© 2007 American Psychological Association. Published by Blackwell Publishing on behalf of the American Psychological Association.All rights reserved. For permissions, please email: journalsrights@oxon.blackwellpublishing.com

279

Blackwell Publishing Inc

Barriers to Dissemination: Exploring the

Criticisms of Behavior Therapy for Tics

Douglas W. Woods, Christine A. Conelea, and

Michael R. Walther, University of Wisconsin–Milwaukee

The review by Cook and Blacher (2007) suggests that

behavior therapy for tic disorders is indeed efficacious.

Given the empirical support for these treatments,

researchers should begin to place effort on examining

various strategies for treatment dissemination. The

current article addresses possible barriers to dissemina-

tion, focusing specifically on various concerns that have

been raised by many medical and psychological care

providers. The validity of these concerns is examined

in the context of existing data. In addition, limitations of

the current literature and future directions for research

are discussed.

Key words:

behavior therapy, criticisms, rebound,

symptom substitution, tic suppression, Tourette.

[Clin

Psychol Sci Prac 14:

279–282

,

2007]

C

ook and Blacher (2007) do an excellent job ofreviewing the existing literature on behavior therapy forTourette syndrome (TS) and other tic disorders. Ques-tions remain about the generalizability and maintenanceof such treatments, as well as the specific mechanisms ofchange underlying their efficacy, but there is compellingevidence that behavior therapy for tics may be beneficial.Still, like many effective psychosocial interventions, thereare barriers to dissemination.

One barrier involves a general lack of knowledgeabout the existence of behavior therapy for tics and alimited number of practitioners trained in the procedures.For example, in a survey of 67 neurologists, psychiatrists,general practitioners, and psychologists, only 14–31% hadheard of habit reversal, and 3–6% knew how to implementit (Marcks, Woods, Teng, & Twohig, 2004). A secondbarrier involves several concerns about behavior therapyfor tics, which are held by many medical and psychological

care providers. In the current article, we discuss concernswe have encountered in the literature and/or in the contextof professional talks. We then examine the extent to whichexisting data support or allay these concerns.

Concerns about behavior therapy for tics can beorganized around two primary themes. The first involvesdoubt about the general possibility of tic suppression viaenvironmental modifications, and the second involvesunintended consequences that may stem from behaviortherapy. Although the list of concerns we address is notcomprehensive, it offers a representative sampling of thequestions raised about behavior therapy for tics. It is ourhope that the current article encourages further collabora-tive exchange between researchers and practicing clinicians,so that other concerns regarding behavior therapy for ticscan be empirically validated or disconfirmed. This type ofexchange has recently been emphasized as an importantstep in the dissemination of empirically based treatments(Kendall & Beidas, 2007).

TIC SUPPRESSION VIA ENVIRONMENTAL MODIFICATIONS

A common criticism of behavior therapy involves doubtthat environmental factors can be mobilized to create ticsuppression. The majority of professionals (55%) surveyedby Marcks et al. (2004) believed that tics are not sup-pressible. Given that a large portion of the TS literaturehas focused on the neurobiological underpinnings of thedisorder, it is not surprising that tic expression is oftenattributed to biological factors that are beyond the reachof environmental influence. Two streams of evidence,however, argue against this belief. First, the review byCook and Blacher (2007) clearly demonstrates that non-pharmacological treatments may yield significant symptomreduction. In addition, recent tightly controlled laboratory-based research has shown that tic suppression can be createdwith proper environmental supports (Himle & Woods,2005; Woods & Himle, 2004).

In one of the first experimental studies examining thetic suppression phenomenon, Woods and Himle (2004)compared verbal instructions to suppress to a conditionin which children with TS were reinforced with tokens forevery 10 s they could go without having a tic. Conditionslasted for 5 min, and following a baseline period, eachcondition was repeated twice. Results showed that simplyasking the children to suppress their tics was relativelyineffective. The verbal instruction condition produced a

Address correspondence to Douglas W. Woods, Department ofPsychology, University of Wisconsin–Milwaukee, 2441 E. HartfordAvenue, Milwaukee, WI 53217. E-mail: dwoods@uwm.edu.

