Review of HR With Childhood Habit Disorders

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A review of habit reversal with childhood habit disorders
Article in Education and Treatment of Children · May 1996
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A Review of Habit Reversal with Childhood Habit Disorders
Author(s): Douglas W. Woods and Raymond G. Miltenberger
Source: Education and Treatment of Children, Vol. 19, No. 2 (MAY 1996), pp. 197-214
Published by: West Virginia University Press
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EDUCATION
ANDTREATMENT Vol.19,No.2,MAY1996
OF CHILDREN
A Review of Habit Reversal with

Childhood Habit Disorders
Douglas W. Woods
Raymond G. Miltenberger
North Dakota State University
Abstract
Thispaperreviews theusesoftheoriginalhabitreversal
procedureas wellas simplified
procedurestotreat
childhoodhabitdisorders.
After
defininganddescribing habit
different
disordersinchildren,
wedescribetheoriginal
habitreversalprocedureandfollow witha
reviewoftheliterature
lookingat thevarious oftheoriginal
applications andsimplified
versionstotreateachclassofhabitdisorderexhibited
in children.
Thepaperconcludes
witha discussion
ofpotential
areasforfuture
research.
★ ★ ★
Habit disorders can be defined as repetitivebehaviors that serve no

recognizable social function,but may negativelyaffectthe individual
(Hansen, Tishelman,Hawkins, & Doepke, 1990). As a resultof excessive
occurrence,habit disordersin childrenmay cause social distressas well
as physical damage. In this paper, we will brieflyreview the fourmain
classes of habitdisordersseen in children:tics,nervoushabits,stuttering,
and Tourette's Disorder. Next we will describe habit reversal, a
treatmentthatappears to be effectivewith childrenand adults, and will
present a review of the literature utilizing the procedure and its
variations to treat each of the 4 classes of habit disorders in children.
Primaryemphasis will be placed on simplifiedversions of the original
habit reversal procedure because simpler procedures are easier to
complywith,and more likelyto be used.
Major Classes of Habit Disorders
Motorand VocalTics
Tics are habitual, seeminglyinvoluntarymovementsof small groups

of muscles thatare not due to spasms, chorea,or tremors(Billings,1978).
There are two types of tics,motortics and vocal tics. Some examples of
Address:
RaymondG.Miltenberger;
NorthDakotaStateUniversity; ofPsy-
Department
chology; ND 51805
Fargo,
Pages 197-214
198 WOODS and MILTENBERGER
motor tics include shoulder shrugging, arm or neck jerking, facial

grimacing,or excessive eye blinking. Examples of vocal tics include
persistentcoughing or throatclearingnot caused by illness,barking,or
coprolalia. The thirdtypeof tic disorder,Tourette'sSyndrome,will be
discussed laterin the paper.
The prevalence of tics among children remains unclear. However,
Verville(1985) suggeststhat15% of childrenbetween the ages of 2 and 4
years may exhibita motoror vocal tic. The age of onset formotor/vocal
tics is also unclear although it is considered a childhood disorder
(American Psychiatric Association, 1994). Most motor/vocal tics in
childhood are transientand remitspontaneouslywithina year. Tics that
persistbeyond a year are consideredto be chronictics.
Although tics may develop in a number of ways that are not fully
understood, they may be maintained by muscle tension reduction
followinga tic occurrence,which negativelyreinforcesthe tic behavior
(Evers & Van De Wetering,1994). The tic behavior may have originally
served a functionalpurpose. For example,theindividual who swings his
or her head violentlyto the leftevery few minutesmay have originally
done this to relieve muscle tension resultingfroma physical injuryto
that region of the body. Although this behavior may have been
functionalat one time,it becomes problematicwhen it persistsafterthe
injuryhas healed and/or when its frequencybecomes excessive (Azrin &
Nunn, 1977). Contributingto the difficultyin controllingtics are two
factors.First,the person may be unaware thathe/she is engaging in the
tic. Withoutawareness of the behavior,it is difficultto control.Second,
the increased muscle tension that precedes tic behavior may be
associated with everydayevents or routines,making the tic more likely
to occur at those times. The events or routines then develop stimulus
controlover the occurrenceof the tic.
NervousHabits
Nervous habitscan be definedas stable,repetitivebehaviorsthatserve

