A new treatment for children with chronic tic disorders – Resource activation
Introduction
Tics are involuntarily sudden and rapid movements or vocal expressions, which are often preceded by a premonitory urge (American Psychiatric Association, 2013). The vast majority of patients with tic disorders have comorbid mental disorders, with estimations reaching up to 90% in the case of Tourette syndrome (TS) (Freeman et al., 2000, Hirschtritt et al., 2015, Khalifa and Von Knorring, 2006). The most frequent comorbid disorders are obsessive-compulsive disorder (OCD; 50.0%) and attention-deficit/hyperactivity disorder (ADHD; 54.3%) (Hirschtritt et al., 2015). Additionally, the quality of life (QoL) is lower in children with tics compared to controls (Hesapçıoğlu et al., 2014, Storch et al., 2007b) and functional impairment (FI) is reduced (Conelea et al., 2011, Himle et al., 2007, McGuire et al., 2015b, Storch et al., 2007a). Moreover, a recent study showed higher rates of insecure peer attachment, problems in peer relationships, difficulty in making friends, stigmatization and lower levels of social functioning in youth with TS (O'Hare et al., 2015). Patients with tics often state that they miss out on activities because of physical or emotional problems (Eddy et al., 2011) or due to social stigma and feelings of embarrassment (Elstner et al., 2001). Regarding self-esteem, the findings are inconsistent: While some studies reported lower self-concept or self-esteem in youth with tics (Hanks et al., 2016, Hesapçıoğlu et al., 2014, Khalifa et al., 2010), others did not (Bawden et al., 1998, Edell-Fisher and Motta, 1990). Nonetheless, it was found that patients with TS plus additional comorbid diagnoses had lower self-esteem than did patients with TS only (e.g. Hanks et al., 2016, Silvestri et al., 2017). In their review, Silvestri et al. (2018) concluded that poor self-concept and self-esteem seem to be related more to comorbid disorders than to tic severity. Furthermore, a relation between self-perception and QoL was shown. Children and adolescents with TS or TS plus OCD were found to experience significantly more psychosocial stress than a healthy control group (Lin et al., 2007). Psychosocial stress was predictive of future depressive symptoms and OCD severity. Additionally, psychosocial stress and depression were independent predictors of future tic severity.
Parents of children with TS have been found to have parental stress (Lee et al., 2007, Stewart et al., 2015), higher caregiver burden, lower self-esteem (Edell-Fisher and Motta, 1990) and to be at greater risk of mental disorders (Cooper et al., 2003). Patients report that their family members argue more frequently (Eddy et al., 2011). This suggests that in order to reduce parental stress and to support positive family relationships, families should be included in the children's treatment.
The broad spectrum of comorbid disorders, stress, reduced self-esteem, problems in peer relationships, overall FI and reduced QoL of patients with tic disorders may be the main reason why interventions aiming primarily to reduce tic symptoms might fall short.
Besides pharmacological treatment, behavior therapy, particularly habit reversal training (HRT) (Azrin and Nunn, 1973, Piacentini et al., 2010, Woitecki and Döpfner, 2011) and exposure with response prevention (ERP) (Verdellen et al., 2004), are recommended treatments with the primary aim to reduce tic symptoms (Verdellen et al., 2011). In the Comprehensive Behavioral Intervention for Tics (CBIT) study, HRT plus relaxation training, psychoeducation, and a function-based approach was found to be more effective than psychoeducation and supportive therapy (Piacentini et al., 2010).
Despite the proven effectiveness of these interventions, a substantial proportion of patients continue to suffer from tic symptoms, comorbid problems and psychosocial impairment at the end of the interventions (Piacentini et al., 2010, Rizzo et al., 2018, Whittington et al., 2016, Woitecki and Döpfner, 2011, Woitecki and Döpfner, 2012). Moreover, medications can have adverse effects (Rössner et al., 2011, Whittington et al., 2016).
Therefore, there is a strong need to develop and evaluate alternative treatments. One possible approach is to develop interventions targeted at the activation of personal resources rather than problem-focused interventions, which aim directly to reduce tic symptoms. According to Grawe and Grawe-Gerber (1999), resource activation (RA) represents a primary principle of change in psychotherapy in addition to problem-focused interventions. All aspects of the emotional process and entire life situation of a patient can be understood as resources. Hence, resources can be found in all intra-personal (e.g. specific skills, interests, goals) and interpersonal (e.g. supporting family members, friends) strengths and abilities. Specific RA interventions (see 2.5 Treatment) reinforce these strengths and abilities, and therefore focus on the healthy part of the personality instead of focusing on the problems (Gassmann and Grawe, 2004, Gassmann and Grawe, 2006, Grawe and Grawe-Gerber, 1999). A successful RA supports and improves the positive perception of one`s own resources, thus enabling need-satisfying experiences in terms of pleasure, self-control, positive relationships and self-esteem. It can lead to better overall well-being and improved coping with the disorder. These goals are in accordance with third-wave cognitive behavioral therapy approaches, which focus, for example, on mindfulness, well-being, behavioral activation and relationships (Hayes, 2004, Kahl et al., 2012).
