Abstract
Behavior therapy is a well-established and empirically supported treatment for tic disorders (TDs). However, concerns have been expressed about the negative effects of behavioral interventions, such as tic worsening, tic substitution, and excessive effort. This study explored perceived negative effects of tic management strategies in adults with TDs and predictors of these experiences. Participants (N = 72) completed semi-structured interviews 11 years after receiving behavior therapy or supportive therapy in a randomized clinical trial. We examined responses to interview questions about managing tics and predictors of reported negative effects. Most participants did not experience tic worsening (84%) or tic substitution (75%) from tic management strategies. The majority felt they could manage tics while participating in their environment (87%) and did not report life interference from tic management (77%). About half (45%) felt less present when managing tics. Treatment non-responders in the original trial were more likely to report negative effects of tic management strategies. No differences in reported negative consequences were found between those who received behavior therapy versus supportive therapy, suggesting that behavior therapy specifically does not lead to such adverse effects. These findings could reduce misconceptions about behavior therapy for TDs and enhance its acceptability and utilization.
Tic disorders (TDs) are neurodevelopmental conditions characterized by the presence of tics, which are rapid, non-rhythmic motor movements or vocalizations. Onset is typically between ages 4 to 8 years, and severity peaks between ages 10 to 12 (Bloch et al., 2006; Hirschtritt et al., 2015). Tics often decline in frequency and severity over the course of adolescence but persist into adulthood for most individuals (Black et al., 2021; Bloch & Leckman, 2009). TDs can lead to psychosocial, academic, and occupational impairment and lower quality of life (Conelea et al., 2011; Conelea et al., 2013; Eapen et al., 2016).
Behavior therapies, including Comprehensive Behavioral Intervention for Tics (CBIT), are recommended as the first-line treatment for TDs (Pringsheim et al., 2019). CBIT includes psychoeducation, habit reversal training (HRT), functional assessment and intervention, and relaxation training (Stiede et al., 2023; Woods, Piacentini, et al., 2008). Two large randomized control trials (RCTs) in children (Piacentini et al., 2010) and adults (Wilhelm et al., 2012) with TDs showed that CBIT led to a greater decrease in tic severity measured via the Yale Global Tic Severity Scale (YGTSS) and greater treatment response than psychoeducation and supportive therapy (PST), although not all participants responded to treatment. A long-term follow-up study indicated that CBIT responders were more likely to achieve at least partial tic remission over a decade later (Espil et al., 2022).
Despite its effectiveness, various concerns about the use of behavioral interventions for tics have been expressed both in the literature and in anecdotal accounts from patients, parents, and healthcare providers (McGuire et al., 2015; Scahill et al., 2013; Woods et al., 2007). Existing qualitative and quantitative research on these concerns offers conflicting evidence regarding whether and how often these concerns materialize in the context of behavior therapy.
For example, one reported concern revolves around the fear that the use of behavior therapy strategies will worsen tics (Marcks et al., 2004; Woods et al., 2007), through either increasing a patient’s attention to and awareness of their tics; or through creating a suppression-induced rebound effect. In a qualitative study of seven youth who had received any type of therapy for tics (including HRT, CBT, a group workshop, person-centered therapy, and systemic family therapy), some patients described higher tic severity/frequency after using treatment strategies (Edwards et al., 2017). However, quantitative research on the efficacy of HRT and CBIT would suggest that tic management generally does not result in tic worsening (McGuire et al., 2014; Wile & Pringsheim, 2013; Yu et al., 2020).
Yet another series of studies have evaluated the tic “rebound,” or an increase in tic frequency or severity above initial levels that immediately follows the use of tic suppression as a management strategy. Qualitative research has examined the perceptions of individuals who describe using tic suppression (albeit not behavior therapy) as a self-initiated strategy to control tics (Buckser, 2008; Cutler et al., 2009; Matsuda et al., 2016). In a sample of adults and children with TDs, 21% self-reported that suppression led to significant tic worsening (Matsuda et al., 2016). In another qualitative study, adults with TDs described suppressing tics in certain settings for a period of time and then “releasing” the tics when appropriate, resulting in an increase in tic expression (Buckser, 2008). In comparison to these qualitative reports, experimental and laboratory-controlled tic suppression studies show little evidence of a post-suppression increase in tic severity above baseline levels (Himle & Woods, 2005; Müller-Vahl et al., 2014; Specht et al., 2013; Verdellen et al., 2007; Woods, Himle, et al., 2008).