no social functionbut may serve a self-stimulatory function(Hansen,
Tishelman, Hawkins, & Doepke, 1990). Nervous habits often involve
manipulation of some part of the body, such as the hands or mouth.
Examples of nervous habits include nailbiting, hairpulling,
thumbsucking,chewing on lips or cheeks, persistent scratching,or
bruxism.
As with tics, studies on the prevalence of nervous habits in children
have been sparse. Malone and Massler (1952) suggest that 60% of
10-year-olds bite theirnails. Thumbsuckingis seen in almost 22% of 12-
year-olds according to Azrin, Nunn, and Frantz-Renshaw (1980b).
Graberand Arndt(1993) found thatbetween 1 and 4% of the population
engage in trichotillomaniaand that this disorder exists primarilyin
children.
CHILDHOODHABITREVERSAL 199
Much like motorand vocal tics,nervous habits may be maintainedby

tension reduction following the occurrence of the habit and may be
difficultto controlbecause of lack of awareness and the stimuluscontrol
of everyday situations(Azrin & Nunn, 1977). In addition, the nervous
habits may also serve a self-stimulatoryfunction instead of, or in
addition to, a tensionreductionfunction(Hansen et al., 1990). Although
trichotillomania in childhood is generallyconsideredto be a benign habit
disorder (Friman & Rostain, 1990), it has been conceptualized as an
impulse controldisorder (AmericanPsychiatricAssociation,1994) or an
obsessive compulsive disorder(Swedo & Rapoport,1991),and therefore,
may at timesbe more severe than a simple nervous habit involvinghair
manipulation.
Stuttering
Stuttering involves whole and part-word repetitions, blocking,

hesitation, and prolongations during speech (American Psychiatric
Association,1994). Although1% of the normal adult population stutters
(Bloodstein, 1981), stutteringoccurs in approximately5% of children
(Leung & Robson, 1990). However, 80% of these childrenwill become
fluentwithouttreatment(Bloodstein,1981).
Although there is evidence that stutteringmay be a result of a
neurologicalanamoly (Moore, 1984),thebehavior may be maintainedby
mechanisms similar to nervous habits and tics (Azrin & Nunn, 1974).
Specific evidence exists for the idea of tension reduction following a
stutter.It has been shown that muscles involved in speech production
are tense and thereis vasoconstrictionpriorto a stutter,with decreased
tensionand vasodilatationoccurringafterthe stutter(Ingham,1984).
As with tics and nervous habits,limitedawareness of each occurrence
of stutteringmay contributeto the difficulty of controllingthe behavior.
There is evidence that stutterersare aware of only 60% of theirstutters
(James,1981). Stimuluscontrolmay also play a role. For example, some
stutterersmay reporthaving problemswith theirspeech only in certain
situationssuch as talkingon the phone or in frontof strangers.
Tourette'sDisorder
The final type of habit disorder that we will discuss is Tourette's

Disorder. This disorderinvolves both motorand vocal tics that seem to
occur in clusters,with the ticsbeing active fora period of time and then
dissipating (Dedmon, 1990). It is estimatedthat approximately0.5% of
the population suffersfromTourette'sDisorder (Dedmon, 1990).
Although factorsunderlyingthe development and maintenance of
Tourette's are unclear, there seem to be a number of potential
explanations.Many cases of Tourette'sappear to occur throughgenetic
transmission.It is also possible that Tourette'scould develop as a side
effectof some stimulantmedicationssuch as Ritalin.Finally,it has been

conceptualized as an obsessive-compulsivetic disorder(Dedmon, 1990).
Again, however, there appears to be a tension reductionfollowingthe
occurrence of the tics associated with Tourette's Disorder (American
PsychiatricAssociation,1994).
We have brieflyreviewed the definition,prevalence statistics,and
etiological factors involved in the four types of habit disorders;
motor/vocaltics,nervoushabits,stuttering, and Tourette'sDisorder. It is
likely that teachers, clinicians, and health care professionals will
occasionally,encounter children who present with habit disorders that
are severe enough to warrant treatment.The remainderof this paper
focuses on one practicalmethod fortreatingindividuals presentingwith
habit disorders. Specifically,the paper will discuss the habit reversal
procedure as it has been applied to various habit disorders,beginning
with a descriptionof the procedure, followed by a discussion of the
studies thathave successfullydecreased the frequencyof habit disorders
using both originaland simplifiedprocedures.
Description of the Habit Reversal Procedure

