Reference Work Entry

Handbook of Clinical Psychology Competencies

pp 1403-1428

Tic and Habit Disorders

  • Christine A. ConeleaAffiliated withUniversity of Wisconsin-Milwaukee
  • , Benjamin T. P. TuckerAffiliated withUniversity of Wisconsin-Milwaukee
  • , Douglas W. WoodsAffiliated withUniversity of Wisconsin-Milwaukee


Repetitive behavior disorders, including tic and habit disorders, are thought to be relatively common among children and adolescents. Tic disorders are characterized by repetitive, sudden movements and/or vocalizations that are seemingly purposeless in nature. Habit disorders are typified by repetitive behaviors focused on the body and include trichotillomania, skin picking, nail biting, thumb sucking, and cheek chewing. Although these disorders may in some cases be benign and short-lived, clinical attention may be needed for children experiencing psychosocial impairment, physical damage, or emotional distress. The current chapter provides an overview of these disorders, their diagnostic assessment, and their purported etiology. Next, evidence-based psychosocial treatments for tic and habit disorders are described. The final portion of the chapter discusses the basic and expert clinician competencies needed to treat tic and habit disorders. Basic competencies include the ability to accurately implement function-based interventions and Habit Reversal Therapy, while expert competencies generally involve the ability to modify treatment for complex or non-responsive cases. The chapter concludes with suggestions to aid a clinician in the transition from basic to expert competence.


Repetitive behavior disorders, including tic and habit disorders, are thought to be relatively common among children and adolescents. Tic disorders are characterized by repetitive, sudden movements and/or vocalizations that are seemingly purposeless in nature. Habit disorders are typified by repetitive behaviors focused on the body and include trichotillomania, skin picking, nail biting, thumb sucking, and cheek chewing. Although these disorders may in some cases be benign and short-lived, clinical attention may be needed for children experiencing psychosocial impairment, physical damage, or emotional distress. The current chapter provides an overview of these disorders, their diagnostic assessment, and their purported etiology. Next, evidence-based psychosocial treatments for tic and habit disorders are described. The final portion of the chapter discusses the basic and expert clinician competencies needed to treat tic and habit disorders. Basic competencies include the ability to accurately implement function-based interventions and Habit Reversal Therapy, while expert competencies generally involve the ability to modify treatment for complex or non-responsive cases. The chapter concludes with suggestions to aid a clinician in the transition from basic to expert competence.

51.1 9.1 Overview

51.1.1 9.1.1 Tic Disorders

Tic disorders are characterized by repetitive, sudden, and seemingly purposeless motor movements and/or vocalizations. Tics can range from simple behaviors that go unnoticed by the casual observer (e.g., forceful eye blinks or throat clearings) to highly conspicuous and complex vocal and motor patterns (e.g., complete words and phrases or complex hand gestures). Tics are commonly found in pediatric populations, with recent epidemiological studies finding tics in 17–21% of children (Kurlan et al., 2002; Peterson, Pine, Cohen, & Brook, 2001). Estimates of the prevalence of Tourette Syndrome (TS), the most severe tic disorder diagnosis, are relatively varied. However, recent research indicates a prevalence of 0.15–1.1% in school-aged children, and a male to female ratio of 4:1 to 6:1 (Coffey et al., 2000; Kadesjö & Gillberg, 2000).

Tic disorders typically develop during early childhood and tend to follow a waxing and waning course, with symptom characteristics changing over time. The onset usually occurs between the ages of 5 and 8 years (Jagger et al., 1982; Leckman, King, & Cohen, 1999; Peterson et al., 2001). Simple motor tics in the head and face region usually appear first, and may be followed by the development of motor tics in the mid-section and extremities, vocal tics, and complex tics (Jagger et al.; Leckman et al., 1999). Also, most children eventually develop bodily sensations (i.e., premonitory urges) preceding their tics, which may be relieved upon tic occurence (Leckman, Walker, & Cohen, 1993; Woods, Piacentini, Himle, & Chang, 2005). Symptoms tend to reach peak severity around the ages of 10–12 years, followed by a steady decline and minimal symptoms as the adolescent reaches adulthood (Bloch et al., 2006; Coffey et al., 2000; Leckman et al., 1998). Adults who retain TS diagnostic status tend to be the most severe patient population (Leckman et al., 1999).

Children with tic disorders often experience impairment in psychosocial functioning and psychiatric comorbidity. Obsessive-compulsive disorder (OCD), attention-deficit/hyperactivity disorder (ADHD), anxiety, mood, and disruptive behavior disorders commonly co-occur and are more likely to be seen in children with tic disorders than those without (Kadesjö & Gillberg, 2000; Kurlan et al., 2002). Presence of comorbidities contributes significantly to negative psychosocial outcomes, but the tics themselves also have been found to be related to negative peer perceptions, poorer social desirability, more negative family functioning, and lower academic performance (e.g., Boudjouk, Woods, Miltenberger, & Long, 2000; Packer, 2005; Stokes, Bawden, Camfield, Backman, & Dooley, 1991; Wilkinson et al., 2002; Woods, 2002).

51.1.2 9.1.2 Habit Disorders

Habit disorders are characterized by body-focused repetitive behaviors (BFRBs), such as hair pulling, skin picking, nail biting, thumb sucking, and cheek chewing. With exception of hair pulling, which may be diagnosed as trichotillomania (TTM), formal diagnostic categories for most BFRBs do not exist and are usually considered stereotypic movement disorders (SMD).

The BFRBs appear to be relatively common among children and adolescents. In many children, these behaviors can be relatively benign and short-lived. However, others will experience significant physical and psychological impairment. Prevalence estimates of BFRBs in children are relatively sparse and mostly limited to hair pulling. An epidemiological study of hair pulling among youth found a lifetime prevalence of 1% and current hair pulling in 0.5% (King, Zohar et al., 1995). It has been suggested that 20–60% of post-preschool age children bite their nails (Friman, Byrd, & Oksol, 2001). In adults, pathological skin picking has been found in approximately 2% of dermatology patients (Griesemer, 1978) and 4% of college students (Bohne, Wilhelm, Keuthen, Baer, & Jenike, 2002; Keuthen et al., 2000). However, skin picking has been relatively under-studied in child populations.

Retrospective reports by adults with BFRBs indicate a typical onset during childhood. The average age of onset for TTM is in early adolescence (around the ages of 12 and 13 years; Christenson, Mackenzie, & Mitchell, 1991; Cohen et al., 1995) and is 15 years for skin picking (Wilhelm et al., 1999). Adults with other BFRBs also report onset during childhood (Croyle & Waltz, 2007). However, these behaviors may begin at any age, with reports ranging from <1 year to late adulthood (Christenson et al., 1991).

The BFRBs can cause significant tissue damage (e.g., skin lesions and hair loss) as well as impairment in functioning and quality of life. Individuals with BFRBs commonly report elevated levels of depression, anxiety, and stress; and low self-esteem, shame, and impairment in social, home, and occupational functioning (Croyle & Waltz, 2007; du Toit, van Kradenburg, Niehaus, & Stein, 2001; Flessner & Woods, 2006; Stemberger, Thomas, Mansueto, & Carter, 2000; Woods et al., 2006). Those presenting with pathological BFRBs commonly meet the criteria for additional psychiatric diagnoses. Depression, anxiety, substance-use disorders, eating disorders, body-dysmorphic disorder, and personality disorders are the most common (Christenson, 1995; Christenson et al., 1991; Wilhelm et al., 1999). Little is known about comorbidity in children with BFRBs. However, small clinical samples of children with TTM have identified comorbid psychiatric conditions in the majority of subjects, with depression, anxiety, and disruptive behavior disorders being especially common (Hanna, 1997; King, Scahill et al., 1995; Reeve, Bernstein, & Christenson, 1992).

