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TIC DISORDERS, TRICHOTILLOMANIA, AND OTHER REPETITIVE BEHAVIOR DISORDERS Behavioral Approaches to Analysis and Treatment
TIC DISORDERS, TRICHOTILLOMANIA, AND OTHER REPETITIVE BEHAVIOR DISORDERS Behavioral Approaches to Analysis and Treatment
edited by
Douglas W. Woods University of Wisconsin-Milwaukee
Raymond G. Miltenberger North Dakota State University
^ S p r iinger
Library of Congress Cataloging-in-Publication Data Tic disorders, trichotillomania, and other repetitive behavior disorders: behavioral approaches to analysis and treatment / edited by Douglas W. Woods and Raymond G. Miltenberger. p. cm. Includes bibliographical references and index. ISBN 0-7923-7319-7 (alk. paper) 1. Stereotyped behavior (Psychiatry) 2. Tic Disorders. 3. Compulsive hair pulling. 4. Habit breaking. I. Woods, Douglas W, 1971- II. Miltenberger, Raymond G. RC569.5.S74 T53 2001 616.8--dc21 2001023032
ISBN-10: 0-387-32566-2 softcover ISBN-13: 978-0387-32459-2 ISBN: 0-7923-7319-7 hardcover Printed on acid-free paper. First softcover printing, 2006 © 2001 Springer Science+Business Media, LLC All rights reserved. This work may not be translated or copied in whole or in part without the written permission of the pubHsher (Springer Science+Business Media, LLC, 233 Spring Street, New York, NY 10013, USA), except for brief excerpts in connection with reviews or scholarly analysis. Use in connection with any form of information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed is forbidden. The use in this publication of trade names, trademarks, service marks, and similar terms, even if they are not identified as such, is not to be taken as an expression of opinion as to whether or not they are subject to proprietary rights. Printed in the United States of America. 9 8 7 6 5 4 3 2 1 springer.com
Contents Contributors
ix
Preface
xi
Acknowledgements Chapter 1. Introduction to Tic Disorders, Trichotillomania, and Other Repetitive Behavior Disorders: Behavioral Approaches to Analysis and Treatment
xiii
1
Douglas W. Woods and Raymond G. Miltenberger Chapter 2. Assessment of Repetitive Behavior Disorders
9
James E. Carr and John T. Rapp Chapter 3. Physical and Social Impairment in Persons with Repetitive Behavior Disorders
33
Douglas W. Woods, Patrick C. Fhman, and Ellen J, Teng Chapter 4. Characteristics of Tic Disorders
53
Diane B. Findley Chapter 5. Behavioral Interventions for Tic Disorders
73
T. Steuart Watson, Lorrie A. Howell, and Stephanie L Smith Chapter 6. Habit Reversal Treatment Manual for Tic Disorders Douglas W, Woods
97
VI
Chapter 7. Characteristics of Trichotillomania
133
Raymond G. Miltenberger, John T, Rapp, and Ethan S. Long Chapter 8. Behavioral Interventions for Trichotillomania
151
Amy J. Elliott and R. Wayne Fuqua Chapter 9. Habit Reversal Treatment Manual for Trichotillomania
171
Raymond G. Miltenberger Chapter 10. Characteristics of Oral-Digital Habits
197
Patrick C. Friman, Michelle R. Byrd, and Erin M. Oksol Chapter 11. Behavioral Interventions for Oral-Digital Habits
223
Vincent J, Adesso and Melissa M. Norberg Chapter 12. Habit Reversal Treatment Manual for Oral-Digital Habits
241
Douglas W, Woods and Michael P. Twohig Chapter 13. Analysis and Treatment of Oral-Motor Repetitive Behavior Disorders 269 Keith D. Allen andJodi Polaha
Vll
Chapter 14. Repetitive Beliavior Disorders in Persons With Developmental Disabilities
297
Joel E. Ringdahl David P. Wacker, Wendy K. Berg, and Jay W. Harding Index
315
Contributors Vincent J. Adesso, Department of Psychology, University of WisconsinMilwaukee, Milwaukee, WI 53201 Keith D. Allen, Munroe-Meyer Institute, 600 S. 42"^ Street, Omaha, NE 68198 Michelle R. Byrd, Department of Psychology, University of Nevada-Reno, Reno, NV 89557 Wendy K. Berg, Department of Psychology, University of Iowa School of Medicine, Iowa City, lA 52242 James E. Carr, Department of Psychology, Western Michigan University, Kalamazoo, MI 49008 Amy J. Elliott, Munroe-Meyer Institute, 600 S. 42""* Street, Omaha, NE 68198 Diane B. Findley, Yale Child Study Center, Yale School of Medicine, 230 S. Frontage Road, New Haven, CT 06520 Patrick C. Friman, Department of Psychology, University of Nevada-Reno, Reno, NV 89557 R. Wayne Fuqua, Department of Psychology, Western Michigan University, Kalamazoo, MI 49008 Jay W. Harding, Department of Psychology, University of Iowa School of Medicine, Iowa City, lA 52242 Lorrie A. Howell, Department of Counselor Education and Educational Psychology, Mississippi State University, Mississippi State, MS 39762
Ethan S. Long, Department of Behavioral Psychology, Kennedy Krieger Institute, 707 N. Broadway, Baltimore, MD 21205 Raymond G. Miltenberger, Department of Psychology, North Dakota State University, Fargo, ND 58105 Melissa M. Norberg, Department of Psychology, University of WisconsinMilwaukee, Milwaukee, WI 53201 Erin M. Oksol, Department of Psychology, University of Nevada-Reno, Reno, NV 89557 Jodi Polaha, Munroe-Meyer Institute, 600 S. 42"^ Street, Omaha, NE 68198 John T. Rapp, Department of Psychology, University of Florida, Gainesville, FL 32611 Joel E. Ringdahl, Department of Psychology, University of Iowa School of Medicine, Iowa City, lA 52242 Stephanie L. Smith, Department of Counselor Education and Educational Psychology, Mississippi State University, Mississippi State, MS 39762 Ellen J. Teng, Department of Psychology, University of WisconsinMilwaukee, Milwaukee, WI 53201 Michael P. Twohig, Department of Psychology, University of WisconsinMilwaukee, Milwaukee, WI 53201 David ?• Wacker, Department of Psychology, University of Iowa School of Medicine, Iowa City, lA 52242 T. Steuart Watson, Department of Counselor Education and Educational Psychology, Mississippi State University, Box 9727, Mississippi State, MS 39762 Douglas W. Woods, Department of Psychology, University of WisconsinMilwaukee, Milwaukee, WI 53201
Preface
The goal of this book is to provide a comprehensive description of tic disorders, trichotillomania, and other repetitive behavior disorders, with an emphasis on behavioral assessment and treatment. The material in this book stems from our (DWW and RGM) research and clinical work with individuals experiencing these disorders. Although we have done substantial work in this area both together and with our respective graduate students, our work has been inspired by the earlier ground breaking work of Nathan Azrin. Nathan Azrin was a pioneer in the development of behavioral technology for the treatment of a wide variety of psychological and behavioral disorders. Azrin's work in the 1970s and 1980s resulted in a number of innovative approaches to treatment that are still the gold standard today. The treatment that has been the impetus for our work is the Habit Reversal procedure Azrin developed and evaluated in the early 1970s. Habit Reversal, described in detail in a number of chapters in this volume, has stood the test of time. A large body of research demonstrates its effectiveness for the treatment of tics, trichotillomania, and other repetitive behavior disorders. Because of its robustness, accessibility, and wide applicability. Habit Reversal is given prominence in this volume. Our hats are off to Nathan Azrin for making it all happen. We have organized this volume and structured the information in the respective chapters with the practitioner, researcher, and student in mind. Important characteristics of tic disorders, trichotillomania, and other repetitive behavior disorders are described so the nature of these disorders, their comorbid conditions, and probable controlling variables can be
Xll
understood. Both ground breaking and recent research on the analysis and treatment of these disorders is presented. Finally, Habit Reversal treatment manuals are provided for each category of disorder as step-by-step guides for practitioners and researchers treating these disorders. The authors of each chapter are active researchers and practitioners who bring a wealth of expertise to their respective chapters.
-D.W.W. andR.G.M.
Acknowledgements
We would like to thank the contributors to this book. Without their expertise and dedication to the project, this book would not have been possible. We would also like to thank Kluwer Academic Publishers for agreeing to publish the book and for their help and guidance throughout the process. We would both like to thank the clients and research participants we have worked with over the years. Because they allowed us into their lives, we have been able to understand the ramifications of repetitive behavior disorders. Their stories provided the motivation for this book. Personally, Doug Woods thanks his wife Laurie, his parents Bill and Jane, his brother Ted, sister Julie, nephew Devin, Bernie Homan, and Rich and Pat Olsen. They have provided me with love, support and encouragement throughout my life. I would like to personally dedicate this book to the memory of my grandfather, Alfred Homan, grandmother. Hazel Buschur, and aunt, Jean Dunno. Personally, ROM thanks his wife, Nasrin, and children, Ryan and Roxanne, for their support and encouragement. I owe a debt of thanks to all of the graduate students who have toiled on my research team over the years as we have evaluated procedures for the analysis and treatment of habit disorders.
Chapter 1 Introduction to Tic Disorders, Trichotillomania, and Other Repetitive Behavior Disorders: Behavioral Approaches to Analysis and Treatment Douglas W. Woods University of Wisconsin-Milwaukee
Raymond G. Miltenberger North Dakota State University
1. INTRODUCTION People engage in a wide variety of behaviors in our presence. Often we fail to notice, but once in a while something catches our eye. We see a peculiar behavior or a behavior that seems out of place. We see a person make odd movements or noises, or notice a person pull her hair, look at it, roll it between her fingers, and drop it to the floor. We observe a 10-year old suck his thumb, a behavior his peers abandoned years ago. This book is about these and similar behaviors. Specifically, this book describes the characteristics of and discusses treatments for tic disorders, trichotillo-mania, and other repetitive behavior disorders. As described in later chapters, tic disorders are characterized by repetitive, stereotyped motor movements or vocalizations; trichotillomania refers to chronic, repetitive hair pulling which results in hair loss; and "other repetitive behavior disorders" refers to a host of other behaviors (in some cases called stereotypic movement disorder), which may occur frequently and cause some type of physical or social concern. Examples of other repetitive behavior disorders include oral-digital habits (i.e., thumb or finger sucking or nail biting), rumination, stuttering, and bruxism.
Tic Disorders, Trichotillomania, and Repetitive Behavior Disorders
2. IMPORTANCE OF THE BOOK Unfortunately, tic disorders, trichotillomania, and other repetitive behavior disorders are not as widely studied as other psychiatric disorders such as mood or anxiety disorders (Stein & Christenson, 1998). To demonstrate this point, we conducted a computerized literature search on medical (Medline, 1971) and psychological (Psychlnfo, 2000) data bases in which we examined the number of published articles (since 1975) for tic disorders, trichotillomania, stereotypic movement disorder (SMD), schizophrenia, and bipolar I disorder. We chose schizophrenia and bipolar I disorder as comparison disorders because their prevalence rates are similar to or below those for tic disorders, trichotillomania or other repetitive behavior disorders (American Psychiatric Association, 1994). Results of our search are presented in Table 1.1. As can be clearly seen, the sheer volume of research in both databases leans heavily toward schizophrenia and bipolar disorder compared to the disorders discussed in this book. Table 1.1. The Number of Published Papers Listed on Medline and PsychLit for Tic Disorders, Trichotillomania, Stereotypic Movement Disorder, and Comparison Disorders. Tic Disorders Trichotillomania SMD Schizophrenia
Bipolar
Medline
2,118
370
87
37,934
12,472
PsychLit
177
309
14
32,741
2,489
The reason for this relative lack of attention is unclear, but considering the prevalence rates of these disorders often match or exceed those of other psychiatric disorders receiving more clinical attention (American Psychiatric Association, 1994; Leckman, King, & Cohen, 1999; Woods, Miltenberger, Flach, 1996), one could assume that tic disorders, trichotillomania, and other repetitive behavior disorders are viewed as having little clinical importance. In fact, both of us (DWW & RGM) have often been asked why we study tics, hairpuUing, and other repetitive behavior disorders when there are more "serious" conditions available for study. Indeed, we have asked ourselves
Introduction
3
the same thing. However, the answer to the question becomes clear when working with a person suffering from one of the conditions described in this book. To the person with one of these disorders, the condition is serious, and the resulting frustration usually high. Indeed, the problems described in this book, though sometimes benign, can cause significant distress to the client or family members experiencing the disorder (see Chapter 3).
3. PURPOSE OF THE BOOK It may seem strange to some that we have decided to cover three seemingly different behavior problems with very different topographies and etiologies in one book. However, this was done for two reasons. First, although the behaviors involved in these disorders appear to be dissimilar, they do have common properties (Miltenberger, Fuqua, & Woods, 1998). For example, they all occur repetitively and it is, in part, this repetitiveness that produces both obvious and subtle negative physical and social effects (see Chapter 3). The second reason we covered these three different disorders in one volume is that the behavioral technology used to assess and treat these disorders is similar regardless of the diagnosis (Miltenberger et al., 1998). Thus, it makes sense to write one volume describing these disorders and discussing the behavioral approach to their treatment. This book was written with four purposes in mind. First, it was designed as a tool for professionals and the public to educate themselves about tic disorders, trichotillomania, and other repetitive behavior disorders. Second, it was written to educate parents, patients, practitioners, and researchers about the possible nonpharmacological treatments for these same conditions. Third, it was intended to provide a comprehensive coverage of the existing literature on the application of behavioral procedures to the understanding and treatment of the different disorders. Finally, the book was designed to include step-by-step treatment manuals practitioners could use when treating clients with tic disorders, trichotillomania, and oral-digital habits. The behavioral technology is available, and this volume is an attempt to disseminate this knowledge.
4. A BEHAVIORAL APPROACH As can be seen from the title, this book takes a behavioral approach to the analysis and treatment of these disorders. It is unfortunate that, in the
4
Tic Disorders, Trichotillomania, and Repetitive Behavior Disorders
scientific literature, a split has emerged between the study of genetic/physiological and environmental influences on behavior. This split is typically reflected in the nature versus nurture debates scientists have engaged in when explaining the etiology of different disorders (Barlow & Durand, 1999). In reality, either side of this dichotomy rarely provides a complete account. Instead, behavior (normal or abnormal) is produced by an interaction of the two. Thus, although we take a behavioral approach, we do not discount the immense contribution of neurology, physiology, genetics, and medicine in understanding the development, expression, and biological treatment of the disorders described in this book. However, the behavioral approach in this book is both novel and necessary for the following reasons. First, although many excellent resources exist for describing biological approaches to the assessment and treatment of tic disorders (e.g., Leckman & Cohen, 1999), such work often pays comparatively less attention to the effects of environmental factors or nonpharmacological interventions when discussing the etiology of tic disorders or their treatment. This is unfortunate because, as you will see in this book, a successful behavioral technology has developed to address many of the problems experienced by persons with tic disorders (Miltenberger et al., 1998; Woods & Miltenberger, 1995; 1996; see also Chapter 5). Second, behavioral treatments for many of the repetitive behavior disorders (e.g., oral-digital habits) have been shown to be effective (Woods & Miltenberger, 1995; 1996; Woods et al., 1999; see also Chapters 8, 11, and 13), yet they do not appear to be widely used (Elliott, Miltenberger, Kaster-Bundgaard, & Lumley, 1996). Third, researchers have generally concluded that traditional psychotherapy is often ineffective when treating the repetitive behaviors involved in tic disorders, trichotillomania, and other repetitive behavior disorders (e.g., Ostfeld, 1988). Unfortunately, behavior therapy is often placed in the same category as traditional psychotherapy (e.g., Gurman & Messer, 1995), and thus its effects may also be disregarded. Again, as the reader will discover, behavioral technology offers a strong method of intervention and thus, should not be casually discarded.
5. SUMMARY OF THE BOOK In this book we take the reader systematically through issues relevant to the application of behavioral technology to tic disorders, trichotillomania, and other repetitive behavior disorders. We begin by discussing assessment procedures and then describe the physical and social effects persons with the
Introduction
5
various disorders may experience. After these two chapters, the book is divided into sections on tic disorders, trichotillomania, and oral-digital habits. The book ends with two additional chapters that discuss oral-motor habits and repetitive behavior disorders in persons with developmental disabilities. Below, we provide a slightly greater description of each chapter and its purpose. Chapter 2 by Carr and Rapp describes assessment procedures pertaining to tic disorders, trichotillomania, and other repetitive behavior disorders. As with any good research project or solid clinical practice, the cornerstone of the endeavor is good assessment. Carr and Rapp discuss the direct and indirect methods used by researchers and clinicians in assessing the various disorders. Chapter 3, by Woods, Friman, and Teng provides an overview of the negative physical and social effects produced by tic disorders, trichotillomania, and other repetitive behavior disorders. Although the physical effects of these disorders can be obvious, the subtle impact of the social disruption is often lost. Woods et al. state clearly that such disorders do indeed have a social impact and offer possible explanations for why this occurs. Next, we begin the first of three sections dedicated to the specific disorders. In Chapter 4, Findley provides an excellent treatment of the characteristics of tic disorders. Chapter 5 by Watson and colleagues then describes behavioral approaches that have been used to treat the various tic disorders with a specific focus on habit reversal. Finally, in Chapter 6, Woods provides a detailed, session-by-session, habit reversal treatment manual for the treatment of tic disorders. Chapter 7 denotes the beginning of the section on trichotillomania. In this chapter, Miltenberger, Rapp, and Long describe trichotillomania, its demographics, and the characteristics of persons with the disorder. Chapter 8 by Elliott and Fuqua provides comprehensive coverage of the behavioral interventions used to treat trichotillomania, again with an emphasis on habit reversal as the most empirically validated treatment. Chapter 9 by Miltenberger then provides a session-by-session habit reversal treatment manual for trichotillomania. The third section deals with oral-digital habits. Oral digital habits were given their own section separate from other repetitive behavior disorders due to their high prevalence. Chapter 10 by Friman, Byrd, and Oksol offers descriptions of oral-digital habits along with demographic data and characteristics of persons with such behaviors. Chapter 11 by Adesso and Norberg goes on to describe behavioral interventions for oral-digital habits
6
Tic Disorders, Trichotillomania, and Repetitive Behavior Disorders
with an emphasis on habit reversal, and finally, Woods and Twohig (Chapter 12) provide a session-by-session habit reversal treatment manual for oraldigital habits. Although not part of any specific section, the final two chapters were included to broaden the scope of the book to more unique repetitive behavior disorders and populations. In Chapter 13, Allen and Polaha describe and discuss behavioral treatments for other repetitive behavior disorders, specifically, stuttering, bruxism, and rumination. For these disorders as well as for the other disorders described in the volume, habit reversal is emphasized as the behavioral treatment with the most empirical support. Finally in Chapter 14, Ringdahl and colleagues discuss the treatment of repetitive behavior disorders in persons with developmental disabilities. After briefly describing various theoretical models, Ringdahl and colleagues emphasize a functional approach to the assessment and treatment of stereotypic and self-injurious behavior.
6. CONCLUSION This book represents the most comprehensive collection of information available on the behavioral approach to the assessment and treatment of tic disorders, trichotillomania, and other repetitive behavior disorders. As you read the book, you will notice we addressed a variety of audiences including researchers, practicing clinicians, and persons or parents of persons with the disorders. For example, the treatment manuals should be valuable as a guide for clinicians, but may also be of interest to researchers engaged in treatment outcome studies or individuals with the disorders who may wish to become better-educated consumers. We realize that this book is only a start. New research is being conducted that will lead to better understanding of, and more effective treatments for, these disorders. However, behavioral technology has something to offer now, and there is no good reason to keep persons with these disorders waiting. Let's begin.
7. REFERENCES American Psychiatric Association (1994). Diagnostic and statistical manual of mental disorders (4"" ed.). Washington, D.C: Author.
Introduction
7
Barlow, D. H., Durand, V. M. (1999). Abnormal psychology (2'"^ Ed). Pacific Grove, CA: Brooks/Cole Publishing Company. Elliott, A. J., Miltenberger, R. G., Kaster-Bundgaard, J., & Lumley, V. A. (1996). A national survey of assessment and therapy techniques used by behavior therapists. Cognitive and Behavioral Practice, 3, 107-125. Gurman, A. S., & Messer, S. B. (1995). Essential psychotherapies: Theory and practice. New York: The Guilford Press. Leckman, J. F., & Cohen, D. .1. (Eds.). Toiirette's syndrome: Tics, obsessions, and compulsions. New York: John Wiley & Sons, Inc. Leckman, J. F., King, R. A., & Cohen, D. .1. (1999). Tics and Tic Disorders. In J.F. Leckman & D.J. Cohen (Eds.), Tourette 's syndrome: Tics, obsessions, and compulsions (pp. 23-42). New York: John Wiley & Sons, Inc. MEDLINE. [Electronic data file]. (1971). Bethesda, MD: National Library of Medicine [Producer and Distributor]. Miltenberger, R. G., Fuqua, R. W., & Woods, D. W. (1998). Applying behavior analysis to clinical problems: Review and analysis of habit reversal. Journal of Applied Behavior Analysis, 31, 447-469. Ostfeld, B. M. (1988). Psychological interventions in gilles de la tourette's syndrome. Psychiatric Annals, 75,417-420. PsychlNFO. [Electronic data file]. (2000). Washington, D.C: American Psychological Association [Producer and Distributor]. Stein, D. J., & Christenson, G. A. (1998). Stereotypic movement disorder: A neglected problem. Psychiatric Annals, 28, 304. Woods, D. W., & Miltenberger, R. G. (1995). Habit reversal: A review of applications and variations. Journal of Behavior Therapy and Experimental Psychiatry, 26, 123-131. Woods, D. W., & Miltenberger, R. G. (1996). A review of habit reversal with childhood habit disorders. Education and Treatment of Children, 19, 197-214. Woods, D. W., Miltenberger, R. G., & Flach, A. D. (1996). Habits, tics, and stuttering: Prevalence and relation to anxiety and somatic awareness. Behavior Modification, 20, 216-225. Woods, D. W., Murray, L. K., Fuqua, R. W., Seif, T. A., Boyer, L. J., & Siah, A. (1999). 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, 30, 289-300.
Chapter 2 Assessment of Repetitive Behavior Disorders James E. Carr Western Michigan University
John T. Rapp The University of Florida
1. INTRODUCTION The purpose of this chapter is to provide an overview of methods for assessing repetitive behavior (RB) disorders (e.g., tic disorders, trichotillomania). The chapter begins by discussing two general approaches, behavioral assessment and functional assessment. These methods produce quite different outcomes than traditional diagnostic assessments or evaluations. The primary function of a diagnostic assessment is to determine whether an individual's problem behaviors meet the specific criteria for a psychological disorder, as defined by a classification system such as the Diagnostic and Statistical Manual of Mental Disorders - 4th edition (American Psychiatric Association, 1994). In contrast, the goal of a behavioral assessment is to define and quantify an individual's presenting problem behaviors so that treatment can be targeted and progress can be monitored. The purpose of functional assessment, a branch of behavioral assessment, is to identify the environmental variables (i.e., reinforcers) that maintain problem behavior. Behavioral and functional assessments can both be conducted regardless of whether the criteria for a psychological diagnosis have been met, as they each involve the description and explanation of the variables related to the occurrence of specific target behaviors, rather than diagnostic conditions. These behaviors may result in a psychological
10
Tic Disorders, Trichotillomania, and Repetitive Behavior Disorders
diagnosis, but they can be quantified and conceptualized in the absence of one. In addition to describing behavioral assessment and functional assessment methods, we describe how clinicians can assess social concerns and other psychological conditions that are relevant for individuals who present with RBs.
2. BEHAVIORAL ASSESSMENT The initial goal of behavioral assessment is to identify and define an individual's problem behavior(s) so that a treatment plan can be specifically targeted. The assessment might occur over the period of several hours to several weeks, depending on client availability and the data that need to be collected. Once the client's RBs have been adequately identified and defined, behavioral assessment strategies can be used to evaluate them over time to monitor treatment progress. Behavioral assessments typically include a variety of different methods, each providing the clinician with different information about the RB. These assessments are traditionally classified into two approaches: indirect and direct assessments. The defining feature of an indirect assessment is that the clinician does not actually observe the RB occur. The clinician instead relies on behavioral interviews, rating scales, and permanent-product measures to evaluate the RB. Alternatively, the hallmark of direct methods is that either the clinician or the client evaluates the RBs as they occur. Common direct assessment methods include direct observation in the natural environment (online) and from videotape samples, caregiver observation, self-monitoring, and automated recording. Below are descriptions of the methods commonly associated with indirect and direct assessment approaches. We describe the indirect methods first, not because they are the most important or psychometrically rigorous, but because they often represent the initial methods used to gather information about RBs in a behavioral assessment.
2.1 Indirect Methods As mentioned above, indirect assessment methods generally do not include direct observation of RBs as they occur. Instead, indirect methods allow the clinician to form impressions based on the information collected
Assessment of Repetitive Behavior Disorders
11
from interviews with the ch'ent and significant others, rating scales and questionnaires, and occasionally, permanent-product measures. Although indirect methods are important to the behavioral assessment process, it is important for the clinician to constantly question the validity (i.e., "Does the assessment measure what it purports to assess?") and reliability (i.e., "How consistent is the outcome of the assessment?") of the methods that are employed. For example, a client may be given a rating scale to assess the frequency with which he bites his fingernails. However, due to embarrassment, he may underreport the actual frequency of the RB. If the clinician relied solely on this information, the integrity of the behavioral assessment might be compromised. Below are descriptions of three common indirect assessment methods: behavioral interviews, rating scales (and questionnaires), and permanentproduct measures.
