Comprehensive behavioural intervention for tics

1. Introduction

Version followed: the 8-session CBIT protocol of Woods, Piacentini, Chang, Deckersbach, Ginsburg, Peterson, Scahill, Walkup and Wilhelm (2008), Managing Tourette Syndrome: A Behavioral Intervention for Children and Adults (Therapist Guide, 1st ed., Oxford University Press, Treatments That Work), as delivered in the CBITS child trial (Piacentini et al., 2010) and adult trial (Wilhelm et al., 2012). The manual itself is not drawn on; its session sequence is reconstructed from trial summaries and Tourette Association (TAA)-linked training slides that cite it. A 2nd edition of the therapist guide (OUP, listed 2025, still an 8-session programme) exists but its contents are not drawn on here [uncertain: any changes in the 2nd edition are not reflected here].

Comprehensive Behavioural Intervention for Tics (CBIT) is a short, skills-based outpatient behaviour therapy for Tourette syndrome and persistent (chronic) motor or vocal tic disorder. At its core is habit reversal training (HRT; Azrin & Nunn, 1973), with function-based assessment and intervention, relaxation training, psychoeducation and, for children, a reward programme added around it. [source: NIMH 2010 and 2012 trial summaries; CDC page; Franklin 2021 slides]

How change happens: most tics are preceded by an uncomfortable premonitory urge, and doing the tic briefly relieves it. That relief negatively reinforces the tic. The environment also shapes tics: some settings and emotional states make them more likely, and other people's reactions can reinforce them. CBIT (a) builds awareness of the tic and its earliest warning sign, (b) trains a competing response that is held until the urge passes, which interrupts the urge-relief cycle, and (c) changes the antecedents and consequences that maintain tics. The proposed mechanisms are habituation to the urge, interrupting negative reinforcement, and better voluntary motor control; the trainers who cite the manual say the exact mechanism is not settled. Tics having a voluntary-control component does not mean they are voluntary or the person's fault. [source: Levenbach (SickKids) slides citing Woods, Piacentini & Walkup 2007; Flancbaum 2023 slides; CDC page]

2. Framework

Format. Individual outpatient therapy. Children attend with a parent or caregiver who sits in on sessions; adolescents may be seen alone with the family brought in as needed; adults need only minor changes. The protocol was designed for ages 9 and up and was tested in children aged 9–17 and in adults. Sessions are usually 45–60 minutes. [source: Scotti-Degnan & Ford 2020; Levenbach slides; NIMH 2010] [uncertain: sessions 1–2 are often reported as longer, about 90 minutes, in the trial protocol; the trial paper confirming this is not drawn on]

Dose. 8 sessions over 10 weeks: sessions 1–6 weekly, then sessions 7 and 8 every other week. In the child trial, responders also had 3 monthly booster sessions. Some clinicians report about 10 sessions in routine practice, and the length depends on how many tics bother the client. [source: NIMH 2010; Wilcox 2021 slides; Flancbaum 2023 slides; Scotti-Degnan & Ford 2020]

Delivery options. In person; live videoconference (reported as roughly as effective as in-person CBIT); internet-delivered or self-guided programmes derived from CBIT (e.g., TicHelper, iCBIT); intensive one-week, group and family/game-based (CBIT-Jr) adaptations. The adaptations are described here only at the level the sources give. [source: Scotti-Degnan & Ford 2020; Levenbach slides; CDC page]

Session sequence (manual structure, as reported in training slides citing Woods et al. 2008):

Session	Content
1	Rapport and tic history; treatment rationale and psychoeducation; build the tic hierarchy; first function-based assessment and intervention; set up reward programme; start home tic monitoring
2	Inconvenience review; review and re-rate hierarchy; function-based assessment plus HRT (awareness training, competing response, social support) for tic 1; homework
3	Review homework and hierarchy; review HRT for tic 1; function-based assessment plus HRT for tic 2; homework
4	As session 3 for the next tic, plus diaphragmatic breathing
5	As session 3 for the next tic, plus progressive muscle relaxation
6	As session 3 for the next tic, plus review of relaxation
7	As session 3, plus begin relapse prevention (2 weeks later: session 8)
8	As session 3; relapse prevention completed; plan boosters
Boosters	Tailored number and timing (monthly ×3 for responders in the child trial): refresh skills, troubleshoot, keep motivation up

[source: Wilcox 2021 slides (sequence); NIMH 2010 (boosters); Levenbach slides (booster aims)] [uncertain: which session introduces each relaxation skill may differ between the 1st and 2nd editions and between training decks]

Phases and their goals.