51.2 9.2 Recognition of Symptoms and Their Assessment

A comprehensive clinical assessment of tic and habit disorders includes gathering information (a) for differential diagnosis, (b) to describe symptom topography, (c) to ascertain maintaining factors, (d) to determine functional impact, and (e) to examine possible comorbid conditions.

51.2.1 9.2.1 Tic Disorders

The DSM-IV-TR (American Psychiatric Association, 2000) includes four tic disorder diagnoses: TS, chronic motor or vocal tic disorder (CMTD, CVTD), transient tic disorder (TTD), and tic disorder not otherwise specified (TDNOS). TS is characterized by the presence of at least two motor tics and at least one vocal tic at some point during the client’s life, with daily or intermittent occurrence for more than 1 year, during which there may not be a tic-free period lasting for more than 3 consecutive months. The onset must occur before the age of 18 years. Criteria for CMTD and CVTD are identical to TS, except that only motor or vocal tics, but not both, are present. TTD may be diagnosed if tics occur many times a day, nearly everyday for at least 4 weeks, but no longer than 12 months. TDNOS is reserved for presentations that do not meet the criteria for a specific tic disorder (e.g., onset after the age of 18 years or tics lasting less than 4 weeks; American Psychiatric Association).

In conducting a differential diagnosis, the clinician should be aware of conditions that have presentations similar to tic disorders. For instance, symptoms of OCD can resemble complex tics (e.g., repetitive touching and tapping). In these cases, it is important to determine whether significant anxiety and obsessions (e.g., a feared consequence for not performing the behavior) precede the target behavior, in which case, the movement or vocalization may be a symptom of OCD. A SMD may also appear similar to a tic disorder and should be considered if a pervasive developmental disorder is also present and/or the movements appear rhythmic, intentional, and self-soothing. In some cases, it will be necessary to refer the client to a neurologist or psychiatrist to rule out alternative neurological conditions (e.g., Sydenham’s chorea or Huntington’s disease) causing the movements suspected as tics.

The clinician should list each tic and gather detailed information on its topography, frequency, intensity, functional interference, controllability, and associated premonitory urge phenomena. The use of self-report instruments (e.g., The Yale Tourette Syndrome Symptom List-Revised; Cohen, Detlor, Young, & Shaywitz, 1980; The Parent Tic Questionnaire; Chang, Himle, Tucker, Woods, & Piacentini, in press; The Premonitory Urge for Tics Scale; Woods et al., 2005) and semistructured clinical rating scales (e.g., The Yale Global Tic Severity Scale; Leckman et al., 1989) can facilitate this process and should be delivered throughout the course of treatment. The clinician should also conduct a functional assessment by interviewing the child and the parent/guardian regarding environmental antecedents and consequences (e.g., parental reaction to tics and stressful and anxiety-provoking situations) that may play a role in tic maintenance. A thorough diagnostic assessment of other psychiatric disorders should be included, because frequently comorbid conditions (e.g., disruptive behavior disorders, ADHD, and anxiety) can be more impairing than the tics themselves (Kadesjö & Gillberg, 2000).

51.2.2 9.2.2 Habit Disorders

As discussed previously, the DSM-IV-TR does not include diagnoses for specific BFRBs, with the exception of hair pulling which may be diagnosed as TTM. Criteria for TTM include (a) recurrent pulling out of one’s hair causing noticeable hair loss; (b) an increased sense of tension immediately before pulling or when attempting to resist pulling; (c) pleasure, gratification, or relief during pulling; (d) the behavior not better explained by another mental disorder (e.g., OCD or a psychotic disorder) or medical condition (e.g., alopecia); and (e) the pulling that causes clinically significant distress or impairment (American Psychiatric Association, 2000). However, in the case of a child, a diagnosis may still be warranted even in the absence of criteria (b) and (c), because a young client may be unable to verbalize these feelings, and a large percentage of youngsters with significant hair pulling do not report associated tension and/or gratification (American Psychiatric Association; Hanna, 1997). A SMD diagnosis should be considered for patients presenting with other BFRBs. The essential features of a SMD are a repetitive, seemingly driven, nonfunctional motor behavior that interferes with functioning or causes physical injury requiring treatment (American Psychiatric Association). If mental retardation is also present, the behavior must be severe enough to become a focus of the treatment (American Psychiatric Association). Again, one should also rule out other medical or psychiatric conditions as the cause of the behavior or the observed tissue damage. Other possible psychiatric diagnoses to consider include body dysmorphic disorder, psychotic disorder, and OCD.

Prior to beginning treatment, it is essential that the clinician gathers detailed information on the topography of the BFRB, severity of symptoms, and environmental antecedents and consequences. It is helpful to establish operational definitions of the BFRB by asking the client to describe the ways in which they perform the behavior (e.g., the use of fingernails to pick skin, or tweezers to pull hair) and the bodily location(s) on which it occurs. Measures of symptom severity should also be taken throughout the course of treatment to evaluate treatment progress. However, to date, the only severity measure for child and adolescent populations with acceptable psychometric characteristics is the Trichotillomania Scale for Children, which includes a child- and parent-report version (TSC; Tolin et al., 2008). A detailed functional assessment of the BFRB of interest should be conducted to facilitate treatment planning. Furthermore, detailed information should be gathered on the environmental situations and internal events (e.g., body-related cognitions or negative affect) that precede the target behavior as well as its consequences (e.g., reduction of negative affect affect or pleasurable bodily stimulation). It is also important to examine the areas of life impacted by the behavior (e.g., impairment in home and school responsibilities, peer relationships, and general well-being and quality of life). Finally, a thorough assessment of possible comorbid disorders should be included, since, like tic disorders, symptoms of other disorders (e.g., depressive symptoms) may be more impairing than the habit itself (Diefenbach, Tolin, Hannan, Crocetto, & Worhunsky, 2005; Keuthen et al., 2004).

51.3 9.3 Maintenance Factors of the Disorder or Problem

51.3.1 9.3.1 Tic Disorders

Symptoms of tic disorders are maintained by both underlying neural dysfunction and environmental antecedents and consequences that develop tic-controlling properties (Himle, Woods, Piacentini, & Walkup, 2006).

Research on the biological bases of tic disorders has focused primarily on the role of cortical-striato-thalomo-cortical (CSTC) circuits and the neurotransmitter dopamine (DA). The CSTC circuits are involved in the planning, modification, and initiation of motor movements, and the involved brain structures communicate through DA and other neurotransmitters, such as glutamate and gamma-aminobutyric acid (GABA). It has been proposed that tic disorders arise and persist because of excessive excitation and decreased inhibition in cortical regions involved in CSTC circuits and increased DA production and receptor sensitivity (see Leary, Reimschisel, & Singer, 2007 for a review).

