Pediatr Invest 2020 Jun; 4(2): 127-132 127

REVIEW

Review of habit reversal training for tic disorders

Shijie Liu1    Ying Li2    Yonghua Cui2

1
Xibeiwang Community Health Center
in Haidian, Beijing, China Abstract
2
Department of Psychiatry, Beijing Tic disorders (TD) is a neurodevelopmental disorder that is often first
Children’s Hospital, Capital Medical recognized in children and adolescents and is characterized mainly by motor
U n i v e r si t y, Na tio n a l Ce n ter fo r and phonic tics. Drug treatment of TD has been criticized because of serious
Children’s Health, Beijing, China side effects, and TD treatment emphasizes behavioral psychotherapy.
This study reviewed the most common behavioral psychotherapy for
Correspondence TD: habit reversal training (HRT). We examined the contents, variation,
Ying Li, Department of Psychiatry, curative effects, and premonitory urge control of HRT and other behavioral
Beijing Children’s Hospital, Capital
psychotherapies. The findings suggest that current understanding of HRT
Medical University, National Center
is insufficient and further studies are needed. First, studies of online
for Children’s Health, Beijing 100045,
China guidance training are needed to implement technology that can help more
Email: [email protected] patients. Second, the future integration of HRT and other technologies is
Yo n g h u a C u i , D e p a r t m e n t o f important. Third, imaging techniques could be used to further explore the
P s y c h i a t r y, B e i j i n g C h i l d r e n ’s brain mechanisms underlying HRT. Research on HRT for TD in China is
Hospital, Capital Medical University, insufficient. We call on more Chinese researchers to study, investigate,
National Center for Children’s Health, and develop technology to promote the development of behavioral
Beijing 100045, China psychotherapy for TD in China.
Email: [email protected]
Keywords
Received: 14 March, 2020
Tic disorders, Habit reversal training, Comprehensive behavioral
Accepted: 23 April, 2020
intervention for tics, Premonitory urges

Introduction transcranial magnetic stimulation).4 Our previous studies

on drug therapy for TD have shown that the efficacy of
Tic disorders (TD) is a neurodevelopmental disorder aripiprazole is stable.5 However, owing to the chronic
that is often first recognized in children and adolescents nature of TD, pharmacological treatment is often long-
and is characterized mainly by motor and/or phonic tics. term and has been criticized for its side effects, such as
TD is generally divided into three categories: transient somnolence, weight gain, and extrapyramidal syndrome.6
TD, persistent (chronic) motor or vocal TD, and Tourette
syndrome (TS).1 Some studies have estimated that about Therefore, non-drug treatment of TD has increasingly
60%–80% of children with TD experience symptoms attracted attention. Non-drug therapy mainly comprises
that can last until the age of 16 years, and about 23% psychological and behavioral interventions and
of adolescents experience moderate and severe tics, neuromodulation techniques (e.g., transcranial magnetic
which seriously affect social functioning.2 At present, stimulation, transcranial direct current stimulation, and
TD treatments mainly include both drug therapies (e.g., deep brain stimulation). Of these therapies, behavioral
aripiprazole and tiapride hydrochloride) 3 and non- psychotherapy has been gradually recognized as safe
drug therapies (e.g., habit reversal training [HRT] and and effective. 7 Currently, there are several kinds of

DOI: 10.1002/ped4.12190

This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any
medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.
2020 Chinese Medical Association. Pediatric Investigation published by John Wiley & Sons Australia, Ltd on behalf of Futang Research Center of Pediatric
Development.
128 wileyonlinelibrary.com/journal/ped4

