Comprehensive Behavioral Intervention for Tics (CBIT): Questions & Answers
We’ve always been told that TS is a neurological disorder and that tics are involuntary. If this is true, then how can CBIT work?
To be very clear, there is absolutely no question that tics are neurological in nature. However, and just as important, tics are often also extremely sensitive to the environment in which they occur. Every person with TS knows that a stressful or hostile environment can make tics worse. Similarly, positive and calming environments can be very helpful in reducing tic severity. In this regard, TS is like diabetes. Diabetes is clearly a medical condition, but is highly influenced by behavioral factors such as consistent diet, exercise, and the ability to monitor blood sugar and take insulin. What CBIT attempts to do is to help children and adults figure out those factors in their environment that make their tics worse; teach these individuals how to create environments that are more stable, predictable and easily manageable; and learn skills to cope with environments that are stressful and tic challenging.
Since CBIT works, does this mean that people with TS are able to suppress their tics?
Because a person can voluntarily suppress tics for a short period of time, some incorrectly assume that a person with tics should be able to control them all the time. This is not the case. Voluntary tic suppression can be done short term, but is not a very effective strategy for regular use. Voluntary suppression is stressful and people who do it become tired, frustrated and irritable. It is very important to realize that CBIT is not the same as voluntary tic suppression. Instead, CBIT teaches people with TS a set of specific skills they can use to manage their tic urges or behaviors, without having to use voluntary suppression. In CBIT we don’t want patients to voluntarily suppress. Rather, we want them to practice the competing response that they developed with their therapist. When a person does the right competing response in a calm focused manner, the tic gets better, and they feel better and more in control, not frustrated and irritable. Initially, this requires some effort and concentration, but with practice, both adults and children can learn to do their competing responses and easily participate in routine activities. In this regard, CBIT is like other learned skills which often are effortful in the beginning, but quickly become second nature.
I’ve been told to ignore my child’s tics because making him more aware of tics makes them worse. Won’t CBIT make tics worse?
Calling extra attention to tics at home, school or in the workplace makes people more self-conscious about their tics and subsequently tics get worse. The goal of CBIT is not to make children and adults more self-conscious, but rather make them more self-aware of their tics. Our experience with hundreds of TS patients is that as people with TS become more self-aware and understand what TS is, they often relax, feel more empowered and self confident – these emotions are all associated with decreased tics, not increased tics. In CBIT, the goal of self-awareness training is to help people understand their tics and what makes tics better and worse. This self-awareness is often described by patients as beneficial by itself, even without other parts of CBIT.
I’ve heard that when people with TS try to stop their tics, it will make other tics worse or will cause a rebound in tics after the efforts to stop have ended. Won’t CBIT cause these problems, too?
Every clinician who has worked with people with TS has heard a patient say that when they voluntarily suppressed their tics, they couldn’t keep it up and when they stopped suppressing, their tics “exploded.” CBIT does not teach voluntary suppression, but rather teaches techniques to control other behaviors that are incompatible with ticcing until the urge to tic or the tic decreases or goes away. Practicing behaviors that are incompatible with ticcing are very different from voluntary suppression.
Researchers have conducted studies on these techniques and have shown that strategies used in CBIT do not cause current tics to worsen or new tics to emerge. That’s not to say there won’t be times when new tics will start or current tics will get worse; that happens in people with TS with or without treatment. However, it isn’t the case that either of these things occur as a side effect of CBIT.
Doesn’t CBIT simply lead to the competing response becoming a new tic?
When people first hear about CBIT they become concerned that the competing response will become a new tic. There are two parts of a competing response that assure that this doesn’t happen. First, we know tics are reduced when people are involved in calm focused activity. So individuals are taught to use the competing response in a calm focused manner for up to one minute or until the urge to tic goes away. Simply focusing on the competing response like this makes it less likely that the tic will occur. Second, practicing the competing response typically leads to a decrease in the tic urge or sensation. As the sensation goes away, the person can stop using the competing response. Once the urge is gone the chance that the competing response will become a new tic is slim.
How effective is CBIT fo r somebody with TS?
The results from our large, multi-site, National Institutes of Health funded studies show that over half of people who undergo CBIT will have significant reductions in tic severity and improved ability to function. Complete elimination of all tics and other TS symptoms does happen occasionally in CBIT, but it is not what is expected. CBIT is not a ‘cure’ for TS, rather, CBIT is a tool that when used appropriately can help individuals better manage their tics and reduce the negative influence that tics may have on their lives
Is CBIT for everybody who has TS or tics?
Although the skills taught in CBIT can be used by everyone with tics, not everyone will necessarily benefit. At this time we don’t understand exactly what makes some people benefit from treatment while others do not. In our clinical experience, teaching this technique to children with untreated ADHD is more difficult because of problems with focusing, impulsivity and low frustration tolerance. Likewise, any other psychiatric or social problem that gets in the way of participating in treatment may make CBIT more difficult. We recommend that before starting CBIT, children and adults get a complete evaluation and address any symptoms that might make it harder for them to learn and practice CBIT. A person can learn CBIT without treating these co-occurring problems, but it might be harder for them and they may not be as successful
Is CBIT easy to do?
