Comprehensive Behavioral Intervention for Tics

I am an occupational therapist who has completed advanced training and certification in Comprehensive Behavioral Intervention for Tics (CBIT).  CBIT is an evidence-based approach that helps individuals (children and adults) who experience motor and/or vocal tics manage their tics so that they do not interfere with daily living activities and routines.  Research has shown that CBIT decreases tic symptom severity and can be equally if not more effective than medications taken for tic management.

CBIT is based on habit reversal or using a competing response.  A competing response is an action that is incompatible with the tic and that can be held until the urge to tic dissipates to the point whereby the individual no longer has to do the tic.  Most individuals feel an urge to do their tic.  The urge is sometimes felt as a tingle, pressure, or an itch that happens right before the tic occurs.  An awareness of the urge and of the tic are necessary to be able to successfully interrupt the tic cycle and to be successful with CBIT.

CBIT is a comprehensive approach that includes:

  • Psychoeducation about tics and co-occurring conditions
  • Self-awareness training
  • Establishing a tic hierarchy to determine which tics to target
  • Developing and practicing a competing response
  • Relaxation training
  • Function based assessment and intervention
  • Social support

Psychoeducation

Psychoeducation is conducted during the assessment phase of CBIT.  It is the process of helping the individual with tics and the support person understand that tics are involuntary and often occur due to one or more underlying factors or co-conditions.  The client and support person are educated about tic disorders, incidence of tic disorders, the difference between motor and vocal tics, the neurophysiological underpinnings of tics, and the CBIT approach.

Self-Awareness Training

Awareness of one’s tics is important to be able to implement the competing response in a timely manner.  Self-awareness training begins with a demonstration of knowing when a tic is about to happen or when it has happened.  Exploration is done to identify the urge or sensation that is felt just prior to the need to do the tic. 

Tic Hierarchy and Subjective Units of Distress (SUDS)

Once awareness is determined, a list of current tics is generated.  Each tic is then rated by the individual on a scale of 0-10 on how bothersome the tic is in terms of how much discomfort it causes to the person with the tic (not to others).  0 means that the tic is not distressful or bothersome at all and a score of 10 suggests that the tic causes the most discomfort.  The tics that are rated the highest are the ones initially targeted for therapy.

Developing a Competing Response

A competing response is an action that is incompatible with the tic, can be held up to a minute or until the urge to do the tic dissipates, and is socially discreet.  Before a competing response is determined, an analysis of the tic is done to determine what the urge is that is felt prior to the tic, where the urge is felt, what the movement or vocalization is and where the relief is felt after the tic has occurred.  Competing responses are also called tic blockers or tic busters.  Once the individual and therapist come up with a competing response, the CR is practiced during the session and then in between sessions on a scheduled basis with the support person so that it develops into a new habit.

Relaxation Training

Relaxation training is a way to teach the individual with tics how to regulate emotions.  Various techniques are used such as breath control, progressive muscle relaxation, and mediation.  In some instances, a person’s sensory preferences and avoidances are also explored to help that individual be more aware of sensory stressors or sensory needs and strategies to regulate their sensory systems throughout their day.

Function Based Assessment and Interventions

An assessment is done during the CBIT process that identifies the antecedents and consequences that occur before and after episodes of tics.  Antecedents and consequences can reinforce tics both positively and negatively and from an internal and external perspective.  Antecedents can be situations or environments that trigger tics and can come from internal feelings or external events.  For example, a child may have increased severity of tics in the morning before leaving for school if school if school presents a source of anxiety.  Anxiety is an internal trigger and being at school is the external trigger.  For an adult, having to present in front of colleagues or his/her boss may trigger tics if that person has anxiety or difficulties speaking in front of others.  Consequences are events that occur after the tic occurs that reinforce tics.  Giving a child more attention or being sympathetic is a consequence for tics because it makes the child feel good which can reinforce the tics.  If a child is allowed special privileges for having tics, this too can reinforce tics.  For example, if a child is watching television with his/her sibling and has tics when he/she cannot watch his/her show, if the parent allows the child with tics to win that battle, that will reinforce the tics. 

Function based interventions focuses on how situations and environments can be modified or adapted so that they are not antecedents or consequences that can reinforce a person’s tics. This is where my training as an occupational therapist comes in to help figure out modifications to tasks or environments that promote optimal independence in activities and routines.  A function-based intervention for a situation in which a child is being bullied at school may be to help the child be a self-advocate for him/herself and to educate other children about tic disorders and why it is not appropriate to make fun of others for differences. If a child is struggling in a particular class to understand the material, a function-based intervention may be to arrange for preferential seating and tutoring to make them feel more at ease with the subject.  Function based interventions for adults can range from practicing relaxation techniques to using sensory based strategies to help him/he regulate their level of arousal.  In some cases, making sure that a person has adequate sleep/rest is necessary for the person to be optimally regulated during the day which also helps with tic management.

Social Support

Social support is someone who will be a cheerleader for the individual who is going through CBIT.  This person is someone who can gently remind the individual to use their competing responses on a regular basis so that it can easily develop into a new habit and someone who can reinforce using the competing response in a positive way to promote motivation and success.

How does CBIT work?

The effectiveness of CBIT has been documented in published peer reviewed journals including a study that was done to demonstrate how the CBIT approach through occupational therapy intervention to promote occupational performance is effective (Rowe & Dure, 2013).  While it does not cure tic disorders, it helps the person learn strategies that allows them to have lifelong control over his/her tics.  CBIT works by interrupting the premonitory urge -> tic-> relief feedback cycle by using the competing response.  In time and with practice, the individual with tics learns how to manage/control his/her tics.  It is important to understand that CBIT does not make the tics go away, but rather teaches the individual strategies to help them manage their tics so that daily life is not disrupted.