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Comprehensive Behavioral
Intervention for Tics
A practical review for clinicians.
By Carinna M. Scotti-Degnan, PhD and Hannah A. Ford, PhD

This review provides an intro- obsessive-compulsive disorder (OCD).3,4 Additional common

duction to the epidemiology, comorbidities include learning disorders, depression, anxiety,
common comorbidities, sus- and disruptive behaviors.3,8 Individuals with tic disorders are
pected etiologies, and thera- also more likely to experience social impairment, educational/
pies of tic disorders including vocational impairment, and decreased quality of life.9,10
Tourette syndrome (TS). We
focus on habit reversal therapy (HRT), and its extension, Clinical Presentation
comprehensive behavioral intervention for tics (CBIT), with Tics are often heterogeneous in presentation. Common
emphasis on the evidence-based nature of these therapies tics include eye blinking, head jerking, sniffing, and throat
as first-line treatment. Core CBIT components (psychoedu- clearing. Although coprolalia, defined as saying obscene
cation, function-based environmental interventions, HRT, words or socially inappropriate statements, is often associ-
and relaxation training) and ideal candidates for CBIT are ated with TS in media portrayals, this feature affects only
discussed. Finally, we review ways to access CBIT, barriers to 10% to15% of people with TS.2,11 Despite variation in symp-
seeking treatment, and new delivery methods including tele- tom presentation across individuals, some common clinical
health and the use of paraprofessionals. features exist. A hallmark of tic disorders is the tendency
for tics to vacillate in frequency and severity.2,3 Tics are also
Epidemiology susceptible to influence from the environment, often wors-
Tics are sudden rapid recurrent nonrhythmic movements ening under certain conditions. Finally, many people with tic
or vocalizations.1 The American Psychiatric Association disorders endorse premonitory urges where they experience
Diagnostic and Statistical Manual-5 (DSM-5) includes 3 pri- a feeling or sensation (eg, itch, tension, or pressure) prior to
mary types of tic disorders. These are TS, characterized by engaging in a tic which is relieved after the tic is performed.2
multiple motor tics and 1 or more vocal tic(s) for at least Individuals with TS often describe this urge as unpleasant
1 year; persistent tic disorder with the presence of only 1 cat- and more bothersome than actual tics.2
egory of tics for at least 1 year; and provisional tic disorder
when tics are present for less than 1 year.1 Tic disorders Etiology
typically present in childhood with an average age of onset Although the underlying cause of tic disorders remains
between 5 and 7 years.2 Tics are relatively common with unknown, several suspected etiologies have been proposed.
prevalence rates of transient tics ranging from 8 to 40 per Considerable research suggests that genetic factors con-
1,000 and TS ranging from 4 to 10 cases per 1,000 in school- tribute to risk for tic disorders. The relative risk of TS is
aged children.3 Tics typically peak in severity during late child- 10 to100 times greater for individuals with first-degree rela-
hood or early adolescence with a marked reduction in tic tives diagnosed with TS, and twin studies show higher con-
severity reported by early adulthood in two-thirds of cases.4,5 cordance rates among monozygotic compared with dizy-
Sex differences exist with tic disorders being more common gotic twins.12 Additional research supports structural differ-
in boys.3,6,7 Several psychiatric comorbidities are frequently ences in the brains of individuals with tic disorders involving
observed in individuals with tic disorders. Between 26% and the basal ganglia, particularly the striatum.7,8 Neurochemical
60% of children with TS meet criteria for attention deficit differences also exist in individuals diagnosed with tic disor-
hyperactivity disorder and 33% to 50% meet the criteria for ders; dopamine has long been considered the primary trans-