2.1.1 Behavioral Interviews The behavioral interview is often the first step in the behavioral assessment process. The purpose of a behavioral interview is to collect relevant information about the client, the current environment, and the RBs. The interview's outcome should inform the interviewer about the problems that need to be addressed (with subsequent assessment and treatment) and the specific behaviors that comprise those problems. In addition to the client, a behavioral interview might also include significant others, who often provide useful information. Relevant question areas might include the following: general client demographics; information about home, work, and leisure environments; sources of social support; what, when, and where specific RBs occur; the intensity of the RBs; medical history, including current and past medications; previous treatments; among others. Behavioral interview formats are generally categorized as structured and unstructured, although they can vary along a number of dimensions. Clinicians often use both structured and unstructured methods during the behavioral interview process. A structured interview format includes specific guidelines on what questions should be included and how they should be asked. In addition, the questions are usually close-ended. That is, the client answers questions by choosing from specific options (e.g., frequently vs. infrequently). Although they are most often used for diagnostic evaluations, structured interviews can be quite useful during a behavioral assessment to help quantify the frequency and intensity of RBs.
12
Tic Disorders, Trichotillomania, and Repetitive Behavior Disorders
The unstructured interview format typically occurs in a more conversational manner and includes open-ended questions that are asked at relevant conversational junctures. For example, if a client mentioned having a tic since childhood, the interviewer could use that as an opportunity to ask questions about life events that may have coincided with tic onset. It is important to clarify that all behavioral interviews are structured in terms of what information is sought (e.g., what, when, and where specific RBs occur); however, the form of the interview (i.e., the questions that are asked) may be unstructured. Examples of RB interviews with psychometric properties reported in the research literature include: the Minnesota Trichotillomania Assessment Inventory-II (Christenson, Mackenzie, Mitchell, & Callies, 1991) for trichotillomania, and the interview sections of the Hopkins Motor and Vocal Tic Scale (Walkup, Rosenberg, Brown, & Singer, 1992), the Shapiro Tourette Syndrome Severity Scale (Shapiro & Shapiro, 1984), and the Tourette Syndrome Global Scale (Harcherik, Leckman, Detlor, & Cohen, 1984) for tic disorders. At the end of the behavioral interview, the interviewer should summarize the results and begin formulating the case. Further assessment (e.g., direct observation; functional assessment) is often required before a treatment can be prescribed and implemented for the RB.
2.1.2 Rating Scales Rating scales are paper-and-pencil assessments designed to quantify the impressions of clients, clinicians, and significant others about RBs. When a clinician is the rater, these scales are often used during a behavioral interview to help determine the importance and severity of RBs. When the client is the rater, the scale is considered a self-report measure. Although many consider self-report measures to have inherent validity problems (i.e., correspondence between self-report and actual events), the measures can nonetheless provide useful information about difficult-to-obtain phenomena (e.g., premonitory urges that occur before tics). Rating scales are often used during the functional assessment process (see 3.1. Informant Assessment below) to identify reinforcers that might maintain RBs. Rating scales are also frequently used to assess client satisfaction with treatment and outcome (e.g., Treatment Evaluation Inventory-Short Form; Kelley, Heffer, Gresham, & Elliott, 1989).
Assessment of Repetitive Behavior Disorders
13
In a typical rating scale, which might include up to several dozen questions, the rater reads each question and provides an answer (i.e., a judgment) using a likert-type scale. The rater is asked to answer questions based on recently observed events, or on events that occurred in the more distant past. Answer scales typically include an ordinal dimension (e.g., 0 to 6) with corresponding descriptive "anchors." For example, the Motivation Assessment Scale (Durand & Crimmins, 1988) includes the following question and scale: "When the behavior is occurring, does this person seem calm and unaware of anything else going on around him or her?" [ 0 (never) to 6 (always) ]. After the rater completes the scale, the answers are quantified to summarize important features of the RB. Rating scales are often incorporated into questionnaires, which might include additional "open-ended" questions. Many of the rating scales and questionnaires that are used to quantify RBs are administered during structured and semistructured behavioral interviews. Examples of RB rating scales with psychometric properties reported in the research literature include: the National Institute of Mental HealthTrichotillomania Severity Scale (Swedo et al., 1989), the Psychiatric Institute Trichotillomania Scale (Winchel et al., 1992), the Trichotillomania Impairment Scale (Swedo et al., 1989), and the Yale-Brown ObsessiveCompulsive Scale modified for Trichotillomania (Stanley, Prather, Wagner, Davis, & Swann, 1993) for trichotillomania, and the observation sections of the Hopkins Motor and Vocal Tic Scale (Walkup et al., 1992), Tourette Syndrome Global Scale (Harcherik et al., 1984), Shapiro Tourette Syndrome Severity Scale (Shapiro & Shapiro, 1984), and Yale Global Tic Severity Scale (Leckman et al., 1989) for tic disorders and Tourette Syndrome. In addition, the following rating scales were designed for parent and/or self raters: the Massachusetts General Hospital Hairpulling Scale (Keuthen et al., 1995; O'Sullivan et al., 1995) for trichotillomania, and the Motor Tic, Obsessions, Vocal Tic Evaluation Survey (Gaffney, Sieg, & Hellings, 1994), and Tourette Syndrome Symptom List (Cohen, Leckman, & Shaywitz, 1985) for tic disorders. We refer the reader to Deifenbach, Reitman, and Williamson (2000), Elliott and Fuqua (2000), and Kompoliti and Goetz (1997) for more in-depth coverage of rating scales for trichotillomania and tic disorders.
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2.1.3 Permanent Products In certain cases, it might not be possible (or practical) to directly observe RBs as they occur in the natural environment. For example, it might not be possible to record the hair pulling of an individual who engages in the behavior only when in private. Similarly, it may be difficult to directly measure some RBs because of reactivity of observation or client embarrassment. In these situations, it might be possible to evaluate permanent products instead. A permanent product is a relatively enduring physical change made by the RB to the environment. For example, hair pulling might result in observable hair loss (e.g., a bald patch) that could be measured over time using photographs. Other permanent products of hair pulling might include measures of hair density and collections of pulled hairs (Elliott & Fuqua, 2000). Similarly, nail biting might result in observable damage to the nails and cuticles that could then be measured. Permanentproduct measures are desirable because they do not require direct observation of the target behaviors as they occur. In addition, permanent product measures are useful when communicating with clients, significant others, and professionals because they are generally easy to evaluate. Although permanent products are relatively easy to assess, there are disadvantages associated with their use. First, many RBs (e.g., tics) do not leave physical products. A second problem with permanent products is their validity as an assessment method. In many cases, the products made by the RB could also have been produced by other behaviors. For example, intense thumb sucking might result in visible tissue discoloration; however, such damage would be a questionable permanent product because of the possibility of other conditions (e.g., a rash) producing the same product. Two general questions can be asked to determine the feasibility of using permanent products to assess the occurrence of RBs. First, does each instance of the RB result in a physical change? Second, do any other behaviors result in the same change? If these questions cannot be satisfactorily answered (i.e., "yes" to the former and "no" to the latter), then permanent products may not be a useful method for a particular case. Even with behaviors that do not leave physical products, videotaped records can be conceptualized as a form of permanent product for later scoring [see 2.2.2 Direct Observation (videotaped) below].
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2.2 DIRECT METHODS The aforementioned indirect methods are most useful for the initial stages of a behavioral assessment. However, it is also important to directly observe RBs as they occur to (a) adequately identify and define their relevant behavioral dimensions (e.g., frequency, intensity) and (b) determine treatment effectiveness. Once the relevant dimensions have been selected, stable measurement of the behavior must be conducted to ensure objective evaluation of the intervention for reducing the relevant dimensions of the RB. The selection of a particular direct assessment method should generally depend on the following variables: (a) the age of the client, (b) the intellectual functioning of the client, (c) the nature of the RJ3 (i.e., Is there an available permanent product?), (d) the circumstances in which the RB occurs, and (e) the form (i.e., topography) of the RB. Direct methods are those procedures that, at a minimum, evaluate at least one dimension of the RB as it occurs. With each assessment method, emphasis is placed on inferring an accurate representation of the RB from relatively brief samples of time in the natural environment. A variety of recording procedures can be used for direct assessment. Frequency (event), duration, interval, and time-sampling recording procedures can be selected depending on the relevant dimensions of the RB and the resources available for direct assessment. We refer the reader to Cooper, Heron, and Heward (1987) for a detailed description of each of these methods. Several variations of direct observation may be utilized to broaden the assessment to as many behavioral dimensions as possible and to produce converging data about the target behavior. Regardless of the method, a second, independent observer should also record data on the same behavioral dimension for approximately 20% to 30% of the observations to reduce the likelihood that the sample is misrepresented. When evaluating behavior in clinical settings, it is generally desirable to have at least 85% agreement between two observers. The following sections describe the conditions/contexts under which procedures classified as direct assessment methods have been and can be applied, alone and in combination, to evaluate tics, hair pulling, and other RBs.
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2.2.1 Direct Observation (online) Online direct observation involves the observation of an individual's behavior by a trained observer through a one-way mirror in clinical settings, in naturally occurring settings (e.g., school or home), and in specifically arranged contexts (e.g., during family meals, while a child does homework). The procedure enables the observer to document via a checklist or laptop computer (see Kahng & Iwata, 1998 for a review of commercially available software programs) relevant antecedents and consequences during an observation period, in addition to relevant dimensions of the target behavior. Online observation should be considered when the individual has a developmental disability, is under the age of 6 years, the target behavior does not yield a permanent product, and the behavior is known to occur (based on informant reports) in the presence of others. It should be noted that many individuals engage in RBs (e.g., hair pulling, finger sucking) in the absence of a social observer. Therefore, the presence of an observer in a stimulus context that is normally void of this observer may result in an inaccurate assessment (i.e., reactivity) of the RB. This relative disadvantage is compounded by the necessity of having a reliability observer occasionally present.
2.2.2
Direct Observation (videotaped)
An alternative to online direct observation is videotaped observation. With videotaped observations, behavior can be recorded during periods when the individual is alone or in the presence of individuals in naturally occurring situations. Likewise, behavior can be videotaped from behind one-way mirrors in a clinical setting. In the case of the former, the video camera is placed in the relevant context and the individual is permitted to engage in his or her typical activities (Miltenberger, Rapp, & Long, 1999). The videotape is later scored by observers. The same data that are collected in online direct observation are available, but the observer need not be present during the assessment period. Likewise, a second observer can view the video segment at a separate time for interobserver agreement purposes. With this procedure, data can be collected on a number of behavioral dimensions such as frequency, duration, and inter-response time (i.e., the time between the offset of one response and the onset of a subsequent response; Rapp, Carr, Miltenberger, Dozier, & Kellum, in press).
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In addition, the exact onset and offset of a response can be assessed, as well as the behavior frequency, to yield a "real-time" (i.e., second-bysecond) measurement of behavior. A number of studies have utilized realtime videotaped observation to evaluate the duration of children's hair pulling and finger sucking in clinical settings (e.g., Miltenberger, Long, Rapp, Lumley, & Elliott, 1998) and in their homes (e.g., Ellingson et al., 2000; Rapp, Miltenberger, Galensky, Roberts, & Ellingson, 1999). In addition, concomitant behaviors such as hair manipulation (e.g., Rapp, Miltenberger, Galensky, Ellingson, & Long, 1999) and hair ingestion (i.e., trichophagia), which are typically secondary to the target behavior but relevant in treatment planning, can also be detected. It is important to note, as with online observation, that the presence of a video camera can produce client "reactivity" that might result in misrepresented samples of behavior. However, despite potential reactivity, repeated exposure to the video camera should eventually result in "habituation" to its presence, which would be reflected in subsequent stability in the level of the RB (Kazdin, 1998).
2.2.3
Direct Observation by Caregivers
Instead of using professional observers, observations can also be conducted by individuals (e.g., teachers, parents, group-home staff) who are part of the client's natural environment. Observers are equipped with counters and/or data sheets with which to record the occurrence of the RB in the natural environment. This procedure should be used in settings that do not permit intrusion by video cameras, where additional observers would be disruptive, and where at least one adult (who is part of the natural environment) is available and willing to be trained to accurately document theRB. Direct observation by caregivers can be particularly useful when the RB occurs in numerous stimulus contexts within the client's home. For example, Watson and Sterling (1998) collected data on the frequency of a 4year-old girl's vocal tics during meal times and other activities using both of her parents as observers. Likewise, after conducting an initial assessment of finger sucking and object attachment of eight children in a clinic, Friman (1990) trained the mothers to collect data on occurrences of their child's behavior using a time-sampling procedure. During approximately 20% of these sessions, fathers served as reliability observers. Thus, even though this approach is recognized as the weakest form of direct observation (when used
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alone), high agreement between two minimally trained observers provides acceptable confidence in the veracity of the sampled behavior. Observations by caregivers can also be used to enhance or verify data collected with other procedures (e.g., videotaped recording). For example, in an investigation involving the assessment and treatment of finger sucking in children's homes, Ellingson et al. (2000) had parents conduct intermittent checks of their child's behavior (in the "habit prone" context) on days when videotaped observations were not conducted. The combination of two observation procedures also provided support for the generalized reduction in finger sucking (i.e., when a video camera was not present).
2.2.4 Self-Monitoring Self-monitoring is a direct observation approach that involves data collection on one or more dimensions of an RB by the client. The individual is equipped with a recording apparatus (e.g., hand counter, note cards) to enable efficient documentation (i.e., with minimal response effort) of the occurrence of the RB. Although this approach yields the least rigorous data of the direct approaches, it is well suited to the assessment of the RBs of older children and adults of typical intellectual functioning, particularly when the RB occurs in the absence of other relevant social observers and across various of stimulus contexts. To adequately utilize self-monitoring, it is imperative that the individual demonstrate an ability to accurately detect, and thereafter record, instances of the RB. This demonstration should ideally occur in the clinician's presence during the training of selfmonitoring skills. Self-monitoring behaviors should always be taught, like any other therapy-related skill (e.g., Bornstein & Hamilton, 1978). In addition, any self-monitoring data sheets should be simply designed, preferably in collaboration with the client. Likewise, there should be evidence that the individual is sufficiently motivated to document occurrences of the RB. Individuals who are self-referred may already be sufficiently motivated to record their RBs, whereas others may need guidance to recognize the social ramifications of their behavior (see Azrin & Nunn, 1973). Many individuals are able to describe and demonstrate their RB with great fidelity; however, others, particularly those who pull hair, may engage in the RB without "awareness" or they may underestimate its occurrence (e.g., Azrin, Nunn, & Frantz, 1980; Winchel et al., 1992). This problem can be remedied by teaching the individual to become more aware of the RB using
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simulation training (see Rapp, Miltenberger, Long, Elliot, & Lumley, 1998). In addition, clients can be taught to deliver a report of their behavior at specific times (e.g., Twohig & Woods, in press) in an effort to provide implicit social contingencies on their recording behaviors. A further consideration is that even though the individual has been trained to monitor his or her own RB for the purpose of behavioral assessment, this procedure may actually reduce the RB. A number of researchers have reported that self-monitoring significantly decreased the occurrence of tics in children and young adults (e.g., Billings, 1978; Ollendick, 1981; Thomas, Abrams, & Johnson, 1971). Another possibility is that although an accurate assessment of RB frequency may be obtained with self-monitoring, this mode of assessment may alter other dimensions (e.g., duration) of the RB due to its physical incompatibility with recording. In the absence of alternative assessments, it may be useful for clinicians to consider self-monitoring as a method to evaluate the RB, with the expectation that a positive side effect of this assessment may be a reduction in the recorded behavior. 2.2.5 Automated Recording The objective assessment of behavior will always pose some difficulty when human observation is required. A few techniques have been developed to evaluate some RBs without the aid of human transducers, but none is without its idiosyncratic limitations. For example, to evaluate the occurrence of finger sucking in the absence of a parent, Hughes, Hughes, and Dial (1978) developed a "behavioral seal" that could be placed on the fingernail of the target finger. If the child wearing the seal engaged in finger sucking, the seal turned blue because of contact with saliva. Thus, a permanent product of finger sucking could be artificially imposed to evaluate the behavior. However, these seals do not indicate the length of time the child engaged in the target response (i.e., the relevant dimension of this behavior). An apparatus known as the Awareness Enhancement Device (AED; Rapp, Miltenberger, & Long, 1998) was initially developed to treat hair pulling, but was later adapted to assess and treat finger sucking as well (Ellingson et al., 2000). The AED is a three-piece electronic apparatus (one unit is worn on the chest and one unit on each wrist) that is worn by an individual who engages in hand-to-head RBs (e.g., hair pulling, finger sucking). When activated, this device emits a --65 dB tone contingent on placement of the wearer's hand within 6 in. of his or her head. The device has also been enhanced so that it collects data on the frequency and duration of hand-tohead behaviors. Thus, data can be collected in a variety of settings without
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cumbersome observational techniques. It is important to stress that assessment devices such as the AED are still in experimental stages and have yet to replace traditional direct observation methods.
3. FUNCTIONAL ASSESSMENT The term "functional assessment" refers to methods used to identify a behavior's maintaining or controlling variables (i.e., the behavior's proximal cause). These variables are typically conceptualized as environmental consequences that may serve to reinforce the RB. Although some RBs (primarily tics) have significant biological correlates, many do not. Regardless of such biological influences, many RBs are affected by the environmental consequences that follow them. For example, Carr, Taylor, Wallander, and Reiss (1996) demonstrated that the transient tic disorder of a 9-year-old typically developing boy was exacerbated by contingent adult attention. Further, a cursory review of the recent literature on the assessment and treatment indicates several examples of RBs maintained by social attention and/or self-stimulation (e.g., Carr et al., 1996; Ellingson et al., 2000). It is because of these environmental influences that all RBs should be assessed (at some level) to identify their reinforcing consequences prior to treatment selection. Within the field of behavioral psychology as it pertains to the treatment of the problem behavior of individuals with developmental disabilities, it has become standard practice to conduct functional assessments prior to treatment selection. Research indicates that interventions based on functional variables are more successful than those based on non-functional variables (e.g., Iwata, Pace, Cowdery, & Miltenberger, 1994; Repp, Felce, & Barton, 1988). Additionally, identifying functional variables before treatment can save time that might have been wasted implementing ineffective interventions. While interventions based on non-functional variables might be immediately successful, the maintenance of treatment gains presumably would not be as durable compared to functional treatments because the RB could eventually come in contact with the original maintaining contingency (Vollmer & Smith, 1996). There are three general approaches to conducting functional assessments: informant assessment, descriptive assessment, and experimental analysis (Lennox & Miltenberger, 1989). Each level of functional assessment varies along at least two dimensions. The first dimension is the ease with which the assessment can be conducted, with informant assessments generally
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requiring less effort than descriptive or experimental methods. The second dimension is the degree of confidence in the assessment's outcome, with experimental methods producing causal information, compared to the correlational information provided by descriptive and informant methods. We will briefly discuss each of these approaches and include examples of their use.
3.1 Informant Assessment The term informant assessment refers to the collection of information relating to a behavior's functional variables via indirect methods. The most common methods of informant assessment are behavioral interviews and rating scales. Behavioral interviews consist of asking relevant persons a series of structured questions relating to behavioral topography, antecedent and consequent stimuli, and other possible applicable variables (e.g., O'Neill et al., 1997). Another informant method is to have relevant parties (e.g., significant others) complete rating scales and questionnaires about the RB and its possible functions. For example, the Motivation Assessment Scale (MAS; Durand & Crimmins, 1988) is a 16-item questionnaire designed for collecting indirect data on four possible behavioral functions. Informant assessments are useful because they take little time to complete and are relatively easy to administer. In some cases in which extended assessment is not possible, they provide information that would not otherwise be obtained. However, there are limitations in the use of informant assessments. With the possible exception of the MAS, adequate psychometric research has not been conducted on many of the informant instruments (for a review of these instruments, see Sturmey, 1994). Information obtained using informant techniques is not based on direct observation of current instances of the behavior and, therefore, is of limited value. The best use of informant methods is when they are employed as hypothesis-generating tools in conjunction with either descriptive or experimental methods.
3,2 Descriptive Assessment A more rigorous approach to functional assessment is the descriptive assessment. Descriptive methods involve the direct observation of behavior in the naturalistic environment in order to detect possible controlling
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variables. One common method, ABC recording, provides data on stimuli that are present immediately prior to and after a behavior occurs (e.g., Bailey & Pyles, 1989). These data can then be interpreted in the form of conditional probabilities (Lerman & Iwata, 1993). That is, the probability that the target behavior occurs given the presence of a stimulus versus the probability that the target behavior occurs given the absence of that stimulus may provide information relevant to behavioral function. Another descriptive assessment method is the scatter plot (Touchette, MacDonald, & Langer, 1985). This entails visually plotting the time of each occurrence of the target behavior on a graph each day. Thus, a visual picture of the time of occurrence of the behavior is obtained, allowing further examination of temporal variables (e.g., time of the day, day of the week). While the aforementioned descriptive assessment methods typically provide more thorough information than informant methods, they too lack a sound research base to support their use (e.g., see Kahng et al., 1998). Further, the data obtained from a descriptive assessment are correlational, and do not necessarily indicate a causal relationship between the variables. In order to determine the exact causal nature of functional variables, an experimental analysis must be conducted.
3.3 Experimental Analysis The most researched method of functional assessment is the experimental or functional analysis. In an experimental analysis, relevant variables are directly manipulated and their effects on the target behavior observed. There have been dozens of studies reporting the utility of experimental analysis variations and the successful interventions that resulted. Iwata, Dorsey, Slifer, Bauman, and Richman (1982/1994) developed the initial procedure for determining the maintaining variables of self-injurious behavior (SIB) in analogue settings. Normally using a multielement design, approximately four conditions are presented to each client. In each condition, a specific variable is manipulated in order to test behavioral sensitivity to different consequences. For example, in the attention condition, social attention is typically provided contingent on the occurrence of the target behavior. If the target behavior rates are higher in this attention condition compared to other conditions, it is concluded that social attention is a maintaining variable for the behavior. An intervention based on social attention (e.g., attention extinction, noncontingent attention) is subsequently implemented.
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The procedure developed by Iwata et al. (1982/1994) has been replicated with different populations and behaviors and can be conducted in analog or naturalistic settings. The test conditions that are conducted are sometimes derived from informant and descriptive methods and, therefore, are customized for each individual. That is, an experimental analysis can test for a variety of different potential maintaining variables depending on the individual case. In addition, experimental analyses can be conducted over time in extended (Vollmer, Marcus, Ringdahl, & Roane, 1995) or brief (Derby et al., 1992) formats. Although originally developed for the assessment of self-injurious behavior of individuals with developmental disabilities, functional assessment methods have proven useful with a variety of RBs in individuals (primarily children) of typical intellectual functioning. Malatesta (1990) used an interview and subsequent experimental analyses to confirm a hypothesis that a father's presence was correlated with increased facial tics of a 9-year-old boy, suggesting a possible attention function. As mentioned earlier, Carr et al. (1996) demonstrated, with an experimental analysis, that the vocal tics of a 9-year-old typically developing boy were maintained by adult attention. Watson and Sterling (1998) used a descriptive assessment and brief experimental analysis to demonstrate that the coughing tic of a 4year-old normally developing girl was maintained by attention. A subsequent intervention based on this finding was successful. Miltenberger et al. (1998) used several experimental analyses to confirm that the hair pulling of a 6-year-old typically developing girl was maintained by selfstimulation. Similarly, Ellingson et al. (2000) also used several experimental analyses to demonstrate that the finger sucking of two typically developing children (ages 7 and 10) was maintained by self-stimulation. Subsequent treatments based on these findings were successful. Finally, Rapp, Miltenberger, Galensky, Roberts et al. (1999) used similar methods that were effective with one of two 5-year-old fraternal twin brothers who engaged in thumb sucking. In addition to the aforementioned research on typically developing individuals, functional assessment methods have also been reported successful in evaluating the RBs of individuals with developmental disabilities (e.g., Miltenberger et al., 1998; Rapp, Dozier, Carr, Patel, & Enloe, 2000; Rapp, Miltenberger, Galensky, Ellingson et al., 1999). As illustrated by the studies described above, the current literature suggests that reinforcement contingencies (perhaps in addition to certain biological variables) are capable of maintaining and/or exacerbating RBs. The strongest evidence supports attention and self-stimulation functions, primarily among children. However, this line of research has only recently
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begun and other variables and populations have not yet been extensively studied.
4. ASSESSMENT OF SOCIAL CONCERNS A number of recent investigations have suggested that individuals who engage in tics, hair pulling, and other RBs are viewed negatively by agerelated peers. In a study of finger sucking by children, Friman, McPherson, Warzak, and Evans (1993) found that children who were photographed in a finger-sucking pose were rated as less desirable friends by age-related peers than when the same children were in non-finger-sucking poses. Long, Woods, Miltenberger, Fuqua, and Boudjouk (1999) evaluated social perceptions of individuals with mental retardation who engaged in hair pulling and fingernail biting. The authors videotaped actors who exhibited each of these behaviors during mock job interviews and then had undergraduate students rate the social acceptability of the applicant using the Social Acceptance Scale. The results indicated that individuals who engaged in hair pulling and fingernail biting were viewed as less acceptable by the students and were less likely to be hired than those who did not exhibit these behaviors. Similarly, Woods and colleagues have found that, as a group, individuals with motor tics, vocal tics, and hair pulling were viewed as less socially acceptable by college students (Woods, Fuqua, & Outman, 1999) and by adolescents (Boudjouk, Woods, Miltenberger, & Long, 2000) than individuals without these behaviors. Based on the collective results from these studies, it appears that the perception of RBs is an important factor to consider when assessing the pre-treatment severity of the behavior and determining the social validity (Wolf, 1978) of the treatment outcome. In general, analogue evaluations of social perceptions of individuals who exhibit RBs suggest that they can affect one's social interactions. That is, if one is viewed as less attractive or less normal by others in his or her environment, this perception will likely result in fewer positive social interactions. Therefore, an intervention for an RB should be deemed efficacious only to the extent that it results in socially significant improvement. This improvement can be assessed in terms of either the social evaluation of the behavior itself (e.g., motor tics) or the product of the behavior (e.g., hair re-growth). To accomplish this type of assessment, videotaped segments of the individual's RB (e.g., tics, finger sucking) before and after treatment should be presented to "blind" observers (preferably ageequivalent peers). Likewise, for behaviors that result in visible products
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(e.g., hair pulling, fingernail biting), pictures and videotaped segments of the regions from which hair pulling or nail biting occurs can be subjected to this same evaluation. To evaluate changes in RBs or their products, observers should be provided with rating scales that they can respond to after viewing a sample of the RB. Questions should be developed to evaluate "how noticeable" and "how natural" the individual's behavior appears to the rater. For example, Woods, Miltenberger, and Lumley (1996) used three graduate and two undergraduate students to evaluate social perceptions of treatment outcomes for four children who exhibited chronic tics. Statistical analyses showed significant increases in social perception ratings for each child from pre- to post-treatment suggesting a substantial improvement in the social evaluation of these children. Similarly, Rapp, Miltenberger, Long et al. (1998) exemplified the use of social evaluation of response products by having four graduate students and three professors independently evaluate pre- and posttreatment photographs and still-frame videotapes of the scalps, eyebrows, and eyelashes of two children who engaged in hair pulling. Statistical analyses of these ratings indicated that both children appeared more natural, more normal, and less likely to have a "problem" one month following treatment (note that the passage of time is required for improvement in hair re-growth to be observable). In both of the above studies, documented behavior change, which was assessed via videotaped observation, was supported and further validated by changes in others' perceptions of the clients' RBs and/or appearances. Despite what appears to be very promising outcomes, these studies are somewhat limited in that age-equivalent peers were not used to evaluate social perceptions. In addition, the psychometric properties of some of the rating scales are unknown. In the future, researchers and clinicians should make every attempt to ensure that treatment outcomes can be socially evaluated in a manner that is most meaningful to the client given his or her specific characteristics.