Phase 1, foundation (session 1, carried on through treatment): a shared understanding of tics, a ranked target list, a motivation system and an initial picture of triggers.
Phase 2, active skills (sessions 2–8): one tic is targeted each session, working down the hierarchy. Each new tic gets function-based assessment and intervention plus HRT, and earlier tics stay in practice. Relaxation is layered in mid-course.
Phase 3, maintenance (sessions 7–8 and boosters): relapse prevention, independent use of skills on new or returning tics, and tapering contact. [source: Wilcox 2021; Levenbach slides; Scotti-Degnan & Ford 2020 describe two phases: 8 weekly sessions followed by 3+ boosters]

Criteria for moving on. The protocol is session-scheduled rather than criterion-gated, but these within-skill mastery rules apply:

Response detection and early-warning training continue until the client detects about 4 of 5 tics or urges.
Competing response practice continues until the client uses it correctly about 4 of 5 times.
A new tic is added each session, while the hierarchy's distress ratings and home records show whether earlier tics are responding.
Move to maintenance once the main targets are rated low on the hierarchy and the client can build a competing response for a new tic on their own. [source: Wilcox 2021 (4 of 5 criteria; weekly ratings); Levenbach slides (relapse-prevention aims)] [synthesis: the rule for moving to maintenance and for holding a tic over]

Assessment before and during treatment. History of tics and earlier treatment; screen for comorbid conditions, especially ADHD and OCD; clinician-rated tic severity (Yale Global Tic Severity Scale, YGTSS); premonitory urge severity (Premonitory Urge for Tics Scale, PUTS); a parent or adult tic questionnaire. The weekly 0–10 hierarchy ratings track progress. Licensed instruments are named only and should be obtained from their publishers. Confirm the diagnosis medically before starting; Tourette Canada's guidance stresses that CBIT should be delivered by a trained clinician, not taught by parents or teachers alone. [source: Levenbach slides; Pally/Tourette Canada 2015]

Training. The TAA Behavior Therapy Institute (TS-BTI) runs a 2-day CBIT training for licensed providers, then 3–5 consultation calls with faculty; a virtual option (CBIT Trainer) also exists. [source: TAA BTI page]

3. Guiding principles

Tics are neurological, not deliberate. Practical meaning: never blame, scold or imply "you could stop if you tried"; frame CBIT as learning to manage a neurological condition. [source: CDC page; Pally 2015]
Tics are shaped by their context. Practical meaning: always ask where, when, with whom and after what the tic happens, and what follows it. [source: Levenbach; Flancbaum]
The urge-relief cycle is the target. Practical meaning: aim the competing response at the urge or the very start of the tic, and hold it until the urge fades rather than until the tic would have passed. [source: Wilcox; Franklin]
One tic at a time, working down a client-ranked hierarchy. Practical meaning: let the client's distress ratings, preferences and likelihood of success choose the target, not the therapist's view of what is most visible. [source: Wilcox; Levenbach; Pally]
The client generates the competing response. Practical meaning: you can offer options, but adopt one only if the client buys in, and check it against the selection rules. [source: Wilcox]
Practise to criterion in session, then generalise. Practical meaning: rehearse until about 4 of 5 are correct, then assign planned and unplanned home practice. [source: Wilcox]
Reward effort, not results. Practical meaning: praise, prompts and rewards are tied to attendance, homework and correct use of the competing response, never to fewer tics. [source: Scotti-Degnan & Ford; Franklin; Flancbaum]
Supportive, not punitive, reminders. Practical meaning: coach support people to prompt in a warm, encouraging tone and to praise correct use. [source: Franklin; Pally]
Aim for a "tic-neutral" environment. Practical meaning: work to make sure tics neither earn attention or escape nor get punished. [source: Levenbach; Franklin]
Don't overprotect. Practical meaning: tic breaks and accommodations must not turn into avoidance; help supporters manage triggers without shielding the client from all stress. [source: Scotti-Degnan & Ford; Levenbach]
Psychoeducation is ongoing. Practical meaning: revisit the model, myths (e.g., that suppression causes rebound) and expectations whenever doubts come up. [source: Scotti-Degnan & Ford; Flancbaum]
CBIT manages tics; it does not cure them. Practical meaning: set realistic goals (fewer, less impairing tics) and present the skills as tools for life. [source: CDC page; Flancbaum]
Collaboration and tailoring. Practical meaning: adjust pace, psychoeducation format (games, parent-only time) and the number of sessions to the client's age, number of tics and comorbid conditions. [source: Levenbach] [synthesis: describing this as a therapist 'stance' is my framing; the sources describe procedures rather than a formal stance]