psychological and behavioral interventions for TD. The Two stages: stage one comprises sessions 1–8. These
most common is HRT, which forms the basis of the contain four main parts: tic awareness training, competing
comprehensive behavioral intervention for tics (CBIT).8 response training, relaxation training, and intensive
Psychosocial and behavioral interventions for TD have training. The second stage is mainly a review and
been recommended in Europe and Canada as a first-line consolidation stage.
TD treatment.9,10 The latest guideline from the American
Academy of Neurology also suggests HRT as a first-line Twelve sessions: the first session introduces the basic
treatment of TD.11 As they worry about medication side process, familiarizes patients with reversal training, and
effects, many parents of children with TD are willing to introduces the methods and procedures. Sessions 2–6
try HRT. occur weekly and develop different competitive behaviors
for different tic symptoms. Sessions 7 and 8 occur every
Drug therapy remains the dominant treatment of TD 2 weeks and mainly review and consolidate the contents
in China; only a few institutions offer behavioral of sessions 2–6. Sessions 9–12 occur every 4 weeks, and
psychotherapy for TD, and it is usually non-standard. consolidate and review the previous training.
This review focused on the following aspects of HRT:
1) an introduction to HRT; 2) variation in HRT; 3) the Variations of HRT: CBIT
curative effect of HRT; 4) the key to HRT: premonitory CBIT is a new comprehensive intervention method
urge control; 5) other behavioral psychotherapies. Finally, first proposed by Woods in 2008. 13 CBIT is a highly
we provide a brief overview of the limitations and future
structured behavioral therapy. The standard therapy is
development of this method.
to complete eight treatments in 10 weeks; treatments
can be personalized according to the specific needs of
Overview of HRT
patients. The method consists of three parts: the first
Content of HRT part familiarizes patients with their own tic symptoms
and premonitory urges; the second part teaches patients
HRT is the main behavioral psychotherapeutic approach competing responses that can be used when premonitory
for TD. HRT consists of three basic steps, two stages, and urges or tic symptoms occur (similar to HRT); the third
twelve sessions.12 step consists of adjustment of daily activities, especially
those that aggravate or induce tic symptoms (for example,
Three basic steps: (1) awareness training: guiding children
tic symptoms are usually aggravated when children
to notice premonitory urges (the sensation before a tic
encounter stressful situations), thereby reducing the
occurs); (2) competing response training: identifying
likelihood of tic symptoms. CBIT is based on HRT. It
competing responses for each tic; for example, breathing
provides an analysis of and response to environmental
could be selected as a competing response for vocal
stimuli that affect the occurrence of tic symptoms. CBIT
tics, and breathing through the nose for sniffing tics; (3)
is a type of tic symptom management strategy and can
intensive training: selecting a family member to assist
be regarded as a supplement and extension of HRT. In
the child to complete the competing response intensive
addition to training of awareness and competing responses,
exercise (Figure 1).
CBIT includes relaxation training and psychoeducational

Figure 1 Three basic steps of habit reversal therapy

Pediatr Invest 2020 Jun; 4(2): 127-132 129

intervention for events and environmental factors that same time, we need to take into account the effect of
affect tic severity. Patients are required to actively cultural factors and age. Personalized treatment based on
participate in the whole treatment process.12 HRT may be developed in the future.