5. ASSESSMENT OF OTHER PSYCHOLOGICAL CONDITIONS In the assessment literature, there are number of psychological conditions that have been found in individuals who also display RBs. Using indirect assessment methods (e.g., the Child Behavior Checklist; Achenbach, 1991), Nolan, Sverd, Gadow, and Spraflkin (1996) found that the comorbid presence
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of chronic tic disorder and attention-deficit/hyperactivity disorder (ADHD) was an indicator of complex psychopathology in children. Likewise, Koenig and Bornstein (1992) found that tic-disorder severity (as rated by parents) in boys was directly correlated with the extensiveness of psychological problems. Still, other RBs may be correlated with disorders of another classification. For example, individuals who engage in nocturnal bruxism (i.e., teeth grinding) may experience disturbances in sleep, which may lead to disorders of depression and anxiety (Ware & Morin, 1997). Informal inspection of a number of single-subject treatment studies (e.g., Rapp, Miltenberger, Long et al., 1998; Woods et al., 1996) reveals that many of the participants are children diagnosed with ADHD. Although this may simply be reflective of a pattern for obtaining referrals (i.e., selection bias), clinicians should be aware of this potential correlation when conducting assessments. Conversely, the presence of an RB is not necessarily indicative of psychopathology. For example, Friman, Larzelere, and Finney (1994) found little evidence to suggest that childhood finger sucking was either a symptom or a correlate of psychopathology. As a whole, it appears that individuals who exhibit RBs may experience other psychological problems. Currently, it is unclear why this correlation exists for some behaviors and not for others. It is speculated that genetic predisposition (especially with tic disorders), the behavioral function of the RB, as well as its developmental course, all are important factors in understanding these relationships. Our recommendation to clinicians who serve individuals who present with RBs is to make every effort to determine if there are covarying psychological problems that might (a) mediate the effects of treatment or (b) require treatment themselves.
6. CONCLUSION In conclusion, a variety of behavioral assessment (i.e., indirect and direct methods) and functional assessment methods are often necessary to identify, define, and (through functional assessment) understand RBs to the extent that successful interventions can be designed and implemented. Because these assessment approaches include different methods that yield different results, it is possible to customize the pre-treatment assessment process for each client, depending on situational idiosyncrasies. A contemporary issue that is relevant to tailored, idiographic assessment is the rise of managed behavioral healthcare. In today's managed-care environment, practitioners are increasingly held to the standards of
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effectiveness and efficiency (Hayes, Barlow, & Nelson-Gray, 1999). Consequently, assessment methods that are both brief and psychometrically sound are needed. Interviews, rating scales, permanent-product measures, caregiver observation, self-monitoring, informant functional assessments, and brief experimental functional analyses, and perhaps some of the other methods described in this chapter, can all be implemented in a time-efficient manner. Clinicians are urged not to discard the assessment and evaluation process in an effort to save time. We believe that a more comprehensive understanding of our cases, which is only possible through sound behavioral assessment and functional assessment, is necessary for effective treatment selection.
7. REFERENCES Achenbach, T. M. (1991). Manual for the Child Behavior Checklist/4-18 and 1991 profile. Burlington, VT: University of Vermont Department of Psychiatry. American Psychiatric Association (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author. Azrin, N. H., & Nunn, R. G. (1973). Habit reversal: A method of eliminating nervous habits and tics. Behaviour Research and Therapy, /7,619-628. Azrin, N. H., Nunn, R. G., & Frantz, S. E. (1980). Treatment of hairpuiling (trichotillomania): A comparative study of habit reversal and negative practice training. Journal of Behavior Therapy and Experimental Psychiatry, 11, 13-20. Bailey, J. S., & Pyles, D. A. M. (1989). Behavioral diagnostics. In E. Cipani (Ed.), The treatment of severe behavior disorders: Behavior analysis approaches (pp. 85-107). Washington, DC: American Association on Mental Retardation. Billings, A. (1978). Self-monitoring in the treatment of tics: A single-subject analysis. Journal of Behavior Therapy and Experimental Psychiatry, 9^ 339-342. Bornstein, P. H., & Hamilton, S. B. (1978). Positive parental praise: Increasing reactivity and accuracy of self-observation. Journal ofAbnormal Child Psychology, 6, 503-509. Boudjouk, P. J., Woods, D. W., Miltenberger, R. G., & Long, E. S. (2000). Negative peer evaluation in adolescents: Effects of tic disorders and trichotillomania. Child & Family Behavior Therapy, 22, 17-28. Carr, J. E., Taylor, C. C, Wallander, R. J., & Reiss, M. L., (1996). A functional-analytic approach to the diagnosis of a transient tic disorder. Journal of Behavior Therapy and Experimental Psychiatry, 27^291-297. Christenson, G. A., Mackenzie, T. B., Mitchell, J. E., & Callies, A. L. (1991). A placebocontrolled, double-blind crossover study of fluoxetine in trichotillomania. American Journal of Psychiatry, 148, 1566-1571. Cohen, D. J., Leckman, J. P., & Shaywitz, B. A. (1985). The Tourette syndrome and other tics. In D. Shaffer, A. A. Ehrhardt, & L. Greenhill (Eds.), The clinical guide to child psychiatry (pp. 3-28). New York: Free Press.
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Cooper, J. O., Heron, T. E., & Heward, W. L. (1987). Applied behavior analysis. Columbus, OH: Merrill. Derby, K. M., Wacker, D. P., Sasso, G., Steege, M., Northup, J., & Cigrand, K. (1992). Brief functional assessment techniques to evaluate aberrant behavior in an outpatient setting: A summary of 79 cases. Journal ofApplied Behavior Analysis, 25, 713-721. Diefenbach, G. J., Reitman, D., & Williamson, D. A. (2000). Trichotillomania: A challenge to research and practice. Clinical Psychology Review, 20, 289-309. Durand, V. M., & Crimmins, D. B. (1988). Identifying the variables maintaining selfinjurious behavior. Journal ofAutism and Developmental Disorders, 18, 99-117. Ellingson, S. A., Miltenberger, R. G., Strieker, J. M., Garlinghouse, M. A., Roberts, J., Galensky, T. L., & Rapp, J. T. (2000). Analysis and treatment of fmger sucking. Journal ofApplied Behavior Analysis, 33, 41-52. Elliott, A. J., & Fuqua, R. W. (2000). Trichotillomania: Conceptualization, measurement, and treatment. Behavior Therapy, 31, 529-545. Friman, P. C, Larzelere, R., & Finney, J. W. (1994). Exploring the relationship between thumb-sucking and psychopathology. Journal of Pediatric Psychology, 19, 431-441. Friman, P. C, McPherson, K. M., Warzak, W. J., & Evans, .1. (1993). Influence of thumb sucking on peer social acceptance in first-grade children. Pediatrics. 91, 784-786. Friman, P.C. (1990). Concurrent habits: What would Linus do with his blanket if his thumbsucking were treated? American Journal of Diseases of Children, 144, 1316-1318. Gaffney, G. R., Sieg, K., & Hellings, J. (1994). The MOVES: A self-rating scale for Tourette's syndrome. Journal of Child & Adolescent Psychopharmacology, 4, 269-280. Harcherik, D. F., Leckman, J. F., Detlor, J., & Cohen, D. J. (1984). A new instrument for clinical studies of Tourette's syndrome. Journal of the American Academy of Child Psychiatry. 23, \53-\60. Hayes, S. C, Barlow, D. H., & Nelson-Gray, R. O. (1999). The scientist practitioner: Research and accountability in the age of managed care (2nd ed.). Boston: Allyn and Bacon. Hughes, H., Hughes, A., & Dial, H. (1978). A behavioral seal: An apparatus alternative to behavioral observation of thumbsucking. Behavior Research Methods & Instrumentation, 70,460-461. Iwata, B. A., Dorsey, M. F., Slifer, K. J., Bauman, K. E., & Richman, G. S. (1994). Toward a functional analysis of self-injury. Journal of Applied Behavior Analysis, 27, 197-209. (Reprinted from Analysis and Intervention in Developmental Disabilities, 2, 3-20, 1982). Iwata, B. A., Pace, G. M., Cowdery, G. E., Miltenberger, R. G. (1994). What makes extinction work: An analysis of procedural form and function. Journal of Applied Behavior Analysis, 27, 131-144. Kahng, S., Iwata, B. A., Fischer, S. M., Page, T. J., Treadwell, K. R. H., Williams, D. E., & Smith, R. G. (1998). Temporal distributions of problem behavior based on scatter plot analysis. Journal of Applied Behavior Analysis, 31, 593-604. Kahng, S. W., & Iwata, B. A. (1998). Computerized systems for collecting real-time observational data. Journal ofApplied Behavior Analysis, 31, 253-261. Kazdin, A. E. (1998). Research design in clinical psychology (3rd ed.). Boston: Allyn and Bacon.
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Kelley, M. L., Heffer, R. W., Gresham, F. M., & Elliott, S. N. (1989). Development of a modified Treatment Evaluation Inventory. Journal of Psychopathology and Behavioral Assessment, 7/^235-247. Keuthen, N. J., O'Sullivan, R. L., Ricciardi, J. N., Shera, D., Savage, C. R., Borgmann, A. S., Jenike, M. A., & Baer, L. (1995). The Massachusetts General Hospital (MGH) hairpulling scale: I. Development and factor analyses. Psychotherapy and Psychosomatics, 64^ 141-145. Koenig, L. J., & Bornstein, R. A. (1992). Psychopathology in boys with Tourette syndrome: Effects of age on the relationship between psychological and physical symptoms. Development & Psychopathology, '^,271-285. Kompoliti, K., & Goetz, C. G. (1997). Clinical rating and quantitative assessment of tics. Neurologic Clinics of North America, 15, 239-254. Leckman, J. F., Riddle, M. A., Hardin, M. T., Ort, S. I., Swartz, K. L., Stenvenson, J., & Cohen, D.J. (1989). The Yale Global Tic Severity Scale (YGTSS): Initial testing of a clinician-rated scale of tic severity. Journal of the American Academy of Child & Adolescent Psychiatry, 28, 566-573. Lennox, D. B., & Miltenberger, R. G. (1989). Conducting a functional assessment of problem behavior in applied settings. Journal of the Association for Persons with Severe Handicaps, 14, 304-311. Lerman, D. C, & Iwata, B. A. (1993). Descriptive and experimental analyses of variables maintaining self-injurious behavior. Journal ofApplied Behavior Analysis, 26, 293-319. Long, E. S., Woods, D. W., Miltenberger, R. G., Fuqua, R. W., & Boudjouk, P. J. (1999). Examining the social effects of habit behaviors exhibited by individuals with mental retardation. Journal of Developmental and Physical Disabilities, 11, 295-312. Malatesta, V. J. (1990). Behavioral case formulation: An experimental assessment study of transient tic disorder. Journal of Psychopathology and Behavioral Assessment, 12, 219232. Miltenberger, R. G., Long, E. S., Rapp, J. T., Lumley, V., & Elliott, A. J. (1998). Evaluating the function of hair pulling: A preliminary investigation. Behavior Therapy. 29, 211-219. Miltenberger, R. G., Rapp, J. T., & Long, E. S. (1999). A low-tech method for conducting real-time recording. Journal ofApplied Behavior Analysis, 32, 119-120. Nolan, E. E., Sverd, J., Gadow, K. D., & Sprafkin, J. (1996). Associated psychopathology in children with both ADHD and chronic tic disorder. Journal of the American Academy of Child & Adolescent Psychiatry, 35, 1622-1630. Ollendick, T. H. (1981). Self-monitoring and self-administered overcorrection: The modification of nervous tics in children. Behavior Modification, 5, 75-84. O'Neill, R. E., Homer, R. H., Albin, R. W., Sprague, J. R., Storey, K., & Newton, J. S. (1997). Functional assessment and program development for problem behavior: A practical handbook (2nded.). Pacific Grove, CA: Brooks/Cole. O'Sullivan, R. L., Keuthen, N. J., Hayday, C. F., Ricciardi, J. N., Buttolph, M. L., Jenike, M. A., & Baer, L. (1995). The Massachusetts General Hospital (MGH) hairpulling scale: 2. Reliability and validity. Psychotherapy and Psychosomatics, 64, 146-148. Rapp, J. T., Carr, J. E., Miltenberger, R. G., Dozier, C. L., & Kellum, K. K. (in press). Using real-time recording to enhance the analysis of within-session functional analysis data. Behavior Modification.
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Rapp, J. T., Dozier, C. L., Carr, J. E., Patel, M. R., & Enloe, K. A. (2000). Functional analysis of hair manipulation: A replication and extension. Behavioral Interventions, 15, 121-133. Rapp, J. T., Miltenberger, R. G., Galensky, T. G., Ellingson, S. A., & Long, E. S. (1999). A functional analysis of hair pulling. Journal ofApplied Behavior Analysis, 32, 329-337. Rapp, J. T., Miltenberger, R. G., Galensky, T. L., Roberts, J., & Ellingson, S. (1999). Brief functional analysis and simplified habit reversal treatment of thumb sucking in fraternal twin brothers. Child & Family Behavior Therapy, 21, 1-17. Rapp, J. T., Miltenberger, R. G., & Long, E. S. (1998). Augmenting simplified habit reversal with an awareness enhancement device: Preliminary findings. Journal of Applied Behavior Analysis, 31, 665-668. Rapp, J. T., Miltenberger, R. G., Long, E. S., Elliott, A. J., & Lumley, V. A. (1998). Simplified habit reversal treatment for chronic hair pulling in three adolescents: A clinical replication with direct observation. Journal ofApplied Behavior Analysis, 31, 299-302. Repp, A. C., Felce, D., & Barton, L. E. (1988). Basing the treatment of stereotypic and selfinjurious behaviors on hypotheses of their causes. Journal of Applied Behavior Analysis, 21, 281-289. Shapiro, A. K., & Shapiro, E. (1984). Controlled study of pimozide vs. placebo in Tourette*s syndrome. Journal of the American Academy of Child Psychiatry, 23, 161-173. Stanley, M. A., Prather, R. C., Wagner, A. L., Davis, M. L., & Swann, A. C. (1993). Can the Yale-Brown Obsessive-Compulsive Scale be used to assess trichotillomania? A preliminary report. Behaviour Research and Therapy, 31. 171-177. Sturmey, P. (1994). Assessing the functions of aberrant behaviors: A review of psychometric instruments. Journal ofAutism and Developmental Disorders, 24, 293-304. Swedo, S. E., Leonard, H. L, Rapoport, J. L., Lenane, M. C, Goldberger, E. L., & Cheslow, D. L. (1989). A double-blind comparison of clomipramine and desipramine in the treatment of trichotillomania (hair pulling). The New England Journal of Medicine, 321, 497-501. Thomas, E. J., Abrams, K. S., & Johnson, J. B. (1971). Self-monitoring and reciprocal inhibition in the modification of multiple tics of Gilles de la Tourette's syndrome. Journal of Behavior Therapy and Experimental Psychiatry, 2, 159-171. Touchette, P. E., MacDonald, R. F., & Langer, S. N. (1985). A scatter plot for identifying stimulus control of problem behavior. Journal of Applied Behavior Analysis, 18, 343-351. Twohig, M. P., & Woods, D. W. (in press). Habit reversal as a treatment for chronic skin picking in typically developing adult male siblings. Journal of Applied Behavior Analysis. Vollmer, T. R., Marcus, B. A., Ringdahl, J. E., & Roane, H. S. (1995). Progressing from brief assessments to extended experimental analyses in the evaluation of aberrant behavior. Journal of Applied Behavior Analysis, 28, 561-576. Vollmer, T. R., & Smith, R. G. (1996). Some current themes in functional analysis research. Research in Developmental Disabilities, 17, 229-249. Walkup, J. T., Rosenberg, L. A., Brown, J., & Singer, H. S. (1992). The validity of instruments measuring tic severity in Tourette's syndrome. Journal of the American Academy of Child & Adolescent Psychiatry, 31, 412-411. Ware, J. C, & Morin, C. M. (1997). Sleep in depression and anxiety. In M. R. Preston & W. C. Orr (Eds.), Understanding sleep: The evaluation and treatment of sleep disorders.
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Application and practice in health psychology (pp.483-503). Washington, DC: American Psychological Association. Watson, T. S., & Sterling, H. E. (1998). Brief functional analysis and treatment of a vocal tic. Journal ofApplied Behavior Analysis. 3/, 471 -474. Winchel, R. M., Jones, J. S., Molcho, A., Parsons, B., Stanley, B., & Stanley, M. (1992). Rating the severity of trichotillomania: Methods and problems. Psychopharmacoiogy Bulletin, 28,457-462. Wolf, M. M. (1978). Social validity: The case for subjective measurement or how applied behavior analysis is finding its heart. Journal ofApplied Behavior Analysis, J J, 203-214. Woods, D. W., Fuqua, R. W., & Outman, R. C. (1999), Evaluating the social acceptability of persons with habit disorders: The effects of topography, frequency, and gender manipulation. Journal of Psychopathology & Behavioral Assessment, 21, 1-18. Woods, D. W., Miltenberger, R. G., & Lumley, V. A. (1996). Sequential application of major habit-reversal components to treat motor tics in children. Journal of Applied Behavior Analysis, 29, 483-493.
Chapter 3 Physical and Social Impairment in Persons With Repetitive Behavior Disorders Douglas W. Woods University of Wisconsin-Milwaukee
Patrick C. Friman University of Nevada-Reno
Ellen J. Teng University of Wisconsin-Milwaukee
1. INTRODUCTION Repetitive behavior disorders (RBD) such as tic disorders, trichotillomania, and a variety of other problematic habitual behaviors can produce a number of detrimental physical and social effects. In this chapter we review a representative sample of harmful sequelae from these disorders. Not all clients will suffer from, or be at risk for all negative effects discussed in this chapter, but clinicians should be aware of the potential for the presentation or development of multiple untoward effects of RBDs, and multiple representative examples will be described here.
2. TIC DISORDERS The cardinal criterion for tic disorders is the presence of motor and/or vocal tics. Motor tics are sudden, rapid, recurrent, and nonrhythmic motor movements, and vocal tics are sudden, rapid, recurrent, and nonrhythmic sounds or verbalizations. Examples of motor tics include eye blinking, head and arm jerking, shoulder shrugging, and facial grimacing. Examples of vocal tics include throat clearing, barking, grunting, and sniffing. As discussed in
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Chapter 4, the category "tic disorders" contains the diagnostic labels of transient tic disorder, chronic tic disorder, and Tourette's syndrome (TS), each distinguished from the other by a different combination of motor and/or vocal tics. For example, TS involves multiple motor tics and at least one vocal tic that have been present for at least one year, whereas chronic tic disorder requires a motor tic(s) or vocal tic(s) (but not both) present for at least one year. In contrast, transient tic disorder involves any combination of motor or vocal tics and the tics must have been occurring for more than four weeks but less than one year. Our central concern is that, regardless of the specific diagnosis, tic disorders can result in a variety of harmful medical and nonmedical sequelae. Although the majority of informative investigations have involved patient samples with TS, the topographical similarities between the cardinal symptoms of TS and other tic disorders suggest the findings of these investigations may be relevant across the spectrum of tic disorders.
2.1 Harmful Medical Sequelae Most of the medical harm associated with tic disorders appears to be linked to the topographies of the tics exhibited, although few systematic studies on the general physical effects associated with tic disorders have been reported. Among the few is a report that between 43 and 67% of persons with TS suffer some form of self-injury (Shimberg, 1995) and an earlier report emphasizing the medical problems associated with topographically specific tics (Messiha & Carlson, 1983). For example, tics involving repetitive lip or cheek biting can result in oral inflammation, abrasion, or infection. Tics involving motor motion directed toward the body (e.g., self-hitting) can result in hematomas, contusions, abrasions, and fractures. When the self-directed motor motion involves the eyes, serious ocular injury can be the result. Tics involving the legs can result in chronic hip pain, shoulder shrugging can result in rib fractures (Moon, Price, & Campbell, 1998), and tics involving head jerking can result in spinal compression, nerve damage, and chronic neck and back pain (see Messiha & Carlson, 1983 and Shimberg, 1995 for more complete accounts). In addition to the harmful sequelae associated with tics, compulsive behaviors resulting from comorbid obsessive-compulsive disorder (OCD; a common comorbid condition with tic disorders; Woods, Hook, Spellman, & Friman, 2000) can produce harmful sequelae of their own. For example persons with TS may compulsively pick at skin imperfections, cuts, or abrasions and may be at risk for self-harm due to a compulsion to touch hot or
Physical and Social Impairment in Persons with RED
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sharp objects (Shimberg, 1995). As indicated above, research on the untoward medical effects of tic disorders is scant. Perhaps the relationship between most tic topographies and potential related harm is so patently obvious, conducting research on causal explanations for that harm may be viewed as unnecessary or unproductive (e.g., additional research is not needed to inform the scientific community that repeatedly banging one's head into a wall during a head jerking tic is likely to cause skull damage). However, more research on medical sequelae may be beneficial in areas unrelated to causation for at least two reasons. First the epidemiology of harmful sequelae is necessary for determining who is most at risk, and how frequently tics actually result in harm. Second, it is still unclear what physical injuries are most likely to occur as a result of tics. Such information may be useful in treatment planning as a guide to determine whether tics should be treated or in which order the tics should be targeted.
2.2 Related Non Medical Concerns In addition to the medical sequelae associated with tics, persons with tic disorders (especially TS) often experience a variety of academic, social, psychological, and occupational concerns. In this section, we describe these concerns and propose some possible explanations for them. 2.2.1 Academic Children and adolescents with tic disorders encounter a variety of difficulties in school including behavior problems and deficient academic achievement. For example, children with TS frequently have difficulty with arithmetic (Dykens et al. 1990), reading, writing, and information retention (Comings & Comings, 1987). As a result, many children with TS are placed in special class settings such as classes for the educationally handicapped or for severely emotionally disturbed children. Children with TS and comorbid attention deficit hyperactivity disorder (ADHD) are particularly at risk for placement in special classes. For example. Comings and Comings (1987) found that 19.7% of children with TS and comorbid ADHD were placed in special classes for the emotionally handicapped compared to 2.1% of these children without ADHD, who were also placed in these classes. Children with TS are not only likely to be placed in special classrooms, but they are also less likely than other children to progress smoothly through their academic career. For example, Comings and Comings (1987) found that 26.4%
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Tic Disorders, Trichotillomania, and Repetitive Behavior Disorders
of all children with tic disorders were held back a grade due to academic problems compared to 8.5% of children in a control group.
2.2.2 Social Compounding the academic difficulties are prevalent problems with socialization. Many studies have documented the serious social burdens children and adolescents with TS must endure, the effects of which can often contribute to a delay in vital developmental processes. For example, Dykens et al. (1990) found a surprisingly large disparity between social and intellectual development in children with TS. Additionally, these children's skills in establishing interpersonal relationships, use of play and leisure time, and coping abilities were substantially beneath normative levels. Similarly, Stokes, Bawden, Camfield, Backman and Dooley (1991) found that children with TS were rated by their peers as less popular than classmates who did not exhibit tics, and Champion, Fulton, and Shady (1988) reported that more than 40% of 210 persons with TS surveyed, acknowledged problems in dating and making/keeping friends.
2.2.3 Psychological As will be described more fully in Chapter 4, persons with tic disorders often have a number of comorbid psychological concerns and diagnoses. Several studies have found that individuals with tic disorders may suffer from feelings of embarrassment, frustration, anxiety, and despair (Carter, Pauls, Leckman, & Cohen, 1994; Champion et al., 1988). Furthermore, persons with TS commonly experience feelings of isolation, self-consciousness, and low self-esteem in response to their peer's reactions to them (Hagin & Kugler, 1988; Thibert, Day, & Sandor, 1995; Walter & Carter, 1997). In addition, persons with tic disorders are at greater risk of being diagnosed with OCD, depression, and ADHD when compared to the general population (King, Leckman, Scahill, & Cohen, 1999; Walkup et al., 1999).
2.2.4 Occupational Note that we have been artificially parceling out sub categories of non medical concerns associated with tic disorders. A more realistic perspective
Physical and Social Impairment in Persons with RBD
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would emphasize interactive rather than main effects. This position is particularly true of the substantial occupational difficulties encountered by persons with tic disorders and especially TS, because the problems mentioned above antedate and accompany entry into the work force. For an adult with a tic disorder, entering the workforce can be a trying and frustrating experience. As evidence, Meyers (1988) reported that 48% of adults diagnosed with TS in Ohio in 1982 were unemployed. Providing greater detail on the occupational experiences of persons with TS, Shady, Broder, Staley, Purer, and Papadopolos (1995) found that 20% of 193 persons with TS claimed to have been fired from a job because of their condition, 17% felt they had been denied a job because of TS, and 12% felt they had been denied a promotion as a result of their tic disorder.