Tics arise from dysfunction in these brain structures and neural circuits and may be influenced and partially maintained by internal and external environmental events and consequences. Perhaps, the most frequently examined environmental factor in the maintenance of tic disorders is the premonitory urge. Premonitory urges seem to develop after the initial appearance of tics (Leckman et al., 1993) and may eventually develop controlling properties over the tics themselves, as the reduction or removal of the urge following a tic can function as a negative reinforcer (Himle et al., 2006; Woods et al., 2005). As will be discussed later in this chapter, decreasing the premonitory urge’s control over tics potentially is an important mechanism of change in successful behavioral treatment.

A number of other environmental antecedents and consequences seem to play a role in the waxing and waning pattern of tic disorders, and to a certain extent, the maintenance of the disorder itself. Antecedent variables such as presence of others, social situations, tic-related talk, and emotional distress have all been associated with increases in tics (O’Connor, Brisebois, Brault, Robillard, & Loiselle, 2003; Silva, Munoz, Barickman, & Friedhoff, 1995; Watson & Sterling, 1998; Woods, Watson, Wolfe, Twohig, & Friman, 2001). Consequence variables such as social attention and tangible reinforcers have also demonstrated controlling properties over tic frequency (Watson & Sterling, 1998; Woods & Himle, 2004).

51.3.2 9.3.2 Habit Disorders

Less is known about the etiology of habit disorders than that of tic disorders. However, like tic disorders, BFRBs seem to be maintained by environmental antecedents and consequences. Mansueto, Stemberger, Thomas, and Golomb (1997) have proposed a behavioral model of TTM, in which conditioned stimuli associated with the urge to pull, discriminative stimuli for pulling itself, various behaviors associated with pulling, and reinforcing consequences for pulling all play a role in TTM maintenance. Many of these factors have been supported by subsequent research and seem to play a role in the persistence of TTM and other BFRBs.

Most attention has been given to the reinforcing effects of BFRBs and their role in the persistence of the behavior. Research using both self-report and experimental designs has suggested that BFRBs often result in decreased tension, anxiety, and boredom (Diefenbach, Mouton-Odum, & Stanley, 2002; Diefenbach, Tolin, Meunier, & Worhunsky, 2008; Wilhelm et al., 1999). Other researchers have emphasized the role of positively reinforcing consequences in BFRBs. Individuals often report increased pleasure and satisfaction while engaging in a body-focused habit (Diefenbach et al., 2008; Wilhelm et al., 1999), and subsequent behaviors such as manipulating pulled hair with one’s hands or mouth can be positively reinforcing (Mansueto et al., 1997; Rapp, Miltenberger, Long, Elliot, & Lumley, 1998). The tendency to perform BFRBs in a conscious, goal-directed manner (e.g., to achieve a reinforcing consequence) has been termed “focused” pulling/skin picking (Christenson et al., 1991; du Toit et al., 2001; Flessner et al., 2007; Walther, Flessner, Conelea, & Woods, 2009).

The BFRBs can also be maintained owing to their occurrence outside of one’s awareness. It is quite common for sufferers to report engaging in the behavior while distracted by a different activity (e.g., reading or watching TV) and realizing what has been done only after seeing the product of the behavior (e.g., the accumulation of pulled hair). This behavioral style has been termed “automatic” pulling/picking, and the extent to which automatic pulling/picking occurs varies across individuals (Christenson et al., 1991; du Toit et al., 2001; Flessner et al., 2007; Walther et al., 2009).

51.4 9.4 Evidence-Based Treatment Approaches

51.4.1 9.4.1 Tic Disorders

Although the mainstay of tic disorder treatment is pharmacotherapy, a growing body of support exists for psychosocial treatments, particularly Habit Reversal Training (HRT). There is also limited support for the use of an adapted version of Exposure and Response Prevention (ERP).

HRT is a multicomponent behavioral treatment package designed to (a) increase the client’s ability to detect tics and their warning signs; (b) teach the client a behavior that is incompatible with the tic (i.e., a competing response) that can be performed following a tic or a warning sign; (c) enhance motivation to practice the techniques and recruit social support; and (d) provide for the generalization of tic awareness and competing response performance to the everyday environment (Azrin & Nunn, 1973). Commonly used techniques include awareness training, self-monitoring, competing response practice, relaxation training, contingency management, and tic inconvenience reviews (Azrin & Nunn, 1973; Azrin & Peterson, 1990; Wilhelm et al., 2003; Woods et al., 2008). HRT also includes psychoeducation about tic disorders and function-based interventions designed to target antecedents and consequences to the tics (Woods et al.).

HRT and simplified forms involving at least awareness training, competing response training, and social support (Miltenberger, Fuqua, & McKinley, 1985; Woods et al., 1996) have demonstrated considerable effectiveness as treatments for tic disorders (Himle et al., 2006). Studies utilizing single-subject experimental designs (multiple baselines or alternating treatments) and direct observation as outcome measures have shown mean decreases in tic frequency ranging from 38% to 96% posttreatment, and maintenance of treatment gains for the majority of subjects at follow-up (see Himle et al. for a review). In single-subject studies of HRT for children with tics, large reductions at posttreatment and follow-up have been observed in vocal tics (Woods & Twohig, 2002; Woods, Twohig, Flessner, & Roloff, 2003) and motor tics (Azrin & Peterson, 1989; Finney, Rapoff, Hall, & Christophersen, 1983; Miltenberger et al., 1985).

Several studies utilizing randomized controlled group designs have shown HRT to be superior to several control conditions including wait-list (Azrin & Peterson, 1990), negative practice (Azrin, Nunn, & Frantz, 1980a), and supportive psychotherapy (Deckersbach, Rauch, Buhlmann, & Wilhelm, 2006; Wilhelm et al., 2003). Cook and Blacher (2007) recently conducted an analysis of the empirical literature on psychosocial treatments for tic disorders (consisting of studies using either single-subject or randomized controlled trial designs) and concluded that HRT could be considered a well-established treatment according to the criteria established by the American Psychological Association Task Force for Promotion and Dissemination of Psychological Procedures (1995) (Chambless et al., 1998).

ERP has also shown promise as a treatment for tic disorders. It is most typically used as a treatment for OCD and involves repeatedly exposing the patient to his/her obsessions, while preventing the performance of neutralizing compulsions. Given the frequent co-occurrence of OCD and TS, and similarities in the functional relationship between obsessions and compulsions to that of premonitory urges and tics, ERP has been adapted as a treatment for TS. In this approach, the client is exposed to the premonitory urge sensations that precede his/her tics and must prevent the occurrence of tics, in the hope that habituation to the premonitory urge will occur and result in subsequent reductions in tic frequency.

In a recent outcome study, Verdellen, Keijsers, Cath, and Hoogduin (2004) compared HRT to ERP in 43 participants with TS (aged 7–55 years). HRT and ERP were found to produce equivalent reductions in both objective measures of tic frequency and tic severity scores. The results of this study indicate that ERP can be considered as a probably efficacious intervention for tic disorders that warrants further investigation and independent replication (Cook & Blacher, 2007).

51.4.2 9.4.2 Habit Disorders

Although the treatment outcome literature for habit disorders is under-developed when compared to that of tic disorders, especially among child and adolescent populations, a few approaches have shown promise. The approach most frequently examined and with the strongest empirical support is HRT. There is also growing evidence to support the use of a combination of acceptance and commitment therapy (ACT; Hayes, Strosahl, & Wilson, 1999) and HRT for BFRBs (Twohig & Woods, 2004; Woods & Twohig, 2008; Woods, Wetterneck, & Flessner, 2006).

