Comprehensive Behavioral Intervention for Tics: A Role for Behavior Analysts

by Andrew Arellano, M.S., BCBA, LBA

Tics commonly emerge between the ages of 4 and 7. While many children experience transient tics (meaning tics that disappear on their own), a subset meets the criteria for a tic disorder diagnosis. Approximately 10–25% of school-aged children develop a tic disorder, which is categorized under neurodevelopmental disorders in the DSM-5-TR. Importantly, the severity or intensity of tics does not determine diagnosis; instead, it depends on the type of tic and its duration.

Types of Tic Disorders

There are three main types of tic disorders, differentiated by the duration and presentation of motor and vocal tics:

1. Provisional Tic Disorder: This diagnosis applies when motor and/or vocal tics have been present for less than one year.

2. Persistent (Chronic) Tic Disorder: This disorder involves either motor or vocal tics (but not both) persisting for at least one year. A diagnosis specifies whether the tics are motor or vocal in nature.

3. Tourette Syndrome (TS): The most well-known tic disorder, Tourette Syndrome, requires the presence of both motor and vocal tics (not necessarily at the same time) persisting for at least one year.

   
   

All three diagnoses share common criteria: onset must occur before age 18, the symptoms must not be attributable to medication or injury, and tics must be the primary symptom. Additionally, tics often wax and wane, meaning their intensity and frequency may fluctuate over time, sometimes disappearing temporarily before returning.

Treatment Options for Tic Disorders

Once diagnosed, patients with tic disorders (TD) have several treatment options, which can be divided into pharmacological, surgical, and behavioral approaches. Unfortunately, there is no cure for TDs, only management. 

1. Medications: Pharmacological interventions include typical and atypical antipsychotics for older patients and alpha-2 agonists, such as clonidine or guanfacine, for younger patients. While these medications can reduce tics, they carry potential side effects, and patients must weigh the risks versus benefits.

2. Botox: For painful or highly visible facial tics, Botox injections can temporarily paralyze the affected muscles, preventing the tic. This treatment is also used for vocal tics by injecting Botox into the vocal cords. While effective and generally safe, Botox can be costly and requires repeated treatments.

3. Deep Brain Stimulation (DBS): This invasive surgical option involves implanting electrodes in the brain to modulate abnormal activity. DBS is typically reserved for severe, treatment-resistant tics due to the risks associated with brain surgery.

4. Comprehensive Behavioral Intervention for Tics (CBIT): CBIT is a non-pharmacological treatment that leverages behavioral principles to manage tics. It has no physical side effects and can significantly reduce tic frequency and intensity. CBIT includes three main components: psychoeducation, function-based assessment and intervention, and Habit Reversal Training (HRT).

CBIT: A Closer Look

CBIT’s effectiveness lies in equipping individuals with the skills to manage their tics by addressing their behavioral and environmental triggers.

1. Psychoeducation

Psychoeducation introduces patients and stakeholders to the nature, prevalence, and impact of tic disorders. This component allows patients to ask questions, understand their condition, and learn how to explain it to others. For youth, particularly, addressing the social stigma of tics is essential to their confidence and well-being.

2. Function-Based Assessment and Intervention

Though tics are neurologically driven and involuntary, internal and external environmental factors can influence their frequency and intensity. This component involves identifying antecedents and consequences of tics to develop strategies that modify environmental triggers and responses, reducing the overall rate of tics.

3. Habit Reversal Training (HRT)

Originally described by Azrin and Nunn (1973), HRT is a structured approach consisting of three key steps:

• Awareness Training: Patients learn to recognize their tics and premonitory urges (the uncomfortable internal sensations preceding tics). Premonitory urges act as triggers, with tics providing escape or relief. Awareness training helps patients identify these patterns and prepare for intervention.

• Competing Response Training: Patients are taught to perform an incompatible behavior—a competing response—when they feel the urge to tic. The competing response must be subtle and sustainable until the premonitory urge naturally dissipates.

• Social Support Training: Support from family, teachers, and peers is critical for success. Supporters are trained to reinforce the use of competing responses and provide encouragement. For younger clients, token economies are often implemented to motivate practice outside therapy sessions.

A Call to Behavior Analysts

Tic disorders offer a valuable opportunity for behavior analysts to apply their expertise outside the traditional realm of autism. CBIT highlights the power of behavior analysis to improve lives by addressing complex behavioral challenges. By expanding their scope to include CBIT, behavior analysts can further demonstrate the versatility and effectiveness of applied behavior analysis in diverse populations.