The TS Puzzle: How Do the Pieces Fit Together?

View the webinar’s corresponding slides here        Download the Webinar 

Presenter: Dr. Martin Franklin

This webinar will present the underlying neurology, development and treatment for TS along with strategies for the management of its typical co-occurring disorders anxiety, OCD and ADHD. Dr. Martin Franklin is an Associate Professor of Clinical Psychology in Psychiatry at the University of Pennsylvania, and Director of the Child and Adolescent OCD, Tic, Trich, and Anxiety Group (COTTAGe) in the Department of Psychiatry. Dr. Franklin received his Ph.D. in clinical psychology from the University of Rhode Island. He has devoted his career to the study of anxiety and body-focused repetitive behaviors (such as chronic tic disorders and trichotillomania) in children and adults.


  1. Joy Kumme says:

    Did I understand you that CBIT is useful for even complex motor tics?

    • Dr. Martin Franklin says:

      Yes, CBIT can be used effectively with complex tics – it is important that the therapist help the patient identify the earliest behavioral sign of the complex tic sequence or, better yet, even the premonitory urge that comes immediately before engaging in the first movement in the complex tic. The CBIT trials for both adults and youth included many patients with complex tics, and complexity of tics did not attenuate treatment outcome according to the moderators and predictors paper presented in the Webinar.

  2. kteabo says:

    With comorbid conditions, how do you know what therapy to use with multiple conditions? What if executive function skills, motivation and sensory processing are more prevalent than the tics?

    • Dr. Martin Franklin says:

      Sometimes this question can be answered simply by asking the patient about their own priorities – we do this with youth by asking “If I had a magic wand and could eliminate one of these problems right away, which one would it be? Why? Most youth with TS will have some degree of executive function challenge, discomfort with sensory experience, etc. – these can be addressed in the context of CBIT, i.e., changing how you teach the concepts to help with motivation, engagement, retention of information, etc., but there are times when you won’t know how these factors will affect treatment until you try. That said, a patient who is adamant that they want no part of the intervention, for whatever reason, is not likely to be ready to tolerate its demands, and I am reluctant to burn the bridge I may want to cross later by forcing patients into a therapy that will require their active participation. Sometimes we are better off waiting until the patient is sufficiently motivated, which does happen on occasion when patients are able to see how tics are affecting them in ways that thwart achievement of goals that are important to them.

  3. GreggE. says:

    Where is TS in the DSM 5?

    • Dr. Martin Franklin says:

      Under Neurodevelopmental Disorders, subheading Motor Disorders. There was considerable debate in the field about whether tics should be moved under the subheading of OCD and related disorders, but in the end it was housed with other disorders typically evident in childhood that are believed to have strong neurobiological roots.

  4. CherylL. says:

    Question about adult with TS and severe ADHD: Tics more problematic in youth and now the ADHD has increased significantly in severity. Huge impact on employment. Hesitation to begin more ADHD meds for fear of increase of tics again. Any suggestions?

    • Dr. Martin Franklin says:

      The experts who have studied this question, Dr. Larry Scahill and colleagues at the Yale Child Study Center (Dr. Scahill is now at Emory University), have consistently noted the impact of untreated ADHD on adult functioning including employment, and have suggested that trying to find solutions to help manage those symptoms are typically the first priority; CBIT can be added down the line if the ADHD medications are resulting in increased tics.

  5. MichelleS says:

    What techniques can be used in reducing anxiety that brings on OCD symptoms in 10 yr old?

    • Dr. Martin Franklin says:

      In CBT for OCD we typically do not make concerted efforts to reduce anxiety, ironically enough – we encourage leaning into the distress rather than away, and learning how to tolerate discomfort rather than run away from it. Stress management and relaxation have not been found to be terribly effective in OCD treatment trials – exposure plus response prevention is the treatment of choice for OCD, either in concert with pharmacotherapy or even alone.

  6. Kerry P. says:

    Should you react to the tics of a 9-year-old boy ( with ADHD, OCD, and a “transient tic disorder”) who is highly aware of his own vocal and motor tics and obsessions (and will openly speak about them), or should you ignore them, when you are both at home and he is making lots of noises? Will making a comment cause an increase? Should you offer an incentive to stop them (ie: extra screen time on iPad, etc),,,,? What do you do when he gets annoyed by your calling his name (not in a scolding way) when he is having tics, because he is annoying YOU?!

    • Dr. Martin Franklin says:

      We typically recommend trying to create a “tic neutral environment,” which likely means that no comments should be made about whether a child is or is not doing tics. The exception is if the parent, or teacher, has been given a specific task of reminding patients to use their competing responses as part of CBIT or some other such behavioral intervention. In the absence of that, it is likely that comment, and especially negative ones, will exacerbate tics and compromise the relationship, so we would steer clear of such unscheduled or likely unappreciated interventions. Possibly, but usually as part of a systematic behavioral intervention that has been agreed upon in advance. More importantly, in CBIT the incentive is usually delivered upon use of treatment techniques, not upon not doing the tic – the latter capitalizes too much on chance and other factors to provide reinforcement, and reinforcement is more important when the patient is struggling in the face of urges rather than not experiencing them. Find a way to suppress your own urges to call out, as the immediate effect of that is probably going to be offset by increasing stress and causing the child to feel like you are punishing them for something they perceive to be out of their control.

  7. A.Block says:

    What is your opinion on Tics induced by medications? I’m pretty sure I had tic side effects from Strattera

    • Dr. Martin Franklin says:

      The factors that caused them may or may not be the factors that maintain them, so regardless of why a person started having tics they may still be able to benefit from CBIT, which focuses on the factors that maintain them, the most potent of which is the negative reinforcement of the urge experienced when the tic is completed.

  8. A.Block says:

    Why not an SSRI?

    • Dr. Martin Franklin says:

      Insufficient evidence of benefit on tics per se, though often times patients with anxiety or OCD comorbidity are prescribed SSRIs for those conditions.

  9. ABlock says:

    Can tics in Tourette’s occur while sleeping? One of my student’s parent told me that she observes abdominal tics in her son while he is asleep. I also don’t know what an abdominal tic looks like.

    • Dr. Martin Franklin says:

      They can, though it would be tricky to differentiate tics from normative movements made during sleep, which are myriad and can look like tics themselves.

  10. ABlock says:

    The myth of vocal tics including cursing or profanity? This was made popular by the movie Deuce Bigalow Male Gigolo.

    • Dr. Martin Franklin says:

      Fewer than 10% of those with vocal tics actually engage in coprolalia, Deuce Bigalow notwithstanding.

  11. ABlock says:

    A student with a Dx of ASD, OCD, Sensory issues and Tic disorder. His IEPs, evaluations which included, Neurodevelopmental, Psychiatric, neuropsych and a few FBAs. The target behaviors were off task verbal, which included cursing. Some of the consequences where hypothesized to be peer attention and work avoidance. A BIP was developed and put in his IEP. As part of the FBA process, you are supposed to include relevant medical conditions in the report and as part of the data collected. I am wondering if, the BCBA who conducted the FBA did a comprehensive review of records and considered his tics. Perhaps his vocal tics were a manifestation of his Tic disorder.

    • Dr. Martin Franklin says:

      Good question – people swear for a wide variety of reasons, so a function-based intervention on that particular behavioral chain would be important to conduct: is it a tic in that it is an attempt to reduce discomfort brought on by an urge in the throat? Is it a response to frustration? An attempt to get people to stop making behavioral demands? Myriad reasons, and the answer to these questions will suggest an intervention (e.g., CBIT vs. social skills training vs. anger management).