During early development, most children experience repetitive or Stereotypie patterns of movement or behavior that can be described as habits. Whether these habits come to be considered as habit disorders depends on individual, family, and social characteristics, and particularly on the degree to which the habit seems to interfere with the child's normal physical, emotional, or social development and function.
In this article, we are referring to simple and common habit behaviors that may be annoying and called to the attention of a child health care provider (pediatrician, family physician, school nurse or school counselor, or other child therapist) for help in eliminating the habit. These may include nail biting, thumbsucking, nose picking, hair pulling (trichotillomania), simple tics (eye blinking, grimacing, and other "twitches"), vocalizations (eg, throat clearing and habit coughs) and habitual behaviors known to have both medical/organic and psychologic or emotional components, such as sleepwalking or other parasomnias, enuresis, and encopresis. We will not consider complex repetitive behaviors more commonly associated with children with physical illness or sensory impairments, degenerative disorders, developmental disabilities, or psychiatric illnesses. A thorough classification and discussion of these more complicated Stereotypie behaviors can be found elsewhere.1 An awareness of the spectrum of such Stereotypie behaviors and possible organic etiologies is important, particularly in the initial assessment of a child with a habit.
Habits are consistently described as so common as to affect virtually all children at one time or another during their early development.2 Thumhsucking may be present in 18% of children 2 to 6 years old3 or in 21% of 6 year olds.4 Enuresis is known to occur in as many as 20 million Americans over the age of 6 and in as many as 20% of 6 year olds.5-6 Trichotillomania occurs in less than 1% of children.6 Nail biting has a reponed incidence as high as 60% of all 10 year olds before it gradually decreases with increasing age.7 As many as 10% of the population may experience a simple tic lasting 1 month or longer.8
Common habits share a number of characteristics, including relative rather than absolute "morbidity" Habits rarely present a serious risk or the threat of serious consequences. One important exception is malocclusion, which may be associated with prolonged thumb-sucking. This may result in not only cosmetic dental needs and financial expense, but also in chronic painful chewing and eating.
We must consider; however, the potentially significant psychosocial morbidity accompanying these habit problems. Although no data exist on the prevalence or incidence of such morbidity, it is usually concern about these potential aspects of habits that define them and bring them to the attention of health care providers.
EVALUATION AND MANAGEMENT
A successful therapeutic approach depends on the development of a meaningful rapport with the patient and his or her parents in the context of obtaining a comprehensive history and physical examination. Particularly when a habit may be a symptom of an underlying physical disorder, (eg, enuresis, encopresis, or complex tics), a thorough diagnostic evaluation is mandatory before therapeutic intervention.
Those habits that are brought to the attention of a health care provider are done so usually because the parent is "annoyed" or "fed up" with the problem and often believes that the child should have "outgrown" the habit "by now." Parents may feel that to not have done so reflects negatively on them, as though they had somehow failed. In response, parents often try various means to help undo the habit. Most turn out to be appropriate and successful. These are the patients who we either don't hear from or who we hear about only incidentally during office visits. We may hear the description of some reasonable intervention, usually gleaned from hearsay, a grandmother, friends, a home health care book, or from one of many "health tips" mentioned in magazines, cable TV shows, or newsletters that are available to the public. Such patients rarely present to us for help because the problem has been solved.
Second, a child may be brought for help because he or she is becoming ambivalent, if not clearly ready, to give up the habit - often by reason of having been teased at school or at home. Or an adult in another setting may have brought an awareness of the habit and its behavioral consequences to the family's attention. This is often the child's teacher, but it may be the football coach, dancing teacher, or girl scout leader who has observed and is bothered by the behavior or more commonly has observed negative reactions to the behavior (teasing by peers and child's sadness). Or the dentist may have now strongly stated the anticipated or existing problem of malocclusion due to thumbsucking.