2.2.5
Potential Causes for Related Non Medical Concerns
As we have indicated above, persons with tic disorders are at risk for a variety of academic, social, psychological, and occupational problems. Why these problems exist and persist, however, remains unclear at least as far as empirically derived accounts are concerned. For example, underlying neurological dysfunction can explain some, perhaps even many, of the academic difficulties of children with TS, but it cannot explain them all (Schultz, Carter, Scahill, & Leckman, 1999), and it certainly does not explain difficulties in social, psychological and occupational functioning. One promising line of research focuses on the negative reactions of others toward persons with tics. Studies on the social problems of persons with TS clearly show that they are perceived more negatively than persons without the disorder. For example, Stokes et al. (1991) found that children with TS were rated by their peers as significantly more withdrawn, aggressive, and less popular than those without the disorder. Unfortunately, it is unclear whether preexisting psychological conditions occasion these negative perceptions (independent of tics) or if the tics themselves occasion the perceptions which then contribute to the psychological, social, and related occupational problems. As previously mentioned and as further discussed in Chapter 4, persons with TS often experience a variety of comorbid conditions and it is possible that social, occupational, and psychological disruption is simply a result of these conditions rather than the tic condition itself (Bawden, Stokes, Camfield, Camfield, & Salisbury, 1998; Shady et al., 1995; Stokes et al., 1991). As we have suggested, however, it is possible that the tics alone produce
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Tic Disorders, Trichotillomania, and Repetitive Behavior Disorders
negative social reactions by peers. To study this possibility, social evaluators must be exposed to persons with and without tics and then judge these persons absent any exposure to comorbid conditions. Using such a framework, recent research has begun to determine the effect of tic occurrence on the social reactions of others, independent of comorbid functioning. In an experimental study examining third and fifth grade children's perceptions of an unfamiliar peer who presented either with or without TS, Friedrich, Morgan, and Devine (1996) found that children rated the peer more negatively when the peer exhibited tics than when the peer did not. Similarly, Boudjouk, Woods, Miltenberger, and Long (2000) found that eighth grade children perceived unfamiliar peers (shown in videotapes) who exhibited a motor tic as less socially acceptable than unfamiliar peers (again shown in videotape) in whom the behavior was absent. Finally, Long, Woods, Miltenberger, Fuqua, and Boudjouk (1998) found that unfamiliar males with mental retardation (shown in videotape) who exhibited motor and vocal tics were rated by college students as less acceptable than unfamiliar mentally retarded males (again shown in videotape) without motor and vocal tics. In the same paper. Long et al. (1998) found that college students who viewed a simulated job interview said they would be less likely to hire persons with tics than persons without tics. This line of research suggests that tics alone may be sufficient to instigate negative social perceptions of by others of persons with tic disorders. The research also suggests that in children, the detrimental effect of tics on social perceptions is greater for girls than for boys (Boudjouk et al. 2000) but that in adults this gender effect may be reversed (Long et al., 1998; Woods, Fuqua, & Outman, 1999). As evidence that tics alone could be directly responsible for some of the social problems of persons with tic disorders accumulates, so too has the importance of studying the effects of some dimensions of tics (e.g., tic frequency, intensity). In the initial study to systematically evaluate the impact of tic frequency and intensity on attitudes toward persons with TS, Woods et al. (1999) found that unfamiliar persons (shown in a video) engaging in highfrequency motor tics, vocal tics, and TS symptom presentations received lower social acceptability ratings than persons who exhibited low-frequency motor tic, vocal tic, and TS symptom presentations. Woods et al. (1999) also showed that persons presenting high intensity motor tics, vocal tics, and/or TS symptom received lower social acceptability ratings than persons whose presenting tics were milder. These findings suggest a positive relationship between tic frequency/intensity and the occurrence of negative peer perceptions which may, in part, explain the social difficulties experienced by
Physical and Social Impairment in Persons with RED
39
persons with tic disorders. The findings are also consistent with a long line of research showing that behavior that is salient to the casual observer and that substantially deviates from social norms typically results in negative social evaluation (Meyers, 1990). Although we have discussed potential reasons for the negative social attitudes toward persons with tic disorders in a categorical fashion, the most plausible, comprehensive account is likely to emphasize the interaction of tics and comorbid conditions rather than the main effects of either. The literature shows that even at a young age, the negative social impact of tics is present (Friedrich et al., 1996). In fact, the age at which this occurs may even predate the development of notable psychopathology. Perhaps some children with tics have a genetic predisposition toward the development of comorbid psychopathology and exposure to negative evaluation by others and the resulting adverse social climate is sufficient to result in a multi problem, comorbid presentation. Various dimensions of the presentation may further adversely influence social perceptions of others and worsen the functioning of persons with tics in social and occupational arenas. Although this is entirely speculative, it is a testable hypothesis and seems worthy of further consideration. In conclusion, tic disorders are associated-with multiple problematic sequelae, several with a high index of impairment, that have the potential to adversely affect virtually every area of the lives of those afflicted with tic disorders. Additional research on the nature and the extent of these adverse influences is still needed but perhaps an even more important investigative agenda would be to focus on the cause of the impairments associated with tic disorders. Valid information on cause often informs research on treatment. The current research on cause cogently endorses comorbid conditions and negative social reactions to tics as mechanisms which mediate the adverse conditions associated with tic disorders. More information on these mechanisms as well as new research on other adverse influences on the lives of persons with tic disorders is needed.
3. TRICHOTILLOMANIA The cardinal criterion for diagnosis of trichotillomania is the recurrent pulling of one's own hair. Additional criteria include an increase in tension that occurs prior to the act of hair pulling or that corresponds with attempts to inhibit the act, a sense of gratification following the act, absence of a causal medical or psychological condition, and significant distress or impairment
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77c Disorders, Trichotillomania, and Repetitive Behavior Disorders
(American Psychiatric Association, 1994). This final criterion is obviously the most relevant to this chapter. Not surprisingly, trichotillomania is associated with a variety of potentially harmful sequelae.
3.1 Harmful Medical Sequelae The most obvious physical effect of trichotillomania is hair loss, the technical term for which is alopecia. Multiple causes of alopecia have been documented ranging from male pattern baldness to the side effects of chemotherapy. Trichotillomania is perhaps unique among these causes because it involves an object (hair) rather than a disorder-specific bodily location and thus the resulting alopecia can be located on any hirsute bodily surface. The scalp is the most common target but cases involving eyebrow (or lash), axillary, and even pubic hair have been documented. Trichotillomania also has a characteristic presentation that distinguishes it from other sources of alopecia (e.g., jagged, broken hairs, non symmetrical bordering, etc) (see Christenson & Mansueto, 1999; Friman, Finney, 8L Christophersen, 1984; Steck, 1979 for reviews). Although aggressive hair pulling of long standing duration can result in follicle damage, changes in the structure and appearance of regrown hair, and occasionally scalp irritation (Christenson & Mansueto, 1999), beyond hair loss trichotillomania is generally not considered a threat to physical health. However, a substantial percentage of persons with trichotillomania also bite, chew on, and sometimes swallow pulled hair. The result of swallowing pulled hair, the technical term for which is trichophagia, can be hair balls or trichobezoars. Bezoar refers to an accumulation of a non-nutritional exogenous substance in the stomach or intestine and with trichobezoars, the substance is hair. Trichobezoars are a serious threat to health and their detection necessitates a medical intervention which can involve emergency surgery. A sample of health threats resulting from trichobezoars include obstruction of gastric outlets or intestinal passageways resulting in anorexia, vomiting, and weight loss. Representative symptoms include abdominal pain, distention, and sometimes severe halitosis. Iron deficiency anemias, hyperproteinemia, and steatorrhea have also been reported (see Wyllie, 1996 for a review). Approximately 4877% of persons who pull their hair engage in an oral behavior involving hair, and 5-18% actually ingest hair. Despite this rate of hair ingestion, the review supplying these figures concluded that the risk of trichobezoar is low and supplied the absence of a single case in a sample of 186 hair pulling persons as
Physical and Social Impairment in Persons with RBD
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evidence (Christenson & Mansueto, 1999). Nonetheless, the same review cited a study that reported a 25% incidence of trichobezoars in a hair pulling sample (Bhatia, Singhal, & Rastogi, 1991). Other more rare but nonetheless real health complications associated with hair pulling include gingivitis secondary to hair chewing (Christenson & Mansueto, 1999), and carpal tunnel syndrome resulting from the repetitive motions required for habitual hair pulling (O'Sullivan, Keuthen, Jenike, & Gumley, 1996). Generally, however, the physical complications associated with hair pulling are isolated to hair loss; but when the pulling leads to trichophagia, threats to health mount rapidly. Thus from the perspective of physical health alone, trichotillomania can be a serious condition. Unfortunately for persons with trichotillomania, there are also serious non medical sequelae to consider.
3.2 Related Non Medical Concerns In a study examining 67 adults diagnosed with trichotillomania, over 80% of patients reported feeling depressed or unattractive as a result of their hairpulling, and over 70% of patients reported feelings of shame, irritability, and low self-esteem (Townsley-Stemberger, Thomas, Mansueto, & Carter, 2000). Furthermore, almost half of the individuals in this sample reported an increase in arguments with loved ones and over half were secretive about their behavior. In addition to the emotional difficulties and relationship strain persons with trichotillomania may experience, social functioning may be further impaired due to avoidance of common activities. In a study by Townsley-Stemberger et al. (2000), over 60% of the adults diagnosed with trichotillomania avoided haircuts and swimming, over 30% were uncomfortable being in windy weather, playing sports, and physical intimacy, and over 20% avoided activities in well-lit areas and public events. In another study, Hansen, Tishelman, Hawkins, and Doepke (1990) found that psychological consequences for hair pulling in college students included lowered selfevaluation and over sensitivity to their own appearance. Similarly, Joubert (1993) found that college students who engaged in hair pulling experienced lower self-esteem and higher levels of anxiety than those with other habits. Unfortunately, the cause for these related non medical concerns is not entirely clear. As with tic disorders, however, a promising line of investigation is focused on the impact of hair pulling on the social perceptions of others. For example, in a study examining the social acceptability of adolescents with a
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motor tic or trichotillomania, peer evaluators rated participants who exhibited either habit as less socially acceptable than participants who did not (Boudjouk et al., 2000). Similarly, Long et al. (1999) found that adults with mental retardation who exhibited trichotillomania were rated (by college students) as significantly less socially acceptable and less desirable for employment than adults with mental retardation who did not exhibit trichotillomania. Similar to the findings on social perceptions of persons with tic disorders. Woods et al. (1999) found that increases in the frequency and intensity of pulling are accompanied by increases in negative social perceptions. The value of this line of investigation not withstanding, a number of issues need to be clarified in future research. First, because hair pulling often occurs as a private behavior, it is less likely that peers would actually view the individual with trichotillomania engaging in hair pulling. Thus, a more pertinent question may be to determine what impact hair loss has on social perceptions. Second, an attempt should be made to experimentally confirm the relationship between negative social perceptions of others and disruptions in the social functioning of persons who pull hair. Third, as with tic disorders, research into the cause of harmful non-medical sequelae will need to consider the role of comorbid psychiatric conditions.
4. OTHER REPETITIVE BEHAVIOR DISORDERS Tic disorders and trichotillomania are salient RBDs associated with a variety of harmful sequelae. There are, however, other RBDs associated with harmful outcomes to consider. Below we will briefly discuss a sample of these. Included among the sample are oral digital habits such as thumb sucking or nail biting which will be covered in greater detail in Chapter 10.
4.1 Harmful Medical Sequelae Although the medical consequences of some repetitive behaviors such as eye poking or head banging are self-evident, medical problems associated with behaviors such as nail biting, thumb sucking, or skin picking may be less evident. However, each of these three behaviors has the potential to produce a number of medical sequelae. Nail biting is related to a variety of dental problems including atypical root
Physical and Social Impairment in Persons with RBD
43
resorption (Odenrick & Brattstrom, 1985), periungual warts, hangnails (Mantoura & Bryan, 1989), phalangeal osteomyelitis (Tosti, Peluso, Bardazzi, Morelli, & Bass, 1994), chronic paronychia (Vogel, 1998), and gingival swelling (Creath, Steinmetz, & Roebuck, 1995). In fact, Creath et al. (1995) attribute the most common cause of gingival injuries to fingernail biting. In addition to the aforementioned problems, nail biting also causes microfractures of the teeth and increases the risk of dermatological infections into the oral cavity (Creath et al., 1995). Thumb or finger sucking produces many similar types of secondary physical effects. These include cracking and/or lichenification of the skin (Vogel, 1998), digital deformities (Reid & Price, 1984), and increased risk of transmitting roundworm, herpes, streptococcal or staphylococcal infections (Vogel, 1998). Similarly, chronic thumb sucking may result in a number of detrimental structural changes to the dentition including, "1) flared and spaced maxillary incisors, (2) lingually positioned mandibular incisors, (3) anterior open-bites, and (4) a constricted maxillary arch form." (p 854, Josell, 1995). Thumb and finger sucking are also sometimes associated with other problems such as speech defects and an increased risk of poisoning (Josell, 1995). Lastly, repetitive skin picking (a.k.a., neurotic excoriation or dermatotillomania) can produce a host of physical problems. For example, Wilhelm et al. (1999) found that 90% of persons with skin picking had minor sores, 81% had permanent scars, 61% experienced skin infections, and 45% had craters on their skin.
4.2 Related Non Medical Concerns In early childhood, oral-digital behaviors such as thumb and finger sucking are generally considered part of normal development. However, continued thumb/finger sucking not only poses a risk of physical harm to the dentition, but may also have detrimental social effects. For example, Friman, McPherson, Warzak, and Evans (1993), discovered that first-grade children rated peers who sucked their thumbs as less socially acceptable than peers who did not engage in the behavior. Specifically, when seen thumb sucking, the participants were rated as significantly less intelligent, attractive, and fun and were less desirable to have as a friend, playmate, and classmate by their peers. Perhaps related to such early negative evaluations, research shows that nail biting behavior (onychophagia) has a negative influence on self-evaluation (Hansen et al., 1990; Joubert, 1993) as well as social and occupational functioning (Stein, Niehaus, Seedat, & Emsley, 1998; Wells, Haines, &
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Williams, 1998). Moreover, nail biting is often connoted with nervousness and inattention (Wells et al., 1998). Research on the harmful non medical effects of other repetitive behaviors is scant. One notable exception examined the phenomenology of skin picking among 31 outpatients, and reported that following an occurrence of picking, patients experienced increased levels of shame, guilt, and physical pain and that these feelings led to increased picking (Wilhelm et al., 1999). Of the people in this study, half reported that social embarrassment caused by their behavior prevented them from seeking treatment. Another study supplemented this report by showing that multiple problematic psychological conditions can comorbidly exist in persons exhibiting repetitive behaviors (e.g, anxiety, depression, ADHD; Teng, Woods, & Twohig 2000). Collectively, these findings further illustrate the extent of harmful sequelae associated with repetitive behavior disorders. Research into the non medical concerns associated with other RBDs is relatively new and definitely limited. Indeed, we found no studies that evaluated directly how these RBDs might cause non medical harm. However, drawing from the research on tic disorders and trichotillomania, we are confident that social perceptions will prove to be central to at least some non medical concerns, some of which will have an emotional component (e.g., shame, guilt, etc.). And as Skinner (1974) has cogently argued, emotional responses such as shame and guilt are high probability emotional accompaniments of punishment delivered by a social group. If the RBDs in question also produce negative reactions in peers (e.g„ Friman et al., 1993) a punishing relation between RBD and social reaction is likely, concomitant emotional responses become possible, and the risk of social problems becomes real. This is but one direction the needed research could take.
5. TREATING IMPAIRMENTS IN FUNCTIONING It is clear that persons with tic disorders, trichotillomania, and other repetitive behavior disorders experience a significant number of secondary medical and non medical concerns. Unfortunately, little research has been conducted to evaluate psychological or behavioral strategies for alleviating these secondary impairments.
Physical and Social Impairment in Persons with RED
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5.1 Treating Harmful Medical Sequelae The primary behavioral approach to harmful medical sequelae is to reduce or eliminate the RBD itself. Although even cessation of the disorder may not alleviate all the medical concerns, perpetuated practice is highly likely to exacerbate them. Thus, effective interventions for the disorders are of paramount importance. Throughout the remainder of this book, a variety of interventions for RBDs are described. Aside from reducing or eliminating the disorders, the role of psychology in the treatment of harmful medical outcomes is limited because most require medical interventions (e.g., abdominal surgery for trichobezoars). Furthermore, even after the repetitive behavior has been successfully treated, the remaining physical effects may require further medical interventions. For example, the medical problems associated with trichobezoars are unaffected by rate of hair pulling and require a completely separate type of treatment. Scarring from skin picking, dental malocclusion from thumb sucking, finger deformities from oral-digital habits, or chronic injuries from tics all require specialized medical care. As a final example, the repetitive behaviors that are part of a syndromal constellation (e.g., tardive dyskinesia) or secondary to a medical condition (e.g., alopecia areata) can be difficult to distinguish from those that have a more functional origin. For these reasons, we recommend collaboration with medical professionals in the evaluation and treatment of persons with RBD. At minimum we recommend that these persons receive a physical examination prior to psychological intervention.
5.2 Treating Harmful Non Medical Sequelae In contrast to treatments for harmful medical sequelae, there is a very important role for psychology in the treatment of harmful non medical sequelae. Also, at least slightly in contrast with harmful medical sequelae, cessation of the disorder does not always lead directly to reduced harm. This is not to say that reductive treatments directly targeting the disorder should not be the first order of business. As indicated above, the association between the disorders and medical harm dictates the primary importance of reductive interventions. Additionally, at least some research shows social benefits for the reduction (or non practice) of target habits (e.g., Friman et al., 1993; Woods et al., 1999). However, the potential for non medical harm posed by
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repetitive behavior disorders is influenced more by current and historical variables than is the potential for medical harm which is more mechanical. For example, the damage to social relationships caused by an excessive, socially proscribed, repetitive behavior (e.g., coprolalia, copropraxia) can continue or even worsen after cessation of behavior. Problematic social relationships are often perpetuated on the basis of past perceptions even when those perceptions are inconsistent with present practices. One bout of coprolalia (i.e., obscene vocal tic) or copropraxia (obscene motor tic) in church is likely to be long remembered by most in attendance and difficult to forgive by at least some. The upshot of these points is that treatment for non medical harm may often be directed to targets (e.g., social relationships) other than its primary source (i.e., disparaged repetitive behavior). One method of treatment involves provision of education about the repetitive behavior disorder to peers, families, teachers, and employers. Research has begun to demonstrate that providing education to people in various settings can substantially reduce the amount of ridicule and other negative attention directed toward persons with repetitive behavior disorders (Comings & Comings, 1987; Meyers, 1988; Woods, in press). Related to education, involvement in national support organizations may be useful to counteract the negative stigma individuals with repetitive behavior disorders sometimes experience. Examples of such organizations include the Tourette's Syndrome Association, Trichotillomania Learning Center, and the Obsessive Compulsive Foundation (see Appendix A for contact information). Although research is limited, there are other methods that at least seem plausible. For example (and as discussed above), persons with RBD are sometimes (probably often) exposed to ridicule and isolation during critical periods of social development. It is thus possible that their development of repertoires necessary for negotiating a variety of social situations may be impaired. For example, some such persons may not have learned to initiate spontaneous conversations and thus social avoidance and escape may be precurrent in many critical social situations (e.g., job interviews, hallway encounters, introductions, etc.). Perhaps a combination of comprehensive social skills assessment and deficit- specific treatment programming could remedy or at least improve the problem for some situations. Another related possibility involves treatment for social rejection. Because of the social stigma attached to the core components of some RBDs and of the consequential negative effect on social functioning, some persons may suffer the reciprocally detrimental effects of social rejection. Abundant research shows that early problems with social interactions can adversely affect subsequent social desirability, distance, and development. In turn, these social
Physical and Social Impairment in Persons with RBD
47
problems can adversely affect other aspects of child life including home, school, and recreation. The result is a psychologically unhealthy montage that can seriously imperil the quality and outcome of a child's life (Parker & Ascher, 1987; Strain, Guralnick, & Walker, 1986). Although not the object of a long line of investigative inquiry (as we have argued above), sufficient evidence exists to argue that children with RBDs that involve public exhibition are at social risk. A recent line of research has shown how strategic use of peer mediation can assuage problematic social interactions and improve social standing for rejected children (e.g., Bowers, Woods, Carlyon, & Friman, 2000; . Ervin, Miller, & Friman, 1996; Friman, 2000). Drawing upon this line of research, we recommend a two-staged approach to address incipient or extant social rejection secondary to repetitive behavior disorders. The first involves programming a target child's social environment (e.g., classroom) to motivate peers to detect, acknowledge, and report prosocial features of the child's behavior (e.g., friendliness, cooperation, sharing, etc.). Unfortunately for children with RBDs, the frequency and salience of their repetitive problem behaviors can occlude exhibition of adaptive behavior and thus prosocial dimensions of their daily interactions may be infrequently detected by others and therefore may not be selected by behavior strengthening processes. In simple economic terms, the problem behaviors may be more likely to recruit the attention of others, and depending on the psychological makeup of the target child, this attention is likely to either strengthen the problem behaviors (for some children any type of attention is reinforcing), instigate retaliation, or result in social withdrawal. Our recommendation is to reverse this process by rewarding peers for detecting and reporting (to adults) examples of the target children's prosocial behaviors. These reports could be delivered to the target children in the form of second and third hand compliments. That is, the adult could either tell the child that a peer caught him in the act of being good, so to speak, or arrange for the child to witness the peer report on their prosocial behavior. The second stage of our recommended approach involves a reversal of the first. Specifically, one of the target child's social environments could be programmed to motivate the child to detect and report prosocial features of peer behavior. Socially active but rejected children often tattle, perhaps because doing so allows them access to attention from adults, retribution against peers, or both. The unfortunate result, however, is a worsening of peer relations. To reverse this process the target children could be rewarded for reporting examples of peer prosocial behavior to adults who would then tell the peer reported on of the report.
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We should note here that the value of these recommendations are largely speculative. Although some (especially the suggestions involving peer mediation) have been shown to produce positive results for troubled children, none of the pertinent research has directly targeted children with RBDs. With the broad flexibility that results from escaping the confines of empirical validation, we could recommend a variety of other approaches that might benefit persons suffering harmful side-effects of RBDs. For example, to cope with negative social interactions surrounding motor and vocal tics, persons have been encouraged to carry Medic Alert bracelets describing the condition, go to restaurants and movies during off-peak hours, give school children with tics a "safe" place to engage in tics such as a counselors office, and place children with tics around supportive peers (Shimberg, 1995). An additional strategy could be to train persons with tic disorders or trichotillomania to speak assertively about their condition. It is the authors' experience that persons with RBDs are often unwilling to discuss their condition and are unlikely to assert themselves when someone reacts negatively to them. Hence, assertiveness training may be of some benefit in alleviating the negative social functioning often found in persons with such conditions.
6. CONCLUSION In this chapter we reviewed a variety of harmful medical and non medical problems associated with tic disorders, trichotillomania, and other RBDs. We also attempted to explain the potential etiology of the concerns, and discussed possible strategies for their clinical management. Although this chapter summarized the extant research on these topics, it is clear that the lines of investigation are either in their early stages or have yet to inaugurated. For example, the epidemiology of secondary non medical problems is incomplete across disorders and research on the cause of these problems is incomplete for some disorders (e.g., tic disorders) and missing entirely for others (e.g., nail biting). The empirical literature on psychological and/or behavioral treatments for the harmful effects of RBDs is also quite limited. Although we describe or propose a sample of interventions to address at least some problems associated with RBDs, few of these have been scientifically evaluated in that context. There are examples of other important research agendas scattered throughout this chapter. It is our ardent hope that research on the sequelae of RBDs will expand sufficiently to achieve a goal of paramount importance for those afflicted, elimination or substantial reduction in related harm.