Some researchers have suggested that CBIT should be The efficacy of HRT
regarded as a first-line treatment option for children over 9 Several studies have confirmed that HRT can significantly
years of age with TD.1 Although CBIT may be effective for reduce TD symptom severity. 4,19,20 A meta-analysis of
young TD children, there is still a lack of evidence-based TD behavioral interventions showed that behavioral
medical support. Wilhelm et al14 randomly divided 122 therapy yields medium to large effects.21 Research on
patients with moderate or higher TS or chronic tic disorder HRT has gradually increased over the past 5 years. Such
(CTD) into two groups: one group was treated with CBIT research indicates that HRT is safe and effective, and also
and the other group was treated with psychoeducation and highlights problems with drug treatment. Moreover, HRT
supportive therapy (PST). After 10 weeks of intervention, has been implemented in various ways. For example,
the CBIT group showed a more obvious alleviation of online HRT has been used as a remote TD intervention
tic symptoms than the PST group, and follow-up after that is cost-effective for parents.22 Group-based HRT has
6 months of intervention showed that CBIT remained been used for group therapy and has produced clinical
effective in 80% of patients with tic symptoms, whereas improvements in symptoms.23 Dutta et al24 reviewed five
PST remained effective for 25% of patients, suggesting randomized controlled studies on the treatment of TS and
that CBIT was superior to psychoeducation in reducing CTD in children and adults with HRT. The results showed
the severity of tics and had better long-term efficacy. that HRT significantly reduces tic severity in children and
Rowe et al15 conducted eight CBIT training sessions with adults with TS and CTD. A study by Yates et al25 randomly
30 TD children and their parents; compared with baseline, divided 33 CTD and TS children aged 9–13 years into
children’s tic severity and anxiety/depression levels a HRT group and a psychoeducation group. Tic severity
reduced after treatment, and their self-perceived cognitive was alleviated in both groups, and children’s quality of
ability improved. life improved; HRT was more effective in reducing motor
tic symptoms than psychoeducation. A follow-up study of
In addition to reducing tic severity, CBIT can also improve 28 children after 12 months by Dabrowski et al23 showed
the self-esteem of patients with TS or CTD. Weingarden that HRT and psychoeducation improved children’s long-
et al16 randomly divided 122 patients over 16 years old term tic symptoms, quality of life, and school attendance
with IQs >80 into CBIT and PST intervention groups. rate; compared with the psychoeducation intervention
These included 88 patients with no clinical comorbidity group, the total tic score in the HRT group decreased more
and 34 patients with at least one of attention deficit/ significantly. These studies have confirmed the stable
hyperactivity disorder (ADHD), obsessive–compulsive efficacy of this method for both adults and children, and
disorder, mood disorder, or anxiety disorder. The baseline its ability to improve tic symptoms and social functioning.
results showed that self-esteem scores were significantly
lower in the comorbidity group than in the simple TS HRT is becoming increasingly popular with families, and
or CTD groups, and self-esteem scores were negatively more parents are choosing behavioral psychotherapy as a
correlated with the severity of comorbidity and depression, TD treatment for their children and adolescents. Online
but had no association with tic severity. After 10 weeks guided HRT is a future development trend. Recent studies
of intervention, self-esteem scores in the comorbidity confirmed its effectiveness by showing that HRT based
group with CBIT intervention were significantly on the guidance of therapists and led by parents had a
improved compared with baseline, whereas self-esteem therapeutic effect of 1.12 and a response rate of 75%; the
scores in the PST group showed no significant change. effect lasted more than 12 months after the intervention
A randomized controlled study by Chang et al17 showed and was more acceptable to parents than other treatment
that CBIT intervention significantly reduced tic severity types.26,27
in children with TS. TS is often accompanied by ADHD
and neurocognitive impairment, but CBIT has no effect on Finally, it should be pointed out that although there have
neurocognitive function in children. Specht et al18 showed been many studies on the efficacy of HRT, the method
that, as CBIT intervention emphasizes the influence of has some limitations. First, a single evaluation index of
environmental factors on tic symptoms, it is therefore HRT’s curative effect tends to be used, the Yale Global
effective in managing or eliminating those environmental Tic Severity Scale (YGTSS), but less attention has been
factors that affect tic occurrence. However, it does not paid to associated obsessive–compulsive symptoms,
substantially improve premonitory urges. emotional and behavioral problems, and possible cognitive
impairment. Premonitory urges have been particularly
The emergence of CBIT indicates that HRT needs further neglected. Second, curative effect evaluation uses simple
development and updating. Continuous application and statistical analysis (e.g., paired t-tests or calculation of pre-
evaluation of the method is needed to improve it. At the and post-intervention efficacy values), and experimental
130 wileyonlinelibrary.com/journal/ped4

controls are not rigorous. Third, most studies focus on symptoms, as well as an important index of the severity
TD in adults; there is little evidence for the use of HRT in of tic symptoms. Our previous meta-analysis further
children and adolescents, particularly in China. confirmed the association between premonitory urges and
tic symptoms.33
The key to HTR: Premonitory urges
On the basis of the previous studies, we suggest that 1)
The first step in HRT is the awareness exercise, and the premonitory urges are an indispensable component of the
object of awareness is the premonitory urge. What is occurrence of tic symptoms; 2) premonitory urges form the
a premonitory urge? A premonitory urge, also known basis or initial symptoms of tic symptoms; 3) premonitory
as a sensory tic, is a special type of tic symptom, and urges indicate the severity of tic symptoms; 4) subsequent
is a sensation that occurs before the occurrence of tic tic symptoms are needed to alleviate premonitory urges;
symptoms.28 Before the occurrence of a tic, there will be and 5) premonitory urges can be regarded as recessive tics
local or overall discomfort, such as “throat itching” before and tic symptoms as dominant tics, which complement
vocal tics and neck discomfort before shrugging shoulders. each other.
Tic symptoms occur to alleviate these sensations. 29
Premonitory urges are more common in patients with Other behavioral treatments for TD
TS. As early as 1993, Leckman et al 30 reported that
nearly 92% of TS children had premonitory urges. The In recent years, many other psychological and behavioral
most common locations of a premonitory urge are the interventions have emerged for TD (Table 1). Some of
head, neck, shoulder, and abdomen. Premonitory urges these methods are the application of existing psychological
are more likely to occur before complex symptoms, and and behavioral techniques in TD treatment, and some
to occur less before simple symptoms such as blinking. have been developed based on HRT. Although the clinical
This suggests that premonitory urges indicate more efficacy of these techniques requires further verification,
complex tic symptoms. At present, the most commonly they provide more clinical options for TD behavioral
used assessment of premonitory urge is the nine-item psychotherapy, especially for children who fail to respond
Premonitory Urge for Tics Scale (PUTS) developed by to HRT.
Woods in 2005.31 This has been widely used to assess
premonitory urges.
Limitations and future prospects
We can draw the following conclusions from the evidence
We previously reported two special tic cases, both of
discussed in this article:
which had tongue itching as the first symptom and often
featured tongue biting to relieve the itching.32 We have also (1) There are two major steps to HRT: perceiving
encountered a large number of clinical cases that showed premonitory urges and developing competing
premonitory urges as the first symptoms. Moreover, we responses to replace tic symptoms.
have found that premonitory urges appear more in children (2) HRT is the most widely used treatment for TD. Its use
with TS, suggesting that they may be a pre-symptom of tic is mostly evidence-based, but there is little evidence