4. Intervention inventory

The inventory follows the order components are introduced. The manual's worksheets and forms (tic hierarchy form, functional assessment form, monitoring sheets) are not reproduced; the steps below are paraphrased from the sources cited. All example language is illustrative unless quoted with a citation. [source for section: Wilcox 2021, Levenbach, Flancbaum 2023, Franklin 2021 slides (all citing Woods et al. 2008 / Woods, Piacentini & Walkup 2007); Scotti-Degnan & Ford 2020; Pally 2015; NIMH 2010]

4.1 Psychoeducation about tics and the treatment rationale

Purpose / when: Session 1, repeated whenever needed. Sets realistic expectations, corrects myths, removes blame and explains why awareness plus a competing response should help.
Steps:
1. Cover what tics are and the relevant DSM-5 diagnoses, their neurological and genetic basis, how common they are, and their typical course (waxing and waning, often improving in late adolescence). Mention treatment options, including when a medication consultation makes sense.
2. Explain the premonitory urge and the urge → tic → relief cycle (negative reinforcement).
3. Explain that settings, emotions and other people's reactions change how often tics happen.
4. Address myths: suppression causing rebound, treating one tic producing another, talking about tics making them permanently worse.
5. Tailor the format: a parent-only segment, games for younger children, handouts and reliable websites; spread it across sessions if needed.
Example language (illustrative): "Many people feel an itch or pressure just before a tic, and doing the tic makes that feeling go away for a bit. That relief is part of what keeps the tic going. We're going to learn to notice that feeling early and do something else until it fades on its own."
Watch for: Shame, or a family belief that tics are 'put on'. The client mixing up 'manageable' with 'voluntary'. Tics briefly increasing while you discuss them (expected; they usually settle once the topic changes). Signs it's working: client and family can explain the cycle back to you and stop blaming.

4.2 Tic hierarchy (target selection and progress tracking)

Purpose / when: Session 1, then reviewed and re-rated every session. Chooses targets and gives a simple weekly outcome measure.
Steps:
1. Start from the tic inventory gathered during assessment (e.g., the YGTSS symptom list), adding the client's and parent's descriptions.
2. The client rates how distressing or bothersome each tic is, 0–10 (a SUDS-style rating).
3. Rank the tics. Usually start with the most bothersome, but take into account client preference and the likelihood of early success (an easier tic first can build confidence).
4. Each session, re-rate every tic, add new tics, and pick the next target.
5. Show the client their ratings over time; improvement often isn't noticeable to them day to day.
Example language (illustrative): "On a 0–10 scale, where 10 is the most it could bother you, how much has the shoulder shrug bothered you this week?"
Watch for: The therapist or parent choosing targets the client doesn't care about. Ratings that just reflect a bad day (ask about the whole week). Working: ratings for targeted tics fall over successive weeks.

4.3 Behavioural reward programme

Purpose / when: Set up in session 1, mainly for children and adolescents. Keeps up engagement with effortful practice.
Steps:
1. Design it together with the child and parents.
2. Choose target behaviours: attending sessions, completing homework and monitoring, taking part in session tasks, and using the competing response.
3. Agree on how points or tokens are earned and what they can be exchanged for. Use rewards the family can realistically deliver, and favour frequent small ones.
4. Review the programme at the start of every session and adjust it if the child loses interest.
Example language (illustrative): "You earn points for practising, not for how many tics you have. Tics go up and down by themselves, but practising is up to you."
Watch for: Rewards accidentally tied to tic counts, which punishes normal waxing and encourages hiding tics. Parents forgetting to deliver rewards. Working: homework completion stays high.