Azrin and Nunn (1973) proposed the habit reversal procedure as a
treatmentfor nervous habits arid muscle tics. The original procedure
consisted of four phases, with a number of techniques specificto each
phase. In the originaltreatment, a totalof nine techniquesare introduced
to the participantsin one 2 hour treatmentsession.
The Awareness phase is introduced firstbecause the rest of the
treatmentis contingent upon the participant being aware of each
occurrence of the target behavior. There are four techniques used to
achieve awareness. The firsttechniqueis Response Description.Withthis
technique,the child is asked to fullydescribethe behavior while looking
into a mirror.The second technique is Response Detection. Here the
child is instructedto acknowledge each occurrenceof thebehavior in the
session withthe therapistpointingout occurrencesthatescape the child's
awareness. The thirdtechnique is Early Warning. With this technique,
the child is taughtto be aware of the earliestsigns of the behavior. For
example, the hairpulleris taughtto be aware as soon as the hand starts
towards the hair. The finalawareness technique is SituationAwareness
Training.Using thistechnique,the child describesall of the situationsin
which the behavior occurs,and thendescribeshow thebehavior is acted
out in these situations.
The second phase of the habit reversal procedure is the Competing
Response phase. The goal of this phase is to engage in a behavior that
produces tensing of muscles opposite to those used in the target
behavior. The competing behavior is applied by the child for up to 3
minutes contingentupon awareness of the urge to engage in, or the
actual occurrenceof the targetbehavior. To be considered a competing
response, the behavior should: "(1) be opposite to the nervous

movement,(2) be capable ofbeing maintainedforseveral minutes,(3) be
producing heightenedawareness by an isometrictensingof the muscles
involved in the movement, (4) be socially inconspicuous, and (5)
strengthenthe muscles antagonisticto the tic movementforthe muscle
tics"(Azrin & Nunn, 1973,p. 623).
The thirdphase in thehabitreversaltreatmentis the Motivationphase.
The goal of this phase is to furthermotivatethe child to implementthe
procedures in the Awareness and Competing Response phases. There
are threetechniques in this phase. In the Habit InconvenienceReview,
the child discusses situations in which the target behavior is
embarrassingor inconvenient.The second techniqueis Social Support,in
which familyor friendspraise the child for not engaging in the target
behavior, and remind the child to practice the competing response
technique if they notice an occurrenceof the targetbehavior that goes
unnoticed by the child. The final motivational technique is Public
Display in which the child demonstrateshis/her abilityto controlthe
targetbehaviorin frontof a group of familymembersor friends.
The finalphase is Generalization.The goal of this phase is to enhance
generalizationofthe resultsof the treatmentto all areas of the child's life.
Using the Symbolic Rehearsal technique, the child imagines him or
herselfin one of the situations discussed during Situation Awareness
Training. The child imagines being about to engage in the target
behavior,but thenengagingin the competingbehavior.
Applications of the Habit Reversal Procedure and Variations
MotorTics
Having describedthe originalprocedure,we will now focuson studies

using this procedure or variationsto treathabit disordersin children.A
numberof studies have used the originalprocedure or slightvariations
to treattics (see Table 1). In the original study,Azrin and Nunn (1973)
taughttwo childrenwith tics to use the procedures.For one 14-year-old
boy with a head /shoulderjerkingtic, the frequencywas reduced from
an estimated8000 occurrencesto 12 occurrencesper day. A second 14-
year-oldboy with an elbow flapping/shoulder-jerkingtic decreased his
tic frequencyfroma self-reportedbaseline of 250 to 0 at three weeks
posttreatment.
Finney, Rapoff,Hall, and Christopherson(1983) added the compo-
nents of self-monitoring and relaxation trainingwhile eliminatingthe
symbolic rehearsal,public display,and earlywarningtechniquesto treat
motortics in two young boys. One of the participantshad an eye- blink
tic thatwas decreased in frequencyto near zero occurrences.The second
participanthad a numberof ticsincludingeye-blinking, grimacing,head
jerking,and head shaking. At the 12-monthfollow-upsession, the four
tics had disappeared. Miltenberger,Fuqua and McKinley(1985) used the