Concerns about tic substitution in behavior therapy have also been raised. In this case, the concern is that either the tic management strategy will itself become a new tic or that the suppression of one tic through the use of tic management strategies will cause a new tic to start. Qualitative case reports document instances of this (Buckser, 2008; Cuenca et al., 2015) but tic substitution was also monitored quantitatively in an RCT testing CBIT. In each treatment arm of the study (i.e., CBIT and PST), participants experienced an average of 1.25 new tics over 10 weeks of treatment (Peterson et al., 2016). Given the waxing and waning nature of tics, the occasional onset of new tics is to be expected (Black et al., 2021; Lin et al., 2002). Importantly, the absence of a significant difference between CBIT and the control condition suggests that the strategies employed in behavior therapy likely did not lead to new tics.
Lastly, concerns have been noted regarding the attention and effort needed to manage tics, potentially leading to disruptions in daily activities or distractions from the present moment (Cuenca et al., 2015; Scahill et al., 2013; Woods et al., 2010). In qualitative studies, some adults and youth with TDs, who had not received treatment, characterized the process of suppressing and controlling tics as effortful and attention-consuming (Buckser, 2008; Cutler et al., 2009; Matsuda et al., 2016). However, in a laboratory-based study, children with TDs (not in behavior therapy) could successfully manage tics while performing another task (Conelea & Woods, 2008a), although accuracy on the task decreased while managing tics.
In summary, quantitative evidence from experimental and controlled studies would suggest that, for most patients, behavior therapy strategies are not associated with tic worsening and tic substitution, nor do they require disruptive expenditures of effort and attention. Nevertheless, qualitative data indicate that some individuals with TDs do encounter such consequences when managing tics. The discrepancies between qualitative and quantitative findings raise uncertainty about whether the majority of behavior therapy patients perceive such adverse effects when employing tic management strategies. In addition, questions remain about the specific effects of using behavior therapy strategies to manage tics. Many prior studies investigating the negative outcomes of managing tics were not focused on behavior therapy, thus calling into question whether such findings would be generalizable to behavior therapy patients. It is also unknown whether the negative effects of managing tics are a persistent concern after an extended period of time following treatment. Finally, patient characteristics that might be associated with experiencing negative effects from the use of tic management strategies have not been explored.
To address these gaps in the literature, this study examined qualitative interview data from adults with TDs who had participated in a long-term follow-up of an RCT comparing CBIT to PST (Espil et al., 2022). By comparing experiences between CBIT and PST recipients, we aimed to determine if perceived negative effects of tic management strategies are specific to behavior therapy or extend to broader tic management strategies. Additionally, as experiences following treatment may shift, it is valuable to examine these concerns in patients over an extended period. We also investigated whether clinical and individual characteristics predicted reporting consequences from managing tics. Clarifying the occurrence and predictors of these concerns may improve our understanding of the experiences of individuals with TDs and have important treatment implications (Curtis-Wendlandt & Reynolds, 2021; Smith et al., 2015).
Methods
Participants
Data for this study were collected as part of a long-term follow-up evaluation of an RCT examining the efficacy of CBIT for tic disorders (Espil et al., 2022). The present study included 72 participants aged 16 to 30 (M = 23.1, SD = 2.51). Participants are a subset of those who participated in a previous RCT (Piacentini et al., 2010) and long-term follow-up study (Espil et al., 2022).
The sample included 53 male and 19 female participants. Of these participants, 33 had received CBIT and 39 had received PST as part of the original RCT. At the end of the acute phase of the clinical trial, 21 had met clinical responder status and 51 had not. From pre- to posttreatment, a total of 26 participants experienced at least a 25% reduction in YGTSS scores (i.e., clinically meaningful change; Jeon et al., 2013), compared to 46 who did not. At the 11-year follow-up, 36 participants had a YGTSS Total Tic Score of 14 or less, indicating “partial or full remission” (Espil et al., 2022), while 36 had a score higher than 14. The average YGTSS score at follow-up was 19.04 (SD = 7.70, range 3–33). In the time between the original trial and follow-up assessments, five participants (CBIT group n = 1; PST group n = 4) received therapy for their tics. One participant from the CBIT group reported receiving cognitive behavioral therapy for tics since completing the original study. The four PST participants reported receiving cognitive behavioral therapy, supportive therapy, CBIT/exposure and response prevention, and “other” therapy for tics.
