This programme is a treatment manual written for mental health professionals. It assumes clinical training, experience of behavioural therapy with children, adolescents or adults, and a supervision framework. It replaces neither your clinical judgement, nor your professional responsibility, nor the medical examination that must precede any diagnosis of a tic disorder. Diagnostic criteria are reformulated in our own words and never reproduced: refer to the original manuals for the wording itself. It is not written for the people concerned or for their families: if you or your child are in danger, if thoughts of suicide are present, or if movements appear suddenly together with other neurological signs, contact your country's emergency services without delay.
1. The programme at a glance
Indication. Persistent tics — Tourette syndrome, persistent motor or vocal tic disorder — in children from the age of eight or nine, in adolescents and in adults, when the tics cause discomfort, pain, distress or social, educational or occupational difficulties, and the person wishes to act on them.
Reference model. The comprehensive behavioural intervention for tics, derived from habit reversal, evaluated in two large controlled trials in children and in adults (Piacentini et al., 2010; Wilhelm et al., 2012) and recommended as first-line treatment by the European and American guidelines (Andrén et al., 2022; Pringsheim et al., 2019). Exposure with response prevention, which did as well as habit reversal in a comparative trial (Verdellen et al., 2004), is presented as an alternative.
Format. Ten sessions of 60 minutes — the first two of 75 to 90 minutes —, weekly up to session 7, then fortnightly. Three monthly boosters for people who have responded. For minors, parents take part in part of every session and in the whole of some.
Target mechanism. Not to suppress the tics, but to give the person a hold on them: to spot the moment when the tic is building, to oppose it with an incompatible movement until the urge passes, and to change what, around the person, maintains or worsens the tics without anyone noticing.
| Session |
Focus |
Session deliverable |
| 1 |
Assess and decide |
Baseline measures, written decision to treat or to wait |
| 2 |
Understand the tics, and rank them |
Tic hierarchy, reward programme set up |
| 3 |
See the first tic coming |
Tic described, signal identified, detection achieved in session |
| 4 |
The competing response, and who helps |
Response chosen and practised, the helper's role agreed |
| 5 |
What surrounds the tics |
Two changes of context, second tic started |
| 6 |
Letting go, and the next tic |
Breathing practised, third tic started |
| 7 |
School, work, other people |
Page for the teacher, a reply to teasing prepared |
| 8 |
Doing it alone |
One tic treated by the person themselves |
| 9 |
When the tics change |
Written plan for a new tic or for a flare-up |
| 10 |
Review and relapse prevention |
Measures repeated, written plan, boosters arranged |
What the person takes away. Nine printable worksheets, listed in section 40. For the child and the adolescent: my tics, I see my tic coming, my competing response, where, when, and what happens afterwards, my plan for what comes next. For parents: the parents' corner. For the teacher: a page for the teacher. For the adult: my working notebook, my situations and my plan.
What sets this programme apart from the other manuals on this site. Three things. The first decision may be to treat nothing at all, because the natural course is often favourable. The disorder has a neurological basis and yet the first-line treatment is behavioural, which has to be explained to everyone. And a whole session is given over to the classroom, to classmates and to teasing.
2. Before you begin
Who this programme is for
This text is written for psychologists, psychiatrists, child psychiatrists, neuropsychologists, psychotherapists and doctors trained in cognitive behavioural therapy. It assumes that you can observe a behaviour precisely, conduct a functional analysis, work with parents and, where appropriate, with a school.
It is written neither for the people concerned nor for those close to them. It contains material — differential diagnosis, risks, prognosis — that is put differently to a family.
The four preliminary decisions
Has the diagnosis been made, and has a doctor examined the person? The diagnosis of a tic disorder is clinical, but it assumes that a neurological or medical cause has been ruled out, particularly when the presentation is atypical. Section 10.
Do the tics bother the person themselves? Not their parents, not their teacher, not you. Many tics, especially in children, bother only those who are watching. Section 15.
Is something else in the foreground? In a large proportion of cases, ADHD, OCD, anxiety or depression weigh more heavily than the tics. What costs the most is treated first. Section 11.
Can the person practise between sessions? The treatment rests on daily practice. A child who is too young, a disorganised family or an adult in crisis are not in a position to do it, and it is better to know that beforehand.
What this programme does not treat
It does not treat the provisional tics of a young child who is not distressed by them. Information and watchful waiting are enough. Section 3.
It does not treat, as it stands, tic-like movements of sudden onset. These call for an approach to functional neurological disorders, with a neurologist. Sections 3 and 37.
It does not treat stereotypies, nor body-focused repetitive behaviours.
It does not, on its own, treat an associated OCD or ADHD. They have manuals of their own: Treating obsessive-compulsive disorder in adults: a therapist's manual, Treating ADHD in children: a therapist's manual and Treating ADHD in adults: a therapist's manual.
How to use it
Read the whole thing before the first session, and in particular sections 5, 8, 30, 31 and 32: the premonitory sensation, the model, awareness training, the competing response and the context of the tics. These are the five places where the treatment succeeds or fails.
Each session is described along the same frame: the aim, the steps, what you say, the common errors, and the criterion for moving on. Adaptations to age are flagged within the sessions where they matter, and gathered in section 36.
Three warnings specific to this reason for consulting.
Tics fluctuate, with or without treatment. They come and go in waves, change form, disappear and return. A better week does not prove that the treatment is working; a worse week does not prove that it is failing. Judgement is made over several weeks, with measures.
The treatment does not ask anyone to hide their tics. It gives a means of managing them when the person wishes. A child who is made to understand that his tics are shameful will do worse, even if his tics diminish.
You will have to watch tics without reacting. During the sessions, tics will occur, sometimes vocal, sometimes coarse. Your neutrality is a model for the parents, and it has to be worked on.
