Terapie Ticuri

Behavior Modification
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Habit Reversal Training for Tic Disorders in Children and Adolescents

John Piacentini and Susanna Chang
Behav Modif 2005; 29; 803
DOI: 10.1177/0145445505279385
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BEHAVIOR
10.1177/0145445505279385
Piacentini, Chang
MODIFICATION
/ HABIT REVERSAL
/ November
TRAINING
2005 FOR TIC DISORDERS
Habit Reversal Training for Tic

Disorders in Children and Adolescents
JOHN PIACENTINI
SUSANNA CHANG
UCLA School of Medicine
Chronic tic disorders, including Tourette’s syndrome (TS), affect approximately .5% of children
and adolescents. Although strong evidence exists supporting a neurobiological etiology, operant
factors may play a role in the maintenance of tic behaviors. Pharmacological approaches remain
the most commonly used intervention for chronic tic disorder in children and adults. Neverthe-
less, the unpredictable efficacy and serious side effects associated with medication along with
parental concerns about long-term medication use in children underlie the need for
nonpharmacological interventions for tics in this age group. This article reviews the rationale and
evidence base for the use of habit reversal training (HRT), a multicomponent behavioral treat-
ment package, as a treatment for childhood tics. Each of the primary treatment components of
HRT is described and implementation is illustrated in case report format. A growing body of data
suggests that HRT is a well-tolerated and efficacious intervention for tic disorders in this age
group.
Keywords: child/adolescent; Tourette’s syndrome; tic disorders; behavior therapy; habit

reversal
Given their complex etiology and variable clinical manifestations,

Tourette’s syndrome (TS) and other tic disorders have traditionally
proven a challenge to health care professionals working in this area.
Although psychopharmacological treatment remains the most com-
mon intervention for chronic tic disorder, psychosocial, including
AUTHORS’ NOTE: This work was supported, in part, by a grant from the Tourette Syndrome
Association Permanent Research Fund and National Institute of Mental Health R01 MH58459
(supplement) to the first author. We would also like to acknowledge the contribution of Courtney
Jacobs, Ph.D., to the development and refinement of the treatment protocol described in this arti-
cle. Please direct all correspondence and requests for reprints John Piacentini, Ph.D., UCLA-
NPI, Room 68-251, 760 Westwood Plaza, Los Angeles, CA 90024; e-mail: jpiacentini@
mednet.ucla.edu
BEHAVIOR MODIFICATION, Vol. 29 No. 6, November 2005 803-822
DOI: 10.1177/0145445505279385
© 2005 Sage Publications
803

804 BEHAVIOR MODIFICATION / November 2005
behavioral, interventions have historically played an important, albeit

generally adjunctive, role in the treatment of these disorders
(Piacentini & Chang, 2001). The most prominent behavioral tech-
nique for addressing tics is habit reversal training (HRT) that was ini-
tially described by Azrin and Nunn (1973). The current report pro-
vides a brief review of childhood tic disorders and describes the use of
HRT for the treatment of tics in this age group.
The prevalence of chronic tic disorders in childhood, including TS,
has not been adequately documented, although estimates up to 1%
have been reported (McCracken, 2000). Although characterized by
short-term waxing and waning and perhaps even brief periods of com-
plete remission, tic severity typically reaches a zenith in mid-
adolescence followed by a gradually waning course for some through
late adolescence and into young adulthood (Leckman, Zhang, &
Vitale, 1998; Sallee & Spratt, 1999). The evolution of tic disorders in
childhood, including TS, follows a relatively predictable course. Sim-
ple tics, such as eye blinking, facial or head and/or neck tics, typically
emerge first at approximately age 6 or 7 years followed by rostral-
caudal progression of increasingly complex motor tics during suc-
ceeding years. On average, vocal tics appear at age 8 or 9 years with
complex tics and/or obsessive-compulsive symptoms (when they do
co-occur) emerging by about age 11 or 12 years. TS and other chronic
tic disorders have been related to a variety of problems in childhood
and adolescence including aggressivity, impulsivity, mood and anxi-
ety disorders, poor social skills, low self-esteem, increased rates of
family conflict, and obsessive-compulsive behaviors (Dykens et al.,
1990; Walkup et al., 1999). In many cases, initial treatment contact is
triggered not by the tics themselves but rather by these associated dif-
ficulties. Nevertheless, a proportion of youngsters do exhibit tics in
the absence of other complicating psychopathology.
Several studies have reported a high frequency of premonitory sen-
sory phenomena immediately preceding tics (Bruun, 1988; Leckman,
Walker, & Cohen, 1993; Miguel et al., 2000; Scahill, Leckman, &
Marek, 1995). These typically distinct and focal sensations (e.g., pre-
monitory urges) are most commonly described as a sense of building
tension or a strong urge and are relieved by movement of the affected
body region (i.e., performing the tic). It has been suggested that the