Procedure
Participants from the original RCT (Piacentini et al., 2010) were recruited for a follow-up study (Espil et al., 2022) over the course of 5 years (March 2014 to January 2019) through telephone, mail, e-mail, and social media. Follow-up evaluations occurred an average of 11.7 years (SD = 0.93; range = 9.92–13.83) after the RCT. Consenting participants were interviewed either in-person or via web-based videoconferencing by trained independent evaluators masked to original treatment condition. These evaluators underwent didactic training from the study’s principal investigators and demonstrated reliability in tic severity ratings. Ongoing supervision and consensus ratings were implemented to prevent rater drift (Espil et al., 2022). The present study included participants who responded to semi-structured interview questions as part of the follow-up evaluations.
Measures
Interview
A semi-structured interview was developed by members of the study team. This interview included 29 closed- and open-ended questions about distraction/flow related to tics and tic management strategies, benefits/consequences of tics, benefits/consequences of tic management strategies, benefits/consequences of being in the study, how tics related to one’s identity, and knowledge about tics. Interview questions from the “distraction/flow related to tics and tic management strategies” and “benefits/consequences of tic management strategies” sections were included in the present study. As the interview was semi-structured, interviewers were instructed to adjust questions as needed, and thus questions were not provided verbatim to every participant. The interview structure used branching logic (e.g., some questions were delivered based on responses to previous questions), so not all participants received all questions.
Participant responses were recorded verbatim. Two coders, trained by the principal investigator of the study, independently reviewed responses to each question and generated labels (codes) for key responses. The two coders discussed their labels and collaboratively developed an agreed-upon set of final codes. The two coders then independently coded all responses to all questions using these codes. Inter-coder agreement for the questions analyzed in our study was κ = 0.95. Discrepancies in coding of individual responses were resolved by a third coder.
Clinical Global Impressions–Improvement Scale
The Clinical Global Impressions–Improvement scale (CGI-I; Berk et al., 2008; Guy, 1976) is a one-item clinician-administered measure used to assess clinical improvement at posttreatment as compared to baseline. The CGI-I is rated on a scale of 1 (very much improved) to 7 (very much worse). The CGI-I has good psychometric properties (Berk et al., 2008; Leon et al., 1993). Treatment response at posttreatment for the CBIT RCT was determined by CGI-I scores of 1 or 2 (i.e., very much improved or much improved, respectively).
Yale Global Tic Severity Scale
The Yale Global Tic Severity Scale (YGTSS; Leckman et al., 1989) is a clinician-administered measure of tic severity and impairment over the previous week. Motor and vocal tics are rated across five dimensions: number, frequency, intensity, complexity, and interference. Motor and vocal tic scores on the five dimensions are summed to produce a Total Tic score ranging from 0 to 50. Tic-related impairment is rated on a single-dimension scale, also ranging from 0 to 50. Higher Total Tic and Impairment scores indicate greater tic severity and impairment, respectively. The YGTSS has demonstrated high reliability and validity (Leckman et al., 1989; McGuire et al., 2018; Storch et al., 2005). For this study, remission at follow-up was indicated by a YGTSS Total Tic Score < 14 (Espil et al., 2022).
Children’s Yale–Brown Obsessive Compulsive Scale
The Children’s Yale–Brown Obsessive Compulsive Scale (CY-BOCS; Scahill et al., 1997) is a clinician-administered semi-structured interview that measures the severity of obsessive-compulsive symptoms in children over the previous week. The CY-BOCS is based on the adult Yale–Brown Obsessive Compulsive Scale (Y-BOCS; Goodman et al., 1989). Obsession and compulsion severity are assessed across five domains: time, interference, distressing nature, effort to resist, and control over symptoms. The CY-BOCS produces an obsession severity score and a compulsion severity score, each ranging from 0 to 20, which are summed to produce a total severity score. Higher scores indicate greater symptom severity. The CY-BOCS has shown good reliability and validity (Storch et al., 2004). For the present study, CY-BOCS scores at baseline of the RCT were analyzed.