With the habit now a "nuisance" and frustrating for parents and other adults, and with the now discernible negative impact on the patient's selfesteem, the habit becomes a problem in need of a resolution. In this way, important morbidity has developed, as the habit has begun to interfere with healthy growth and development, relationships, and self-esteem. Intervention, therefore, seems warranted.
Critical to the evolution of any appropriate management is a comprehensive and thoughtfully and sensitively conducted history. It seems germane to always begin with the expectation of obtaining the history directly from the child. With attention to personal style, the nature of the approach to the patient and the history-taking is such an integral part of both the diagnostic and the therapeutic process that it deserves careful and thoughtful planning. Engaging the child in the process of taking the history is critical to the formation of a quick, positive therapeutic alliance and, therefore, positive expectations for outcome. Children should be asked the reason they came to the office that day, whose idea it was, and what they were wondering would happen. Such inquiries are designed to let the child know that he or she is important, is able to give the history, and is entitled to be involved intimately in this process.
Beyond traditional inquiries about onset, associated life events, or Stressors, interventions "tried," and outcomes thereof and current status in regard to timing, location, frequency, and effects of the habit behavioi; it is particularly important to know the child's view of the problem. Usually, this is readily available from the child in the presence of the parent. As the history unfolds, it is useful to know how the child perceives the habit as interfering with his or her life, ie, what can't he or she do because of the habit? What is bad and what is good about it? What will he or she be able to do or not do differently when the habit is gone? Such inquiries offer the child positive expectancies about the possibility that the habit can and will be gone, and also continue to provide egostrengthening compliments by implication, ie, that you trust and believe the child has considered these issues, and can articulate a response to them (which most children can do). Such questions are both part of a preliminary investigation into the presence of secondary gain that may be associated with the habit and an assessment of the child's motivation to participate in making a change toward "giving up" the habit.
As rapport is developed, it is important to discover both the child's and the parent's beliefs about the habit's origins. While the clinician clearly must know the child's thoughts before proceeding to offer impressions and suggestions, such inquiry is also designed to specifically reinforce the clinician's acceptance of the child's thoughts and feeling, and thus build a strong therapeutic relationship. One may ask, therefore, "I know you don't know for sure, but I wonder what has crossed your mind as the reason for the habit?" This is often useful in unlocking rroublesome worries of parents and identifying fantasies that a child may have, eg, the habit arising from some prior misbehavior.
The clinician must also assure that a thorough physical examination has been conducted. This is particularly important for counselors or psychotherapists who may be asked by families to mange problems such as tics or enuresis, or other habits that may have pathophysiologic origins. Once the examination and any related studies are found to be normal, the clinician can proceed confidently with further therapeutic intervention.
Childhood habit problems are not usually a reflection of deep-seated or long-ago ingrained and "habituated" emotional problems.5'9 Known initiating events have been long forgotten while the habituated behavior has persisted. If the history suggests, however, that either the secondary gain from the problem is great or that unresolved conflicts or other psychological issues are prominent, psychotherapeutic intervention with the child and family are indicated before direct management of the habit itself is undertaken. Once such therapies begin to reflect success, it is appropriate for the same or a different clinician to also begin further intervention for amelioration of the habit. In the absence of the unusual need for psychotherapy, symptom-removal approaches are safe, efficient, and effective.
A myriad of treatment programs have been employed for habit problems. Many of these behavioral modification approaches employ a negative conditioning model, such as the common practice of putting a bitter or distasteful substance on the thumb to "help" stop thumbsucking.10 While such aversive methods are described as successful, studies reporting their success do not comment on the potential negative impact of these approaches. One should worry about the short- and long-term impact on the child of being treated in effect punitively for problems that by definition have low morbidity; one must wonder if the morbidity in terms of potential decreased trust in adults and costs to self-esteem may be greater from the "treatment" than from the problem.