HRT for BFRBs was also developed by Azrin and Nunn (1973); it follows the same general protocol as HRT for tic disorders. Patients are taught to recognize the behavior and its warning signs as they occur and to perform a competing response. Social support, psychoeducation, and function-based interventions are also important components.

The outcome studies generally support HRT’s effectiveness for a range of BFRBs. Early group studies compared HRT with negative practice for the treatment of TTM (Azrin, Nunn, & Frantz, 1980b), nail biting (Azrin, Nunn, & Frantz, 1980c), and other oral habits (e.g., lip biting and chewing; Azrin, Nunn, & Frantz-Renshaw, 1982). In each report, HRT out-performed negative practice. More recent outcome studies have also shown positive results for HRT. Twohig, Woods, Marcks, and Teng (2003) conducted a trial comparing HRT with a placebo control for the treatment of nail biting. Significantly greater increases in nail length were observed at posttreatment and follow-up in the HRT group than in the placebo control group. Also, a recent trial compared HRT for skin picking with a wait-list control condition, and found a significantly greater decrease in self-reported skin-picking episodes and independent ratings of physical damage in the HRT group, with maintenance of gains at follow-up (Teng, Woods, & Twohig, 2006). Also of note, van Minnen, Hoogduin, Keijers, Hellenbrand, and Hendriks (2003) conducted a randomized controlled trial comparing behavior therapy, fluoxetine, and wait-list control in patients with TTM. The results demonstrated significantly greater reductions in symptom severity in the behavior therapy group when compared with the fluoxetine group and the wait-list control group. Importantly, the behavior therapy condition largely consisted of techniques commonly used in HRT (e.g., self-monitoring, stimulus control, and incompatible responses). Controlled group studies of behavioral treatments for BFRBs in children are quite limited. However, in a recent open trial of Cognitive Behavioral Therapy (consisting of HRT components, cognitive restructuring, and relapse prevention) for pediatric TTM, decreases in pulling severity at posttreatment and follow-up were observed, with the majority of subjects being identified as treatment responders (Tolin, Franklin, Diefenbach, Anderson, & Meunier, 2007).

There has been recent interest in combining HRT with ACT as a treatment for TTM. ACT seeks to decrease the influence of aversive internal states on behavior through techniques designed to increase one’s ability to accept rather than avoid or deliberately alter these experiences. Because pulling is often performed to manage negative affect or reduce an urge (Christenson, Ristvedt, & Mackenzie, 1993), incorporating techniques to promote the acceptance of urges or feelings into HRT may improve treatment effectiveness. A recent trial compared HRT plus ACT to a wait-list control condition, and found significantly greater reductions in pulling severity, anxiety, and depression in the treatment group (Woods et al., 2006). This combined treatment package has also demonstrated effectiveness in the majority of subjects in single-subject experimental studies for both TTM (Flessner, Busch, Heideman, & Woods, 2008; Twohig & Woods, 2004) and skin picking (Flessner et al., 2008). There is some evidence to suggest that ACT without HRT may be a promising treatment for BFRBs (Twohig, Hayes, & Masuda, 2006), but further investigation is needed. It is also important to note that the ACT plus HRT treatment package is yet to be investigated in pediatric populations.

51.5 9.5 Mechanisms of Change

51.5.1 9.5.1 Tic Disorders

Behavioral treatments for tic disorders are effective, and several hypotheses have been proposed regarding the mechanisms through which they have their effect. Although no outcome studies have directly examined potential mediators using established data analytic techniques (see Baron & Kenny, 1986), indirect evidence from treatment trials, laboratory experiments, and correlational studies suggest several potential mediating variables.

A functional magnetic resonance imaging study of tic suppression (Peterson et al., 1998) provides clues regarding the possible role of CSTC circuits in mediating response to behavioral treatments. In this study, significant changes in activation were observed in several brain regions involved in CSTC circuits during a tic suppression task. These findings suggest that effective behavioral treatment incorporating tic suppression training (i.e., HRT) could exert its effect by producing changes in brain activity in regions implicated in voluntary tic suppression. Another important proposed mechanism of change is habituation to the premonitory urge. Tics appear to be maintained partially by the negatively reinforcing effect of their removal or reduction of the premonitory urge (Himle, Woods, Conelea, Bauer, & Rice, 2007). Therefore, decreasing the premonitory urge’s control over tics may be an important mediator of successful behavioral treatment. In support of this hypothesis, ERP, the behavioral treatment of choice for OCD, whose effects seem to be due to habituation to the anxiety response (Grayson, Foa, & Steketee, 1982), may also be effective in tic disorders (Verdellen et al., 2004). It has also been demonstrated that subjective ratings of urge severity decrease both within and between ERP sessions, suggesting that habituation to the urge may be a mechanism of change in behavioral treatment (Verdellen et al., 2008).

51.5.2 9.5.2 Habit Disorders

Although behavioral treatments for BFRBs appear to be quite effective, little is known about the factors that may mediate their effect. However, as is the case in tic disorder, indirect evidence from several lines of research has implicated some candidates for a mechanism of change.

One possible mechanism of change in BFRB treatment is reduction of experiential avoidance. Experiential avoidance is a behavioral tendency to avoid unpleasant internal states and is believed to be a common maintaining factor in many psychiatric disorders (Hayes, Wilson, Gifford, Follette, & Strosahl, 1996). BFRBs are often performed to reduce aversive feelings (Christenson et al., 1993; Diefenbach et al., 2002, 2008; Walther et al., 2009; Wilhelm et al., 1999), suggesting that experiential avoidance may play a role. In support of this proposition, research has shown that experiential avoidance is positively correlated with symptom severity (Begotka, Woods, & Wetterneck, 2004) and may mediate the effect of negative cognitions on pulling (Norberg, Wetterneck, Woods, & Conelea, 2007). Furthermore, in subjects treated with ACT plus HRT, decreases in pulling severity were moderately correlated with decreases in experiential avoidance (Woods et al., 2006). Despite these preliminary supportive findings, the experiential avoidance hypothesis needs to be tested using more methodologically rigorous studies.

Another possible mechanism of change is increased awareness of the BFRB. As mentioned previously, BFRBs are often performed without the patient’s knowledge while he/she is distracted by another activity. A major goal of HRT is to increase awareness of the behavior, which may be an important mechanism of change for those who engage in the habit in a more “automatic” fashion.