CLINICAL PSYCHOLOGY: SCIENCE AND PRACTICE • V14 N3, SEPTEMBER 2007 280

10.3% reduction in tic frequencies from baseline levels.However, when the children were reinforced for suppres-sion, tics were reduced 76.3% from baseline. A later studyusing a similar preparation yielded similar results (Himle& Woods, 2005). Combined, existing data support thehypothesis that tics can be suppressed if environmentalcontingencies are arranged to support such behavior.Although these findings would be strengthened byreplication in larger samples and by examination of thesuppression effect in other environmental settings, theynonetheless cast doubt on the idea that the environmentcannot be arranged to support tic suppression.

NEGATIVE CONSEQUENCES OF BEHAVIOR THERAPY?

The second theme of concerns surrounding the use ofbehavior therapy for tics involves the perceived negativeconsequences of the procedures. In the following section,we explore four commonly encountered concerns.

Suppression Causes Rebound

Up to 77% of healthcare providers believe that tic suppres-sion strategies (including behavior therapy) may increasetic frequency (i.e., rebound) to above baseline levels,following a period of suppression (Burd & Kerbeshian,1987; Marcks et al., 2004). This concern may stem, in part,from clinical observations that many parents report increasedtic frequencies in their children upon returning home fromschool, where they have been “holding in” their ticsthroughout the day. Two recent empirical studies havebeen conducted to examine whether tic suppression causesa rebound in tic frequency.

Using a similar experimental manipulation as Woodsand Himle (2004), Himle and Woods (2005) comparedtic frequencies in conditions of baseline, reinforcement-enhanced suppression, and postsuppression across sevenchildren with TS. Although successful suppression wasachieved, when the suppression period ended, there wasno evidence of a rebound effect. There were no significantdifferences in tic frequencies between baseline andpostsuppression conditions. In fact, tic frequencies wereobserved to decrease by 17% from baseline in the post-suppression phase. Using a slightly different preparation,Meidinger et al. (2005) found similar results.

Although additional research is needed to examine issuessuch as how these results generalize to other settings,apply to individuals who have comorbid conditions, and

are consistent at different developmental stages, existingresearch does not support the idea of a rebound effectfollowing tic suppression. Nevertheless, should theclinical observation of tic exacerbations after school beempirically confirmed, it would require an explanation.As an alternative to a postsuppression rebound effect, anumber of other hypotheses should be explored. First,the impact of contextual variables should be examinedto determine whether a change in environmental setting(from school to home) is responsible for the change intic frequency. Perhaps tic frequency increases at homebecause the home context does not include as manystimuli that elicit suppression behaviors as the schoolcontext. Likewise, it may be the case that the childengages in a number of competing behaviors at school(e.g., writing, recess activities, physical education classes)that are not as common in the home environment.

Nontargeted Tics Get Worse

Some have expressed concern that behavior therapy fortics may result in exacerbation of those tics not targetedfor treatment (Burd & Kerbeshian, 1987). To test thishypothesis, Woods, Twohig, Flessner, and Roloff (2003)investigated the efficacy of habit reversal in five childrenwith TS using a multiple baseline across subjects design.Only vocal tics were targeted in the three treatmentsessions; motor tics were left untreated. Using directobservation of tics in home settings, results showed thatfour of the five children demonstrated immediate reduc-tions in vocal tics (M = 83% reduction). There was also26% reduction in the untreated motor tics. If untreatedtics are exacerbated following treatment of other tics,one would have expected motor tics (untreated in thestudy) to increase. Results of the study suggest thatnonpharmacological treatments may not result inexacerbation of untreated tics; in fact, they may evendecrease. Woods, Miltenberger, and Lumley (1996) alsofound similar results in a multiple baseline design withfour children with tic disorders.

