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Can the Internet be Used to Improve Tic Severity in Tourette Syndrome?

  • Authors: News Author: Batya Swift Yasgur, MA, LSW; CME Author: Charles P. Vega, MD
  • CME / ABIM MOC / CE Released: 10/28/2022
  • Valid for credit through: 10/28/2023, 11:59 PM EST
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Target Audience and Goal Statement

This activity is intended for primary care physicians, psychiatrists, pediatricians, nurses/nurse practitioners, physician assistants, and other members of the healthcare team who treat and manage children and adolescents with Tourette syndrome.

The goal of this activity is for learners to be better able to compare an online exposure and response prevention program with an online educational intervention among patients with Tourette syndrome.

Upon completion of this activity, participants will:

  • Distinguish the main goal of comprehensive behavioral intervention for tics
  • Compare an online exposure and response prevention program with an online educational intervention among patients with Tourette syndrome
  • Outline implications for the healthcare team


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News Author

  • Batya Swift Yasgur, MA, LSW

    Freelance writer, Medscape


    Batya Swift Yasgur, MA, LSW, has no relevant financial relationships.

CME Author

  • Charles P. Vega, MD

    Health Sciences Clinical Professor of Family Medicine
    University of California, Irvine School of Medicine


    Charles P. Vega, MD, has the following relevant financial relationships:
    Consultant or advisor for: GlaxoSmithKline; Johnson & Johnson Pharmaceutical Research & Development, L.L.C.

Editor/Compliance Reviewer

  • Amanda Jett, PharmD, BCACP

    Associate Director, Accreditation and Compliance, Medscape, LLC


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  • Lisa Simani, APRN, MS, ACNP

    Associate Director, Accreditation and Compliance, Medscape, LLC


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Can the Internet be Used to Improve Tic Severity in Tourette Syndrome?

Authors: News Author: Batya Swift Yasgur, MA, LSW; CME Author: Charles P. Vega, MDFaculty and Disclosures

CME / ABIM MOC / CE Released: 10/28/2022

Valid for credit through: 10/28/2023, 11:59 PM EST


Clinical Context

Tourette syndrome (TS) is a common and impactful health condition, affecting approximately 1% of school age children. Although medications such as alpha-2 agonists or dopamine antagonists can be used to treat TS, behavioral therapy is a preferred option for many children. An editorial by Pringsheim and Placentini, which accompanies the current study, describes the practice of comprehensive behavioral intervention for tics (CBIT).

Tics are typically a negative response to unpleasant stimuli among children. CBIT does not deny noxious stimuli to children but instead teaches techniques to suppress tics in the setting of such stimuli. Moreover, the typical course of CBIT involves exposing patients to increasing levels of noxious stimuli to build their strength in tic suppression. This treatment modality has been demonstrated to improve tic symptoms over the long-term after completion of therapy.

Could a form of CBIT be effectively delivered online? The current study addresses this question.

Study Synopsis and Perspective

A novel internet-delivered, therapist-supported version of exposure and response prevention (ERP) therapy can yield improvements in tic severity in TS or chronic tic disorder (CTD), new research suggests.

In a randomized controlled trial (RCT), more than 200 adolescents with TS or CTD received either 10 weeks of therapist-supported internet-delivered ERP for tics or therapist-supported internet education for tics.

Results showed that both groups had significant improvement in tics from baseline to 3-month follow-up, but almost half of participants in the ERP group vs about one third of participants in the education group were classified as treatment responders.

"Therapist-supported internet-delivered ERP and education were both associated with significantly and clinically meaningful improvements in tic severity, although treatment response rates and satisfaction were significantly higher in the ERP group," write the investigators, led by Per Andrén, PhD, Karolinska Institutet, Department of Clinical Neuroscience, Child and Adolescent Psychiatry Research Center, Stockholm, Sweden.

"Implementation of the digital ERP intervention into regular health care would increase availability of treatment for young people with TS or CTD," they add.

The findings were published online August 15 in JAMA Network Open.[1]

Promising Results

Behavior therapy is recommended by clinical guidelines as first-line treatment for TS and CTD, but its availability is "very limited," the researchers note. Therefore, "various formats of remote delivery have been proposed to improve access," they write.

In a previous study, the investigators developed an internet-delivered behavior therapy program for TS and CTD and found that ERP was "particularly well-suited to guided online delivery."