4.4 Inconvenience review

Purpose / when: Session 2 onward, for each target tic. Builds motivation by identifying why that tic matters to the client.
Steps:
1. For the target tic, ask about its costs in four areas: physical (pain, fatigue), social (teasing, stares), school or work (distraction, interrupted tasks) and daily life (e.g., sleep, eating, writing).
2. Summarise the costs back to the client and connect them to the effort that practice takes.
3. Return to the list when motivation dips.
Example language (illustrative): "What does this tic get in the way of? Does it hurt, does it make writing harder, do people say things?"
Watch for: Clients who report no inconvenience for a tic. Consider whether it should be targeted at all [synthesis]. Working: the client links practice to things they value. [source: Levenbach (categories); Wilcox (placement in session 2)] [uncertain: the manual's exact inconvenience-review format was not seen]

4.5 Self-monitoring of tics at home

Purpose / when: Begins after session 1. Builds awareness, supplies data for the functional assessment and later records competing-response use.
Steps:
1. Schedule about three to four 30-minute monitoring periods a week, ideally at times when tics are frequent.
2. During each period the client (or the parent, for younger children) tallies the target tic. Also note the day, time, setting and what was happening.
3. Once competing-response training has started, also record how often the competing response was used and how well it worked.
4. Review the sheets at the start of each session.
Example language (illustrative): "Pick a half hour when tics tend to be busy, like homework time, and just make a mark each time the eye tic happens."
Watch for: Monitoring that becomes constant, anxious checking. Keep it time-limited. Sheets filled in from memory just before the session. Working: records reveal patterns that feed 4.6. [source: Wilcox; Levenbach]

4.6 Function-based assessment (FBA)

Purpose / when: In session 1 for the first tic, then for each new target tic. Identifies antecedents and consequences that make tics more likely, so they can be changed.
Steps:
1. Use an antecedent-behaviour-consequence (ABC) frame for one tic at a time.
2. Interview the client and caregiver about antecedents. External: places, situations, activities, people (e.g., classroom, video games, car rides, getting ready to leave). Internal: emotional or physical states (worry, excitement, fatigue, hunger, boredom).
3. Ask about consequences. What do others do after the tic (stare, comment, ask if the person is okay, tease, send them out, excuse them from a task)? What does the client do (stop the activity, leave)? Note possible negative reinforcement (escape from a demand; relief of the urge) and positive reinforcement (attention, comfort).
4. Add between-session tracking-sheet data (from 4.5).
5. Write a brief summary of the main triggers and maintaining consequences for that tic.
Example language (illustrative): "Think about the last few times this tic was really bad. Where were you, and what was going on just before? What happened right after?"
Watch for: Families who report 'it happens everywhere'. Ask about best and worst times to sharpen the picture. Consequences that look kind (e.g., being excused from chores) but may keep tics going. Working: you can name at least one changeable trigger and one changeable reaction. [source: Levenbach (ABC, interview + tracking sheet); Flancbaum (antecedent and consequence categories); Franklin (escape, attention, urge reduction as maintaining consequences)]

4.7 Function-based interventions: antecedent strategies

Purpose / when: Right after each FBA, assigned as home practice. Reduces exposure to avoidable triggers and prepares the client for unavoidable ones.
Steps:
1. For each trigger, decide: can it be reduced or rearranged without becoming avoidance?
2. Where it can, change the setting or routine. Examples from the sources: leave earlier so the client isn't rushed; get dressed or organised ahead of time; break demanding tasks into smaller parts; schedule demanding activities for times when tics are lower; adjust test settings at school.
3. Where it can't, prepare: use relaxation or a coping thought before going in, and start practising the competing response on the way into a high-risk situation.
4. Build in planned short breaks where helpful, but keep them brief and agreed in advance so they don't become escape.
5. Write it down as a short plan for each setting and review it the next session.
Example language (illustrative): "Changing rooms before hockey is a big tic time. What could make it less rushed? Could you start your tic blocker in the car?"
Watch for: Avoidance creeping in (skipping school or activities), which can worsen tics and impairment. Plans that rely on others who haven't agreed to them. Working: fewer tic peaks in the targeted setting on monitoring. [source: Levenbach (hockey change-room worked example); Scotti-Degnan & Ford; Flancbaum]

