European clinical guidelines for Tourette Syndrome and other tic disorders. Part III: behavioural and psychosocial interventions

An Erratum to this article is available


This clinical guideline provides recommendations for the behavioural and psychosocial interventions (BPI) of children and adolescents with tic disorders prepared by a working group of the European Society for the Study of Tourette Syndrome (ESSTS). A systematic literature search was conducted to obtain an update on the efficacy of BPI for tics. Relevant studies were identified using computerised searches of the Medline and PsycINFO databases and the Cochrane Library for the years 1950–2010. The search identified no meta-analyses, yet twelve (systematic) reviews and eight randomised controlled trials provided evidence for the current review. Most evidence was found for habit reversal training (HRT) and the available but smaller evidence also supports the efficacy of exposure with response prevention (ERP). Both interventions are considered first line behavioural treatments for tics for both children and adults and should be offered to a patient, taking into account his preference. Treatments that are considered second line or add-on behavioural treatments are contingency management, function based interventions and relaxation training. Neurofeedback is still experimental. Almost no research was identified that examined the efficacy of psychosocial interventions, e.g., psychoeducation and group work. Based on clinical practice, this guideline recommends behavioural treatment as first line offer to patients in most cases. It should be embedded within a psychoeducational and supportive context and can be combined with drug treatment.

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  1. 1.

    Robertson MM (2008) The prevalence and epidemiology of Gilles de la Tourette syndrome. Part 1: the epidemiological and prevalence studies. J Psychosom Res 65(5):461–472. doi:10.1016/j.jpsychores.2008.03.006

    PubMed  Article  Google Scholar 

  2. 2.

    Schlander M, Schwarz O, Rothenberger A, Roessner V (2010) Tic disorders: administrative prevalence and co-occurrence with attention-deficit/hyperactivity disorder in a German community sample. Eur Psychiatry. doi:10.1016/j.eurpsy.2009.10.003

  3. 3.

    Döpfner M, Rothenberger A (2007) Behavior therapy in tic-disorders with co-existing ADHD. Eur Child Adolesc Psychiatry 16(Suppl 1):89–99. doi:10.1007/s00787-007-1011-7

    PubMed  Article  Google Scholar 

  4. 4.

    Döpfner M, Rothenberger A (2007) Tic- und Zwangsstörungen; Themenschwerpunkt. Kindheit und Entwicklung 16:75–138

    Article  Google Scholar 

  5. 5.

    Rothenberger A, Roessner V, Banaschewski T (2006) Habit formation in Tourette Syndrome with associated obsessive-compulsive behaviour: at the crossroads of neurobiological modelling. Behav Brain Sci 29:627–628

    Article  Google Scholar 

  6. 6.

    Azrin NH, Nunn RG, Frantz SE (1980) Habit reversal vs negative practice treatment of nervous tics. Behav Ther 11(2):169–178

    Article  Google Scholar 

  7. 7.

    Azrin NH, Nunn RG (1973) Habit reversal: a method of eliminating nervous habits and tics. Behav Res Ther 11:619–628

    PubMed  Article  CAS  Google Scholar 

  8. 8.

    Azrin NH, Peterson AL (1990) Treatment of Tourette Syndrome by habit reversal: a waiting-list control group comparison. Behav Ther 21(3):305–318

    Article  Google Scholar 

  9. 9.

    Woods DW, Miltenberger RG (1995) Habit reversal: a review of applications and variations. J Behav Ther Exp Psychiatry 26(2):123–131

    PubMed  Article  CAS  Google Scholar 

  10. 10.

    Wilhelm S, Deckersbach T, Coffey BJ, Bohne A, Peterson AL, Baer L (2003) Habit reversal versus supportive psychotherapy for Tourette’s disorder: a randomized controlled trial. Am J Psychiatry 160(6):1175–1177

    PubMed  Article  Google Scholar 

  11. 11.

    Deckersbach T, Rauch S, Buhlmann U, Wilhelm S (2006) Habit reversal versus supportive psychotherapy in Tourette’s disorder: a randomized controlled trial and predictors of treatment response. Behav Res Ther 44(8):1079–1090. doi:10.1016/j.brat.2005.08.007

    PubMed  Article  Google Scholar 

  12. 12.

    O’Connor K, Gareau D, Borgeat F (1997) A comparison of a behavioural and a cognitive-behavioural approach to the management of chronic tic disorders. Clin Psychol Psychother 4:105–117

    Article  Google Scholar 

  13. 13.

    O’Connor KP, Brault M, Robillard S, Loiselle J, Borgeat F, Stip E (2001) Evaluation of a cognitive-behavioural program for the management of chronic tic and habit disorders. Behav Res Ther 39(6):667–681

    PubMed  Article  Google Scholar 

  14. 14.