Behavior Therapy Replaces an Old Tic With a New Tic

A related concern we encounter when giving presenta-tions about behavior therapy for tics is that the treatmentwill result in an old tic being replaced by a new ticor that the competing response will become a new tic.Research addressing these questions is limited, but

COMMENTARIES ON COOK & BLACHER 281

existing data do not support these notions. As mentionedpreviously, Woods et al. (2003) demonstrated a meanreduction of 83% in vocal tics across five children withTS. If the argument that nonpharmacological treatmentsresult in new tics replacing old ones (i.e., the treatedtic goes away, only to be replaced by a new one) is valid,one would expect either no overall reduction in tics, or avery small reduction in tics, neither of which was the case.The additional finding that motor tics also decreasedfurther argues against the idea, because it was unlikely thatthe participants’ treated vocal tics were replaced by motortics. Although never directly examined in studies of behaviortherapy for tics, our clinical experience is that thecompeting response does not become a “new tic.” Incontrast, the competing response seems to decrease infrequency as the tics decrease. Clearly, more systematicresearch on this topic is needed before any strong conclu-sions can be made.

Focusing Attention on Tics Makes Them Worse

A final concern about behavior therapies for tics isthat the treatment increases attention on tics, whichmay result in a worsening of symptoms (e.g., Shimberg,1995). Relatedly, there is a belief among many who treatthose with TS that talking about tics makes them worse(Marcks et al., 2004). To investigate this concern usingexisting evidence, it is helpful to first clarify the issue.Increasing the salience or one’s awareness of the tic andits effects on frequency must be considered in two ways.First, one must ask the general question of whetherheightening the salience of tics results in increased ticfrequency. Second, one must ask whether increasingawareness

in the context of treatment

produces an increasein tics.

Few studies utilizing experimental methodology haveevaluated the impact of increasing tic salience, independentof the treatment context, on tic occurrence. In one of thefirst, Woods et al. (2003) utilized a withdrawal designacross two children with TS. During the 5-min baselinephases, the researcher and subjects talked about anythingbut tics, and in the 5-min tic-conversation phases, theytalked only about the tics. Results for both childrenshowed a similar pattern in which vocal tics, but notmotor tics, occurred more frequently when conversationwas tic-related. Although the generalizability of thesefindings is unclear, the results support the general idea

that at least some tics may be made worse by heighten-ing their salience.

In a second study, Piacentini et al. (2006) comparedconditions in which children with TS or CTD were alonein a room and recorded either overtly (camera in the room)or covertly (camera hidden). Assuming that the overtrecording would heighten focus on tics, results showedthat 63% of the sample displayed more tics when overtlyrecorded, 12% displayed fewer tics when overtly recorded,and 24% responded similarly across conditions. In summary,the Woods et al. (2003) and Piacentini et al. findingssupport the claim that increasing the salience of ticsoutside of the therapeutic context may increase thefrequency of some tics for some children with tic disorders.

The second question of whether increased awarenessof tics in the context of behavior therapy also increasestic occurrence requires separate consideration. Two piecesof evidence argue against the claim that behavior therapyregularly creates symptom worsening via increasingthe awareness of tics. First, the global outcome data onbehavior therapy for tics, which includes an element ofawareness enhancement, suggests that tics improve, notworsen (Cook & Blacher, 2007). Second, a dismantlingstudy by Woods et al. (1996) looked specifically at theeffects of awareness training components of habit reversalin an additive sequential multiple baseline across subjectsand behaviors design in children with TS. Results clearlyshowed that awareness training did not exacerbate ticsfor any of the four children in the study, and in fact,produced significant reductions in directly observed ticfrequency for two of the children. Such results areconsistent with other studies (e.g., Ollendick, 1981;Peterson & Azrin, 1992; Wright & Miltenberger, 1987),which suggest that awareness training and/or self-monitoring may produce modest

reductions

in tics.In summary, there appears to be evidence supporting

the role of increased tic salience in producing an increasein tic frequency. Nevertheless, the claim should be qualifiedbecause it only appears relevant outside of the therapeuticcontext and only appears to apply to a subset of individualswith TS. It is by no means a global effect found in thosewith tic disorders. Although it would appear that cliniciansdo not need to be concerned about the tic-exacerbatingrole of awareness in the context of treatment, there areclinical and research implications. First, it may be usefulto determine if increased attentional focus on tics makes