Table 1 Psychological and behavioral interventions for tic disorders

Psychological and behavioral intervention technique Central principle
Allow the child actively repeat the target tics symptom, thus causing reaction inhibition
Massed negative practice (MNP)34
or fatigue, and finally the extinction of the symptoms.
Let the patient record the frequency of tics, improve their self-awareness of tic
Self-monitoring (SM)35
symptoms, so as to reduce tics.
Continuously expose the child to premonitory urges, break the positive strengthening
Exposure with response prevention (ERP)36 cycle of premonitory urges and tics, gradually adapt the patient to this impulse, and
reduce tics.
Intervene in the negative cognition that causes tics symptoms, rather than the tic
Cognitive behavioral therapy (CBT)37
symptoms themselves.
Assertiveness training (AT)38 Teach patients how to confidently face their tics symptoms, and make responses.
A psychophysiological therapy based on inducing two different physiological states of
Biofeedback training (BT)39
sympathetic arousal and relaxation.
Change behavior through stimulating control and positive reinforcement, which is widely
Contingency management (CM)13
used in the treatment of material dependence.
Relaxation training before the onset of tic symptoms (premonitory urge) to reduce the
Relaxation therapy (RT)40
occurrence of tics symptoms.
To accept rather than suppress the tic symptoms, and to reduce the occurrence of tics by
Acceptance and commitment therapy (ACT)41
adding relaxation training during tics.
Pediatr Invest 2020 Jun; 4(2): 127-132 131

from Chinese samples at present.   4. Nissen JB, Kaergaard M, Laursen L, Parner E, Thomsen
(3) HRT should be further developed and updated to meet PH. Combined habit reversal training and exposure response
the treatment needs of individuals of different cultural prevention in a group setting compared to individual
backgrounds, ages, and genders, and the integration of training: A randomized controlled clinical trial. Eur Child
other treatment techniques based on HRT is a future Adolesc Psychiatry. 2019;28:57-68.
research direction.   5. Cui YH, Zheng Y, Yang YP, Liu J, Li J. Effectiveness and
(4) Premonitory urges play an important role in HRT, and tolerability of aripiprazole in children and adolescents with
clarification of the relationship between premonitory Tourette’s disorder: A pilot study in China. J Child Adolesc
urges and tic symptoms would be useful in further Psychopharmacol. 2010;20:291-298.
investigations of the possible mechanisms underlying   6. Pandey S, Dash D. Progress in pharmacological and surgical
HRT. management of tourette syndrome and other chronic tic
(5) With the development of Internet technology, online disorders. Neurologist. 2019;24:93-108.
guidance from therapists to parents may be an   7. Houghton DC, Capriotti MR, Scahill LD, Wilhelm S,
important future development. Peterson AL, Walkup JT, et al. Investigating habituation
to premonitory urges in behavior therapy for tic sisorders.
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behavioral intervention of TD is not yet well developed in   8. Conelea CA, Wellen BCM. Tic treatment goes tech: A
China. First, there are few studies on HRT interventions review of TicHelper.com. Cogn Behav Pract. 2017;24:374-
in this area, and there is no evidence of its curative effect; 381.
second, although individual research centers have begun to   9. Steeves T, McKinlay BD, Gorman D, Billinghurst L, Day L,
apply psychological and behavioral interventions for TD, Carroll A, et al. Canadian guidelines for the evidence-based
non-standard implementation and low standardization are treatment of tic disorders: Behavioural therapy, deep brain
problems, indicating the necessity and urgency of research stimulation, and transcranial magnetic stimulation. Can J
in this area; third, HRT has not been tailored to specific Psychiatry. 2012;57:144-151.
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11. Pringsheim T, Holler-Managan Y, Okun MS, Jankovic J,
implementation process, evidence for a curative effect,
Piacentini J, Cavanna AE, et al. Comprehensive systematic
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