This is a 4 post series centered on ‘The Combined Approach’ that is explained in the ‘Atopic Skin Disease’, a manual for practitioners authored by Christopher Bridgett, Peter Noren and Richard Staughton (copy of book viewable by joining here). The Combined Approach uses habit reversal to stop habitual scratching in atopic eczema. Dr Christopher Bridgett has previously helped in Friday Doctor Q&A from November 2011 to February 2012 and MarcieMom has invited him to share more about the Combined Approach.
Development of a Nervous Habit
I read in your manual ‘Atopic Skin Disease’ of how a nervous habit develops, namely:
1. Normal initial specific response to an injury (or itch)
2. Increased frequency by positive reinforcement that leads to
3. Behavior (or scratching) becomes automatic
4. The habit generalizes to cause more situations precipitating the behavior
5. Decreased personal and social awareness
Also illustrated in your manual, another habit is introduced to reverse the scratching:
1. New habit is opposite to the old habit
2. Can be maintained for several minutes
3. Socially acceptable and compatible with normal activities
4. Strengthen muscles antagonistic to those of old habit
The techniques used in Noren and Melin, 1989 study mentioned in Atopic Skin Disease are:
1. Clenching fists and counting to 30 as an alternative to habit of scratching
2. Pinching the skin where it was itching as an alternative to itch-provoked scratching
Can you explain to our parents how to tell their child to clench fist and pinch skin? Is this something that can be understood by young children? And will pinching skin lead to the child using painful techniques to get rid of scratching? (I read in your manual not to say ‘Stop Scratching’, just as I’ve posted!)
The method of clenching a fist, then pinching the skin, is only suitable for older children, who are able to understand the instruction, and can accept responsibility for following the recommendations. The younger child requires a different approach which sees the parents as responsible for the treatment, with an adapted programme in between: see http://www.atopicskindisease.com/articles/20120115
So, no pinching small children please!
And yes – it is important to avoid saying “Stop Scratching” – you are quite right, of course!
Homework: Registering Scratching Frequency
In The Combined Approach, the first homework assignment to patients is to register the scratch frequency. This aids in the analysis of the scratching habit, following an ABC format of understanding the antecedents, behavior and consequences. Do you normally explain the ABC to patients before requesting them to register their scratching frequency? How can a parent help explain this to a young child? How can a parent help a child to count the scratching?
The explanation of the ABC normally comes after registration, as part of the instruction of how habit reversal works. See the patient handbook for Older Children: http://atopicskindisease.com/categories/20110503_1
The younger child has a different treatment programme, without any counting of scratching: for the younger child it is the parents who are responsible. They can achieve awareness of the childs behaviour without using a counter. See http://atopicskindisease.com/articles/Mark
MarcieMom: Thank you Dr Christopher Bridgett for explaining habit reversal that is part of The Combined Approach. In our next post, we will understand the three levels of treatment and conclude the series.
For previous posts in this series, see