Behavior therapy in tic-disorders with co-existing ADHD




To give an overview concerning the behavioral treatment approaches for Chronic Tic Disorder (CTD) and Attention-Deficit/Hyperactivity Disorder (ADHD) and to provide some suggestions for the behavioral treatment of children and adolescents with a combination of both disorders.


Pharmacotherapy plays an important role in the treatment of both ADHD and CTD. However, behavior therapy has also been proven to ameliorate the core symptoms of both disorders. The most prominent behavioral technique to reduce tics is habit reversal training. In ADHD behavioral interventions, especially parent training and behavioral interventions in preschool/school, are effective in reducing ADHD core symptoms and comorbid problems. In children and adolescents with ADHD plus CTD both ADHD and tic symptoms can be treated by behavioral interventions alone or in combination with pharmacotherapy. However, most of the published studies on behavioral interventions in children with ADHD or CTD do not give detailed information on comorbidity and many studies excluded patients with comorbid problems.


Clinical experience suggests that in CTD+ADHD success may be easier to achieve using behavioral treatment of ADHD first. Adherence to the habit reversal procedure to reduce tics in daily living is the most important problem in the behavioral treatment of tics especially in children with comorbid ADHD. Practical suggestions to overcome these difficulties are presented.


ADHD Tourette’s syndrome Chronic Tic Disorder behavioral treatment habit reversal 