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mitter implicated in tics, but recent studies suggest that Comprehensive Behavioral Intervention for Tics
glutamate, GABA, serotonin, and norepinephrine may also Program Content
play roles in symptom presentation.2,7 Despite evidence for There are 2 primary phases of CBIT including 8 weekly
biological underpinnings of tic disorders, a singular etiology primary sessions followed by 3 or more periodic booster
has yet to be identified. sessions to maintain treatment gains.2 Length of treatment
varies depending on individual factors (eg, number of both-
Behavioral Therapies vs Medication ersome tics). Primarily suited for children, CBIT can be used
Although there is no cure for tic disorders, symptom in adults with minor modifications. For children, sessions
reduction can be achieved with treatment.9 Historically, are completed jointly with primary caregiver(s). Treatment
medications have been considered first-line treatment for for adolescents may be completed individually with families
tics, with antipsychotics used most commonly. Medications included as needed for education and support.
can be beneficial but also have significant side effects, par- There are 4 primary treatment components of CBIT: psy-
ticularly antipsychotics.7 Behavioral therapy offers an alter- choeducation, HRT, function-based environmental interven-
native to medication under the premise that, although tics tion, and relaxation training.2 These are delivered in a com-
are neurologic, internal and external triggers can affect tic plementary fashion over the course of treatment (Table 1).
frequency.2,9,13,14 Behavioral therapy addresses those internal
(ie, the premonitory urge) and external (eg, task avoidance) Psychoeducation
triggers directly to provide symptom relief.2,14 Different types Psychoeducation at the outset of treatment typically
of behavioral therapy have been investigated with compel- includes information on diagnosis and etiology. It is often
ling evidence for HRT, and the newest extension of this necessary to revisit and discuss this information throughout
treatment, CBIT, as the most effective therapy.9,13-15 the course of treatment.2

Habit Reversal Therapy Function-based Environmental Intervention

First developed to treat habits (eg, nail biting and head Function-based environmental interventions iden-
shaking),16 HRT consists of awareness training, compet- tify and modify factors that exacerbate tics or increase
ing response (CR) practice, social support procedures, and impairment(s). These factors can be divided into anteced-
generalization training. In the initial study of HRT, there was ents (occur before tics) and consequences (occur in reaction
a 90% reduction in habits that were treated.16 Subsequent to tics, such as teasing, being comforted, or being asked to
studies, including randomized controlled trials, reported leave the classroom). Antecedents may be internal phenom-
excellent outcomes for HRT vs most other behavioral thera- ena (eg, anxiety or excitement) or external events includ-
py with sustained improvement.6,9,13,14 ing particular settings (eg, certain classes or meeting new
people).2,13 A function-based assessment identifies these
Comprehensive Behavioral Intervention for Tics factors through interviews with the child and family and
As a manualized approach, CBIT adds psychoeducation, self-monitoring between sessions.
function-based assessment, and behavioral incentives to the Once identified, interventions are developed for each
aforementioned components of HRT.2,13,17 In a randomized antecedent and consequence. Antecedent interventions
controlled trial of CBIT vs supportive therapy for children may include educating others about tics, breaking down
with tics, 52% of participants treated with CBIT responded tasks that exacerbate tics into smaller components, or
and maintained improvements at 6-months follow-up.18 scheduling activities during a time of day when tics happen
In a study with adult participants, more than 38% of those less frequently. Some examples of consequence interven-
treated with CBIT were responders with similar maintenance tions are encouraging others to ignore tics or encouraging
of treatment gains.17 Similar results have since been seen in the child to persist in activities despite tics. Short tic breaks
additional randomized controlled trials.19 The preponderance may be helpful but should not result in avoidance of activity
of evidence shows CBIT is as effective as antipsychotic medi- because this may exacerbate tics.
cation in reducing tics, with moderate-to-large effect sizes and
a more favorable side-effect profile.6,19,20 Habit Reversal Training
In light of the strong evidence for CBIT, European and The primary components of HRT incorporated in CBIT
Canadian guidelines in 2011 and 2012, respectively, stated are awareness and CR training. Awareness training aims to
that CBIT should be first-line treatment for individuals increase recognition of when a tic happens or is about to in
with tics.13,21 It is recommended that CBIT, when available, order to facilitate the implementation of a CR. Awareness
be offered as an initial treatment option relative to other training during sessions involves thoroughly describing and
behavioral therapies and medication.20 practicing the recognition of tics and premonitory urges.

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TABLE 1. COMPREHENSIVE BEHAVIORAL

