The Best Treatment for Tics and Tourette's

Tics — repetitive, usually rapid movements or sounds that a child makes involuntarily — vary in severity. Some tics are barely noticeable and don’t require professional attention. But when these movements are disrupting a child’s quality of life, then it’s time to pursue treatment. While there is no cure for tic disorders, there are interventions that can help. Especially promising is comprehensive behavioral intervention for tics (CBIT), a therapeutic approach that has been proven to alleviate tics with lasting results.

For many years, the most common treatment for tic disorders has been a form of cognitive behavioral therapy called habit reversal training (HRT). In HRT, a therapist will first train patients to be more aware of their tics and the feeling they get when they’re about to happen. The next step is to come up with a competing response that makes it difficult to carry out the tic. HRT has been extensively studied and has proven to help reduce tics. But CBIT, which evolved from HRT, takes things a step further. CBIT is widely recommended as the first line of treatment for tics, before trying medication or other strategies. It has been found to be as effective as antipsychotic medication, without the undesirable side effects.

Like HRT, CBIT also focuses on when, where, and why the tics occur before coming up with alternative actions. But as its name implies, CBIT is more comprehensive in its approach. “It incorporates habit reversal training — that’s the core piece of the treatment — but it’s an overall treatment package,” explains Amanda Greenspan, LCSW, training coordinator and social worker in the Anxiety Disorders Center at the Child Mind Institute. CBIT adds several elements to treatment, including identifying situations that trigger or can make tics worse and finding ways to alter them, providing relaxation techniques to cope with stress, and offering behavioral incentives to help kids learn skills to reduce tics.

CBIT is effective for both kids and adults, vocal and motor tics, and varying levels of impairment. Greenspan says that kids as young as five might be able to learn the skills. “The first step is helping kids be motivated to do it and work on it,” says Greenspan. If it’s not really bothering the child, she adds, and they don’t care about it, the treatment isn’t likely to be as effective.

CBIT starts with someone who is motivated to make a change. If they are seeking treatment, then tics are likely interfering with their life in some way. CBIT is a collaborative process with a few key steps:

In CBIT, the first focus is on helping families understand what tics and Tourette’s are, and the science behind them. They learn what sort of things trigger and reinforce tics, how they manifest in kids and adults, and how they evolve over time. The hope is that by establishing a baseline understanding of how tics work, learning how to treat them will be more productive.

Next, a person undergoing CBIT starts to zero in on the details of their tics. “That’s where you work with the family on getting a sense of factors and situations that make the tics worse and reinforce them,” says Greenspan.

Kids work on developing an awareness of the chain of specific sensations that they experience leading up to the tic and where they are feeling it in their body.

“It’s helping them be able to identify first when the tics are happening and then being able to identify what’s called the premonitory urge, which is the feeling that people get before the tic happens,” explains Greenspan. “It’s kind of like when you’re about to sneeze, where it just feels like tension in the body. It’s helping them catch those moments.”

The child, often with the support of parents and teachers, will then begin to keep track of when and where the tics occur. Perhaps they tend to happen whenever the child feels anxious or excited, or when they’re on the way to school, waiting to get called on in class, or simply watching TV. By noting when and where tics occur, kids can start to see patterns.

Once there is a good sense of the antecedents to the tic, the next step is teaching the child to develop a competing response — a different behavior or action that prevents the tic from happening. It’s best to focus on one tic at a time. Here, the therapist and patient will work together to brainstorm. When coming up with a competing response, therapists will make sure it checks all these boxes:

• Is it less noticeable than the tic?
• Is it something they can do for a minute or longer?
• Is it something they can do anywhere?
• Is it something that will block the actual tic?

If the suggested behavior doesn’t meet the criteria, it’s back to the drawing board. Holding your breath, for example, won’t work because doing it for over a minute is unrealistic. When Greenspan worked with a child whose tic was jerking his head to the side, they came up with the competing response of having him put his chin down; this checked all the boxes and proved to be effective. The therapist may offer some suggestions and guidance but it’s important that the child plays a big role in the process and has a sense of ownership over the plan.

