1. Tourette Syndrome: Getting Started John T. Walkup, MD Division of Child and Adolescent Psychiatry Weill Cornell Medical College New York, NY Part 3

2. Function-based Interventions Assess and address antecedents and consequences Provoking experiences Social consequences Positive reinforcement – active rewards Negative reinforcement – escape consequences

3. Types of Reinforcement Positive Reinforcement Negative Reinforcement Internally Reinforcing Provides gratificationRelieves distress Externally Reinforcing Attention and support Avoidance

4. Depends on the audience Psychology Psychiatry Neurology Primary care doctors Other medical professionals Kids Families School personnel Advocacy organizations

5. Change In Advice Old - intuitive Ignore tics Can’t be controlled Don’t punish Behavioral treatments don’t work Don’t try to suppress Suppression worsens tics Suppression worsens premonitory urges New tics develop when you suppress New - counterintuitive Become more aware Learn to manage Reward successful management Use behavioral strategies Tics don’t get worse with behavioral treatment Premonitory urge will fade away New tics don’t develop when you use behavioral strategies

6. Parent specific advice Old - intuitive Advocacy Provide support Provide comfort Protect Don’t think about them Give time to tic Ignore tics Reduce stress Celebrate your specialness New – counterintuitive Advocacy Take on challenges Comfort very carefully Expose Be mindful Take time to manage Understand their ABCs Stress proof tic management skills Celebrate successes

7. New Treatment Paradigms Readiness for reducing tic severity Comorbidity management Family and child intervention for “CBIT Lifestyle” CBIT CBIT + Meds Meds + CBIT Meds + CBIT to CBIT only Training nurses in Neurology clinics Parent training for children under 9 yrs

8. What will assessment and treatment look like in the future? Tics as a “marker” for neurodevelopmental disorders Complete work up for co-morbidity Treat comorbidity aggressively with meds and behavioral treatment Monitoring for development of new comorbid conditions First contacted doc will know the new advice. First intervention would be to work with families to provide a non-reinforcing environment for tics Parents would take what works to the school and advocate for a non-reinforcing environment for tics Professionals’ (all types) offices would teach specific interventions for a specific tic as tics develop. Kids would learn management strategies as they go

10. Not without controversy Neurological disorder What will teachers say? Tics get worse when you suppress If you suppress other tics will get worse How can one focus on activities if they are suppressing?

11. Himle & Woods (2006) Behaviour Research and Therapy 7 children with TS Three conditions Baseline Reinforced suppression Rebound evaluation All conditions were 5 min Tics were reduced in suppression condition Rebound did not occur

12. Does Symptom Substitution Occur? Vocal tics decreased, untreated motor tics did not change or decreased 83% reduction in vocal tics 26% reduction in motor tics Suggests that untreated symptoms at the very least do not change, but may improve following nonpharmacological intervention Other studies evaluating habit reversal have also not reported adverse symptom increases, nor have they reported excessively high dropout rates Woods et al. (2003). Journal of Applied Behavior Analysis

13. What is the effect of stress? Stress makes tics worse How? Mental stress – time math test Tic severity unchanged Stress impacts ability to suppress Clinical Implications – Stress proof CBIT

14. And now for something completely different!!!

15. How about this?? Tourette syndrome Structural-reflex disorder Neurocranio Vertical Distractor (NCVD) Brendan Stack DDS, MS Anthony Sims DDS

17. The Procedure Moving the mandible down and forward Tongue depressors Construct an appliance Speech training etc Long term natural or surgical restructuring of the TMJ joint