  1. 1.
    Abikoff H (1991) Cognitive training in ADHD children: less to it than meets the eye. J Learn Disabil 24:205–209PubMedGoogle Scholar
  2. 2.
    Allen KD (1998) The use of an enhanced simplified habit-reversal procedure to reduce disruptive outbursts during athletic performance. J Appl Behav Anal 31:489–492PubMedCrossRefGoogle Scholar
  3. 3.
    Azrin NH, Nunn RG (1973) Habit-reversal: a method of eliminating nervous habits and tics. Behav Res Ther 11:619–628PubMedCrossRefGoogle Scholar
  4. 4.
    Azrin NH, Peterson AL (1988) Habit reversal for the treatment of Tourette syndrome. Behav Res Ther 26:347–351PubMedCrossRefGoogle Scholar
  5. 5.
    Azrin NH, Peterson AL (1990) Treatment of Tourette syndrome by habit reversal: a waiting-list control group comparison. Behav Ther 21:305–318CrossRefGoogle Scholar
  6. 6.
    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 45:700–703PubMedCrossRefGoogle Scholar
  7. 7.
    Banaschewski T, Neale BM, Roessner V, Rothenberger A (2007) Comorbidity of tic disorders and ADHD – conceptual and methodological considerations. Eur Child Adolesc Psychiatry 16(Suppl 1): I/5–I/14Google Scholar
  8. 8.
    Banaschewski T, Coghill D, Santosh P, Zuddas A, Asherson P, Buitelaar J, Danckaerts M, Döpfner M, Faraone SV, Rothenberger A, Sergeant J, Steinhausen HC, Sonuga-Barke EJS, Taylor E (2006) Long-acting medcations for the hyperkinetic disorders: a systematic review and European treatment guidelines. Eur Child Adolesc Psychiatry 15:476–498PubMedCrossRefGoogle Scholar
  9. 9.
    Barkley RA (2006) Attention-deficit hyperactivity disorder: a handbook for diagnosis and treatment. Guilford Press, New YorkGoogle Scholar
  10. 10.
    Bergin A, Waranch HR, Brown J, Carson K, Singer HS (1998) Relaxation therapy in Tourette syndrome: a pilot study. Pediatr Neurol 18:136–142PubMedCrossRefGoogle Scholar
  11. 11.
    Billings A (1978) Self-monitoring in the treatment of tics: a single-subject analysis. J Behav Ther Exper Psychiatry 9:339–342CrossRefGoogle Scholar
  12. 12.
    Bohlhalter S, Goldfine A, Matteson S, Garraux G, Hanakawa T, Kansaku K, Wurzman R, Hallett M (2006) Neural correlates of tic generation in Tourette syndrome: an event-related functional MRI study. Brain 129:2029–2037PubMedCrossRefGoogle Scholar
  13. 13.
    Carpenter LL, Leckman JF, Scahill L, McDougle C (1999) Pharmacological and other somatic approaches to treatment. In: Leckman JF, Cohen DJ (eds) Tourette’s syndrome–tics, obsessions, compulsions: developmental psychopathology and clinical care. John Wiley & Sons, New York, pp 370–397Google Scholar
  14. 14.
    Carr JE (1995) Competing responses for the treatment of Tourette syndrome and tic disorders. Behav Res Ther 33:455–456PubMedCrossRefGoogle Scholar
  15. 15.
    Carr JE, Chong IM (2005) Habit reversal treatment of tic disorders: a methodological critique of the literature. Behav Modif 29:858–875PubMedCrossRefGoogle Scholar
  16. 16.
    Castellanos FX, Giedd JN, Elia J, Marsh WL, Ritchie GF, Hamburger SD, Rapoport JL (1997) Controlled stimulant treatment of ADHD and comorbid Tourette’s syndrome: effects of stimulant and dose. J Am Acad Child Adolesc Psychiatry 36:589–596PubMedCrossRefGoogle Scholar
  17. 17.
    Cohen DJ, Bruun RD, Leckman JF (1988) Tourette’s syndrome and tic disorders: clinical understanding and treatment. Wiley, New YorkGoogle Scholar
  18. 18.
    Connor DF (2006) Stimulants. In: Barkley RA (ed) Attention-deficit hyperactivity disorder: a handbook for diagnosis and treatment. Guilford Press, New York, pp 608–647Google Scholar
  19. 19.
    Doleys D, Kurtz P (1974) A behavioral treatment program for the Gilles de la Tourette syndrome. Psychol Reports 35:43–48Google Scholar
  20. 20.
    Döpfner M, Breuer D, Schürmann S, Wolff Metternich T, Rademacher C, Lehmkuhl G (2004) Effectiveness of an adaptive multimodal treatment in children with Attention Deficit Hyperactivity Disorder – global outcome. Eur Child Adolesc Psychiatry 13(suppl 1):I/117–I/129Google Scholar
  21. 21.
    Döpfner M, Schürmann S, Frölich J (2002) Therapieprogramm für Kinder mit hyperkinetischem und oppositionellem Problemverhalten (THOP). Beltz, Psychologie Verlags Union, WeinheimGoogle Scholar
  22. 22.