4.8 Function-based interventions: consequence strategies (tic-neutral environment)

Purpose / when: After the FBA. Removes reactions that reinforce tics and reduces the social impact of tics.
Steps:
1. Coach parents, partners and teachers to respond neutrally: no comments, questions, comforting or reprimands when a tic happens.
2. Stop tics from earning an exit: keep the person in the activity, with support to continue despite tics.
3. Educate others (classmates, team-mates, teachers, colleagues) so that staring and teasing decrease. Consider classroom psychoeducation and address teasing directly.
4. Agree on a discreet signal at school for the competing response, and reinforce effort.
5. Allow small accommodations (e.g., a grace period for lateness) when tics cause unavoidable delays.
Example language to a parent (illustrative): "When the sniff happens, try carrying on as if it didn't. Save your attention for when you see him using his breathing."
Watch for: Parents swinging from over-attention to visible irritation. Neutral means calm, not cold. Teachers punishing tics. Working: supporters can describe what they now do differently, and tics in that setting fall. [source: Levenbach; Franklin (school-based interventions, tic-neutral); Scotti-Degnan & Ford]

4.9 Awareness training (a): response description

Purpose / when: The first HRT step for each target tic (from session 2). Gives the client and therapist a precise, shared picture of the tic from the urge to the end of the movement or sound, so that its earliest moment can be caught.
Steps:
1. Give the rationale: you can't interrupt what you don't notice.
2. Before the session, try performing the tic yourself and describing it, so you know what detail looks like.
3. Ask the client to describe the tic in full: every body part involved, the order, the direction and force of the movement (or the pitch and length of the sound), and the premonitory sensation that comes before it (where it is felt and what it feels like).
4. If the tic isn't happening in session, ask the client to imitate it while describing it.
5. When the client runs out of detail, add what you observe. Work outward from the main point of movement.
6. For vocal tics, move the description from the sound to the movements and breathing that produce it.
7. Write the agreed description down.
Example language (illustrative): "Walk me through it in slow motion. What's the very first thing that moves? Then what? And just before it starts, what do you feel, and where?"
Watch for: The sources' common errors: stepping in too early, stopping before the description is thorough, and accepting a vague account. Tic description is hard, so expect it to take time. Working: the description pins down an identifiable first movement and a warning sensation. [source: Wilcox (steps and common mistakes); Flancbaum; Pally]

4.10 Awareness training (b): response detection

Purpose / when: Straight after the description. Trains the client to notice each tic as it happens.
Steps:
1. First, demonstrate: you simulate the tic during conversation, and the client signals (e.g., by raising a finger) each time.
2. Then hold a natural conversation or play a game. The client signals each time their own tic happens (they can simulate it if it doesn't come up).
3. Praise each correct detection. After a missed tic, prompt gently (e.g., "That was one").
4. Continue until the client detects about 4 out of 5 tics.
Example language (illustrative): "Let's just chat about your weekend. Each time the tic happens, lift a finger. I'll let you know if one slips past."
Watch for: Staring intensely, which makes the situation unnatural and can increase tics. Getting absorbed in the chat and forgetting to give feedback. Working: the client reaches the 4-of-5 criterion. [source: Wilcox; Franklin; Flancbaum]

4.11 Awareness training (c): early warning sign

Purpose / when: After detection reaches criterion. Moves detection earlier, to the urge or the first movement, so the competing response can start before the tic finishes.
Steps:
1. Refer back to the premonitory sensation or first movement identified in the description.
2. Repeat the detection procedure, but the client now signals when they feel the urge or warning sign, before the full tic.
3. Praise correct early signals and prompt after misses. Continue to about 4 of 5.
4. Warn the client in advance that paying attention to urges may make them feel stronger at first.
Example language (illustrative): "This time, try to lift your finger at the tingle in your throat, before the sound comes out."
Watch for: Clients who say they feel no urge (common in younger children). Use the first visible movement as the warning sign instead [synthesis]. Working: the client signals before most tics happen. [source: Wilcox; Flancbaum; Pally]

Note: classic HRT (Azrin & Nunn, 1973) also included a 'situational awareness' step. In the CBIT sources, this role is covered by self-monitoring (4.5) and function-based assessment (4.6), so it is not listed separately here. [uncertain: not checked in the manual]

