In this article, we’ll explain Cognitive Behavioral Interventions for Tics (CBIT). CBIT is an evidence-based treatment that helps children reduce the frequency and intensity of their tics through awareness and alternative strategies. Read to learn more about how this therapy works, plus exercises you can use at home to support your child.
Tics are sudden, repetitive movements or sounds that a child makes, often uncontrollably. Examples include blinking, throat clearing, or jerking movements. Tics can increase with stress, excitement, or fatigue, and they can cause both the child and their caregivers discomfort. In severe cases, they can inhibit the child’s ability to communicate or interact socially.
There are many reasons why a child might develop tics. In our practice, we frequently see tics as a part of PANS (Pediatric Autoimmune Neuropsychiatric Disorders) and PANDAS (Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections). PANS and PANDAS cause autoimmune inflammation of certain parts of the brain in response to bacterial infections, toxic mold exposure, or other environmental factors. This article explains more about the signs and symptoms of PANS/PANDAS.
Other conditions and issues that may cause tics include:
Tourette Syndrome (TS) – The most well-known condition associated with tics, Tourette Syndrome is a neurological disorder characterized by both motor and vocal tics that persist for at least a year.
Chronic Tic Disorders – These include Chronic Motor Tic Disorder and Chronic Vocal Tic Disorder, where a child experiences either motor or vocal tics (but not both) for over a year.
Transient Tic Disorder – Many children experience unexplained tics temporarily, often between the ages of 5 and 7, with symptoms resolving within a year.
ADHD (Attention-Deficit/Hyperactivity Disorder) – There is a proven relationship between ADHD and tic disorders, with some children developing tics as a co-occurring condition. Some stimulant medications commonly prescribed for ADHD can also trigger or exacerbate tics in children.
OCD (Obsessive-Compulsive Disorder) – Some children with OCD experience tics, particularly if their OCD symptoms include compulsive movements that resemble tics.
Anxiety and Stress – Tics can be exacerbated or triggered by stress, anxiety, or significant life changes, such as starting a new school, family conflicts, or academic pressure.
Autism Spectrum Disorder (ASD) – While tics are not a core feature of autism, some children on the spectrum exhibit tic-like behaviors, often related to self-stimulatory actions or repetitive movements.
Sensory Processing Issues – Some children with sensory processing challenges develop tics or tic-like behaviors in response to overwhelming stimuli.
Tic disorders tend to run in families, and children with a parent or sibling who has tics, Tourette Syndrome, OCD, or ADHD are at a higher risk. Sleep deprivation and fatigue also play a role, as a lack of sleep can make tics worse, and fatigue can lower a child’s ability to suppress or manage them.
For children with tics, we also look at diet and any signs of potential food sensitivities or nutritional deficiencies. While not a direct cause, some children may experience worsened tic symptoms due to sensitivities to food dyes, preservatives, or deficiencies in magnesium, zinc, or omega-3 fatty acids.
No matter the cause, tics can be disruptive for the child, their loved ones, teachers, and friends. CBIT offers a natural strategy to help reduce and manage tics, so kids feel more in control again.
CBIT (Cognitive Behavioral Intervention for Tics) is a non-medication therapy that helps children manage their tics by becoming more aware of them and learning ways to reduce or change them. It’s based on the idea that while tics are involuntary, kids can train their brains to respond to the urge to tic in a different way.
Tics are like habits the brain has learned over time, and CBIT helps retrain the brain by replacing the tic with a more controlled response. Many kids see big improvements with CBIT, and studies show that it works as well as (or even better than) medication for some children. Unlike medicine, it doesn’t have side effects and gives kids skills they can use for life.
CBIT has three main parts:
1. Awareness Training
Your child learns to recognize the feeling or urge that happens right before a tic. This “premonitory urge” often feels like a pressure or tension in the body that is temporarily relieved by the tic. By noticing these urges, they gain more control over their reactions.
2. Competing Response Training
Once a child recognizes the urge to tic, they learn to do a different movement instead – something that makes it hard to do the tic. This “competing response” is usually a subtle movement that doesn’t stand out, like gently pressing their hands together or lightly tensing a muscle. Over time, this helps weaken the tic response.
3. Functional Interventions
An important part of CBIT is you and your child working together to identify situations that worsen tics and make modifications to reduce their impact. CBIT also teaches kids how to reduce stress, improve sleep, and manage emotions, since tics can get worse when kids are anxious, tired, or overwhelmed. Parents and teachers can help by making small changes to daily routines to support CBIT progress.
If you feel your child would benefit from CBIT, it’s important to connect with a licensed therapist who has experience with Cognitive Behavioral Therapy or CBIT specifically.
