Behaviour Research and Therapy 50 (2012) 565e570
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A randomized pilot trial comparing videoconference versus face-to-face delivery of behavior therapy for childhood tic disorders Michael B. Himle a, *, Malinda Freitag a, Michael Walther b, Shana A. Franklin b, Laura Ely b, Douglas W. Woods b a b
University of Utah, USA University of Wisconsin-Milwaukee, USA
a r t i c l e i n f o
a b s t r a c t
Article history: Received 28 December 2011 Received in revised form 16 May 2012 Accepted 25 May 2012
Comprehensive Behavioral Intervention for Tics (CBIT) has been shown to be effective for reducing tics in children with chronic tic disorder. Unfortunately, there remain significant barriers to dissemination. The aim of the current study was to examine the effectiveness of CBIT delivered over videoconference. Twenty children were randomly assigned to receive CBIT over videoconference or via traditional face-to-face delivery. Results show that both treatment delivery modalities resulted in significant tic reduction with no between group differences. Furthermore, acceptability and therapist-client alliance ratings were strong for both groups. Together, these results suggest that videoconference is a viable option for disseminating CBIT. Ó 2012 Elsevier Ltd. All rights reserved.
Keywords: Tourette Tic Behavior therapy Telehealth
Chronic tic disorders (CTDs), including Tourette Disorder (TD), are characterized by involuntary motor and vocal tics (APA, 2000). The most common treatment for CTD is psychotropic medication (see Scahill et al., 2006), however behavioral techniques have also been shown to be effective for reducing tics (see Himle, Woods, Piacentini, & Walkup, 2006). A collection of behavioral techniques referred to as Comprehensive Behavioral Intervention for Tics (CBIT; Woods et al., 2008a) uses psychoeducation, self-monitoring, function-based interventions, relaxation training, and habit reversal training (HRT; Azrin & Nunn, 1973) to teach children and families a specific set of skills to manage and reduce tics. Research over the past decade has established CBIT as an empirically well-established treatment (Cook & Blacher, 2007). Perhaps the most convincing evidence for the efficacy of CBIT comes from a recent multi-site randomized controlled trial comparing CBIT to a psychoeducation and supportive therapy (PST) control (Piacentini et al., 2010). In this trial, 126 children with CTD (approximately 60e65% of which were unmedicated) were randomly assigned to receive eight sessions of either CBIT or PST. Results showed that 53% of children receiving CBIT demonstrated a clinically significant improvement in symptoms compared to 19% of those assigned to PST, and gains were generally maintained at 6 months post-treatment. * Corresponding author. Department of Psychology, University of Utah, 380 S 1530 E, Behavioral Sciences Building Room 502, Salt Lake City, UT 84112, USA. Tel.: þ1 801 581 7529; fax: þ1 801 581 5841. E-mail address:
[email protected] (M.B. Himle). 0005-7967/$ e see front matter Ó 2012 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.brat.2012.05.009
Unfortunately, CBIT is not widely available. A recent survey of 740 parents of children with CTD found that only 6% of treatmentseeking children/families and 4% of treatment seeking adults had received HRT/CBIT (Woods, Conelea, & Himle, 2010). One of the most commonly endorsed treatment barriers was a lack of trained providers, highlighting the need for novel strategies to increase the availability of CBIT. One dissemination strategy that holds particular promise is telehealth, which utilizes communication technology, such as videoconference (VC), to deliver therapeutic or consultation services. Several studies concerning a variety of psychiatric and behavioral problems have shown promising results for delivering behavior therapy via telehealth (e.g., Himle, Fischer, et al., 2006; Himle, Woods, et al., 2006). The nature of CBIT, however, poses unique challenges to remote delivery. For example, when conducting HRT (a primary component of CBIT) the clinician must be able to observe, detect, and discriminate discreet episodes of tics, which are often very subtle, rapid, and can occur in paroxysms. Similarly, the client needs to be able to observe the therapist modeling treatment techniques and the therapist needs to be able to observe whether the client is performing subtle skills so that he/ she can provide corrective feedback and reinforcement. Any disruption or delay in the video exchange due to technological limitations or other remote-delivery factors might well undermine treatment relative to traditional face-to-face delivery. Preliminary evidence suggests that VC-delivered CBIT is feasible. Himle, Olufs, Himle, Tucker, and Woods (2010) used a multiple
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Fig. 1. Participant flow-chart.
