Behavioral treatments for Tourette’s disorder and tics

Chronic tic disorders are marked by repetitive, uncontrolled movements or vocalizations that can range from mild to disruptive and are sometimes painful. These tics are neurobiological in origin, but the first-line treatment for tics and Tourette’s disorder (TD)—a condition marked by both vocal and motor tics—is behavioral.

Comprehensive Behavioral Intervention for Tics (CBIT), a program designed and tested by psychologists and psychiatrists, has been recommended by the American Academy of Neurology as the first-line treatment for TD and other chronic tic disorders since 2019. Randomized controlled trials suggest that behavioral therapy is equally as effective as medication for reducing tic severity, without the potential side effects of medication (Piacentini, J., et al., Journal of the American Medical Association, Vol. 303, No. 19, 2010opens in new window).

“You have to remember that one of the biggest things that tic disorders take away from people who are affected is a sense of predictability and control over their own actions,” said Douglas Woods, PhD, a clinical psychologist now at Loyola University Chicago and a CBIT pioneer. “CBIT teaches patients that tics can be effectively managed, and by learning that, patients learn they are more in control over what they do. That can have a very powerful impact on how a person with tics approaches the world.”

Access and efficacy remain an issue, however. Experts say that not enough kids and adults with tics have access to CBIT because of a lack of skilled providers. Experts are also looking for improvements, as the intervention is effective only about half the time for kids and less than that for adults. One persistent question is how to help support the 85% of people with tics who have a comorbid psychiatric disorder such as anxiety and obsessive-compulsive disorder.

Epidemiological studies suggest that about 1% of children and 0.01% of adults experience chronic tic disorders (Yilmaz, A. Y., & Jankovic, J., Brain Sciences, Vol. 15, No. 5, 2025opens in new window). For that reason, psychologists are wise to be familiar with tic disorders and their treatments. They might also find that they can help patients through referrals to a CBIT provider, by providing psychoeducation on these conditions, or even by becoming trained to provide CBIT themselves.

“We see it in our offices, and we need to know how to adequately address it, we need to know how to talk about it with compassion,” said Suzanne Mouton-Odum, PhD, a clinical psychologist at the Baylor College of Medicine in Houston who treats tic disorders. “[Otherwise] we’re going to miss the opportunity to help a significant number of people.”

Tics can come in the form of uncontrolled motor movements or as vocal utterances. People with only vocal tics or only motor tics for more than 1 year are said to have persistent or chronic tic disorders.

Although TD is sometimes thought to be the “worst case” of tic disorders, this is a myth. A TD diagnosis simply means a person experiences both motor and vocal tics, which can be anywhere on the spectrum from mild to severe. Tics are most common in children, with an estimated 20% of kids experiencing transient tics that clear up on their own (Black, K. J., et al., Current Developmental Disorders Reports, Vol. 8, 2021opens in new window). Even chronic tic disorders improve with age. A meta-analysis found that 0.77% of kids had TD, which dropped to 0.05% in adulthood (Knight, T., et al., Pediatric Neurology, Vol. 47, No. 2, 2012opens in new window). Although the reasons that tics improve with age are not entirely clear, experts suspect that brain maturation plays a major role.

The specific tic can determine how impactful these disorders are. Some people may have subtle tics that do not interfere with their daily lives. Others may experience tics that cause muscle pain or social stigma. The most stigmatizing tics tend to define the disease in the public imagination, though they are not the most common: The stereotypical TD coprolalia, or inappropriate utterances of obscenities or slurs, occurs in only 10% to 15% of people with TD.

“There are a lot of myths and misconceptions when it comes to tics,” said Joseph McGuire, PhD, a clinical psychologist at Johns Hopkins School of Medicine who specializes in TD. Beyond the stigma, parents often fear their children’s tics are signs of a dangerous neurological condition, such as a brain tumor. Or they may not realize that most tics improve with age. Sometimes one of the most impactful statements for a family, McGuire said, simply is: “You’re not alone.”

Transient childhood tics are common, with about 15% to 20% of kids experiencing temporary tics that lessen on their own, said John Piacentini, PhD, a clinical psychologist at the University of California, Los Angeles, and one of the pioneers of CBIT.

Tics that last less than a year fall under the diagnosis “provisional tic disorder.” The trajectory of provisional tic disorder is somewhat controversial. Prospective research led by Washington University in St. Louis psychiatrist Kevin Black, MD, suggests that these transitory tics may not be as transitory as they sometimes seem (Comprehensive Psychiatry, Vol. 134, 2024opens in new window). In that study, 98% of 89 kids recruited to a study of children with new tics were still experiencing them a year later. The tics had become less bothersome and clinically relevant, but the finding suggests that previous research may have missed or not counted tics that had diminished in severity but were still present.