RATIONALE, METHODOLOGY, AND EXAMPLES OF HYPNOTHERAPY (RELAXATIONAMAGERY) FOR HABIT PROBLEMS
Teaching children self-hypnosis for the management of habit problems is often one of the most gratifying areas for the application of relaxation/ mental imagery (RMI) and cyberphysiologic skills.11 With the presence of a habit problem and a clear indication that the patient (and not just the family) is ready for the habit to end, the teaching and use of RMI skills can and should be presented as a technique and approach of choice, where the focus can be expected to be complete disappearance of the problem.9
Habits are, by definition, unconscious, and certainly seem to be involuntary and inadvertent. This belief is reinforced in common parlance through the use of language implying and defining reduced or absence of control, eg, "He can't help it," "She doesn't even know she's doing it," or "He's not aware of when he's doing it." To the degree that habits seem to operate separate from conscious awareness, such statements are true. However, repetitive use of such language usually serves only to reinforce to children the sense of helplessness and lack of control that they experience in many aspects of their daily lives. They become, therefore, counterproductive phrases that probably are best avoided.
The hypnotic experience, like habits, occurs largely in the unconscious; because of this, it is particularly well-suited to use for ameliorating problems residing in or emanating from the unconscious. Its clinical usefulness is in helping individuals to use unconscious (which children understand and accept as identical to what we coil pretending, daydreaming, or imagination) to develop and maximize control, in this case over a bothersome habit. Habits and the way people respond to them imply a lack of self-control (and patients too may say "I can't help it. . . "), while self-hypnosis implies, allows, and builds a strong sense of personal self-control. Parents may try to control habits (eg, by saying "stop that!") but find that they don't seem to be able to do so consciously. In their frustration, they become angry and punitive, and contribute to a negative cycle of habitQridicule or blaming^trying unsuccessfully to change^decrease in self-esteem and perpetuation of the habit. On the other hand, selfhypnosis provides a child-centered, cMd'ControUed con' ceptuaL framework for habit management in which the child is taught and encouraged to practice selfmanagement skills (exemplified in the cases noted below). Beyond problem resolution, self-hypnosis also serves as a process of empowerment and growth through which a common and positive spinoff is often enhanced of self-esteem.
Viewed as a process of "cultivation of imagination" for the patients own benefit, hypnotherapy for habit resolution seems to be easier for children than for adults. This may be because children are more intimately familiar with their imaginations as they are naturally and normally in and out of imaginative states of mind all day long. As such, children easily learn and accept that they can use that state of mind called hypnosis to achieve mastery over a problem such as a habit disorder.
As with any therapeutic modality, hypnotic techniques and suggestions must be individualized. While there is no way to predict how quickly an individual child will completely eliminate a given habit, patients and families easily accept and are relieved to hear the positive expectation that most children who wish to stop the problem not only learn self-hypnosis RMI very quickly within one or two visits, but also usually demonstrate definitive progress toward resolution within four to five visits.11 Symptom substitution is rarely seen5'9 when habit problems are managed with the teaching of these cyberphysiologic strategies.
It often seems critical to not only develop rapport with the child-patient, but also to provide some specific education about the manner in which the body works and to formulate in their language how their "problem" has come about. As even children in kindergarten are often aware of computers, the use of a so-called computer analogue or metaphor has been very useful in talking with children about what habits are and how they develop. At the same time, hypnosis also may be presented and explained as a natural everyday phenomenon that we are in and out of as we absorb ourselves in and attend to things we do and like. Analogies to pretending, daydreaming, or imagining are often useful. The following example illustrates the management of the "traditional" habit problem of thumbsucking.
The following presentation should be discussed with the child with or without the parent present depending on the child's age. While this type of discussion may precede any "official" hypnosis training, it does clearly contain hypnotic-like language and hypnotic suggestions to be offered later during more formal self-hypnosis training.
