting and cheek biting. We compared rates of BFRBs in online samples of SPD sufferers and college students. We also examined family history of HPD and skin picking problems and correlates of BFRB comorbidity in the SPD sample. Prevalence of BFRBs was significantly higher in the SPD sample compared with the college student sample. One-half (50.8%) of the SPD sample had a first-degree relative with problematic skin picking, and 7.9% had a first-degree relative with diagnosed HPD. Finally, correlates of BFRB comorbidity indicated that when multiple habits co-occur in an individual, they tend to involve the same body area. These findings are the first to show that SPD and BFRBs other than HPD frequently co-occur. Furthermore, they extend previous...
Tic-suppression-based treatments (TSBTs) represent a safe and effective treatment option for Chro... more Tic-suppression-based treatments (TSBTs) represent a safe and effective treatment option for Chronic Tic Disorders (CTDs). Prior research has demonstrated that treatment naive youths with CTDs have the capacity to safely and effectively suppress tics for prolonged periods. It remains unclear how tic suppression is achieved. The current study principally examines how effective suppression is achieved and preliminary correlates of the ability to suppress tics. Twelve youths, ages 10 to 17 years, with moderate-to-marked CTDs participated in an alternating sequence of tic freely and reinforced tic suppression conditions during which urge intensity and tic frequency were frequently assessed. Probability of tics occurring was half as likely following high-intensity urges during tic suppression (31%) in contrast to low-intensity urges during tic freely conditions (60%). Age was not associated with ability to suppress. Intelligence indices were associated with or trended toward greater ability to suppress tics. Attention difficulties were not associated with ability to suppress but were associated with tic severity. In contrast to our "selective suppression" hypothesis, we found participants equally capable of suppressing their tics regardless of urge intensity during reinforced tic suppression. Tic suppression was achieved with an "across-the-board" effort to resist urges. Preliminary data suggest that ability to suppress may be associated with general cognitive variables rather than age, tic severity, urge severity, and attention. Treatment naive youths appear to possess a capacity for robust tic suppression. TSBTs may bolster these capacities and/or enable their broader implementation, resulting in symptom improvement.
Journal of Clinical Child & Adolescent Psychology, 2010
This study reports an open-trial of family-based cognitive-behavioral therapy (CBT) in children a... more This study reports an open-trial of family-based cognitive-behavioral therapy (CBT) in children and adolescents with obsessive-compulsive disorder (OCD). Thirty primarily Caucasian youth with OCD (range = 7-19 years; 15 girls) who were partial responders or nonresponders to two or more medication trials that were delivered either serially or concomitantly received 14 sessions of intensive family-based CBT. Eighty percent of participants were considered improved at posttreatment and at 3-month follow-up, and symptom severity was reduced by 54% at both posttreatment and follow-up. Seventeen (56.6%) and 16 (53.3%) participants were classified as being in remission at posttreatment and follow-up, respectively. Significant reductions in OCD-related impairment, depressive symptoms, behavioral problems, and family accommodation were noted. No significant difference in youth-reported anxiety was found.
ABSTRACT This study examined the relative efficacy of intensive versus weekly cognitive-behaviora... more ABSTRACT This study examined the relative efficacy of intensive versus weekly cognitive-behavioral therapy (CBT) for adults with obsessive-compulsive disorder (OCD). Sixty-two adults with OCD received either 14 sessions of weekly (n=30) or intensive CBT (n=32; daily psychotherapy sessions) in a non-randomized format. Assessments were conducted at Pre-treatment, Post-treatment, and 3-month Follow-up by raters who were blind to treatment group at the Pre-treatment assessment. Intensive and weekly CBT were similar in efficacy at Post-treatment and Follow-up and associated with large treatment effect sizes. Since many people with OCD do not have access to trained CBT providers, intensive treatment may be a viable option in such cases.
The comprehensive behavioral intervention for tics (CBIT) represents a safe, effective non-pharma... more The comprehensive behavioral intervention for tics (CBIT) represents a safe, effective non-pharmacological treatment for Tourette's disorder that remains underutilized as a treatment option. Contributing factors include the perceived negative consequences of tic suppression and the lack of a means through which suppression results in symptom improvement. Participants (n = 12) included youth ages 10-17 years with moderate-to-marked tic severity and noticeable premonitory urges who met Tourette's or chronic tic disorder criteria. Tic frequency and urge rating data were collected during an alternating sequence of tic freely or reinforced tic suppression periods. Even without specific instructions regarding how to suppress tics, youth experienced a significant, robust (72%), stable reduction in tic frequency under extended periods (40 min) of contingently reinforced tic suppression in contrast to periods of time when tics were ignored. Following periods of prolonged suppression, tic frequency returned to pre-suppression levels. Urge ratings did not show the expected increase during the initial periods of tic suppression, nor a subsequent decline in urge ratings during prolonged, effective tic suppression. Results suggest that environments conducive to tic suppression result in reduced tic frequency without adverse consequences. Additionally, premonitory urges, underrepresented in the literature, may represent an important enduring etiological consideration in the development and maintenance of tic disorders.