These "promising results" spurred 2 parallel RCTs in England and Sweden that compared therapist-supported internet-delivered ERP with the "robust comparator" of internet-delivered education. Results from the British Online Remote Behavioral Intervention for Tics (ORBIT) trial showed that ERP was superior to the comparator in reducing tic severity.[3] The current analysis presents the results of the Swedish RCT.

Participants (n=221; 68.8% boys; mean age, 12.1 years) were randomly assigned to either the ERP or comparator groups (n=111 and 110, respectively). All were assessed at baseline and then at 3 and 5 weeks into treatment, at posttreatment, and 3 months afterward, which constituted the primary endpoint.

Most of the participants (91.4%) had TS, and 38.0% had 1 or more comorbid diagnosis, particularly attention-deficit/hyperactivity disorder (15.4%) and anxiety disorders (14.0%). The majority of participants (85.5%) were not receiving medications at baseline.

The interventions consisted of 10 chapters, each completed weekly. Treatment completion was defined a priori as the completion of the first four child chapters, which contained "the core ingredients of each intervention," the researchers note.

In both interventions, children and parents were supported by a designated therapist trained in behavior therapy, whose role was to "provide feedback, answer questions, and encourage treatment adherence."

The intervention focused on practicing tic suppression (response prevention) and gradually provoking premonitory urges, or the unpleasant sensations typically preceding tics. The latter was designed to "make the tic suppression more challenging," the investigators write. The active comparator consisted of education about TS and CTD and common comorbidities, as well as about behavioral exercises.

Tic severity, which was the primary outcome, was measured by the Total Tic Severity Score of the Yale Global Tic Severity Scale (YGTSS-TTSS).

Increased Treatment Access

From baseline to 3-month follow-up, there was significant improvement in tic severity in both groups. However, there was a higher mean reduction on the YGTSS-TTSS in the ERP vs the comparator group (6.08 vs 5.29, respectively).

The mean YGTSS-TTSS score for the ERP group at baseline was 22.25 vs 16.17 at follow-up. For the comparator group, the scores were 23.01 vs 17.72, respectively.

The investigators report intention-to-treat analyses showing that both groups "improved similarly over time" (interaction effect, −0.53; 95% confidence interval [CI], −1.28 to 0.22; P=.17).

However, at 3-month follow-up, significantly more patients were classified as treatment responders in the ERP group vs the comparator group (47.2% vs 28.7%, respectively; odds ratio, 2.22; 95% CI, 1.27-3.90; P=.005).

Although both groups improved from baseline to 3-month follow-up on most secondary outcomes, including the YGTSS Impairment Score, quality-of-life measures, obsessive-compulsive symptoms, and mood and feelings, only the ERP group showed improvements on the Clinical Global Impression Severity and Improvement Scales and the parent-reported KIDSCREEN-10.

The mean intervention costs (therapist-support time) were "slightly higher" for the ERP vs the comparator group (mean difference, $15.14; 95% CI, $5.08-$25.20), the investigators report. "ERP resulted in more treatment responders at little additional cost compared with structured education," they write.

The researchers list several strengths of the study, including use of an active comparator, nationwide recruitment, a large sample size, and very low data attrition.

Limitations cited include the absence of a third wait-listed group to control for the natural passage of time, inclusion of a "generally mild group of participants," and exclusion of participants with comorbid autism, potentially limiting the generalizability of the findings.

Despite these limitations, the findings "suggest that both internet-delivered interventions could be implemented into regular health care to increase treatment access for children and adolescents with TS or CTD," the researchers write.

They favor the implementation of ERP vs the educational intervention "based on its higher treatment response rates, likely cost-effectiveness, superior working alliance and satisfaction ratings, as well as the results from the parallel ORBIT trial."

'Critical Door'

Commenting for Medscape Medical News, Michael Okun, MD, director of the Norman Fixel Institute for Neurological Diseases, University of Florida Health, Gainesville, said that the study "reinforces the idea that using telemedicine to bring therapies for tic disorders into the home will be an important element to making interventions more practical and available."

Dr Okun, who was not involved with the research, added that the intervention has utility not only for youth but also potentially for adults.

Although not tested by the current investigators, he noted that cognitive-behavioral intervention for tics is another therapy used for the disorder that has been shown, in previous studies, to be effective when delivered via telemedicine.

"Therapies for tic disorders are challenging to deliver when multiple sessions over short periods of time are a requirement for success," Dr Okun said. "The use of telemedicine has opened a critical door to the future."

