**4.5 Behavioral treatment**

Behavioral therapies have not been particularly beneficial for patients with disabling tics. Behavioral approaches have included operant conditioning models, rewarding tic suppression and discouraging disruptive tics and massed practice, repeated, voluntarily performance of a tic until fatigue occurs. Habit reversal therapy (HRT) can be considered if a single tic or small subset of tics is unduly disruptive or causing self-injury or pain. HRT trains patients to recognize their tics and to perform a volitional movement different from the tic each time a problem tic occurs. Open-label assessments have identified sustained benefit from HRT for up to 10months48. However, current trials will include raters blinded to treatment assignment lacking in previous trials.

In the school setting, approaches often include preferential classroom seating, extra time for tests, an opportunity to take tests in a separate quiet room and assistance with organizing schoolwork. An alpha-2-agonist, such as guanfacine, is a good first choice medication for patients experiencing problematic tics and ADHD because this type of drug can improve both conditions.