4.12 Competing response (CR) selection

Purpose / when: After awareness training for each target tic. Produces a behaviour the client will use at the warning sign or start of the tic.
Steps:
1. Explain what the CR is for: it lets the urge fade without the tic. It is not a way to relieve the urge.
2. Ask the client to propose a CR that blocks or interrupts the earliest part of the tic as described.
3. Check it against the rules. (a) The tic can't happen while the CR is being done, and the CR must not make the tic more noticeable. (b) It can be held anywhere for at least 1 minute or until the urge passes. (c) It is less noticeable than the tic and socially acceptable. (d) It needs no equipment or props.
4. If it fails a rule, the client tries again. You may suggest options, but adopt one only if the client accepts it.
5. Examples from training sources: holding the shoulders down and back for a shoulder shrug; slow, controlled blinking for eye blinking; gently pressing the lips together for mouth movements; tensing the neck and holding the head slightly down for neck or head jerks; making fists or holding the arms against the body with light fists for arm or hand tics; crossing the arms for arm flailing; pressing the feet into the floor or locking the knees for leg tics; slow rhythmic or diaphragmatic breathing for vocal tics.
Example language (illustrative): "What could you do with your neck that would make that jerk impossible, that you could keep up for a minute in class without anyone noticing?"
Watch for: CRs chosen by the therapist (poorer adherence). CRs that are more conspicuous than the tic. CRs that recreate the tic or give urge relief. Sources differ on whether a CR must be strictly physically incompatible: some trainers say it does not have to be, provided it is used at the urge or start of the tic, and that an incompatible CR is the logical starting point. This guide uses incompatible CRs first. [uncertain] [source: Wilcox (rules, steps, mistakes); Pally (no devices); Flancbaum (examples table); Levenbach and Franklin (incompatibility debate); Scotti-Degnan & Ford (shoulder example; breathing for vocal tics); NIMH 2010]

4.13 Competing response practice and generalisation

Purpose / when: In the same session as selection, then reviewed every session. Makes the CR automatic and moves it into daily life.
Steps:
1. Model the CR and show the client how long one minute is.
2. The client practises the CR on its own, then in response to simulated tics.
3. Hold a conversation or play a game. Whenever the urge or tic happens, the client starts the CR and holds it for 1 minute or until the urge passes, whichever is longer, while carrying on with the activity.
4. Praise correct use. Prompt when a tic happens without a CR, or when the CR is dropped early. Continue until about 4 of 5 are correct.
5. Homework: use the CR in planned practice periods, during unplanned moments throughout the day, and for every occurrence of the target tic. Record use on the monitoring sheet.
6. In later sessions, review earlier tics' CRs before adding a new one.
Example language (illustrative): "Good catch. Hold it... keep chatting... that's a minute. Is the urge still there? Then keep going until it fades."
Watch for: Holding the CR for too short a time. A CR that slowly turns into a new tic-like movement. Children who use it only in session. Working: the CR is used outside sessions, hierarchy ratings fall, and the CR fades naturally as the tic fades. [source: Wilcox; Flancbaum; Franklin]

4.14 Social support (support-person training)

Purpose / when: From the first HRT session onward, especially with children (most likely necessary there); optional with adults. Supports noticing and use of the CR between sessions.
Steps:
1. Pick a support person with the client: a parent, partner, housemate, older sibling or teacher.
2. Teach them, by demonstration and role-play in session: (a) praise correct CR use; (b) when a tic happens without a CR, give a brief, warm prompt to use it.
3. Make sure they praise effort and correct CR use, not fewer tics.
4. Agree with the client on the wording or signal for prompts.
5. Have the support person help with self-monitoring periods.
Example language for support person (illustrative): "Nice job using your arm hold." / "Remember your arm hold?" said kindly.
Watch for: Nagging, a critical tone, or prompts in front of peers the client hasn't agreed to. Teenagers rejecting parental prompts (choose another supporter or use a discreet signal) [synthesis]. Working: the client welcomes prompts and CR use rises. [source: Franklin; Pally; Wilcox; Flancbaum; Levenbach; NIMH 2010 (parent training)]

4.15 Diaphragmatic breathing

Purpose / when: Introduced mid-treatment (session 4 in the sequence followed). Reduces tension and arousal (anxiety, excitement, stress) that make tics worse. It is also the usual basis for vocal-tic CRs.
Steps:
1. Explain the link between stress or arousal and tics.
2. Teach slow breathing into the belly: in through the nose, a brief pause, a slow exhale. Repeat several times.
3. For children, use props or games: blowing out pretend candles, blowing up a balloon, four-square (box) breathing, apps or stories.
4. Practise in session, then assign daily practice and use before known trigger situations (link to 4.7).
Example language (illustrative): "Put a hand on your tummy. Breathe in slowly so your hand rises, pause, and let it out slowly like you're cooling soup."
Watch for: Over-breathing or dizziness (slow down). Use as avoidance. Working: the client reports feeling calmer in trigger situations. [source: Wilcox; Levenbach; Scotti-Degnan & Ford]