Analysis
For the purposes of the present study, all available patient data were included. Missing data were excluded on a casewise basis. The frequencies of responses to each interview question were analyzed. We also analyzed whether treatment group (CBIT vs. PST) and certain individual and clinical characteristics at baseline, posttreatment, and follow-up predicted responses to interview questions. Baseline predictors included age, YGTSS total tic score, YGTSS impairment score, CY-BOCS score, and tic medication status. Posttreatment predictors included responder status and YGTSS. Follow-up predictors included age, remission status, YGTSS total tic score, YGTSS impairment score, and tic medication status. We also examined age of tic disorder onset and gender. Binomial and multinomial logistic regressions were used to examine if these variables predicted whether participants were more likely to endorse experiencing negative consequences from managing tics.
Results
See Table 1 for interview questions and frequencies of responses for the full sample and for participants who received CBIT in the original trial. Participants were asked, “After using strategies to manage your tics, do your tics end up getting worse?” Most respondents (84.1%) said no, while 15.9% said yes, sometimes, or that they used to. Treatment group (CBIT vs. PST) did not predict responses to this question. A binary logistic regression indicated that being a non-responder at posttreatment was associated with a greater likelihood of reported tic worsening after using management strategies (B = 2.31, SE = 1.48, p = .032, odds ratio [OR] = 2.81 [95% CI 1.07, 24.92]). Across both treatment groups, all treatment responders at posttreatment answered “no” to this question (n = 17). Participants on tic medication at baseline were more likely to endorse tic worsening after using management strategies (B = 1.87, SE = 0.76, p = .013, OR = 2.43 [95% CI 1.24, 5.31]).
Frequencies of Responses to Interview Questions by Treatment Group.
Note. Not all participants responded to all interview questions. CBIT = comprehensive behavioral intervention for tics; PST = psychoeducation and supportive therapy.
Participants were also asked if any tic management strategies became new tics. Most (74.6%) responded no, while 25.4% indicated yes, sometimes, or that they used to. Responses did not differ between participants who received CBIT and PST in the original RCT. Regardless of treatment condition, non-responders at posttreatment were more likely to report tic management strategies becoming tics (B = 2.20, SE = 1.07, p = .040, OR = 2.71, [95% CI 1.25, 10.28]). Higher posttreatment (B = 0.15, SE = 0.05, p = .005, OR = 1.20, [95% CI 0.45, 2.13]) and follow-up YGTSS total tic scores (B = 0.10, SE = 0.03, p = .003, OR = 2.70, [95% CI 1.45, 5.62]) also predicted reports of tic management strategies becoming new tics. Participants who responded that strategies became new tics were also less likely to meet remission criteria at follow-up. (B = −1.58, SE = 0.64, p = .013, OR = 0.45 [95% CI 0.23, 0.82]) and had higher baseline scores on the compulsion subscale of the CY-BOCS (B = 0.12, SE = 0.06, p = .039, OR = 1.85 [95% CI 1.05, 3.44]).
Participants were asked if they felt tic management strategies interfered with other activities. Most participants responded no (76.5%), while some said yes (13.2%) and a few replied that they do not currently use any tic management strategies (10.3%). Binomial logistic regressions for this question only included data from participants who replied no or yes. Treatment condition did not predict responses to this question. However, being a treatment non-responder predicted that management strategies were more likely to interfere with other activities (B = 2.32, SE = 1.48, p = .032, OR = 2.91 [95% CI 1.08, 27.42]). Higher posttreatment YGTSS total tic scores (B = 0.16, SE = 0.07, p = .020, OR = 3.67 [95% CI 1.39, 12.91]), higher follow-up YGTSS impairment scores (B = 0.08, SE = 0.03, p = .013, OR = 2.35 [95% CI 1.22, 4.87]), greater age at baseline (B = 0.03, SE = 0.01, p = .028, OR = 2.05 [95% CI 1.08, 4.03]) and at follow-up (B = 0.02, SE = 0.01, p = .029, OR = 2.07 [95% CI 1.09, 4.15]) all predicted that tic management strategies were more likely to interfere with doing other things.
