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Habit Reversal: A Treatment Approach for Tics, Tourette's Disorder and Other Repetitive Behavior Disorders

Habit Reversal

Old habits die hard, and everyone - in one way or another - has experienced this familiar adage first hand.  Kicking an old habit can be a difficult and
frustrating process, whether the habit is procrastinating, fidgeting, nail-biting, or staying up too late.  For some people, including children, habits become so ingrained and reflexive that they are considered a repetitive behavior disorder, a category that includes tics and Tourette's Syndrome. Fortunately, there are several successful strategies and methods for relieving repetitive behavior disorders. 

Habit Reversal (HR) is one type of behavioral treatment used to reduce repetitive behaviors that have become bothersome and serve no adaptive purpose. Developed in the 1970s and found by research to be effective with lasting results, HR is based on the premise that people are often not aware of their repetitive behaviors when they occur, and that those repetitive behaviors often serve to relieve urges or feelings of discomfort. HR, therefore, focuses on bringing these behaviors into conscious awareness and then replacing them with less bothersome behaviors.      

Before beginning HR, a plan and rationale are developed and the unwanted behaviors are thoroughly examined in terms of history, precipitating factors, and frequency of occurrence.  Clear instructions are then given about self-monitoring these behaviors to help bring them into consciousness.  This may be done by keeping a log each time the behavior occurs to record the place, time of day, and precipitating situation.  It is also helpful to enlist outside help in recognizing repetitive behaviors; a child's team may consist of his/her parents and teacher, who can help to point out to the child when he/she is engaging in the unwanted behavior.

Once a patient consistently recognizes his/her unwanted behavior as it is happening, he/she can begin the next step of HR: to develop a competing response.  A competing response is a less bothersome behavior that is performed in place of the unwanted behavior, and is typically a behavior that makes it impossible to engage in the problem behavior at the same time.  For example, a child with a shoulder shrug tic may use the competing response of lengthening his neck and pushing his shoulder downward.  A person who snacks too much may use the competing response of moving out of the kitchen and into another room to perform another activity.  Competing responses should be held or performed for at least one minute, be inconspicuous, and, in the case of tics, strengthen the muscles opposite those used in the repetitive behavior.

For many people, it is helpful to practice competing responses even when the unwanted behavior is not occurring so that they become more comfortable. This also increases the likelihood of actually employing the competing response whenever an unwanted behavior is occurring, or when the patient feels that the unwanted behavior is about to occur. Additionally, it is helpful to practice relaxation techniques because repetitive behaviors often occur or increase during times of stress or tension.  For children using HR, parents can help by praising their child whenever he/she correctly uses the competing response or whenever the repetitive behavior is reduced in frequency over a period of time. 

Habit Reversal is currently recommended as the first approach to treatment for children and adolescents with mild to moderate tics, and should be considered as an addition or alternative to medication therapy for people with severe repetitive behaviors.  As with all approaches, it is important to discuss habit reversal with a professional before beginning therapy.  The Child Study Center has many experts who can provide guidance and help.  If you believe your child may benefit from HR therapy, do not hesitate to contact our Intake Coordinator at 646-754-5000 or services@aboutourkids.org.

Our Clinicians

Aleta Angelosante, PhD

Candice Baugh, MA, LMHC

Kirsten Cullen Sharma, PsyD

Melissa Nishawala, MD

Carrie Spindel, PsyD