Eur Child Adolesc Psychiatry [Suppl 1] 16:I/89I/99 (2007) DOI 10.

1007/s00787-007-1011-7

ORIGINAL CONTRIBUTION

pfner Manfred Do Aribert Rothenberger

Behavior therapy in tic-disorders with co-existing ADHD

j Abstract Objectives To give an

overview concerning the behavioral treatment approaches for Chronic Tic Disorder (CTD) and Attention-Decit/Hyperactivity Disorder (ADHD) and to provide some suggestions for the behavioral treatment of children and
pfner (&) Prof. Dr. M. Do Department for Child and Adolescent Psychiatry and Psychotherapy University of Cologne Robert Koch Str. 10 50931 Koeln, Germany Tel.: +49-221/478-6905 Fax: +49-221/478-3962 E-Mail: manfred.doepfner@uk-koeln.de Prof. Dr. A. Rothenberger Department for Child and Adolescent Psychiatry ttingen University of Go Von-Siebold-Str. 5 ttingen, Germany 37075 Go

adolescents with a combination of both disorders. Results Pharmacotherapy plays an important role in the treatment of both ADHD and CTD. However, behavior therapy has also been proven to ameliorate the core symptoms of both disorders. The most prominent behavioral technique to reduce tics is habit reversal training. In ADHD behavioral interventions, especially parent training and behavioral interventions in preschool/school, are effective in reducing ADHD core symptoms and comorbid problems. In children and adolescents with ADHD plus CTD both ADHD and tic symptoms can be treated by behavioral interventions alone or in combination with pharmacotherapy. However, most of the published studies on behavioral

interventions in children with ADHD or CTD do not give detailed information on comorbidity and many studies excluded patients with comorbid problems. Conclusions Clinical experience suggests that in CTD+ADHD success may be easier to achieve using behavioral treatment of ADHD rst. Adherence to the habit reversal procedure to reduce tics in daily living is the most important problem in the behavioral treatment of tics especially in children with comorbid ADHD. Practical suggestions to overcome these difculties are presented.
j Key words ADHD Tourettes syndrome Chronic Tic Disorder behavioral treatment habit reversal

Introduction
The overlap between Attention-Decit/Hyperactivity Disorder (ADHD) and Chronic Tic Disorder (CTD; including Tourette syndrome (TS) is well documented. The most common disorder in children and adolescents with CTD is ADHD, as evidenced by an enormous literature on the subject [58, 65]. Children with ADHD do also have a higher risk for CTD but the rate of tic disorders in ADHD is lower than the rate of ADHD in tic disorders [7, 9]. Pharmacotherapy plays an important role in the treatment of both ADHD and CTD. Nevertheless, behavioral interventions have

been perceived to be important in both disorders, because there are limitations of pharmacotherapy: (1) Limited efcacy: Controlled medication trials in patients with CTD have yielded reductions in tic symptoms ranging from 25 to 80% [13, 67]. In children and adolescents with ADHD 5075% of subjects with ADHD havent been determined to be clinical responders to stimulants [8, 24, 25]. Despite the strong effects of pharmacotherapy found in both conditions there is still a substantial rate of children and adolescents who do not benet or do not benet enough from medication.

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(2) Unstable effects: The pharmacological treatment in both disorders is mainly symptomatic and most effects relapse after discontinuation of the medication [9, 13]. Therefore long-term medication is usually needed in both conditions. (3) Side effects. The most effective medications for CTD are associated with serious side effects that limit their utility with younger populations [66]. In adult samples, signicant side effects have been found to occur in up to 80% of individuals [13] and up to 90% of patients have been reported to discontinue medication prematurely because of these adverse effects [68, 70]. Stimulant medications are generally well tolerated in the treatment of children with ADHD, however, decreased appetite, marked insomnia and irritability were seen in most studies [18, 74]. (4) Patients and parents preference and compliance problems: In addition to efcacy and safety concerns, many parents deny psychopharmacologic treatment for their children because there is little information regarding long-term medication effects [8, 74].