Piacentini, Chang / HABIT REVERSAL TRAINING FOR TIC DISORDERS 805
relationship between sensory phenomena and tics may be analogous

to the relationship between obsessions and compulsions in obsessive-
compulsive disorder (OCD; Shapiro & Shapiro, 1992), although
OCD-related compulsions are characteristically triggered by cogni-
tive stimuli and/or physiologic symptoms of anxiety as opposed to
sensory phenomena (Miguel et al., 1995). Historically, tics were
described as involuntary and uncontrollable behaviors; however,
Leckman et al. (1993) found that more than 90% of ticcers reported
that they experienced their tics as controllable and, in fact, volitionally
expressed tics on at least some occasion. Premonitory urges and
volitionality appear to be developmentally related (Chang &
Piacentini, 2002). Younger children are less likely to describe their
tics as controllable, and premonitory urges are typically not seen in
children younger than age 10 years (Leckman, King, & Cohen, 1999).
In addition, simple tics, such as eye blinking, are less likely to be
controllable than more complex tics.
Converging lines of evidence strongly support the dominant role of
genetic and neurobiological factors in the etiology of TS and other tic
disorders (see McCracken, 2000, for review). Within this
neurobiological framework, however, the notion of premonitory urge
and volitionality play a key role in behavioral models of tic expression
and the development and implementation of behavioral treatments for
tic disorders across the age span. The aversive nature of premonitory
urges in most individuals along with the fact that tic expression typi-
cally leads to full or at least partial dissipation of the urge (Scahill
et al., 1995) suggests that tic behaviors may be, at least, partially main-
tained via negative reinforcement. If this conceptualization is accu-
rate, then behavioral interventions aimed at extinguishing this con-
nection, such as HRT, should be helpful for treating tic disorders.
Until recently, however, the acceptance of HRT within the broader TS
treatment community was hampered by the lack of well-controlled
efficacy trials and the incorrect belief that, as neurobiological phe-
nomena, tics are completely involuntary and thus not amenable to
behavioral intervention.
The use of HRT for tic suppression has received some empirical
support (Peterson, Campise, & Azrin, 1994; Piacentini & Chang,
2001; Woods & Miltenberger, 1995, 2001). In their initial study, Azrin

and Nunn (1973) treated 12 individuals with habits or tics and

reported a mean reduction in symptom frequency of 90% after a single
treatment session and 99% symptom reduction at 3-month follow-up.
Azrin, Nunn, and Frantz (1980) compared HRT to massed practice
and reported one session of HRT led to an immediate 84% reduction
in tics and 97% reduction at 18 months. Peterson and Azrin (1992)
compared the single-session efficacy of three behavioral techniques in
six patients with TS treated in a laboratory setting. The results showed
a clear advantage for HRT that led to a tic reduction of 55% as com-
pared to 44% for self-monitoring and 32% for relaxation training. In a
review of the HRT literature, Peterson et al. (1994) concluded that the
full HR procedure can lead to reductions in tic frequency of up to 90%
at home and up to 80% in clinic settings. Unfortunately, the utility of
these collective data is limited by a number of methodologic short-
comings, including, among other factors, poor sample characteriza-
tion, problematic assessment methods (primarily retrospective self-
reports), the use of analogue settings, and the lack of controlled
treatment-outcome designs with adequate follow-up.
However, two controlled trials, funded by the Tourette Syndrome
Association (TSA), provided additional support for the efficacy of
HRT. Wilhelm, Deckersbach, and Coffey, (2003) reported HRT to be
more effective than supportive psychotherapy in a sample of 32 adults
with TS with gains maintained at 10-month follow-up. Piacentini,
Chang, Barrios, and McCracken (2002) compared HRT to awareness
training in 25 children and adolescents with TS and found HRT to be
associated with significant tic reduction posttreatment and at 3-month
follow-up. Collectively, these two studies suggest that HRT is associated
with significant, yet modest, results in tics and associated impairments.
The shortcomings of pharmacological interventions for TS and
other tic disorders provide further impetus for the establishment of
HRT and other nonpharmacological techniques as viable interven-
tions for childhood tic disorders. As noted above, medication is, by
far, the most commonly used intervention for tic disorders in children
and adults (cf., Kurlan, 1997), and controlled medication trials have
yielded reductions in tic symptoms ranging from 25% to 80% (Car-
penter, Leckman, Scahill, & McDougle, 1999; Chappell, Leckman, &

Riddle, 1995; Sallee, Nesbitt, Jackson, Sine, & Sethuraman, 1997;