CLINICAL PSYCHOLOGY: SCIENCE AND PRACTICE • V14 N3, SEPTEMBER 2007 282

them worse for individual clients and modify theindividual’s environment accordingly. Second, it wouldbe worth understanding the mechanism by which thedifferential tic expression pattern emerges in reaction toincreased salience when in therapeutic and nontherapeuticcontexts. Identifying the variables responsible for thisdifferential functioning may allow for the developmentof other treatment options.

REFERENCES

Burd, L., & Kerbeshian, J. (1987). Treatment-generatedproblems associated with behavior modification in Tourettedisorder.

Developmental Medicine and Child Neurology

,

29

,831–832.

Cook, C. R., & Blacher, J. (2007). Evidence-based psycho-social treatments for tic disorders.

Clinical Psychology: Scienceand Practice

,

14

, 252–267.Himle, M. B., & Woods, D. W. (2005). An experimental

evaluation of tic suppression and the tic rebound effect.

Behavior Research and Therapy

,

43

, 1443–1451.Kendall, P. C., & Beidas, R. S. (2007). Smoothing the trail for

dissemination of evidence-based practices for youth: Flexi-bility within fidelity.

Professional Psychology: Research andPractice

,

38

, 13–20.Marcks, B. A., Woods, D. W., Teng, E. J., & Twohig, M. P.

(2004). What do those who know, know? Investigatingproviders’ knowledge about Tourette’s syndrome and itstreatment.

Cognitive and Behavioral Practice

,

11

, 298–305.Meidinger, A. L., Miltenberger, R. G., Himle, M., Omvig, M.,

Trainor, C., Crosby, R., et al. (2005). An investigation of

tic suppression and the rebound effect in Tourette’s disorder.

Behavior Modification

,

29

, 716–745.Ollendick, T. H. (1981). Self-monitoring and self-administered

overcorrection.

Behavior Modification

,

5

, 75–84.Peterson, A. L., & Azrin, N. H. (1992). An evaluation of

behavioral treatments for Tourette syndrome.

BehaviourResearch and Therapy

,

30

, 167–174.Piacentini, J. C., Himle, M. B., Chang, S., Baruch, D. E.,

Buzzella, B. A., Pearlman, A., et al. (2006). Reactivity of ticobservation procedures to situation and setting.

Journal ofAbnormal Child Psychology

,

34

(5), 649–658.Shimberg, E. F. (1995).

Living with Tourette syndrome

. New York:Simon & Schuster.

Woods, D. W., & Himle, M. B. (2004). Creating tic suppression:Comparing the effects of verbal instruction to differentialreinforcement.

Journal of Applied Behavior Analysis

,

37

, 417–420.

Woods, D. W., Miltenberger, R. G., & Lumley, V. A. (1996).Sequential application of major habit-reversal componentsto treat motor tics in children.

Journal of Applied BehaviorAnalysis

,

29

, 483–493.Woods, D. W., Twohig, M. P., Flessner, C. A., & Roloff, T. A.

(2003). Treatment of vocal tics in children with Tourettesyndrome: Investigating the efficacy of habit reversal.

Journal of Applied Behavior Analysis

,

36

, 109–112.Wright, K. M., & Miltenberger, R. G. (1987). Awareness

training in the treatment of head and facial tics.

Journal ofBehavior Therapy and Experimental Psychiatry

,

18

, 269–274.

Received November 1, 2006; revised November 6, 2006;accepted November 7, 2006.