4.16 Progressive muscle relaxation (PMR)

Purpose / when: Session 5 in the sequence followed, then reviewed in session 6. Reduces general muscle tension and stress.
Steps:
1. Work through the muscle groups, usually from head to toe or in reverse.
2. Tense each group for about 5–10 seconds, then release and notice the relaxation for about 5–10 seconds.
3. For young children, use simplified, playful scripts (e.g., squeezing lemons; robot versus rag doll).
4. Assign home practice, and later a shortened version for use in stressful moments.
Example language (illustrative): "Squeeze your hands into tight fists... hold... and let go. Notice how different they feel now."
Watch for: Pain from tensing in tic-affected muscles. Use gentler tension there [synthesis]. Working: the client can relax on cue. [source: Wilcox; Levenbach]

4.17 Relapse prevention

Purpose / when: Sessions 7–8. Prepares the client to manage new or returning tics on their own.
Steps:
1. Review every skill learned (awareness, CR, function-based changes, relaxation, support).
2. Set realistic expectations: tics wax and wane, and new tics may appear. A flare is not a failure.
3. Rehearse the client building a full HRT plan for a tic not yet targeted (description → warning sign → CR → practice), with as little help from you as possible.
4. Coach supporters to keep managing triggers and consequences without overprotecting.
5. Write a personal plan covering warning signs of a flare, what to do and when to seek help. Schedule boosters and make referrals as needed.
Example language (illustrative): "Let's pretend a new tic shows up next month. Talk me through exactly what you'd do."
Watch for: Dependence on the therapist to design CRs. Working: the client designs a workable CR independently. [source: Wilcox; Levenbach]

4.18 Booster sessions

Purpose / when: After the acute course: monthly for 3 months for responders in the child trial; otherwise tailored. Maintains gains.
Steps: Review the hierarchy and monitoring; refresh CRs and relaxation; troubleshoot new tics and triggers; renew the reward or motivation plan; decide on further spacing.
Example language (illustrative): "What's been happening with tics since we last met, and which tools have you been using?"
Watch for: Skills dropping off as tics decrease. Working: gains maintained at follow-up. [source: NIMH 2010; Levenbach; Scotti-Degnan & Ford]

4.19 Delivery adaptation: telehealth / videoconference CBIT

Purpose / when: When access to a trained CBIT clinician is limited. The sources report outcomes similar to in-person CBIT.
Steps: Deliver the same session content by video. For practical points (camera framing so tics and CRs are visible, a parent in the room for children, sending monitoring sheets electronically) [synthesis].
Watch for: Tics or warning movements out of camera view, and a weaker sense of the support person's coaching. Working: detection and CR criteria are reached as in person. [source: Scotti-Degnan & Ford; Flancbaum; CDC page]

5. Handling problems

The CBIT sources deal mainly with technique errors and myths. Most of the clinical problem-solving below is my own synthesis, built on the CBIT principles above, and is marked as such.

Urges or tics seem to get worse when treatment starts. Explain beforehand that attention to urges can make them feel stronger at first, and that tics often rise while being discussed but go back to baseline once the topic changes. Evidence does not support lasting worsening after a standard course. Keep going with the protocol, and point to the hierarchy ratings over weeks rather than day-to-day changes. [source: Wilcox; Scotti-Degnan & Ford]

Fear of rebound or new tics ("if I block it, it'll come out worse later" / "another tic will replace it"). Use psychoeducation: the sources report that experimental studies show no rebound after suppression and no evidence that treating one tic produces substitute tics or increases comorbid symptoms. If a new tic appears, treat it as the natural waxing and waning of tics: add it to the hierarchy and give it its own CR. [source: Scotti-Degnan & Ford; Flancbaum]

No tics happen in session. Ask the client to simulate the tic for description, detection and CR practice. Schedule part of the session around an activity they find triggering (e.g., a video game, a timed task), if that is acceptable to them. [source: Wilcox; Flancbaum (simulation)] [synthesis: in-session trigger activity]

The client can't describe the tic or feels no urge. Slow the description down, use a mirror or (with consent) video, and add your own observations. If no urge can be found, use the first movement as the warning sign. Younger children often report fewer urges. [source: Wilcox (add observations)] [synthesis: mirror or video, first-movement substitute]