    Piacentini J, Woods DW, Scahill L, Wilhelm S, Peterson AL, Chang S, Ginsburg GS, Deckersbach T, Dziura J, Levi-Pearl S, Walkup JT (2010) Behavior therapy for children with Tourette disorder: a randomized controlled trial. JAMA 303(19):1929–1937. doi:10.1001/jama.2010.607

    PubMed  Article  CAS  Google Scholar 

  15. 15.

    Verdellen CW, Keijsers GP, Cath DC, Hoogduin CA (2004) Exposure with response prevention versus habit reversal in Tourettes’s syndrome: a controlled study. Behav Res Ther 42(5):501–511. doi:10.1016/S0005-7967(03)00154-2

    PubMed  Article  Google Scholar 

  16. 16.

    Carr JE, Chong IM (2005) Habit reversal treatment of tic disorders: a methodological critique of the literature. Behav Modif 29(6):858–875. doi:10.1177/0145445505279238

    PubMed  Article  Google Scholar 

  17. 17.

    Cook CR, Blacher J (2007) Evidence-based psychosocial treatments for tic disorders. Clin Psychol Sci Pract 14(3):252–267

    Article  Google Scholar 

  18. 18.

    Himle MB, Woods DW, Piacentini JC, Walkup JT (2006) Brief review of habit reversal training for Tourette syndrome. J Child Neurol 21(8):719–725

    PubMed  Article  Google Scholar 

  19. 19.

    Peterson AL (2007) Psychosocial management of tics and intentional repetitive behaviors associated with Tourette syndrome. In: Woods DW, Piacentini JC, Walkup JT (eds) Treating Tourette syndrome and tic disorders: a guide for practitioners. Guilford Press, New York, pp 154–184

    Google Scholar 

  20. 20.

    Piacentini J, Chang S (2001) Behavioral treatments for Tourette syndrome and tic disorders: state of the art. Adv Neurol 85:319–331

    PubMed  CAS  Google Scholar 

  21. 21.

    Piacentini J, Chang S (2005) Habit reversal training for tic disorders in children and adolescents. Behav Modif 29(6):803–822. doi:10.1177/0145445505279385

    PubMed  Article  Google Scholar 

  22. 22.

    Miltenberger RG, Fuqua RW, McKinley T (1985) Habit reversal with muscle tics: replication and component analysis. Behav Ther 16(1):39–50

    Article  Google Scholar 

  23. 23.

    Woods DW, Conelea CA, Walther MR (2007) Barriers to dissemination: exploring the criticisms of behavior therapy for tics. Clin Psychol Sci Pract 14:279–282

    Article  Google Scholar 

  24. 24.

    Peterson AL, Azrin NH (1992) An evaluation of behavioral treatments for Tourette syndrome. Behav Res Ther 30(2):167–174

    PubMed  Article  CAS  Google Scholar 

  25. 25.

    Billings A (1978) Self-monitoring in the treatment of tics: a single-subject analysis. J Behav Ther Exp Psychiatry 9(4):339–342

    Article  Google Scholar 

  26. 26.

    Turpin G, Powell GE (1984) Effects of massed practice and cue-controlled relaxation on tic frequency in Gilles de la Tourette’s syndrome. Behav Res Ther 22(2):165–178

    PubMed  Article  CAS  Google Scholar 

  27. 27.

    Woods DW, Himle MB (2004) Creating tic suppression: comparing the effects of verbal instruction to differential reinforcement. J Appl Behav Anal 37(3):417–420. doi:10.1901/jaba.2004.37-417

    PubMed  Article  Google Scholar 

  28. 28.

    Watson TS, Sterling HE (1998) Brief functional analysis and treatment of a vocal tic. J Appl Behav Anal 31(3):471–474. doi:10.1901/jaba.1998.31-471

    PubMed  Article  CAS  Google Scholar 

  29. 29.

    Bergin A, Waranch HR, Brown J, Carson K, Singer HS (1998) Relaxation therapy in Tourette syndrome: a pilot study. Pediatr Neurol 18(2):136–142

    PubMed  Article  CAS  Google Scholar 

  30. 30.

    Culbertson FM (1989) A four-step hypnotherapy model for Gilles de la Tourette’s syndrome. Am J Clin Hypn 31:252–256

    PubMed  CAS  Google Scholar 

  31. 31.

    Hoogduin K, Cazemier B, Verdellen C (1995) Exposure, responspreventie en zelfcontrole bij Gilles de la Tourette-patiënten [Exposure, response prevention and self-control in patients with Gilles de la Tourette syndrome]. Gedragstherapie 28:31–40

    Google Scholar 

  32. 32.

