LOS ANGELES – Sometimes, it’s possible to bring an end to tics without drugs.

Habit reversal training (HRT), a behavioral tic treatment, is not only a useful medication adjunct, but can sometimes prove to be the better first-line option, Dr. James T. McCracken said at the meeting, sponsored by the American Academy of Child and Adolescent Psychiatry.

"This is an interesting and potentially very important treatment," said Dr. McCracken, director of the division of child and adolescent psychiatry at the University of California, Los Angeles, Semel Institute for Neuroscience and Human Behavior.

First, the patient is made aware of his tic in one or two treatment sessions; tic counting and other exercises help, Dr. McCracken said.

The premonitory urge is addressed next. A patient who cannot stop flashing his middle finger, for instance, might describe an initial tingling in the hand, or maybe the shoulder.

The patient is then taught a competing response for the urge. The middle-finger flasher might straighten his arm or grab the offending hand until the urge fades.

Meanwhile, the therapist addresses environmental triggers; anxious parents might be told, for instance, to stop fussing about the tic.

In short, "if you’ve got somebody [who is] really working with you and practices, you can knock out a tic in about maybe one or two sessions," Dr. McCracken said.

Phonic tics and dominant motor tics respond especially well. "You can really [target them] with behavioral intervention," he said.

In a recent study of children with Tourette’s syndrome or chronic tic disorder, HRT substantially reduced tics in 32 out of 61 children after 10 weeks, a response rate above 50%. Benefits remained durable at 6-month follow-up (JAMA 2010;303:1929-37).

"By no means does [HRT] propose to replace medication treatment," Dr. McCracken said. About half of the kids in the trial were on alpha-agonists, antipsychotics, or other medications.

But "I think it can be a very useful adjunct for some, where the degree of tic control is just falling short," and "it might be a good place to start if you gain confidence with this approach," he said.

Several manuals teach the technique, and the Tourette Syndrome Association offers training, he said.

The Big Guns

Dr. McCracken said it’s sometimes best to wait before starting medications.

Tics ebb and flow, and are often driven by anxiety-provoking – and temporary – life-changes, like the start of the school year.

"Because this disorder occurs in bouts, you want to wait it out for at least a couple of weeks, assuming you’re not looking at eye-gouging tics or something else of major concern," he said.

When watchful waiting doesn’t do the trick, however, "our big guns for treating tics are the antipsychotics," Dr. McCracken said.

Haloperidol and pimozide "certainly work. Risperidone and ziprasidone have their own controlled trials as well," he said.

He starts with a low dose – about 3 or 4 mg/day – and titrates up slowly to avoid side effects, adding no more than a milligram a week.

"I often stretch it out longer than that," Dr. McCracken said.

In general, antipsychotics reduce tics by about 40%.

Because of that, "I caution parents from the get-go [to] not expect the tics to go away. Our goal is to reduce the impairment," he said.

Pimozide has been associated with lethal arrhythmias at doses of about 10 mg. Though tic control doesn’t usually require high doses, an ECG is a smart move when they do, he said.

Alpha-agonists are an option before bringing out the big guns, with some evidence supporting both clonidine and guanfacine. Adding an alpha-agonist to an antipsychotic also can "be enough to knock out a tic substantially," he said.

Antibiotics? Maybe

For most children, a comorbid problem – typically attention-deficit/hyperactivity disorder –causes more impairment than their tic.

When ADHD is the main problem, "I think the consensus is that stimulants can be used cautiously," Dr. McCracken said.

Methylphenidate and clonidine together, for instance, have been shown to both help ADHD and control tics (Neurology2002;58:527-36).

Dr. McCracken said he prefers the immediate-release type, when stimulants are used.

"I have found some kids who are very sensitive to stimulant-induced tic-worsening can get by with adding in a stimulant during the day just when they need it, really trying to minimize that exposure," he said.

Group A streptococcal infections have been associated with new-onset tics, which suggests that may be a role for antibiotics in tic treatment, as well. "Continuing the antibiotics may reduce the incidence of subsequent relapse, but that is not so firmly established. Beta-lactam antibiotics, which include amoxicillin and cephalosporins, seem to be most useful. [Try] standard treatments first, though," Dr. McCracken said.

Dr. McCracken said he is an adviser to BioMarin Pharmaceutical Inc., and receives research funding from Bristol-Myers Squibb and Seaside Pharmaceutical.

Habit Reversal Training a Valid Drug Alternative for Tics