Online Behavioral Treatment for Tics in Children Prove Useful and Cost-Effective

Online therapist-supported exposure and response prevention can effectively reduce tic symptoms in children and adolescents.

Tic symptoms in children and adolescents can be reduced cost-effectively with durable and sustained long-term benefits with online therapist-supported exposure and response prevention (ERP), according to investigators who had their findings published in The Journal of Child Psychology and Psychiatry.

Researchers sought to evaluate online therapist-supported, parent assisted ERP therapy for tic disorders for long-term clinical and cost-effectiveness in children and adolescents vs remote therapist-supported, parent assisted psychoeducation. The main endpoint was the Yale Global Tic Severity Scale Total Tic Severity Score (YGTSS-TTSS).

They conducted the multicenter, randomly assigned, single-blind, superiority-controlled ORBIT (Online Remote Behavioral Intervention for Tics) trial ( Identifier: NCT03483493). This 2-arm (1:1 ratio) trial recruited 224 participants (21% girls; 87% White) from 2 child and adolescent mental health services in England, as well as 16 other mental health clinics in England, and by self-referral via websites, randomly assigned to ERP (n=112) or psychoeducation (n=112).

The 2 phases of this trial consisted of Phase I (intention-to-treat, results previously reported), and the current study, Phase II, a naturalistic follow-up to 18-month postrandomization, during which time participants (mean age 12 years) were permitted alternative treatments prescribed by their usual treating clinician. Enrollment was from May 2018 through September 2019, and the last participant’s 18-month follow-up was completed in April 2021.

Evidence from this trial suggests that online therapist-supported ERP is an effective behavioral therapy for reducing tic symptoms, which has durable and sustained long-term benefits.

Engagement with the intervention was 88% in the ERP group and 94% in the psychoeducation group for participants receiving at least the minimum treatment dose. At 12 months YGTSS-TTSS data were collected from 81% of participants in each group, and at 18 months, data were collected from 79% of the ERP group and 80% of the psychoeducation group and researchers noted a considerable amount of missing data.

Inclusion criteria included children and adolescents aged 9 to 17 years with moderate/severe tic disorder (defined as YGTSS-TTSS scores of >15, or >10 if only vocal or motor tics were present). Exclusion criteria included starting or stopping tic medication within the previous 2 months, suspected moderate/severe intellectual disability, or engaging in behavioral intervention for tics in the previous 12 months.

Researchers found a reduction from baseline YGTSS-TTSS with the ERP intervention by 2.64 points (95% CI, -4.48 to -0.79) with an effect size of -0.36 (95% CI, -0.61 to -0.11) after 12 months compared with psychoeducation. After 18 months, they noted a reduction of 2.01 points (95% CI, -3.86 to -0.15) with an effect size of -0.27 (95% CI,-0.52 to -0.02). Investigators noted that less than 10% of participants started a new tic treatment during the follow-up period.

They found the ERP vs psychoeducation cost difference was £304.94 (95% CI, -139.41 to 749.29). They calculated the cost per quality-adjusted life years (QALYs) gained was £16,708 for ERP compared with psychoeducation at 18 months.

Study limitations include study results not yet repeated, inability to evaluate potential moderating effects of additional treatments, the preponderance of White participants and the preponderance of male participants limit generalizability, recall bias for self-reported outcomes, and possible effect modification during longer-term follow-up of anxiety disorder and attention-deficit/hyperactivity disorder.

Researchers concluded, “Evidence from this trial suggests that online therapist-supported ERP is an effective behavioral therapy for reducing tic symptoms, which has durable and sustained long-term benefits.” They wrote that in health care settings where, “tic treatments are difficult to access, therapist-supported online ERP as a first-line intervention could greatly increase the availability of a durable and cost-effective behavioral treatment for children and adolescents with tic disorders.”

This article originally appeared on Psychiatry Advisor


Hollis C, Hall CL, Khan K, et al. Long-term clinical and cost-effectiveness of a therapist-supported online remote behavioral intervention for tics in children and adolescents: extended 12- and 18-month follow-up of a single-blind randomized controlled trial. J Child Psychol Psychiatry. Published online January 17, 2023. doi:10.1111/jcpp.13756