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7. REFERENCES American Psychiatric Association (1994). Diagnostic and statistical manual of mental disorders (4'^ edition). Washington, D.C: Author. Bawden, H. N., Stokes, A., Camfield, C. S., Camfield, P. R., & Salisbury, S. (1998). Peer relationship problems in children with Tourette's disorder or diabetes mellitus. Journal of Child Psychology and Psychiatry. 39, 663-668. Bhatia, M. S., Singhal, P. K., & Rastogi, V. (1991). Clinical profile of trichotillomania. Journal of the Indian Medical Association, 89, 137-139. Boudjouk, P. J., Woods, D. W., Miltenberger, R. G., & Long, E. S. (2000). Negative peer evaluation in adolescents: Effects of tic disorders and trichotillomania. Child and Family Behavior Therapy, 22, 17-28. Bowers, F. E., Woods, D. W., Carlyon, W. D., & Friman, P. C. (2000). Using positive peer reporting to improve the social interactions and acceptance of socially isolated adolescents in residential care: A Systematic Replication . Journal of Applied Behavior Analysis, 33, 239242. Carter, A. S., Pauls, D. L., Leckman, J. F., & Cohen, D. J. (1994). A prospective longitudinal study of Gilles de la Tourette's syndrome. Journal of the American Academy of Child and Adolescent Psychiatry, 33, 377-385. Champion, L. M., Fulton, W. A., & Shady, G. A. (1988). Tourette syndrome and social functioning in a Canadian population. Neuroscience and Biobehavioral Reviews, 12, 255257. Christenson, G. A., & Mansueto, C. S. (1999). Trichotillomania: Descriptive characteristics and phenomenology. In D. J. Stein, G. A. Christenson, & E. Hollander (Eds.), Trichotillomania_{^-^2). Washington, D. C: American Psychiatric Press, Inc. Comings, D. E. & Comings, B. G. (1987). A controlled study of Tourette syndrome. I. Attention-deficit disorder, learning disorders, and school problems. American Journal oj Human Genetics, 41, 701-741. Creath, C. J., Steinmetz, S., & Roebuck, R. (1995). Gingival swelling due to a fingernail biting habit. Journal of the American Dental Association, 126, 1019-1021. Dykens, E., Leckman, J., Riddle, M., Hardin, M., Schwartz, S., & Cohen, D. (1990). Intellectual, academic, and adaptive functioning of Tourette syndrome children with and without attention deficit disorder. Journal ofAbnormal Child Psychology, 18, 607-615. Ervin, R., Miller, P., & Friman, P.C. (1996). Feed the hungry bee: Using positive peer reports to improve the social interactions and acceptance of a socially rejected girl in residential placement. Journal ofApplied Behavior Analysis, 29, 251-253. Friedrich, S., Morgan, S. B., & Devine, C. (1996). Children's attitudes and behavioral intentions toward a peer with Tourette syndrome. Journal of Pediatric Psychology, 21, 307319. Friman, P. C. (2000). Profound social skills deficit and a 6-point plan. Cognitive and Behavioral Practice, 7,_ 228-231. Friman, P. C, Finney, J. W., & Christophersen, E. R. (1984). Behavioral treatment of trichotillomania: An evaluative review. Behavior Therapy, 15, 249-266. Friman, P. C, McPherson, K. M., Warzak, W. J., & Evans, J. (1993). Influence of thumb sucking on peer social acceptance in first-grade children. Pediatrics, 9L 784-786. Hagin, R. A. & Kugler, J. (1988). School problems associated with Tourette's syndrome. In D. J. Cohen, R. D. Bruun, & J. F. Leckman (Eds.), Tic and tic disorders: Clinical understanding
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and treatmentXpP' 223-236). New York: John Wiley & Sons. Hansen, D. J., Tishelman, A. C, Hawkins, R. P., & Doepke, K. J. (1990). Habits with potential as disorders: Prevalence, severity, and other characteristics among college students. Behavior Modification, 7^,66-80. Josell, S. D. (1995). Habits affecting dental and maxillofacial growth and development. Dental Clinics of North America, 39, 851-860. Joubert, C. E. (1993). Relationship of self-esteem, manifest anxiety, and obsessivecompulsiveness to personal habits. Psychological Reports, 73, 579-583. King, R. A., Leckman, J. F., Scahill, L., & Cohen, D. J. (1999). Obsessive-compulsive disorder, anxiety, and depression. In J.F. Leckman & D.J. Cohen (Eds.), Tourette's syndrome: Tics, obsessions, and compulsions (pp. 43-62). New York: John Wiley & Sons. Long, E. S., Woods, D. W., Miltenberger, R. G., Fuqua, R. W., & Boudjouk, P. (1998). Examining the social effects of habit behaviors exhibited by individuals with mental retardation. Journal of Developmental and Physical Disabilities, 11, 295-312. Mantoura, A., & Bryan, H. (1989). Nail disorders due to trauma and other acquired conditions of the nail. Clinics in Podiatric Medicine and Surgery, 6, 347-354. Messiha, F. S., & Carlson, J. C. (1983). Behavioral and clinical profiles of Tourette's disease: A comprehensive overview. Brain Research Bulletin, 11, 195-204. Meyers, A. S. (1988). Social issues of Tourette's syndrome. In D.J. Cohen, R. D. Bruun, & J. F. Leckman (Eds.), Tic and tic disorders: Clinical understanding and treatment_{PV- 257264). New York: John Wiley & Sons. Meyers, D. G. (1990). Social Psychology, 3'"^ Edition. New York: McGraw-Hill, Inc. Moon, B. S., Price, C. T., & Campbell, J. B. (1998). Upper extremity and rib stress fractures in a child. Skeletal Radiology, 27, 403-405. Odenrick, L., & Brattstrom, V. (1985). Nail biting: Frequency and association with root resorption during orthodontic treatment. British Journal of Orthodontics, 12, 78-81. O'Sullivan, R. L., Keuthen, N. J., Jenike, M. A., & Gumley, G. (1996). Trichotillomania and carpal tunnel syndrome. Journal of Clinical Psychiatry, 57, 174. Parker, J.G., & Asher, S.R. (1987). Peer relations and later personal adjustment: Are lowaccepted children at risk. Psychological Bulletin, 102^351-3^9. Reid, D., & Price, A. (1984). Digital deformities and dental malocclusion due to finger sucking. British Journal of Plastic Surgery, 37, 445-452. Schultz, R. T., Carter, A. S., Scahill, L., & Leckman, J. F. (1999). Neuropsychological findings. In J.F. Leckman & D.J. Cohen (Eds.), Tourette 's syndrome: Tics, obsessions, and compulsions (pp. 80-103). New York: John Wiley & Sons. Shady, G., Broder, R., Staley, D., Purer, P., & Papadopolos, R. B. (1995). Tourette syndrome and employment: Descriptors, predictors, and problems. Psychiatric Rehabilitation Journal, 19, 35-42. Shimberg, E. F. (1995). Living with Tourette syndrome. New York: Simon & Schuster. Skinner, B. F. (1974). About Behaviorism. New York: Random House. Steck, W. D. (1979). The clinical evaluation of pathologic hair loss. Cutis, 24, 293-301. Stein, D. J., Niehaus, D., Seedat, S., & Emsley, R. A. (1998). Phenomenology of stereotypic movement disorder. Psychiatric Annals, 28, 307-312. Stokes, A., Bawden, H. N., Camfield, P. R., Backman, J. E., & Dooley, J. M. (1991). Peer problems in Tourette's disorder. Pediatrics, 87^ 936-942. Strain, P.S., Guralnick, M.J., & Walker, H.M. (1986). Children's social behavior. Orlando: Academic Press. Teng, E. J., Woods, D. W., & Twohig, M. P. (2000). Is stereotypic movement disorder a simple habit? An investigation ofcomorbid conditions and the validity ofDSM-IV criteria in
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typically developing adults. Unpublished manuscript. Thibert, A. L., Day, H. I., & Sandor, P. (1995). Self-concept and self-consciousness in adults with Tourette syndrome. Canadian Journal of Psychiatry, 40, 35-39. Tosti, A., Peluso, A. M., Bardazzi, F., Morelli, R., & Bassi, F. (1994). Phalangeal osteomyelitis due to nail biting. Acta Dermatologica Venereol, 74, 206-207. Townsley-Stemberger, R. M., Thomas, A., Mansueto, C. S., & Carter, J. G. (2000). Personal toll of trichotillomania: Behavioral and interpersonal sequelae. Journal of Anxiety Disorders, 14, 97-104. Vogel, L. D. (1998). When children put their fingers in their mouths: Should parents and dentists care? New York State Dental Journal, 64, 48-53. Walkup. .1. T., Khan, S., Schuerholz. L., Paik, Y. S.. Leckman, .1. F., & Schultz, R. T. (1999). Phenomenology and natural history of tic-related ADHD and learning disabilities. In .l.F. Leckman & D.J. Cohen (Eds.), Tourette's syndrome: Tics, obsessions, and compulsions (pp. 63-79). New York: John Wiley & Sons. Walter, A. L. & Carter, A. S. (1997). Gilles de la Tourette's syndrome in childhood: A guide for school professionals. School Psychology Review, 26, 28-46. Wells, J. H., Haines, J., & Williams, C. L. (1998). Severe morbid onychophagia: The classification as self-mutilation and a proposed model of maintenance. Australian and New Zealand Journal of Psychiatry, 32, 534-545. Wilhelm, S., Keuthen, N. J., Deckersbach, T., Engelhard, I. M., Forker, A. E., Baer, L., O'Sullivan, R. L., & Jenike, M. A. (1999). Self-injurious skin picking: Clinical characteristics and comorbidity. Journal of Clinical Psychiatry, 60, 454-459. Wyllie, R. (1996). Illeus, adhesions, intussesception, and closed loop obstructions. In R. E. Behrman, R. M. Kliegman, and A. M. Arvin (Eds.), Nelson textbook ofpediatrics (pp. 10721075). Philadelphia: Saunders. Woods, D. W., Fuqua, R. W., & Outman, R. C. (1999). Evaluating the social acceptability of persons with habit disorders: The effects of topography, frequency, and gender manipulation. Journal of Psychopathology and Behavioral Assessment, 21, 1-18. Woods, D. W., Hook, S. S., Spellman, D. F., & Friman, P. C. (2000). Exposure and response prevention for an adolescent with Tourette's syndrome. Journal of the American Academy of Child and Adolescent Psychiatry, 39, 904-907. Woods, D. W. (in press). The effect of video based peer education on the social acceptability of adults with Tourette's syndrome. Journal of Developmental and Physical Disabilities.
7. APPENDIX A Below is a list of contact information for education and/or advocacy organizations related to the disorders identified in this chapter. Tourette Syndrome Association, Inc. 42-40 Bell Boulevard Bayside,NY 11361-2820 Phone: (718)224-2999 e-mail: tourette(a)ix.netcom.coni
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Tic Disorders, Trichotillomania, and Repetitive Behavior Disorders website: http://tsa.mgh.harvard.edu Obsessive Compulsive Foundation 337 Notch Hill Road North Branford,CT 06471 Phone: (203)315-2190 e-mail: kish(g)ocfoundation.org website: http://vvww.ocfoundation.org Trichotillomania Learning Center 1215 Mission Street, Suite 2 Santa Cruz, CA 95060 Phone:(831)457-1004 e-mail: trichsterfSjaol.com website: http://www.trich.org
Chapter 4 Characteristics of Tic Disorders Diane B. Findley Yale Child Study Center
1. INTRODUCTION Tics are defined as sudden, repetitive, stereotyped movements and vocalizations (American Psychiatric Association, 1994) which are described as either simple or complex. Motor tics are those which involve repetitive contractions of muscle groups whereas vocal (or phonic) tics are those which involve repetitive sounds (i.e., snorting, coughing, chirping) or vocalizations (syllables, words, or phrases). Because the production of sound necessarily involves contraction of muscles, the distinction between motor and vocal tics may be only one of semantics and not one that has biological significance. The complexity of tics is another distinction used in their classification. Simple tics are generally described as those which are rapid and appear to have no purpose whereas complex tics are generally described as slower, more orchestrated, and appearing as if they might serve some purpose such as brushing hair back with the hand in combination with a head jerk which appears as if the individual is simply moving hair away from the face.
2. DSM-IV CLASSIFICATIONS AND DISTINCTIONS Various tic disorder classifications are based upon the length of time tics have been present as well as the presence or absence of motor and vocal tics. Transient tic disorders are those in which tics have been present for less than one year. Although there is nothing biologically significant about the twelvemonth demarcation, this distinction has been made because tics are not uncommon in childhood, and many children's tics spontaneously remit after
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a brief period of time (Leckman, King & Cohen, 1999). It is believed that if a child's tics last longer than twelve months, they are likely to continue for at least a few years. Tics that do last longer than twelve months warrant a diagnosis of chronic tic disorder. If only motor tics are present a diagnosis of chronic motor tic disorder is given whereas a symptom presentation of only vocal tics yields a diagnosis of chronic vocal tic disorder. If both motor and vocal tics have been present for over one year, Tourette syndrome (TS) is diagnosed. Using DSM-IV criteria, the diagnosis of a tic disorder is fairly straightforward with the only major difficulty being the determination of whether a particular movement or sound is actually a tic. In that regard, tics must sometimes be identified based upon the entire clinical presentation rather than upon a single movement or sound in isolation. It would be very unusual to see a child with complex tics who did not also have (or have had in their history) at least one simple tic.
2.1 Differential Diagnosis The primary issues in differentiating tic disorders from other movement disorders stem from the form and rhythm of the movements. Movement disorders are differentiated by whether the movements are continuous or paroxysmal. Continuous movements include choreas, tremors, myoclonus, athetosis, dyskinesias and dystonias, whereas paroxysms include tics, the hyperekplexias (exaggerated startle response), paroxysmal ataxia, and paroxysmal tremors (Towbin, Peterson, Cohen, & Leckman, 1999). Stereotypies can also be considered paroxysmal movements and are most often seen in individuals with other developmental disorders such as autism and mental retardation (American Psychiatric Association, 1994). Occasionally stereotypies do occur in typically developing children and may be difficult to distinguish from complex tics, although stereotypies are typically more rhythmic and appear more intentional than tics. In the absence of simple tics or developmental delays, a stereotypy would be diagnosed as a stereotypic movement disorder. In such cases, a thorough history of the patient that describes the progression of the movements and places them in context should allow for an accurate diagnosis. Tics are often described as involuntary in the same way that tremor, chorea, myoclonus, and dystonia are involuntary but this is probably not an accurate comparison. Rather, tics can be viewed as voluntary in that they are intentionally produced but are irresistible. Lang (1991) interviewed 60
Characteristics of Tic Disorders
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patients with tic disorders. Of those, only four thought their movements and vocalizations were completely involuntary whereas 102 of 110 non-tic movement disorder patients thought their movements were completely involuntary. Many of the individuals with tic disorders described the difference as being that of having an involuntary urge to move although the movement itself is voluntary. Fifteen of the 60 described their tics as having both voluntary and involuntary aspects. Lang suggested that an assessment of the voluntary/involuntary nature of the repetitive behavior might be a useful way to distinguish tic disorders from other movement disorders. Describing tics as intentionally produced, but irresistible, indicates a closer relationship to compulsions. Indeed, complex tics can be difficult to distinguish from compulsions (King, Leckman, Scahill & Cohen, 1999). Given the practical difficulty and lack of operational criteria for distinguishing many complex motor tics (characteristic of TS) from compulsions (characteristic of obsessivecompulsive disorder) and evidence suggesting a common pathophysiology for these two disorders, the objective term "repetitive behaviors performed in a stereotyped manner (intentional or unintentional)" has been proposed to characterize the various stereotyped repetitive behaviors, including tic disorders and obsessive compulsive disorder (Miguel et al.,1995).
2.2 Prevalence and Incidence Most cases of TS are mild and do not come to medical attention, or are often unrecognized and misdiagnosed by physicians (Kurlan, 1989). In a study of regular education children aged 13 to 14 years old, Mason, Banerjee, Eapen, Zeitlin, and Robertson (1998) found a prevalence rate of 299 per 10,000, or 3% of the population, suggesting that TS in the general population is more common and not as severe as one might think given the prevalence estimates and descriptions from secondary and tertiary healthcare service settings. However Apter et al. (1993) found that of 28,037 adolescents aged 16 to 17 screened for induction into the Israeli army, only 12 (for a prevalence rate of 4.2 per 10,000) met diagnostic criteria for TS. Prevalence rates for males were 4.9 per 10,000 and prevalence rates for females were 3.1 per 10,000. In epidemiological studies of transient and chronic tics in childhood, prevalence rates of all tics have ranged from 5.9 - 18% for boys and 2.9 11% for girls (Lapouse & Monk, 1964; Rutter, Tizard, & Whitmore, 1970).
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No well-controlled epidemiological studies of the prevalence of tic disorders in minority groups have been reported.
3. CHARACTERISTICS OF TIC DISORDERS 3.1 Natural Course For most children, tics begin around the ages of 6 or 7 years, although onset can be earlier. Motor tics generally appear before vocal tics. The most common initial presentation of a motor tic is eye blinking followed by other facial movements which include eye movements (gazing up, down or sideways), nose wrinkling, mouth movements, jaw movements, and facial grimacing. Tics most often take a head-downward trajectory in that they begin in the face and gradually move downward to affect the neck, shoulders, limbs, and trunk. The most common initial vocal tics include sniffing, snorting, throat clearing, and coughing (Leckman et al., 1999) but may progress to include vocalizations of varying complexity. Individual tics are usually brief in duration but often occur in clusters or bouts. It is believed that the clustering of tics occurs regardless of the time period being specified. In other words, during a period of an hour, there can be periods in which several tics occur repetitively in a cluster for several moments followed by a period of no tics followed by another cluster of tics. This same pattern is seen over a day, a week, a month, even years, resulting in the characteristic waxing (increasing) and waning (decreasing) of tics observed in tic disorders (Peterson & Leckman, 1998). Carr, Taylor, Wallander and Reiss (1996) demonstrated the waning nature of tics over a seven-week period in which there was a trend for a decreasing frequency of tics in spite of the lack of a treatment intervention. For children whose tics are chronic, tics tend to increase in intensity, frequency, and complexity throughout childhood and into puberty. For most children, the intensity, frequency, and complexity will begin to gradually abate around puberty so that, for approximately 65% of people who had tics when they were children, by the time adulthood ( 1 8 - 2 0 years) is reached, the tics are either very mild or have remitted (Leckman et al., 1998).
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3.2 Sensory Phenomena In addition to motor and vocal tics, sensory phenomena are quite commonly experienced by individuals with tic disorders. "Sensory tics" are patterns of repetitive bodily sensations, described by patients as feelings of pressure, tickle, temperature or other unusual sensations in skin, bones, muscles, and joints (which can include the throat and larynx). They are often confined to specific regions of the body and produce uncomfortable feelings or tension. Attempts are made to relieve the sensations by making movements, usually contracting or stretching muscles. Relief is only temporary and is followed by more sensations. Sensory tics are described as qualitatively different from the more generalized prodromal feeling or premonitory urge that a tic is about to occur (Kurlan, Lichter & Hewitt, 1989; Leckman, Walker & Cohen, 1993). Kurlan et al (1989) surveyed 34 patients regarding the sensory experience related to their tics. Of these, 41% reported symptoms indicating sensory tics were present, 24% reported no sensory phenomena, and 35% had generalized sensations. Most (96%) who had sensations felt the sensation could be relieved by movement but relief did not always occur. Most (96%) with sensory phenomena were able to voluntarily suppress tics compared with 63% of subjects with no sensory phenomena. Miguel et al. (2000) used specific descriptions of sensory phenomena in their study of 61 patients with TS and/or obsessive-compulsive disorder (OCD). Descriptions were categorized into two groups, bodily sensations and mental sensations, with subcategories for each. Bodily sensations were described as either focal or generalized somatic sensations that occur before the performance of the repetitive behavior. These were further divided into tactile (sensation of the skin), muscular-skeletal or visceral (sensation in muscles, bones, or viscera), or both. Mental sensations were described as generalized uncomfortable feelings that occur before or during the performance of the repetitive behavior. These were further divided into: urge only (a drive to perform the repetitive behaviors without any obsession, fear, worry, or bodily sensation); energy release (a generalized feeling of inner tension that needs to be released); incompleteness (a subjective sense of incompleteness, imperfection or insufficiency); and just-right perceptions (the general feeling of something not being "just-right" and feeling the need to perform certain behaviors until "it feels just right"). In this study, the TS alone and TS + OCD groups reported that sensory phenomena (both bodily sensations and mental sensations) preceded their repetitive behaviors more frequently than did the OCD alone group. Of the subtypes of sensory
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phenomena, the TS + OCD group reported more feelings of incompleteness and more "just right" perceptions than the TS alone group.
3.3 Comorbidity in Tic Disorders The most common conditions comorbid with tic disorders are attentiondeficit hyperactivity disorder (ADHD) and OCD. In individuals w^ith TS, the average comorbidity for ADHD is approximately 50% (Spencer et al., 1998) and for OCD is approximately 30%, with rates of obsessive compulsive features ranging from 11% to 80%. (King et al., 1999). Although many studies have provided estimates of rates and descriptions of psychiatric disorders commonly comorbid with tic disorders, recent studies have focused on attempts to understand the effects of psychiatric comorbidity on the symptom presentation of tic disorders. For example, Pauls, Leckman, and Cohen (1994) studied 85 subjects with TS and their 338 first-degree relatives and found that compared to unaffected controls, subjects with TS had a higher frequency of major depressive disorder (40.7% versus 14.2%), obsessive-compulsive disorder (36% versus 1.8%), panic disorder (12.8% versus 2.7%), and simple phobia (18.6% versus 4.4%). Further analyses indicated that much of the major depression was secondary to OCD. Subjects with TS only (without comorbid psychiatric disorders) did not differ from unaffected controls in regard to rates of depression. Because of the clinical heterogeneity of tic disorders, the interpretation of epidemiological, genetic, and therapeutic studies of tic disorders has been difficult. Subjects with TS and variations of ADHD and OCD have often been included as one group in analyses. More recently researchers have been making efforts to delineate phenomenological and genetic differences between people with TS alone and those with TS + ADHD, TS + OCD, and TS + ADHD -f OCD, leading to some interesting findings concerning the degree of disability experienced by individuals with various combinations of these disorders. Recent findings suggest that it is the presence or absence of either ADHD or OCD that predisposes people with tic disorders to cognitive impairments. Children with TS alone have been found to be no different from controls on tasks measuring inhibitory function while those with TS and comorbid ADHD, OCD or both tend to perform less well than controls (Ozonoff, Strayer, McMahon, & Filloux, 1998). These results lend support to the notion that neuropsychological impairment varies as a function of
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comorbidity. As discussed in Chapter 3, social and emotional functioning in children with TS also appear to be related to comorbidity, with children with TS -f- ADHD having more behavioral difficulties and problems with social adaptation compared to children with TS alone and controls, with the TS alone group not being significantly different from the controls (Carter, et al., 2000). In fact Spencer et al (1998) found that disturbances of mood, disruptive behaviors, and most anxiety disorders were accounted for by comorbidity with ADHD and were not specific correlates of TS. Stephens and Sandor (1999) examined the effects of comorbid conditions on aggression and found that children with TS + ADHD and TS + OCD were at increased risk for developing aggressive behavior compared to children with TS alone. Children with TS alone did not differ from controls in aggression. Additionally, there was a high prevalence of separation anxiety in all groups (TS, TS + OCD, and TS + ADHD). Carter et al. (2000) found that when compared to children with TS alone and unaffected controls, children with TS + ADHD showed increased externalizing and internalizing behavior problems and poorer social adaptation. Children with TS alone were not significantly different from unaffected controls in externalizing behaviors and social adaptation but did have more internalizing symptoms. Interestingly, the severity of the children's tic symptoms was not associated with social, behavioral, or emotional functioning. In a study of 238 male subjects, Spencer et al. (1999) found evidence to suggest that ADHD and tic disorders are separate clinical entities with distinct courses. The onset of ADHD (by age 6 or 7) was earlier than the onset of tics (by age 10). There was remission of tics by age 20 for the majority (approximately 60%) but remission of ADHD was much less likely, with 80 to 90% of subjects continuing to have symptoms past age 20. The presence of a tic disorder did not add to functional impairment in children with ADHD. A growing body of research indicates that tic-related OCD (Leckman et al.,1995) is a disorder which is distinct from OCD without tics. It seems to be characterized by an earlier age of onset, greater frequency in males, and a family history of tics. In an epidemiological sample of 861 adolescents, 40 were identified as having OCD. Of those, the adolescents with co-morbid tics were more likely to have aggressive and sexual obsessions and intrusive images than those without co-morbid tics (Zohar et al., 1997). The need to touch, tap, or rub is found in 70 to 80% of those with tic-related OCD but only 5 to 25% of those with non-tic-related OCD (King et al., 1999). Other differences center on the antecedents to compulsive behaviors. Miguel et al. (1997) found that compulsions that are similar to complex motor tics are
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more frequent in people with tic-related OCD, leading to the suggestion that patients could be subtyped with OCD and/or TS based on the antecedent subjective experiences that precede their repetitive behaviors. In general, uncomfortable urges or sensations (sensory phenomena) usually preceded tics and compulsions in patients with TS whereas thoughts, ideas, or images (cognitive phenomena) and symptoms of autonomic arousal (e.g., dry mouth, sweating, palpitations, etc.) usually preceded compulsions in patients with OCD. The authors found that patients with TS had significantly fewer cognitive phenomena preceding their repetitive behavior while subjects with OCD reported significantly fewer sensory phenomena preceding their repetitive behaviors. Subjects with both OCD and TS reported that significantly more repetitive behaviors were preceded by both cognitive and sensory phenomena and also reported significantly more "just-right" phenomena (Leckman, Walker, Goodman, Pauls & Cohen, 1994) compared to the TS only and OCD only groups. Subjects with TS alone reported significantly less autonomic arousal preceding repetitive behaviors.
4. THEORIES OF CAUSATION In spite of great efforts over the years to identify the etiology of tic disorders, it remains unknown. In the nineteenth century, physicians reported a relationship between symptoms similar to Tourette syndrome and a prior illness with rheumatic fever. However, in the early twentieth century this view seems to have been abandoned in favor of a psychoanalytic interpretation of tics, with the recommended treatment being psychoanalysis. In the 1960's, the use of haloperidol, which lowers the action of dopamine, was found effective in treating tics, leading to the abandonment of psychoanalytic explanations and treatments (Kushner, 1999). Now, at the beginning of the twenty-first century, we look to the fields of genetics and neurobiology to identify the cause(s) of tic disorders.
4.1 Contributions of Genetic Variables Efforts to find the gene(s) responsible for TS have been underway for several years. The basis for the belief that tic disorders are transmitted genetically is the higher incidence of tic disorders and OCD in biological relatives of individuals with TS. Data from a number of family studies have
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been consistent, showing that for a family member of a person with TS, the risk is about 10-11% for TS and 15% for chronic tics. The risk for OCD alone among first degree relatives of a person with TS is 11-12%. Hence, for a first-degree relative of a person with TS, the risk of having TS, chronic tics, or OCD is approximately 35% (Pauls, Alsobrook, Gelernter & Leckman, 1999). Comings and Comings (1990 a-c) have proposed that a wide range of psychiatric disorders are variant expressions of a putative gene(s) for TS. However, Pauls et al. (1994), in their examination of subjects with TS and their relatives, found no evidence to support that hypothesis. There were no significant elevations in psychiatric disorders among the relatives who did not have tics, TS, or OCD when compared to unaffected controls. Pauls and Leckman (1986) performed a segregation analysis on a sample of 30 TS families and found that the autosomal dominant model best described the pattern of transmission of TS in those families. These results have been replicated in Eapen, Pauls, and Robertson (1993) with additional support provided in Carter, Pauls, Leckman, and Cohen (1994). The probability of finding a single gene for TS is now believed unlikely (Walkup et al., 1996). The results of the first systematic genome scan did not find any areas on the genome that reached statistical significance although two regions (4q and 8p) were suggestive of genetic linkage and four other regions showed promise. These results led the authors to conclude that there are likely several genes which have some moderate effect on the susceptibility of TS (Tourette Syndrome International Consortium for Genetics, 1999).