The client rejects or doesn't use the CR. Check whether you chose it. If so, return to client-generated options. Check whether it is too noticeable, uncomfortable or hard to hold for a minute, and adjust it while keeping to the selection rules. Revisit the inconvenience review to reconnect effort with what the client values. [source: Wilcox (client generates CR; rules)] [synthesis: troubleshooting sequence]

The CR is held too briefly, or turns into a new tic-like movement. Re-teach the 'one minute or until the urge passes, whichever is longer' rule with a timer in session. If the CR has become tic-like (rapid, repetitive, relieving the urge), choose a different, steadier CR. [source: Wilcox; Flancbaum] [synthesis: CR drift]

Non-adherence to homework or monitoring. Shrink the task (shorter or fewer monitoring periods), attach practice to existing routines, let the support person take on prompting, and reward completion through the reward programme, never tic reduction. Explore barriers such as shame, family conflict or low expectations of success. [source: Scotti-Degnan & Ford (reward programme as adherence strategy)] [synthesis: other steps]

Family responses that keep tics going (over-attention, punishment, nagging). Repeat the tic-neutral coaching. Role-play praise and warm prompts with the parent. If needed, hold a parent-only segment on their own distress about the tics. [source: Levenbach; Franklin] [synthesis: parent-only segment for parental distress]

Overwhelm (many tics, high distress, comorbid anxiety). Keep to one tic at a time and pick an early target likely to succeed. Use relaxation earlier if arousal is clearly driving tics [synthesis: moving relaxation earlier departs from the standard sequence]. Comorbid ADHD, OCD and anxiety did not moderate CBIT response in the trial reported, so they are not reasons to exclude someone. Do treat them if they are impairing (e.g., separate OCD or ADHD care), and coordinate the order of treatments. [source: Franklin citing Sukhodolsky et al. 2017] [synthesis: sequencing]

Attention difficulties (ADHD) in session. Use shorter practice blocks, more frequent rewards, game formats and more parent coaching. [synthesis] [uncertain: a CBIT adaptation for ADHD is mentioned in the Levenbach slides but its contents were not seen]

Stuck: no change after several sessions on a tic. Check the description for a missed first movement, check whether the warning sign is caught early enough, check that the CR is really being used outside sessions (the monitoring sheet), and repeat the FBA for unaddressed triggers or reinforcing consequences. If the tic still doesn't budge, move on down the hierarchy and come back to it later. Consider referral for a medication review if impairment remains high (no dosing guidance here). [synthesis]

Tic breaks or accommodations turning into avoidance. Agree on breaks in advance and keep them brief. Fade accommodations, keep attendance and activities going, and remind the client that avoidance can worsen tics. [source: Scotti-Degnan & Ford; Levenbach]

Ruptures (feeling blamed, criticised or watched). Name it, and restate that tics aren't the client's fault. Cut back intense observation (staring is a known error) and give the client more control over targets and CRs. With teenagers, agree on what the parent will and won't prompt. [source: Wilcox (staring)] [synthesis: repair steps]

Self-injurious, painful or very complex tics; coprolalia. Treat these as priorities in the hierarchy when the client agrees. For tics causing injury, get a medical or neurological review. CR design for complex or vocal tics usually builds on controlled breathing or holding a posture. The suitability of self-guided programmes for these presentations is limited. [source: Scotti-Degnan & Ford (self-guided limits); NIMH 2010 (breathing for vocal tics)] [synthesis: prioritisation and medical review]

Young children (under 9) and clients with cognitive limitations. The evidence is limited, and most trials excluded cognitive impairment. Lean more on parents, simplify the language, and consider family/game formats (e.g., CBIT-Jr). [source: Scotti-Degnan & Ford; Levenbach] [uncertain: CBIT-Jr procedures not seen]

Sudden-onset, rapidly escalating tic-like behaviours (especially in adolescents and young adults). Before starting CBIT, review the diagnosis. Atypical onset can point to functional tic-like behaviours, which may need a different formulation and treatment. [synthesis] [uncertain: not addressed in CBIT sources]

Risk. If assessment or treatment uncovers suicidal ideation or self-harm (more likely with severe impairment, bullying or comorbid conditions), follow standard risk assessment and safety planning. CBIT itself has no special risk procedures. [synthesis]

Sources

Sources:

Not drawn on directly: the PMC and Europe PMC full text of the adult trial (PMC3772729) and the JAMA Psychiatry page for Wilhelm et al. 2012. Their details here come from the NIMH summaries. [uncertain]