Following awareness training, the child begins CR train-
INTERVENTION FOR TICS PROGRAM CONTENT
ing, which involves learning a behavior to perform when a
Week 1 Psychoeducation on tic disorders premonitory urge or tic starts. A CR should be a behavior
Session 1 Development of a behavioral reward program that is either physically incompatible with the tic or a
Introduction to function-based interventions more subtle variation of the tic. For example, if a child has
Develop a hierarchy of tics to address in treatment a shoulder raising tic, an incompatible behavior might be
Week 2 Review tic hierarchy holding the shoulders down and back. For motor tics, CRs
Session 2 Enhance motivation by listing reasons tics are are typically alternate movements, whereas CRs for vocal
inconvenient tics involve changing breathing patterns. After identifying
Develop function-based interventions for first tic an appropriate CR, these skills are practiced in therapy
Awareness training and develop a competing sessions to prepare for use whenever tics or premonitory
response (CR) for first tic urges occur. It is helpful, especially for younger children, to
Review behavioral reward program identify a support person to encourage and reinforce con-
Week 3 Review tic hierarchy sistent use of CRs.2
Session 3 Inconvenience review
Develop function-based interventions for second tic Relaxation Training
Awareness training and develop a CR for second tic Children also receive instruction in diaphragmatic breath-
Review behavioral reward program ing and progressive muscle relaxation. These can help
Week 4 Review tic hierarchy and inconveniences reduce some of the stress or tension created by tics and may
Session 4 Develop function-based interventions for third tic also be helpful during times of increased anxiety, excite-
Awareness training and develop a CR for third tic
ment, or stress, which can exacerbate tics.2
Introduce and practice diaphragmatic breathing
Reward Programs
Review behavioral reward program
Behavioral reward programs assist in motivating the child to
Week 5 Review tic hierarchy
participate in sessions, encourage home practice, and increase
Session 5 Inconvenience review
overall adherence. Reward systems are developed collabora-
Develop function-based interventions for fourth tic tively with the child and family. Target behaviors include session
Awareness training and develop a CR for fourth tic attendance, homework completion, and session activity partici-
Introduce and practice progressive muscle relaxation pation. It is important that opportunities to earn rewards are
Review behavioral reward program based on adherence to treatment, not tic reduction; in other
Week 6 Review tic hierarchy words, the effort is rewarded rather than the result.
Session 6 Inconvenience review
Develop function-based interventions for fifth tic Candidates
Awareness training and develop a CR for fifth tic Individual factors that improve or attenuate treatment suc-
Review relaxation skills cess are generally understudied, but some useful patterns have
Review behavioral reward program emerged. Designed for individuals age 9 years or more, CBIT is
Week 7 Review tic hierarchy most effective when participants are motivated, aware of their
Session 7 Inconvenience review tics and associated premonitory urges, and cognitively able to
Develop function-based interventions for sixth tic fully engage in therapy. Although robust evidence to recom-
Awareness training and develop a CR for sixth tic mend behavioral interventions in younger children is generally
Introduce relapse prevention lacking, recent guidance suggests CBIT may be effective in this
Review behavioral reward program population.20 Likewise, it is unclear if CBIT is effective for chil-
dren with cognitive limitations, because most studies excluded
Week 8 Review tic hierarchy
participants with cognitive impairments.2,6,10,15,17,18,20
Session 8 Inconvenience review
Review treatment procedures
Concerns and Barriers to Treatment
Discuss strategies for relapse prevention Despite recommendations for behavioral therapy as
Review behavioral reward program first-line treatment, many children do not have access to
Weeks Review tic hierarchy it. Families and providers may also be hesitant to pursue or
12-20 Inconvenience review recommend behavioral therapy because of misunderstand-
Sessions Review previous treatment content ings regarding safety, fear of worsening of tics, and concern
9-11 Review behavioral reward program for a potential rebound effect.