3. Four presentations not to be confused
1. The provisional tics of childhood
What you observe. In a school-age child, eye blinking, a grimace, sniffing or throat clearing, present for a few weeks or a few months. Sometimes several, one after another.
What points to it. A duration of less than a year, no distress for the child, and otherwise ordinary development. These tics are common: in a meta-analysis, transient tic disorder was the most frequent tic disorder in children (Knight et al., 2012).
What that implies. Information for the parents, advice on not centring attention on the tics, and reassessment if they persist or if they cause distress. No systematic behavioural treatment.
2. Persistent tics and Tourette syndrome
What you observe. Tics present for more than a year, having begun in childhood, which fluctuate and change form. Motor tics alone or vocal tics alone for persistent tic disorder; both, at some point in the course, for Tourette syndrome.
What points to it. The duration, the age of onset, the fluctuation, the ability to hold the tics back for a while, and often a sensation that precedes them.
What that implies. This is the indication for this programme when the tics bother the person.
3. Tic-like movements of sudden onset
What you observe. In an adolescent or a young adult, almost always a girl or a young woman, complex movements and sounds that appeared over a few hours or a few days, intense from the outset, often with words or phrases, frequently after exposure to tic videos on social media, without that exposure being found in everyone. This presentation was described in numbers during the COVID-19 pandemic (Pringsheim et al., 2021).
What that implies. A neurological assessment and management along the lines of functional neurological disorders. The protocol in this manual does not apply as it stands. Sections 10 and 37.
4. Stereotypies and compulsions
What you observe. Repetitive movements of another nature: rhythmic and very early for stereotypies, preceded by a thought or a fear for compulsions.
What that implies. Other forms of management. Tics and compulsions often coexist, and the boundary is sometimes blurred. Section 10.
The three other things to have ruled out
A neurological or medical cause. A neurological illness, a head injury, an infection, or an effect of a medicine or a substance. That is the doctor's job, and it is more likely when the tics begin in adulthood.
Abnormal movements of another nature. Section 10.
A local cause. A child who sniffs or clears his throat may have rhinitis; a child who blinks, conjunctivitis or a visual problem. The reverse is true too: many vocal tics have been treated for months as allergies.
The three sorting questions
"Since when, and how did it come on?" This separates the provisional tic, the persistent disorder, and the sudden onset that points elsewhere.
"Do you feel something just before?" This looks for the premonitory sensation, which points to a tic, and which will be the foothold of the treatment.
"What does it stop you doing?" This separates the person's own distress from that of those around them. It is this question that decides whether to treat.
4. Tics, as they are observed
The definition
A tic is a sudden, rapid, recurrent and non-rhythmic movement or sound. It resembles an ordinary gesture — blinking, shrugging, clearing the throat — but it occurs out of context and repeats.
The forms
Simple motor tics. Blinking, grimacing, movements of the eyes, the nose or the mouth, head jerks, shoulder shrugs, abdominal contractions. These are the most frequent, and almost always the first.
Complex motor tics. Longer sequences, which may look intentional: touching an object or a person, jumping, turning around, hitting oneself, imitating a gesture, making an obscene gesture.
Simple vocal tics. Sniffing, throat clearing, coughing, grunting, shouting, whistling.
Complex vocal tics. Syllables, words or phrases; the repetition of other people's words or of one's own; and, in a minority of cases, coarse or socially unacceptable words. In a large series of patients referred to specialist centres, coprolalia occurred over the lifetime in 19% of boys and men and in 15% of girls and women, on average at about eleven years, that is five years after the onset of the tics; coprophenomena, words and gestures taken together, concerned about one patient in five (Freeman et al., 2009). And yet this is the only image most people have of the syndrome.
What characterises them
They fluctuate. In frequency, in intensity and in form, over days, weeks and months. One tic disappears, another replaces it. That is the rule, not the sign of a failure.
They often begin with the face and then spread, inconsistently, to the neck, the shoulders, the trunk and the limbs.
They can be held back for a while. At the cost of an effort, of a rising tension, and of attention diverted from what the person is doing. That does not mean that they are voluntary.
They vary with the context. Beyond their neurological basis, their expression is modulated in a systematic way by contextual factors (Conelea and Woods, 2008). In practice, people often describe an increase with tiredness, stress, excitement, boredom, and when the tics are talked about, and a decrease during an absorbing activity.
They decrease markedly during sleep, without always disappearing.
5. The premonitory sensation
What it is
An unpleasant sensation that precedes the tic: an itch, a pressure, a tension, a tingling, a feeling of something missing or unfinished, often located in the area where the tic is about to occur. The tic relieves it, briefly.
What is known
It is very common in adolescents and adults. In a series of 135 people aged 8 to 71 with a tic disorder, 93% reported premonitory urges, and the great majority described relief after the tic (Leckman et al., 1993). This is a clinical sample, not a population estimate.
It is harder to describe in young children. The scale measuring premonitory urges did not have satisfactory properties at ten years and below (Woods et al., 2005). That does not mean that the sensation is absent, but that one cannot rely on its description.
Relief reinforces the tic. The experimental data point towards negative reinforcement: the urge rises when the tic is held back and falls when it is performed (Capriotti et al., 2014). That is the engine the treatment targets.
Why it is the foothold of the treatment
Because it is a signal. If the person feels the tic coming, they can act before it occurs. That is the object of awareness training and of the competing response.
Because it is a sensation that wears off. If the person holds out without performing the tic, the urge eventually falls, and it falls faster with repetition: during exposure with response prevention, the intensity of the sensations decreases within sessions and from one session to the next (Verdellen et al., 2008).
And because it explains what nobody understands. Why the tic "has to" come out, why holding it back is exhausting, and why saying "stop" is of no use.