movements triggered internally by unpleasant sensations, as has been shown for pain and itching [12]. For most patients these urges are aversive and usually tic expression leads to full or partial dissipation of the urge. Therefore tics may be, at least partly, understood as a negatively reinforcing stimulus. Behavioral interventions aimed at extinguishing this connection should therefore be helpful for treating tic disorders. Sensorymotor phenomena and volitionality of tics are developmentally inuenced. Younger children are less likely to describe their tics as controllable, and sensorymotor phenomena are typically not reported by children younger than 10 years of age [6, 34]. Moreover, simple tics are less likely to be controllable than more complex ones. To develop the principles for BT of tics one should have in mind that a movement cannot be performed if the muscles are either stiff or relaxed and that attentional abilities signicantly predict tic suppressibility [27]. This is particularly relevant for the development of well evaluated methods as knowledge concerning the ability of self-regulation and tic suppression advances. Especially, the ability of older children with CTD to monitor their sensorymotor phenomena, and thus being conscious about their physical signs related to the tics is a good precondition for introducing behavioral treatment. It was, however, found that the ability to suppress tics is not dependent on the awareness of premonitory urges, which is important for younger children, who may not yet be aware of the specic sensorymotor phenomena [6]. When including contingency management techniques to encourage children in controlling their tics; it is important to give the children the feeling of mastering of tic behavior. The impression should be avoided that exhibiting tics is ostracized, which would attribute a form of stigmatization to the tics. Experience and training help to sculpture the brain in such a way that it can perform successfully to control the tics in different social settings. Thus, brain development and plasticity may be viewed as intertwingled with behavioral treatment of CTD and ADHD. The most prominent behavioral technique for addressing tics is habit reversal (HR) training, initially described by Azrin and Nunn [3] as a multicomponent behavior therapy program that consists of (a) awareness training, (b) self-monitoring, (c) relaxation training, (d) competing response training, and (e) contingency management. The relative contribution of these components to treatment outcome is unclear. Miltenberger et al. [40, 41] reported that awareness training plus competing response training were as effective as the full HR package described by Azrin and Nunn [3]. Woods et al. [78] sequentially

Behavioral treatment (BT) of CTD

The dominant role of genetic and neurobiological factors in the etiology and pathophysiology of CTD has been strongly supported [28, 32, 33, 55]. Within this neurobiological framework two characteristics of tics play a key role in behavioral models of tic expression and in the development and implementation of behavioral treatments for tic disorders [52]. (1) Volitionality of tics: Despite the fact that tics are described as involuntary and uncontrollable behaviors, about 90% of adult patients report that they experience their tics as somewhat controllable and that they sometimes show voluntarily initiated movements to release an inner urge. This suppressibility of tics seems to be related to increased frontal lobe activity [33, 35, 55]. (2) Sensorymotor phenomena: Several studies have reported a high frequency of sensorymotor phenomena immediately preceding or sometimes following tics (e.g., [6, 35, 38]). These sensations are most commonly described as a sense of building tension or a strong urge. Withholding the behavior does not always decrease the sensorymotor urge with time. Bohlhalter et al. identied by fMRI a brain network of paralimbic areas (anterior cingulate, insular cortex, supplementary motor area, parietal opperculum) predominantly activated before tic onset; somewhat similar to

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applied the four major HR components (awareness training, self-monitoring, social support, and competing response training) in four children with motor tics to identify the most parsimonious treatment combination. Although all showed a positive treatment response, each child responded to a different treatment combination. Moreover, compliance tended to decrease as the demands of treatment increased. The authors concluded that self-monitoring be utilized as the rst line of treatment, given its relative ease in training and use, with other treatment components added as necessary when awareness of baseline tic level has been established. In a typical HR session, participants are rst instructed to verbally describe each tic and to increase their awareness of the tics. Participants are then taught competing responses (to perform immediately after each tic for 13 min). In addition to these two components, relaxation training, self-monitoring, contingency management, and social support interventions are sometimes used as ancillary treatment components. Awareness training is based on the assumption that increased awareness of tic behaviors facilitates better self-control. The original training specied by Azrin and Nunn [3] included four components (a) response description where the participant is trained to describe tic reactions in detail and to re-enact tic movements while looking in a mirror; (b) response detection where the therapist aids patients tic detection abilities by using feedback techniques immediately after each tic occurred during the training session; (c) an early warning procedure where the child practices identifying the earliest signs of tic occurrence; and (d) situation awareness training where the high-risk tic evoking situations are identied. Awareness training thus is used as the initial step in HR training. The self monitoring procedures used in awareness training may work by making the occurrence of the tic an aversive event it may be a self-punishment for tic expression [4, 79]. A few studies provide some support for the short-term efcacy of awareness training as a primary treatment intervention [11, 44, 48]. Competing-Response Training is the central intervention in the HR training. After the patient is able to detect tic urges reliably, the child is instructed to invoke the competing response at each occurrence of the urge and hold the response until the urge passes, a procedure which has to deal with the problem that the urge often builds up with time than to decrease by suppression. Azrin and Nunn specied that the competing response should be opposite to the tic behavior, be capable of being maintained for several minutes, produce heightened awareness of the tic by isometric tensing of the muscles involved in the