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Safety and Tolerability. Both landmark studies of CBIT Telehealth also does not address the time commitment need-
found participants were no more likely to have adverse ed for CBIT or the expense of participating in treatment. To
events, require increased medication dosing, or experience further increase the number of CBIT providers, studies investi-
worsening psychiatric symptoms compared with those who gated training paraprofessionals and found that master’s level
received supportive therapy.17,18 Studies observed low attri- clinicians, occupational therapists, and nurse practitioners can
tion rates, suggesting that although participation in therapy effectively deliver CBIT.24,25 Table 2 summarizes methods to
requires more effort than taking medicine, behavioral treat- access CBIT.
ment is well-tolerated by children and families.21 To address the need for trained providers and accessibility,
Tic Worsening. Although tics can increase during conver- TicHelper, a web-based interactive self-help program based on
sations about tics, they generally subside back to baseline the CBIT protocol was created.15 It is a family-based program
levels when the topic shifts, arguing against a worsening of recommended for children age 8 years or more that includes
tics resulting from behavioral therapy.13 Research also shows parent skills training. TicHelper is designed to be completed
clinician-guided self-monitoring and awareness training has in 8 weeks, with approximately 30 to 60 minutes of website
a beneficial effect on tics.13,14 The preponderance of evidence activity and practice per day. This program contains 4 mod-
provides no support for worsening of tics after a typical ules paralleling CBIT modules, including tic education, reduc-
course of CBIT.17,18,21 ing tic triggers, tic awareness, and tic blocking. Although
Symptom Substitution. Symptom substitution is the notion TicHelper shows promise in reducing some of the burdens in
that if 1 tic is treated another will emerge or a comorbid accessing treatment, research data regarding efficacy is lack-
psychiatric symptom will increase. This is rooted in psycho­ ing and there are limitations to the program. In particular,
dynamic theory and clinical anecdotes, but there is no empiric TicHelper may not be appropriate for complex cases such as
evidence to support this hypothesis, whereas behavioral comorbid diagnoses or self-injurious tics. Although TicHelper
therapy has been shown to decrease tics and comorbid psy- allows for individualization, administering treatment without
chiatric symptoms.9,10,13,14,16,19 a therapist limits the customizability of CRs and would not
Rebound Effects. A study of neurologists and psychologists identify tics a child does not explicitly endorse. The program
found that 77.4% believed that suppression of tics increases also does not address psychosocial comorbidities that often
tics over and above the natural baseline, termed the rebound contribute to decreased quality of life.15
effect.22 This has been tested experimentally, however, and
evidence is consistent that suppression does not result in a Conclusions
rebound effect.13,14,18 Chronic tic disorders are common and impairing for
Awareness. An additional barrier to CBIT appears to be a children and adolescents.3,6,7 Although tics may improve
lack of awareness of behavioral treatments for tic disorders. In over time, many adolescents continue to experience func-
a study examining the use of behavioral therapy in communi- tional impairments from tics into adulthood, making early
ty samples, the top 2 reasons for not accessing CBIT were that access to treatment essential.6,7,9,10 There is a rich evidence
families had not heard of it and did not know how to access base for CBIT efficacy, comparable to medication with
it.5 Many providers treating TS are also unaware of behavioral fewer side effects and maintenance of treatment gains.6,17-
20
therapy for tics, with only 14.3% of physicians and 31.3% of American, Canadian, and European guidelines all recom-
psychologists having heard of HRT in a 2004 survey study.22 mend CBIT as first-line treatment for children and adoles-
Shortage of Trained Providers. Even when there is interest cents with tics.3,20,21 However, despite the recommendation
in pursuing CBIT, it is difficult to find trained providers.15,23 to seek behavioral therapy for tics, few children and ado-
Use of telehealth for delivery of CBIT via video or internet lescents have access.5,15,23 Future directions include contin-
conference has been investigated and shows similar efficacy ued efforts to disseminate the evidence for CBIT, training
to in-person CBIT.23,24 Thus, telehealth could increase access of professionals and paraprofessionals to deliver CBIT, and
to CBIT, although the number of trained therapists is still too continued development of alternative treatment delivery
low to meet the needs of the population of people with tics. methods to improve access.5,15,23,24  n
TABLE 2. ACCESS TO COMPREHENSIVE BEHAVIORAL INTERVENTION FOR TICS
Modality Websites Further Instructions
In-person tourette.org/find-a-provider Use the filters to search by state, age, and expertise (comprehensive behavioral
therapy intervention for tics [CBIT])
Online self-guid- TicHelper.com You can either enroll for the therapy directly or access a demonstration to see
ed therapy how the website functions

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American Psychiatric Association; 2013.
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Adults, Therapist Guide. New York, NY: Oxford University Press; 2008.
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emerging area of practice for psychologists. Prof Psychol-Res Pr. 2010;41:518-525.
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2016;16(4):37.
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9. Franklin SA, Walther MR, Woods DW. Behavioral interventions for tic disorders. Psychiatr Clin North Am. 2010;33(3):641-655.
10. McGuire JF, Piacentini J, Scahill L, et al. Bothersome tics in patients with chronic tic disorders: characteristics and
individualized treatment response to behavior therapy. Behav Res Ther. 2015;70:56-63.
11. Leckman JF, King RA, Cohen DJ. Tics and Tic Disorders. In: Leckman JF, Cohen DJ, eds. Tourette’s Syndrome-Tics, Obses-
sions, Compulsions: Developmental Psychopathology and Clinical Care. New York: John Wiley & Sons, Inc; 1999:23-42.
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Neurol. 2006;21:719-725.
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Carinna M. Scotti-Degnan, PhD

Pediatric Psychologist
Division of Child and Adolescent Psychiatry and
Behavioral Sciences
Division of Neurology
The Children’s Hospital of Philadelphia
Philadelphia, PA

Hannah A. Ford, PhD

Pediatric Psychologist
Department of Pediatrics
Center for Advancement of Youth
Department of Psychiatry and Human Behavior
University of Mississippi Medical Center
Jackson, MS

Disclosures
CMS-D and HAF report no disclosures

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