same procedures as Finney et al. (1983) and greatly decreased the
frequencyof an eye-blinkingtic in a 12-year-oldgirl.Pray,Kramer,and
Lindskog (1986) added the componentof noncontingentpracticeof the
competing response to the procedures used by Finney et al. (1983) to
treata head-shakingtic in a 9-year-oldgirl.At a 1-yearfollow-up,the tic
had completelydisappeared (see Table 1).
Although a number of studies demonstratethe effectivenessof the
originalhabitreversalprocedureor slightvariations,more recentstudies
have attempted to refine the procedures. Miltenbergeret al. (1985)
evaluated the originalhabit reversalprocedureand a simplifiedpackage
consistingof awareness training(response descriptionand detection),
self-monitoring, and competing response trainingfor the treatmentof
motor tics. They found that the full procedure and the simplified
package were both effective.From thisstudy,the authorsconcluded that
the only necessary components of the habit reversal treatmentwere
awareness training and competing response training.Their research
went on to show that the competing response must be applied
contingentupon the targetbehavior (Miltenberger& Fuqua, 1985), but
need not be similar to the targetbehavior to be effective(Sharenow,
Fuqua, & Miltenberger,1989). There have been a numberof studies that
have used this simplifiedtreatmentwith slightvariationsto treathabit
disordersin children.
Miltenbergeret al. (1985) used awareness training and competing
response trainingto treattwo motortics in a 9-year-old-boy.The boy's
shoulder-jerkingtic during treatmentwas reduced 35% frombaseline,
while his head-jerking tic was reduced 26% during treatment.The
decrease in tic frequencies for this child were not as great as those
reportedin otherstudies due to the factthatthis child exhibitedsevere
emotional/behavioral problems and was noncompliant with the
treatmentprocedures. Azrin and Peterson (1989) used these same
proceduresand added noncontingentpracticeof the competingresponse
and social support to reduce an eye-blinkingtic by 97% in a 9-year-old
girl.
Ollendick (1981) used awareness, self-monitoring, and a competing
response as treatment for eye-blink tics in 2 boys, 9 and 11 years old.
Interesting to note is thatthe tic frequency forone boy decreased to zero
with only self-monitoring,while for the other boy, tic frequency
decreased by 50% with self-monitoring, and decreased furtherwith the
use of the competing response. This suggests that in some cases,
self-monitoringmay be sufficientto decrease the frequency of tics.
Further support for this idea comes from Billings (1978) who used
self-monitoring (pressing a wristcountercontingentupon awareness of
the tic) to eliminatea motorand a vocal tic in a 17-year-oldgirl.Woods
and Miltenberger(1995) have speculated thatself-monitoring may serve
to decrease ticsby increasingawareness of theiroccurrenceor by serving
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as a punishermuch like the dissimilarcompetingresponse evaluated by