Scahill et al., 2001). Unfortunately, the most effective medications,
including haloperidol (haldol) and pimozide (orap), are associated
with serious side effects that limit their utility with younger popula-
tions (Sallee et al., 1997). In adult samples, significant side effects
have been found to occur in up to 80% of individuals (Carpenter et al.,
1999) and up to 90% of patients have been reported to discontinue
medication prematurely because of these adverse effects (Shapiro
et al., 1989; Silva, Munoz, Daniel, Barickman, & Friedhoff, 1996).
Moreover, for those patients remaining on medication, inconsistent
compliance with their treatment regimen is quite common (Cohen,
Riddle, & Leckman, 1992). In addition to efficacy and side-effect con-
cerns, many parents are resistant to psychopharmacologic treatment
for their children because of the lack of information regarding long-
term medication effects in this age group (Piacentini, Gitow, Jaffer,
Graae, & Whitaker, 1994).
The mechanisms underlying habit reversal are not currently well
understood. Azrin and Nunn (1973) initially suggested that treatment
effect stems from the strengthening of muscles incompatible with tic
expression and heightened awareness of the tic produced by the
opposing CR. However, the fact that CRs that are topographically dis-
similar to the targeted tic can also be effective (Sharenow, Fuqua, &
Miltenberger, 1989) runs counter to this hypothesis. Miltenberger and
Fuqua (1985) speculated that the aversive nature of the CR functions
as inadvertent punishment for the tic behavior. According to these
authors, the CR can be seen as a self-administered punishment proce-
dure that is paired contingently with the tic and leads to tic reduction
via operant conditioning. Conversely, the competing response (CR)
may be viewed as an active coping mechanism that directly competes
with the aversive tic behavior and, thus, helps to motivate the patient
and build increasing self-control. HRT has also been conceptualized
as a form of exposure plus response prevention (ERP) in which the use
of a CR to block tic expression actually results in habituation of the
premonitory sensory urge (Bliss, 1980; Hoogduin, Verdellen, & Cath,
1997). A positive study by Hoogduin et al. (1997) examining ERP for
tic reduction provides some initial support for this explanation.

DESCRIPTION OF HABIT REVERSAL
As originally specified by Azrin and Nunn (1973), HRT consisted

of eight primary intervention components aimed at increasing tic
awareness, developing CRs to tics, and building and sustaining moti-
vation and compliance. Because of the complex nature of habit rever-
sal as originally conceptualized, a programmatic research effort led by
Miltenberger and colleagues has focused on identifying and refining
the active components of HRT. Miltenberger, Fuqua, and McKinley
(1985) found that awareness plus CR training were as effective for tic
reduction as the full Azrin and Nunn procedure. Subsequent studies
by this group established that the CR must be performed contingently
on the targeted tic behavior (Miltenberger & Fuqua, 1985) but did not
have to involve topographically similar muscles as the targeted tic
(Sharenow et al. 1989). Twohig and Woods (2001) reported the opti-
mal length of the CR, albeit in nail biters not ticcers, to be 1 to 3 min-
utes with shorter instances actually leading to exacerbation of the
targeted behavior. Woods, Miltenberger, and Lumley (1996) sequen-
tially applied the four major HRT components in order of
effortfulness (awareness training, self-monitoring, social support, and
CR) in four children with motor tics to identify the most parsimonious
treatment combination. Although all showed a positive treatment
response, each child responded to a different treatment combination.
Moreover, compliance tended to decrease as the demands of treatment
increased. Woods et al. (1996) concluded that self-monitoring be uti-
lized as the first line of treatment, given its relative ease in training and
use, with other treatment components added as necessary when
awareness of baseline tic level has been established.
In addition to the refinements noted above, some treatment pro-
grams, including ours at UCLA, have begun to place less emphasis on
the use of physically forceful and antagonistic CRs and greater
emphasis on shaping strategies to reduce tic intensity and intrusive-
ness (Piacentini & Chang, 2000, 2001). Cognitive strategies designed
to enhance the early recognition of tic urges and accurate labeling of
these urges to facilitate greater control over tic behaviors (e.g.,
Schwartz, 1998) have also been introduced to bolster feelings of self-

efficacy and increase motivation for treatment. The primary compo-

nents of HRT are described more fully below.
AWARENESS TRAINING
Awareness training is based on the premise that increased aware-