Regardless, most kids who experience tics do outgrow them or inhibit them to the point where they are not bothersome without treatment. Thus, the first step for clinicians seeing a child with new tics is often psychoeducation, Piacentini said. Families need to understand that tics typically wane over time and they should be taught ways to avoid accidentally reinforcing tic behavior.

“I’ve seen parents have little kids with tics, and every time the kid tics, the parent will look at the child and try not to cry,” Piacentini said. “The kids see this. Or every time the kid comes home from school with tics, and the loving parent comes up and [rubs their back] and says, ‘You don’t need to do your homework.’ All of that serves to reinforce the tics.”

Family education may be enough unless the tics are particularly long-lasting or disruptive to the child’s daily life, Piacentini said.

Often, reassuring parents and kids that tics are not a symptom of a dangerous medical condition and that most kids with tics will see improvement as they get older gives families hope, said Christine Conelea, PhD, a clinical psychologist at the University of Minnesota who researches tic disorders.

“We see this in our data,” Conelea said. “Just having education about it makes people feel a lot better.”

For people for whom tics do not ease on their own, there are treatment options. The first is typically CBIT. Medication options may be added after CBIT if disruptive tics remain, Piacentini said. However, medication tends to be most effective on simple tics, said John Walkup, MD, a psychiatrist at Lurie Children’s Hospital and the Northwestern University Feinberg School of Medicine in Chicago who specializes in TD. More complex tics respond better to behavioral treatment because there are more opportunities to disrupt the tic.

CBIT intervention takes place in about eight sessions over 10 weeks and consists of three components. First, the patient learns to be more aware of tics and the premonitory urge, a feeling that sometimes rises before the tic. Second, the CBIT practitioner helps the patient develop a competing response, which is a movement or action that makes it difficult or impossible to do the tic. For example, if the tic is jerking one’s head back, the competing urge might be to tuck the chin, straighten the neck and hold that position, said Mouton-Odum. The third step is functional intervention, which involves figuring out which situations tend to exacerbate or reinforce tics and changing the circumstances so as not to encourage the tics.

A systemic review of the evidence conducted during the development of practice guidelines for treating chronic tic disorders found that medications and CBIT are similarly effective in reducing tics (Neurology, Vol. 92, No. 19, 2019opens in new window). A randomized clinical trial led by Piacentini and Woods found that 53% of kids age 17 or younger who received CBIT saw a clinically significant improvement in tics as measured by the Yale Global Tic Severity Scale (Journal of the American Medical Association, Vol. 303, No. 19, 2010opens in new window). A follow-up trial in adults found that 38% saw improvements after CBIT compared with psychoeducation and supportive counseling (JAMA Psychiatry, Vol. 69, No. 8, 2012opens in new window). An 11-year follow-up study found that 67% of youth who responded to CBIT in the original trial achieved remission at follow-up, with 40% of people across the entire clinical trial sample experiencing partial remission (Journal of the American Academy of Child and Adolescent Psychiatry, Vol. 61, No. 6, 2022opens in new window). The same follow-up found that contrary to fears that suppressing or attending to tics would worsen them, most participants did not experience tic worsening, tic substitution, or life interference from tic management (Behavior Modification, Vol. 48, No. 4, 2024opens in new window).

“Twenty years ago, individuals with Tourette’s syndrome and other tic disorders had very few treatment alternatives, and those that were available often had significant unwanted side effects,” Woods said. “With the development, testing, and dissemination of CBIT, the field of psychology has made an important contribution toward improving the lives of those with these conditions.”

Nevertheless, many people report they cannot access the treatment because trained CBIT practitioners are in short supply, said Michael Himle, PhD, a clinical psychologist at the University of Utah. Himle and his colleagues have been working on closing the research-practice gap. He has partnered with Woods, Mouton-Odum, and the Tourette Association of America to launch an online training program for professionals, CBIT Trainer, and is currently collecting data for a noninferiority trial to ensure that the online program is as effective as in-person training. The program, available at cbittrainer.com, takes about 10 hours to complete and costs $699.

Himle, Woods, and Mouton-Odum have also launched TicHelper, an online self-help version of CBIT that uses video sessions to walk kids and their families through the intervention. (The researchers receive royalties from TicHelper fees.) They are now analyzing data from the first 2,000 users of TicHelper to assess how well it works.

Because about half of kids and most adults who try CBIT do not respond or only partially respond to it, there is a lot of interest in how to improve behavioral tic treatment. One alternative is exposure and response prevention (ERP), which involves learning to tolerate the urge to tic, a feeling that can be quite uncomfortable. CBIT often works tic by tic, picking a competing response appropriate to each, but ERP works on all tics at once. In a randomized controlled trial comparing ERP and habit reversal training with medication and psychoeducation, ERP showed a similar reduction in tic severity as medication, while psychoeducation made no difference (Rizzo, R., et al., Frontiers in Psychiatry, Vol. 9, 2018opens in new window). ERP response rates are also similar to CBIT. However, sessions are 60 to 90 minutes, which is a barrier for some patients.