baseline across participants design to examine the feasibility of eight sessions of CBIT delivered over VC for three children with CTD. All three children demonstrated significant tic reduction and both children and their parents indicated high ratings on treatment acceptability and therapeutic relationship. Given the effectiveness of CBIT for reducing tics, the difficulty finding adequate care providers to deliver CBIT, and the promise of telehealth for delivering behavioral interventions for related disorders (e.g., Himle, Fischer, et al., 2006; Himle, Woods, et al., 2006) CBIT seems a prime candidate for Telehealth dissemination. The purpose of the current study was to extend the previous findings of Himle et al. (2010) in a larger sample of children and to assess the comparative efficacy of CBIT delivered over VC versus face-to-face. Method Participants Participants were 20 children, ages 8e17, who met DSM-IV-TR criteria for TD or CTD and their parents. Additional eligibility criteria included (1) a Yale Global Tic Severity Scale (YGTSS;
Leckman et al., 1989) Total Tic Severity Score > 14 for TD or > 10 for CTD; (2) intellectual functioning in the low-average range or above (3) no history of behavioral treatment for tics and (4) no selfreported recent (i.e., in the prior 4 weeks) changes in medication status or planned changes in medication status during the course of the study. Eighteen children completed the study. A CONSORT diagram is shown in Fig. 1 and a summary of participant characteristics is shown in Table 1. Sites, setup & materials Participants attended sessions at one of two university-based Tic Disorder Specialty Clinics. Within each site, participants received treatment either locally (face-to-face, F2F) or remotely via videoconference (VC). Face-to-face sessions were conducted at the local site by the local therapist. Participants in the VC condition attended sessions at their local site and treatment was delivered over VC by a therapist located at the remote site. During all VC sessions, trained study personnel were present at the local site but were not involved in treatment. Study personnel helped the client connect to the remote therapist, managed technical difficulties, and transmitted hard-copy
M.B. Himle et al. / Behaviour Research and Therapy 50 (2012) 565e570 Table 1 Participant characteristics. Variable
Completers (N ¼ 18)
Telehealth (N ¼ 10)
Face-to-face (N ¼ 8)
%Male Age IQ Estimate % No Medication % Tic Medication Alpha-Adrenergic Agonists Atypical Neuroleptic % Other Psychotropic Medication SSRI Psychostimulants Comorbid Diagnoses (%)a TS-Only þADHD þComorbid Externalizing þOCD þComorbid Anxiety þComorbid Mood CBCL (T-Scores) Internalizing Externalizing Total Problems MASC Total Score (T-Score) CPRS (T-Scores) Oppositional Cognitive Problems Hyperactivity ADHD Index
94% 11.6 (2.7) 110 (12.5) 72% 28% 22%
90% 11.3 (2.3) 108 (9.3) 70% 30% 20%
100% 12.0 (3.3) 112 (14.3) 75% 25% 25%
11% 33%
10% 40%
13% 25%
33% 17%
40% 20%
25% 13%
67% 28% 6%
40% 30% 10%
75% 25% 0%
22% 33% 6%
30% 40% 0%
13% 25% 13%
54.0 50.3 53.5 50.9
(13.2) (10.9) (13.0) (12.1)
55.8 52.4 55.2 50.1
(11.8) (12.3) (13.1) (10.2)
51.8 47.8 51.4 51.9
(15.3) (9.0) (13.5) (14.9)
54.1 52.8 57.2 53.9
(13.6) (12.3) (14.2) (13.0)
57.5 54.5 59.1 57.1
(14.5) (12.5) (16.7) (12.9)
49.9 50.6 55.0 50.0
(11.8) (12.6) (11.1) (12.8)
ADHD ¼ Attention Deficit Hyperactivity Disorder, CBCL ¼ Child Behavior Checklist, CPRS ¼ Conners Parent Rating Scale, MASC ¼ Multidimensional Anxiety Scale For Children, OCD ¼ Obsessive Compulsive Disorder, SSRI ¼ Selective Serotonin Reuptake Inhibitor. a Some children had more than one comorbid diagnosis.