    DuPaul GJ, Eckert TL (1997) The effects of school-based interventions for attention deficit hyperactivity disorder: a meta-analysis. School Psychol Rev 26:5–27Google Scholar
  23. 23.
    DuPaul GJ, Stoner GD (2003) ADHD in the schools: assessment and intervention strategies. Guilford Press, New YorkGoogle Scholar
  24. 24.
    Greenhill LL, Halperin JM, Abikoff H (1999) Stimulant medications. J Am Acad Child Adolesc Psychiatry 38:503–512PubMedCrossRefGoogle Scholar
  25. 25.
    Greenhill LL, Pliszka S, Dulcan MK, Bernet W, Arnold V, Beitchman J, Benson RS, Bukstein O, Kinlan J, McClellan J, Rue D, Shaw JA, Stock S (2002) Practice parameter for the use of stimulant medications in the treatment of children, adolescents, and adults. J Am Acad Child Adolesc Psychiatry 41:26S–49SPubMedCrossRefGoogle Scholar
  26. 26.
    Heinrich H, Gevensleben H, Strehl U (2006) Annotation: Neurofeedback - train your brain to train behaviour. J Child Psychol Psychiatry 48:3–16CrossRefGoogle Scholar
  27. 27.
    Himle MB, Woods DW (2005) An experimental evaluation of tic suppression and the tic rebound effect. Behav Res Ther 43:1443–1451PubMedCrossRefGoogle Scholar
  28. 28.
    Hoekstra P, Anderson G, Troost P, Kallenberg C, Minderaa R (2007) Plasma kynurenine and related measures in tic disorder patients. Eur Child Adolesc Psychiatry 16(Suppl 1):I/71–I/77Google Scholar
  29. 29.
    Hoogduin K, Verdellen CW, Cath DC (1997) Exposure and response prevention in the treatment of Gilles de la Tourette’s syndrome: four case studies. Clin Psychol Psychotherapy 4:125–135CrossRefGoogle Scholar
  30. 30.
    Houlihan D, Hofschulte L, Patten C (1993) Behavioral conceptualizations and treatments of Tourette’s syndrome: A review and overview. Behav Res Treatment 8:111–131Google Scholar
  31. 31.
    King R, Scahill L, Findley D, Cohen DJ (1999) Psychosocial and behavioral treatments. In: Leckman JF, Cohen DJ (eds) Tourette’s syndrome–tics, obsessions, compulsions: developmental psychopathology and clinical care. John Wiley & Sons, New York, pp 338–359Google Scholar
  32. 32.
    Kirov R, Banaschewski T, Uebel H, Kinkelbur J, Rothenberger A (2007) REM-sleep alterations in children with co-existence of tic disorder and attention-deficit/hyperactivity disorder: impact of hypermotor symptoms. Eur Child Adolesc Psychiatry 16(Suppl 1): I/45–I/50Google Scholar
  33. 33.
    Leckman J, Vaccarino F, Kalanithi P, Rothenberger A (2006) Annotation: Tourette syndrome: a relentless drumbeat – driven by misguided brain osciallations. J Child Psychol Psychiatry 47:537–550PubMedCrossRefGoogle Scholar
  34. 34.
    Leckman JF, King R, Cohen DJ (1999) Tics and tic disorders In: Leckman JF, Cohen DJ (eds) Tourette’s syndrome–tics, obsessions, compulsions: developmental psychopathology and clinical care. John Wiley & Sons, New York, pp 23–42Google Scholar
  35. 35.
    Leckman JF, Walker DE, Cohen DJ (1993) Premonitory urges in Tourette’s syndrome. Am J Psychiatry 150:98–102PubMedGoogle Scholar
  36. 36.
    Long ES, Miltenberger RG (1998) A review of behavioral and pharmacological treatments for habit disorders in individuals with mental retardation. J Behav Ther Exp Psychiatry 29:143–156PubMedCrossRefGoogle Scholar
  37. 37.
    Long ES, Miltenberger RG, Ellingson SA, Ott SM (1999) Augmenting simplified habit reversal in the treatment of oral-digital habits exhibited by individuals with mental retardation. J Appl Behav Anal 32:353–365PubMedCrossRefGoogle Scholar
  38. 38.
    Miguel EC, do Rosario-Campos MC, Prado HS, do Valle R, Rauch SL, Coffey BJ, Baer L, Savage CR, O’Sullivan RL, Jenike MA, Leckman JF (2000) Sensory phenomena in obsessive-compulsive disorder and Tourette’s disorder. J Clin Psychiatry 61:150–156; quiz 157PubMedCrossRefGoogle Scholar
  39. 39.
    Miller AL (1970) Treatment of a child with Gilles de la Tourette’s syndrome using behavior modification techniques. J Behav Ther Exp Psychiatry 1:319–321CrossRefGoogle Scholar
  40. 40.
    Miltenberger RG, Fuqua RW (1985) A comparison of contingent vs non-contingent competing response practice in the treatment of nervous habits. J Behav Ther Exp Psychiatry 16:195–200PubMedCrossRefGoogle Scholar
  41. 41.
    Miltenberger RG, Fuqua RW, McKiney T (1985) Habit reversal with muscle tics: replicaton and component analysis. Behav Therapy 16:39–50CrossRefGoogle Scholar
