The efficacy of habit reversal therapy for tics, habit disorders, and stuttering: A meta-analytic review

https://doi.org/10.1016/j.cpr.2011.03.013Get rights and content

Abstract

A meta-analysis based on 575 participants in 18 studies found Habit Reversal Therapy (HRT) to be an efficacious intervention for a wide variety of maladaptive repetitive behaviors, including stuttering, tics, nail biting, temporomandibular disorder, thumb sucking, and mixed repetitive oral-digital habits. Compared to control conditions, HRT showed a large effect size pre-treatment to final post-treatment assessment, d = 0.80. Moderator analyses revealed significant treatment effects for HRT for most moderator levels, indicating that HRT is efficacious in a number of variations for a variety of types of maladaptive behaviors, across a wide range of sample characteristics. The findings provide substantial support for the efficacy of HRT for disorders it is commonly used to treat. The findings are consistent with recent arguments for the classification of HRT as a well-established treatment for tic and habit disorders.

Highlights

► Habit reversal therapy has a large effect size in the treatment of tic disorders, habit disorders, and stuttering. ► Habit reversal therapy tends to be efficacious for both adults and children. ► The positive effects of habit reversal therapy tend to endure over time.

Section snippets

Primary ingredients of HRT

The complex nature of the original conceptualization of HRT has led to attempts by a number of researchers to identify the active primary components of the procedure and to elucidate which elements were necessary for the effectiveness of the package. Many authors considered HRT to be a lengthy and overly comprehensive procedure (O'Connor, 2005). Subsequently, researchers have evaluated a number of variations of HRT for the treatment of habit disorders (O'Connor, 2005). The majority of component

Efficacy of HRT

Many studies have examined the efficacy of HRT for habit disorders. Clinical case studies involving tics have consistently reported target behavior reductions of 75% to 100% with HRT (O'Connor & Leclerc, 2008). Randomized controlled trials have also provided support for the efficacy of HRT with tics, starting with Azrin, Nunn, and Frantz (1980a). Carr and Chong, 2005, Cook and Blacher, 2007 reviewed the empirical evidence on use of HRT to ameliorate tics and found substantial evidence of

Literature search

A systematic literature search included PsycINFO, Cambridge Scientific Abstracts, ProQuest, Google Scholar, and PubMed online databases for studies published prior to or during July 2009. We extracted studies containing “habit reversal” as a keyword and at least one of the following search terms: (a) cognitive-behavioral or behavioral, (b) intervention or treatment or therapy, (c) control group or placebo or comparison, (d) habit disorder, repetitive behavior disorder, Tourette's syndrome, or

Results

Eighteen studies produced effect sizes, with a total of 19 between-groups comparisons and a total of 575 participants. Table 1 summarizes key characteristics of the studies included in the meta-analysis, including sample characteristics and effect size. The overall effect of HRT was large (Cohen, 1988), d = 0.80 [95% CI: 0.53, 1.07], with 57 as the fail-safe N (Borenstein, Hedges, Higgins, & Rothstein, 2009), specifically the number of zero-effect-size studies needed to reduce d to 0.20, an

Discussion

The present study found that the overall effect of HRT from pre-assessment to final post-treatment assessment was large in comparison with control conditions. The overall finding suggests that HRT is an efficacious behavioral intervention for the symptoms of disorders for which it is commonly used: tics; stuttering; and habit disorders such as nail biting, thumb sucking, and lip biting. The large effect size, d = 0.80, roughly equivalent across disorders, is noteworthy. Furthermore, the moderator

References2 (58)

  • C.A. Flessner et al.

    An evaluation of the social support element of simplified habit reversal

    Behavior Therapy

    (2005)
  • R. *Ladouceur et al.

    Evaluation of a regulated-breathing method with and without parental assistance in the treatment of child stutterers

    Journal of Behavior Therapy and Experimental Psychiatry

    (1982)
  • J.M. Malouff et al.

    The efficacy of problem solving therapy in reducing mental and physical health problems: A meta-analysis

    Clinical Psychology Review

    (2007)
  • R.G. Miltenberger et al.