study materials between sites. In addition, a doctoral level study staff member was available at the local site to implement a crisis plan if needed (no crises occurred during the study). Treatment was delivered by CBIT-experienced doctoral level therapists in accord with a manualized protocol (Woods et al., 2008a). Each family was provided with a copy of the CBIT parent workbook, which contained copies of all therapy forms and supplemental materials to help guide them through treatment (Woods et al., 2008b). Videoconference sessions were conducted using a Sony PCS-XG80 High Definition VC Communication System connected to a 2700 Sony High-Definition monitor. The VC transmission used a 128bit Advanced Encryption Standard (AES) to maximize secure audio and visual exchange between therapist and participant. In order to further protect participants’ confidential information, a “minimal necessary personal information” approach was used when conducting VC sessions. During VC, both the therapist and participant were able to control both near- and far-end visual and audio functions (e.g., camera angle, zoom, volume). Written therapeutic materials (e.g., weekly assessments, homework sheets) were transmitted between sites via facsimile before each session. Assessment Baseline Potential study participants were first phone screened for eligibility. Participants who met screening criteria underwent a comprehensive diagnostic assessment to determine study eligibility and to assess for presence and severity of co-occurring conditions. CTD diagnosis was confirmed via clinical observation and interview with the YGTSS (Leckman et al.,1989). Comorbid status was determined via the Anxiety Disorder Interview Schedule (ADIS-IV; Silverman & Albano, 1996) and
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a battery of self- and parent-report measures including the MultiDimensional Anxiety Scale for Children (MASC; March, Parker, Sullivan, Stallings, & Conners, 1997), the Conners’ Parent Rating Scale-Revised, Short Version (CPRS-R:S; Conners, 1997), and the Child Behavior Checklist (CBCL; Achenbach, Thomas, & Rescorla, 2001). All baseline measures were administered by Master’s level graduate students enrolled in clinical psychology Ph.D. programs at the respective sites. Assessors were trained on administration of clinical interviews and tic severity ratings during a cross-site training meeting using the same procedures developed for training independent evaluators in the CBIT trial (Piacentini et al., 2010). Post-treatment and follow-up assessment A trained independent evaluator who was naïve to treatment assignment assessed tic severity at pre-treatment (week 0), posttreatment (week 10), and at 4-month follow-up using the Yale Global Tic Severity Scale (YGTSS) and the Clinicians Global Improvement Scale (CGI-I). Parents also completed the Parent Tic Questionnaire (PTQ) prior to each session and at follow-up. Children and parents completed process (acceptability and alliance) measures at post-treatment. The primary process measures were the Working Alliance Inventory (WAI) and the Treatment Acceptability Questionnaire (TAQ). Measures Yale Global Tic Severity Scale (YGTSS; Leckman et al., 1989). The YGTSS is a clinician-completed measure consisting of a tic symptom checklist, motor and vocal tic severity ratings, and a global tic impairment rating. To ascertain tic severity ratings, the examiner rates five different dimensions of tic severity each on a 0e5 scale: tic number, frequency, duration, intensity, and complexity. Each of the dimensions is scored separately for motor and vocal tics to produce motor and vocal tic subscale scores (range 0e25). These subscales are then combined to produce a total tic severity score (range 0e50), with higher numbers indicating more severe tics. The YGTSS has demonstrated acceptable internal consistency and acceptable convergent and divergent validity (Leckman et al.). Clinician Global Severity & Improvement Scales (CGI-S and CGI-I; Guy, 2000). The CGI-I is a clinician rating used to assess overall clinical improvement based on observed and patient-reported symptom severity and symptom-related impairment. Scores range from 1 to 7 where: 1 ¼ very much improved, 2 ¼ much improved, 