    Leckman JF, Walker DE, Cohen DJ (1993) Premonitory urges in Tourette’s syndrome. Am J Psychiatry 150(1):98–102

    PubMed  CAS  Google Scholar 

  33. 33.

    Hoogduin C, Verdellen C, Cath D (1997) Exposure and response prevention in the treatment of Gilles de la Tourette’s syndrome: four case studies. Clin Psychol Psychother 4:125–137

    Article  Google Scholar 

  34. 34.

    Verdellen CW, Hoogduin CA, Keijsers GP (2007) Tic suppression in the treatment of Tourette’s syndrome with exposure therapy: the rebound phenomenon reconsidered. Mov Disord 22(11):1601–1606. doi:10.1002/mds.21577

    PubMed  Article  Google Scholar 

  35. 35.

    Banaschewski T, Woerner W, Rothenberger A (2003) Premonitory sensory phenomena and suppressibility of tics in Tourette Syndrome—developmental aspects in children. Dev Med Child Neurol 45:700–703

    PubMed  Article  Google Scholar 

  36. 36.

    Heinrich H, Gevensleben H, Strehl U (2007) Annotation: neurofeedback—train your brain to train behaviour. J Child Psychol Psychiatry 48(1):3–16. doi:10.1111/j.1469-7610.2006.01665.x

    PubMed  Article  Google Scholar 

  37. 37.

    Tansey MA (1986) A simple and a complex tic (Gilles de la Tourette’s syndrome): their response to EEG sensorimotor rhythm biofeedback training. Int J Psychophysiol 4(2):91–97

    PubMed  Article  CAS  Google Scholar 

  38. 38.

    Breteler MHM, van Heeswijk L, Arns M, Verdellen C (2008) Psychologische interventies bij het syndroom van Gilles de la Tourette [Psychological interventions in Gilles de la Tourette syndrome]. Tijdschrift voor Neuropsychiatrie en Gedragsneurologie 7:158–164

    Google Scholar 

  39. 39.

    Nagaia Y, Cavanna A, Critchley HD (2009) Influence of sympathetic autonomic arousal on tics: Implications for a therapeutic behavioral intervention for Tourette syndrome. J Psychosom Res 67:599–605

    Article  Google Scholar 

  40. 40.

    Woods DW, Piacentini JC, Walkup JT (2007) Treating Tourette syndrome and tic disorders: a guide for practitioners. Guilford Press, New York

    Google Scholar 

  41. 41.

    Conelea CA, Woods DW (2008) The influence of contextual factors on tic expression in Tourette’s syndrome: a review. J Psychosom Res 65(5):487–496. doi:10.1016/j.jpsychores.2008.04.010

    PubMed  Article  Google Scholar 

  42. 42.

    Packer LE (2005) Tic-related school problems: impact on functioning, accommodations, and interventions. Behav Modif 29(6):876–899. doi:10.1177/0145445505279383

    PubMed  Article  Google Scholar 

  43. 43.

    Peterson BS, Cohen DJ (1998) The treatment of Tourette’s syndrome: multimodal, developmental intervention. J Clin Psychiatry 59(Suppl 1):62–72 discussion 73–64

    PubMed  Google Scholar 

  44. 44.

    Dooley JM, Berna PM, Gordon KE (1999) Parent perception of symptom severity in Tourette’s syndrome. Arch Dis Child 81:440–441

    PubMed  Article  CAS  Google Scholar 

  45. 45.

    Cutler D, Murphy T, Gilmour J, Heyman I (2009) The quality of life of young people with Tourette syndrome. Child Care Health Dev 35(4):496–504. doi:10.1111/j.1365-2214.2009.00983.x

    PubMed  Article  CAS  Google Scholar 

  46. 46.

    Kepley HO, Conners S (2007) Management of learning and school difficulties in children with Tourette syndrome. In: Woods DW, Piacentini JC, Walkup JT (eds) Treating Tourette syndrome and tic disorders: a guide for practitioners. Guilford Press, New York, pp 242–264

    Google Scholar 

  47. 47.

    Wand RR, Matazow GS, Shady GA, Furer P, Staley D (1993) Tourette syndrome: associated symptoms and most disabling features. Neurosci Biobehav Rev 17(3):271–275

    PubMed  Article  CAS  Google Scholar 

  48. 48.

    Boudjouk PJ, Woods DW, Miltenberger RG, Long ES (2000) Negative peer evaluation in adolescents: effects of tic disorders and trichotillomania. Child Fam Behav Ther 22:17–28

    Article  Google Scholar 

  49. 49.