ness of tic behaviors facilitates better self-control. Although one ana-
logue and several case studies provide some support for the short-term
efficacy of awareness training as a primary treatment intervention
(Billings, 1978; Ollendick, 1981; Peterson & Azrin, 1992), this tech-
nique is most commonly used as the initial step in HRT.
The original awareness training components specified by Azrin
and Nunn (1973) included (a) response description where the partici-
pant is trained to describe tic occurrences in detail and to reenact tic
movements while looking in a mirror; (b) response detection where
the therapist aids patient’s tic detection abilities by pointing out each
tic immediately as it occurs in the training session; (c) an early warn-
ing procedure where the participant becomes knowledgeable and
practices identifying the earliest signs of tic occurrence; and (d) situa-
tion awareness training where a functional analysis is conducted to
identify the high-risk situations where tic are most likely to occur.
These steps can be accomplished in a variety of manners including
direct visual feedback using videotapes and mirrors, and the use of
wrist counters, small notebooks, or other devices to record each tic
occurrence (i.e., self-monitoring).
The mechanisms underlying awareness training are not well
defined, although a number of hypotheses have been put forth. Azrin
and Peterson’s (1988) speculation that observed tic reduction is
because of increased awareness of tic occurrence is not supported by
the fact that decreases in tic frequency occur even for participants with
limited ability to accurately monitor their tics or who are unable to
reliably identify tic occurrence in session (e.g., Wright & Miltenberger,
1987). Alternate mechanisms postulate that self-monitoring works by
making the occurrence of the tic an aversive event (e.g., via social
evaluation or demand characteristics) or that monitoring activities

serve as punishers for tic expression (Azrin & Peterson, 1988; Wright
& Miltenberger, 1987).
CR TRAINING
When the ability to reliably detect tic urges has been demonstrated,
the child is instructed to invoke the CR at each occurrence of the urge
and hold the response until the urge passes. Azrin and Nunn (1973)
specified that the CR should be opposite to the tic behavior, be capable
of being maintained for several minutes, produce heightened aware-
ness of the tic by contraction of involved muscles, be socially incon-
spicuous and compatible with normal activity, and, finally, should
strengthen the muscles antagonistic to the tic behavior. Although the
CR does not have to be physically incompatible with the targeted tic to
be effective, CRs involving muscles antagonistic to the targeted tic are
the most commonly employed perhaps because of the logical relation-
ship between tic and CR enhances the likelihood of correct usage.
As noted earlier, CRs can also be implemented in a gradual manner
using a shaping procedure (Piacentini & Chang, 2000). Younger chil-
dren or those with more forceful tics may feel overwhelmed at the
prospect of completely blocking their tics or may actually be physi-
cally unable to do so. The goal of shaping strategies in these situations
is not to completely block tic expression but rather to attenuate the
paroxysmal (i.e., explosive) aspects of tic expression. An initial or
intermediate goal may be to “morph” the tic into a more socially
inconspicuous behavior. For example, a young boy with an arm-jerk-
ing tick may apply a CR designed to slow down the behavior and make
it look like he is smoothing his hair. As the child gains greater control
over the targeted tic, the CR becomes increasingly more forceful with
the ultimate goal of greater tic control. Given that the paroxysmal
aspects are typically the most noticeable, distressing, and physically
damaging features of tic behaviors, attempts to “slow down” or
“deintensify” targeted tics through the use of shaping procedures may
lead to more rapid treatment gains than more forceful, yet less easily
implemented, CRs. Carr (1995) provided a list of alternative CRs for
the most common tics. The preferred CR for vocal tics is slow
rhythmic breathing through the nose until the tic urge has passed.

ANXIETY MANAGEMENT TECHNIQUES
The use of anxiety management techniques for tic control is based

on the observation that increases in stress and anxiety lead to concom-
itant increases in tic frequency, intensity, and duration (Cohen,
Friedhoff, Leckman, & Chase, 1992). Deep breathing, progressive
muscle relaxation, and imagery are the most frequently used anxiety
management techniques for tic disorders (Peterson et al., 1994;
Turpin, 1983). Although case reports and analogue studies have
described modest but short-lived benefits, any observed tic reduction
has not been found to generalize beyond in session training periods
(Peterson & Azrin, 1992; Turpin, 1983). Moreover, the only random-
ized controlled trial found no difference in tic severity posttreatment
between a group of youngsters with TD who received 6 weeks of
relaxation training and a minimal treatment control group (Bergin,
Waranch, Brown, Carson, & Singer, 1998). Nevertheless, relaxation
techniques may have some utility as part of multicomponent interven-
tions, such as HRT, especially for youngsters with increased levels of
anxiety and/or stress.
OPERANT TECHNIQUES
Operant conditioning in the form of contingency management is

