What treatments are available?

Behavioural techniques
A number of nonpharmacological treatments can be used to treat patients with TS of moderate severity. One
behavioural technique which may help with tics is exposure plus response prevention therapy. Tics are
suppressed for prolonged periods of time, in order for patients to learn to habituate to associated premonitory
urges. Verdellen and colleagues showed that this method could reduce tics according to observation and YGTSS
ratings and that this treatment was equally effective to the more widely applied technique of habit reversal
training [Verdellen et al. 2004]. Although focusing attention on tics may increase inhibitory effort leading to
exacerbation [Robertson and Stern, 2000], Verdellen and colleagues reported no evidence for a rebound effect
after exposure plus response prevention therapy sessions [Verdellen et al. 2007].
The effectiveness of habit reversal training has been evaluated more thoroughly [for a review, see Himle et al.
2006]. Woods and colleagues reported improvements of between 89% and 96% in four children with motor tics
[Woods et al. 1996]. Habit reversal training may also help with vocal tics, as shown by Woods and colleagues
[Woods et al. 2003]. Four out of five children (aged 1013 years) showed a reduction in vocal tic frequency of
3896%, while untreated motor tics remained the same; these gains were maintained three months later. Studies
by Azrin and colleagues have also provided favourable evidence. Ten patients were found to exhibit 93%
reduction in tics at home and 93.5% reduction in clinic after treatment [Azrin and Peterson, 1990]. Beneficial
effects were apparent in both children and adults, in both motor and vocal tics and in tic severity and frequency.
A study of 22 adults [Azrin et al. 1980] found this technique more effective than another behavioural technique
(massed negative practice). Self-reported tics decreased by 92% in the habit reversal group and 33% in the
massed negative practice group. Habit reversal training can also be successful when combined with cognitive
behavioural therapy [OConnor et al. 1997]. One clear limitation associated with this behavioural technique is
that tics in one part of the body may be replaced by tics in another part [Robertson and Stern, 2000]. Long-term
evaluation of treatment outcome is therefore necessary.

How does Habit Reversal work?
HR is based on the premise that people are often not aware each time a tic or other repetitive
behavior occurs, and that repetitive behaviors often follow an urge or feeling of discomfort which is
only relieved by engaging in the behavior itself. HR works to increase awareness of one's behaviors
and to provide relief with strategies that replace the unwanted behavior with a less bothersome
behavior.
After the initial evaluation and before the start of treatment, the plan and rationale are presented
to the child and family. The history and occurrence of the behavior are identified and described,
including the estimated frequency of each occurrence of the behavior and its precipitating factors
such as bedtime, homework, social situations, etc. Clear instructions are given about self-
monitoring, which involves keeping a log or record of each time the behavior occurs. The log should
include not only frequency of the behavior, but also places and times of day when it occurs, so that
the child can recognize those situations in which the behavior is more likely to happen. To benefit
most from the program, it is helpful to enlist a partner, such as a parent, to help with maintaining
awareness of the behavior and to ease record-keeping. If the behavior is frequent, it may be
helpful to begin monitoring a specified amount of time each day, such as 30 minutes. As the
process becomes more comfortable, the child may then log each occurrence of the behavior
throughout the day. It is also useful to discuss challenges to self-monitoring and to problem-solve
around those difficulties before they occur.
The next step in Habit Reversal is developing a competing response. A competing response is
another behavior that the child may do in place of the repetitive behavior. A competing response
often uses the same muscles used in the initial behavior, so that the child is unable to do the
behavior while performing the competing response. For example, a child who has a shoulder shrug
tic might use the competing response of lengthening the neck and pushing the shoulders downward.
The competing response should be held for at least one minute, be inconspicuous, and strengthen
the muscles opposite to the repetitive behavior.
It may be helpful for the child to practice his competing response in front of a mirror to show that
it is not noticeable to others and to help him become more comfortable with this new behavior.
The child should be encouraged to use the competing response whenever he notices himself doing
the repetitive behavior or even feels the urge to do so. Parents should praise their child's correct
use of the competing response and remind the child to use it when he is engaged in the repetitive
behavior. Praise should also be used whenever the behavior is reduced in frequency.

1) Have a schedule. Having and using a schedule will lessen your child's stress. He will know what to
expect and for the child with Tourette's Syndrome, there is safety in a routine.
2) Establish an order. Ryan gets ready for school in the same order every day. He's up. We cuddle for a
few minutes while I drink my coffee. He eats breakfast, gets dressed and brushes his teeth. Your child
may already have a preferred order, if he does stick with that!
3) De-clutter your child's room. (That should be done when they are not home and don't get rid of any
favorites!) Order brings peace for the child with Tourette's Syndrome.
4) Help your child clean his room. I don't do it for him but I sit in the room and guide him. If you put
my child in a room and give him a general direction like clean your room, he falls to pieces. But when I
say Okay let's pick up the clothes first. After that's done I give him another specific direction like, Okay
let's pick up all the dinosaurs. Now, I am giving him directions from another room. But we had to
work up to that.
5) Creating special bins and labels for your child's toys is a great idea. These little extras resources
help your child create and maintain order in his room.
6) Have a special cubby or bin for school shoes and back pack.
7) Be involved with your child's class. Meet the teacher and the school nurse. Make them aware of
your child's Tourette's disorder and bring them some materials that you think may help them care for
your child. Try not to be defensive if they began a dialogue with you about your child.
8) Listen to your child's worries and fears. He needs to know that you believe in him.
9) Slow down. Life in the fast lane is not conducive for a child with Tourette's.
10) Rubbing your child's back in a soothing manner and instructing him to take a deep breath are
helpful in dealing with an onslaught of Tourette's. We also sing songs.
11) Be understanding. Ryan will tell me, "Mom, my Tourette's won't shut up today." At the same time,
recognize when your child is leaning on his disorder as an excuse for bad behavior!
12) Limit television and gaming time. Outdoor play brings down Tourette's while television time
brings it up. At least this is true in my home anyway.
13) No scary movies or books. It's too much for children with neurological disorders.
14) Communicate with your other children about Tourette's and explain to them how it must feel.
Allow them to ask questions and express their own frustrations.