3 ¼ minimally improved, 4 ¼ no change, 5 ¼ minimally worse, 6 ¼ much worse, 7 ¼ very much worse. By convention, responders were defined as those who received a score of 1 or 2 on the CGI-I (Piacentini et al., 2010). Parent Tic Questionnaire (PTQ; Chang, Himle, Woods, & Piacentini, 2009). The PTQ is a paper-and-pencil parent-report measuring the number, frequency, intensity of motor and vocal tics. Parents first complete a checklist of common motor and vocal tics over the past week. For each tic endorsed, the parent rates how frequent (4 ¼ constantly, 3 ¼ hourly, 2 ¼ daily, 1 ¼ weekly, 0 ¼ absent) and intense or noticeable (1e4 with higher scores associated with increased intensity) each tic was during the past week. A separate 0-8 score was for each tic was calculated by adding the frequency rating (1e4) and the intensity rating (1e4) for each tic. Motor and vocal tic subscale scores were computed by summing the weighted scores for all motor and vocal tics, respectively, and an overall score was computed by summing the motor and vocal tic subscale scores. In the current sample, scores ranged from 0 (no tics) to 79. The PTQ has been shown to have excellent internal consistency, test-retest reliability and convergent validity (Chang et al.). Working Alliance Inventory (WAI, Hovarth & Greenberg, 1989). The 12-item short form version of the WAI was used to assess the
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child’s perception of the therapeutic alliance. Higher scores indicate stronger alliance along three dimensions: agreement on goals of treatment (Goal Agreement), agreement on how to achieve treatment goals (Task Agreement), and therapist-client bond (Bond Scale). The WAI was originally developed and psychometrically validated for adults, but has more recently been shown to demonstrate adequate reliability and validity with youth (e.g., Kazdin, Marciano, & Whitley, 2005). Treatment Acceptability Questionnaire (TAQ, Hunsley, 1992). The TAQ is a 6-item measure designed to assess the acceptability of psychological treatments for adults and children. The TAQ items assess acceptability of treatment, ethics of the procedures, perceived effectiveness of the treatment, side effects, and knowledge and trustworthiness of the therapist. The wording of the TAQ was modified slightly for delivery to children and parents posttreatment (i.e., changed to past tense). Higher scores indicating higher levels of treatment acceptability. The TAQ has shown good internal consistency and test-retest stability. Procedures Randomization Within each site, eligible children were randomly allocated to 8 weekly sessions of CBIT delivered either over videoconference (VC, N ¼ 10) or face-to-face (F2F, N ¼ 10).
(YGTSS Total Tic Score) at post-treatment. Results showed a significant within-group effect of time F(1,14) ¼ 19.51, p < .001, ES1 ¼.59, but no significant effects of site F(1,14) ¼ .004, p ¼ .95, or condition F(1,14) ¼ .38, p ¼ .55. There were no significant two-way or three-way interactions. The mean YGTSS scores across time and group are presented in Table 2 and show that both treatments were effective for reducing tics. The telehealth group showed a mean YGTSS reduction of 7.8 points and the F2F group showed a mean reduction of 6.5 points. Within-group effect sizes for the two treatment delivery modalities were ES ¼ .54 and ES ¼ .75, for telehealth and F2F, respectively. Primary outcome: follow-up A 2 (condition) 2 (time, Pre & Follow-up) 2 (site) mixed ANOVA was used to examine the effect of treatment on the YGTSS Total Tic Score at follow-up. Results showed a significant withingroup effect of time F(1,12) ¼ 8.79, p < .05, ES ¼ .42, but no significant effects of site F(1,12) ¼ .061, p ¼ .81 or condition F(1,12) ¼ .376, p ¼ .55 and no two- or three-way interactions (all p’s > .05). The mean YGTSS scores across time and group are shown in Table 2. The telehealth group showed a mean YGTSS reduction of 6.4 points at follow-up and the F2F group showed a mean reduction of 4.2 points. Within-group effect sizes for the two delivery modalities were ES ¼ .39 and ES ¼ .41, for telehealth and F2F, respectively. Secondary outcomes
