Advances in Pediatric Psychiatry

Dr. Shannon Bennett

During her clinical training in pediatric anxiety, OCD, and Tourette syndrome, Shannon M. Bennett, PhD, saw her first young patient with tics and began treating her through Comprehensive Behavioral Intervention for Tics, or CBIT. “Her tics got better, and that experience was transformative for me in being able to help her with something that was so impairing and bothersome,” says Dr. Bennett, Assistant Professor of Psychology in Clinical Psychiatry at Weill Cornell Medicine and Director of the Weill Cornell Medicine Center of Excellence for Tourette Syndrome with Co-Director Corinne Catarozoli, PhD. Dr. Bennett is also the site Clinical Director at NewYork-Presbyterian/Weill Cornell Medical Center of the Center for Youth Mental Health. Today in her clinical practice and research endeavors, Dr. Bennett develops and evaluates cognitive behavioral approaches for anxiety and tic disorders, testing the efficacy of novel treatments and seeking better understanding of the mechanisms that control tics in Tourette syndrome.

Persistent tic disorders are chronic neurodevelopmental disorders characterized by motor and/or vocal tics – unwanted sudden and rapid movements or vocalizations. In children, tic onset usually begins between the ages of 5 and 7 years, with tic severity peaking between the ages of 10 and 13 years and then decreasing during late adolescence and early adulthood.

“Traditionally there are four categories or diagnoses that a patient could receive based on the types of tics that they have and how long they’ve had them,” says Dr. Bennett. “Particularly in young children, tics can be transient, and in some children they just go away. For a smaller group of individuals, the tics become chronic. If the tics have only lasted for a couple of months, we may just wait and observe to see if they endure and, more importantly, begin to interfere in a child’s social, school, or family life. After six months, if the tic persists and is interfering or bothersome, then it’s likely the child might benefit from an intervention.”

Antipsychotic medications, including haloperidol, risperidone, and aripiprazole, and CBIT are the treatment modalities most often recommended. “Medications can reduce but rarely eliminate tics and can be associated with a range of side effects, such as weight gain, fatigue, and sedation,” says Dr. Bennett. “For children and adults with mild to moderate tics, the American Academy of Neurology and the American Academy of Child and Adolescent Psychiatrists, as well as most pediatricians, recommend CBIT as a first-line treatment. CBIT teaches strategies for becoming more aware of the physiological urges to tic and learning how to ride the wave of those urges while stopping the tics using a competing response. This behavioral intervention can significantly reduce tics with continued practice.”

In her treatment Dr. Bennett first conducts a comprehensive assessment to determine if the patient has other associated conditions. “Individuals who have tics have a higher likelihood of having ADHD, OCD, or anxiety, and for older individuals, sometimes depression, substance use, and anger issues,” she says. “A comprehensive assessment is very important for understanding the variety of tics that an individual may have and how long they’ve had them. Also, what are the situations that make them more or less present?”

“We help individuals and their family to understand tics – what they are and what they are not,” continues Dr. Bennett. “Tics are a neurological condition with a genetic basis. But they’re also heavily influenced by the environment, so they can come and go and can change. This can be confusing for someone who is experiencing tics or for their family members. Education is important to reduce stigma, to reduce anxiety, and to reduce blame and shame.”

Tics: Triggers and Interventions

Understanding environmental triggers for tics and the situations or emotions that might make them more frequent or more intense is a key component of CBIT. The most common triggers can be stress, strong emotion, as well as changes in routine, fatigue, anxiety, and excitement. For some, just talking or thinking about tics will make someone tic more if they are prone to tics. “It doesn't always have to be a negative experience, but those events that rev up the body can make tics more present,” says Dr. Bennett.

As one example, she cites the start of the school year. “That is a big change in routine and brings on anxious or excited anticipation. Tics are often more present in the first couple of weeks as children get used to their new routines and environments.”

Dr. Bennett teaches patients to become aware of when tics are more likely to come out, and then learn to use competing behaviors to stop or block the tics. “Young children may not always be aware when they are exhibiting tics. They can happen outside of a person’s conscious awareness. For many, there is a premonitory urge, an uncomfortable sensation or feeling right before they tic.”

Competing response training provides an alternative behavior that makes doing the tic more difficult but is not more noticeable than the tic itself. “The competing response can be integrated into their daily life or routine, something that they can use or hold for at least a minute or until that urge to tic passes. We practice a competing response in a session, and then it’s crucial that the patient practices it at home. It is an effortful process.”

“The competing responses are specific to the tic that we are trying to treat,” says Dr. Bennett. “For a vocal tic, we might use slow, controlled deep breathing as a competing response. With a motor tic, you’re often targeting the muscles that are involved in the tic. For example, with a shoulder shrug we might focus on holding the shoulders down and tightening those muscles to reduce that movement. The person who has the tic has to feel comfortable with the given competing response and be able to use it in their daily life for the treatment to work optimally.”

With children, Dr. Bennett may involve parents or other support people, such as teachers, who can implement a reward system to motivate the practice. Older adolescents or adults may be internally motivated to learn and use these strategies. “It’s a repetitive process until we have targeted each individual tic that a person may have,” says Dr. Bennett. “They learn this set of skills that they can then apply on their own should tics recur in the future.”

As Dr. Bennett explains, some individuals have a genetic predisposition to experience tics in times of stress or certain circumstances. CBIT doesn’t eliminate that vulnerability, but it gives them a strategy by which they can manage the symptoms, such that they are no longer as bothered by the symptoms. “And for some, the tics don't come out anymore,” she says. “They can manage those ups and downs in physiological sensations without the tic movements coming.”

A Research and Teaching Agenda

Dr. Bennett serves on the Medical Advisory Board of the Tourette Association of America and participates in several international working groups. “Our initial research for children using CBIT focused on 9- to 17-year-olds,” she says. “We then adapted the treatment, calling it CBIT-JR, and tested it with younger kids who often present between the ages of 4 and 8. This collaboration included investigators at Weill Cornell Medicine, UCLA, and Marquette University.”

In earlier research, Dr. Bennett tested an adaptation of CBIT with occupational therapists at NewYork-Presbyterian/Weill Cornell who used the treatment effectively with patients. “We also completed a 10-year longitudinal follow-up of youth from the original CBIT research trials and are now analyzing the 10- to 12-year follow-up outcomes for youth who received this treatment and those who did not,” she says. The results of this investigation were published in the September 8, 2021, issue of the Journal of the American Academy of Child and Adolescent Psychiatry.

“Another important aspect of our program is educating and disseminating information to other clinicians,” adds Dr. Bennett. “We know this treatment works very well, so we've been teaching other clinicians how to identify, diagnose, and treat tics from a behavioral treatment perspective.”

Most recently, Dr. Bennett has been working with collaborators to better understand the increase in tics and other tic-like symptoms in adolescents since the start of the COVID-19 pandemic. “We have seen a steep increase in teenagers presenting with very interfering and atypical complex motor and vocal tics since the fall of 2020. For some, this may be a pre-existing vulnerability for tics brought out by the stress of the pandemic, and for others it is likely a separate condition altogether, currently categorized as a functional neurological disorder. “I am a member of an international working group that is trying to initiate research to better understand both this phenomenon and the optimal treatment for this condition,” notes Dr. Bennett.