Additional Exercises to Help Stop Tics
In addition to standard awareness and competing response training, the following exercises can provide your child with tools to manage tics more effectively. All of these exercises use the same principles as CBIT and can help your child manage and reduce their tics.
1. The Stop Sign Exercise
Goal: Help your child use visual cues to interrupt the tic before it happens.
How: When your child feels the urge to tic, they imagine a big red stop sign in their mind. This visual signal reminds them to pause and focus on stopping the tic. You can also place small stop sign images in areas of the home where tics frequently occur to reinforce the habit.
Example: If your child feels the urge to blink excessively, they imagine the stop sign and instead hold their eyes closed for a few seconds, relaxing the muscles around their eyes.
2. Deep Breathing Exercise
Goal: Relax your child’s body and mind to reduce tic urges.
How: Teach your child to take slow, deep breaths when they feel the urge to tic. Deep breathing can calm the nervous system and reduce stress, which often triggers tics. Practice this regularly during moments of rest.
Example: If your child feels a throat-clearing tic coming, they can take a slow breath in through the nose and exhale slowly through the mouth, focusing on the breath instead of the tic.
3. Progressive Muscle Relaxation (PMR)
Goal: Reduce overall muscle tension that can lead to tics.
How: Your child tenses and then relaxes different muscle groups in their body, helping them identify where tension builds up before a tic. This can be done once or twice a day to relieve general tension and make them more aware of physical sensations.
Example: Ask your child to tighten the muscles in their hands and hold for five seconds, then relax completely. Repeat with other muscle groups, such as the arms, legs, and shoulders.
4. Tension Release Exercise
Goal: Provide an immediate outlet for pre-tic tension.
How: When your child feels the urge to tic, they consciously tighten the muscles involved in the tic for a few seconds and then release them slowly. This release helps alleviate the sensation without letting the tic happen.
Example: If your child experiences a neck-jerking tic, they can gently tense their neck muscles for 3-5 seconds and then slowly relax them.
5. Counting Exercise
Goal: Distract the brain and focus on mental tasks instead of tics.
How: When your child feels the urge to tic, encourage them to count to 10 in their head slowly or to do some simple mental math (e.g., counting by twos). This cognitive distraction can help interrupt the cycle of tics.
Example: If your child feels the need to sniff repeatedly, they can start counting in their head, focusing on the numbers instead of the urge to sniff.
6. Mindful Distraction Exercise
Goal: Help your child focus on something enjoyable to reduce the frequency of tics.
How: Teach your child to shift their attention to a favorite object, activity, or sound when they feel a tic urge. Mindful distraction engages the brain in a pleasant task, which can reduce stress and tic frequency.
Example: If your child loves music, they can focus on a song playing in the background and listen intently to the instruments or lyrics to divert attention from the tic.
7. Finger Tapping Exercise
Goal: Provide a competing response that involves the hands.
How: When your child feels an urge for a hand- or arm-related tic, they can practice tapping their fingers together or tapping their fingers on their lap in a rhythmic pattern. This replaces the tic with a controlled movement.
Example: If your child has a hand-flapping tic, they can tap their thumb to each finger on one hand, focusing on the pattern instead of the urge to tic.
Supporting Your Child Through CBIT
CBIT takes time and patience, but the benefits can be life-changing. To best support your child, remember to offer:
Consistent Practice
CBIT works best when your child practices these exercises daily. Encourage them to use the exercises even when they are not feeling stressed or tired, so it’s easier to do in times when they’re struggling.
However, it’s important to support your child without making them feel pressured. Gently remind them to use the exercises, but avoid being overly focused on their tics, as this can create anxiety.
Positive Reinforcement
Praise your child for using their competing responses and trying out these exercises. It’s about the process, not whether they always succeed in stopping or lessening their tics. This positive encouragement will motivate them to keep practicing.
Remember, frustration during CBIT is normal for your child, especially at first. Encourage your child to take breaks and remind them that progress takes time. Celebrate small successes along the way.
Stress Management
Since tics can increase with stress, help your child find relaxing activities like drawing, listening to music, or spending time outdoors. If there are conflicts or relationships causing your child stress, work to find adult solutions to reduce the impact on their life.
For additional CBIT resources, we recommend two books: What to Do When Your Brain Gets Stuck by Dawn Huebner and Tics and Tourette Syndrome: A Handbook for Parents and Professionals by Uttom Chowdhury.
CBIT offers a range of tools and exercises to help your child gain control over their tics. By practicing these strategies regularly and receiving positive reinforcement from you, your child can reduce the frequency and intensity of their tics over time.
If you suspect your child has PANS/PANDAS or would like the support of our award-winning Integrative Medicine team in Carmel, Indiana, please contact our office at (317) 989-8463, Monday – Thursday 8AM to 5PM Eastern, or fill out the contact form below.
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