51.6 9.6 Basic Competencies of the Clinician

In addition to nonspecific therapeutic skills central to all behavioral interventions, the basic competencies needed by a clinician treating TS and BFRBs include providing a treatment rationale, delivering psychoeducation, conducting a functional assessment and implementing function-based interventions, conducting HRT, assigning homework, maintaining motivation, and taking care to prevent relapse. A list of both basic and expert competencies associated with behavioral treatment of TS and BFRBs is provided in Table 9.1.
Table 9.1

Basic and expert clinician competencies associated with the treatment of tic and habit disorders

Basic competencies

Expert competencies


•Provide the treatment rationale

•Provide accurate psychoeducation about tic disorders and BFRBs

•Conduct a functional assessment

•Design and implement function-based interventions

•Implement core HRT procedures, including awareness training, competing response training, and social support

•Assign homework

•Maintain motivation and reduce noncompliance

•Establish procedures to prevent relapse

•Adapt treatment to meet the needs of children with commonly occurring comorbid disorders (e.g., ADHD, OCD, ODD, PDD)

•Address compliance difficulties related to the premonitory urge

•Enhance awareness training for those with limited awareness of the target behavior

•Troubleshoot client complaints related to competing response procedures

•Apply HRT to complex tics

•Address BFRBs that occur at night or during sleep

•Ensure generalization of treatment gains to multiple settings


Providing a treatment rationale. Client expectations should be addressed at the onset of therapy. Given the chronic nature of TS and its waxing and waning symptom pattern, clinicians working with this population should ensure that the child and parent have a reasonable picture of “treatment success.” Within the treatment rationale, clinicians should emphasize that HRT aims to help the child learn to manage tics to his/her satisfaction rather than to “cure” tics. It may also be beneficial to help the client attribute gains to the treatment, as some clients may have the tendency to attribute symptom reduction to natural waning or other extraneous situations (e.g., less stress during a summer vacation).

The treatment rationale provides the client with information regarding the two major features of treatment: function-based interventions and competing response training. When presenting the rationale for function-based interventions, clinicians should ensure that the client understands the treatment well, and in part, focus on modifying the client’s environment to help reduce the likelihood of the behavior and/or its impact. The clinician should explain that the treatment, particularly the competing response, is designed to help the client manage symptoms rather than completely eliminate them (particularly in the case of tics).

A metaphor can sometimes help children and their families understand the rationale better. For example, many children are familiar with asthma, so the clinician can explain that a competing response is a tool used to manage tics/habits, just like an inhaler used as a tool to manage asthma symptoms. To parallel the function-based intervention component, the clinician could point out that children with asthma also try to change situations to make their symptoms less likely to happen (e.g., stay away from allergens, avoid too much exertion, try to stay relaxed). Using such a metaphor can also help to normalize and destigmatize the child’s experience and help them to be more willing to engage in treatment.

Psychoeducation. Often, children and their parents seek information about the disorder. Also, clients often come to treatment with inaccurate information obtained through hearsay or unreliable sources on the internet. Psychoeducation is designed to address these issues and can help to address issues of stigma and anxiety related to the child’s diagnosis by normalizing the child’s and family’s experiences.

Before implementing psychoeducation, clinicians should have sufficient understanding of tic and habit disorders. Basic psychoeducation competencies include being able to describe and/or answer questions about the definition of a disorder and its differences from other diagnoses, etiology, common symptoms and phenomenology, prevalence, commonly co-occurring difficulties or disorders, course, and prognosis. Psychoeducation can also be used to inform the family about outside resources, such as national organizations or local patient support groups, or to dispel myths related to the disorder (see Woods, Conelea, & Walther, 2007). Clinicians can access psychoeducation information by reading relevant research studies, review articles, or books (e.g., Swain, Scahill, Lombroso, King, & Leckman, 2007; Woods & Miltenberger, 2001; Woods, Piacentini, & Walkup, 2007). The clinicians can also access information on support group websites designed to educate treatment providers (TS: www.​tsa-usa.​org; Trichotillomania: www.​trich.​org).

Functional assessment and function-based interventions. Functional assessments are interviews conducted with the goals of operationally defining the target behavior; predicting the situations, settings, or times when the target behavior is most likely to occur; and identifying behavioral functions that may maintain or exacerbate expression of the behavior (Kratochwill & McGivern, 1996).

Creating operational definitions of the child’s tics/habits is an important step early in the treatment. This step aids the clinician in the functional assessment process and may begin to enhance awareness by encouraging the child and parents to understand the behavior in greater detail. Clinician skills needed for this step include being able to generate detailed and comprehensive definitions that include antecedent and consequent phenomenological events, balance perceptions of the behavior that may differ between parent and child, and identify behaviors that the family may not be aware of (especially in the case of TS). For those with TS, it can be beneficial to adopt a child’s name for his/her own tics to help the child feel more comfortable describing or modeling them.

In the case of children with TS or multiple habits, hierarchies based on symptom distress are usually created to aid in treatment planning. Subsequently, HRT can be implemented for the child’s most distressing symptom first as a way to reduce functional impairment or interference. If hierarchies are used, the clinician should be able to help the child quantify the distress associated with each symptom. In addition, if the clinician is able to determine the reasons for the child’s distress (e.g., peers teasing the child), the clinician may also identify additional areas for intervention (e.g., peer education).

After defining the tics, the clinician should conduct a functional assessment interview. Competent clinicians should be familiar with the behavioral principles on which functional assessments are based, such as positive and negative reinforcement, stimulus control, and broader motivating factors. Clinicians should be able to apply this basic knowledge to identify possible antecedent factors that precipitate the behavior as well as the potential maintaining consequence variables. In cases where hypothesized maintaining factors can be re-created in session, the therapist may want to use functional analytic techniques to verify the effect of those factors by observing them directly. Familiarity with functional assessment and analysis procedures can be gained by reading general information about these procedures (e.g., mini-series edited by Neef & Iwata, 1994; Mace, Lalli, & Lalli-Pinter, 1991) and their use specifically in relation to TS and TTM (Miltenberger, Woods, & Himle, 2007).

After relevant antecedent and consequence variables have been identified, the clinician should use this information to develop function-based interventions. Function-based interventions generally fall into one of two categories (Newcomer & Lewis, 2004). First, for behaviors that are maintained by factors that are difficult to manipulate, intervention consists of teaching the child a functionally equivalent behavior as an alternative to the target behavior. HRT itself is built to address this function by teaching the use of a competing response as an alternate to the tic/habit. Second, when a functional assessment identifies contextual variables that exert stimulus control over the target behavior, interventions are designed to make changes specific to those variables. Woods et al. (2008) outlined five principles that clinicians can use to guide the development of function-based interventions. First, situations or settings associated with increases in the target behavior should be eliminated or minimized if possible. Second, maintaining events that follow occurrences of the target behavior should be eliminated, such as parent comfort or excusal from homework. Third, children should be reminded to use competing responses when situations associated with target behavior increases. Fourth, the child should be taught strategies (e.g., stress-reduction techniques) to minimize emotional reactions that may contribute to an increase in the target behavior. Fifth, the impact of the tic/habit on the child should be minimized. For example, the child’s peers could be educated about the child’s condition to reduce teasing. In addition to following these principles, clinicians may find it beneficial to familiarize themselves with the types of interventions that are recommended for situations and settings commonly reported to exacerbate tics or habit behaviors (for a review of commonly reported tic-exacerbating factors, see Conelea & Woods, 2008a).

For example, in the case of TTM, clients often report that the bathroom mirror elicits the urge to pull hair. In this case, possible interventions could include limiting the child’s time in the bathroom, dimming bathroom lights to make it harder to see individual hairs, putting a note on the mirror to remind the child to use a competing response, or asking the child to wear gloves while in the bathroom to make pulling more difficult. Clinicians can read published treatment literature to familiarize themselves with other examples of function-based interventions for TS (e.g., Carr, Sidener, Sidener, & Cummings, 2005; Woods et al., 2008), TTM (e.g., Rapp, Miltenberger, Galensky, Ellingson, & Long, 1999; Rothbaum, 1992; Woods & Twohig, 2008), and nail biting (e.g., Woods et al., 2001).