Behavior therapy is an evidenced-based intervention with moderate-to-large treatment effects in r... more Behavior therapy is an evidenced-based intervention with moderate-to-large treatment effects in reducing tic symptom severity among individuals with Persistent Tic Disorders (PTDs) and Tourette's Disorder (TD). This review describes the behavioral treatment model for tics, delineates components of evidence-based behavior therapy for tics, and reviews the empirical support among randomized controlled trials for individuals with PTDs or TD. Additionally, this review discusses several challenges confronting the behavioral management of tics, highlights emerging solutions for these challenges, and outlines new directions for treatment research.
Journal of telemedicine and telecare, Jan 13, 2015
Comprehensive Behavioral Intervention for Tics (CBIT) has been shown to be efficacious for chroni... more Comprehensive Behavioral Intervention for Tics (CBIT) has been shown to be efficacious for chronic tic disorders (CTDs), but utilization is limited by a lack of treatment providers and perceived financial and time burden of commuting to treatment. A promising alternative to in-person delivery is voice over Internet protocol (VoIP), allowing for remote, real-time treatment delivery to patients' homes. However, little is known about the effectiveness of VoIP for CTDs. Therefore, the present study examined the preliminary efficacy, feasibility, and acceptability of VoIP-delivered CBIT (CBIT-VoIP). Twenty youth (8-16 years) with CTDs participated in a randomized, waitlist-controlled pilot trial of CBIT-VoIP. The main outcome was pre- to post-treatment change in clinician-rated tic severity (Yale Global Tic Severity Scale). The secondary outcome was clinical responder rate (Clinical Global Impressions - Improvement Scale), assessed using ratings of 'very much improved' or ...
ABSTRACT Comprehensive Behavioral Intervention for Tics (CBIT) is an efficacious treatment for ch... more ABSTRACT Comprehensive Behavioral Intervention for Tics (CBIT) is an efficacious treatment for children with chronic tic disorders (CTDs). Nevertheless, many families of children with CTDs are unable to access CBIT due to a lack of adequately trained treatment providers, time commitment, and travel distance. This study established the interrater reliability between in-person and Voice over Internet Protocol (VoIP) administrations of the Yale Global Tic Severity Scale (YGTSS), and examined the preliminary efficacy, feasibility, and acceptability of VoIP-delivered CBIT for reducing tics in children with CTDs in an open case series. Across in-person and VoIP administrations of the YGTSS, results showed mean agreement of 91%, 96%, and 95% for motor, phonic, and total tic severity subscales. In the pilot feasibility study, 4 children received 8 weekly sessions of CBIT via VoIP and were assessed at pre- and posttreatment by an independent evaluator. Results showed a 29.44% decrease in clinician-rated tic severity from pre- to postassessment on the YGTSS. Two of the 4 patients were considered treatment responders at posttreatment, using Clinical Global Impressions–Improvement ratings. Therapeutic alliance, parent and child treatment satisfaction, and videoconferencing satisfaction ratings were high. CBIT was considered feasible to implement via VoIP, although further testing is recommended.
Tics associated with Tourette syndrome and other chronic tic disorders (CTDs) often draw social r... more Tics associated with Tourette syndrome and other chronic tic disorders (CTDs) often draw social reactions and disrupt ongoing behavior. In some cases, such tic-related consequences may function to alter moment-to-moment and future tic severity. These observations have been incorporated into contemporary biopsychosocial models of CTD phenomenology, but systematic research detailing the nature of the relationship between environmental consequences and ticcing remains scarce. This study describes the development of the Tic Accommodation and Reactions Scale (TARS), a measure of the number and frequency of immediate consequences for ticcing experienced by youth with CTDs. Thirty eight youth with CTDs and their parents completed the TARS as part of a broader assessment of CTD symptoms and psychosocial functioning. The TARS demonstrated good psychometric properties (i.e., internal consistency, parent-child agreement, convergent validity, discriminant validity). Differences between parent-reported and child-reported data indicated that children may provide more valid reports of tic-contingent consequences than parents. Although preliminary, results of this study suggest that the TARS is a psychometrically sound measure of tic-related consequences suited for future research in youth with CTDs.
Annals of clinical psychiatry : official journal of the American Academy of Clinical Psychiatrists, 2012
There is a lack of consensus on how to conceptualize skin picking disorder (SPD). It has been pro... more There is a lack of consensus on how to conceptualize skin picking disorder (SPD). It has been proposed that SPD is related to other problematic body-focused repetitive behaviors (BFRBs), such as hair pulling disorder (HPD) and problematic nail biting and cheek biting. We compared rates of BFRBs in online samples of SPD sufferers and college students. We also examined family history of HPD and skin picking problems and correlates of BFRB comorbidity in the SPD sample. Prevalence of BFRBs was significantly higher in the SPD sample compared with the college student sample. One-half (50.8%) of the SPD sample had a first-degree relative with problematic skin picking, and 7.9% had a first-degree relative with diagnosed HPD. Finally, correlates of BFRB comorbidity indicated that when multiple habits co-occur in an individual, they tend to involve the same body area. These findings are the first to show that SPD and BFRBs other than HPD frequently co-occur. Furthermore, they extend previous...
