Neuropediatrics 2023; 54(02): 089-098
DOI: 10.1055/a-1993-3783
Original Article

Exposure and Response Prevention: Evaluation of Tic Severity Over Time for Children and Adolescents with Tourette Syndrome and Chronic Tic Disorders

1   Danish Tourette Clinic at Herlev University Hospital, Department for Children and Adolescents, Denmark
Theis Lange
2   Section of Biostatistics, Department of Public Health, Copenhagen University, Denmark
Sidsel Normann Jensen
2   Section of Biostatistics, Department of Public Health, Copenhagen University, Denmark
Judy Grejsen
1   Danish Tourette Clinic at Herlev University Hospital, Department for Children and Adolescents, Denmark
Lone Aaslet
1   Danish Tourette Clinic at Herlev University Hospital, Department for Children and Adolescents, Denmark
Liselotte Skov
1   Danish Tourette Clinic at Herlev University Hospital, Department for Children and Adolescents, Denmark
1   Danish Tourette Clinic at Herlev University Hospital, Department for Children and Adolescents, Denmark
› Author Affiliations
Funding None.


Tourette syndrome and chronic tic disorders are characterized by the presence of tics. Different behavioral therapies have shown to be efficacious for treating tics in children and adolescents, but Exposure and Response Prevention (ERP) is a less researched method. However, ERP is a method often used in the clinical setting. Therefore, the present study evaluated the severity of tics over time from beginning of ERP to follow-up approximately 1 year after last training session.

In total, 116 patients treated with ERP face to face or ERP via web-based videoconferencing were included. The primary outcome measure was tic severity measured with the Danish version of the Yale Global Tic Severity Scale.

The results showed that tic severity decreased during ERP and lasted in the follow-up period, with a statistically higher decrease in the group with patients who completed ERP as planned and the group that stopped earlier than planned because of reduction in tics, compared with those who dropped out due to lack of motivation (p < 0.001).

The study concludes that ERP seems to have an immediate and a long-term effect on severity of tics, especially in those who complete the program or those who discontinue earlier due to good results.

Publication History

Received: 17 August 2022

Accepted: 01 December 2022

Accepted Manuscript online:
06 December 2022

Article published online:
25 January 2023

© 2023. Thieme. All rights reserved.

Georg Thieme Verlag KG
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  • References