Core HRT skills. Core HRT skills include awareness training, competing response training, and social support.

Awareness training is used to enhance the child’s ability to recognize the target behavior and its “warning signs,” which can include urge sensations or movements preceding the behavior, such as raising the arm to start pulling. This segment of therapy is an interactive process that includes therapist modeling of the child’s tics/habits. The child also practices identifying the target behavior and its preceding sensations. Occurrences of target behaviors that are not recognized by the client are pointed out by the therapist. During this process, sensitivity on the part of the clinician is needed to ensure that the child does not feel mocked or scrutinized. Depending on the age of the child, it may be appropriate to couch awareness training as a “game” that the child can “win” by catching his/her own or therapist-simulated target behaviors. Verbal praise for correctly identified target behaviors can often help children stay engaged in the activity and reduce discomfort related to the activity.

Although awareness training for tics often involves detection of the urge, it is important to note that the urge is not a universal phenomenon among those with TS or TTM. Research suggests that many children do not report experiencing an urge (Banaschewski, Woerner, & Rothenberger, 2003), and this finding seems to be particularly true for children aged 10 years and younger (Woods et al., 2005). When children do not experience an urge, clinicians can focus awareness training entirely on recognizing other behaviors that tend to occur before the target behavior. For example, a child with a head-shaking tic may drop his/her chin slightly prior to a tic, or a child with TTM may engage in hair twirling or stroking prior to pulling. Clinicians can also direct more treatment efforts toward function-based interventions to reduce the likelihood of target behavior occurrences. Functional assessment results can also be used to recommend high-risk situations in which the child and parent can practice additional awareness training.

During competing response training, the clinician helps the child identify a behavior that is physically incompatible with the target behavior, maintainable for at least 1 min, socially inconspicuous, and compatible with the child’s usual activities. A basic competency for HRT is familiarity with commonly recommended competing responses, as well as the ability to work with the child to design a competing response for a less common behavior (e.g., an atypical tic).

Treatment manuals included in the book edited by Woods and Miltenberger (2001) contain possible competing responses. For BFRBs, competing responses consist of behaviors that prevent or limit hand movements, such as making a fist while holding the hand to the side, crossing the arms, putting the hands in pockets, or grasping an object, such as a pencil or a toy. Competing responses for tics vary depending on the type of tic the child has. For example, the competing response for a tic involving head movements is contraction of the neck so that the head is tilted downward slightly, while the competing response for a leg movement tic would be pressing the feet flat against the floor. Descriptions of other competing responses can also be found in a paper by Carr (1995).

For children who experience an urge prior to their tic or habit, it is important for the clinician to monitor the child’s experience of the urge during in-session competing response practice. The negative reinforcement hypothesis suggests that removal of the urge following the tic/habit negatively reinforces the behavior, making it more likely to occur in the future. Therefore, if a child’s urge has not dissipated while he/she is holding the competing response, the procedure may not be effective. Clinicians can monitor urge intensity by asking the child for subjective ratings during competing response practice. In this way, the clinician can ensure the loss of urge before the child releases the competing response. It is often helpful for the clinician to provide encouraging statements when the urge is particularly aversive. Clinicians may also want to graph the child’s urge experience to show the child that urge intensity can decrease on its own. Doing this across several trials may also help the child to see that urge intensity will decrease more quickly with additional practice.

For the social support component of HRT, clinicians can identify a person in the child’s life who is able to reward the child for using competing responses and remind the child to use them when tics or habits go unnoticed. In most cases, the best candidate for this role is the parent. However, clinicians should attend to the relationship dynamics between the child and individuals in his/her social environment to ensure that appropriate support persons are selected. For example, if an adolescent and his parents frequently argue, it may be more beneficial to recruit a friend or sibling to serve in the support role. Modifications to social support procedures could also be made, such as asking the parents to only focus on helping the adolescent a few times per week or developing less invasive reminders, such as a hand signal or code word.

Homework. Homework in HRT consists of self-monitoring and competing response practice. Self-monitoring generally occurs prior to competing response development to enhance the child’s awareness of the target behavior. Here, again, clinician’s competency with functional assessment procedures can be beneficial, as the clinician can recommend that homework assignments be completed during times or situations in which tics/habits are most likely to occur. Once the child learns the competing response for the tic/habits, competing response practice can also occur during these high-risk times or situations.

Given the importance of homework in HRT, clinicians should be capable of creating manageable homework assignments, rewarding homework compliance, and dealing with homework noncompliance. For children who frequently do not complete homework assignments, clinicians can use behavioral reward programs or a problem-solving process to identify and reduce any barriers to completion. Clinicians should also attend to the demands being placed on the child to ensure that homework assignments are reasonable. Shaping procedures can be used to reinforce gradual improvements in compliance. If the child is having difficulty implementing the competing response outside of therapy sessions, the clinician can work closely with the social support person to ensure that competing response use is prompted and rewarded on a regular basis.

Maintaining motivation. As HRT for tics and BFRBs is difficult, it is often useful to have strategies in place to enhance motivation and reduce noncompliance. Behavioral reward programs are often for this purpose. In a typical reward program, target behaviors are identified with the help of the child and parents. Such behaviors typically include attending therapy sessions, participating during in-session activities, and completing homework assignments. Rewards are identified and linked to specific point values, which can be attained by engaging in clearly identified treatment-related behaviors. Should a child demonstrate noncompliance or motivational difficulties, adjustments to the reward system may be beneficial, such as giving the child rewards or points for successive approximations to the desired behavior. In order to decrease frustration that comes with attempting to alter long-standing behavior patterns, it is important that rewards be contingent upon the child’s efforts and attempts to comply with the treatment, rather than on actual symptom reductions.

Relapse prevention. Given the chronic nature of TS and some BFRBs, relapse prevention is an important component of treatment. Clinicians should be able to discuss the likelihood of symptom relapses with the family and frame relapses as opportunities to focus on diligently using the tools learned throughout treatment. The clinician can help the family prepare for potential relapses by revisiting function-based recommendations and reminding the family that the situations previously identified as high risk are likely to be associated with symptom exacerbations in the future. The clinician should ensure that the parent and child are familiar with treatment procedures. Given the natural changes in tic repertoire that occur in TS, clinicians should ensure that the client is capable of developing competing responses for new tics that may emerge.

51.7 9.7 Expert Competencies of the Clinician

Expert clinician competencies in HRT generally involve the ability to treat more complex cases and adapt or modify treatment procedures when particular treatment components are problematic for a client.

51.7.1 9.7.1 Dealing with Complex Cases

Children with severe comorbid conditions or considerable diagnostic overlap are often more difficult to treat. A clinician working with these children needs to be well versed in diagnostic assessment and the subtle differences that distinguish one disorder for another.

OCD. A common example is the overlap with TS and OCD (Mansueto & Keuler, 2005). Some children with TS have repetitive behaviors that are difficult to categorize either as a complex tic or a compulsion, such as repeatedly tapping or touching objects, rewriting words, or stating particular phrases repeatedly. To distinguish between compulsive behavior and complex tics, it is important to keep in mind that tics and compulsions are distinguished not on the basis of their topography, but on the basis of their function. Compulsions often function to alleviate the worry or anxiety associated with an obsession and tend to be associated with cognitions about specific feared consequences. Tics, on the other hand, often function to alleviate a premonitory urge, which is a vague or transient somatic sensation. Expert clinicians should be able to make these diagnostic distinctions and plan treatment accordingly. Given that repetitive behaviors classified as compulsions rather than tics are likely to be more amenable to an ERP treatment approach than to an HRT approach, expert clinicians should also be competent in ERP.

