Habit reversal (HR) is a behaviorally based treatment that is used to reduce repetitive behaviors which may bothersome and serve no adaptive function, such as tics, hair-pulling and nervous habits. HR was first developed in the 1970s, and has since been used in the treatment of several repetitive behavior disorders, particularly tic disorders. This article will review the principles and procedures of habit reversal as well as some things to consider before beginning this treatment approach.
What are tics?
Tics are sudden, rapid, repetitive movements (motor tics) or sounds (vocal or phonic tics). Tics are involuntary, in that the child cannot control them, but they can be at least partially suppressed for varying periods of time, often during the school day. Tics are classified as either simple or complex. Simple motor tics involve one muscle group, such as eye blinking, neck rolling, or should shrugging. Complex motor tics are characterized by slower, more purposeful, coordinated movements involve more than one muscle group, such as jumping, squatting, or turning around repeatedly. Simple vocal tics are characterized by one sound, such as throat clearing, coughing, or sniffing. Complex vocal tics are characterized by combinations of sounds, such as repetitive words, syllables or phrases, such as "shut up" or "Joey's a chicken."
How common are tics?
Tics are very common in school age children, and most are transient, lasting less than one year. Chronic tics, which persist for more than one year, are less common. Tourette's Disorder is a chronic tic disorder characterized by multiple motor tics and one or more vocal tics that have been present for more than one year. Tourette's Disorder may co-occur with psychiatric and behavioral disorders, such as Attention-Deficit/Hyperactivity Disorder, Obsessive-compulsive Disorder and other anxiety and mood disorders. Tics and the co-occurring disorders may impair a child's social, educational and recreational functioning. The problem that causes the most impairment or distress is often the one that is most amenable to treatment.
What are other repetitive behavior disorders?
Other repetitive behavior disorders include chronic motor tics as well as nail biting, thumbsucking, and hair pulling. Trichotillomania is diagnosed when there is recurrent hair pulling resulting in noticeable hair loss.
How are Tourette's and other repetitive behavior disorders treated?
Medication is often prescribed depending on the severity of the problem and whether a co-occurring disorder is present. Among nonpharmacological treatments Habit Reversal (HR) has become the treatment of choice.
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 in which it occurs so that the child can recognize those situations in which the behavior is more likely to happen. To get the most benefit 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 uses the same muscles used in the initial behavior, so that the child is unable to do the behavior while doing 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 responses 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.
What other strategies may be used to decrease repetitive behaviors?
Because many repetitive behaviors are often increased during times of stress or tension, it may be helpful to implement strategies that lead to an overall decrease in tension. For example, children may be taught to breathe in slowly through the nose and to exhale through the mouth. They can also learn to recognize the way their diaphragm expands with each inhale and contracts with each exhale. This tends to have a calming effect, and it is another strategy that may be used inconspicuously in any situation.
What about research?
HR has been used and found effective, rapid and lasting in treating chronic tics, other repetitive behaviors, and Tourette's Disorder. Despite numerous studies, only a few controlled studies have been conducted. In these studies HR was found effective when compared to individuals on a wait list and when compared to supportive psychotherapy. When compared to exposure and response prevention treatment, no differences were found and both treatments were found effective. Overall, a large body of evidence supports the effectiveness of habit reversal. It is critical that additional research be conducted, using controlled studies with larger sample sizes and comparing behavioral interventions with medication.
Who should consider trying habit reversal?
Habit reversal should be considered as an addition or alternative to medication therapy. This may be particularly true for those who refuse or discontinue medication due to side effects or residual problems. As with other approaches, please discuss habit reversal with your treating physician before beginning any new type of treatment.
About the NYU Child Study Center
The New York University Child Study Center is dedicated to increasing the awareness of child and adolescent psychiatric disorders and improving the research necessary to advance the prevention, identification, and treatment of these disorders on a national scale. The Center offers expert psychiatric services for children, adolescents, young adults, and families with emphasis on early diagnosis and intervention. The Center's mission is to bridge the gap between science and practice, integrating the finest research with patient care and state-of-the-art training utilizing the resources of the New York University School of Medicine. The Child Study Center was founded in 1997 and established as the Department of Child and Adolescent Psychiatry within the NYU School of Medicine in 2006. For more information, please call us at (212) 263-6622 or visit us at www.aboutourkids.org.
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Reprinted with the permission of the NYU Child Study Center. © NYU Child Study Center.
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