  42. 42.
    MTA Study Group (1999) A 14-month randomized clinical trial of treatment strategies for attention-deficit/hyperactivity disorder. The MTA Cooperative Group. Multimodal Treatment Study of Children with ADHD. Arch Gen Psychiatry 56:1073–1086CrossRefGoogle Scholar
  43. 43.
    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 39:667–681PubMedCrossRefGoogle Scholar
  44. 44.
    Ollendick TH (1981) Self-monitoring and self-administered overcorrection: the modification of nervous tics in children. Behav Modification 5:75–84CrossRefGoogle Scholar
  45. 45.
    Pelham WE, Fabiano GA (2007) Empirically supported treatments for ADHD. J Clin Child Psychol (in press)Google Scholar
  46. 46.
    Pelham WE Jr, Wheeler T, Chronis A (1998) Empirically supported psychosocial treatments for attention deficit hyperactivity disorder. J Clin Child Psychol 27:190–205PubMedCrossRefGoogle Scholar
  47. 47.
    Peterson AL, Azrin NH (1992) An evaluation of behavioral treatments for Tourette syndrome. Behav Res Ther 30:167–174PubMedCrossRefGoogle Scholar
  48. 48.
    Peterson AL, Azrin NH (1993) Behavioral and pharmacological treatments for Tourette syndrome: a review. Appl Prev Psychology 2:231–242CrossRefGoogle Scholar
  49. 49.
    Peterson AL, Campise RL, Azrin NH (1994) Behavioral and pharmacological treatments for tic and habit disorders: a review. J Dev Behav Pediatr 15:430–441PubMedCrossRefGoogle Scholar
  50. 50.
    Peterson BS, Pine DS, Cohen P, Brook JS (2001) Prospective, longitudinal study of tic, obsessive-compulsive, and attention-deficit/hyperactivity disorders in an epidemiological sample. J Am Acad Child Adolesc Psychiatry 40:685–695PubMedCrossRefGoogle Scholar
  51. 51.
    Piacentini J, Chang S (2001) Beahvioral therapy for Tourette syndrome and tic disorders: state of the art. In: Cohen J, Jankovic J, Goetz C (eds) Advances in neurology, Vol. 85, Tourette syndrome. Lippincott Williams and Wilkins, Philadelphia, pp 319–332Google Scholar
  52. 52.
    Piacentini J, Chang S (2005) Habit reversal training for tic disorders in children and adolescents. Behav Modification 29:803–822CrossRefGoogle Scholar
  53. 53.
    Piacentini J, Chang S, Barrios V, McCracken J (2002) Habit reversal training for childhood tic disorders: a randomized controlled trial. In: Association for the Advancement of Behavior Therapy Meeting. Reno, NVGoogle Scholar
  54. 54.
    Pierre CB, Nolan EE, Gadow KD, Sverd J, Sprafkin J (1999) Comparison of internalizing and externalizing symptoms in children with attention-deficit hyperactivity disorder with and without comorbid tic disorder. J Dev Behav Pediatr 20:170–176PubMedGoogle Scholar
  55. 55.
    Plessen K, Royal J, Peterson B (2007) Neuroimaging of tic disorders with co-existing attention-deficit/hyperactivity disorder. Eur Child Adolesc Psychiatry 16(Suppl 1):I/60–I/70Google Scholar
  56. 56.
    Poncin Y, Sukhodolsky D, McGuireBA, Scahill MSN (2007) Drug and non-drug treatment of children with ADHD and tic disorders. Eur Child Adolesc Psychiatry 16(Suppl 1):I/78–I/88CrossRefGoogle Scholar
  57. 57.
    Rapp JT, Miltenberger RG, Long ES (1998) Augmenting simplified habit reversal with an awareness enhancement device: preliminary findings. J Appl Behav Anal 31:665–668PubMedCrossRefGoogle Scholar
  58. 58.
    Robertson MM (2006) Attention deficit hyperactivity disorder, tics and Tourette’s syndrome: the relationship and treatment implications. A commentary. Eur Child Adolesc Psychiatry 15:1–11PubMedCrossRefGoogle Scholar
  59. 59.
    Robertson MM, Schnieden V, Lees AJ (1990) Management of Gilles de la Tourette syndrome using sulpiride. Clin Neuropharmacol 13:229–235PubMedCrossRefGoogle Scholar
  60. 60.
    Roessner V, Becker A, Banaschewski T, Freeman RD, Rothenberger A (2007) Developmental psychopathology of children and adolescents with Tourette Syndrome – impact of ADHD. Eur Child Adolesc Psychiatry 16(Suppl 1):I/36–I/44Google Scholar
  61. 61.
    Roessner V, Becker A, Banaschewski T, Rothenberger A (2007) Psychopathological profile in children with chronic tic disorder and co-existing ADHD: additive effects. J Abnorm Child Psychology 35:79–85CrossRefGoogle Scholar
  62. 62.