ADHD. ADHD is also prevalent among children with TS and may warrant changes in the HRT protocol. For example, it is typically recommended that a child hold a competing response for at least 1 min. However, a child with ADHD, or even a young child, may find it difficult to hold the competing response for this duration. Therefore, it may be appropriate to ask the child to hold a competing response for a shorter duration. Although the effect of this modification on the outcome has not yet been studied empirically, it may at least help to bolster compliance by making the treatment more manageable for the child. A child with ADHD may also have difficulty staying on task during the session or completing homework as assigned. Clinicians may also implement a behavioral reward system to reward the child for staying on task during smaller intervals of the session or for approximations of homework completion. Behavior modification techniques that have been shown to be effective for children with ADHD (Chronis, Jones, & Raggi, 2006) could also be used by the therapist in session, as well as taught to the parents for home use. For example, desired behavior could be increased using praise or positive attention, and undesired behavior could be reduced using planned ignoring or time out (for a more complete description of these techniques, see Barkley, 1998).

Oppositional behavior. Children who are oppositional or noncompliant, such as those with comorbid oppositional defiant disorder (ODD), may also have difficulties with HRT. In particular, these children may refuse to use competing responses as directed, participate poorly during sessions, or argue when their parents try to implement social support procedures. Expert clinicians could address these behaviors by incorporating behavioral treatment for noncompliance into the treatment plan (e.g., McMahon & Forehand, 2003). Clinicians may also address treatment resistance using motivational interviewing (Miller & Rollnick, 2002), which is designed to address ambivalence toward treatment and enhance the client’s desire to initiate and maintain behavior change.

Developmental disorders. When treating a child with a co-occurring pervasive developmental disability (PDD), expert clinicians should be able to distinguish tics and habits from stereotypic movements and be able to adapt HRT procedures for this population. Woods, Piacentini, and Himle (2007) suggested that three symptom features can aid a clinician differentially diagnosing tics from stereotypies. First, although tics do occur in this population, it is more likely for a repetitive behavior to be a stereotypy when there is also a diagnosis of a developmental disability. This is especially true for complex repetitive movements such as body rocking. Second, a single stereotypic movement that does not vary in location or severity is more likely to be a stereotypy. Third, stereotypic movement disorder is a more appropriate diagnosis if the child has a limited number of complex movements in the absence of a history of simple head or facial tics.

Although some literature supports use of HRT for tics and BFRBs in persons with a PDD (Richman & Lindauer, 2002; Roane, Piazza, Cercone, & Grados, 2002), an empirical evaluation of how a PDD diagnosis moderates HRT efficacy has not yet been conducted. Children with PDDs may have difficulty with treatment compliance, may have limited awareness of the target behavior, and may demonstrate a limited ability to independently implement a competing response. Given these possible limitations, expert clinicians may choose to focus primarily on function-based interventions. In the case of a self-injurious habit, clinicians may also want to teach the use of a competing response using discrete-trial training or shaping procedures (Sigafoos et al., 2006).

A case may also be complicated when difficulties arise for some children during particular components of HRT. Some of these difficulties are highlighted and discussed as follows.

Urge does not diminish or patient cannot tolerate urge. Ideally, children can use the competing response contingent upon the experience of an urge, so that habituation to the urge can occur. However, the child may have an intense or particularly strong urge that is difficult to endure.

When children have an urge that is particularly difficult for them to endure, clinicians may want to devote entire sessions toward competing response practice to provide additional support and encouragement. As mentioned previously, clinicians can also graph the child’s subjective urge ratings during practice, to help the child notice any reductions in urge intensity.

Urge difficulties might also be addressed by the expert clinicians using a combined ACT/HRT approach to enhance the client’s ability to willingly experience the urge. This approach is generally recommended for older adolescents and adults. A treatment manual for ACT-enhanced behavior therapy for TTM by Woods and Twohig (2008) is available for clinical use. It is likely that this treatment approach could be easily adapted for other habit behaviors, such as skin picking. It is recommended that clinicians using this approach understand the competencies thought to be associated with successful application of ACT, which have been described elsewhere (Strosahl, Hayes, & Wilson, 2005).

Difficulty in establishing awareness. Another treatment challenge that may arise during awareness training is the difficulty in establishing awareness. Occasionally, instances of the target behavior and/or its preceding sensations do not occur naturally during the session. In this case, it can be beneficial for the clinician to elicit occurrences of the behavior by creating high-risk situations that were identified in the functional assessment. For example, a clinician could ask the child to describe a stressful event, sit with the child in front of a mirror, or center conversation around a topic related to the target behavior, such as hair or skin. If this strategy does not work, clinicians could ask the child to model instances of the behavior to at least allow him/her the opportunity to practice identifying it in the session. Clinicians could also ask the child’s parent to videotape the child during a high-risk situation that occurs outside of session. The clinician could then review the tape with the child and ask the child to point out instances of the target behavior as they occur on the video.

In the case of TTM or oral-digital habits, clinicians may also recommend the use of an electronic awareness-enhancement device, which is designed to emit sound whenever the client’s hand is raised above his/her neck (Rapp, Miltenberger, & Long, 1998). Alternatively, for females, a set of bracelets that make a sound when the arm is moved may serve a similar function. Another treatment idea comes from Risvedt and Christenson (1996), who found that a woman’s awareness of hair pulling was enhanced when a topical cream called capsaicin, which increases skin sensitivity, was applied to her scalp.

Difficulties in implementing the competing response. Difficulties that an expert clinician should be able to troubleshoot often arise during competing response training. Children may be dissatisfied with a competing response for a host of reasons. They may find that the competing response is too conspicuous, painful, difficult to hold for a long period of time, or disruptive of other activities.

Clinicians should thoroughly assess the reasons for a child’s dissatisfaction. In some cases, alternative competing behaviors can be selected if they are available. For example, if a child finds that doing controlled breathing for 1 min interferes too much with his/her ability to hold a conversation, a clinician might suggest a slight modification, in which the child pauses speech upon experience of an urge, takes a breath in, and speaks on exhale (Conelea, Rice, & Woods, 2006). Research also suggests that competing responses may still be effective even if they are compatible with the tic (Woods et al., 1999). For example, if a client experiences neck pain while tightening neck muscles, he/she could be told to tighten the leg muscles contingent upon the urge for the head tic.

Children may be worried that the competing response will be too distracting, and make it more difficult to attend to concurrent activities. Preliminary experimental data suggest that some children with TS may experience decrement in the accuracy of a concurrent task while they are suppressing tics (Conelea & Woods, 2008b). However, the authors of this study suggest that increased practice of the competing response will probably increase automaticity of the behavior, making it easier for the child to implement in a distracting environment. Therefore, if a child presents with this concern, the clinician may suggest that the child initially practice the competing response in an “easy” setting with few concurrent demands. Once competing response use has been mastered in this setting, the child can be encouraged to implement it in more complex or demanding settings.