In a similar attempt to build tolerance for the frustrating feeling of wanting to tic, McGuire and Hannah Reese, PhD, a psychologist at Bowdoin College in Brunswick, Maine, are looking at the effectiveness of a mindfulness intervention. Their method, Mindfulness-Based Intervention for Tics (MBIT), developed in collaboration with Alan Brown, MA, a mindfulness teacher who has TD, overlaps with CBIT, Reese said. MBIT focuses on using traditional mindfulness practices to increase awareness of premonitory urges and tics, decrease stress, enhance distress tolerance, and boost self-compassion.

“We initially just start by teaching people how to pause and slow down the process,” Reese said. “Can they observe that urge, notice what it feels like in their body, notice what thoughts and emotions might be arising at the same time? And then, once they have done that, can they begin exploring whether they might be able to respond differently to that urge to tic?”

Sometimes, people will imagine the urge as an ocean wave and let it crest and collapse, Reese said. Other people will anchor themselves to their breath and ride out the urge. “Different approaches seem to work for different people,” she said.

A pilot randomized controlled trial of 28 people comparing eight sessions of MBIT to eight sessions of psychoeducation, relaxation, and supportive therapy showed significantly greater improvements with MBIT, with 69% of participants responding to MBIT compared with only 13% who received the supportive therapy (Movement Disorders, Vol. 39, No. 9, 2024opens in new window).

McGuire and Reese are now halfway through a 5-year clinical trial to further test the intervention and to investigate the mechanisms that lead to the most improvement. This might be attentional control; awareness of premonitory urges; general stress relief, which can improve tics indirectly; or self-compassion. “If we find out what that is, we can also think about other types of treatments that could also help provide that same relief,” McGuire said.

In similar research, Conelea, who runs the University of Minnesota’s Minnesota Tic and Compulsivity Lab opens in new window(MnTic), is working on a trial of CBIT aimed at understanding why it works, using fMRI and EEG to see how brain networks change over the course of treatment. In another ongoing MnTic study, researchers are combining behavioral treatment with noninvasive transcranial magnetic stimulation (TMS), which uses external magnetic fields to stimulate brain activity changes. The lab was recently designated as a Tourette Association of America Center of Excellence, meaning it provides the highest level of treatment and conducts groundbreaking research on the condition.

Neurologically speaking, Conelea said, people with chronic tics have an overactive, overconnected corticostriatal sensorimotor circuit that links the cortex to deep motor structures in the brain. They also have underactive, underconnected inhibitory circuits and overactive limbic circuits. Collectively, this circuitry makes movements more likely, more difficult to inhibit, and more impacted by emotional states. Behavioral interventions such as CBIT likely help strengthen the prefrontal inhibitory circuits, Conelea said. She and her colleagues are targeting the corticostriatal sensorimotor connection with TMS, hoping that the stimulation encourages plasticity in that system. Initial results in the first phase of the research suggest that TMS helps reduce the overconnection in sensorimotor circuitry, Conelea said (Frontiers in Human Neuroscience, Vol. 19, 2025opens in new window). The researchers are now recruiting for a randomized controlled trial of CBIT with or without active TMS, which they hope will link brain changes to changes in tic symptoms.

One major factor in tic disorders is that they often appear alongside comorbidities such as obsessive-compulsive disorder or attention-deficit/hyperactivity disorder, said Walkup. It is important not to jump straight to behavioral treatment for tics without evaluating for comorbidities that may need to be treated as well—or even prioritized for treatment if their effects are more onerous than the tics, Walkup said. “Tics wax and wane,” he said. “They increase with excitement and stress, and they improve with calm, focused activities.”

Anxiety disorders, separation anxiety, and generalized worry can all worsen tics, Walkup said. Depression, which typically presents later in adolescence, may also worsen tics for some teenagers who previously had their tics under control. Life stressors also play a big role, he said, so while most people see their tics decline as they pass into late adolescence or young adulthood, some may see their tics worsen as they get to college or take their first high-pressure job.

“When I see a 22-year-old, my goal there is not just to treat the tic, but to figure out why the tic is bouncing outside of the normative developmental pathway,” Walkup said.

Helping patients get “in the zone,” as Walkup puts it, can create an environment where tics are less likely. Because tics decline during focused, functional activity, Walkup helps kids and families set up routines and responsibilities that get kids in that mindset.

It is essential for psychologists to “teach the lifestyle component,” Walkup said. “Exercise is really good for tics, getting a good night’s sleep is really good for tics, developing your daily routine and putting some sophistication into it so you are in control of the things you can control is really good for tics.”