Intensive outpatient comprehensive behavioral intervention for tics: A case series

Table 1 Summary of patient information

	Patient A	Patient B
Age (yr)	10	14
Ethnicity	Asian-American	African-American
Academic history	4th grade	9th grade
	Gifted and talented	Dysgraphia, low-intellectual functioning, and disorder of written expression
Psychological history	Tourette syndrome	Tourette syndrome, ADHD, specific phobia, anxiety, insomnia, and stuttering
Tic interference	Minimal	Significant
Type (number) of tics	Motor (5)	Motor (6) and vocal (4)
Treatment teams	Psychologist, psychology postdoctoral fellow, and psychology intern	Psychologist and two psychology postdoctoral fellows
Length of treatment	4 d, 8 treatment sessions	4 d, 3 treatment sessions

ADHD: Attention deficit hyperactive disorder.

Table 2 Patient A and B’s outcome assessment scores

Measures	Baseline	1 wk posttreatment	1 mo follow-up	7 mo follow-up	Baseline		1 wk posttreatment		1 mo follow-up		6 mo follow-up
	Patient A				Patient B
	M	M	M	M	M	P	M	P	M	P	M	P
YGTSS
Total	15	9	6	5	21	18	15	13	11	12	14	13
Number	2	1	1	2	5	4	4	4	2	2	2	2
Frequency	4	4	2	2	3	3	3	3	2	2	2	3
Intensity	4	3	2	1	4	4	2	2	3	4	2	4
Complexity	3	0	0	0	4	3	2	2	2	3	4	3
Interference	2	1	1	0	5	4	4	2	2	1	4	1
CGI-SI	4	3	2	2	5		3-4		3		4
CGI-I		1	1	1	-		2		2		3

M: Motor tic; P: Phonic tic; YGTSS: Yale Global Tic Severity Scale (Clinical Cut-off: 14), YGTSS subscales are out 5, with 0: None, 5: Severe; CGI-SI: Clinical Global Impressions-Severity of Illness (0: Not assessed; 1: Normal; 2: Borderline; 3: Mild; 4: Moderate; 5: Mark; 6: Severe; 7: Extreme); CGI-I: Clinical Global Impression-Improvement (0: Not assessed; 1: Very much improved; 2: Much improved; 3: Improved; 4:Minimal improvement; 5: No change; 6: Minimal worse; 7: Much worse; 8: Very much worse).

Table 3 Overview of Patient A’s treatment schedule

	Day 1	Day 2	Day 3	Day 4
Session	1:90 min	3:60 min	5:60 min	7:60 min
Number	Review history	Review OOSAs	Review OOSAs	Review OOSAs
	Treatment rational	Inconvenience review	Inconvenience review	Inconvenience review
	Psychoeducation	Review treatment tic 1	Review treatment tic 1-3	Review treatment tic 1-3
	Tic hierarchy	Functional intervention	Functional intervention	Functional intervention
	Introduce function-based interventions	Competing response tic 2	Competing response tic 2	Competing response tic 2 Review relaxation
	Introduce reward program	Reward review	PMR	Relapse prevention
	Teach tic monitoring		Reward review	Reward review
Lunch (2 h)	Monitor tic 1	Monitor tics 1, 2	Monitor tics 1-3	Monitor tics 1-3
	Functional assessment	Practice CRs 1, 2	Practice CRs 1-3	Practice CRs 1-3
Session	2:90 min	4:60 min	6:60 min	8:60 min
Number	Review OOSAs	Review OOSAs	Review OOSAs	Review OOSAs
	Inconvenience review	Inconvenience review	Inconvenience review	Inconvenience review
	Functional assessment and treatment tic 1	Review treatment tic 1 and 2	Review treatment tic 1-3	Review treatment tic 1-3
	Competing response tic 1	Functional intervention tic 3	Functional intervention tic 2	Functional intervention
	Reward review	Competing response tic 3	Competing response tic 2	Competing response tic 2
		Introduce relaxation	Review relaxation	Review relaxation
		Diaphragmatic breathing	Reward review	Relapse prevention
		Reward review		Reward review
OOSAs	Practice CR for tic 1	Practice CRs tics 1-3	Practice CRs tics 1-3	Posttreatment assessment
	Monitor 30 min	Monitor 30 min	Monitor 30 min
		Relaxed breathing	Relaxation

CR: Competing response; OOSA: Out of session assignment; PMR: Progressive muscle relaxation.

Table 4 Patient’s A tic symptom hierarchy tracker ratings

	S1	S3	S4	S5	S6	S7	S8	1 mo	6 mo
Eye Blink	6	6	4	4	3	1	2	0	1
Upper Lip	4	4	4	1	1	0	1	0	0
Facial Grimace	6	6	0	1	1	0	0	0	0
Neck Jerk	9	3	2	1	1	0	1	1	0
Nose Flair	4	4	0	0	0	0	0	0	0

Session 2 (S2) scores were not recorded; Subjective Unit of Distress Scale range from 0 to 10, with 0: No Distress; 10: Extreme distress.

Table 5 Overview of Patient B’s treatment schedule

	Day 1	Day 2	Day 3	Day 4
Session	S1: (1.5 h)	S2: (3.5 h)	S3: (3.5 h)	S4: (3.5 h)
Number	Baseline assessment	Psychoeducation	Review relaxation OOSAs	Competing response
		Introduce relaxation	Tic hassles form	Inconvenience review
	Meet therapists	Stress vs relaxation	Competing responses	Relaxation practice
		Relaxation postures	Inconvenience review	Review OOSAs
	Introductions	PMR + 12	Review tic 1 and 2	Review CR for all tics
	Treatment overview	Diaphragmatic breathing	Competing responses 1, 2	Summarize progress
		Visual imagery	Review treatment tic 1	Emphasize social support
		Awareness training	Practice relaxation	Reward review
		Psychoeducation about tics	Competing response 1 and 2
		Rationale for treatment	Assign homework
		Tic Sx hierarchy
		Feedback about assessment
OOSAs		Practice relaxation	CR tics 1-2	F(x) based interventions
		Practice PRM + 12	Monitor 15 min, 3-4x	Relaxation
		Practice visual imagery	F(x) based interventions	Family and social support
			Relaxed breathing

PMR: Progressive muscle relaxation; Sx: Symptoms; CR: Competing response; OOSA: Out of session assignment; F(x) = Function.