A thorough assessment of competing response dissatisfaction may also reveal areas of difficulty that necessitate additional treatment procedures. For example, a child with a BFRB may think that the competing response is too embarrassing and may fear using it in front of his/her classmates. Cognitions related to this fear could be explored and addressed using cognitive restructuring. In the case of children with overlapping TS and OCD symptoms, the competing response may be ineffective for a compulsion incorrectly classified as a tic. For example, the child might engage in another compulsive behavior to alleviate obsession-related anxiety or simply be unable to hold the competing response for a sufficient amount of time. Therefore, when children with TS and OCD present with competing response difficulties, it is recommended that clinicians conduct additional assessment of the child’s premonitory experience and include questions specifically designed to reveal possible obsessions. Clinicians should keep in mind that children who are embarrassed or uncomfortable talking about their obsessions may not have discussed them at the outset of therapy, but may be more likely to discuss them later in the treatment. If the assessment suggests that the “tic” might be better classified as a compulsion, a shift to ERP is likely warranted.

Addressing complex tics. Complex tics may present a challenge during competing response training. For example, a child may have a series of tics that occur in a particular pattern and last for a long duration. In this case, the clinician should focus on helping the child implement a competing response for the first tic in the sequence. Competing responses should also be selected for each distinguishable movement within the complex tic sequence, as well as enable the child to suppress the tic at any point in the sequence. Therefore, if a child forgets or is unable to implement the competing response for the first tic in the sequence, he/she can still benefit from implementing a competing response to prevent the full complex tic from occurring. As has been mentioned elsewhere in this chapter, complex tics may also be difficult to treat because of their similarity with compulsions or stereotypies. If a clinician decides to treat the target behavior as a tic using the traditional HRT approach but encounters limited success, it may be beneficial to re-assess the behavior to ensure that it has been accurately categorized.

BFRBs occurring at night or during sleep. Night-time oral-digital habits, such as thumb sucking, may be difficult to treat using standard HRT procedures. It has been recommended that function-based interventions be used to address these habits. First, a safe but aversive substance could be applied to the child’s digits prior to bedtime (Friman, Barone, & Christopherson, 1986). Second, the child can wear gloves or bandages during sleep (Ellingson et al., 2000). The second intervention option may also work well for children who pull their hair while they are trying to fall asleep.

Establishing generalization. Expert clinicians should understand how to ensure that generalization of treatment gains occurs. One potential generalization problem that may arise is that the child only uses the competing response in the presence of the support person or the therapist. Remote detection procedures, in which the support person covertly monitors the child and rewards independent use of the competing response, may be helpful in this case. It may also be beneficial to recruit other people in the child’s life to help praise the child for correct implementation of the competing response, such as the child’s siblings or other family members, coaches, teachers, babysitters, or peers. Similarly, the child may have trouble using the competing response in places other than home or the therapy room. Again, providing reinforcement across multiple settings, situations, and events may probably increase competing response use globally and enhance generalization.

One area in which children may have difficulty using competing responses is in the school setting. Clinicians can help to create situations that simulate the school experience so that the child is able to practice the competing response in a similar setting. For example, a clinician may ask the child to sit at a desk during a portion of the session or ask him/her to take notes while watching an educational video or listening to the therapist talk. It may also be beneficial to recruit the child’s teacher as a social support person. For older children with multiple teachers, a close peer who is with them for multiple portions of the day may also serve as a social support person. When social support procedures are used in the school setting or any other public setting, it may be beneficial for communication between the client and their social support person to be inconspicuous, so as not to draw attention to the child or his/her problem behavior. Hand signals or code words may be used as subtle reminders for the child to use a competing response.

51.8 9.8 Transition from Basic Competence to Expert Competence

Although there are no data to help define the distinction between basic and expert HRT competencies, it is likely that the variables that best distinguish these competency levels are related to a clinician’s ability to treat cases of varying complexity and to adapt treatment procedures to best serve the needs of a particular client. There are several strategies that can help a clinician develop the competencies that probably capture the abilities of an expert.

One of the most important steps in the transition from basic to expert involves having exposure to multiple cases that cover a wide breath of symptom presentations. Although TS and habit disorders share key features, the distinct features associated with each diagnosis call for slightly different variations of the HRT procedure. Even HRT for one disorder, such as TS, may differ depending on several case variables, such as the number, complexity, and severity of tics; degree of tic awareness and premonitory urge experience; comorbidity profile; and social support network. By seeing a variety of children with TS and habit disorders, clinicians are more likely to be exposed to the types of clinical issues discussed in this chapter and to have the opportunity to practice adapting the basic principles of HRT across an array of individually nuanced cases.

Another step in developing expert competencies involves seeking out training and, if possible, supervision from another clinician who is already an HRT expert. Interaction with an expert gives clinicians the opportunity to ask questions about a typical case presentation, to receive personalized guidance and feedback about their own skills, and the potential to learn by observing the expert deliver the treatment. In order to establish contact with an expert, clinicians can seek out training opportunities at research conferences or workshops, which are occasionally sponsored by patient support organizations such as the Tourette Syndrome Association and the Trichotillomania Learning Center. These organizations also offer clinician referral services that clinicians can use to find experts in their geographic area.

Finally, reading the existing treatment literature on TS and habit disorders, as well as staying up to date on recent research, can greatly enhance a clinician’s knowledge base. Knowing the literature on TS/habit disorders benefits a clinician in various ways. First, clinicians who are well versed in the literature can share their knowledge with clients during psychoeducation. Second, staying up to date on the literature ensures that clinicians are using empirically supported variants of HRT. Although the core principles of HRT have remained similar since the initial treatment outcome study by Azrin and Nunn (1973), empirically based modifications to the treatment have occurred over the years, culminating in recent adaptations of the treatment (e.g., Woods & Twohig, 2008; Woods et al., 2008). In addition, it is likely that the future research will begin to examine the differential benefit of these approaches. It is possible that the data garnered from this research will lead to differences in the way the treatment for TS and habit disorders is currently practiced. Staying abreast of the literature will help the clinicians to make empirically sound and informed treatment decisions, currently and in the future.

51.9 9.9 Summary

Treatment of tic and habit disorders in children and adolescents requires familiarity with the symptoms of these disorders and their assessment. In addition, understanding the principles and techniques associated with efficacious treatments is likely to contribute to treatment success.

Although outcome research has demonstrated the efficacy of some TS and habit disorder treatments, particularly HRT, no research has yet examined the role of therapist competency in client outcome. This chapter provides information on competencies that likely contribute to outcome variance, such as treatment compliance, acceptability, and maintenance. Where possible, data were used to substantiate suggestions regarding therapist competencies; however, it is important to note that many of the recommendations provided in this chapter are yet to be explored empirically. For example, no research has yet examined if or how outcome is impacted when clinicians make modifications to the HRT protocol, such as changing the duration of the competing response or using cognitive restructuring to address a child’s thoughts about his/her symptoms. Similarly, the distinction between basic and expert competency with respect to the treatment of these disorders has not been empirically delineated.

Future research will likely help to guide our understanding of therapist competency as it relates to the successful treatment of tic and habit disorders. For example, effectiveness studies could be a first step in examining the impact of protocol deviations on outcome. This research could also provide insight into understanding whether the outcome differs between those categorized as basic and those categorized as expert clinicians. However, until these data are available, it is likely that the recommendations provided here will serve, at the least, as a starting point to guide clinicians interested in treating patients with these disorders.

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