1. Wallis, Laura


Habit-reversal training disrupts tics.


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Appropriately delivered behavioral interventions can effectively reduce tics and tic-related impairment in children with Tourette's or chronic tic disorder, according to a study published in the May 19 issue of JAMA. The randomized controlled trial, including 126 children recruited from December 2004 through May 2007 (ages nine through 17 years), found that when compared with supportive therapy and education, a comprehensive behavioral intervention resulted in greater reductions in symptoms and tic severity. The magnitude of response was comparable to results achieved in other studies through antipsychotic medications.

Figure. Campers part... - Click to enlarge in new windowFigure. Campers participate in a team-building exercise at a summer camp for children with Tourette's disorder in Ingleside, Illinois. Photo by Candice C. Cusic /

This could be good news for anyone working with patients who have Tourette's disorder. "It's an intervention that nurses in advanced practice can learn," said Lawrence Scahill, professor of nursing and child psychiatry at Yale University and one of the authors of the study. "It gives them options beyond just prescribing medication."


Tourette's disorder is a chronic neurologic disorder characterized by tics-typically brief, rapid movements or vocalizations. In most patients, the tics begin in childhood and peak in severity in adolescence, leading to significant social impairment.


Those with the disorder often experience a premonitory urge before the tic-an unpleasant sensation that's relieved by its execution.


The researchers randomly assigned trial participants to either eight sessions of behavior therapy over 10 weeks or a control treatment consisting of supportive therapy and education. Those who responded positively to either treatment received three monthly booster treatment sessions and were reassessed at three and six months after treatment.


The intervention therapy focused primarily on habit-reversal training-helping patients to recognize the premonitory urge before the tic (tic awareness) and then to engage in a voluntary behavior physically incompatible with the tic until the urge subsides (competing-response training). An example would be to practice slow, rhythmic diaphragmatic breathing upon noticing that a vocal tic is about to occur. This allows patients to manage the urge in a more socially acceptable manner and to disrupt the negative reinforcement cycle that encourages the tics.


Habit-reversal training isn't the same as deliberate tic suppression-an approach that's often dismissed because of its implication that combating the disorder is a matter of will power.


"Behavioral modification is not about asking patients to grit their teeth," said Scahill. "The treatment is not about suppression, but rather about making use of the natural phenomena of tics to lead us down a different pathway." In addition, the approach allows patients to take an active, positive role in their treatment.-Laura Wallis




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Piacentini J, et al. JAMA 2010;303(19):1929-37.