"Bobby, from what you've told me I guess that sometimes it seems like that thumb [dissociation suggestion = that thumb, not your thumb] makes its way to your mouth without even noticing it? [The child agrees.] And. . . it's kind of amazing that sometimes you are so used to it that you don't even notice it until it's been there a while? You know what a habit is, don't you? It's something that is automatic, that happens (no responsibility) without knowing it or thinking about it on purpose.
Do you have any habits? [Bobby agrees that thumbsucking is one little habit.] Do you know what computer is the best in the world? [After Bobby finishes guessing IBM, etc, the clinician points to Bobby's head and he knows that the brain is in there.] One of the ways that the brain works so well and so fast is by having habits - just like a computer does - so if you push ?* on the computer it always types 1A* or if you give some other direction it always does it the same way. Our brains are the same. After you learn something you don't always have to think about it, do you? Like walking - do you think about walking or talk about it out loud or do you just do it? You just walk, don't you?
"That's because your brain, the computer, knows how and it has a good habit. Now the feet and legs and back know how to walk, don't they! You don't have to say Okay, feet, now walk. . .' but you did have to learn didn't you?
When you were just a little kid you learned a lot of good habits with your parents' help. Sometimes, you learned other habits that you then stopped using-like crawling, you don't still crawl most of the time do you? Well, your brain still knows how, but it stopped using that habit that it used to need, didn't it.' [pause] Well, that's right and when you were younger [this is a purposeful appeal to the developing ego and desire for growth, mastery, and development present in all children] you learned that other habit very well of sucking that thumb and back then it was a good one to use, but now you don't need it any more. Do you? Welt, it was such a good automatic one when you first started that it has kept going, and now that you don't need it anymore, you just have to reprogram that computer we call the brain to do it differently. . . and that's how daydreaming and imagination can help. . . and I'll be your coach/teacher/helper."
Such a discussion is often sufficient for younger children to accept and to begin to change. For somewhat older school children and parents, it is useful to explain further that since such automation is, by definition, "sub-conscious" and out of our usual awareness, which makes it a "habit," then getting rid of it or "undoing it" is best accomplished through the use of the so-called subconscious or what we use when we daydream, imagine, or do self-hypnosis - what we prefer to call relaxation/mental imagery or RMI.
In an initial 1-hour visit, the primary goals are to establish rapport with the child and parent(s) and learn as much as one can about the habit, the circumstances/context of its onset, its frequency and intensity, and its meaning to the patient and family. In the context of such a history, positive expectations, positive implications, and refraining kinds of language - all components of hypnotic "strategies" - are used to plant seeds expected to grow into positive outcomes in later clinical sessions. These are cornerstones to the introduction of hypnosis and hypnotic techniques along with open and matter-of-fact discussions with the patient and family about their own preconceptions about hypnosis. Hypnosis should be explained and questions answered, as it is presented as a phenomenon with which the patient and family are already familiar. Thus, "You probably know about this, because most people find out that they know but didn't know that they knew. Hypnosis is like the feeling we get when we are daydreaming, or pretending or imagining - you know how sometimes we seem not to bear or see or notice other things quite the same when we are reading a book or listening to a concert, or really concentrating on something. . . well, it's like that. . . only when we use hypnosis clinically for something, such as headaches or a habit, we learn to do the daydreaming or imagining on purpose to work on changing the problem first in our thinking." Specific emphasis is placed on straightforward, honest, and open communication particularly in answering questions and dispelling any myths that families may have from popularized images of hypnosis; and then upon the emergence of an autonomous role for the child in the development of selfregulation skills with the clinician as teacher, coach, and guide.