one of the more common behavioral treatment approaches for tics
(Peterson et al., 1994; Turpin, 1983). Operant techniques entail the
manipulation of environmental contingencies so that tic-free intervals
are positively reinforced, and tic behaviors are punished. Although
multiple case reports provide some support for contingency-based
approaches, the widespread applicability, generalizability, and dura-
bility of these interventions remains somewhat questionable (Doleys
& Kurtz, 1974; King, Scahill, Findley, & Cohen, 1999; Miller, 1970;
Turpin, 1983). It is also unclear whether observed treatment effects
are because of a learned reduction in tic frequency or from a tempo-
rary enhancement in patient motivation to suppress tic behaviors.
Because only the former mechanism is consistent with operant theory,
such a distinction must be clarified before positive outcomes can be
accurately attributed to this theory. Nevertheless, in cases where clear
functional relationships between tic expression and environmental

contingencies can be documented, the use of operant techniques as an

adjunct to HRT should be considered.
MOTIVATIONAL AND/OR ANCILLARY TECHNIQUES
Although Miltenberger et al. (1985) reported that awareness train-

ing plus the CR were as effective as the full HRT package described by
Azrin and Nunn (1973), the ancillary techniques described below are
typically included in treatment because they are easy and inexpensive
to administer and may serve to enhance the acceptability of HRT to
children and their families undergoing this intervention.
Habit inconvenience review. Early in treatment, the child and thera-

pist make a list (the Tic Hassles List) of all the negative features asso-
ciated with his or her tics (i.e., embarrassing, painful, disruptive, need
to come to clinic, etc.). The hassles list is revisited occasionally when
improvement in the child’s tics render a list item obsolete. In addition
to breaking down the child’s denial of symptoms and enhancing moti-
vation for treatment, the hassles list also serves as a step toward an
exploration of consequences of their tic disorder and a more realistic
acceptance of their condition.
Creation of a tic hierarchy. At the beginning of treatment, the child

and therapist create a comprehensive list of the child’s tics and then
rate how bothersome or distressing each tic is on a 1-to-10 scale (10 =
most bothersome). For some younger children or those denying any
tic-associated distress, it may be necessary to have the children rate
their tics based on frequency of occurrence rather than distress or use
different rating metric (i.e., 1 to 5 instead of 1 to 10). Tics are then rank
ordered from least to most distressing (or frequent, etc.). This list is
reviewed, and tics are rerated at the beginning of each session to pro-
vide a systematic and immediate method for identifying treatment
gains and difficult areas. The tic hierarchy also serves as the mecha-
nism by which tics are selected for institution of awareness training
and CR.
Social support. Other family members, and at times teachers and

even friends, provide praise and support to youngsters for successful

use of awareness techniques and other treatment tasks, tic-free inter-

vals, and adherence to treatment protocol.
Behavioral reward system. Most children who undertake an inten-

sive behavioral treatment program such as HRT benefit from a sys-
tematic rewards program to boost motivation and compliance.
Cognitive strategies. Cognitive strategies are used to enhance the

early recognition of tic urges and accurate labeling of these urges to
facilitate greater control over tic behaviors (e.g., Schwartz, 1998).
Through the use of these strategies, youngsters are trained to recog-
nize and label tic urges in a conscious manner to facilitate the use of
the CR or other attempts to resist tic urges. Analogies are often
employed to provide the child with a better understanding of his or her
tics and the rationale underlying HRT. As an example, befitting the
geographical location of our clinic, we often employ the analogy of a
surfer riding a wave to explain HRT. The urge to tic and eventual
expression of the urge can be seen as a wave breaking on the beach.
The youngster can either try to “stop the wave” (completely block the
tic urge) which is not likely to succeed, or else “ride the wave” control-
ling it with his or her HRT “surfboard” (express the tic but in a con-
trolled and less conspicuous manner; Piacentini & Chang, 2001).
CASE REPORT
BA was an 11-year-old boy who was brought to the clinic by his

mother for evaluation and treatment of TS. BA presented with a 2-year
history of various motor tics. Mother first reported noticing motor tics
at age 9 years at the start of the fifth grade. Simple facial tics, such as
eye blinking and rolling, emerged first followed by other facial tics,
including nose wrinkling and mouth grimacing, which developed in
the subsequent months along with simple hand, arm, and shoulder
movements that consisted primarily of stretching and shrugging
motions. In the past 2 months, BA had also developed a simple vocal
tic that consisted of a low guttural noise in the back of his throat. BA’s
tics were not highly distressing to him or his family until about 1 year
ago, when during a school choir performance, he experienced an