Sharenow et al. (1989).
Although it appears that the habit reversal procedure and its
variationsare effectivein the treatmentof motortics,we must evaluate
the researchdesigns used to evaluate treatmenteffectiveness. Of the six
studies reviewed, three used multiple baseline designs (Finney et al.,
1983; Miltenbergeret al., 1985; Ollendick, 1981), and the rest relied on
simple AB designs. Although four of the six studies used direct
observationto obtain theirdata, two relied on self-reportedmethods of
data collection(Azrin & Nunn, 1973; Azrin & Peterson,1989). Of the four
studies using directobservation,threereportedinterobserverreliability
data with overall mean agreements of 87% (Finney et al., 1983), 89%
(Ollendick,1981),and 90% (Miltenbergeret al., 1985). Only two of the six
studies reported social validity data in which significantothers made
judgementsabout the effectiveness of treatment(Finneyet al., 1983; Pray
et al., 1986), and only two of the studies using direct observation
methodscollecteddata in more thanone setting(Ollendick,1981; Pray et
al., 1986). This informationdemonstratesthat, although the treatment
appears effectivein reducing tic frequency,it has not undergone
extensivesocial validation,and generalizationof the resultshas not been
well addressed.
NervousHabits
The original habit reversal procedure and variations have also been
used to treata numberof nervous habitsin children(see Table 2). Azrin
and Nunn (1973) eliminated finger sucking in a 5-year-old girl,
thumbsuckingin a 6-year-oldgirl,and fingernailbitingin an 8-year-old
boy with habit reversal. In a separate study, Azrin et al. (1980b)
significantlyreduced thumbsuckingin 18 childrenusing all the original
habit reversal techniques except early warning, response description,
and symbolic rehearsal. In this study, comparisons to a controlgroup
showed that the children receiving the habit reversal procedure had
improved more than those receivingthe applicationof a bittersubstance
on the thumb. Azrin, Nunn, and Frantz (1980a) used the original
procedures along with a relaxationcomponent,self-monitoring, positive
hair grooming,and noncontingentpracticeof the competingresponse to
treathairpullingin 4 children.At 4 weeks posttreatment, hairpullingwas
completely eliminated in all 4 children.With slight these
modifications,
procedures were also used to reduce the frequency hairpulling a 10
of in
year-old girl (Rosenbaum & Ayllon, 1981a) and in an 11-year-oldgirl
(Tarnowski,Rosen, McGrath,& Drabman, 1987). Rosenbaum and Ayllon
(1981b) also used the original procedure (minus response detection,
social support, and public display) and reduced the frequency of
scratchingin a 16-year-oldgirlby 60%.
Researchon the use of the simplifiedprocedureto treatnervous habits
in children has been sparse (see Table 2). Azrin, Nunn, and
Frantz-Renshaw(1982) compared a simplifiedversion of habit reversal
(consisting of early warning, situation awareness training,competing
response training,social support, and symbolic rehearsal) to negative
practice(engaging in the habit every30 seconds) fortreatingoral habits.
At the end of treatment,the negative practicegroup had reduced their
habit frequencyby 66% frombaseline and the habit reversalgroup had
reduced theirhabit frequencyby 97% at follow-up.This study suggests
that habit reversalis a more effectivetreatmentfornervous habits than
negativepractice.
Christensen and Sanders (1987) compared the effectivenessof a
simplifiedversion of habit reversal (situationawareness, early warning,
competingresponse,and social support),to differential reinforcementof
other behavior (DRO) and a wait-listcontrolto treatthumbsuckingin
children. Results showed that both DRO and habit reversal reduced
thumbsuckingfrombaseline, but therewere no differencesbetween the
two treatments.The wait-list control group did not improve from
baseline to posttreatment.
Rosenbaum (1982) utilized a simplified procedure of awareness
training(response descriptionand early warning), social support, and
competing response training,to treat hairpulling in a 7-year-oldboy.
Following one, 20 minutesession, the behavior disappeared and did not
reappear at the 18-monthfollow-up assessment. Anthony (1978) used
self-monitoring to eliminate hairpullingin a 9-year-oldboy. The child
was asked to press a wristcountereach time he pulled a hair,or started
to pull his hair. Althoughthe contingentbehavior was self-monitoring, it
may have functionedas a similarcompetingresponse in thatthe child's
hands were engaged in an incompatible response while monitoring
(pressingthe counter).
Althoughthe researchsuggests thatthe habit reversal procedure and
its variationsare effectivein the treatmentof nervous habits,we mustbe
cautious in our conclusions due to concerns about the research
methodology.Of the nine studies reviewed, only three used a control
group (Azrin et al., 1980a; Azrin et al., 1980b; Christensen& Sanders,
1987), and the rest relied on simple AB designs. In seven of the nine
studies, data collection involved self-reportor parental report (the
exceptions were Christensen& Sanders, 1987; Tarnowski et al., 1987).
Only fourof the nine studies reportedinterobserverreliabilitydata with
mean agreement scores of 100% (Rosenbaum & Ayllon, 1981a), 98%
(Tarnowski et al., 1987), 80% (Rosenbaum & Ayllon, 1981b), and 99%
(Christensen& Sanders, 1987). Two of the nine studies reportedsocial
validitydata (Christensen& Sanders, 1987; Tarnowski et al., 1987), and
only one study using directobservationmethods collected data in more
than one setting (Christensen & Sanders, 1987). A review of the
methodologyin these studies demonstratesthat although the treatment
appears effective in reducing habit frequency, information on
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generalizationand social validityof the behavior change is limited,and