In an accompanying editorial, Tamara Pringsheim, MD, Cumming School of Medicine, Department of Clinical Neuroscience, Psychiatry, Pediatrics, and Community Health Sciences, University of Calgary, Alberta, Canada, and John Piacentini, PhD, Department of Psychiatry and Biobehavioral Sciences, Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles, note that the intervention "has the potential to address several of the many significant barriers" often faced by patients and their families.[2]

"The ability [for patients with TS] to use a remote delivery system with therapist support could greatly increase both acceptability and capacity for care and is a meaningful advance in the ability to provide therapeutic interventions in our field," they write.

The study was funded by the Swedish Research Council for Health, Working Life and Welfare, and the Swedish Research Council. The investigators' disclosures are in the original paper. Dr Okun reports no relevant financial relationships. Dr Pringsheim reports having received research funding from Alberta Health and the Alberta Children's Hospital Research Institute and employment as an evidence-based medicine methodology consultant for the American Academy of Neurology. Dr Piacentini reports receiving research support from the National Institute of Mental Health, the Patient-Centered Outcomes Research Institute, the TLC Foundation for BFRBs, and the Nicholas Endowment; consultant fees from Spinnaker Health; publication royalties from Guilford Press, Oxford University Press, and Elsevier; and travel/speaking honoraria from the Tourette Association of America, International OCD Foundation, and TLC Foundation for BFRBs.

JAMA Netw Open. Published online August 15, 2022.

Study Highlights

  • The study was designed as a single-masked randomized trial comparing an online ERP program with an online program limited to education only. Both programs were led by therapists experienced with TS.
  • Patients eligible for the study intervention were between the ages of 9 and 17 years and met criteria for TS or CTD. The study featured a broad patient recruitment across Sweden.
  • The ERP and educational programs were performed using 10 chapters for both parents and children during a 10-week period. Therapists supported patients and families through text messages embedded in the chapters, and they also provided telephone calls when needed.
  • ERP emphasized the format of CBIT. The educational intervention featured disease-state education and behavioral exercises that excluded tic suppression.
  • The main study outcome was the YGTSS-TTSS, which is scored by clinicians on a scale up to 50. This and multiple other secondary outcomes were clinician-rated, but researchers also followed multiple symptom and improvement ratings by patients and families, as well as measures of treatment satisfaction.
  • There were several assessment points for study outcomes, with the main study outcome at the 3-month point after cessation of the treatment protocol.
  • 221 participants underwent randomization. The mean age of participants was 12.1 years, and 68.8% were boys. Only 14.5% of patients were receiving medication at baseline. The mean baseline score on the YGTSS-TTSS was 22.
  • The average number of chapters completed was nearly 9 for both parents and children, with little difference in comparing the ERP and education cohorts.
  • Both interventions were significantly and similarly effective in reducing the YGTSS-TTSS score (mean reduction in the ERP and education groups at 3 months: −6.08 and −5.29 points, respectively).
  • Secondary measures of participant symptoms by clinicians, patients, and parents were also improved from baseline and were similar in the ERP and education cohorts.
  • In the clinician assessment, 47.2% of participants in the ERP cohort were considered treatment responders compared with 28.7% of participants in the education cohort (odds ratio, 2.22; 95% CI, 1.27 to 3.90).

Table 1. Effect of ERP vs Education Alone on Tic Severity

  ERP (n=111) Education Comparator (n=110)  
Mean reduction in YGTSS-TTSS from baseline to 3 months 6.08 points 5.29 points Interaction effect: −0.53; P=.17
Treatment responders at 3 months 47.2% 28.7% Odds ratio: 2.22; P=.005

ERP, exposure and response prevention; YGTSS-TTSS, Total Tic Severity Score of the Yale Global Tic Severity Scale.

  • Parents and children gave higher ratings for credibility to the ERP vs education intervention, and children were happier with the working relationship with the therapist in the ERP group.
  • In a cost analysis, ERP was slightly more expensive than the education intervention but was associated with a better treatment response. The estimated cost per additional responder in the ERP vs education cohorts varied between $79 and $476.
  • Post hoc analyses demonstrated that ERP was most effective for adolescents between 12 and 17 years of age, as well as for males.

Clinical Implications

  • CBIT promotes active tic suppression among patients with TS while exposing them to increasing levels of noxious stimuli.
  • The current study demonstrates that both ERP and disease education can improve the frequency of tics among children and adolescents, whether measured by clinicians, patients, or parents. Satisfaction with treatment was higher in the ERP vs education groups.

Implications for the Healthcare Team

ERP and disease education can be effectively delivered online to improve symptoms of Tourette syndrome.


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