movement, be socially inconspicuous and easily compatible with normal ongoing activity, and, nally, should strengthen the muscles antagonistic to the tic behavior. Carr [14] provided a list of alternative competing responses for the most common tics. For vocal tics the preferred competing response is slow rhythmic breathing through the nose until the tic urge has passed. The subjects were instructed to perform the competing response for 1 min after: (a) sensing the urge that a tic was about to occur, (b) after the actual occurrence of a tic, or (c) being in tic-prone situations. Competing responses involving muscles antagonistic to the targeted tic are the most commonly employed, because of the logical relationship between tic and competing response enhances the likelihood of correct usage [52]. However, competing response does not have to be physically incompatible with the targeted tic to be effective [69]. Moreover, as Piacentini and Chang [52] pointed out, competing responses can be implemented in a gradual manner using a shaping procedure. Younger children or those with more forceful tics often feel overwhelmed at the idea of completely blocking their tics or they may actually be physically unable to do so. The goal of shaping strategies in these situations is not to completely block tic expression but rather to attenuate the explosive aspects of tic expression. An intermediate goal may be to morph the tic into a more socially inconspicuous behavior. Given that the paroxysmal aspects are typically the most noticeable, distressing, and physically damaging features of tic behaviors, attempts to slow down or deintensify targeted tics through the use of shaping procedures may lead to more rapid treatment gains than more forceful, yet less easily implemented, competing responses. The most frequently used relaxation techniques for tic disorders are deep breathing, progressive muscle relaxation, and imagery [49]. The underlying rational for relaxation techniques is the observation that increases in stress and anxiety lead to concomitant increases in tic frequency, intensity, and duration [17]. However, in studies only modest and short-lived benets were found for relaxation and the observed tic reduction did not generalize beyond in session training periods [47, 75]. Compared to minimal treatment control group no effects of relaxation training were found [10]. Nevertheless, relaxation techniques may have some utility as part of multicomponent interventions, such as HR training, especially for youngsters with increased levels of stress [52]. Contingency management has been frequently employed in behavioral treatment of tics [49, 75]. Usually tic-free intervals are positively reinforced, and tic behaviors are punished. Case reports provide

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limited support for contingency-based approaches, and the generalisability, and durability of such interventions to reduce tics remains questionable [19, 31, 39, 75]. Since treatment compliance is one of the biggest problems in HR training positive reinforcement in natural setting - in form of praise and encouragement from signicant others or as formal behavioral reward system using token economymay be used to increase adherence to HR treatment protocol [51]. Positive reinforcement by itself is not expected to signicantly and reliably reduce the frequency or intensity of tics. It is also unclear, whether the treatment effects observed are due to a learnt reduction of tics (as proposed by operant theory) or result from a temporary enhancement in patient motivation to suppress tic behavior [51]. The recent empirical neurobiological evidence of tic control by involvement of the frontal lobes supports the latter [33] and may argue against the usage of punishment to treat tics. The effects of HR training are quite well documented. Since the early trials [15] more than 100 published studies examined the effects of different behavioral treatments for individuals with tic disorders [15]. Several narrative literature reviews on the effects of psychosocial interventions have been published [4, 15, 30, 48]. Peterson et al. [49] concluded in a review of the HR training literature, that the full HR procedure may lead to reductions in tic frequency of up to 90% at home and up to 80% in clinic settings. Unfortunately, the data presented is limited by a number of methodological shortcomings, including poor sample characterization, problematic assessment methods (primarily retrospective self-reports), the use of analogue settings, and the lack of controlled treatment-outcome designs with adequate follow-up. The majority of the studies employed within-subject (i.e., single-case) design methodology to evaluate treatment effects with relatively few participants. In total, in the 20 studies analyzed by Carr and Chong [15] 114 participants (mostly adults) were exposed to some variation of HR. The component common to all of these HR variations was the performance of the competing response. Of these 114 participants, 108 were successfully treated. The authors concluded that on the surface, a 95% efcacy rate with more than 100 participants appears to strongly support the use of HR for tic reduction. However, of these 20 studies, only 15 employed an experimental design capable of demonstrating experimental control of the independent variable. Of the 15 studies that employed experimental designs, only 12 of them incorporated direct measurement of the dependent variables, which the authors analyzed in more detail. These studies included 90 participants (age range: 666), approximately 73% of which were treated in three studies [5,

