In its new guideline for Tourette syndrome, the American Academy of Neurology (AAN) recommends as first-line treatment a therapy called comprehensive behavioral intervention for tics (CBIT, pronounced see-bit). It helps people with Tourette’s learn to identify tics, slow them down, reduce their frequency, and in some cases, eliminate them.

We consulted two experts about the therapy: John C. Piacentini, PhD, professor of psychiatry and biobehavioral sciences at UCLA, a co-author of the AAN Guideline on Tourette syndrome, and CBIT researcher; and Mindy Meyer, APN, a pediatric nurse practitioner at Northwestern Medicine Central DuPage and Delnor Hospitals in Winfield, IL, who uses CBIT with her pediatric patients diagnosed with Tourette’s and other tic disorders. Other professionals who teach the intervention include psychologists, occupational therapists, social workers, or other healthcare practitioners with formal CBIT training.

Dr. Piacentini cites a 2010 study by the Tourette Association of America that found that three times as many children and adolescents had significantly reduced tics compared to children receiving standard psychotherapy. Preliminary data from a follow-up study due to be released next year show that these benefits can continue for years after treatment has ended, according to Dr. Piacentini. “My numbers are even higher,” says Meyer. “I treat to eliminate tics.”

Here, Meyer and Dr. Piacentini explain how the intervention works.

1. Know your tics.
   “When people are first diagnosed with Tourette syndrome, they may not be fully aware of when they tic,” Meyer says. “So the first step is to identify a tic and recognize when they feel it coming.” To accomplish that, Meyer asks her patients to raise a finger every time they tic during a session. They might do this while she and the patient are playing a game or taking a nature walk. Meyer will raise a finger if she observes a tic but sees that the patient doesn’t realize it. This practice makes patients more aware of each time they tic and the signs they exhibit beforehand, she says.
2. Identify pre-tic behavior.
   Once they are aware of their tics, patients are instructed to pay attention to any behavior or internal sensation they experience before they tic, like muscle tightness, tingling, or discomfort, says Dr. Piacentini. With some of her patients, Meyer asks them to stand in front of a mirror to witness the tic or pre-tic behavior. This can help them redirect or slow the tic.
3. Learn a competing response.
   “Three characteristics define a competing response,” Meyer explains. “First, it makes it impossible to do the tic. Second, it isn’t as noticeable as the tic would be. And third, you can do it anywhere.” If the patient’s tic is a shoulder shrug, which is usually on one side, Meyer teaches the patient to keep the shoulder down slightly, which prevents shrugging. For some vocal tics such as throat clearing, Meyer recommends inhaling in through the nose and out through the mouth. If the tic is picking skin, she tells patients to keep their hands on their desk or another hard surface. For a patient who always tilted his head to the right for a neck stretch, Meyer suggested he keep his head tilted slightly to the left to disrupt the stretch. For patients who need to bounce their legs, she instructs them to keep their heels on the floor. “If patients can use these strategies every time they feel a tic coming on, the urge will disappear eventually,” says Meyer.  To be most helpful, the competing response should be held for at least one minute or until the urge to tic greatly decreases or goes away.
4. Don’t talk about tics.
   “The more attention you give a tic, the worse it gets,” says Meyer. If a patient’s shoulders tic, for instance, don’t rub them in response. Instead, she recommends trying to determine what triggers the behavior. Loved ones should ask the patient if he’s had a stressful day at school or work, or how she’s feeling in general. “The key is to ignore the tic as much as possible,” she says. “This is very hard for family members in the beginning.”
   
5. Get physical.
   Exercise is a wonderful distraction, says Meyer. She encourages patients to ride a bicycle, shoot hoops, or go for a run or swim. Less-vigorous activities like squeezing a stress ball, modeling with Play-Doh or Silly Putty, journaling, or coloring are also good.
6. Improvise other competing responses.
   “For some patients, one tic disappears only to be replaced by another,” says Meyer. “The goal of CBIT is to encourage patients to devise their own responses by the end of treatment.” A patient of hers who originally had 29 tics now has one minor tic, and the patient came up with her own competing responses for the last three tics she experienced. One of them was grinding her teeth sideways. The patient responded by keeping her teeth slightly apart so they wouldn’t touch, an adjustment that effectively eliminated the tic, says Meyer.
7. Other helpful behaviors.
   Depending on the tic and pre-tic behavior, patients and their families pick an appropriate tactic to slow and reduce the frequency of it. For example, Meyer says, if the tic is throat clearing and is preceded by anxiety, patients can do deep breathing and keep a glass of water handy. If the urge to tic is in the feet, patients should wear firmer shoes and use insoles so their feet feel different, which may delay or decrease the tic. Patients whose tics worsen when they get home after school or work should practice deep breathing or progressive muscle relaxing as soon as they return, before tics start.