When they first hear about CBIT, professionals, patients and families sometimes say that the treatment seems simple and easy. Make no mistake, time and hard work are needed for CBIT to work well. As with any new skill, CBIT usually requires more work at the beginning to master the techniques and then becomes easier over time.
Should CBIT be used as a first line of treatment used with medications, or if I use medication can I stop using medication?
It is important to answer this question by first saying that all medication decisions should be made by the patient in consultation with his or her prescriber. Medication is and will likely remain the primarytreatment for Tic Disorders. However, as it becomes more widely available, CBIT may be used increasingly as a first-line treatment, particularly in young children where side-effects and other safety concerns may limit the use of medication. We also know that those who are already taking medication can get additional benefit from CBIT, but we don’t know whether someone who learns CBIT will be able to decrease or stop their medication. More studies will be needed to answer this question. It is not recommended to stop tic medications before starting CBIT unless this strategy has been recommended by the patient’s prescriber.
Once mastered, will CBIT last a lifetime?
Our results tell us that most of those who benefit from CBIT will keep their gains. In a recent study, 87% of those who did well in treatment, continued to do well 6 months after treatment. The important thing to remember is that CBIT isn’t a cure … it’s a management strategy. During CBIT, patients are taught a set of management skills that can be applied for the rest of their lives as needed.
Since CBIT is a behavioral treatment, does that mean I should punish my child for having tics and reward him for not having tics?
For over 30 years, professionals have rejected the use of punishmentprocedures as a first-line treatment for any problem. CBIT does not employ or advocate punishment for tics; just the opposite. Punishing a child for ticcing or for not suppressing his/her tics is mean-spirited, short sighted and ineffective. Scolding a child, raising one’s voice, or taking away privileges because he/she tics is not helpful and will likely result in psychological problems and worse tics. It is also unhelpful to reward children for not having tics as this encourages children to voluntary suppress, which doesn’t work well either. One of the great joys of helping children learn CBIT is sharing in their excitement when they really master the techniques and begin to experience a reduction in tic symptoms. To get to that point we want children to practice their competing response and we want parents to reward and support their child for their efforts. CBIT may be a challenge to learn, so parental and professional support andpositive feedback for good effort can be critical in helping the child early in treatment.
What should I do if my child refuses to do his CBIT exercises?
How many of us always do what is in our best interest – exercise, eat right, get a good night’s sleep, etc.? Doing something new for oneself is not always easy. Some kids with TS might really struggle to learn CBIT. Recognizing how hard it is for them, helping them keep their spirits up, motivating them to keep trying, are all roles parents can play. Although pushing, pestering, and prodding your child to do CBIT exercises may seem like a good idea at the time, it often backfires by making the child even more angry, nervous, or disheartened about therapy – all things that are associated with worse, not better, tics. Encouraging and rewarding children for doing their CBIT exercises is a much better way to go. Part of the CBIT training for parents is to help them understand how best to encourage and reward so the parent doesn’t become a “nag” and the child has the best chance of learning. We are also making a special effort to educate teachers, school personnel and employers about CBIT, not because we want them to perform CBIT, but because we want them to get the best information about CBIT from the right source. We have noticed that people often have opinions about CBIT without knowing the facts. We want people who live and work with patients with TS to have the facts – CBIT is an important skill for people with Tic Disorders that is taught by skilled and trained therapists. Telling people to “stop ticcing” is wrong and unhelpful, and not what CBIT is all about. That is not to say that teachers, parents, co-workers, and bosses won’t have a role in CBIT. In fact, they may play a pivotal role in helping to create and maintain the positive environment necessary for CBIT to be most effective.
Where can I go to have CBIT performed?
CBIT can be taught by a trained psychologist, doctor, nurse, social worker, or other therapist. As with any treatment, the training and skill of the clinician are critical to outcome. It is our recommendation that only therapists who have been trained in the principles of cognitive behavior therapy and have received specific training in CBIT should provide this treatment. Unfortunately, right now, few clinicians have been trained in CBIT.
About the Tourette Association Behavioral Science Consortium
The Tourette Association’s Behavioral Science Consortium was established in 2001. Members are previous recipients of Tourette Association grant awards who were brought together to enhance progress in this field by testing CBIT. The mission of the Behavior Science Consortium is to develop, test, and disseminate evidencebased behavioral treatments for children and adults with Tourette Syndrome.
About the Authors
Douglas Woods, Ph.D. is Co-Chair of the Tourette Association Medical Advisory Board and Professor and Head of Psychology at Texas A&M University.
John Piacentini, Ph.D., A.B.P.P. is Chair of the Tourette Association Behavioral Science Consortium and Professor and Director of the Child OCD, Anxiety, and Tic Disorders Program at the UCLA Semel Institute for Neuroscience and Human Behavior.
Now that our collaborative research project has shown how well CBIT can reduce tic severity, we are working closely with the Tourette Association to get the word out to the professional community and to establish training programs in CBIT across the country for professionals who work with TS individuals and their families. Until this is done, there will likely continue to be a shortage of therapists trained in CBIT. Some professionals who are not well-trained in CBIT will try to do the treatment, and it is important to understand that their results may not be as good as the results obtained from a trained and experienced CBIT clinician. We encourage you to select your therapist carefully and ask about their training in CBIT.