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 Jan.Rowe@childrensal.org Drjanrowe@gmail.com 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 disorder.  Persons with TS have greater tendency to develop depression and have higher rates of learning disorders.   TS + Co-occurring Disorders TS + OCD + ADHD TS + OC + separation anxiety/phobias  TS + ADHD + LD  TS + OCD + ADHD + Depression  TS + PDD + OCS + ADHD  TS + ADHD + Bipolar + Substance Abuse   Medical Track, March 21 1 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 environments.  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 2 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 Self-awareness  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 3 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 habits, ◦ Feedback on skill and habit development, and ◦ Application of skills and habits to occupational performance. 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 occupational performance and participation as a method of decreasing reliance on external support systems.  Medical Track, March 21 4 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 factors.  Persons with Tourette’s have premonitory urges or feelings that signal their tics.  CBIT Principles & Occupational Therapy  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 5 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 self-awareness.  2-6th sessions are held weekly and follow the CBIT main intervention protocol involving homework review, habit reversal training, ongoing assessment, and environmental/situational modifications.  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. QUESTIONS?? Medical Track, March 21 6