Document 69764

Tourette Syndrome Association
2014 National Conference
OTs Can Help Children With
Tourette Or Tic Disorders:
Jan Rowe, Dr. OT, MPH, OTR/L, FAOTA
Coordinator,Tourette syndrome and
Tic disorders program
Children’s of Alabama
[email protected]
[email protected]
TSA 3/2014
Some facts to consider
Co-Occurring Conditions
Attention deficit/hyperactivity disorder
occurs with 50% of persons with TS
 Obsessive-compulsive behavior occurs
with 50-90% of persons with TS
 30-40% develop Obsessive-compulsive
 Persons with TS have greater tendency to
develop depression and have higher rates
of learning disorders.
TS + Co-occurring Disorders
TS + OC + separation anxiety/phobias
 TS + ADHD + LD
 TS + OCD + ADHD + Depression
 TS + ADHD + Bipolar + Substance Abuse
Medical Track, March 21
Tourette Syndrome Association
2014 National Conference
Other observed behaviors
Self-injurious behaviors- 17-22%
occurrence- includes self-biting, slapping,
head banging, hitting, punching, pinching,
orifice digging, and picking.
 Trichotillomania- .02-3% occurrencerepetitive hair pulling. More common with
TS + OCD than either one alone.
Medication may be effective.
Impact on Participation
TS can have effects on children’s
participation in the areas of occupation,
education and socialization in varying
 School/work- fulfilling student/worker roles,
peer relations, sports, learning, feeding, play
 Social- Friendship, community involvement,
group participation
 Family- fulfilling family role, responsibilities
and relationships
Comprehensive Behavioral
Intervention (CBIT)
Shown in a randomized controlled trial to
be effective in children (Piacentini,
Woods,et al., 2010).
Piacentini, J., Woods, D. ,Scahill, L. ,Wilhelm, S., Peterson, A. L., Chang, S., et
al. (2010). Behavior therapy for children with Tourette disorder: A
randomized controlled trial. JAMA, 303, 1929-1937.
Medical Track, March 21
Tourette Syndrome Association
2014 National Conference
Rowe, Yuen & Dure (2013) found
occupational therapists to be an appropriate
and effective discipline to provide CBIT.
◦ In all measures of the study children improved with a significant
reduction in tics and limits to daily occupations.
◦ This study involved 30 children where the purpose was to determine
the outcomes achieved for children with tic disorders after receipt of
CBIT provided by the Occupational Therapy.
◦ Significant reduction in the number of tics
◦ Improvement in scores from the Parent Tic Questionnaire,
Subjective Units of Distress Scale and the Child Occupation Self
Assessment on post assessment as compared to scores at baseline.
Components of CBIT
Psychoeducation about tics
 Habit reversal
 Relaxation training
 Function-based approaches to determine
how the environment and social
situations sustain or influence tic severity
CBIT & Occupational Therapy
Consistent with knowledge about
behavioral and cognitive-behavioral
interventions used to change behavior in
support of:
Skill & Role Development and/or Modification
Habit development
Habit modification
Habit disruption
Stoffel,V. C., & Moyers, P. A., (2004).An evidence-based and occupational perspective of
interventions for persons with substance-use disorders. American Journal of Occupational
Therapy, 58, 570–586.
Medical Track, March 21
Tourette Syndrome Association
2014 National Conference
Occupational Therapy Cognitive-Behavioral
Principles for Evaluation (Stoffel & Moyers, 2004)
Involvement of the client in daily activities
provides the context to:
◦ Evaluate occupational performance ability.
◦ Examine the cognitive, affective, and behavioral skill
and habit issues associated with occupational
performance problems.
◦ Determine ways to reinforce and motivate change.
Varying the environments in which occupational
performance is evaluated determines issues
related to generalization of skills and habits to
multiple situations.
Occupational Therapy Cognitive-Behavioral
Intervention Principles (Stoffel & Moyers, 2004)
Help clients to:
 Change distorted thinking,
 Develop self-efficacy,
 Facilitate coping and relapse prevention skill
development through:
◦ Role modeling,
◦ Structured opportunities to rehearse skills and
◦ Feedback on skill and habit development, and
◦ Application of skills and habits to occupational
Occupational Therapy Cognitive-Behavioral
Intervention Principles (Stoffel & Moyers, 2004)
Help clients to:
 Use activity and occupational performance
and participation to apply newly developed
problem solving and coping skills.
Recognize and reinforce their own improved
performance and
participation as a method of decreasing
reliance on external support systems.
Medical Track, March 21
Tourette Syndrome Association
2014 National Conference
CBIT Principles
Not based on the assumption that tics are
bad habits and thus within the child’s
behavioral control.
 Tics are involuntary, but expression is
influenced by environment and situational
 Persons with Tourette’s have premonitory
urges or feelings that signal their tics.
CBIT Principles & Occupational
Child is taught self-awareness to pre-empt
tics through a competing response.
The competing behavioral response is
reinforced to become a new habit.
The Occupational Therapy Practice Framework:
Domain and Process, 2nd Edition (AOTA, 2008),
describes developing habit patterns that
support optimum occupational performance
and participation.
Overview of CBIT
Protocol consists of 8-11 sessions (60-90
minutes in length):
◦ Increasing the child’s awareness of his or her tics,
◦ Determining the order for intervention
(establishing a tic hierarchy),
◦ Ascertaining the impact of the tics on the child’s
daily life functioning,
◦ Developing a reward system or methods of
motivating the child’s change in behavior, and
◦ Establishing a home program.
Woods, D., et al., (2008). Managing Tourette syndrome: A behavioral intervention for children
and adults. New York: Oxford University Press.
Medical Track, March 21
Tourette Syndrome Association
2014 National Conference
Overview of CBIT
First session consists of psychoeducation about tics, functional
assessment, and homework self-assessment strategies to promote
2-6th sessions are held weekly and follow the CBIT main
intervention protocol involving homework review, habit reversal
training, ongoing assessment, and environmental/situational
Sessions 4 & 5 add relaxation techniques to the main protocol.
2-week break
Sessions 7 & 8 occur two weeks apart with Session 8 focusing on
relapse prevention.
Sessions 9-11 are booster sessions and are scheduled as needed on
a monthly basis beginning four weeks after the 8 th week.
Medical Track, March 21