41, 43]. Of the 90 participants included in the 12 studies, reductions from pretreatment assessment were reported for 85 (94%) of them. 10 out of the 12 studies included some follow-up or long-term assessment (mean = 10 months; range, 1 month to 2 years), most of which were successful. The studies reviewed by Carr and Chong [15] fulll most of the criteria for a well-established treatment according to the guidelines of the Task Force on Promotion and Dissemination of Psychological Procedures [73]. However, most of the studies do not meet additional criteria (use of treatment manuals, assessment of treatment integrity, and sufcient information on participant characteristics). Therefore, the authors concluded the current literature on the use of HR to treat tics might not support the Task Forces most prominent classication. However, it does meet the requirements for a probably efcacious classication. Two further studies not included in Carr and Chong are worth to be mentioned. Wilhelm et al. [77] reported HR training to be more effective than supportive psychotherapy in a sample of 32 adults with TS with gains maintained at 10-month follow-up. Piacentini et al. [53] compared HR training to awareness training in 25 children and adolescents with TS and found HR training to be associated with signicant tic reduction post treatment and at a 3month follow-up. Collectively, these two studies suggest that HR is associated with signicant, yet modest, results in tic reduction and associated impairments. The mechanisms underlying habit reversal are not well understood. Azrin and Nunn initially suggested that treatment effect stems from the strengthening of muscles incompatible with tic expression and heightened awareness of the tic produced by the opposing competing response [3]. However, the fact that competing responses that are topographically dissimilar to the targeted tic can also be effective [69] runs counter to this hypothesis. Miltenberger and Fuqua speculated that the aversive nature of the competing response functions as punishment for the tic behavior [40]. According to these authors, the competing response can be seen as a self-administered punishment procedure that is paired contingently with the tic and lead to tic reduction via operant conditioning. Conversely, the competing response may be viewed as an active coping mechanism that directly competes with the aversive tic behavior and, thus, helps to motivate the patient and build increasing self-control. The latter can be brought in line with the neurobiological background of CTD saying that frontal lobe activation and good attentional capacity is used to compensate the disturbed sub cortical networks in CTD [33, 55]. Hoogduin and colleagues used exposure and response prevention in four patients as an extension to

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HR. Exposure and response prevention entails exposure to the sensations and urges that precede tics, and response prevention of the tics [29]. Theoretically, the patient habituates to the premonitory experiences, thus resulting in tic reduction. In the training sessions, patients systematically learn to suppress tics for even longer lasting times. Whenever a tic occurred, the therapist spurred the patient to improve his performance. To optimize exposure, patients were asked to concentrate on the sensory experiences and the corresponding locations in their bodies. In the following sessions, patients were to apply the response prevention procedure for two consecutive hours. Verdellen and colleagues compared the effect of exposure and response prevention with the effects of habit reversal in 43 TS patients aged 318 years. Both treatment conditions resulted in statistically signicant improvements and no signicant differences were found between the treatment conditions on any of the outcome measures [76]. The underlying mechanism seem to be similar to those mentioned above.