    Friedrich S, Morgan SB, Devine C (1996) Children’s attitudes and behavioral intentions toward a peer with Tourette syndrome. J Pediatr Psychol 21(3):307–319

    PubMed  Article  CAS  Google Scholar 

  50. 50.

    Woods DW, Fuqua RW, Outman RC (1999) Evaluating the social acceptability of persons with habit disorders: the effects of topography, frequency, and gender manipulation. J Psychopathol Behav Assess 21:1–18

    Article  Google Scholar 

  51. 51.

    Woods DW, Marcks BA (2005) Controlled evaluation of an educational intervention used to modify peer attitudes and behavior toward persons with Tourette’s Syndrome. Behav Modif 29(6):900–912. doi:10.1177/0145445505279379

    PubMed  Article  Google Scholar 

  52. 52.

    Murphy T, Heyman I (2007) Group work in young people with Tourette Syndrome. Child Adolesc Mental Health 12:46–48

    Article  Google Scholar 

  53. 53.

    Taubert KA (1999) Role of voluntary organizations in clinical care research and public policy. In: Leckman JF, Cohen DJ (eds) Tourette’s syndrome-tics obsessions compulsions: developmental psychopathology and clinical care. Wiley, Hoboken, pp 399–413

    Google Scholar 

  54. 54.

    Griendt Jvd, Verdellen C, Verbraak M, Hoogduin C (Manuscript in preparation) The effect of exposure length on treatment outcome for tics in Tourette’s syndrome: One hour sessions versus two hour sessions

  55. 55.

    Gevensleben H, Holl B, Albrecht B, Vogel C, Schlamp D, Kratz O, Studer P, Rothenberger A, Moll GH, Heinrich H (2009) Is neurofeedback an efficacious treatment for ADHD? A randomised controlled clinical trial. J Child Psychol Psychiatry 50(7):780–789. doi:10.1111/j.1469-7610.2008.02033.x

    PubMed  Article  Google Scholar 

  56. 56.

    Gevensleben H, Holl B, Albrecht B, Schlamp D, Kratz O, Studer P, Rothenberger A, Moll GH, Heinrich H (2010) Neurofeedback training in children with ADHD: 6-month follow-up of a randomised controlled trial. Eur Child Adolesc Psychiatry 19(9):715–724. doi:10.1007/s00787-010-0109-5

    PubMed  Article  Google Scholar 

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Conflict of interest

Commercial firms and governmental organisations did not play a role in, or fund, the development of these guidelines. Cara Verdellen, Jolande van de Griendt, Andreas Hartmann, Tara Murphy declare that they have no conflict of interest.

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Correspondence to Cara Verdellen.

Additional information

Members of the ESSTS Guidelines Group are listed under Appendix.

An erratum to this article can be found at

Appendix: Members of the ESSTS Guidelines Group

Appendix: Members of the ESSTS Guidelines Group

Christos Androutsos, Harald Aschauer, Gillian Baird, Netty Bos-Veneman, Ariana Brambilla, Francesco Cardona, Danielle C. Cath, Andrea E. Cavanna, Virginie Czernecki, Sandra Dehning, Alan Eapter, Luca Farkas, Julia Gadaros, Andreas Hartmann, Elizabeth Hauser, Isabel Heyman, Tammy Hedderly, Pieter J. Hoekstra, Anne Korsgaard, Georgina M. Jackson, Linnea Larsson, Andrea G. Ludolph, Davide Martino, Claudia Menghetti, Nanette Mol Debes, Norbert Muller, Kirsten Muller-Vahl, Alexander Munchau, Tara Murphy, Richard Musil, Peter Nagy, Judith Nurnberger, Ben Oostra, Perry Paschou, Massimo Pasquini, Kirsten J. Plessen, Mauro Porta, Hugh Rickards, Renata Rizzo, Mary M. Robertson, Veit Roessner, Aribert Rothenberger, Domenico Servello, Liselotte Skov, Jeremy S. Stern, Gerd Strand, Zsannett Tarnok, Cristiano Termine, Jolande Van der Griendt, Cara Verdellen, Veerle Visser-Vandewalle, Ebba Wannag, Tomas Wolanczyck

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Verdellen, C., van de Griendt, J., Hartmann, A. et al. European clinical guidelines for Tourette Syndrome and other tic disorders. Part III: behavioural and psychosocial interventions. Eur Child Adolesc Psychiatry 20, 197–207 (2011).

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  • Tourette
  • Tic disorders
  • Guidelines
  • Behavioural treatment
  • Psychosocial interventions
  • Literature review