A 6-year-old female came to clinic because teachers and parents had noticed that she was more fidgetty when sitting. She would cross and uncross her legs frequently especially the lower legs but more often the entire leg. This would cause her to shift her weight to her hip and sit awkwardly in a chair. There had been an increase in this behavior since the beginning of school and she seemed to not notice the problem. The teachers had offered frequent bathroom breaks thinking this was a urine holding behavior but this did not improve the problem. The parents said that she didn’t have increased frequency or urgency with urination. She denied pain or itching of the perineum. She had soft bowel movements. The past medical history showed a healthy female with normal development who had thumb sucking until 5 years of age. The family history was negative for genitourinary problems and neurologic problems. There was a distant cousin with depression, but no tics or verbal dysfluency in the family. The review of systems was negative.
The pertinent physical exam showed a healthy female with growth parameters in the 50-75%. Her abdominal, genitourinary and neurological examinations were normal. During the interview she was noted to do the behavior when she was reading a book. The laboratory evaluation of a urinalysis was negative. Stool for ova and parasites including pinworms was negative. The diagnosis of a simple habit was felt to be most consistent, but testing for possible other common problems was done. The patient was encouraged to sit properly and to put her legs around the chair, desk or table that she was sitting at. She was also offered the option to sit cross-legged. Parents and teachers helped support these changes and during a subsequent acute care visit the mother reported that she had much less fidgeting than before.
In 1973, Azrin and Nunn published the first paper on habit reversal. Their 12 patients (ages 5-64 years) had immediate improvement in a variety of problems including nail-biting, thumb-sucking, hair pulling and tic behaviors. Others have built upon their methods and shown efficacy in a number of habits including tics, stuttering, hair pulling, skin picking, nail biting, finger sucking, etc.
Habits can be automatic or focused. Automatic being that the habit occurs when the patient is not aware (e.g. studying, sitting in a car, etc.). Patients are not aware of the habit until sometime later or the episode is complete (e.g. nail is ripped off). Focused is when there is a awareness of the episode, but the patient does the habit anyways.
As patients need some cognitive awarness to be able to do habit reversal techniques, children younger than 5 years may not be able to comply with the methods. Additionally, habits that are bothersome to others but are not causing problems to the child socially, mentally or physically may not need treatment.
Habit reversal training has 3 main components:
- Awareness training – methods to make the patient more aware of the habit including being aware of its warning signs (e.g. tickle in throat before tic), movements that make up the habit (e.g. moving head down and arm up to pull hair), and the circumstances around the habit (e.g. finger sucking worse when tired).
- Methods can include:
- Daily recording of the number of times the habit is performed
- Listing problems the habit is causing
- Identifying the situation, people and activities that cause the habit to occur
- Documenting how the habit physically takes place
- Practicing how to deal with the habit in various situations
- Methods can include:
- Competing response training – teaching the patient to do something that competes with performing the habit, i.e. substitute a different behavior (e.g. deep breathing to lessen tic, clinching fists for hair pulling, pulling on clothing or chair for nail biting, etc.) The competing response should be something that competes with the habit, is easily physically possible and is inconspicuous.
- Social support – having family and friends support the patient to perform these activities.
- Methods can include:
- Having family and friends positively comment when the patient performs the competing response
- Having family and friends gently remind the patient to be more aware and perform the competing response when they perform the habit
- Having the family and friends support the patient in situations they may have avoided because it increases the habit
- Methods can include:
Other habit reversal methods can include performing relaxation techniques and massed practice (having the patient do the habit multiple times at different times of the day).
For example, a teen who knows that she inadvertenly does skin picking when she is stressed, tired and/or doing homework, could try to use hand lotion during those times as a competing response. This also helps to briefly decrease the skin dryness which is also a contributor. A child like the one was taught to wrap her feet around the legs of the chair, and sit cross-legged instead of frequently criss-crossing her legs.
Questions for Further Discussion
1. What signs or symptoms would make one concerned about an underlying psychiatric diagnosis and not a simple habit?
2. When does a habit need psychological treatment?
- Symptom/Presentation: Behavior Problems
- Age: School Ager
To Learn More
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Azrin NH, Nunn RG. Habit-reversal: a method of eliminating nervous habits and tics. Behav Res Ther. 1973 Nov;11(4):619-28.
Christophersen ER. Behavior Management Theory and Practice. In Behavioral and Developmental Pediatrics, Parker S and Zuckerman B, eds.. Little Brown and Co. Boston, MA, 2005;50-51.
de Kinkelder M, Boelens H. Habit-reversal treatment for children’s stuttering: assessment in three settings. J Behav Ther Exp Psychiatry. 1998 Sep;29(3):261-5.
Piacentini J, Chang S. Habit reversal training for tic disorders in children and adolescents. Behav Modif. 2005 Nov;29(6):803-22.
Chida Y, Steptoe A, Hirakawa N, Sudo N, Kubo C. The effects of psychological intervention on atopic dermatitis. A systematic review and meta-analysis. Int Arch Allergy Immunol. 2007;144(1):1-9.
Flessner CA, Busch AM, Heideman PW, Woods DW. Acceptance-enhanced behavior therapy (AEBT) for trichotillomania and chronic skin picking: exploring the effects of component sequencing. Behav Modif. 2008 Sep;32(5):579-94.
Flessner CA. Cognitive-behavioral therapy for childhood repetitive behavior disorders: tic disorders and trichotillomania. Child Adolesc Psychiatr Clin N Am. 2011 Apr;20(2):319-28.
ACGME Competencies Highlighted by Case
1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
2. Essential and accurate information about the patients’ is gathered.
3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
4. Patient management plans are developed and carried out.
5. Patients and their families are counseled and educated.
7. All medical and invasive procedures considered essential for the area of practice are competently performed.
10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.
17. A therapeutic and ethically sound relationship with patients is created and sustained.
18. Using effective nonverbal, explanatory, questioning, and writing skills, the healthcare professional uses effective listening skills and elicits and provides information.
19. The health professional works effectively with others as a member or leader of a health care team or other professional group.
. Sensitivity and responsiveness to patients’ culture, age, gender, and disabilities are demonstrated.
24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital