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How Habit Reversal Therapy Works for Tics

The best behavioral treatment for tics, excoriation disorder, and trichotillomania

Clinical Expert: Barbara Coffey, MD

en Español

Psychiatrist Barbara Coffey details the steps of habit reversal therapy (HRT) and how it empowers people with tic disorders to overcome the urge to tic. It’s a lot of work, but the results can be remarkable. Dr. Coffey is Chief of the Division of Child and Adolescent Psychiatry and Professor of Psychiatry at the University of Miami Miller School of Medicine.


Tics are described as involuntary movements, except a better way of understanding tics would be a semi-involuntary movement, meaning that there’s a preceding experience that the child can often learn to describe before that actual movement or sound occurs. Those we describe as “premonitory experiences,” and it’s very important for parents to be aware of this.

Although they’re probably true for even very young children, we know that kids by about age 9 or 10 can describe these premonitory experiences. And what it means is that before the tic occurs, the child will get a signal that a tic is going to happen. It could take a variety of forms — it doesn’t have to be related to the same muscular area where the tic is occurring.

A good example would be with a child who has to tilt the head to the left, there could be a feeling in the child’s neck that builds up in the few seconds before that left-sided neck movement that feels like a flush or a tingling that gives the child a signal that the tic is going to occur. It’s that sensation that we capitalize on when we teach the child the behavioral treatment to identify that the tic is going to occur.

So then once the child is aware of that sensation, he can be taught a “competing response,” which is the essence of habit reversal therapy. A good example would be in the child who has a left-sided neck tilt, the child could be taught to move the head to the right when he feels that feeling of tingling or that flushing feeling that occurs in the neck. And since the brain can’t do two things in the exact same instant in this way, the child can then substitute a right-sided movement for the left neck tilt, and therefore that left neck tilt is neutralized over time.

It can work for vocal tics, it can work for motor tics, and the effect size that is the magnitude of the strength of this treatment is as good as — if not better than — some medications.

The wonderful thing about this habit reversal therapy is that the child and the therapist choose the competing response together, so therefore the child feels empowered him or herself to be able to use these approaches outside the therapist’s office.

This article was last reviewed or updated on October 30, 2023.