It is also often useful to begin to change thinking about the habit by bringing it further away from its usual residence in the unconscious to conscious discussion. Beyond the discussion in the office, the child should become increasingly conscious of the habit without feeling critiqued by parents or other well-meaning adults or ridiculed by siblings or peers. An effective way of accomplishing this is to involve the patient in measuring and monitoring the habit. Predicated on the notion that self-monitoring leads to se If- regulation, this should involve some mutuallyagreed upon record -keeping by the child. This should be presented matter-of-factly during the first visit. The intent is to establish a contract and an "assignment" preparatory to subsequent visits. One might say, "Now I know you don't have this habit all the time, because you said sometimes it's more and sometimes it's less - like it's more when you are bored or tired, and it's less when you are at school, and some days are different than others, right? So, let's say we could measure this - let's say we had a ruler that goes from 0-12. . . let's say that the '12' end was the very most nail biting in the world - all the time or a whole bunch. . . and let's say O' was no nail-biting all day or night. . . What number would be your usual day? What would be the worst day you ever had? And the best? What makes the number go up higher?"
Such inquiries serve several purposes. They reinforce the concept that the habit is dynamic, not static, and that it is a highly variable rather than an all or none behavior. Via the child's selection of numbers and measurement, the potential for personal control and mastery are reinforced while increased awareness of the habit is also fostered. Acceptance of the concept of such a scale and willingness to identify different ratings implies that the child believes that achieving "O" all the time is an attainable goal. Thus, if it can be "5" or "8" or "3," it can be "0." The only question is how to get to that.
After introduction of this process, the child should be helped to number a blank calendar chart on which to keep daily track of the habit, giving a rating once a day ("At bedtime think back on the day and think whether it was a '3' or a '9' or a '5' day for the habit and put that number down"). At other times, the child should keep track more often, particularly if the habit is situation-specific (eg, "Give yourself a rating after school for the daytime and then again at bedtime for the time after school until bed"). This helps the clinician foster increased awareness and responsibility, reinforce autonomy, and indicate that the information is needed in order to be helpful as a coach. Rather than a hierarchy of rewards for "better numbers," the daily records should speak for themselves and be discussed on subsequent visits.
Experiencing HypnosisfTeaching Self-Hypnosis
The process of formally teaching a self-hypnosis exercise commonly takes place at the second or a subsequent visit. With a highly motivated preadolescent or adolescent, the clinician may wish to begin at a first visit; in others, a slower development of rapport may require waiting until a later visit. Favorite place/activity imagery in association with progressive relaxation usually provides a very positive initial experience. During this first session, general principles of clinical hypnosis should be followed to provide positive feedback and reinforcement that:
1. they are doing it "right,"
2. it is their imagery or fantasy and they can enjoy and create it however they wish,
3. they can notice bodily changes during the imagery experience (such as relaxation, slowing of respirations), and
4. each time they practice it gets easier and better.
Such positive feedback and ego-strengthening (hypnotic) suggestions are particularly important during a first session. Before the end of a first session, the process is reviewed in order to teach self-hypnosis for practice at home. (Thus, "Before you finish today it's nice to know that you have learned very well and very quickly, and that every time you practice it gets easier and better. When you practice at home, choose a place and time where no one will bother or disturb you, such as your bedroom after supper, after school, or before bed, and then close your eyes and begin imagining and relaxing just like you've done so well today. . . ") The details are then reviewed as well.
At subsequent visits, the patient is usually seen privately, the calendar of progress is reviewed, and the patient's experience with practicing selfhypnosis at home is discussed and reviewed. Hypnosis is practiced again, with a focus on restructuring any misconceptions, reinforcing successes, and reinforcing positive expectations for outcome, including, for example, developing an image in their mind of "how the calendar will look when it's completely the way you want it to be." In individual cases, an audio tape of the clinical session may be prepared for the child to take home and use as a support for times when he or she is feeling discouraged or wishes to "have the coach at home." In order to foster self-reliance and mastery, however, audio tapes are only prepared when the child has already demonstrated at least a preliminary understanding of self-hypnosis and has practiced at home without the use of a tape.