impulsivity and promoting social adjustment [22]. No one scheme has been shown to be superior to others, and the following outline adapted from Taylor and colleagues [74] is an integration of several [9, 21, 23]. 1. Discuss classroom structure and task demands (e.g., having the child seated close to the teacher, brief academic assignments, interspersing classroom lectures with brief periods of physical exercise). 2. Identify specic problem situations and specic behavior problems (e.g., blurts out answers before questions have been completed; leaves seat in classroom). Monitor the childs progress frequently with a rating scale. 3. Analyze positive and negative consequences and contingencies of appropriate and problem behaviors. 4. If coercive and unpleasant teacher-child interactions occur very often while positive teacher-child interactions rarely occur, then it may be possible to enhance the differential attending skills of the teacherfor example, during individual feedback after a period of observation. 5. Use token systems in order to reinforce appropriate behavior in specic situations. Back-up reinforcement may be located in the kindergarten or school (e.g., special playtime or lesser homework assignment), at home, or outside (e.g., special playtime with a therapist). 6. Response cost systems is useful to reduce very frequent problem behaviors (e.g., often leaves seat, or disrupts others). 7. Use brief time-out from reinforcement as a punishment procedure for more serious forms of child noncompliance if negative consequences to problem behavior are not effective. Make sure, however, that leaving the classroom is not positively reinforcing to the child and that it does not become punitive. 8. The child needs to be integrated as an active member in this therapeutic process. Behavioral interventions implemented in recreational settings (e.g., summer programs) with social skills training and contingency management have been proven to be effective [45] while isolated cognitive behavioral training approaches for the child (e.g., selfinstructional trainings) have not been shown to be effective by controlled trials [1]. However, experience suggests they may be helpful in individuals in combination with other behavioral approaches. Treatment generalization is often limited, all the more if the application of the newly acquired skills is not reinforced in the natural environment of the child. Selfinstruction is most relevant if the child is motivated and

Behavioral treatment of ADHD

Behavioral interventions are perceived to be important in ADHD, not only to reduce the core symptoms. The following cognitive-behavioral interventions have been used in children and adolescents with ADHD: (1) Behavioral parent training and behavioral interventions in the family; (2) behavioral interventions in the kindergarten, the preschool or the school; (3) behavioral interventions in peer/recreational summer program and (4) cognitive behavior therapy of the child/adolescent. Since children with ADHD have decits in executive functioning (correlated with their neurobiological decits in their frontal lobes) it is important to outsource their self-regulatory support (e.g., by parent training). Hence, the principles of behavioral interventions in patients with ADHD can be grounded on and guided by neurobiological knowledge [63]. While behavioral parent training, classroom management and peer-focused behavioral interventions implemented in recreational settings (e.g., summer programs) are well-established treatments for children with ADHD according to the guidelines of the Task Force on Promotion and Dissemination of Psychological Procedures [73], the evidence base for cognitive behavior therapy of the child/adolescent is controversial [22, 45, 46]. Behavioral interventions in the kindergarten, the preschool or the school are known to be effective in reducing hyperactive behavior, inattention and

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if impairing symptoms of inattention or impulsivity can be observed even under optimal learning conditionse.g., with reinforcement for attentive and reective behavior. The parents and teachers are taught to help the child to apply self-instruction procedures at home or at school. These procedures can be used to increase attention and to reduce impulsivity in learning settings but also as social problem solving steps in social problem solving trainings and subsequently in natural-social interactions especially in children with high impulsivity in social interactions. Besides the core problems of hyperactivity, impulsivity and inattention additional problems are often present, and if so they may need treatment. Training of social competence is often needed. It may help children to make and keep relationships, solve interpersonal problems and provide substitutes for aggressive behavior to peers. Remedial teaching of academic skills may be needed for co-existent learning disorders. The curriculum may need to be modied, and individual attention from a teaching aide provided. Family support may need to go beyond the provision of advice, guidance and treatment and include appropriate nancial help for a disabled child and the provision of short periods of respite care [74]. In their review on evidence-based psychosocial treatment for ADHD Pelham and Fabiano [45] concluded that for behavioral interventions (behavioral parent training, classroom management and peer-focused behavioral interventions implemented in recreational settings) moderate effect sizes (ES) in between-group design studies (median ES = 0.47) and in within-subject design studies (median ES = 0.64) were found and high effect sizes in singlesubject studies (median ES = 3.46). In the Multisite Treatment Study on ADHD (MTA) behavioral interventions treatment were equivalent to community treatment (mostly medication), and the MTA medication management was only modestly better than behavioral interventions (ES = )0.24), with most of those advantages being for teacher and parent symptom ratings rather than functional impairments [42]. Behavioral therapy may be less effective than medication in the treatment of ADHD, however it is still helpful for many children and multimodal behavioral interventions with parent training, interventions in school and cognitive behavior therapy of the child have been shown to be effective in a substantial proportion of patients (e.g., [20]). Decisions on how to start will depend on the analysis of the individual child, the strengths and weaknesses of their school and classroom environment, the severity of disturbance of peer relationships, and the preferences of the families. It is quite reasonable to start with either therapy, in the knowledge that one will proceed to the other should the response be suboptimal [74].