intense paroxysm of tics that included gross movements of his shoul-

ders, arms, and trunk. This episode, which was unmistakably notice-
able to others, was very embarrassing to BA and his parents. Since that
time, the family had sought a neurological evaluation that resulted in
BA being given the diagnosis of TS. At the time of this clinic presenta-
tion, BA had no history of psychotropic medication treatment for his
tic disorder or any other psychiatric condition and was in good physi-
cal health. BA and his parents noted that they did not want to follow a
recent recommendation for medication treatment and were instead
seeking an alternative to psychopharmacological treatment.
As part of his initial clinic evaluation, BA underwent a comprehen-
sive diagnostic evaluation that included the Yale Global Tic Symptom
Severity Scale (YGTSS; Leckman et al., 1989). On the YGTSS, BA
and his mother described his tics as being generally simple in charac-
ter, mostly of moderate intensity, and occurring frequently (at the rate
of every few minutes) that yielded a YGTSS Global Severity Score of
38/50. BA’s illness was rated as markedly ill on the Clinical Global
Improvement Scale. Tic-associated impairments in social, family, and
academic realms were overall in the mild range. However, BA did
report significant subjective distress about his tics, as well as a grow-
ing sense of helplessness about their occurrence. According to his
mother, BA’s distress about the increasing frequency and visibility of
his tics had negatively affected his self-esteem and led him to express
thoughts about hurting himself, although he had no current plan or
past history of such behavior. BA did not demonstrate any obsessive
or compulsive symptoms on the Children’s Yale-Brown Obssessive
Compulsive Scale (CY-BOCS; Goodman, Price, Rasmussen, Riddle,
& Rapoport, 1991) and, apart from TS, did not meet criteria for any
other DSM-IV disorder. Following completion of this evaluation, BA
was offered an 8-week course of HRT. Delivery of this treatment was
guided by a detailed treatment manual (Piacentini & Chang, 2000).
The first treatment session was focused on gathering pertinent his-
tory, providing psycho-education about TS, and building rapport. The
tic hierarchy, consisting of all of BA’s tics rank ordered in terms of
associated distress, was created by BA and the therapist. A functional
analysis was also conducted to better delineate any particular pattern
that may have characterized BA’s tic occurrences. BA reported that

some of his tics (eye blinking, finger and neck stretching) were pre-
ceded by a buildup of a sense of pressure in the localized body area,
which was relieved when the tic motion was performed. He denied
any specific thoughts or emotions preceding any of his tics. The func-
tional analysis indicated that BA’s tics tended to decrease in frequency
when he was focused and engaged in certain activities like soccer or
videogames. In contrast, when he was actively thinking or talking
about his tics, they tended to increase in frequency and intensity. Tics
were also reported to be exacerbated by anxiety-provoking situations
such as public performances (e.g., choir performance, spelling bee)
and physical fatigue. Following completion of the behavioral evalua-
tion, BA and the therapist completed the habit inconvenience review,
or Tic Hassles List. Items included negative attention from his peers at
school, sense of helplessness, tic disruption of ongoing activities, and
physical pain from his arm-jerking tic. Each list item was discussed,
and the therapist provided empathetic feedback to BA while also not-
ing the importance of treatment for eliminating these negative prob-
lems. After completion of the hassles list, the therapist reviewed the
treatment rationale for habit reversal and emphasized to BA, and his
mother, the importance of their active participation and effort in the
treatment program.
Next, awareness training was introduced as the first step in helping
BA become more aware of, and ultimately being better able to man-
age, his tics. BA was asked to choose one tic to monitor in session with
his clinician. He chose a shoulder shrug tic (rated as a 3 or mildly dis-
turbing on his tic hierarchy) to monitor. BA was asked to describe his
shoulder tic in physical detail during the session and record the
description in a tic diary that he kept and reviewed on regular occa-
sions. BA was also asked to look in a mirror in session as he performed
the tic to check the physical description of his tic and to obtain direct
visual feedback. If he did not demonstrate the tic spontaneously in
session, BA was asked to deliberately perform the tic motion. Follow-
ing this, a monitoring procedure was introduced in session. BA was
asked say the letter t whenever he noticed his shoulder tic occurring. If
he missed a tic, the therapist would say the letter t as a reminder. As an
initial homework assignment, BA and his mother were asked to prac-
tice monitoring the shoulder tic for 30 minutes at a time on 3 to 4 sepa-