4.2 Contributions of Biological Variables Knowledge of the neuroanatomical circuitry of the brain has enhanced our understanding of the underlying mechanisms of these disorders. Because of the variety of behaviors associated with tic disorders, brain circuits which involve motor regions (the hyperkinesis of TS, hyperactivity of ADHD, compulsions and repetitive behaviors of OCD), higher cognitive processes (premonitory urges of TS and OCD), and inhibitory brain regions (disinhibition in TS, ADHD, and OCD) are likely candidates for involvement in these disorders. The cortico-striatal-thalamo-cortical (CSTC) circuits seem to subserve the diversity of behavior involved in these repetitive behavior disorders and indeed, substantial evidence for the involvement of the CSTC circuits in tic disorders exists (for a thorough
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review see Peterson, Leckman, Arnsten et ai., 1999). Heinz (1999) suggested that different areas of the circuitry have different effects on the behavioral outcome. For example, simple motor tics may be caused by a disinhibition of stereotypies encoded in the head of the caudate, while more complex compulsions are associated with a disinhibition in the frontocortical-striatal circuits. Activation of the orbitofrontal cortex seems to be essential for anxiety and disinhibition of subcortical stereotypies to occur. Lang (1991) hypothesized that the involuntary premonitory urge is possibly generated in the limbic system, while the intentionally produced response is mediated more within the cortex. He also speculated that as actions are repeated, they eventually become automatic through the participation of subcortical motor pathways not originally involved in their development. Jog, Kubota, Connolly, Hillegaart and Graybiel (1999) were able to provide support for this by demonstrating neuronal representation in the basal ganglia of freelymoving rats during habit acquisition and found an overall restructuring of neuronal response patterns as learning occurred and as habits were formed. There has been considerable focus on the basal ganglia's involvement because of the prominence of motoric features, difficulty with attention, and the learning that leads to habit formation and the performance of learned routine activities (Graybiel, 1998). Dopamine (DA) has been found to play a critical role in the control of the output of the basal ganglia. Evidence for dopamine involvement in TS comes primarily from observations of the effects of pharmacological agents. Those which increase DA functioning result in an increase in tics while those which block or decrease DA lead to an improvement in tic symptoms (Anderson, Leckman & Cohen, 1999). Likewise, norepinephrine is implicated in tic disorders. Noradrenergic agonists such as clonidine have been shown to reduce tic symptoms.
4.3 Contributions of Environmental Variables As the search continues for the genetic and physiological factors involved in the development of tic disorders, another focus has been to examine the role of environmental factors and their interaction with possible genetic vulnerability. The focus of this work has been on the effects of perinatal complications, infectious and autoimmune processes, stress, and stimulant exposure. (Peterson et al., 1999). For example, perinatal complications that produce hypoxia could result in damage to the basal ganglia causing a genetically vulnerable individual to develop more severe symptoms than they might have otherwise.
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The nineteenth century notion (Kushner, 1999) of the possible role of infectious processes in the etiology of Tourette syndrome has recently been revisited. Case reports of children with the sudden onset of symptoms who did not respond to standard treatment but did respond to cortico-steroid therapy suggested that some cases of TS might reflect an autoimmune disorder directed at the brain following infection, resulting from brain antineuronal antibodies that develop as a cross reaction to streptococcal bacteria antigens (Kurlan, 1998). This hypothesis has generated much clinical research in recent years leading to the characterization of Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal infections or PANDAS. Swedo et al. (1998) described the working diagnostic criteria for PANDAS: "1) the presence of OCD and/or tic disorder, 2) prepubertal symptom onset, 3) episodic course of symptom severity, 4) association with group A beta hemolytic streptococcal (GABHS) infection, and 5) association with neurological abnormalities (abnormal results on neurological exam; distractibility and impulsivity; motoric hyperactivity and adventitious movements, including choreiform movements or tics)." In a review of 50 cases, Swedo et al (1998) found that in all cases, symptom onset was acute and dramatic. The cases had a characteristic relapsing-remitting symptom pattern with significant psychiatric comorbidity occurring at the time of each exacerbation. Psychiatric symptoms included emotional lability, separation anxiety, nighttime fears and bedtime rituals, cognitive deficits, oppositional behaviors, and motoric hyperactivity. The working hypothesis has been that dysfunction in the basal ganglia could lead to a wide variety of neuropsychiatric symptoms. Support for this is the basal ganglia involvement in Sydenham's chorea and neuroimaging of basal ganglia dysfunction in Sydenham's chorea, OCD, and ADHD (Peterson et al., 2000). Additionally, similar antineuronal antibodies are found in both disorders. It has been theorized that children who have tics or obsessive compulsive symptoms are those for whom the "dose" of a presumed etiologic agent was not sufficient to cause frank chorea. Therefore, the proposed model of pathogenesis of PANDAS is: Pathogen + Susceptible Host > Immune Response > Sydenham's chorea or PANDAS (Swedo et al, 1998). There are arguments against the PANDAS hypothesis. For example, tics generally worsen with stress or illness and the exacerbations could be a more nonspecific response to stress. The presence of acute illness or antibiotics may impair the absorption of anti-tic medications. The antineuronal antibodies have not been found in a substantial number of the patients and in fact have been found in unaffected people. There has been no correlation
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found between the severity of symptoms and the presence of autoantibodies. Additionally, there has been no increase in the rate of rheumatic fever. Given this, Kurlan (1998) concluded that it is not accurate to refer to TS as a manifestation of PANDAS but rather to conceptualize post-infectious, immune-mediated mechanisms as possibly leading to tic and obsessivecompulsive symptoms, not the disorders per se. Although the PANDAS story is relatively new in the attempt to identify etiology of tic disorders, stress, whether aversive or pleasurable, is another environmental factor that is assumed to influence short-term exacerbations and severity of tics although there is little empirical data to confirm this. It is not uncommon for a child's tics to increase at holidays, vacations, school transitions, and other major events. Evidence that individuals with tic disorders may be more susceptible to the effects of stress comes from a study by Chappell et al. (1994). An especially stressful medical procedure (a lumbar puncture) was shown to produce greater elevations in plasma ACTH in TS than in control subjects, as well as an increase in urinary excretion of catecholamines in direct proportion to the severity of tic symptoms. These changes suggested the presence of an exaggerated stress reactivity that could result in higher tic symptom severity. The relationship between tics and stimulant medication has been clinically apparent for some time. Because many children who were prescribed stimulant medications for ADHD symptomotology subsequently developed tics, these agents were thought to cause tics. However, this could be an example of correlation being confused with causation in that children with ADHD symptoms are often placed on stimulant medications as they reach school-age, around 6 or 7. This is also the age at which tics often first appear. Because of this apparent relationship, conventional wisdom has been that a person with tics should not be given stimulant medication but recent evidence has not supported that approach. Given the superior efficacy of stimulants, particularly methylphenidate (MPH), to increase attention, focus, and decrease hyperactivity (Elia, Ambrosini, & Rapoport, 1999) and the high rate of co-morbidity with TS, this is an issue of critical importance to children affected with these disorders. Gadow, Sverd, Sprafkin, Nolan and Grossman (1999) followed 34 children with ADHD and tics for over two years while on MPH and concluded that the drug did not result in the exacerbation of either motor or vocal tics. Direct observation of motor tic frequency prior to initiation of MPH was almost identical to observations at the end of the two-year period. Castellanos et al. (1997) evaluated the effects of MPH and dextroamphetamine (DEX) on tic severity over a period of 1 - 3 years in boys with
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ADHD and TS. Relatively high doses of both medications produced significant increases in tic severity, which sustained with DEX, but attenuated with MPH. Adverse effects of stimulants were reversible in all cases. While some boys' tics continued to worsen on stimulants, the majority of subjects experienced improvement in ADHD symptoms without significant adverse effects on tics. Brocherding, Keysor, Rapoport, Elia, and Amass (1990) found that any adverse effects associated with MPH and DEX were generally subtle and transient. For children with ADHD and mild to moderate tics, MPH did not produce significantly more tics than placebo. Interestingly, there was no significant difference between the percentage of subjects who developed tics while on MPH compared to those on placebo. For children receiving MPH and placebo, 66% with pre-existing tics had improvement or no change, while 33% worsened (Law & Schachar, 1999). Sverd, Gadow, and Paolicelli (1989) found improvement in ADHD symptoms with no significant tic exacerbation. The benefit for ADHD symptoms may be worth the risk of possibly exacerbating symptoms (Erenberg, Cruse, & Rothner, 1985). It seems that the evidence for the contributions of genetic and neurobiological variables in the etiology of repetitive behaviors is clear, although exactly how these mechanisms result in specific clinical phenomena is less clear. Attention also has been placed on the role of environmental variables such as perinatal risks, stress, infection, and stimulant exposure in tic etiology. There has been relatively scant attention given, however, to the contributions of environmental variables as conceptualized by behavior analysts (Woods, Watson, Wolfe, Twohig & Friman, in press), specifically antecedent and consequent variables. Carr et al (1996) used functional analysis as a diagnostic tool for a tic disorder to determine if the vocal tics of an 11-year-old boy were maintained by operant variables. Tics occurred over a seven-week period across five different setting conditions, suggesting that the tic behaviors were neurologically based. Because tics were emitted at higher frequencies during attention (positive reinforcement) and escape (negative reinforcement) conditions, the authors concluded that the tic behaviors, like most other behaviors, were capable of being socially reinforced. It is also important to note that the condition of attention involved asking the subject to "try not to make that noise" every time he emitted a vocal tic. It is not uncommon for parents and teachers to use similar approaches in an effort to stop the child's tic behaviors. While most clinicians experienced with tic disorders discourage parents and teachers from doing that, this study provides support for that recommendation, in that the tics actually increased during this
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condition. This is consistent with the clinical observation that asking an individual to discuss his tics or otherwise drawing attention to them often results in a noticeable increase of the symptom being discussed. Woods et al. (in press) evaluated this effect of tic-related conversation on motor and vocal tics in two boys with TS. There were two conditions: one in which the therapist and subject talked about the tics and one in which tics were not discussed. Interestingly, talking about tics resulted in significant increases of vocal, but not motor, tics in both subjects. Based on clinical observation, it is also apparent that non-tic-related words, phrases, or topics can stimulate tics. In one unfortunate case, an adolescent's peers discovered that hearing the word "tree" would cause him to have a paroxysm of tics. In his classic description of the experience of having tics. Bliss (1980) described how tics could be elicited simply by intense concentration on a particular site. In this conceptualization, attention may actually serve as an antecedent stimulus rather than a reinforcing consequence. Affected children very often are completely unaware of their initial tic symptoms. It seems that for many children (but not all), it is only after they have been exhibiting tics for some period of time that they become aware of them. Additionally, there seems to be a lag from the time of onset of tic symptoms to the emergence of sensory phenomena (Scahill, Leckman & Marek, 1995), suggesting a developmental maturational process, conditioning, or some combination of factors. It can be speculated that a movement is triggered biologically which is followed by a feeling of relief, much as one feels after sneezing or scratching an itch, resulting in negative reinforcement for the movement. The nature of the movement is repetitive and the movements are continually reinforced by the feeling of relief, resulting in the movements becoming habits with a neuronal representation consistent with habitual behavior. At some point in this process, whether due to maturation or conditioning, the person begins to experience a premonitory urge. Woods and Miltenberger (1996) hypothesized that the premonitory urge is one of the factors contributing to the difficulty in controlling tics as it eventually develops stimulus control over the occurrence of the tic. Performing the repetitive behavior temporarily reduces the urge thereby negatively reinforcing the repetitive behavior. This may partially explain the promise offered by the application of exposure and response prevention techniques to repetitive behaviors (Bullen & Hemsley, 1983; Hoogduin, Verdellen, 8L Cath, 1997; Woods et al., 2000). The individual is exposed to the sensory urge without being allowed to perform the behavior. Over time with practice, the intensity of the urge decreases as the repetitive behavior is not performed, leading to extinction of the sensory urge. Unfortunately for
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some individuals, new sensations often develop (Bliss, 1980; Bullen & Hemsley, 1983). Manipulation of antecedent variables while preventing the reinforcement that occurs when the behavior is performed appears to be a promising method of treatment and one that deserves further study. The role of consequences in increasing or maintaining tic and other repetitive behaviors is less apparent and more research is clearly needed.
5. CONCLUSIONS Our understanding of tic disorders has increased significantly over the past twenty years through research that has focused on genetics, neurobiological substrates, environmental factors, and effective treatments. Through these empirical efforts as well as clinical experiences, the prevalence, natural course, and phenomenology of tic disorders have become clearer. High rates of comorbidity with ADHD and OCD have made it necessary to tease apart the biological and behavioral differences between individuals who have only tics (motor and/or vocal) and those who have these comorbidities, as well as the varying effects of these differences. These disorders provide a remarkable demonstration that behavior is the result of the on-going interaction of biology and environment and that simplistic approaches that consider only one without the other may prove insufficient to the understanding of tic disorders and to the development of effective treatments.
6. REFERENCES American Psychiatric Association (1994). Diagnostic and Statistical Manual of Mental Disorders, 4'^ £"f/._Washington, DC: American Psychiatric Association. Anderson, G.M., Leckman, J.F., & Cohen, D.J. (1999). Neurochemical and neuropeptide systems. In J.F. Leckman & D.J. Cohen (Eds.), Tourette's syndrome: Tics, obsessions, compulsions: Developmental psychopathology and clinical care (pp. 261 - 280). New York: John Wiley. Apter, A., Pauls, D., Bleich, A., Zohar, A., Kron, S., Ratzoni, G., Dycian, A., Kotler, M., Weizman, A., Gadot, N., & Cohen, D.J. (1993). An epidemiological study of Giiles de la Tourette's syndrome in Israel. Archives of General Psychiatry, 50, 734-738. Bliss, J. (1980). Sensory experiences of Giiles de la Tourette syndrome. Archives of General Psychiatry, 27, 1343-1347.
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Brocherding, B.G., Keysor, C.S., Rapoport, J.L., Elia, J., & Amass, J. (1990). Motor/vocal tics and compulsive behaviors on stimulant drugs: Is there a common vulnerability? Psychiatry Research, 33, 83-94. Bullen, J.G. & Hemsley, D.R. (1983). Sensory experience as a trigger in Gilles de la Tourette's syndrome. Journal of Behavior Therapy and Experimental Psychiatry, 14, 197201. Carr, J.E., Taylor, C.C, Wallander, R.J., Reiss, M.L. (1996). A functional-analytic approach to the diagnosis of a transient tic disorder. Journal of Behavior Therapy & Experimental Psychiatry, 27, 29\-291. Carter, A.S., O'Donnell, D.A., Schultz, R.T., Scahill, L., Leckman, J.F., & Pauls, D.L. (2000). Social and emotional adjustment in children affected with Gilles de la Tourette's syndrome: Associations with ADHD and family functioning. Journal of Child Psychology and Psychiatry, 41, 215-223. Carter, A.S., Pauls, D.L., Leckman, J.F., & Cohen, D.J. (1994). A prospective longitudinal study of Gilles de la Tourette's syndrome. Journal of the American Academy of Child & Adolescent Psychiatry. 33, 377-385. Castellanos, F.X. Giedd, J.N., Elia, J., Marsh. W.L., Ritchie, G.F., Hamburger, S.D., & Rapoport, J.L. (1997) Controlled stimulant treatment of ADHD and comorbid Tourette's syndrome: effects of stimulant and dose. Journal of the American Academy of Child and Adolescent Psychiatry, 36, 589-596. Chappell, P.B., Riddle, M., Anderson, G., Scahill, L., Hardin, M., Walker, D., Cohen, D., & Leckman, J.F. (1994). Enhanced stress responsivity of Tourette syndrome patients undergoing lumbar puncture. Biological Psychiatry, 36, 35-43. Comings, D.E. & Comings, B.G. (1990a). A controlled family history study of Tourette syndrome: L Attention deficit disorder, learning disorders, and school problems. Journal of Clinical Psychiatry, 51, 275-280. Comings, D.E. & Comings, B.G. (1990b). A controlled family history study of Tourette syndrome: II. Alcoholism, drug abuse and obesity. Journal of Clinical Psychiatry, 57,_281287. Comings, D.E. & Comings, B.G. (1990c). A controlled family history study of Tourette syndrome: III. Affective and other disorders. Journal of Clinical Psychiatry, 51, 288-291. Eapen, V., Pauls, D.L., & Robertson, M.M. (1993). Evidence for autosomal dominant transmission in Tourette's syndrome - United Kingdom Cohort Study. British Journal of Psychiatry, 162, 593-596. Elia, J., Ambrosinsi, P.J., & Rapoport, J.L. (1999). Treatment of attention-deficithyperactivity disorder. New England Journal of Medicine, 340. 780-788. Erenberg, G., Cruse, R.P., & Rothner, A.D. (1985). Gilles de la Tourette's syndrome: effects of stimulant drugs. Neurology, 35, 1346-1348. Gadow, K.D., Sverd, J., Sprafkin, J., Nolan, E.E., & Grossman S. (1999). Long-term methylphenidate therapy in children with comorbid attention-deficit hyperactivity disorder and chronic multiple tic disorder. Archives of General Psychiatry, 56, 330-336. Graybiel, A.M. (1998). The basal ganglia and chunking of action repertoires. Neurobiology of Learning & Memory, 70, 119-136. Heinz A. (1999). Neurobiological and anthropological aspects of compulsions and rituals. Pharmacopsychiatry, 32, 223-229.
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Hoogduin, K., Verdellen, C. & Cath, D. (1997). Exposure and response prevention in the treatment of Gilles de la Tourette's syndrome: Four case studies. Clinical Psychology and Psychotherapy, 4, 125-135. Jog, M.S., Kubota, Y., Connolly, C.I., Hillegaart, V. & Graybiel, A.M. (1999). Building neural representations of habits. Science, 286^ 1745-1749. King, R.A., Leckman, J.F., Scahill, L. & Cohen, D.J. (1999), Obsessive-compulsive disorder, anxiety, and depression. In J.F. Leckman & D.J. Cohen (Eds.), Tourette 's syndrome: Tics, obsessions, compulsions: Developmental psychopathology and clinical care (pp. 43 - 61). New York: John Wiley. Kurlan, R. (1989) Tourette's syndrome: Current concepts. Neurology. 39, 1625-1630. Kurlan, R. (1998). Tourette's syndrome and "PANDAS": Will the relation bear out? Neurology. 50,_\530'\534. Kurlan, R., Lichter, D., & Hewitt, D. (1989). Sensory tics in Tourette's syndrome. Neurology, 39,731-734. Kushner, H.I. (1999). A cursing brain? The histories of Tourette syndrome. Cambridge, MA: Harvard University Press. Lang, A. (1991). Patient perception of tics and other movement disorders. Neurology, 41, 223-228. Lapouse, R., & Monk, M.A. (1964). Behavior deviations in a representative sample of children. American Journal of Orthopsychiatry, i<_436-446. Law, S.F. & Schachar, R.J. (1999). Do typical clinical doses of methylphenidate cause tics in children treated for attention-deficit hyperactivity disorder? Journal of the American Academy of Child and Adolescent Psychiatry, 38, 944-951. Leckman, J.F., Grice, D.E., Barr, L.C., de Vries, A.L.C., Martin, C, Cohen, D.J., McDougle, C.J., Goodman, W.K., & Rasmussen, S.A. (1995). Tic-related vs. non-tic-related obsessive compulsive disorder./lAu/e(v, J, 208-215. Leckman, J.F., King, R.A., & Cohen, D.J. (1999). Tics and tic disorders. In J.F. Leckman & D.J. Cohen (Eds.), Tourette's syndrome: Tics, obsessions, compulsions: Developmental psychopathology and clinical care (pp. 23-41). New York: John Wiley. Leckman, J.F., Walker, D.E., & Cohen, D.J. (1993). Premonitory urges in Tourette's syndrome. American Journal of Psychiatry, 150, 98-10. Leckman, J.F., Walker, D.E., Goodman, W.K., Pauls, D.L., & Cohen DJ. (1994). "Just right" perceptions associated with compulsive behaviors in Tourette's syndrome. American Journal ofPsychiatry, 151, 675-680. Leckman, J.F., Zhang, H., Vitale, A., Lahnin, F., Lynch, K., Bondi, C, Kim, Y-S., & Peterson, B.S. (1998). Course of tic severity in Tourette's syndrome: The first two decades. Pediatrics, 102, 14-19. Mason, A., Banerjee, S., Eapen, B., Zeitlin, H., & Robertson, M.M. (1998). The prevalence of Tourette syndrome in a mainstream school population. Developmental Medicine & Child Neurology, 40, 292-296. Miguel, E.C., Baer, L., Coffey, B.J., Rauch, S.L., Savage, C.R.., O'Sullivan, R.L., Phillips, K., Moretti, C, Leckman, J.F., Jenike, M.A. (1997). Phenomenological differences appearing with repetitive behaviours in obsessive-compulsive disorder and Gilles de la Tourette's syndxome. British Journal ofPsychiatry, 170, 140-145.
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Miguel, E.G., Coffey, B.J., Baer, L., Savage, C.R., Rauch, S.L., & Jenike, M.A. (1995). Phenomenology of intentional repetitive behaviors in obsessive-compulsive disorder and Tourette's disorder. Journal of Clinical Psychiatry, 56, 246-255. Miguel, E.G., Rosario-Gampos, M.G., Prado, H.S., Valle. P Rauch, S.L., Goffey, B.J., Baer, L., Savage, G.R., O'Sullivan, R.L., Jenike, M.A., & Leckman, J.F. (2000). Sensory phenomena in obsessive-compulsive disorder and Tourette's disorder. Journal of Clinical Psychiatry, 61, 150-156. Ozonoff, S., Strayer, D.L., McMahon, W.M., & Filloux, F. (1998). Inhibitory deficits in Tourette syndrome: A function of comorbidity and symptom severity. Journal of Child Psychiatry, 39, 1109-1118. Pauls, D.L., Alsobrook, J.P., Gelernter, J., & Leckman, J.F. (1999). Genetic vulnerability. In J.F. Leckman & D.J. Gohen (Eds.), Tourette's syndrome: Tics, obsessions, compulsions: Developmental psychopathology and clinical care (pp. 194-211). New York: John Wiley. Pauls, D.L., & Leckman, J.F. (1986). The inheritance of Gilles de la Tourette syndrome and associated behaviors: Evidence for an autosomal dominant transmission. New England Journal of Medicine, 315, 993-997. Pauls, D.L., Leckman, J.F., & Gohen, D.J. (1994). Evidence against a relationship between Tourette's syndrome and anxiety, depression, panic, and phobic disorders. British Journal of Psychiatry, 164, 215-221. Peterson, B.S. & Leckman, J.F. (1998). The temporal dynamics of tics in Gilles de la Tourette syndrome. Biological Psychiatry, 44, 1337-1348. Peterson, B.S., Leckman, J.F., Arnsten, A., Anderson, G.M., Staib, L.H., Gore, J.G., Bronen, R.A., Malison, R., Scahill, L., & Gohen, D.J. (1999). Neuroanatomical circuitry. In J.F. Leckman & D.J. Gohen (Eds.), Tourette's syndrome: Tics, obsessions, compulsions: Developmental psychopathology and clinical care (pp. 230-259). New York: John Wiley. Peterson, B.S., Leckman, J.F., Lombroso, P., Zhang, H., Lynch, K., Garter, A.S., Pauls, D.L., ('. Gohen, D.J. (1999). Environmental risk and protective factors. In J.F. Leckman & D.J. C ^hen (Eds.), Tourette's syndrome: Tics, obsessions, compulsions: Developmental ps chopathology and clinical care (pp. 213 - 228). New York: John Wiley. Peterson, B.S., Leckman, J.F., Tucker, D., Scahill, L.S., Staib, L., Zhang, H., King, R., Gohen, D.J., Gore, J.G., & Lombroso, P.J. (2000). Antistreptococcal antibody titers and basal ganglia volumes in chronic tic, obsessive-compulsive, and attention deficit-hyperactivity disorders. Archives of General Psychiatry, 57, 364 - 372. Rutter, M., Tizard, J., & Whitmore, K. (1970). Education health and behavior. London: Hamilton. Scahill, L.D., Leckman, J.F. & Marek, K.L. (1995). Sensory phenomena in Tourette's syndrome. Behavioral Neurobiology of Movement Disorders, 65, 273-280. Spencer, T., Biederman, J., Goffey, B., Geller, D., Wilens, T., & Faraone, S. (1999) The 4year course of tic disorders in boys with attention-detlcit/hyperactivity disorder. Archives of General Psychiatry, 56, 842-847. Spencer, T., Biederman, J., Harding, M., O'Donnell, D., Wilens, T., Faraone, S., Goffey, B., & Geller, D. (1998). Disentangling the overlap between Tourette's disorder and ADHD. Journal of Child Psychology and Psychiatry, 39, 1037-1044.