  • 1 Association AP. Diagnostic and Statistical Manual of Mental Disorders (DSM-5). 5th ed. American Psychiatric Publishing
  • 2 Knight T, Steeves T, Day L, Lowerison M, Jette N, Pringsheim T. Prevalence of tic disorders: a systematic review and meta-analysis. Pediatr Neurol 2012; 47 (02) 77-90
  • 3 Scharf JM, Miller LL, Mathews CA, Ben-Shlomo Y. Prevalence of Tourette syndrome and chronic tics in the population-based Avon longitudinal study of parents and children cohort. J Am Acad Child Adolesc Psychiatry 2012; 51 (02) 192-201 .e5
  • 4 Bloch MH, Leckman JF. Clinical course of Tourette syndrome. J Psychosom Res 2009; 67 (06) 497-501
  • 5 Leckman JF, Zhang H, Vitale A. et al. Course of tic severity in Tourette syndrome: the first two decades. Pediatrics 1998; 102 (1 Pt 1): 14-19
  • 6 Groth C, Mol Debes N, Rask CU, Lange T, Skov L. Course of Tourette syndrome and comorbidities in a large prospective clinical study. J Amer Acad Child Adolescent Psychiatr 2017; 56: 304-312
  • 7 Mol Debes NMMM, Hjalgrim H, Skov L. Validation of the presence of comorbidities in a Danish clinical cohort of children with Tourette syndrome. J Child Neurol 2008; 23 (09) 1017-1027
  • 8 Conelea CA, Woods DW, Zinner SH. et al. Exploring the impact of chronic tic disorders on youth: results from the Tourette Syndrome Impact Survey. Child Psychiatry Hum Dev 2011; 42 (02) 219-242
  • 9 Roessner V, Plessen KJ, Rothenberger A. et al; ESSTS Guidelines Group. European clinical guidelines for Tourette syndrome and other tic disorders. Part II: pharmacological treatment. Eur Child Adolesc Psychiatry 2011; 20 (04) 173-196
  • 10 Scahill L, Erenberg G, Berlin Jr CM. et al; Tourette Syndrome Association Medical Advisory Board: Practice Committee. Contemporary assessment and pharmacotherapy of Tourette syndrome. NeuroRx 2006; 3 (02) 192-206
  • 11 McGuire JF, Ricketts EJ, Piacentini J, Murphy TK, Storch EA, Lewin AB. Behavior therapy for tic disorders: an evidenced-based review and new directions for treatment research. Curr Dev Disord Rep 2015; 2 (04) 309-317
  • 12 Azrin NHH, Nunn RGG. Habit-reversal: a method of eliminating nervous habits and tics. Behav Res Ther 1973; 11 (04) 619-628
  • 13 Andrén P, Jakubovski E, Murphy TL. et al. European clinical guidelines for Tourette syndrome and other tic disorders-version 2.0. Part II: psychological interventions. Eur Child Adolesc Psychiatry 2022; 31 (03) 403-423
  • 14 Fründt O, Woods D, Ganos C. Behavioral therapy for Tourette syndrome and chronic tic disorders. Neurol Clin Pract 2017; 7 (02) 148-156
  • 15 McGuire JF, Piacentini J, Brennan EA. et al. A meta-analysis of behavior therapy for Tourette Syndrome. J Psychiatr Res 2014; 50: 106-112
  • 16 Dabrowski J, King J, Edwards K. et al. The long-term effects of group-based psychological interventions for children with Tourette syndrome: a randomized controlled trial. Behav Ther 2018; 49 (03) 331-343
  • 17 Rizzo R, Pellico A, Silvestri PR, Chiarotti F, Cardona F. A randomized controlled trial comparing behavioral, educational, and pharmacological treatments in youths with chronic tic disorder or Tourette syndrome. Front Psychiatry 2018; 9: 100
  • 18 Woods D, Piacentini J, Chang S. et al. Managing Tourette Syndrome: A Behavioral Intervention for Children and Adults. 1st ed. Oxford University Press; 2008
  • 19 van de Griendt JMTM, van Dijk MK, Verdellen CWJ, Verbraak MJPM. The effect of shorter exposure versus prolonged exposure on treatment outcome in Tourette syndrome and chronic tic disorders—an open trial. Int J Psychiatry Clin Pract 2018; 22 (04) 262-267
  • 20 Verdellen CWJ, Hoogduin CAL, Kato BS, Keijsers GPJ, Cath DC, Hoijtink HB. Habituation of premonitory sensations during exposure and response prevention treatment in Tourette's syndrome. Behav Modif 2008; 32 (02) 215-227
  • 21 Verdellen CWJJ, Keijsers GPJJ, Cath DC, Hoogduin CALL. Exposure with response prevention versus habit reversal in Tourettes's syndrome: a controlled study. Behav Res Ther 2004; 42 (05) 501-511