rate days during the next week. They were instructed to separately
note with paper and pencil each time the targeted tic occurred during
the monitoring interval. Mother was also encouraged to say the letter t
or some other brief alternative signal whenever BA demonstrated the
tic to generalize awareness outside the times assigned to homework.
BA was also given a manual counter with a lever that he could push to
record the number of tics he experienced during the course of his day.
He was encouraged to use the counter during homework sessions and
during other times at home and at school. The counter was small
enough to fit into his pocket and easy to use which served to encourage
active self-monitoring. BA’s mother was also asked to videotape BA at
home while he was engaged in a routine activity like homework or
watching TV to provide a sample of spontaneous tic activity.
Review of the homework at the next session revealed that initially,
BA’s ratings were lower than his mother’s. However, during the course
of the week, BA and his mother achieved greater rating concordance
as BA’s self-awareness of his tics increased. The therapist also
reviewed the videotapes of BA to provide BA with an objective view
of what his tics looked like. In session, BA and the therapist separately
monitored the shoulder tic for the first few minutes of the session to
check his level of tic awareness.
When the therapist was able to establish that BA was a relatively
reliable observer of his shoulder tic, the CR technique was introduced.
BA’s therapist worked with him to develop a physical CR (i.e., to pull
his shoulders down and hold his elbows into his body) to his shoulder
tic that he could easily implement as soon as he felt the slightest urge
to tic. BA and the therapist practiced the CR several times to make sure
that BA was implementing it correctly. BA reported an increasing
sense of pressure in his upper back prior to expressing the shoulder tic,
and this sensation served as the signal for BA to engage in his CR.
However, BA was told to practice the CR even if the tic had already
occurred to practice and routinize the CR into his motor repertoire.
BA was also instructed to sustain the CR for at least a full minute or
until the urge to tic had passed. To enhance his sense of time, BA and
his therapist practiced holding the CRs for 1, 2, 3, and 5 minutes at a
time. BA was asked to practice the CR for the rest of the therapy ses-
sion. Each successful implementation was praised by the therapist. On

those occasions when BA missed the opportunity to employ the CR,

the therapist gently prompted him to practice the CR even though the
tic had already passed. Homework involved self-monitoring and
implementing the CR to the target tic for a 30-minute block 4 times a
week, and then practicing the CRs as much as he could outside these
assigned times at home and at school. Mother was encouraged to posi-
tively support BA with verbal praise whenever she noticed him imple-
menting the CR outside of assigned times, and to remind him when
she noticed a missed tic. Outside the treatment sessions, both of BA’s
parents were actively involved in his homework assignments, serving
to monitor tics and provide reminders for the CRs.
After BA had demonstrated the reliable use of the CR for his shoul-
der tic, a second tic, namely, arm jerking, was selected and the aware-
ness and/or monitoring procedures were repeated. This process was
repeated throughout the remainder of treatment. Although attempts
were made to identify and practice CRs that utilized muscles isometri-
cally opposed to the targeted tic movement, it was stressed to BA and
his mother that the goal of treatment was not necessarily to completely
block physical expression of the tics right away. Instead, it was
emphasized that the use of the CR would help BA to better modulate
his movements and, in doing so, to decrease the intensity and impact
of his tics. CRs were also chosen that would provide BA an alternative
physical expression contingent on tic urge that would be more socially
adaptive and acceptable. For example, the CR to BA’s arm-jerking tic
was designed so that initially he was to raise his arm up only halfway
rather than the full swing of his original tic. As this CR became
increasingly easier to implement, BA began to practice bringing his
arms closer toward his sides in a process of successive approxima-
tions. Similar shaping procedures were used to develop and practice
CRs for other tics on BA’s hierarchy.
In addition to the awareness and CR training, relaxation techniques
were introduced into treatment at Sessions 4 and 5. The association
between anxiety, stress, and tic exacerbation was explained to BA and
his mother, and BA’s specific stress triggers were identified. Strategies
that he utilized when feeling stressed or anxious were reviewed
(including going to his room to read, playing with his dog, etc.), and
relaxation techniques were introduced as a means to supplement his

current coping strategies. Diaphragmatic breathing and progressive

muscle relaxation were taught to BA, and he was instructed to practice
them at home several times a week and to monitor his relaxation levels
before and after each practice session. Eventually, as he became more
proficient with the relaxation techniques, BA was instructed to utilize
them before upcoming stressful events (choir performance, spelling
contest, etc.) along with his CRs.
BA’s level of compliance and motivation was generally good. BA
and his mother worked with the clinician early in treatment to set up a
reward program where he would earn a sticker for every homework
assignment completed. After earning a set number of stickers, BA was
able to trade them in for a reward agreed on by him and his mother.
Rewards were generally earned every week to 2 weeks, and enhanced
BA’s homework compliance. BA’s mother was an active participant in
all aspects of the treatment. Part of every session was spent with the
mother alone, obtaining feedback about treatment progress at home
and at school, discussing any family concerns and stressors, and pro-
viding social support to the family around BA’s tic disorder. The
importance of family involvement and support of the treatment pro-
gram was continually emphasized and discussed.
The final session involved a thorough review of all the techniques
taught in previous sessions, particularly awareness and CR training.
All the previously learned CRs were reviewed, and BA practiced gen-
erating CRs for potential future tics to ensure he had learned the con-
cepts behind the CR training. Relapse prevention training also
involved reviewing the steps to be taken in case of renewed tic exacer-
bation, which included self-monitoring, CR development, relaxation
training, and professional consultation as needed.
By the end of treatment, BA’s tic disorder had improved signifi-
cantly. He and mother reported his tics as very much better since the
beginning of treatment, and BA’s overall level of illness at the end of
treatment was rated on the Clinical Global Improvement Scale as
mildly ill compared to the baseline rating of markedly ill. BA received
a YGTSS Global score of 18/50 (53% drop from baseline). In addi-
tion, BA also expressed improved self-esteem based on feelings of
greater control over his tics and on knowledge that he had techniques
at his disposal to use when he needed them.