Intervention Therapists were doctoral level psychologists with extensive CBIT training and experience providing CBIT to children with CTD. The 8session Comprehensive Behavioral Intervention for Tics (CBIT) protocol (Woods et al., 2010) was administered across 10 weeks (6 weekly sessions followed by 2 bi-weekly sessions). The primary components of CBIT were psychoeducation, habit reversal training (HRT), function-based assessment and intervention (FAI), and relaxation training. A new tic was targeted each week and children and their parents were assigned to practice therapeutic activities daily. Results Sample description The final randomized sample consisted of 20 children (11 from Site #1, 9 from Site #2). One child (F2F condition) discontinued after the fourth session for unknown reasons and a second child (F2F condition) discontinued after randomization but prior to the first session in order to change medication dosage for a comorbid condition. Because this was a small-sample pilot trial with no midpoint assessment, all post-treatment and follow-up outcome analyses were conducted using the completer sample (N ¼ 18 for post-treatment analyses, and N ¼ 16 for follow-up analyses). Baseline characteristics A series of independent samples t-tests were used to compare the two sites on relevant baseline characteristics, including baseline tic severity, comorbid status, ADHD, anxiety, and internalizing/ externalizing problems. There were no significant site differences on any relevant baseline variables (all p’s > .05). Baseline characteristics are presented in Table 1. Primary outcome: acute treatment A 2 (site) 2 (condition) 2 (time) mixed ANOVA was conducted to examine the effect of treatment on the primary outcome variable
The CGI-I was used to assess clinical response at post-treatment. Responders were defined as those who received a score of 1 or 2 (very much improved or much improved) on the CGI-I. Results show that 8/10 children (80%) in the Telehealth condition and 6/8 (75%) children in the F2F condition were rated as post-treatment responders, which was not significantly different (p > .05, Fisher’s exact test). Response rates were similar for children who were on tic medication (4/5, 80%) and those not on tic medication (10/13, 77%). At follow-up, 5/9 (56%) children in the Telehealth condition and 3/7 (44%) children in the F2F condition were rated as responders, which was not significantly different (p > .05, Fisher’s exact test). The PTQ was also used as a secondary outcome measure. First and last-session Total Tic scores from the parent-rated PTQ were compared using a 2 (site) 2 (condition) 2 (time) mixed ANOVA. Results showed a significant within-group effect of time F(1,14) ¼ 14.93, p < .01, ES ¼ .53, but no significant effects of site or condition and no significant two- or three-way interactions (all p’s > .05). The mean PTQ scores across time and group are shown in Table 2 and show that both treatments were effective for reducing tics. The telehealth group showed a mean 50% reduction in tic severity PTQ scores across treatment and the F2F group showed a comparable 49% reduction in tic severity. Within-group effect sizes for both treatment delivery modalities were large (ES ¼ .51 and ES ¼ .56, for telehealth and F2F, respectively). A 2 (time) 2 (condition) mixed ANOVA found significant pre-treatment to follow-up differences on the PTQ for the combined completer sample F(1,14) ¼ 14.80, p < .01. Within-group effect sizes for both treatment delivery modalities were large (ES ¼ .53 and ES ¼ .64, for telehealth and F2F, respectively). Treatment acceptability and alliance Independent samples T-Tests were used to examine whether child or parent treatment acceptability ratings differed across the two conditions. Comparisons were made for parent- and child- ratings
1
All effect size statistics (ES) are partial eta squared.
18.2b (9.4) 17.9b (15.3) 50% .59 .53 e
ES ¼ Partial Eta Squared; CGI-I ¼ Clinician’s Global Improvement Scale; PTQ ¼ Parent Tic Questionnaire; Tx ¼ Treatment; YGTSS ¼ Yale Global Tic Severity Scale. Note. Within each group (Completer Sample, Telehealth, and Face-To-Face), means with different superscripts denote significantly different means within respective groups (all p’s < .05). There were no significant differences between the two conditions (all p’s > .05).
