Remote Behavioral Therapy Works for Kids With Tic Disorder

For reducing tic severity in children with Tourette syndrome, an online behavioral therapy worked as well as internet-based education alone and had better participant response, a small randomized trial found.

The intervention — 10 weeks of a therapist-supported, internet-delivered exposure and response prevention (ERP) program — was associated with a mean reduction of 6.08 points on the Total Tic Severity Score of the Yale Global Tic Severity Scale (22.25 at baseline to 16.17 at 3-month follow-up).

The comparator group, supported by therapists without ERP assignments, experienced a similar improvement of 5.29 points on the scale on intention-to-treat analysis (from 23.01 to 17.72, P=0.17), according to study findings reported by Per Andrén, PhD, clinical neuroscientist at Karolinska Institutet in Stockholm, and colleagues in JAMA Network Open.

However, significantly more participants were classified as treatment responders in the ERP group (47.2%) than in the comparator group (28.7%) at 3 months (OR 2.22, 95% CI 1.27-3.90).

Current guidelines from the American Academy of Neurology list a Level B recommendation for the use of Comprehensive Behavioral Intervention for Tics (CBIT) as a first-line treatment over medications and other behavioral interventions. ERP and remote CBIT got a weaker Level C endorsement instead.

Overall, the latest evidence supports a stronger recommendation for ERP for tics, especially internet-delivered ERP, said Tamara Pringsheim, MD, a neurologist at the University of Calgary in Alberta, and John Piacentini, PhD, a pediatric psychologist at the University of California Los Angeles, in an editorial.

The study authors noted that despite clinical guidelines recommending behavioral therapy as a first-line treatment, there is a limited availability of therapy for individuals with Tourette syndrome and chronic tic disorder. They suggested that the implementation of digital ERP intervention would increase availability of this treatment for young people.

In the trial, the $117.38 mean cost of ERP significantly exceeded the comparator’s $102.23. However, the incremental cost per quality-adjusted life-years gained was below the Swedish willingness-to-pay threshold and the probability of ERP being cost-effective ranged from 66% to 76%, according to Andrén’s group.

“Importantly, the validation of a therapist-assisted remote intervention has the potential to address several of the many significant barriers faced by individuals and families in search of effective treatment for their tic disorder,” according to Pringsheim and Piacentini.

The duo traced disparities in treatment for tic disorders to the centralization of medical knowledge and skills in larger cities.

“Most health regions experience major barriers to accessibility to behavioral therapies because of a lack of trained care professionals, long waiting times, cost, and travel distance required to see a qualified therapist,” Pringsheim and Piacentini wrote. “The ability 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.”

The single-masked, parallel group, superiority randomized clinical trial was conducted at the Karolinska Institutet in Stockholm and had nationwide recruitment across Sweden.

To be eligible, children were required to meet the diagnostic criteria for Tourette syndrome or chronic tic disorder and be 9 to 17 years of age. This resulted in 221 participants (mean age 12.1 years, 68.8% boys) enrolled from April 2019 to April 2021.

The ERP intervention consisted of 10 weeks of practiced tic suppression (response prevention) and gradually provoked premonitory urges to make the tic suppression more challenging (exposure). Controls receiving structured education underwent 10 weeks of education on Tourette syndrome, chronic tic disorder, and common comorbid disorders. Behavioral exercises were also provided to this group.

Andrén and colleagues acknowledged the lack of a third arm of children not receiving either intervention to control for the natural passage of time. In addition, inclusion of generally mild groups may have diluted between-group differences and exclusion of participants with comorbid autism may limit generalizability of the results. Finally, the short time frame may not fully capture societal costs associated with Tourette syndrome.