Participants were asked, “Would you say that you can 1) manage your tics OR participate in your environment or 2) manage your tics AND participate in your environment?” Most participants (87.3%) said that they can both manage their tics AND participate in their environment. Some participants (9.9%) reported they could only do one or the other, while a few participants (2.8%) said they could do neither. Logistic regressions for this question did not include data from participants who said they could do neither due to the small sample size. Treatment group and responder status did not predict responses to this question. No other individual or clinical variables predicted responses to this question, suggesting that a broad array of patients feel capable of integrating tic management strategies into their daily routine.
In response to the question “Do you feel more or less present with your environment when managing your tics?” the plurality of respondents said they felt less present (45.2%) with their environment. Other participants (27.4%) said they felt more present, and 27.4% replied neither. Multinomial logistic regressions included “more,” “less,” and “neither” as outcomes. Treatment group and posttreatment responder status did not predict responses to this question. Those with higher YGTSS impairment scores at follow-up had an increased likelihood of reporting being more present while using strategies (vs. neither more nor less present; B = −0.08, SE = 0.04, p = .031, OR = 0.41 [95% CI 0.18, 0.84]). Those who were younger at baseline (B = −0.03, SE = 0.01 p = .030, OR = 0.46 [95% CI 0.23, 0.94]) and follow-up (B = −0.03, SE = 0.01 p = .032, OR = 0.47 [95% CI 0.23, 0.95]) were more likely to report being less present (vs. more) when using tic management strategies.
Discussion
Concerns about the negative side effects of behavior therapy for tics are commonly reported among patients, parents, and clinicians, and such perceptions may be a key barrier to the implementation of evidence-based treatment for tics. This study examined patient reports of negative consequences stemming from the use of tic management strategies over an extended time period and explored factors that may predict such experiences.
Tic Worsening
One concern about tic management strategies is that attempts to control tics will result in an increase in tic expression. In this study, most participants reported that strategies did not worsen tics, and there were no significant differences between those who received CBIT and PST. This finding supports the notion that tics do not generally worsen after attempts to control them, and such occurrences, when they do happen, are not specific to those receiving behavior therapy. Nevertheless, a small percentage of participants did report tic worsening, countering earlier findings suggesting that tic suppression does not increase tic severity or frequency. This discrepancy might be related to our study’s broader focus on tic management strategies, as opposed to the exclusive emphasis on tic suppression in past research. Moreover, the current study assessed patient reports of tic worsening, while prior studies used direct observation or clinician-administered measures of tic severity (Müller-Vahl et al., 2014). Inconsistencies might also be attributed to study setting; most tic suppression studies occurred in controlled experimental environments, free from tic-exacerbating antecedents and consequences. In contrast, clinically-based tic management strategies often occur in the presence of such factors. Future research could use ecological momentary assessment to explore how settings influence daily experiences of tic worsening after using strategies.
In our sample, a group at particular risk of tic worsening after using tic management strategies were treatment non-responders in either treatment group (CBIT or PST). Treatment non-responders may have experienced more frustration or distress around tic control, emotions which could further exacerbate tic expression (Conelea & Woods, 2008b). Additionally, it could be that tics do not objectively increase in severity above initial levels after using strategies, but the contrast of tics occurring after temporary control is perceived as an increase. Research should explore emotional and cognitive mechanisms that might underlie this connection.
Tic worsening after using management strategies was also more likely to happen in those who had been taking tic medication at baseline of the RCT. Some research suggests that tic-reducing medications may impede learning processes (Salvador et al., 2017); medicated patients might struggle to learn effective tic management, increasing the chance of less successful tic control. Alternatively, taking tic medication at baseline could indicate higher pretreatment tic severity, and those who discontinued medication may have experienced a subsequent increase in severity. Future studies could investigate whether certain patients, based on their medication profile, are more prone to tic worsening after using management strategies.
Tic Substitution
Another frequently reported concern involves tic substitution. The current findings partially contradict previous research suggesting that tic management strategies generally do not transform into new tics. Although most participants did not report this phenomenon, nearly one-quarter (23% of CBIT participants; 27% of PST participants) responded yes, sometimes, or previously.