.41 .64 e 20.1 (5.9) 23.3b (15.9) 44% .75 .56 e 17.6b (6.5) 17.9b (18.5) 75% 24.1a (3.9) 35.0a (10.7) e .39 .53 e 16.5b (8.4) 16.8b (16.5) 78% 23.7a (6.0) 33.2a (12.2) e YGTSS (Total) PTQ CGI-I %Responders
F/U (N ¼ 16) ES
.42 .56 e
Pre (N ¼ 10)
23.4a (7.5) 31.8a (13.8) e
15.6b (9.8) 16.0b (15.7) 80%
.54 .51 e
16.8 (11.5) 13.7b (14.4) 56%
Post (N ¼ 8) Pre (N ¼ 8) ES F/U (N ¼ 9) Telehealth
Post (N ¼ 18) Pre (N ¼ 18)
ES Completer sample
Table 2 Means, standard deviations, and effect sizes for outcome across time and group for completer sample.
Post (N ¼ 10)
ES
Face-to-face
ES
F/U (N ¼ 7)
ES
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separately. Results show that both children and parents gave high acceptability ratings. Mean child acceptability ratings were 38.5 and 36.2 (scale range ¼ 7e42) for telehealth and F2F, respectively. Mean parent acceptability ratings were 35.5 and 36.7 for telehealth and F2F, respectively. There were no significant differences between the two conditions for either child or parent ratings (all p’s > .05). Independent samples T-Tests were also used to examine whether children’s alliance with the therapist differed between the two treatment delivery modalities. Comparisons were made for parent- and child- ratings separately and for the WAI Total Score and 3 subscale scores (Task Agreement, Goal Agreement, and Bond). There were no differences on any of the parent- or childrated WAI scales (all p’s > .05) between the two-groups. Overall mean WAI Total scores were 77.6 and 75.7 (scale range 12e84) for parent and child, respectively. Exploratory analyses were also conducted to examine the association between child-therapist alliance and clinical outcomes. Correlational analyses found significant associations between follow-up outcomes and two of the child-alliance subscales. Specifically, YGTSS change scores at follow-up (but not posttreatment, all p’s > .05) correlated significantly with children’s WAI total scores (r ¼ .63, p < .05), Task Agreement (r ¼ .61, p < .05), and Goal Agreement (r ¼ .67, p < .01).
Discussion The present study examined the relative efficacy of CBIT delivered via telehealth (videoconference) compared to traditional faceto-face delivery. Regardless of CBIT modality, tic severity was reduced from pre-treatment to post-treatment, providing preliminary support that CBIT can be effectively delivered over telehealth. Furthermore, the absolute tic reduction observed on the primary outcome measure (YGTSS) in the current study is comparable to what was observed in the recently completed CBIT randomized controlled trial (Piacentini et al., 2010). The current study found mean YGTSS reductions of 7.8 points for telehealth and 6.5 points for face-to-face (33% and 27% reductions from baseline, respectively) which is comparable to the 7.6 point (31%) reported by Piacentini et al. in a much larger sample of children receiving CBIT. In addition, children and parents found both modalities to be acceptable and the two groups did not differ on ratings of working alliance. The current study has several limitations that warrant mention. First, the sample size was small and had lower rates of some comorbid conditions relative to other recently reported samples (although current rates were similar to those reported in Piacentini et al., 2010). In addition, the study did not include a non-CBIT control group. Collectively, these limitations limit generalizability of the results. The small-sample size also limited statistical power, which in turn limited the number of exploratory analyses that could be conducted (e.g., whether medication status moderated response). It is likely that not all children and families will respond equally well to the telehealth delivery format, or that all children/ families will find this to be a preferable delivery modality. Tourette syndrome is a complex disorder with a highly varied presentation. It is possible that some tics may be more difficult to address over VC or that some children may respond differentially to the two modalities. Of particular interest is how to best engage children with comorbid ADHD and anxiety, as these are common comorbidities that pose particular clinical challenge. Future studies (with larger samples) will help to identify predictors of outcome. A related limitation is that only tics were targeted for intervention in the current study. Future research should also evaluate whether comorbid conditions can be effectively assessed, managed and treated over telehealth.