otheraspects ofresearchmethodologyare lackingin some studies.
Stuttering
Azrin and Nunn (1974), adapted the originalhabitreversalprocedures
to treatstuttering.They used all of the originaltechniques,but modified
the competingresponse. The competingresponse forstutteringinvolved
regulatedbreathing.Upon awareness of a stutter,the clientwas told to:
"(1) stop speaking,(2) take a deep breathby exhalingand thenslowly in-
haling,(3) consciouslyrelax one's chestand throatmuscles,(4) formulate
mentallythe words to be spoken, (5) startspeaking immediatelyafter
taking a deep breath,(6) emphasize the initial part of a statement,(7)
speak forshorterdurations,and (8) eventuallyincrease the duration of
the speech" (Azrin & Nunn, 1974, p. 282). They also added relaxation
trainingand positive practicein which the child was asked to engage in
the competingresponse while reading.The child was instructedto grad-
ually increase the numberof words read per breath,untilthe child was
readinglong phrases fluently.
Two studies used the habit reversal procedure to treat stutteringin
children(see Table 3). Azrin and Nunn (1974) eliminatedstutteringin a
9-year-oldgirl and a 4-year-oldboy. Ladouceur and Martineau (1982)
used the same procedures as Azrin and Nunn (1974) and reduced
stutteringby 40% in 8 children afteronly three,45 minute treatment
sessions. This studyalso examined the effectiveness of the habit reversal
procedure implementedby parents for their child's stuttering.Results
showed that parentswere also effectivein administeringthe treatment,
withthe 7 childrenin thatgroup decreasingtheirstuttering by 40% from
baseline at posttreatment.This finding is important in that a
parent-implemented treatmentwould be more cost-effective.
A number of studies have used awareness training (response
descriptionand detection),competing response, and social support to
modifystutteringin children(see Table 3). Caron and Ladouceur (1989)
added facial relaxation and positive practice as well as daily
noncontingentpracticeof the competingresponse to these proceduresto
treat4 stutterers.Of the four,threewere stutteringbelow the clinically
significantlevel of 3% words stuttered(WS) at posttreatmentand at 6
month follow-up.These improvementsdid not come at the expense of
slowed speech rate.In fact,the childrenin thisstudyincreasedin speech
rate from baseline to follow-up. In another study using the same
procedures as Caron and Ladouceur (1989), 10 of 11 childrendecreased
their stutteringto under 3% WS and maintained the results at the
follow-up(Gagnon & Ladouceur, 1992). Again, the improvementdid not
come at the expense of speech rate, with the rate being stable or
increasedin all 12 children.
Perhaps the best support for the effectivenessof the simplified
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treatmentfor stutteringin childrencomes froma study by Wagaman,