  • 22 Cook CR, Blacher J. Evidence-based psychosocial treatments for tic disorders. Clin Psychol Sci Pract 2007; 14 (03) 252-267
  • 23 van de Griendt JMTMTM, Verdellen CWJJ, van Dijk MK, Verbraak MJPMPM. Behavioural treatment of tics: habit reversal and exposure with response prevention. Neurosci Biobehav Rev 2013; 37 (06) 1172-1177
  • 24 Andrén P, Aspvall K, Fernández de la Cruz L. et al. Therapist-guided and parent-guided internet-delivered behaviour therapy for paediatric Tourette's disorder: a pilot randomised controlled trial with long-term follow-up. BMJ Open 2019; 9 (02) e024685
  • 25 Andrén P, Holmsved M, Ringberg H. et al. Therapist-supported internet-delivered exposure and response prevention for children and adolescents with Tourette syndrome: a randomized clinical trial. JAMA Netw Open 2022; 5 (08) e2225614
  • 26 Pringsheim T, Okun MS, Müller-Vahl K. et al. Practice guideline recommendations summary: treatment of tics in people with Tourette syndrome and chronic tic disorders. Neurology 2019; 92 (19) 896-906
  • 27 Himle MB, Freitag M, Walther M, Franklin SA, Ely L, Woods DW. A randomized pilot trial comparing videoconference versus face-to-face delivery of behavior therapy for childhood tic disorders. Behav Res Ther 2012; 50 (09) 565-570
  • 28 Ricketts EJ, Bauer CC, Ran D, Himle MB, Woods DW. Pilot open case series of voice over internet protocol-delivered assessment and behavior therapy for chronic tic disorders. Cognit Behav Pract 2016; 23 (01) 40-50
  • 29 Ricketts EJ, Goetz AR, Capriotti MR. et al. A randomized waitlist-controlled pilot trial of voice over Internet protocol-delivered behavior therapy for youth with chronic tic disorders. J Telemed Telecare 2016; 22 (03) 153-162
  • 30 Wilhelm S, Deckersbach T, Coffey BJ, Bohne A, Peterson AL, Baer L. Habit reversal versus supportive psychotherapy for Tourette's disorder: a randomized controlled trial. Am J Psychiatry 2003; 160 (06) 1175-1177
  • 31 Soerensen CB, Lange T, Jensen SN. et al. Exposure and Response Prevention for children and adolescents with Tourette syndrome delivered via web-based videoconference versus face-to-face. Neuropediatrics (e-pub ahead of print). DOI: 10.1055/a-1987-3205.
  • 32 Leckman JF, Riddle MA, Hardin MT. et al. The Yale Global Tic Severity Scale: initial testing of a clinician-rated scale of tic severity. J Am Acad Child Adolesc Psychiatry 1989; 28 (04) 566-573
  • 33 McGuire JF, Piacentini J, Storch EA. et al. A multicenter examination and strategic revisions of the Yale Global Tic Severity Scale. Neurology 2018; 90 (19) e1711-e1719
  • 34 Scahill L, Riddle MA, McSwiggin-Hardin M. et al. Children's Yale-Brown Obsessive Compulsive Scale: reliability and validity. J Am Acad Child Adolesc Psychiatry 1997; 36 (06) 844-852
  • 35 Bloch MH, Peterson BS, Scahill L. et al. Adulthood outcome of tic and obsessive-compulsive symptom severity in children with Tourette syndrome. Arch Pediatr Adolesc Med 2006; 160 (01) 65-69
  • 36 Szomlaiski N, Dyrborg J, Rasmussen H, Schumann T, Koch SV, Bilenberg N. Validity and clinical feasibility of the ADHD rating scale (ADHD-RS) A Danish Nationwide Multicenter Study. Acta Paediatr 2009; 98 (02) 397-402
  • 37 Nissen JB, Kaergaard M, Laursen L, Parner E, Thomsen PH. Combined habit reversal training and exposure response prevention in a group setting compared to individual training: a randomized controlled clinical trial. Eur Child Adolesc Psychiatry 2019; 28 (01) 57-68
  • 38 Scahill L, Leckman JF, Schultz RT, Katsovich L, Peterson BS. A placebo-controlled trial of risperidone in Tourette syndrome. Neurology 2003; 60 (07) 1130-1135
  • 39 Rachamim L, Zimmerman-Brenner S, Rachamim O, Mualem H, Zingboim N, Rotstein M. Internet-based guided self-help comprehensive behavioral intervention for tics (ICBIT) for youth with tic disorders: a feasibility and effectiveness study with 6 month-follow-up. Eur Child Adolesc Psychiatry 2022; 31 (02) 275-287