Behavioral treatment of CTD+ADHD

The pharmacological treatment of CTD+ADHD with stimulants rarely exacerbates pre-existing tics (but does not trigger a rst onset of tics) [62, 74]. However, Robertson reviewed treatment studies with stimulants and found that the 215 individuals with tics or CTD+ADHD studied under controlled conditions with stimulants, the stimulants appear to be safe and in many cases reduced the tics rather than increased them [58]. Nevertheless, the behavioral treatment of children with CTD+ADHD may be of special interest, since the ADHD part raises usually most of the psychosocial problems. The neurobiological basis of co-existing CTD+ADHD is less clear than in the single disorder [7, 32, 55, 80], although a merely additive model could be the basis for planning treatment approaches (see also [56]). However, most of the published studies on the effects of habit reversal and other psychosocial interventions in children with CTD disorder do not give detailed information on comorbid problems and disorders of the patients analysed and some of these studies excluded patients with comorbid problems. For example, in the largest study on the effects of habit reversal patients with other psychiatric problems were excluded [43]. In their comparison of the effects of exposure with response prevention and habit reversal in TS Verdellen and colleagues report a rate of 30% of patients with ADHD [76]. In children and adolescents with CTD+ADHD both ADHD and tic symptoms can be treated by behavioral interventions alone or in combination with pharmacotherapy. In both conditions it is quite reasonable (after thorough individual evaluation of the child in question) to start with either therapy (e.g., behavioral interventions), with the option at hand that one may precede to the other (e.g., pharmacotherapy) if the treatment response turns out to be insufcient (see Fig. 1). Moreover additional problems of the patients with CTD+ADHD may be handled by psychosocial/ behavioral interventions (e.g., emotional problems, social withdrawal, academic problems, oppositional behavior problems, or obsessive-compulsive symptoms). These treatment targets are more important in patients with CTD+ADHD compared to those with ADHD-only or CTD-only because CTD+ADHD often shows additional co-existing problems [58, 60, 61, 72]. Pierre et al. compared internalizing and externalizing symptoms in children with attention-decit/hyperactivity disorder with and without comorbid tic disorder and found that boys with ADHD+tics received signicantly higher scores for the Anxious/Depressed, Thought problems, and Attention Problem Scale as

 pfner and A. Rothenberger M. Do Behavior therapy of CTD and ADHD Fig. 1 Combination of psychosocial and pharmacological interventions in the treatment of children and adolescents with CTD+ADHD
ADHD prominent/ more impairing

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Prominent / impairing symptoms

Tics prominent/more impairing

treatment of ADHD
Psychosocial Intervention, Pharmacotherapy, Multimodal Treatment of ADHD
ADHD improves but not Tics

treatment oftics
Psychosocial Intervention, Pharmacotherapy, Multimodal Treatment of tics

ADHD+ Tics improve

Tics improve butn ot ADHD

Tics+ADHD improve

Continuation

Continuation

rated by the parents on the Child Behaviour Checklist (CBCL) and also for Delinquent Behavior, Thought Problems and Somatic Complaints as rated by teachers than boys did without tics [54]. In children with CTD+ADHD the therapist has to decide which symptoms to treat rst either with pharmacotherapy or behavioral interventions. Both the pharmacological and behavioral interventions aiming at the treatment one disorder may have an effect on the other disorder. Pharmacotherapy of ADHD (stimulants or atomoxetine) may decrease tics but stimulants may also increase tic severity at least in high doses [16] and pharmacotherapy of tics may decrease hyperactivity and impulsivity but also increase attention problems or drowsiness as possible side effects (e.g., [59]). No empirical data on the efcacy and safety of the behavioral treatment of one disorder on the other are at hand. Clinical experience suggests that behavioral interventions for children with ADHD may also result in a reduction of tic frequency or tic intensity. On the other hand behavioral interventions for the reduction of tic symptoms may also decrease ADHD symptoms. The explanation for this effect may be that both kinds of behavioral interventions aim to increase synchronization and focusing of neuronal networks related to better selfregulation. The following rules may help to guide the decision on the order of behavioral interventions: 1. Treat the more severe symptoms rst. In children with severe ADHD symptoms and less severe tics, ADHD should be treated rst; conversely in children with severe tics the treatment of the tics should be focused rst. 2. Treat the more impairing or distressing symptom rst. The treatment of the most impairing and/or distressing symptoms may help to increase treatment motivation which helps to better coordinate

