## 4 Discussion
Additionally, other authors suggest a delayed impact of the intervention on vocal tics, with more significant improvements observed in follow-up phases [20; 31]. Other explanations are related to differences in neurobiological substrate [44] and higher sensitivity of vocal tics to environmental and social conditions [45; 46]. It is known, for example, that tics tend to increase with social attention and decrease with isolation [47]: during discussions about tics (\"tic-talk\") or in group-based interventions, a higher increase in vocal tics compared to motor tics can be observed [29; 30; 31; 48]. In this case, it could be hypothesized that group settings could contribute to the maintenance of some tics, especially vocal tics [31]. Finally, regarding the type of intervention, as in the case of motor tics, bigger improvements in vocal tics were observed for the Comprehensive Behavioral Intervention for Tics (CBIT), independently of the delivery method used [15; 19; 20; 31; 29; 30]. Overall, studies [15; 19; 20; 31; 22; 29; 31] have shown that both the CBIT (delivered online or in-person) and the Internet-based ERP were effective in improving tic-related impairments in children and adolescents with TDs. Improvements appeared to be associated with enhancements in quality of life, as well as in emotional and behavioral functioning [29], with results comparable to those observed with other treatments (e.g., [43; 49]). Specifically, studies by [PERSON] and colleagues [31] and [PERSON] and colleagues [22] suggested that CBIT and ERP are particularly effective not only in managing tics, but also in reducing comorbid conditions, such as anxiety and behavioral symptoms. These findings are consistent with previous reports highlighting the contribution of behavioral interventions and supportive psychoeducational strategies in addressing anxiety and behavioral problems in youths [49; 50]. Similarly, techniques such as relaxation [14; 49] may contribute to improvements in emotional and behavioral well-being. Therefore, these interventions offer benefits which goes far beyond tic management, suggesting that an integrated approach,also addressing comorbid conditions and incorporating complementary techniques, might be particularly effective. This systematic review provides novel insight into the use of behavioral therapies (CBIT, HRT, and ERP) delivered either online or face-to-face, summarizing its effectiveness on motor, vocal tics, and tic-related impairments. Overall, the interventions were associated with high satisfaction levels among children and adolescents. The observed tics reduction and response rates aligned with those reported in previous trials on pharmacological interventions for tic reduction in pediatric populations [51; 52], thus confirming the validity of recommending nonpharmacological treatments as first-line alternatives in the management of tic disorders in children and adolescents [7]. In light of the side-effects associated with the use of pharmacological medications for TDs [7], it is of primary importance to explore alternative treatment modalities. Therefore, the results of the present review significantly add to the literature by supporting the efficacy and the use of nonpharmacological treatments for TDs in pediatric populations.