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From Chapter 4: Behavior Therapies for Tourette Syndrome by John Piacentini, Ph.D

Medication is, by far, the most commonly used treatment for Tourette syndrome, and it can be very effective. Clinical trails have shown that medication can reduce tic symptoms by anywhere from 25 to 80 percent. However medication doesn't work in all cases. Even when it is effective, unwanted side effects and other safety concerns can limit the use of some medications, especially with children (see Chapter 3).

Increasingly, researchers have been looking at behavior therapies--most prominently Habit Reversal Training, but also functional interventions--as alternative treatments for tic disorders. These are used either as an addition to medication or as stand-alone treatments. Much of this recent work has been conducted by members of the Tourette Syndrome Association Behavioral Sciences Consortium.A¹

WHAT IS BEHAVIOR THERAPY?

Just about every parent knows the basic premise of behavior therapy (even if you've never put a name to it): Reward a child (or adult, or animal) for a given behavior, and she'll tend to repeat it. That's why handing your toddler a cookie every time she starts whining doesn't produce a well-behaved child--it produces a whiny, overweight child. You've taught (or conditioned) her to whine by pairing the behavior with a reward.

Wouldn't it be great if we could eliminate tics just by withholding cookies? (That's a sacrifice most kids with TS would gladly make!) Unfortunately, it's a lot more complicated than that. Most behaviors are rewarded in subtle ways that might not be evident to either you or your child. A behavior therapist is a trained, objective third party (usually a psychologist) who can analyze the way in which a behavior is rewarded (or reinforced), and then come up with an alternate plan of reinforcement to modify the behavior.

Does lumping tics in with other behaviors that can be changed through behavior therapy imply that a child's tics are deliberate? Absolutely not! Although it may seem counterintuitive, scientists learned years ago that even involuntary behaviors can be influenced through behavioral conditioning. Perhaps the most common example of this is the development of a fear or phobia following a frightening situation. For example, someone who got stuck in an elevator may experience all the physiological symptoms of anxiety (e.g., rapid heartbeat, shortness of breath, sweating, muscle tension, etc.) the next time they need to ride one. Fortunately, the same conditioning process that created the fear can also be used to alleviate it.

Behaviorists look at two different types of reinforcement that may strengthen a behavior. Positive reinforcement occurs when a behavior is rewarded by something good--a word of praise, a cookie, or even some less tangible inner reward, such as a sense of satisfaction. Negative reinforcement, on the other hand, occurs when a behavior is rewarded by removing something bad or unpleasant. For example, if an annoying little brother goes away when your child punches him, the punching is being negatively reinforced. Or how about that the whining toddler....if she stops whining when mom gives her a cookie, then mom is receiving negative reinforcement for her own behavior!

A Word about Punishment
If rewarding a behavior makes it increase, then punishing it should make it decrease... right? Well, sometimes. Punishment--following an unwanted behavior with a bad/unpleasant response (e.g., a spanking or a dirty look)--can be very tricky. A child may associate the punishment with the punisher, rather than with the behavior. That is, she may attribute the punishment to the fact that the punisher is a mean person, rather than the fact that she did something wrong. Or she may associate the punishment with getting caught, which just encourages her to hide the behavior. Alternatives to punishment used in behavior therapy include extinction (removing whatever reward is reinforcing the unwanted behavior) or time out (removing the child, for a limited period of time, from the circumstances that are reinforcing the unwanted behavior).

Punishment, we know, is not an appropriate approach to treating a tic disorder. Fear of punishment makes a child feel stressed and anxious. And what happens when a child with TS feels anxious? She tics. If she has obsessive-compulsive (OC) symptoms as well, she may increase her ritualistic behaviors. While a child may be able to suppress her symptoms for a short period because she is afraid she'll be punished for them, her worries about being punished for her tics will more than likely lead to more tics rather than fewer. In fact, behavioral theory would predict that the child's tics would be especially bad whenever she was around the person threatening punishment, since this would be such an anxiety-provoking situation. Unfortunately, the use of punishment often ends up making the problem worse rather than better. No child should ever be put in this position.

Fortunately, there are more effective ways of dealing with tics through behavior therapy. The most well-studied behavioral method, by far, is Habit Reversal Training.

HABIT REVERSAL TRAINING

Habit Reversal Training (HRT) was first developed about thirty years ago to treat what was, back then, called nervous habits (hence the term habit reversal). This included not only tics--which were considered nervous habits by some clinicians and researchers at that time--but also nail biting, thumb sucking, compulsive hair pulling, skin picking or scratching, and nose picking. Over time, researchers and therapists found HRT often could be successfully used to treat all of these problems, as well as the tics associated with TS.

HRT is related to a strategy many people with TS already use: replacing a tic with a more socially acceptable behavior. For example, a person with arm-jerking tic might run his fingers through his hair at the end to make the tic look like a more purposeful behavior. However, the ultimate goal of HRT is not simply to camouflage or hide the tics, but, rather, to greatly lessen, and in some cases, eliminate the premonitory urge and/or the tics altogether.

Not every tic is worth tackling. If a tic doesn't cause your child any injury, embarrassment, or social difficulties, the best thing you can do is learn to ignore it. Some tics can be more distressing for Mom and Dad--who are observing them--than for the child who's actually experiencing them. Therapy--be it HRT or pharmaceuticals--usually isn't advisable for a child who isn't bothered by her minor tics.

A¹Including John Piacentini, Ph.D., Chair, and Susanna Chang, Ph.D. (UCLA); John Walkup, M.D. & Golda Ginsburg, Ph.D. (Johns Hopkins University); Douglas Woods, Ph.D. (University of Wisconsin-Milwaukee); Sabine Wilhelm, Ph.D. and Thilo Deckersbach, Ph.D. (Massachusetts General Hospital/Harvard University); Alan Peterson, Ph.D. (University of Texas San Antonio Health Sciences Center); and Lawrence Scahill, MSN, Ph.D. (Yale University).