12 AAP News •
www.aapnews.org • September 2015
by Jonathan W. Mink, M.D., Ph.D., FAAP
While medication has been the mainstay of therapy
for tics, an emerging body of evidence supports the use
of behavior therapy to treat the sudden, involuntary,
repetitive movements or sounds.
Tourette syndrome and other chronic tic disorders
affect at least 1% of children. These neurobehavioral disorders are characterized by the presence of tics for more
than a year. Many more children have tics for less than
a year (transient tic disorder or provisional tic disorder).
Most children with Tourette syndrome or chronic
tic disorders report an unpleasant sensation or warning
preceding some or all of their tics. This sensation often is
referred to as a “premonitory urge.” They also report that
the execution of movement or sound temporarily relieves
these unwanted sensations. Tics can be suppressed in
the short term, with effort and difficulty in many cases.
Although defined by tics, Tourette syndrome and
chronic tic disorders are commonly accompanied by
symptoms of attention-deficit/hyperactivity disorder,
obsessive-compulsive disorder, anxiety and learning
disabilities. In many cases, these symptoms are more
bothersome than the tics and should be the primary
target of treatment.
Many children, however, report impairment due to
tics based on pain, discomfort, distraction or embarrassment.
Until recently, therapy for tics primarily has been
pharmacologic treatment. The most commonly used
evidence-based treatments include the alpha- 2 ad-
renergic agonists (e.g., clonidine, guanfacine), potent
dopamine D2 receptor blocking agents (e.g., halo-
peridol, pimozide) and atypical antipsychotics (e.g.,
risperidone, ziprasidone). In some cases, topiramate,
botulinum toxin and tetrabenazine are used.
In the past few years, evidence has supported the use
of behavior therapy for the treatment of tics. The core
of this therapeutic approach is habit reversal training
(HRT). Using this approach, the child is taught to
recognize the premonitory sensation and then use a
strategy to replace the tic. For example, a child with
a tic that involves blinking first would describe the
sensation that precedes the tic. Then when he feels the
sensation, he might close his eyes for a few seconds.
HRT first was evaluated in small studies in the 1970s.
Since then, it has been tested in two large multicenter
clinical trials involving children and adults as part of what
is called comprehensive behavioral intervention for tics
(CBIT) (Piacentini J, et al. JAMA. 2010;303:1929-1937;
Wilhelm S, et al. Arch Gen Psychiatry. 2012;69:795-
803). CBIT combines HRT with procedures designed
to mitigate influences of daily life that worsen tics.
CBIT was superior to psychoeducational control in
both children and adults. The benefit appears to be sus-
tained, with most patients experiencing improvement
in symptom severity six months after therapy sessions
ended. The CBIT trials are the largest clinical trials to
date in Tourette syndrome. The effect size in the CBIT
trials was comparable to those in placebo-controlled
pharmacologic treatment trials.
Many neurologists and psychiatrists in the U.S. are
starting to recommend CBIT as a first-line treatment
option for children with Tourette syndrome or chronic
tic disorders. Treatment guidelines from professional
societies in Europe and Canada recommend HRT as
a first-line treatment for tics.
It is not known if certain clinical features predict
better response to CBIT than to specific medications.
Based on present knowledge, however, CBIT should
be considered for any patient with bothersome tics due
to Tourette syndrome.
One obstacle to treatment with CBIT has been low
availability of therapists trained to deliver HRT or
CBIT. In recognition of this, the Centers for Disease
Control and Prevention and the Tourette Association
of America have partnered to provide CBIT training
for health professionals (see resource). In addition to
psychologists and psychiatrists, an increasing number
of occupational therapists, nurse practitioners and oth-
er health professionals are receiving this training and
offering it to patients with Tourette syndrome.
With wider availability, CBIT likely will become a
first-line treatment for even more pa-
tients with Tourette syndrome.
Dr. Mink is a member of the AAP Section
on Neurology Executive Committee.
Behavior therapy effective alternative to medication for treatment of tics
For information on free training programs on comprehensive behavioral intervention for tics offered by the
Tourette Association of America and the Centers for Disease Control and Prevention, visit http://bit.ly/1CTKfRD.
from the AAP Department of Community,
Chapter and State Affairs
A Florida law that prohibits physicians from counseling families about safe storage of firearms does not
violate their First Amendment right to free speech,
the U.S. Court of Appeals for the 11th Circuit ruled
in a 2-1 decision on July 28.
This was the second time the appeals court ruled
on the case. Although the court voided its 2014
ruling, it still upheld the Privacy of Firearms Owners
Act, which restricts physicians, nurses and medical
staff from asking patients and their families about
firearms. Physicians accused of violating the law
would be sent before the Florida Board of Medicine
for disciplinary action.
Signed by Florida Gov. Rick Scott in June 2011,
the law was challenged by the Academy, individual
pediatricians and other medical associations.
The Academy is working with attorneys representing the Florida chapters of the Academy, the American Academy of Family Physicians, the American
College of Physicians and the individual physician
plaintiffs to seek further review of the decision before the full 11th Circuit. The injunction blocking
enforcement of the law remains in effect until the
full 11th Circuit decides whether to rehear the case.
If the court agrees to the rehearing, the injunction
will remain in effect until a decision is issued.
The Academy continues to advise its members in
Florida and throughout the United States to uphold
the standard of medical practice and ask about the
presence of guns in the environments of children,
and counsel families in their care about the importance of storing guns safely.
“Practicing gun safety saves children’s lives,” said
AAP President Sandra G. Hassink, M.D., FAAP.
“The important message is that pediatricians in
Florida continue to fight to protect children. Ask-
In the resubmitted opinion, Judge Gerald Tjoflat
wrote for the majority “good medical care does not
require inquiry or record-keeping regarding fire-
arms when unnecessary to a patient’s care…” He
also stated that the act is a “permissible restriction
of physician speech.”
According to Douglas Hallward-Driemeier, at-
torney for the plaintiffs, “The majority’s opinion is
deeply concerning because it marks the first time a
court has upheld a state’s attempt to silence doctors
from engaging in patient counseling that is uniform-
ly recommended by all the relevant national medical
In his dissent, Judge Charles Wilson wrote, “Re-
gardless of whether we agree with the message con-
veyed by doctors to patients about firearms, I think
it is perfectly clear that the doctors have a right to
convey that message.”
Since the Florida legislation was signed into law
in 2011 and was upheld by the 11th Circuit ap-
peals court in 2014, at least 12 other states have
introduced bills restricting physician counseling on
firearm safety, but none have been enacted. In 2015,
four states introduced bills, but none have passed.
“This is because state legislators know that this
type of law is a blatant violation of a physician’s
First Amendment rights,” said Anne R. Edwards,
M.D., FAAP, chair of the AAP Committee on State
Court ruling another blow to physician counseling on gun safety
For consultation or technical assistance with this or
other state advocacy issues, contact the AAP Division of
State Government Affairs at 800-433-9016, ext. 7799,