steroids and emollients become a successful treatment. While there is no topical treatment strong enough to deal with the damage caused by scratching, habit reversal without proper use of topical steroids and moisturisers will not be effective. A combined approach is necessary.
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Fig 5.10 Requirements for Changing Behaviour
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• Understanding the old behaviour • Motivation for change • Knowing what to do • Doing it!
Level 3: habit reversal (Fig 5.10) As a behaviour modification technique based on learning theory, habit reversal (Ch 3) is usually of interest to parents. Time should be spent discussing behavioural analysis the importance of antecedents and consequences, as well as the behaviour itself. Important principles need clarification, especially the need for understanding and motivation, and the significance of keeping all interventions positive. The child needs to know what to do, and not what not to do. No habit can be successfully treated until awareness has been accomplished. In older children and adults preliminary registration by the patient is necessary. In the youngest patient the parents and others are available to observe behaviour and be aware of the situations most likely to be provocative. Parents will already be concerned about scratching, but they seldom appreciate the extent to which it is occurring, or understand the relevance of scratching in the development of chronic eczema. Explanation and instructions given by the therapist serve to make the family aware of the behaviour that needs modification. If time is allowed between first visit and starting treatment, an opportunity will be available for the family to make their own observations for further discussion. As for adults, for children there are two types of scratching. There is scratching because of itching, and scratching because of circumstances. If the child is old enough to understand, 'itch scratch' can be controlled without damaging the skin by teaching the child to pinch or press a fingernail into the itching area. The procedure needs to be actively demonstrated to both parents and child. If the child is able to participate in this way they gain an important sense of being actively involved in the healing process. Children as young as three years old have been taught how to use this method. After a week of treatment using The Combined Approach the procedure becomes redundant, as the behaviour of young children changes quickly.