Tic-suppression-based treatments (TSBTs) represent a safe and effective treatment option for Chro... more Tic-suppression-based treatments (TSBTs) represent a safe and effective treatment option for Chronic Tic Disorders (CTDs). Prior research has demonstrated that treatment naive youths with CTDs have the capacity to safely and effectively suppress tics for prolonged periods. It remains unclear how tic suppression is achieved. The current study principally examines how effective suppression is achieved and preliminary correlates of the ability to suppress tics. Twelve youths, ages 10 to 17 years, with moderate-to-marked CTDs participated in an alternating sequence of tic freely and reinforced tic suppression conditions during which urge intensity and tic frequency were frequently assessed. Probability of tics occurring was half as likely following high-intensity urges during tic suppression (31%) in contrast to low-intensity urges during tic freely conditions (60%). Age was not associated with ability to suppress. Intelligence indices were associated with or trended toward greater ability to suppress tics. Attention difficulties were not associated with ability to suppress but were associated with tic severity. In contrast to our "selective suppression" hypothesis, we found participants equally capable of suppressing their tics regardless of urge intensity during reinforced tic suppression. Tic suppression was achieved with an "across-the-board" effort to resist urges. Preliminary data suggest that ability to suppress may be associated with general cognitive variables rather than age, tic severity, urge severity, and attention. Treatment naive youths appear to possess a capacity for robust tic suppression. TSBTs may bolster these capacities and/or enable their broader implementation, resulting in symptom improvement.
Journal of Clinical Child & Adolescent Psychology, 2010
This study reports an open-trial of family-based cognitive-behavioral therapy (CBT) in children a... more This study reports an open-trial of family-based cognitive-behavioral therapy (CBT) in children and adolescents with obsessive-compulsive disorder (OCD). Thirty primarily Caucasian youth with OCD (range = 7-19 years; 15 girls) who were partial responders or nonresponders to two or more medication trials that were delivered either serially or concomitantly received 14 sessions of intensive family-based CBT. Eighty percent of participants were considered improved at posttreatment and at 3-month follow-up, and symptom severity was reduced by 54% at both posttreatment and follow-up. Seventeen (56.6%) and 16 (53.3%) participants were classified as being in remission at posttreatment and follow-up, respectively. Significant reductions in OCD-related impairment, depressive symptoms, behavioral problems, and family accommodation were noted. No significant difference in youth-reported anxiety was found.
ABSTRACT This study examined the relative efficacy of intensive versus weekly cognitive-behaviora... more ABSTRACT This study examined the relative efficacy of intensive versus weekly cognitive-behavioral therapy (CBT) for adults with obsessive-compulsive disorder (OCD). Sixty-two adults with OCD received either 14 sessions of weekly (n=30) or intensive CBT (n=32; daily psychotherapy sessions) in a non-randomized format. Assessments were conducted at Pre-treatment, Post-treatment, and 3-month Follow-up by raters who were blind to treatment group at the Pre-treatment assessment. Intensive and weekly CBT were similar in efficacy at Post-treatment and Follow-up and associated with large treatment effect sizes. Since many people with OCD do not have access to trained CBT providers, intensive treatment may be a viable option in such cases.
The comprehensive behavioral intervention for tics (CBIT) represents a safe, effective non-pharma... more The comprehensive behavioral intervention for tics (CBIT) represents a safe, effective non-pharmacological treatment for Tourette's disorder that remains underutilized as a treatment option. Contributing factors include the perceived negative consequences of tic suppression and the lack of a means through which suppression results in symptom improvement. Participants (n = 12) included youth ages 10-17 years with moderate-to-marked tic severity and noticeable premonitory urges who met Tourette's or chronic tic disorder criteria. Tic frequency and urge rating data were collected during an alternating sequence of tic freely or reinforced tic suppression periods. Even without specific instructions regarding how to suppress tics, youth experienced a significant, robust (72%), stable reduction in tic frequency under extended periods (40 min) of contingently reinforced tic suppression in contrast to periods of time when tics were ignored. Following periods of prolonged suppression, tic frequency returned to pre-suppression levels. Urge ratings did not show the expected increase during the initial periods of tic suppression, nor a subsequent decline in urge ratings during prolonged, effective tic suppression. Results suggest that environments conducive to tic suppression result in reduced tic frequency without adverse consequences. Additionally, premonitory urges, underrepresented in the literature, may represent an important enduring etiological consideration in the development and maintenance of tic disorders.
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Papers by Emily Ricketts