Miltenberger, and Arndorf er (1993) who assessed social validity,
generalization,and long-termmaintenanceof the results.In this study,
stutteringwas assessed both in the home and in school settingsforeight
children (ages 6-10) in a multiple baseline across subjects design. The
authors implementedawareness and competingresponse trainingwith
social supportfromthe parents.At one year posttreatment, all 8 children
were below the 3% WS criteriain both the home and in the generaliza-
tion settingof the school. The speech rate was eitherstable or improved
in each of the children.The resultswere also sociallyvalid, as speech pa-
thologistsand parentsrated posttreatment speech samples as significant-
ly less pathological and more normal-soundingthan baseline speech
samples. A 3.5 year followup study,conductedon the participantsin this
study (Wagaman, Miltenberger,& Woods, 1995) showed that,of the sev-
en childrenlocated, five remained at or below the 3% WS criteria,with
most of the childrenshowing a continued increase in speech rate from
posttreatment.
This research suggests that the habit reversal procedure and it's
variationsare effectivein the treatmentof stuttering.Of the five studies
reviewed, three used multiple baseline designs (Caron & Ladouceur,
1989; Gagnon & Ladouceur, 1992; Wagaman et al., 1993), one utilized a
controlgroup (Ladouceur & Martineau,1982),and one used a simple AB
design (Azrin & Nunn, 1974). In addition, fourof the five studies used
direct observation to obtain their data; only Azrin and Nunn (1974)
relied on self-reportof stuttering.All four studies using direct
observationreportedinterobserverreliabilitydata rangingfrom84% to
98% agreement(Caron & Ladouceur, 1989; Gagnon & Ladouceur, 1992;
Ladouceur & Martineau, 1982; Wagaman et al., 1993). Only two of the
five studies socially validated theirresults(Gagnon & Ladouceur, 1992;
Wagaman et al., 1993), and only one of the studies using direct
observationmethods collected data in more than one setting(Wagaman
et al., 1993). The methodologyin these studies allows more reasonable
conclusions about the effectivenessof habit reversal and simplified
versions forthe treatmentof stuttering, although furtherdata on social
validityand generalizationwould be valuable.
Tourette'sDisorder
Only one study has looked at the effectsof the habit reversal
procedure in the treatmentof Tourette'sDisorder in children.Azrin and
Peterson (1990) used the full procedure and added the components of
self-monitoring and progressive muscle relaxation to treat 7 children
with Tourette'sDisorder. The multiple tics were treatedone at a time,
with the most frequenttic being targetedfirst.As can be seen in Table 4,
all 7 children decreased in tic frequencyby at least 89% following an
average of20 treatmentsessions.
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Only one study has assessed the effectivenessof a simplifiedhabit

reversalprogramforTourette'sDisorder in children. Petersonand Azrin
(1992) looked at the effectiveness
of threedifferenttreatments(see Table
4). Two children (10 and 13 years old) were taught self-monitoring,
relaxation, and a simplified habit reversal package consisting of
awareness and competing response training. The participants were
asked to engage in each of the threetreatmentsfor10 minutes.Withina
counterbalanced design, the results showed that both the simplified
habitreversaland self-monitoring proceduresled to greatertic reduction
than the relaxation procedure. It should be noted, however, that this
treatmentcomparisonstudydid not provide long termfollow-updata.
Despite a limitednumberof studies,it appears thatthe habit reversal
procedure and a variation consisting of awareness and competing
response training,are effectivein the treatmentof tics associated with
Tourette's Disorder. Of the two studies reviewed, both used group
designs. Both studies used direct observationto obtain their data and
both reportedinterobserverreliabilitydata with mean agreementscores
of 92% (Azrin & Peterson,1990) and 90% (Peterson& Azrin,1992). Azrin
and Peterson(1990) socially validated theirresultsand collected data in
more than one location. This informationsuggests that habit reversal
holds promise as a treatmentfortics associated with Tourette'sdisorder
in children, although additional methodologically sound research is
needed to confirmtheresultsofthesetwo studies.
Conclusions
This paper definedthe different typesof habitdisordersand discussed

their prevalence in children.The paper reviewed the various applica-
tions forboth fulland simplifiedversionsof the habitreversaltreatment
for a number of habit disorders including motor tics, nervous habits,
stuttering,and tics associated with Tourette'sDisorder. At best, the dis-
tinctionbetween the originaland simplifiedversions of habit reversalis
blurred.Many componentshave been added or deleted by authorswho
call theirtreatment"Habit Reversal,"although the awareness and com-
petingresponse componentsare included in almost all of the habitrever-
sal variations.This only strengthensthe argumentthathabitreversalcan
be effectivelysimplified.
From this review of the literature,a number of conclusions seem
warranted. First,the complete habit reversal treatmentappears to be
effectivein reducing the frequency of motor tics, nervous habits,
stuttering,and tics associated with Tourette's Disorder in children.
Second, it seems thata simplifiedhabitreversalprocedure,consistingof
some type of awareness training(usually includingresponse description
and detection)and competingresponse training,is effectivein reducing
the frequencyof these same disorders.Third,the role of self-monitoring
is unclear as it may functionas a dissimilar competingresponse or a
procedure that enhances awareness. Finally, we are unclear of the