While nocturnal enuresis may not be a habit disorder in the same way as thumbsucking or nailbiting, the presentation as such is not only honest and direct, but also often effective in relieving a sense of guilt or responsibility, and in turn empowering and motivating the child to work to make a change. Prior to the introduction of hypnotherapeutic management of nocturnal eneuresis, it is critical that a comprehensive medical history, physical examination, and urinalysis have assured both the clinician and the family that no evident or easily remediable physical problem is present to explain the problem.5,12,13
In developing rapport and evolving a clinical strategy, the clinician must understand the patient's (and family's) beliefs and attitudes about the origin of the problem as well as their expectations for participation in successful resolution. For enuresis it has been particularly important to offer an easily understood explanation of normal genitourinary anatomy and physiology. Enuresis may be presented as analogous to a habit problem while also introducing RMI as a useful strategy for change. Such explanations of habits with the use of computer analogue/metaphor serve several purposes, beginning with relief of guilt/shame for the problem, a way of thinking about the problem that is useful, and the planting of seeds of motivation and positive expectations for the resolution of the problem in and through hypnotic techniques.
Habit problems in children are common, undesirable, and may interfere with normal growth, development, and happiness while contributing to difficulties with self-esteem. When patients seek help for habit problems, hypnotherapy seems particularly ideally suited to help because it, like the habits themselves, occurs within and uses the unconscious. When evaluation confirms the absence of organic etiologies, when a sensitive and thorough history identifies that a child is well motivated to reduce or eliminate the habit, and when parents and child are prepared to allow the child to assume primary responsibility for habit elimination, then the clinician trained and skilled in hypnotherapeutic techniques can and should offer hypnotherapy as a methodology of choice. In so doing, gratification for child, family, and therapist will follow, as hypnotherapy will usually prove to be less time consuming, non-aversive, more ego-strengthening, and less expensive than many other approaches.
1. Hoder EL, Cohen DJ. Repetitive behavioi patterns of chiidhood. lit Levine MU Carey WB, Cracker AC, Gross RT, eds. Devdopmeraai-Behaaaral Pediatrics. Philadelphia, Pa: WB Saunders Co; 1983:607-622.
2. Bchrman R, Vaughan V, Nelson WE, eds. Nelson's Textbook tf Pediatrics. Philadelphia, Pa: WB Saunders Co; 1987.
3. Infante PE An epidemiologie study of finger habits in preschool children, as related co malocclusion, socioeconomic status, race, sex, sine of community. J Dem Child. 1976;43:33-38.
4. Klackenberg G. Thurnbsucking. frequency and etiology Pediatra. 1949;4:41 8-424.
5. Olness KN, Gardner GG. Hypnosis and Hypnotherapy Wish Children. 2nd ed. Philadelphia, Pa: Crune and Stratton; 1988.
6. Levine MD, Carey WB, Crocket AC, Gross RT, eds. Dselopmewal-Beiiaworai Pediatrics. Philadelphia, Pa: WB Saunders Co; 1983.
7. Malone Aj, Massler M- Index of nailbiting in children. Journal of Abnormal and Social Piycholog,. 1952;47:193-202.
8. Schowalter JE. Tics. Pediatr Rev. 1980;2:55-57.
9. Gardner OG. Hypnotherapy in the management of childhood habit disorders. J Pidiatr. 1978i92:83B-840.
10. Riman FC, Barone VJ. Aversive taste treatment of finger and thumb sucking Pefiomcs. 1986;78: 174-1 76.
11. Kohen Q Olncss K, Cohvell S, Heimel A. Relaxation/mental imagery (self-hypnosis) in the management of 505 pediatrie behavioral encounters. J Dw Behav Pcdtatr. 1984i5(l):21-25.
12. Kohen DP. Hypnosis with children. In: Hammond C, ed. Handbook of Hypnotic Saggestions end Metaphors. New !fork, NY: WW Norton and Co; 1990:489-493.
13. Kohen DR Hypnosis fot enuresis in children. In: Hammond C, ed. Handbook of Hypnotic Sugpniota and Mwapton. New ibrk, NY: WW Norton and Co; 1 990:495-498.