Typically, the child and therapist will have weekly check-ins to monitor progress. “If we’re seeing that it’s hard for them to physically do or hold for a long time, then we might switch that up and be like, all right, let’s try something different,” says Greenspan.

A reward system can be used to help with motivation and boost engagement. The therapist and family can work together to provide small rewards when the child practices building awareness and then using their competing response.  Typically, rewards should be given for practicing skills, not based on having less frequent tics.

Changes to the environment or routines associated with the tic can also contribute to reducing tics. For example, if a child tends to tic when they are studying for an exam, they could try taking short movement breaks at predictable intervals. If tics are more common when a child is stressed, then the therapist may teach them relaxation strategies such as deep breathing, mindfulness, listening to music, visualizations, or progressive muscle relaxation.

Sometimes kids will be excused from an activity that is associated with tics, but experts argue that this actually reinforces rather than extinguishes the tic. The idea is not to let the child off the hook, but rather to give them the tools to participate in the activity without the tics.

When kids are undergoing CBIT, families play a crucial role. “We want the parents to really understand exactly what we’re doing in session so that they can implement the practice at home,” says Greenspan. Parents typically join their child during therapy sessions to offer their observations, and to learn alongside their child.

Parents are coached to gently remind kids to use the skills they are working on and practice the competing response. They’re encouraged to actively assist their child in practicing and mastering new skills, even if it’s just a focused 15 minutes each day so they can really get into the habit of doing it. Additionally, they may need to be coached to ignore, rather than draw attention to tics, as that can make them worse.

And according to Greenspan, when parents see their kids using their learned skills, they can provide positive reinforcement by giving a thumbs up or an acknowledgement of the child’s hard work. And then for even younger kids it can often be helpful to incorporate some kind of extrinsic reward or motivator.

When possible, therapists will speak with their patients’ teachers to get a more complete picture of when and where tics occur. They will also advise teachers against calling attention to the tic or allowing the child to avoid certain situations (for example tests or class subjects they dislike) due to their tics. Ideally, Greenspan notes, the teachers will be informed of the CBIT strategies and can help the child implement them.

School accommodations through a 504 plan or IEP can be helpful as well. Rather than sending a child out of the room when they tic, for example, teachers can provide planned breaks. Specific accommodations will vary by the type and severity of the child’s tics, but may include extended test times, reduced homework, the option to type assignments, or testing in a separate room.

While it varies from person to person, the typical format for CBIT is eight 60-to-90-minute sessions over the course of 10 weeks. The first six sessions occur weekly and the final two sessions are two weeks apart. “This can vary depending on how many tics there are to target,” says Greenspan. For someone with a single, simple tic the treatment process should be straightforward. Someone with a variety of complex tics will probably take longer.

The biggest treatment challenge with CBIT is the child following through on the plan and staying motivated. “It’s definitely hard work. It requires them practicing on their own between sessions, not just in session,” says Greenspan. “I would say that’s usually the biggest barrier for kids.” Motivation and consistent practice may be particularly difficult for kids with co-occurring conditions like ADHD that affect attention and motivation.

If kids aren’t practicing, the therapist may review why the child wanted to make a change in the first place. Was it because it prevented them from doing desired activities? Were other kids teasing them about their tics? Helping them remember their initial motivation is sometimes enough to help them re-commit. Parents play a big role as well. “If parents are having a hard time following through with the practice, then understandably it’s going to be a lot harder for the child too,” says Greenspan. For these kids, reward systems may be particularly important as well.

CBIT has shown to have typically long-lasting results. “It’s not a cure, in that it doesn’t mean that tics are fully going to go away. But what the research has shown is that there’s a significant reduction in tics and a significant reduction in the impairment and intensity,” says Greenspan. Ideally, patients who’ve completed treatment will have built the skills to know how to tackle new challenges as they come up.

“The tricky thing with tics is that they do really wax and wane so new ones can come up at different points,” notes Greenspan. “It’s pretty common for a patient to come back and get more support on a specific tic, if it reemerges. But usually, it’s a faster process because it’s more of a booster session.”