Habit reversal training (HRT) is a form of Cognitive Behavioral Therapy that systematically targets tics. The idea behind HRT is that even though tics are generated neurobiologically, they are enhanced by conditioning. Specifically, the urge to have a tic is uncomfortable, and by having one, the discomfort is removed in the short term. The tic is therefore rewarding, and the behavior is reinforced. The more tics one has, the more difficult it becomes to stop having them. In HRT, the object is to refrain from having the tic until the urge passes. Below is a step by step guide to the basics:

• First, the child is taught to recognize when a tic is coming, either by noting the premonitory
  urge or by the first muscle movements of the tic itself. This is practiced until the child learns to reliably predict tics. (An approach for children who find it difficult to recognize the premonitory urge is to time the frequency of the tics, and then challenge him or her to increase the time between tics, moving perhaps from having a tic every few seconds to having them several minutes apart.)


• The child is taught to make a competing movement using the same muscle groups: for example, if the tic is to make a kissy noise, the child is taught to blow out or whistle. If the tic is to twist the head to the right, the child is taught to actively move the head left, or make circles with the head. This motion is continued for a few minutes until the urge to tic passes.


• Often, the child is encouraged to keep a tic diary. Because tics can be worsened or induced by specific situations, this helps identify those situations, and strategies to reduce the influence of those situations are devised.


• General relaxation and anxiety reducing strategies are also taught, because anxiety itself worsens tics.


• When a child uses these skills—even when they are not immediately effective—he or she must be rewarded. To that end, therapists work with the family to increase the social support for the child’s use of the strategies in situations outside the therapy office.

The use of competing movements itself is not the therapeutic intervention. Rather, it is the consistent experience of not giving in to the urge to tic that reduces tics overall. Psychoeducation is particularly important, or you risk families thinking you have merely substituted one bizarre motion for another. Habit reversal has been shown to be effective in reducing tics in several studies (for a review, see Himle MB et al, J Child Neurol 2006;21(8):719–725). Although the studies are small and conducted in both children and adults, the outcomes were excellent. The majority of subjects experienced a 50% to 99% reduction in tics. The improvement was generally maintained over the length of the follow up period, the longest of which was six months.