neuronal networks. In most cases symptom severity and impairment or distress caused by the symptoms covary but sometimes even one less intensive tic may be very distressing to a certain patient. 3. Treat the underlying disorder rst. The disorder with the earlier onset can be regarded as underlying disorder. Usually ADHD symptoms are present before tics emerge [50, 71] and clinical experience suggest that the treatment of ADHD results are more likely in a reduction of tic symptoms than the other way round. Therefore clinicians tend to treat comorbid ADHD conditions rst because they may be the greatest sources of difculty. On occasion, the successful treatment of a comorbid condition will lead to an amelioration of tics. 4. Treat the problem which is easier to treat. Especially at the beginning of the treatment a rapid reduction of problems increases treatment motivation. Therefore to start with a problem, which promises a rapid treatment success may help to increase treatment motivation for problems, which are harder to treat. Circumscribed behavior problems associated with ADHD (e.g., homework problems) may be easier to treat than for example tics with high frequency throughout the day. Psychoeducation and advice for patients, parents and teachers should be the base of any treatment. As in the treatment of ADHD [74] one should interview parents and child and about their health beliefs and causal and control attributions; and inform them all about ADHD and CTD, especially symptoms, etiology, clinical course, prognosis, and treatment options. The common characteristics of ADHD and CTD should be stressedthe reduced ability of self control in motor movements, behavior, attention, and of ones own impulses. The relationship of tics, sleep and stress should be elaborated [64]. Other stressors in the

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family and the school should be identied. The therapist should help the child (if old enough), the parents and teachers to identify those problem situations in the family, the school and other contexts in which ADHD symptoms, tics or other behavioral or emotional problems of the child are especially prominent. Consultation with parents and school, on appropriate class or school placement and management, is often needed. Children who are old enough should be educated about self-observation and self-management.

condence are especially important because the distress the children with CTD+ADHD are suffering from may be stronger compared to those with pure ADHD or pure CTD.

j Behavioral treatment of CTD in children with CTD+ADHD

As already noted the published studies on the effects of habit reversal and other behavioral interventions in children with CTD do not give detailed information on comorbid problems or disorders of the patients or they excluded those patients. However, a few reports suggest that habit reversal may be less successful for young children or individuals with developmental disabilities [36, 37, 57], most likely because of problems with treatment compliance by these individuals. In our clinical experience the same is true for children with comorbid ADHD. Adherence to the habit reversal procedures and implementing of competing responses in daily living is in our opinion the most important problem in the behavioral treatment of tics especially in children with comorbid ADHD. Habit reversal is a very difcult technique for children with ADHD because these children have to train what they are lacking and that is self-control, i.e., they have little neuronal capacity to directly compensate the symptoms. Instead they activate diffusely their neuronal assemblies. This needs a high amount of effort, which breaks down from time to time for regeneration and is reected in the high variability and inconsistency of the childs behavior. Therefore, methods for promoting adherence to the habit reversal procedures are especially important for children with comorbid ADHD. In order to boost motivation and compliance timely social support and praise by parents, at times teachers and even friends for successful use of awareness techniques, competing responses and other treatment tasks, as well as tic-free intervals, and adherence to treatment protocol are very important. Additionally behavioral reinforcement systems (token economy) should be used to boost motivation and compliance. Instead of rewardsystems response cost contingencies can be used to promote adherence to habit reversal [2]. Further ancillary methods for increasing treatment motivation described by Piacentini and Chang are the habit inconvenience review and the creation of a tic hierarchy [52]. The habit inconvenience starts with the child and therapist making a list of all the negative features associated with his or her tics. This hassles list is revisited occasionally when improvement in the childs tics render a list item obsolete. In addition to breaking down the childs denial of symptoms and enhancing motivation for treatment, the hassles list