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Stephens, R.J. & Sandor, P. (1999). Aggressive behaviour in children with Tourette syndrome and comorbid attention-deficit hyperactivity disorder and obsessive-compulsive disorder. Canadian Journal of Psychiatry, 44, 1036-1042. Sverd, J., Gadow, K.D., & Paolicelli, L.M. (1989). Methylphenidate treatment of attentiondeficit hyperactivity disorder in boys with Tourette's syndrome. Journal of the American Academy of Child & Adolescent Psychiatry, 28, 574-579. Swedo, S.E., Leonard, H.L., Garvey, M., Mittleman, B., Allen, A.J., Perlmutter, S., Dow, S., Zamkoff, J., Dubbert, B.K. & Lougee, L. (1998). Pediatric autoimmune neuropsychiatric disorders associated streptococcal infections: clinic description of the first 50 cases. American Journal of Psychiatry, 155, 264-271. The Tourette Syndrome International Consortium for Genetics. (1999). A complete genome screen in sib-pairs affected with Gilles de la Tourette syndrome. American Journal of Human Genetics, 65, 1428-1436. Towbin, K.E., Peterson, B.S., Cohen, D.J., Leckman, J.F. (1999). Differential diagnosis. In J.F. Leckman & D.J. Cohen (Eds.), Tourette's syndrome: Tics, obsessions, compulsions: Developmentalpsychopathology and clinical care (pp.118-138). New York: John Wiley. Walkup, J.T., LaBuda, M.C., Singer, H.S., Brown, J., Riddle, M.A., & Hurko, O. (1996). Family study and segregation analysis of Tourette syndrome: Evidence for a mixed model of inheritance. American Journal of Human Genetics, 59, 684-693. Woods, D.W. & Miltenberger, R.G. (1996). A review of habit reversal with childhood habit disorders. Education & Treatment of Children, 19, 197-214. Woods, D.W., Watson, T.S., Wolfe, E., Twohig, M.P., & Friman, P.C. (in press). Analyzing the influence of tic-related conversation on vocal and motor tics in children with Tourette's syndrome. Journal ofApplied Behavior Analysis. Zohar, A. H., Pauls, D.L., Ratzoni, G., Apter, A., Dycian, A., Binder, M., King, R., Leckman, J.F., Kron, S., & Cohen, D.J. (1997). Obsessive-compulsive disorder with and without tics in an epidemiological sample of adolescents. American Journal of Psychiatry, 154, 274276.
Chapter 5 Behavioral Interventions for Tic Disorders T. Steuart Watson Lorrie A. Howell Stephanie L. Smith Mississippi State University
1. INTRODUCTION The primary focus of this chapter is on describing the various interventions used to treat motor and vocal tics occurring alone or resulting from Tourette's syndrome. We begin by discussing pharmacological agents because they constitute the most commonly used treatment modality. We then focus on behavioral techniques, paying special attention to habit reversal as it has been shown to be moderately to highly effective for reducing tics. We also describe other behavioral techniques that have been less effective or that show promise but do not have the same history of empirical support as habit reversal. Finally, we briefly describe nonbehavioral treatments that have been used with tic disorders. In the remainder of this chapter, we describe conditions that are often comorbid with tic disorders and how these comorbid conditions may influence the treatment of tics. The following section on intervention is not meant to be an exhaustive review of the literature; rather we have tried to present studies that best represent the pharmacological or nonpharmacological treatments described in the literature.
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2. INTERVENTIONS After Gilles de la Tourette (1885) first described the pattern of motor and vocal tics that later became known as Tourette's syndrome, treatment consisted primarily of psychotherapy because tics were believed to be the manifestation of the psychodynamics of aggression, interpersonal difficulties, or neuroses (Azrin & Peterson, 1988a). Although pharmacological and behavioral treatments are currently the most common interventions for tics, treatment modalities prior to the 1980's typically included brief analytic outpatient family therapy, dream analysis, hypnosis, psychoanalysis and play therapy (Matthews, Leibowitz, & Matthews, 1992). Leung and Fagan (1989) noted that traditional psychotherapeutic techniques (e.g., family therapy and psychoanalysis) were often ineffective in treating tic disorders but were helpful in providing support for the family.
2.1
Pharmacological Treatment
Neuroleptics are the most commonly used pharmaceutical treatment for tic disorders (Bagheri, Kerbeshian, & Burd, 1999; Castellanos, 1998). Neuroleptics decrease the frequency and intensity of tic behaviors by blocking the uptake of the neurotransmitter dopamine (Moore, 1999). Because a complete discussion of the biochemical action of neuroleptics is far beyond the scope of this chapter, interested readers are referred to Blin (1999) and Moore for a more in-depth treatment of the topic. Neuroleptics are categorized into two types: typical (conventional) and atypical (novel; Bezchlibnyk-Butler & Jeffries, 2000; Castellanos, 1998). Typical neuroleptics include haloperidol (Haldol) and pimozide (Orap). Haloperidol is the most commonly prescribed pharmacological agent for TS and results in about 80% tic reduction when successful. Pimozide also yields a 70-80% reduction in tic frequency (Kurlan, 1997). About 70% of patients respond favorably to either haloperidol or pimozide (Leckman, Peterson, Pauls, & Cohen, 1997). Typical neuroleptics have a long list of possible side effects that range from annoying to dangerous. Some of the annoying side effects include dry mouth, constipation, weight gain, photosensitivity, impotence, restlessness, and muscle spasms. More serious side effects include acute extra-pyramidal symptoms (EPS), tardive dyskinesia (TD), neuroleptic malignant syndrome (NMS), and seizures (Arana, 2000).
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Atypical neuroleptics include olanzapine (Zyprexa), clozapine (Clozaril), and risperidone (Risperdal). This group of drugs is often as effective as typical neuroleptics but carries a lesser risk of EPS, TD, and NMS. Side effects attributed to atypical neuroleptics include insomnia, sedation, weight gain, headache, restlessness, constipation, incontinence, and hypersalivation (Blin, 1999). In open trials, risperidone has been found moderately successful in reducing tics (Bruun & Budman, 1996; Lombroso et al., 1995; Peterson & Cohen, 1998) with only 16% of patients experiencing EPS (Bruun & Budman, 1996). Olanzapine has been successfully used to decrease or eliminate vocal and simple motor tics and appears to be relatively safe for adolescents (Karam-Hage & Ghaziudden, 2000; Semerci, 2000). The relationship between olanzapine and tardive movement disorders is inconclusive, however, as Dunayevich and Strakowski (1999) reported that olanzapine induced tardive dyskinesia while Jaffe and Simpson (1999) reported that olanzapine reduced tardive dyskinesia in their patient. Clozapine has also been used to treat tic disorders and is the only neuroleptic that does not carry the risk of EPS. However, the use of clozapine dictates frequent blood testing due to the risk of agranulocytosis, a potentially fatal condition if not treated promptly (Miller & Pharm, 2000). Lastly, guanfacine is an antihypertensive that has been found to successfully treat tics. The use of guanfacine is less likely to cause hypotension and sedation than clonidine, but the drug does produce other side effects including transient sedation and headaches. Although more clinical trials are needed to clearly investigate the utility of the drug, openlabel trials have found guanfacine to decrease tics as well as symptoms associated with attention deficit hyperactivity disorder (Leckman et al., 1997). Although pharmacotherapy has a rather lengthy history of successfully reducing tics, nonpharmacological procedures have also been found effective. Among the more successful procedures are those derived from operant learning principles. The following section describes those procedures and the research on their effectiveness.
2.2 Behavioral Procedures Treatment for tics using operant based procedures began in earnest in the 1970s. Behavioral techniques include massed negative practice (Frederick, 1971; Knepler & Sewall, 1974; Yates, 1958), contingency management (Barrett, 1962; Varni, Boyd, & Cataldo, 1978), relaxation training (Miller,
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1970), self-monitoring (Billings, 1978), habit reversal and simplified habit reversal (Azrin & Nunn, 1973; Azrin, Nunn, & Frantz, 1980; Miltenberger, Fuqua, & McKinley, 1985; Woods, Miltenberger, & Lumley, 1996), prolonged exposure (Lamontagne, 1978), differential reinforcement (Doleys & Kurtz, 1974; Watson & Heindl, 1996; Watson & Sterling, 1998), and assertiveness training (Mansdorf, 1986). Hypnobehavioral methods, such as biofeedback and relaxation training (Culbertson, 1989; Young & Montano, 1988) have also been used in the treatment of tics. Although highly effective, behavioral approaches have been unpopular and overlooked by many professionals (Bruun & Bruun, 1994; Wodrich, 1998). Wodrich, for instance, suggests that contingency management programs not be used by school psychologists because tics are not operant behaviors. He asserted that persons with tics should seek medical treatment from an expert. Despite the assertion that only medical professionals are equipped to appropriately treat tics, several behavioral techniques have been found effective for managing tics without the use of adjunctive pharmacotherapy.
2.2.1
Massed Negative Practice.
Massed negative practice requires the individual to deliberately perform each tic movement accurately and effortfully for a specified amount of time (Yates, 1958). In theory, the procedure results in conditioned inhibition or conditioned fatigue, which then results in a diminution of tics. In a review of studies using massed negative practice, Azrin and Peterson (1988a) noted that in 10 of 18 studies, subjects showed a decrease in tic frequency upon completion of treatment. The remaining studies found no decrease in tic frequency, an increase in tic frequency, or even a re-emergence of a former tic. When compared to habit reversal, only 17% of subjects using massed practice were tic free as compared to 80% of the subjects using habit reversal (Azrin et al., 1980). Other studies have also failed to support the efficacy of massed practice as a treatment for tics (Canavan & Powell, 1981; Feldman & Werry, 1966; Nicassio, Liberman, Patterson, & Ramirez, 1972). Thus, there is insufficient evidence to support the use of massed practice as a singular treatment for tic disorders.
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2.2.2 Punishment Although punishment has been cited as an effective treatment for tics, it is often used in conjunction with other procedures making it difficult to determine the relative effects of punishment. For instance, Varni et al. (1978) used time-out in conjunction with self-monitoring and reinforcement to treat facial grimacing in a 7 year-old male client. Time-out was implemented contingent upon tics occurring more than 10 times in a 5minute interval. Reinforcement was provided in two ways: (1) the therapist provided praise for the absence of the tic (DRO) during the 5 minute interval and (2) a brief play period was provided contingent upon exhibiting the tic fewer than 10 times in the 5-minute interval. The treatment package reduced facial tics to zero and produced positive effects on untreated tics (i.e., rump protrusions, vocal tics, and shoulder shrugging). Given that self-monitoring and reinforcement were used in conjunction with punishment, it is impossible to determine the unique contributions of each in tic reduction. Although other studies have also shown that time out (Canavan & Powell, 1981; Lahey, McNees, & McNees, 1973) produces decreases in tic frequency, it remains unclear as to whether punishment is an effective strategy for promoting tic reduction.
2.2.3 Reinforcement Typically, when positive reinforcement procedures are implemented in the treatment of tics, they are in the form of differential reinforcement of other behaviors (DRO) or differential reinforcement of alternative behaviors (DRA). Doleys and Kurtz (1974) conducted a study in which differential reinforcement of alternative behaviors was used to decrease multiple tics in an adolescent male. Other behaviors, such as reading, conversation, and eye contact were reinforced. It was found that reinforcing these behaviors led to an increase in appropriate behavior and a reduction in tics. Watson and Sterling (1998) successfully treated a vocal tic (coughing) using differential reinforcement of other behavior. A functional analysis determined that the tic was reinforced with attention. Treatment included withholding attention when the tic occurred (attention extinction) and providing verbal attention contingent upon short periods of no coughing. After 4 days of treatment, the rate of tics decreased to zero. Zero rates of coughing were also found at follow-up observations. Other studies have obtained similar results in the reduction of tics using differential
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reinforcement (Pawlicki & Galotti, 1978; Varni et al., 1978; Wagaman, Miltenberger, & Williams, 1995). Despite generally favorable results using positive reinforcement and punishment in the treatment of tics, there are at least two significant limitations that preclude definitive conclusions regarding their effectiveness. First, most studies that have used reinforcement and punishment procedures were confounded because multiple treatment components were used. Rarely were the effectiveness of reinforcement and punishment evaluated independently of other procedures, thus making it difficult to distinguish whether tic reduction was due to reinforcement, punishment, or some other component (e.g., pharmacotherapy) in the treatment package (Azrin & Peterson, 1988a). Second, most studies cited in this section did not use rigorous experimental designs to evaluate treatment effectiveness. For instance, Pawlicki and Galotti (1978) used a case study format and Watson and Sterling (1998) used an AB design to evaluate treatment. A notable exception is the Wagaman et al. (1995) study that used an extended reversal design and generalization probes to evaluate the effects of DRO on throat clearing and coughing. Their study demonstrated that reductions in both tics occurred with the introduction of DRO. Clearly, more sophisticated single subject designs are needed to demonstrate a causal relationship between the use of either reinforcement or punishment and tic reduction.
2.2.4 Relaxation Training Relaxation training is a generic term used to describe any procedure that produces relaxation of the skeletal muscles. Operating on the hypothesis that tics result in tension- or arousal-reduction, relaxation training focuses on reducing tension before the occurrence of tics (Azrin & Nunn, 1973; Miltenberger, Fuqua, & Woods, 1998). For example, Evers and Van de Wetering (1994), treated two adult clients by first teaching them to become aware of tension in the muscles involved in the tics and then teaching them to relax those muscles. After relaxation training, one client reported elimination of his complex motor tic and the other client reported a marked decrease in his simple motor tic. Poth and Barnett (1983) evaluated the effects of relaxation and self-control techniques to treat a "shuddering" tic using a multiple baseline design across two settings. In conjunction with relaxation training, positive reinforcement was provided for not exhibiting shuddering during activities (differential reinforcement of other behavior).
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Results indicated that the tic decreased significantly when intervention was introduced into each of the two settings. Despite the sometimes favorable results reported when using relaxation for treating tics, there are a number of methodological problems associated with these and related studies. For instance, relaxation training was often combined with other procedures (O'Brien & Brennan, 1979; Poth & Barnett, 1983) or the data were limited to self-report (Evers & Van de Wetering, 1994; Frederick, 1971). However, a few studies have examined the effectiveness of relaxation training alone and used more than self-report data to assess treatment effects. Azrin and Peterson (1989), for example, conducted an experiment using a counterbalanced design in which relaxation training was compared to a competing response and the combination of both procedures. Results indicated that relaxation training resulted in a 54% reduction in tics, the competing response reduced tics by 97%, and the combination of the two reduced tics by 77%. The results suggested that the competing response was sufficient for reducing eye tics without inclusion of the relaxation component. Likewise, Bergin, Waranch, Brown, Carson, and Singer (1998) found that relaxation training did not produce significant reductions in tic severity in a group of persons with tics. Peterson and Azrin (1992) treated six subjects with Tourette's using selfmonitoring, relaxation training, and habit reversal in a counter-balanced design. Each treatment procedure was implemented singularly. Results from across the participants indicated that self-monitoring reduced tics by 44%, relaxation training by 32%, and habit reversal by 55%. An obvious limitation is that one cannot "remove" or reverse the effects of relaxation training. That is, once individuals are trained to relax, they do not cease using that skill merely because the researchers have implemented a phase change. Based on data from the studies cited above, it appears there is little empirical support for using relaxation training as a sole treatment for tics. These same studies, however, suggest relaxation training may be a useful adjunct to other nonpharmacological procedures.
2.2.5 Habit Reversal Originally developed by Azrin and Nunn (1973) for the treatment of nervous habits and tics, habit reversal has been shown to be a highly effective procedure for reducing tics (Azrin et al., 1980; Azrin & Peterson, 1988b; 1990; Finney, Rapoff, Hall, & Christophersen, 1983; Miltenberger et al., 1998). The original procedure, which we call "complete habit reversal,"
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actually consisted of four steps. The first step promotes awareness through four techniques: (1) response description, (2) response detection, (3) early warning, and (4) situation awareness training. The second step of habit reversal prompts a competing response. A competing response should be physically incompatible with the tic, be able to be maintained for a number of minutes, produce awareness by tensing opposing muscles, be socially covert, and strengthen muscles antagonistic to those used in the habit. Three motivation techniques make up the third step and include habit inconvenience review, social support, and public display. The last step in habit reversal is generalization. In this step, the individual uses a symbolic rehearsal technique (Woods & Miltenberger, 1996). Symbolic rehearsal involves imagining the tic beginning to appear in likely situations, stopping the tic, and then emitting the practiced competing response. It is important to remember that this entire sequence is performed imaginally. Azrin and Nunn (1973) found that the complete habit reversal procedure was effective for rapidly reducing nervous habits (e.g., thumb sucking, fingernail biting) and tics (e.g., shoulder jerking, head shaking) in twelve participants. Perhaps the most clinically significant finding from this study was that training in the habit reversal procedure only required one or two sessions. Despite the positive results, there were some methodological limitations including the use of self-report data, no control or treatment comparison group, a small sample size with restricted tics (i.e., four persons with only motor tics), and short duration of follow-up. In response to the methodological limitations of Azrin and Nunn (1973), Azrin et al. (1980) evaluated the effectiveness of complete habit reversal and negative practice in 22 participants with various motor tics randomly assigned to one of the two treatment procedures. The habit reversal procedure used in this study was the same as that used in Azrin and Nunn (1973). Negative practice involved replicating the tic in front of a mirror for 30 s periods for one hour each day until four days had passed since the last occurrence of the tic. Results indicated that, after only one habit reversal session, tics decreased by a mean of 84% as compared with a mean of 33% for the negative practice group. Long-term follow-ups (i.e., 18 months) showed a 97% mean reduction in tics for participants receiving habit reversal. Participants in the negative practice group were only followed for four weeks post-treatment and maintained about a 30% mean reduction in tics. In addition, 8 of the 10 habit reversal participants reported improvements in "secondary" tics that had not been targeted for intervention. Again, despite very favorable results for habit reversal, there were at least five rather significant limitations of the study. The first is that no individual
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participant data were reported; only mean percentage reductions in tics were reported for both treatment groups. Second, the negative practice group was not followed for the same length of time post-treatment as the habit reversal group. A third limitation was that only one baseline measurement was taken and was based on the participant's self-recording. A fourth limitation is that treatment data were collected via self-recording with no reliability or validity measures. And fifth, like Azrin and Nunn (1973), participants only evidenced motor tics. Using a concurrent multiple baseline across subjects and behaviors design, Finney et al. (1983) conducted the first well-controlled experimental evaluation of habit reversal with two adolescents who exhibited motor tics. The researchers video taped participants in their home to obtain objective data on treatment effectiveness in a natural setting and assessed maintenance of treatment effects at one-year post-treatment. Significant reductions were found in each tic for which habit reversal was implemented. Further, these treatment effects were maintained at 12-month follow-up. Social validity ratings by both participants' teachers and peers indicated noticeable differences in tics following treatment. One of the most interesting findings was that untreated tics increased as targeted tics decreased. Finney et al. attributes this to covariation; that is, when one behavior in a hierarchical response class decreases, another behavior that is lower in the response class emerges or increases in frequency. To determine the effectiveness of complete habit reversal on tics associated with Tourette's syndrome, Azrin and Peterson (1988b) treated motor and vocal tics in three adults with Tourette's syndrome. Immediate reductions were observed in each subject with more reductions in tics after several months of treatment. Eight months after beginning the use of habit reversal, all subjects showed a 93-99% decrease in tics in the clinic and a 6487% reduction in tics at home. Azrin and Peterson (1990) extended the Azrin and Peterson (1988b) study by using complete habit reversal to treat the motor and vocal tics of a larger number of participants with Tourette's syndrome and a more rigorous experimental design. Three of the. ten participants were receiving medication at the time of the study and all participants evidenced multiple motor and vocal tics. Participants were randomly assigned to either an immediate habit reversal treatment group or a waiting list control group that eventually received treatment. Within- and between-subjects measures indicated that habit reversal was effective for treating both motor and vocal tics with an average reduction in tic frequency of 93% across participants with a range of 66% to 100%. The authors noted that tic reductions were
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much slower in this study than previous studies, perhaps because of treating multiple versus single tics. This study was a methodological improvement over previous studies on complete habit reversal in that both within- and between-subjects comparisons were made, data were collected in clinic and home settings, and a larger sample was included. However, no follow-up data were gathered to assess durability of treatment effects. Recognizing that the complete habit reversal procedure, although effective for tics, is a lengthy, multi-component treatment, subsequent research explored the efficacy of using specific components of the habit reversal technique. These abbreviated forms of the complete habit reversal procedure are collectively referred to as Simplified Habit Reversal (SHR). Miltenberger et al. (1985) treated motor tics in nine subjects using a multiple baseline design across subjects. Five participants received SHR while four participants received the complete habit reversal procedure. The SHR procedure involved awareness training and competing response training. Results indicated SHR was sufficient for reducing motor tics and was equally effective as the complete habit reversal procedure. Earlier in this chapter, we cited results from the Peterson and Azrin (1992) study regarding the effectiveness of relaxation training for treating tics. The researchers also implemented a simplified habit reversal procedure which consisted of a rationale for the procedure and competing response training for the same six participants (4 adults and 2 children) with Tourette's syndrome. The results indicated that the greatest reduction in motor and vocal tics occurred in the simplified habit reversal phase. Tic reductions ranged from 16% to 95% with an average of 55% reduction across all participants. Woods et al. (1996) evaluated the effectiveness of four habit reversal components (i.e., awareness training, self-monitoring, social support, and competing response) in a mixed multiple baseline design across participants and behaviors. Four children with chronic motor tics participated in the study. Results indicated that three components (awareness training, social support, and competing response training) reduced tics (mouth and eye tics and a leg tic) in two of the four participants to near zero levels. Interestingly, one component, awareness training, successfully eliminated the neck tic in one child and awareness training and self-monitoring resulted in cessation of a hand tic in another child. Over the past twenty years, a substantial body of literature has accumulated that supports the effectiveness of habit reversal, simplified habit reversal, and in some instances simplified habit reversal in conjunction with other procedures for reducing tic behaviors (Woods & Miltenberger, 1995).
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In fact, as few as two components, awareness training and competing response training, may be sufficient for significantly reducing tics (Azrin & Peterson, 1989; Miltenberger et al., 1985; Ollendick, 1981). Similar research has shown that awareness training combined with self-monitoring (Billings, 1978; Ollendick, 1981; Wright & Miltenberger, 1987), awareness training alone and awareness training with social support and competing response training (Woods et al., 1996), are also highly effective for reducing motor tics. For a more thorough review of habit reversal, its variations, effectiveness for both habits and tics, and its limitations, interested readers are referred to Miltenberger et al. (1998).
2.2.6 Function Based Treatments Because of the effectiveness of habit reversal and pharmacological interventions, there is only a small body of literature addressing the function of tics and the use of function based treatments. Like many problem behaviors, tics may serve four functions: (1) social-negative reinforcement, (2) social-positive reinforcement, (3) automatic-positive reinforcement, and (4) automatic-negative reinforcement. An individual may emit a tic because exhibiting that behavior allows him or her to escape or avoid a stimulus they find aversive, such as an unpleasant social interaction, an academic task, or public speaking (social-negative). A tic may also result in social attention in the form of comments and/or reprimands delivered contingent upon the tic or in the attainment of a reinforcing object such as consumables or toys (socialpositive). Lastly, the behavior itself may result in sensory stimulation (automatic-positive) and/or the attenuation of unpleasant physiological stimulation (automatic-negative). For instance, tics may result in kinesthetic or olfactory stimulation or a reduction of muscular tension. Theoretically, when the function of the tic is known, the behavior may be decreased by selectively applying the consequences that maintain the tic to nontic behavior. For instance, if a tic results in social attention, caregivers ignore the tic (extinction) and attend only when the individual is emitting an alternative or other behavior (differential reinforcement). Eventually, the tic will diminish because the individual has learned to access the same class of reinforcers that maintain tics with more appropriate behaviors. Several recent studies have reported conflicting results associated with treating tics using function-based procedures. In one example, Watson and Sterling (1998) combined functional assessment and functional analysis to identify the environmental variables associated with a young child's vocal
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tic. The functional assessment indicated that the tic occurred only when the child was eating at the kitchen table. Results of a functional analysis indicated that the vocal tic was more frequent when followed by parental verbal attention than when followed by a tangible reinforcer. Therefore, verbal attention from the parents was used to reinforce tic free periods during mealtimes and snacks while tics were placed on extinction. After only four days, the child's vocal tic was eliminated. Other researchers, however, have been unsuccessful in developing function-based treatments. For example, Scotti, Schulman, and Hojnacki (1994) found that an adult male with profound mental retardation exhibited higher rates of vocal and motor tics when these behaviors resulted in the escape from a demand (negative reinforcement). Because of the covariance and similarity of identified function between the vocal and motor tic, only the vocal tic was targeted for intervention. The authors attempted to reduce the frequency of tics through escape extinction and social disapproval but were unsuccessful. Haloperidol was then administered due to the individual's unresponsiveness to the extinction/social disapproval intervention. After 23 weeks of using Haloperidol, the frequency of the vocal tic was still at baseline levels and unacceptable side effects including tongue thrusts, increased urinary incontinence, and lethargy had emerged. The authors speculated that their failure to ameliorate the tic might have been due to a strong organic basis for the tic and/or their failure to assess the arousal induction/arousal reduction function of the tic. Two recent studies examined the possible effects of environmental variables on tics but did not implement treatment. The results of these studies may, however, carry implications for developing treatments based on identifying antecedent and consequent variables. Carr, Taylor, Wallander, and Reiss (1996) manipulated the antecedents and consequences of a child's vocal tic and discovered that the frequency of the vocal tic increased most when the consequences yielded attention or when the child was allowed to escape a demand. However, upon further inspection of the data, the authors concluded that attention and demand were not the only functions of the tic, because it was also elevated in the alone, freeplay, and sensory stimulation conditions. The authors also noted downward trends in the tic within all five conditions, which lead them to believe the tic was naturally "waning" and thus controlled to a lesser extent by environmental variables. Thus, the inability to clearly identify the function of a tic would negatively impact designing a function-based treatment. A different approach to assessing the influence of environmental variables on tics was recently undertaken by Woods, Watson, Wolfe, Twohig, and
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Friman (in press). They examined the influence of tic-related conversation on the vocal and motor tics of two boys, ages 6 and 16, diagnosed with Tourette's. Using an ABAB withdrawal design, results indicated that vocal tics, but not motor tics, increased in the B phase (tic-related conversation). It was unclear from this one study how talk affected tics and why only vocal tics were so influenced, but perhaps the most important findings were the potentially evocative effects of verbal antecedent stimuli and the demonstration of a methodology for assessing these types of antecedents. Clearly, more research is needed to determine whether identifying the function of tics results in more effective treatments than those described previously. Given that other behavioral ly-based treatments have a rather solid empirical basis (e.g., complete or simplified habit reversal), the issue of treatment efficiency is also a concern. That is, is determining the function an efficient use of time when an effective treatment could have been applied during the time of assessment? Another question that remains unanswered by the extant research is whether tics have a clearly identifiable function and what role function plays in intervention outcome. For instance, in the two studies cited above that have taken a functional approach for assessing and treating tics, the only one that evidenced a positive outcome was the study in which the vocal tic had a clear social function. Results from the other study showed variable results and potential automatically reinforcing functions for the tic. Perhaps function-based treatments are more efficient and effective when there is a clear, discernable social function for the tic and less so when the tic has automatically reinforcing or multiple functions because socially mediated consequences are much easier to control than are sensory consequences.