necessityof the social supportcomponentin treatmentwithchildren.
These conclusions suggest two broad areas forfutureresearch.First,
researchers should evaluate the effectivenessof a simplified habit
reversal procedure to treat a number of childhood habit disorders
includingnailbiting,bruxism,Tourette'sDisorder,oral habits,and other
nervous habits.Thereis a paucityof researchon the simplifiedtreatment
with those habit disorders,whereas, in the areas of tics,hairpulling,and
stutteringthere is relativelymore evidence for the effectivenessof the
simplifiedhabitreversalprocedure.
When conducting furthertreatmentresearch with the simplified
procedures,a numberof issues should be considered.First,the studiesto
date have included relatively small samples of children (including a
numberof case studies). Futureresearchshould include childrenwith a
range of ages and abilitylevels, a varietyof familycharacteristics, and
various coexisting problems to evaluate the generalizabilityof the
findings.Second, researchersshould furtherassess the generalizationof
behavior change resultingfromthe use of habit reversaland variations
by assessing the habit disorder in multiple situationsbefore and after
treatment.The third consideration involves using direct observation
methods of data collection and sound research designs to evaluate
treatmenteffects.This will allow more confidence in the results of
studies evaluating habit reversal procedures.The fourtharea forfuture
research should be the social validation of treatmentoutcome. Social
validation involves judgements by clients, parents, or relevant
professionalsregardingthe methods and outcomes of treatment.This is
importantdue to the potential for social difficultiesarising from the
occurrenceof the habit disorder. In addition, when a habit disorder is
not totallyeliminatedfollowingtreatment, social validityis importantto
document the value of the treatmenteffects.Social validation of
treatmentprocedures is also importantin futureresearchto determine
how acceptable parentsand childrenfindhabit reversalprocedures and
variations.This has implicationsforcomplianceand continueduse of the
procedure over time. Fifth,the role of social support with children
should be furtherinvestigated. As yet, its necessity for effective
implementationof a simplifiedhabit reversaltreatmentwith childrenis
unclear. The final issue that should be addressed in this research
involves the reportingof long-termfollow-up data. This is important
because demonstrationsthat the effectsof treatmentare durable will
enhance the clinicalutilityof the treatment.
The second broad area of research involves theoretical issues.
Researchersshould continueto investigatethe mechanismsthatunderlie
the effectivenessof the simplified treatment (for a more detailed
discussion on this topic, see Woods & Miltenberger,1995). Put briefly,
does awareness and the use of a competing response decrease the
frequencyof habit disorders in childrenbecause they serve to increase
awareness of each occurrence of the habit behavior, because the

competingresponse functionsas a punisher for the habit behavior, or
because the competingresponse is an alternativebehaviorthatsupplants
the habit behavior? Answers to these and otherquestions will enhance
our understandingof habitreversaland habitdisordersin children.
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A review of habit reversal with childhood habit disorders

Article in Education and Treatment of Children · May 1996

Douglas William Woods

The user has requested enhancement of the downloaded file.

A Review of Habit Reversal with

Habit disorders can be defined as repetitivebehaviors that serve no

Major Classes of Habit Disorders

Tics are habitual, seeminglyinvoluntarymovementsof small groups

motor tics include shoulder shrugging, arm or neck jerking, facial

Nervous habitscan be definedas stable,repetitivebehaviorsthatserve

Much like motorand vocal tics,nervous habits may be maintainedby

Stuttering involves whole and part-word repetitions, blocking,

The final type of habit disorder that we will discuss is Tourette's

effectof some stimulantmedicationssuch as Ritalin.Finally,it has been

Description of the Habit Reversal Procedure

response, the behavior should: "(1) be opposite to the nervous

Applications of the Habit Reversal Procedure and Variations

Having describedthe originalprocedure,we will now focuson studies

tics had disappeared. Miltenberger,Fuqua and McKinley(1985) used the

as a punishermuch like the dissimilarcompetingresponse evaluated by

generalizationand social validityof the behavior change is limited,and

! 1S-/ lift fTj GP

treatmentfor stutteringin childrencomes froma study by Wagaman,

Only one study has assessed the effectivenessof a simplifiedhabit

This paper definedthe different typesof habitdisordersand discussed

procedure that enhances awareness. Finally, we are unclear of the

awareness of each occurrence of the habit behavior, because the

American Psychiatric Association.(1994).Diagnostic andstatisticalmanual ofmental disorders

Ingham,R.J.(1984).Stuttering and behavior therapy; Current statusand experimental

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