    A comparison of contingent vs non-contingent competing response practice in the treatment of nervous habits

    Journal of Behavior Therapy and Experimental Psychiatry

    (1985)
  • R.G. Miltenberger et al.

    Habit reversal with muscle tics: Replication and component analysis

    Behavior Therapy

    (1985)
  • R.G. Miltenberger et al.

    Simplified treatment and long term follow-up for stuttering in adults: A study of two cases

    Journal of Behaviour Therapy & Experimental Psychiatry

    (1996)
  • K.P. O'Connor et al.

    Evaluation of a cognitive-behavioural program for the management of chronic tic and habit disorders

    Behaviour Research and Therapy

    (2001)
  • L. *Saint-Laurent et al.

    Massed versus distributed application of the regulated-breathing method for stutterers and its long-term effect

    Behavior Therapy

    (1987)
  • D. *Townsend et al.

    Use of a habit reversal treatment for temporomandibular pain in a minimal therapist contact format

    Journal of Behavior Therapy and Experimental Psychiatry

    (2001)
  • C.W.J. Verdellen et al.

    Exposure with response prevention versus habit reversal in Tourette's Syndrome: A controlled study

    Behaviour Research and Therapy

    (2004)
  • K.K. *Waterloo et al.

    The regulated-breathing method for stuttering: An experimental evaluation

    Journal of Behavior Therapy and Experimental Psychiatry

    (1988)
  • D.W. Woods et al.

    Habit reversal: A review of the applications and variations

    Journal of Behavior Therapy and Experimental Psychiatry

    (1995)
  • D.W. *Woods et al.

    Comparing the effectiveness of similar and dissimilar competing responses in evaluating the habit reversal treatment for oral-digital habits in children

    Journal of Behavior Therapy and Experimental Psychiatry

    (1999)
  • D.W. Woods et al.

    A controlled evaluation of acceptance and commitment therapy plus habit reversal for trichotillomania

    Behaviour Research and Therapy

    (2006)
  • A.N. Adams et al.

    Habit reversal training

  • K.A. Allen

    The use of an enhanced simplified habit-reversal procedure to reduce disruptive outbursts during athletic performance

    Journal of Applied Behavior Analysis

    (1998)
  • N.H. Azrin et al.

    Habit-reversal: A method of eliminating nervous habits and tics

    Behaviour Research and Therapy

    (1973)
  • N.H. Azrin et al.

    Comparison of regulated-breathing versus abbreviated desensitization on reported stuttering episodes

    The Journal of Speech and Hearing Disorders

    (1979)
  • A. Barak et al.

    A comprehensive review and a meta-analysis of the effectiveness of Internet-based psychotherapeutic interventions

    Journal of Technology in Human Services

    (2008)
  • Cited by (105)

    • Self-help for body-focused repetitive behaviors: A randomized controlled trial

      2023, Journal of Obsessive-Compulsive and Related Disorders
    • Interventions for children and adolescence who stutter: A systematic review, meta-analysis, and evidence map

      2021, Journal of Fluency Disorders
      Citation Excerpt :

      A total of 20 studies met the inclusion criteria. Of these, six were systematic reviews (Bate, Malouff, Thorsteinsson, & Bhullar, 2011; Baxter et al., 2015, 2016; Herder, Howard, Nye, & Vanryckeghem, 2006; Lowe, O’Brian, & Onslow, 2013; Nye et al., 2013), six were registered trials (De Sonneville-Koedoot, 2007; Onslow, 2008, 2009a, 2009b, 2013; Paterson, 2009) and eight were RCTs (Arnott et al., 2014; Bridgman, Onslow, O’Brian, Jones, & Block, 2016; de Sonneville-Koedoot, Stolk, Rietveld, & Franken, 2015; Donaghy et al., 2015; Franken, Kielstra-Van der Schalk, & Boelens, 2005; Jones et al., 2005; Lattermann, Euler, & Neumann, 2008; Lewis, Packman, Onslow, Simpson, & Jones, 2008). Systematic reviews were used to ensure we had identified all relevant studies.

    View all citing articles on Scopus
    1

    Contributed equally to this publication.

    2

    References marked with an asterisk indicate studies included in the meta-analysis.

    View full text