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John Piacentini, Ph.D., ABPP, is professor in residence, director of the UCLA Child
OCD, Anxiety, and Tic Disorders Program, and chief child psychologist, Medical Psy-
chology Program, in the Division of Child and Adolescent Psychiatry at the UCLA-
Neuropsychiatric Institute. His primary research interests involve development and test-
ing of evidence-based treatment approaches for childhood disorders, most notably

chronic tic disorders, obsessive-compulsive and other anxiety disorders, and suicidal
behavior in adolescents. He is currently chair of the Tourette Syndrome Association
(TSA) Behavioral Sciences Consortium and principal investigator for an ongoing
National Institute of Mental Health (NIMH) controlled multisite study examining the effi-
cacy of habit reversal training (HRT) for child and adolescents with chronic tic disor-
ders. His publications have appeared in New England Journal of Medicine (as part of the
RUPP Anxiety Study Group, 2001), Journal of Cognitive Psychotherapy (with R. L. Berg-
man, 2001), in Advances in Neurology (with S. Chang, 2001), Journal of Anxiety Disor-
ders (with R. L. Bergman, C. Jacobs, J. McCracken, & J. Kretchman, 2002), and in Child
and adolescent therapy: Cognitive-behavioral procedures (with J. March & M. Franklin,
in press).
Susanna Chang, Ph.D., is a research psychologist in the UCLA Child OCD, Anxiety and
Tic Disorders Program, Division of Child and Adolescent Psychiatry, UCLA-
Neuropsychiatric Institute. She is recipient of an NIMH Minority Faculty Supplement,
member of the Tourette Syndrome Association (TSA) Behavioral Sciences Consortium,
and has served as co-principal investigator for multiple funded assessment and treat-
ment studies in pediatric tic disorders. In addition to child treatment research, Her
research interests include the neurocognitive aspects of childhood disorders, especially
OCD and chronic tic disorders. Her publications appeared in Advances in Neurology
(with J. Piacentini, 2001), in Handbook of Serious Emotional Disturbance in Children
and Adolescents (with J. Piacentini, 2002), and in Journal of Developmental and Behav-
ioral Pediatrics (with D. Woods, J. Piacentini, & M. Himle, in press).

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Behavior Modification

Habit Reversal Training for Tic Disorders in Children and Adolescents

The online version of this article can be found at:

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Habit Reversal Training for Tic

Keywords: child/adolescent; Tourette’s syndrome; tic disorders; behavior therapy; habit

Given their complex etiology and variable clinical manifestations,

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behavioral, interventions have historically played an important, albeit

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relationship between sensory phenomena and tics may be analogous

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and Nunn (1973) treated 12 individuals with habits or tics and

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Riddle, 1995; Sallee, Nesbitt, Jackson, Sine, & Sethuraman, 1997;

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DESCRIPTION OF HABIT REVERSAL

As originally specified by Azrin and Nunn (1973), HRT consisted

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efficacy and increase motivation for treatment. The primary compo-

Awareness training is based on the premise that increased aware-

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ANXIETY MANAGEMENT TECHNIQUES

The use of anxiety management techniques for tic control is based

Operant conditioning in the form of contingency management is

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contingencies can be documented, the use of operant techniques as an

MOTIVATIONAL AND/OR ANCILLARY TECHNIQUES

Although Miltenberger et al. (1985) reported that awareness train-

Habit inconvenience review. Early in treatment, the child and thera-

Creation of a tic hierarchy. At the beginning of treatment, the child

Social support. Other family members, and at times teachers and

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use of awareness techniques and other treatment tasks, tic-free inter-

Behavioral reward system. Most children who undertake an inten-

Cognitive strategies. Cognitive strategies are used to enhance the

BA was an 11-year-old boy who was brought to the clinic by his

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intense paroxysm of tics that included gross movements of his shoul-

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those occasions when BA missed the opportunity to employ the CR,

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current coping strategies. Diaphragmatic breathing and progressive

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Downloaded from http://bmo.sagepub.com by Anca Grigorovici on October 31, 2008

Downloaded from http://bmo.sagepub.com by Anca Grigorovici on October 31, 2008

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