Responses to whether tic management strategies became new tics did not differ between patients who received CBIT and PST, indicating that this phenomenon is not specific to behavior therapy (Peterson et al., 2016). However, individuals with more severe tics and more compulsive behaviors were more likely to report this phenomenon. Reasons for this are unclear, but one possibility is that new tics simply could be more likely to emerge in severe cases, independent of strategy use. Likewise, it is plausible that for patients with more severe comorbid obsessive-compulsive symptoms, strategies used to manage tics could evolve into compulsions perceived as tics. Further research is needed to clarify the connection between tic substitution and compulsive symptoms.
Attention and Effort
In this study, 77% of participants reported that managing tics does not interfere with ongoing activities, and 87% indicated that they could manage tics while participating in their environment. Nevertheless, about half (45%) of participants reported feeling less present with the environment when managing tics. These reported experiences did not differ based on treatment group (CBIT vs. PST), suggesting that the attention and effort required for tic management are not unique to behavior therapy strategies. Rather, this may be more related to individual differences and clinical characteristics.
Treatment non-responders were more likely to report that tic management strategies interfered with doing other things, regardless of treatment type. Further, higher posttreatment and follow-up tic severity predicted endorsing interference from managing tics. Indeed, managing more intense, frequent, or complex tics may inherently require more effort and draw attention away from doing other things. This could plausibly contribute to higher tic-related impairment, which was also observed in these participants.
Older age at baseline and follow-up also predicted interference from tic management strategies. Older individuals may have more life responsibilities and activities, creating more opportunities for managing tics to interfere. Additionally, in the RCT, older participants may have been more engaged in treatment and motivated to implement strategies in their lives. Regular strategy use would also increase the chance of interference with other activities. It is also possible that older individuals were exposed to older conceptual models of tics suggesting the ineffectiveness and intrusiveness of behavior therapy strategies, potentially influencing perceptions of the interference of these strategies in daily life.
Participants who felt more present while managing tics were also older on average, possibly reflecting age-related differences in cognitive and executive functioning, which peak between the ages of 20 to 30 (Ferguson et al., 2021; Zelazo et al., 2014). Additionally, individuals who reported feeling more present with the environment while managing tics had higher follow-up YGTSS impairment scores (vs. those who reported feeling “neither more nor less” present). Reasons for this association are unclear but warrant further exploration.
Limitations
Findings from this study should be interpreted with consideration of its limitations. First, our sample, aged 16 to 30, may not reflect the experiences of younger children or older adults with TDs. Our sample also comprised mainly White males, limiting the generalizability of results. Additionally, the use of a semi-structured interview introduces the risk of participant recall bias. The extended follow-up period could have influenced responses, as experiences post-treatment and 11 years after may differ. It would be valuable to investigate these concerns in patients who received treatment more recently. Moreover, participants were asked about the consequences of tic management strategies generally, not behavior therapy strategies specifically. Future research should investigate the effects of specific strategies. Additionally, not all interview questions explicitly inquired about common behavior therapy concerns. A few participants (CBIT group n = 1; PST group n = 4) received tic therapy between the original trial and follow-up, potentially impacting responses. However, only one participant in the PST group received CBIT, increasing confidence that our treatment group findings were not influenced by external treatment.
Implications
Our findings have implications for practitioners and individuals with TDs, as concern over negative consequences is a barrier to the dissemination of behavior therapy (McGuire et al., 2015; Scahill et al., 2013; Woods et al., 2007). For those hesitant about seeking behavior therapy for tics, results from this study might alleviate concerns regarding the likelihood of unintended negative consequences from behavioral strategies. However, a minority of individuals may experience negative effects from tic management strategies, irrespective of therapy type. This information is important for patients to form realistic expectations about strategy use and make informed treatment decisions.
Insights from this study could also help dispel clinician misconceptions about consequences specific to behavior therapy, as our findings suggest that these effects occasionally occur regardless of treatment type. This clarification might encourage more clinicians to expand their scope of practice and adopt evidence-based interventions to treat individuals with TDs (Woods et al., 2010). Further, our findings can inform early-treatment psychoeducation, supporting a favorable risk-benefit ratio for most behavior therapy patients. This, in turn, might lead to more positive treatment expectations and enhance treatment outcomes (Sukhodolsky et al., 2017). This study’s exploration of characteristics predicting adverse effects of managing tics (e.g., age, tic severity, compulsive symptoms) is also relevant for treating clinicians. For instance, in cases of higher tic severity, clinicians may dedicate more time to ensure a strategy does not become a new tic and monitor for potential tic worsening after strategy use. Overall, findings from this study have the potential to decrease misconceptions about behavior therapy and improve treatment accessibility and outcomes for individuals with TDs.