Given that many children with TS experience severe stress, negative peer relationships and negative self-esteem, important therapy goals should be to support positive relationships, positive activities and self-esteem. Moreover, the reduction of stress may also have a positive impact on tic symptoms.
In their Comprehensive Integrated Model, Woods et al. (2007) suggest that while tics emerge because of genetic and/or neurobiological factors, they are influenced by individual internal and external antecedents and consequences. In their review, Conelea and Woods (2008) conclude that stress, anxiety, frustration and tension are often related to an increase in tics. Therefore, the occurrence of tics might be influenced by the positive design of situational constraints and other environmental factors, as well as by reducing stress. In a review of behavioral treatments for TS, Frank and Cavanna (2013) discuss the effectiveness of relaxation therapy, emphasizing that most of the studies are single-case studies or very small-sample studies. The results show improvements in tic symptoms, but the effects are often of short duration. For example, in a study by Bergin et al. (1998), children and adolescents in a relaxation group revealed a greater tic symptom reduction compared to a control group, but this difference was not statistically significant. A recent study (Reese et al., 2015) found mindfulness (meditation) to be effective in reducing tics and impairment in older youth and adults.
The therapy program “Living with Tics” (LWT, 10 weekly sessions) has similar goals to those of the present study (e.g. improving tic-related impairment and psychosocial functioning, increasing QoL). In a randomized control trial conducted in youth, the LWT group (n = 12) showed significantly greater improvements in impairment and QoL compared to the waiting group (n = 12) (McGuire et al., 2015a). However, in contrast to the present study, the treatment protocol was problem-focused. The present study aims to achieve the mentioned goals without focusing on the tics, and instead by conducting RA exercises. To the best of our knowledge, no previous study has assessed the efficacy of RA treatments for children and adolescents with tic disorders. Some studies have used supportive therapy as a control group treatment (Deckersbach et al., 2006, Piacentini et al., 2010, Wilhelm et al., 2003, Wilhelm et al., 2012). There are some similarities between these control group interventions and our study, as all used psychoeducation, therapists were prohibited from providing advice on tic management strategies, and most studies included problem solving. However, there are also some important differences: In the aforementioned studies, the supportive treatment was basically non-directive in nature, and patients (and their families) were allowed to focus on and talk about the tics, related problems and other issues. In the RA treatment used in the current study, talking about tics and other problems was minimized and the treatment was manualized and highly structured. Therapists guided the patients to focus on positive topics, and exercises were set which required active participation of the patients (see 2.5. Treatment).
Deckersbach et al. (2006) (n = 15 adults) formulated similar goals to our own: improving self-esteem, life satisfaction and psychosocial functioning by reducing distress and increasing coping skills. Treatment components included encouragement, reassurance, reframing, clarification and ventilation (Novalis et al., 1993, Pinsker, 1997). While improvements in life satisfaction and functioning were shown, there was no reduction in tic symptoms in the supportive therapy group. The only study to include a supportive therapy group comprising children and adolescents (Piacentini et al., 2010) revealed a reduction of tic symptoms and impairment during the course of the treatment.
The present study investigates the efficacy of a manualized RA treatment program in children and adolescents (Perri et al., 2018b). It is expected that RA exercises will improve the patients’ perceptions regarding their own resources, which may indirectly result in a reduction of tic symptoms, impairment and comorbid conditions.
It is suggested that a focus on the patient's own strengths and interests as well as other personal internal and external resources by the patient him/herself and his/her family, and a focus on improving relationships and increasing the rate of positive activities, will lead to (a) an increase in self-esteem and (b) a decrease in tic symptoms, comorbid symptoms, and impairment.
Section snippets
Inclusion criteria
Inclusion criteria were age 8 to 19 years and a diagnosis of TS (F95.2) or a chronic motor/vocal tic disorder (F95.1) according to the ICD-10 criteria (World Health Organization, 1992). Further inclusion criteria were (1) tic symptoms with at least moderate severity (YGTSS Total Tic Score > 13 for TS and > 9 for children with motor or vocal tics only) (cf. Piacentini et al., 2010); (2) IQ > 80; (3) ability and willingness to attend at least 21 weekly outpatient treatment sessions. Moreover, (4)
Participant recruitment
Participant recruitment occurred through a call in a local newspaper and flyers sent to local doctors, psychotherapists and clinicians. In addition, patients were referred from the outpatient unit of the School of Child and Adolescent Cognitive Behavior Therapy at the University Hospital Cologne. After the procedure had been fully explained, all parents and children provided consent to participate in the study. Participant inclusion took place between December 2013 and February 2017. Fig. 1
Discussion
During the treatment phase, a significant reduction of tic symptoms with small to medium effect sizes (ES = 0.38 to ES = 0.51) was shown for parent-rated primary outcome (SCL-TIC-P), video-observed motor tics and clinician rating of tic severity (YGTSS), but not for other ratings. However, when comparing pre- and post-assessment (t-test) of self-rated tic symptoms, a significant reduction can be found, which might indicate that the reduction is too small to show a significant effect with this
Funding
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Conflict of interest
Manfred Döpfner, Anja Görtz-Dorten and Katrin Woitecki are authors of the treatment manual evaluated and of books about tic disorders or questionnaires used in this study for which they receive royalties from Hogrefe. Other authors have no potential conflict of interests.
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