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Another limitation of the current study is that participants were required to come to a university setting for treatment. As such, the technology used in the current study was relatively advanced. Whether the current findings can be generalized to other delivery settings (e.g., community mental health clinics, private practice offices), which may have less advanced equipment, slower upload/ download speeds, etc., is unclear. In addition, it is possible that participants who were willing to travel to the respective universities (note: some families traveled considerable distances each week) were highly motivated and thus may or may not represent the typical client treated in other settings. The minimum technological specifications necessary to delivery CBIT via telehealth, and whether other technologies (e.g., voice/video-over-internet-protocols such as SkypeÔ) can be effectively used to delivered CBIT are empirical questions and important directions for future research. Though not necessarily a limitation, it is important to note that the results from follow-up are less encouraging that what was reported in previous studies. Although there was an overall effect of time for the combined completer sample, analyses of the individual groups show that both groups demonstrated some decrement of treatment gains between post-treatment and follow-up. Given that this was the case for both conditions, it is difficult to argue that this can be attributed to aspects of the delivery modality. Rather, we hypothesize that it is due to differences in protocol between this and other studies. For example, Piacentini et al. (2010) included three booster sessions, delivered monthly, after acute treatment had ended. Booster sessions were not delivered in this study. Whether these additional sessions help to maintain treatment gains needs further investigation. In addition to the overall findings that both delivery modalities were effective for reducing tics, some interesting additional findings emerged. One interesting finding is that children and parents reported strong alliance with their therapist for both delivery modalities. While similar findings have been noted in other studies of telehealth-delivered CBT (e.g., Himle, Fischer, et al., 2006; Himle, Woods, et al., 2006), threats to clinical alliance have been cited as one of the biggest barriers to the adoption of telehealth (Rees & Stone, 2005). As noted by Germain, Marchand, Bouchard, Drouin, and Guay (2009), many psychologists seem to spontaneously adopt a negative attitude toward telehealth because they fear that it is likely to compromise important elements of the therapisteclient alliance and relationship. In this study, that did not seem to be the case for CBIT delivered over VC as both conditions rated all elements of the alliance (as they were measured in this study) as strong. Furthermore, all families were interviewed at the end of treatment and each family in the telehealth condition reported overall satisfaction with the treatment and said they would recommend both the treatment and the delivery modality to other treatment-seeking children and families. Also interesting is the exploratory finding that elements of working alliance were related to outcome at follow-up (but not immediately post-treatment). Specifically, high scores on overall alliance, task agreement, and goal agreement correlated significantly with better outcomes at follow-up. To our knowledge, this is the first study to report alliance as a predictor of outcome in children receiving behavior therapy for TS. One explanation for this finding is that children who understand and agree with the goals of therapy and who view the therapy techniques as a promising way to achieve those goals, are more likely to continue to use the treatment tools to maintain or continue treatment progress. Future research should examine not only how to enhance CBIT techniques, but what role these “non-specific” factors play in treatment outcome. In conclusion, the current study replicates and extends initial findings by Himle et al. (2010) by demonstrating CBIT can be effectively delivered via telehealth and that telehealth delivery was as efficacious as traditional face-to-face delivery. Treatment gains were
comparable to what has been observed in large-scale randomized controlled trials (e.g., Piacentini et al., 2010) and, importantly, VC was rated as acceptable by children and parents and did not negatively impact working alliance. With limitations in mind, the findings of this study suggest that telehealth is one promising way to overcome barriers to treatment accessibility and utilization. Acknowledgments This research was supported by a grant from the Tourette Syndrome Association, Inc. awarded to Michael B. Himle and Douglas W. Woods. The authors would like to thank Whitney Fitts, Rob Kent, Laura Graham, Heidi Aringer, Olivia Loran Smith, and Christopher Bauer for their assistance with they study. References Achenbach, T. M., Thomas, M., & Rescorla, L. A. (2001). Manual for the ASEBA preschool and school-aged forms and profiles. Burlington, VT: Department of Psychiatry, University of Vermont. American Psychiatric Association. (2000). 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