Footnotes
Declaration of Conflicting Interests
The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Ms. Barber, Mr. Pitts, Mr. Stiede, and Dr. Compton declare that they have no conflicts of interest. Dr. Espil has received research support from the Foundation for OCD Research and honoraria from Springer Nature. Dr. Woods receives royalties from Guilford Press, Springer Press, and Oxford University Press and royalties for 
. Dr. Woods also receives speaking fees from the Tourette Association of America. Dr. Specht receives research support and speaking honoraria from the Tourette Association of America. Dr. Bennett receives royalties from UpToDate for an entry on child anxiety, and honoraria from the Tourette Association of America for CBIT training/talks and Lyra Health for speakers’ bureau. Dr. Walkup has served on advisory boards for the TLC Foundation for Body-Focused Repetitive Behaviors, Tourette Association of America, and the Anxiety and Depression Association of America. He has received speaking fees from the Tourette Association of America and AACAP. Dr. Walkup receives research funding from the Tourette Association of America and royalties from Oxford Press, Guilford Press, and Wolters Kluwer. Dr. Ricketts has received research funding from the National Institute of Mental Health (NIMH), Brain and Behavior Research Foundation, and the TLC Foundation for Body-Focused Repetitive Behaviors. She has received honoraria and research funding from the Tourette Association of America (TAA). She has received honoraria from the Centers for Disease Control and Prevention and Springer Nature. Dr. McGuire has received research support from the American Academy of Neurology, American Brain Foundation, American Psychological Foundation, Hilda and Preston Davis Foundation, Misophonia Research Fund, Tourette Association of America, and National Institute of Health. Dr. McGuire has received royalties from Elsevier and serves as a consultant for Signant Health, Syneos Health, and Luminopia. He has received editorial honoraria from Springer Nature and speakers’ bureau from the International OCD Foundation Pediatric Behavior Therapy Training Institute, and Tourette Association of America Scientific Advisory Board. Dr. Peterson reports receiving royalties from Oxford University Press for treatment manuals on tic disorders and receiving honoraria for CME presentations from the Tourette Association of America. Dr. Scahill has received research support from the Eunice Kennedy Shriver National Institute of Child Health and Human Development, the US Department of Defense, and the Marcus Foundation. He has served as a consultant to Janssen Pharmaceuticals, Impel NeuroPharma and Cogstate. Dr. Scahill has received licensing fees from Roche, Yamo Pharmaceuticals, and Abbvie. He has received royalties from Guilford Press, Oxford University Press, and American Psychiatric Association Publishing. Dr. Wilhelm is a presenter for the Massachusetts General Hospital Psychiatry Academy in educational programs supported through independent medical education grants from pharmaceutical companies. She has received royalties from Guilford Publications, New Harbinger Publications, Springer, and Oxford University Press. Dr. Wilhelm has also received speaking honoraria from various academic institutions and foundations, including the International Obsessive Compulsive Disorder Foundation, the Tourette Association of America, and the Centers for Disease Control and Prevention. In addition, she received honoraria for her role on the Scientific Advisory Board for One-Mind (PsyberGuide), Koa Health, Inc., and Noom, Inc. Dr. Wilhelm has received research and salary support from Koa Health, Inc. Dr. Piacentini receives research support from NIMH, Patient-Centered Outcomes Research Institute (PCORI) and the TLC Foundation for BFRBs, advisor fees and equity from Lumate Health; publication royalties from Guilford Press, Oxford University Press, and Elsevier; and travel/speaking honoraria from the Tourette Association of America and International OCD Foundation.
Funding
The author(s) dis closed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was conducted with research support from the Tourette Association of America Research Grants Award and the National Institute of Mental Health (NIMH) R01MH070802. The content is the responsibility of the authors and is not necessarily representative of the views of the Tourette Association of America or the National Institutes of Health.