    Roessner V, Robatzek M, Knapp G, Banaschewski T, Rothenberger A (2006) First-onset tics in patients with ADHD: impact of stimulants. Dev Med Child Neurol 48:616–621PubMedCrossRefGoogle Scholar
  63. 63.
    Rothenberger A, Banaschewski T (2004) Informing the ADHD debate. Sci Am Mind 14:50–55Google Scholar
  64. 64.
    Rothenberger A, Kostanecka T, Kinkelbur J, Cohrs S, Woerner W, Hajak G (2001) Sleep and Tourette’s syndrome. In: Cohen DJ, Jankovic J, Goetz C (eds) Tourette syndrome, advances in neurology, Vol. 85. Lippincott Williams and Wilkens, Philadelphia, pp 245–259Google Scholar
  65. 65.
    Rothenberger A, Roessner V, Banaschewski T, Leckman JF (2007) Co-existence of tic disorders and attention-deficit/hyperactivity disorder – recent advances in unterstanding and treatment. Eur Child Adolesc Psychiatry 16(Suppl 1):I/1–I/4Google Scholar
  66. 66.
    Sallee FR, Nesbitt L, Jackson C, Sine L, Sethuraman G (1997) Relative efficacy of haloperidol and pimozide in children and adolescents with Tourette’s disorder. Am J Psychiatry 154:1057–1062PubMedGoogle Scholar
  67. 67.
    Scahill L, Chappell PB, King RA, Leckman JF (2000) Pharmacologic treatment of tic disorders. Child Adolesc Psychiatr Clin N Am 9:99–117PubMedGoogle Scholar
  68. 68.
    Shapiro E, Shapiro AK, Fulop G, Hubbard M, Mandeli J, Nordlie J, Phillips RA (1989) Controlled study of haloperidol, pimozide and placebo for the treatment of Gilles de la Tourette’s syndrome. Arch Gen Psychiatry 46:722–730PubMedGoogle Scholar
  69. 69.
    Sharenow E, Fuqua R, Miltenberger R (1989) The treatment of muscle tics with dissimilar competing response practice. J Appl Behav Analysis 22:35–42CrossRefGoogle Scholar
  70. 70.
    Silva RR, Munoz DM, Daniel W, Barickman J, Friedhoff AJ (1996) Causes of haloperidol discontinuation in patients with Tourette’s disorder: management and alternatives. J Clin Psychiatry 57:129–135PubMedGoogle Scholar
  71. 71.
    Spencer T, Biederman M, Coffey B, Geller D, Wilens T, Faraone S (1999) The 4-year course of tic disorders in boys with attention-deficit/hyperactivity disorder. Arch Gen Psychiatry 56:842–847PubMedCrossRefGoogle Scholar
  72. 72.
    Steinhausen H, Novik T, Baldrusson G, Curatolo P, Lorenzo M, Pereira R, Ralston S, Rothenberger A, ADORE Study Group (2006) Co-existing psychiatric problems in ADHD in the ADORE cohort. Eur Child Adolesc Psychiatry 15(suppl 1):i25–i29CrossRefPubMedGoogle Scholar
  73. 73.
    Task Force on Promotion, Dissemination of Psychological Procedures (1995) Task Force on Promotion and Dissemination of Psychological Training in and dissemination of empirically validated psychological treatments. Clin Psychologist 48:3–23Google Scholar
  74. 74.
    Taylor E, Döpfner M, Sergeant J, Asherson P, Banaschewski T, Buitelaar J, Coghill D, Danckaerts M, Rothenberger A, Sonuga Barke E, Steinhausen H-C, Zuddas A (2004) Clinical guidelines for hyperkinetic disorder – first upgrade. Eur Child Adolesc Psychiatry 13(suppl 1):I/7–I/30Google Scholar
  75. 75.
    Turpin G (1983) The behavioral management of tic disorders: a critical review. Adv Behav Res Ther 5:203–245CrossRefGoogle Scholar
  76. 76.
    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 42:501–511PubMedCrossRefGoogle Scholar
  77. 77.
    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 160:1175–1177PubMedCrossRefGoogle Scholar
  78. 78.
    Woods DW, Miltenberger RG, Lumley VA (1996) Sequential application of major habit-reversal components to treat motor tics in children. J Appl Behav Anal 29:483–493PubMedCrossRefGoogle Scholar
  79. 79.
    Wright KM, Miltenberger RG (1987) Awareness training in the treatment of head and facial tics. J Behav Ther Exp Psychiatry 18:269–274PubMedCrossRefGoogle Scholar
  80. 80.
    Yordanova J, Heinrich H, Kolev V, Rothenberger A (2006) Increased event-related theta activity as a psychophysiological marker of comorbidity in children with tics and attention-deficit/hyperactivity disorders. Neuroimage 32:940–955PubMedCrossRefGoogle Scholar

Copyright information

© Steinkopff Verlag Darmstadt 2007

Authors and Affiliations

  1. 1.Department for Child and Adolescent Psychiatry and PsychotherapyUniversity of CologneKoelnGermany
  2. 2.Department for Child and Adolescent PsychiatryUniversity of GöttingenGöttingenGermany

Personalised recommendations