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. It derives from habit reversal, an older method that teaches the person to spot the tic and to oppose it with an incompatible movement (section 31), and it adds to it, in particular, psychoeducation and work on the context of the tics (components detailed in section 8). It has been evaluated in two large controlled trials in children and in adults (Piacentini et al., 2010; Wilhelm et al., 2012) and placed as first-line treatment by the European and American guidelines (Andrén et al., 2022; Pringsheim et al., 2019). Exposure with response prevention, which here consists of holding back all one's tics while staying in contact with the sensation that precedes them (section 33), did as well as habit reversal in a comparative trial (Verdellen et al., 2004); it is presented as an alternative.
Format. Ten sessions of 60 minutes — the first two of 75 to 90 minutes —, weekly up to session 8, 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 (awareness training, section 30), to oppose it with an incompatible movement until the urge passes (the competing response, section 31), 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" and "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" and "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
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, attention deficit hyperactivity disorder (ADHD), obsessive-compulsive disorder (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, that is, a reassessment later on without treatment (section 15), 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, also known as conversion disorders, with a neurologist. Sections 3 and 37.
It does not treat stereotypies (sections 3 and 10), nor body-focused repetitive behaviours, such as pulling out one's hair, picking at one's skin or biting one's nails.
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, the name given to provisional tic disorder before DSM-5, 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, most often 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 distinguishes a tic from a stereotypy or another abnormal movement, but not from a tic-like movement of functional origin (section 10), 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, which is known as coprolalia. 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, also called the premonitory urge, and which the rest of this manual often simply calls "the urge": 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 (section 13) 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.
Frequently asked questions
Will holding tics back not make them explode later?
The available data do not show it (Himle and Woods, 2005). More numerous tics in the evening are better explained by tiredness and by the fact that the person is holding out less. And the treatment does not ask for holding out all the time.
Will the treatment not bring out other tics?
No. In the two large trials, the treated participants had no more new tics than those in the control group (Peterson et al., 2016). New tics will appear, because that is the nature of the disorder. Section 14.
If a behavioural treatment works, are the tics voluntary?
No. Tics have a neurological basis, and one can learn to manage them, just as a movement is rehabilitated after a brain lesion. That is the sentence to repeat to parents and teachers when the tics decrease.
Should a child whose tics do not bother him be treated?
Generally not. Information is given, advice not to centre attention on the tics, and reassessment. Watchful waiting is part of the guidelines (Pringsheim et al., 2019).
From what age can this treatment be offered?
The large trials covered children from the age of nine. Before eight or nine, an adapted version exists, evaluated only in an open study (Andrén et al., 2022): preference is given to information, to work on the context and to a playful version guided by the parents.
He has almost no tics at school, and a great many at home. Is he doing it on purpose?
No. He holds out all day, at the cost of an effort that takes up attention, and he lets go on getting home, tired, in a safe place. It is a very common picture, and it has to be explained to the school, which does not see the tics, as much as to the parents, who see nothing else.
Should the school and the classmates be informed?
Often, yes, and it is recommended (Pringsheim et al., 2019). But it is for the child or the adolescent to decide, with their parents, what is said and to whom. Informing the class may help the classmates and the child themselves (Nussey et al., 2014).
Do ADHD medicines make tics worse?
A meta-analysis of controlled trials did not find more new or worsened tics on psychostimulants than on placebo (Cohen et al., 2015). The decision belongs to the doctor, who will judge case by case.
Can an adult who has had tics for thirty years benefit from this?
Yes. The trial in adults included people aged 16 to 69, with a clear benefit in some of them (Wilhelm et al., 2012).
Tics appeared over a few days in an adolescent girl who was watching tic videos. Is this Tourette syndrome?
Probably not. A sudden, late onset that is complex from the outset points to tic-like movements of functional origin (Pringsheim et al., 2021). Refer to a neurologist; the protocol in this manual does not apply as it stands. Section 37.