j Behavioral treatment of ADHD in children with CTD+ADHD

ADHD increases the childs stress in the family, the school and in other psychosocial contexts and can therefore cause an increase in tic symptoms. Reduction of ADHD symptoms and concurrent stress may reduce tics and teach the child ways of better selfcontrol which may also help the child to strengthen the ability of self control of tics. Psychosocial treatment of ADHD symptoms in patients with CTD+ADHD may be especially indicated when ADHD are mild, when pharmacological ADHD treatment is not effective or has too strong side effects or in combination with pharmacotherapy when residual ADHD symptoms persist. The psychosocial treatment of ADHD symptoms in children with CTD goes along with the treatment of ADHD without CTD. Behavioral parent training and behavioral interventions in the family (including sleep hygiene) as well as Behavioral interventions in the kindergarten, the preschool or the school aim at the reduction of ADHD symptoms in the family and the preschool/school. In children with CTD+ADHD it may be more important to treat those problems, which are especially distressing to the child and not those that are especially distressing to the environment. This strategy may lead to stress reduction in the child and to subsequent tic reduction. However, in many cases those symptoms that stress for example the parents do also stress the child because of the aversive reactions of the parents. Cognitive behavior therapy of the child/adolescent using self-monitoring, self-evaluation, and self-management procedures may strengthen self-control of the child. These techniques are similar to those used in the habit reversal training for tic symptoms. The experience of coping problems successfully may strengthen the treatment motivation for subsequent habit reversal training. Besides the techniques that aim at symptom reduction methods that activate resources and strengthen the childs sense of competence and self-

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also serves as a step toward an exploration of consequences of their tic disorder and a more realistic acceptance of their condition. Another technique is the creation of a tic hierarchy. At the beginning of treatment, the child and therapist create a comprehensive list of the childs tics and then rate how bothersome or distressing each tic is on a 110 scale. Tics are then rank ordered from least to most distressing. This list is reviewed, and tics are rated again at the beginning of each session to provide a systematic and immediate method for identifying treatment gains and difcult areas. The gradual implementation of homework paced by the child himself or herself (what do you think can you achieve next?) may also help to increase treatment adherence. In children with high frequent tics self-monitoring and competing response training should be implemented to one target tic for example for a 30-min block 4 times a week. Thereafter timeframe can be extended. In order to reduce the risk of a failure it may be also important to dene the treatment goals as a hierarchy where complete reduction of the tics can be the ultimate goal but treatment may be already perceived as a success if the use of the competing response training would help the child to better modulate his/her movements and, in doing so, to decrease the intensity and impact of his/her tics and or shaping them socially. Competing responses can also provide an alternative physical expression contingent on tic urge and would be more socially adaptive and acceptable. These shaping procedures may be easier to conduct and success may be easier to achieve. Cognitive strategies may help to facilitate greater control over tic behaviors. Analogies are often helpful to provide the child with a better understanding of his or her tics and the rationale underlying HR training. Piacentini and Chang describe as an example the analogy of a surfer riding a wave to explain HR training. The urge to tic and

eventual expression of the urge can be seen as a wave breaking on the beach. The youngster can either try to stop the wave (completely block the tic urge) which is not likely to succeed, or else ride the wave controlling it with his or her HR surfboard (express the tic but in a controlled and less conspicuous manner [52]). Within the framework of training cognitive-self regulatory abilities to reduce symptoms of ADHD and CTD the treatment approach with neurofeedback (NF) might be useful as part of a multimodal program, especially since immediate feedback and positive reinforcement are included [26]. Children with ADHD as well as those with CTD were able to shape their brain electrical activity to reduce symptoms, either inuencing neuronal oscillations and/or neuronal excitability over anterior brain areas. Thus, NF may also be helpful in CTD+ADHD. Clinical trials are recommended. The active involvement of parents in the treatment is important, but they have to be introduced carefully especially when parentchild interaction problems are a major concern. Parents can be actively involved in monitoring homework assignments, serving to monitor tics and provide reminders for competing response training. Overall, the clinical experience suggests that in children with CTD + ADHD success may be easier to achieve in the behavioral treatment of ADHD than in the behavioral treatment of CTD. However, treatment success mainly depends on the severity of the respective problem and the treatment compliance of the child and the family. Empirical evidence on the effects of behavioral interventions for ADHD with CTD and/or other comorbid symptoms are lacking. Nevertheless, the combination of habit reversal (to reduce tics) and parent training/certain BT techniques (to reduce ADHD symptoms) may be recommended for clinical practice, either with psychopharmacotherapy or without it.

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