2.2.7 Other Treatments Other interventions that have been used to reduce tics include prolonged exposure, hypnosis, biofeedback, and assertiveness training. Although the empirical evidence regarding these techniques is sparse, they seem promising. For instance, Lamontagne (1978) used prolonged exposure in the treatment of a vocal tic. The participant in this study emitted grunting sounds in all situations but particularly in stressful, anxiety-producing situations (i.e., social situations). Baseline data indicated that the tic occurred approximately 9 times per minute. Treatment consisted of an in-vivo flooding procedure in which the therapist and four students sat and stared at the participant over the course of 20 sessions. The first seven sessions
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consisted of three 10-minute intervals with S-minute rest intervals between the prolonged exposure. Sessions 8 to 15 consisted of prolonged exposure of 30 minutes while sessions 16 to 20 consisted of 60-minute intervals of prolonged exposure. There was no reinforcement component during the treatment. As treatment continued, anxiety was considerably less noticeable and the tic gradually decreased until it was finally eliminated. The author's explanation for the effectiveness of this unorthodox procedure was that flooding, without the opportunity for the subject to escape or avoid the anxiety provoking stimulus, eventually led to a decrease in social anxiety and the concomitant tics. A possible, alternative explanation is that the vocal tic was placed on an escape extinction schedule that ultimately led to its elimination. That is, because the vocal tic did not result in the escape or avoidance of an aversive social stimulus (i.e., the experimenters staring at the participant), the tic decreased in frequency. Biofeedback has also been utilized to reduce tics. Stanwood, Lanyon, and Wright (1984) taught an adult male to be aware of and decrease EMG activity to control his facial tic. While in the laboratory and at home, the client practiced keeping his EMG readings below a certain level (so that the tic physiologically could not occur) with the help of auditory tones from an EMG unit. At the termination of treatment, the individual's mean EMG level had decreased by 58% and tic behavior decreased by 70%. However, due to unreliable follow-up use of the EMG unit, both EMG levels and tics returned to approximately 85% of the pre-treatment level (Stanwood et al., 1984). The most obvious limitation of biofeedback procedures such as the one used in this study is that the EMG unit becomes the discriminative stimulus for decreasing EMG levels. That is, without the aid of the unit, the person with tics may find it difficult to control muscle tension. O'Connor, Gareau, and Borgeat (1995) also used biofeedback training to help nine adult subjects decrease their tics. The subjects were trained to discriminate EMG levels in tic-related muscles and select muscles not instrumental in the performance of the tic. Eight of the nine subjects established control over muscle contractions involved in their tic. The authors reported that six of the nine individuals evidenced a clinically significant decrease in tics (a decrease of over 40%). The authors speculated that the individual's ability to control the muscles involved in the tic while adopting slight responses in opposing muscles operated as a type of learned competing response similar to that seen in habit reversal. Mansdorf (1986) reported a successful reduction in the facial tic of a child with assertiveness training. The ten-year-old was taught to make positive self-statements, to make appropriate requests to peers, and to respond
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assertively to a particular child who harassed him. In addition, the child's mother was instructed to avoid reprimanding the child for his tics while praising him in situations when he was tic-free (differential reinforcement of other behavior). The results indicated almost zero-levels of tic behavior by the sixth week of treatment. A one year follow-up indicated a zero level of tics. Unfortunately, due to the procedures used in this study, it is difficult to separate the relative contributions of assert!veness training and DRO for reducing tics.
2.3 Surgical Treatment If all other therapies have failed, surgical treatment for tics is sometimes attempted (Kurlan, 1997; Leckman et al., 1997). Individuals who resort to surgery typically have severe tics and complications that have not responded to other treatments. Some surgical procedures that have been conducted include bimedial frontal leukotomy, bilateral anterior cingulotomy, bilateral limbic leukotomy, and coagulation of dorsomedian and intermediate lateral thalamic nuclei (Kurlan, 1997). Although surgery has been used as a treatment, it continues to be experimental and is only used as a final option.
3. COMORBIDITY BETWEEN TIC DISORDERS AND OTHER CHILDHOOD DISORDERS As discussed in Chapter 4, there is a high rate of comorbidity between tic disorders and other childhood disorders such as attention deficit hyperactivity disorder (ADHD), obsessive compulsive disorder (OCD), another anxiety disorder, or a specific learning disability. In fact, Houlihan, Hofschulte, and Patten (1993) suggest that treatment should not simply focus on the tic disorder but also on the covarying problem behaviors. In the sections that follow, we present the limited research that has been conducted on tics and the most common comorbid conditions, paying special attention to treatment implications for both disorders.
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3.1 Obsessive Compulsive Disorder (OCD) Because there is limited research on the success of cognitive behavioral therapy with comorbid tic disorder and OCD, the use of selective serotonin reuptake inhibitors (SSRI) is typically the first treatment attempted (Hawkridge, Stein, & Bouwer, 1996; King, Leonard, & March, 1998). Because some believe that OCD and tic disorder are behavioral manifestations of the same underlying disorder, some suggest that SSRIs or the use of both neuroleptics and SSRIs might be effective in the treatment of tics and OCD simultaneously (Hawkridge et al., 1996; Kurlan, Como, Deeley, McDermott, & McDermott, 1993). Hawkridge et al. found that in four of five patients, neuroleptics decreased tics somewhat but had no effect on the OCD symptoms. When neuroleptics and SSRIs were combined, improvements in OCD symptoms were observed. In only one case, however, were there further improvements in tics.
3.2 Attention Deficit Hyperactive Disorder Much of the research surrounding tic disorder and comorbid ADHD involves determining whether or not the use of stimulants to treat ADHD exacerbates tics. Findings have been mixed on the issue as some studies have found that stimulant medication increases tics 27% to 50% (Comings & Comings, 1987; Price, Leckman, Pauls, Cohen, & Kidd, 1986; Shapiro & Shapiro, 1981) whereas other studies have found that the use of stimulant medication, such as methylphenidate (MPH; Ritalin), decreased tic frequency and other ADHD related behaviors (Comings & Comings, 1987; Gadow, Sverd, Sprafkin, Nolan, & Grossman, 1999; Sverd, Gadow, & Paolicelli 1989). Singer and Brown (1995) found that neither desipramine nor clonidine worsened tic behavior. Guanfacine was used to treat 10 children with comorbid ADHD and TS. Results indicated reductions in ADHD-related behaviors as measured by the Continuous Performance Test (CPT) and the Conners Parent Rating Scale. Reductions were also noted in motor and vocal tics, as measured by the Yale Global Tic Severity Scale and the Tic Symptom Self Report (Chappell et al., 1995). Although specific stimulant medications may or may not exacerbate tics, dosage may play a significant role. In a recent study, Castellanos et al. (1997) found that medium doses of methylphenidate and high doses of dextroamphetamine worsened tic symptoms by 21% and 25%, respectively. These effects were not noted with either drug at lower doses. An equally
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interesting finding was that long-term administration of methylphenidate was not associated with increased tic severity whereas long-term administration of dextroamphetamine was. Most studies that have examined the relationship between psychostimulants and tics have involved either small numbers of participants and/or examined only the short-term effects of the medication. In response to these methodological shortcomings, Law and Schachar (1999) studied 90 children diagnosed with ADHD over the course of one year, 27 of whom were also diagnosed with mild to moderate tics. No participants were included who had either severe vocal or motor tics or Tourette's syndrome. Participants were randomly assigned to either an MPH or placebo group. Results indicated that, although MPH resulted in increased tic symptoms for 33% of the participants previously diagnosed with a tic disorder, 33% of participants receiving MPH experienced complete remission of tics. It should be also noted that tics were completely eliminated in 66% of participants in the placebo group. There was no difference between the MPH and control groups on the percentage of participants who developed tics. Based on the most recent data available, it appears that stimulant medication, particularly methylphenidate, does not cause or exacerbate tics for most participants. These effects are less clear for participants with severe tics or Tourette's syndrome. Some do seem to respond adversely to the medication, either by a worsening of tics or development of Tourette's-like symptoms. Dosage, type of medication, and length of time on medication may also play a role in worsening tics.
3.3 Learning Disabilities Learning disabilities (LD) are also quite common in children who have a tic disorder. Lerer (1987) stated that more than half of the children with Tourette's syndrome also have a specific learning disability, perceptualmotor problem, and/or abnormalities in psychoeducational testing. Students who exhibit tics have a tendency to experience more difficulty in reading and mathematics. When students have a tic disorder, their concentration is often impaired, thereby negatively impacting their academic performance. When children present with comorbid LD and a tic disorder, it is important to remember both the positive and adverse side effects of drugs typically used to treat TS and other tic disorders. Some of the most commonly prescribed medications for tics, including clonidine, pimozide, haloperidol, and
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fluphenazine have side effects with possible positive academic implications because they may improve attention, information processing, reaction time, alertness, and working memory (Bezchlibnyk-Butler & Jeffries, 2000). However, Singer, Schuerholz, and Denckia (1995) noted that cognitive impairment may result with even low doses of neuroleptics including problems with memory and academic performance. Additionally, medications prescribed to improve attention problems may aggravate tics (Lerer, 1987; Singer et al., 1995). From an academic intervention perspective, there is no reason to suspect or suggest that treatment of a comorbid learning disorder would be significantly different from treatment of a learning disability not accompanied by a tic disorder. For example, if a child with a tic also has a learning disability in reading, there are no data to suggest that an effective academic intervention would be less effective than for a child without a tic. Although pharmacotherapy has been studied extensively in the treatment of comorbid tics and ADHD and OCD, research appears to be limited in the study of comorbid learning disabilities and tics. One possible reason for this is that learning disabilities often occur with other disorders such as ADHD. In some cases, a tic disorder, ADHD, and OCD may occur comorbidly. The studies in which pharmacotherapy was used as treatment for comorbid OCD and tic disorder were not well-controlled (Hawkridge et al., 1996). Empirical evaluation of behavioral procedures during treatment of these comorbid disorders is also limited. Cognitive behavioral therapy has been used in the treatment of OCD and tic disorder but only in conjunction with pharmacotherapy (King et al., 1998). Clearly, more research is needed to evaluate the effectiveness of behavioral interventions with comorbid disorders.
4. SUMMARY In this chapter, we presented research on the pharmacological and behavioral approaches to the treatment of tic disorders and related conditions. It is important to mention that we have not provided exhaustive reviews of the literature on any of the topics. Instead, we attempted to a) provide a historical perspective by reviewing both current and dated studies and b) discuss those studies that provide the greatest representation for each topic. Interested readers may also consult some of the more recent references to obtain additional information on a specific topic.
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One observation that should come from reading this chapter is that behavioral methods, in particular complete and simplified habit reversal, and differential reinforcement have been shown to be effective for treating a variety of tics. These techniques have robust empirical support, although the results are a bit more equivocal for treating tics associated with Tourette's syndrome (Houlihan et al., 1993). Medications, particularly neuroleptics, are generally effective but potentially have serious side effects that must be considered. Given that both behavioral and pharmacological approaches have been shown to be effective in treating tics, it is unfortunate that few studies have examined the potency of combining the two. Although the functional approach to treatment is a well-established and effective methodology for a number of other problematic behaviors, the research regarding the functional treatment of tics is scant. Preliminary data from two recent studies provides equivocal evidence for the effectiveness of function-derived treatment. The data from these studies illustrates that the functional analysis methodology may not be sufficiently developed to accurately identify the variables maintaining tics. Continued work in this area is needed to develop an appropriate methodology for assessing the function of tics as well as possibly enhancing the effectiveness of behavioral treatments by matching interventions with the identified function. Although tics often occur in isolation, there are a number of other conditions that may be comorbid with tics including OCD, ADHD, anxiety disorder, and specific learning disabilities. Research on the effectiveness of using behavioral treatments for tics comorbid with another disorder is almost nonexistent. The research that does exist in this area is almost exclusively pharmacological. Given the relatively large percentage of children with tics and a comorbid disorder, it is surprising that there is so little behavioral research in this area. It is our hope that by reading this chapter, the clinician will have a better understanding of effective treatments for tic disorders. It is also our hope that those who conduct research in this area will fill some of the large gaps in the behavioral literature by addressing the concerns listed here. Although behavioral treatment of tics has made great strides in the past 25 years, there are some areas in which our knowledge has not advanced.
5. REFERENCES Arana, G. W. (2000). An overview of side effects caused by typical antipsychotics. Journal of Clinical Psychiatry, 61,5-\\.
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Lamontagne, Y. (1978). Case report and study: Treatment of a tic by prolonged exposure. Behavior Therapy, 9, 647-651. Law, S. F., & Schachar, R. J. (1999). Do typical clinical doses of methylphenidate cause tics in children treated for attention-deficit hyperactivity disorder? Journal of the American Academy of Child and Adolescent Psychiatry, 38, 944-953. Leckman, J. F., Peterson, B. S., Pauls, D. L., & Cohen, D. J. (1997). Tic disorders. Psychiatric Clinics of North America. 20, 839-861. Lerer, R. J. (1987). Motor tics, Tourette syndrome, and learning disabilities. Journal of Learning Disabilities, 20, 266-267. Leung, A. K., & Fagan, J. E. (1989). Tic disorders in childhood (and beyond). Postgraduate Medicine, 86, 251-252, 257-261. Lombroso, P. J., Scahill, L., King, R. A., Lynch, K. A., Leckman, .1. F., & Peterson, A. L. (1995). Risperidone treatment of children and adolescents with chronic tic disorders: A preliminary report. Journal of the American Academy of Child & Adolescent Psychiatry, 34, 1147-1152. Mansdorf, I. J. (1986). Assertiveness training in the treatment of a child's tics. Journal of Behavior Therapy & Experimental Psychiatry, 17, 29-32. Matthews, L. H., Leibowitz, J. M., & Matthews, J. R. (1992). Tics, habits, and mannerisms. In C. E. Walker and M. C. Roberts (Eds.), Handbook of clinical child psychology (2"^ ed., pp. 283-302). New York, NY: John Wiley & Sons. Miller, A. L. (1970). Treatment of a child with Gilles de la Tourette's syndrome using behavior modification techniques. Journal of Behavior Therapy & Experimental Psychiatry, 7,319-321. Miller, D. D., & Pharm, D. (2000). Review and management of clozapine side effects. Journal of Clinical Psychiatry, 61, 14-17. Miltenberger, R. G., Fuqua, R. W., & McKinley, T. (1985). Habit reversal with muscle tics: Replication and component analysis. Behavior Therapy, 16, 39-50. Miltenberger, R. G., Fuqua, R. W., & Woods, D. W. (1998). Applying behavior analysis to clinical problems: Review and analysis of habit reversal. Journal of Applied Behavior Analysis, 31, 447-469. Moore, N. A. (1999). Behavioural pharmacology of the new generation of antipsychotic agents. British Journal of Psychiatry, 174,5-\\. Nicassio, F. J., Liberman, R. P., Patterson, R. L., & Ramirez, E. (1972). The treatment of tics by negative practice. Journal of Behavior Therapy & Experimental Psychiatry, 3, 281-287. O'Brien, J. S., & Brennan, J. H. (1979). The elimination of severe long term facial tic and vocal distortion with multi-facet behavior therapy. Journal of Behavior Therapy & Experimental Psychiatry, 10, 257-261. O'Connor, K., Gareau, D., & Borgeat, F. (1995). Muscle control in chronic tic disorders. Biofeedback and Self-Regulation, 20, 111-122. Ollendick, T. H. (1981). Self-monitoring and self-administered overcorrection: The modification of nervous tics in children. Behavior Modification, 5, 75-84. Pawlicki, R. E., & Galotti, N. (1978). A tic-like behavior case study emanating from a selfdirected behavior modification course. Behavior Therapy. 9, 671-672. Peterson, A. L., & Azrin, N. H. (1992). An evaluation of behavioral treatments for Tourette syndrome. Behaviour Research Therapy, 30, 167-174.
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Peterson, B. S. & Cohen, D. J. (1998). The treatment of Tourette's syndrome: Multimodal, developmental intervention. Journal of Clinical Psychiatry, 59(Suppl J), 62-72. Poth, R., & Barnett, D. W. (1983). Reduction of behavioral tic with a preschooler using relaxation and self-control techniques across settings. School Psychology Review, 12, All476. Price, R. A., Leckman, J. F., Pauls, D. L., Cohen, D. J., & Kidd, K. K. (1986). Gilles de la Tourette syndrome. Tics and central nervous system stimulants in twins and non-twins. Neurology, 36, 232-237. Scotti, J. R., Schulman, D. E., & Hojnacki, R. M. (1994). Functional analysis and unsuccessful treatment of Tourette's syndrome in a man with profound mental retardation. Behavior Therapy, 25. 721-738. Semerci, Z. B. (2000). Olanzapine in Tourette's disorder. Journal of the American Academy of Child & Adolescent Psychiatry, 39, 140. Shapiro, A. K., & Shapiro, E. (1981). Do stimulants provoke, cause or exacerbate tics and Tourette's syndrome? Comprehensive Psychiatry, 22, 265-273. Singer, H. S., & Brown, J. (1995). The treatment of attention-deficit hyperactivity disorder in Tourette's syndrome: A double-blind placebo-controlled study with clonidine and desipramine. Pediatrics, 95, 74-81. Singer, H. S., Schuerholz, L. J., & Denckia, M B. (1995). Learning difficulties in children W\X\\To\xxQiiQsyx\dvor[\t. Journal of Child Neurology, 10 (Suppi 1), 58-61. Stanwood, J. K., Lanyon, R. I., & Wright, M. H. (1984). Treatment of severe hemifacial spasm with biofeedback. Behavior Modification, 8, 567-580. Sverd, J. Gadow, K. D., & Paolicelli, L. M. (1989). Methylphenidate treatment of attentiondeficit hyperactivity disorder in boys with Tourette's syndrome. Journal of the American Academy of Child & Adolescent Psychiatry, 28, 574-579. Varni, J. W., Boyd, E. F., & Cataldo, M. F. (1978). Self-monitoring, external reinforcement, and timeout procedures in the control of high rate tic behaviors in a hyperactive child. Journal of Behavior Therapy & Experimental Psychiatry, 9, 353-358. Wagaman, J. R., Miltenberger, R. G., & Williams, D. E. (1995). Treatment of a vocal tic by differential reinforcement. Journal of Behavior Therapy & Experimental Psychiatry, 26, 35-39. Watson, T. S., & Heindl, B. (1996). Behavioral case consultation with parents and teachers: An example using differential reinforcement to treat psychogenic cough. Journal of School Psychology, 34, 365-378. Watson, T. S., & Sterling, H. E. (1998). Brief functional analysis and treatment of a vocal tic. Journal ofApplied Behavior Analysis, 31, 471-474. Wodrich, D. L. (1998). Tourette's syndrome and tics: Relevance for school psychologists. Journal of School Psychology, 36, 281-294. Woods, D. W., & Miltenberger, R. G. (1996). A review of habit reversal with childhood habit dxsovdQVS. Education and Treatment of Children, 19, 197-214. Woods, D. W., & Miltenberger, R. G. (1995). Habit reversal: A review of applications and variations. Journal of Behavior Therapy & Experimental Psychiatry, 26, 123-131. Woods, D. W., Miltenberger, R. G., & Lumley, V. A. (1996). Sequential application of major habit-reversal components to treat motor tics in children. Journal of Applied Behavior Analysis, 29, 483-493.
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Woods, D. W., Watson, T. S., Wolfe, E., Twohig, M. P., Friman, P. C. (in press). Analyzing the influence of tic-related conversation on vocal and motor tics in children with Tourette's syndrome^ Journal ofApplied Behavior Analysis. Wright, K. M., & Miltenberger, R. G. (1987). Awareness training in the treatment of head and facial tics. Journal of Behavior Therapy and Experimental Psychiatry, 18, 269-274. Yates, A. J. (1958). The application of learning theory to the treatment of tics. Journal of Abnormal & Social Psychology, 56, 175-182. Young, M. H., & Montano, R. J. (1988). A new hypnobehavioral method for the treatment of children with Tourette^s disorder. American Journal of Clinical Hypnosis, 31, 97-106.
Chapter 6 Habit Reversal Treatment Manual for Tic Disorders Douglas W. Woods University of Wisconsin-Milwaukee
1. INTRODUCTION As discussed in Chapter 5, one of the most effective nonpharmacological treatments for tic disorders is habit reversal. This chapter provides a structured manual for the implementation of habit reversal with children, adolescents, and adults who are experiencing a transient tic disorder, chronic tic disorder, or Tourette's syndrome. The manual presented in this chapter is based on the habit reversal procedure originally created by Azrin and Nunn (1973; 1977). Consistent with previous research, users of the treatment protocol outlined below should expect relatively high success in treating persons with transient or chronic motor tic disorder (Miltenberger, Fuqua, & Woods, 1998; Peterson, & Azrin, 1993; Peterson, Campise, & Azrin, 1994). Though few studies exist evaluating the effectiveness of habit reversal as a treatment for vocal tic disorders or Tourette's syndrome, the current literature suggests the procedure outlined below may also be an effective intervention for such disorders (Peterson & Azrin, 1993). After describing the treatment, specific techniques and modifications to the protocol are discussed.
2.
HABIT REVERSAL TREATMENT PROTOCOL FOR TIC DISORDERS
The following protocol (see Appendix A for Therapist Checklist which summarizes the treatment) is designed to be implemented in 3 sessions for a person exhibiting a transient or chronic tic disorder (single tic presentation).
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As described below, persons with transient or chronic tic disorders (multiple tics) or Tourette's syndrome will require additional sessions.
2.1 Session 1 The goals of Session 1 are (1) to develop an understanding of the client's tics through an initial interview; (2) to utilize supplemental standardized assessments to determine the client's psychological functioning, social functioning, and tic severity; and (3) to establish a protocol for ongoing assessment. Due to the large number of components, the clinician should schedule 2-3 hours to complete Session 1. In addition, the patient should have a complete medical evaluation prior to the start of treatment. Only after a physician has examined the client and determined the tic is not secondary to another medical condition, should the clinician proceed with the protocol outlined in this chapter.
2.1.1
Interview
The purpose of the initial interview is to identify and operationally define the tic, identify possible environmental functions of the tic(s), and identify any comorbid conditions (e.g., Obsessive Compulsive Disorder or Attention Deficit/Hyperactivity Disorder) which may influence treatment implementation.
2.1.1.1 Identifying and Defining Tic(s) The interview should start by having the client list his or her tics. For child clients, it is useful to have the child's parent(s) in the room to assist in listing the tics. All tics should be listed, regardless of whether or not they are currently being exhibited. After identifying all tics, the client should estimate the daily frequency of each tic and rank order each tic from least to most distressing. The ranking serves two purposes. First, it allows the clinician to understand how the client views the tics' impact on his or her life. Second, it provides a treatment hierarchy which allows the clinician to plan for treatment in Session 2. After the tics have been identified, the clinician and client should create operational definitions for each tic currently being exhibited by the client.
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For example if a person has a neck shaking tic, the clinician and client may agree on the following definition, "A neck shaking tic is when your head departs from midline, moves left, and then returns to midline." Obtaining operational definitions for all current tics is useful for communicative purposes between client and clinician, and such definitions allow the clinician to accurately count tics during assessment. See Figure 6.1 for a form to assist in the identification, definition, and ranking of the tics.
TIC IDENTIFICATION, DEFINITION, and IMPAIRMENT RANKING
TIC
OPERATIONAL DEFINITION
CURRENT (V/N)
Figure 6.1. Identifying, Defining, and Ranking Tics
RANKING
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2 A A.2 Identifying Environmental Functions of Tics After identifying and defining the tic(s), it is necessary to determine if the tic(s) is being maintained via socially mediated environmental variables. Though there is little argument among behavior therapists that tics have an organic origin, it is understood that tics may come under operant control (Miltenberger et al., 1998). In this phase of the interview, the clinician should attempt to determine the environmental events that may control the expression of the tics. There are two primary reasons for collecting data on tic function. First, in some cases, habit reversal fails. Having information on tic function may provide data to explain the failure or may lead to modifications or supplements to the habit reversal procedure which may prevent treatment failure. Second, in still other cases, habit reversal may be unnecessary if the function of the behavior is very clear and a more appropriate treatment strategy may be utilized. In general, three primary functions may maintain tics; socially mediated positive reinforcement, socially mediated negative reinforcement, and automatic reinforcement. When tics are maintained by socially mediated positive reinforcement, attention is delivered to the person contingent on occurrences of the tic, which results in an increase in tic strength. For example, a study by Malatesta (1990) showed that a child with a tic was more likely to engage in the tic when around his father who was very critical of his son. In this case, the father may have made critical comments contingent on his son's tics, which resulted in an increase in tic frequency. To determine if a client's tic(s) is maintained by socially mediated positive reinforcement, clinicians should ask questions such as "Does the tic occur more around any one person? If yes, what does that person do after the client has the tic?" Although such a scenario is unlikely, if it appears the tic is entirely maintained by socially mediated positive reinforcement, the clinician should forego habit reversal in lieu of an alternative treatment focusing on eliminating the attention for the tic. However, if the tic does not appear to be entirely maintained by contingent attention, the clinician should proceed with the habit reversal protocol described below. When tics are maintained by socially-mediated negative reinforcement, something aversive is removed from the environment immediately after the tic. For example, suppose through our interview we discover that an adolescent exhibits tics only in history class. Upon further questioning, we discover that History requires much reading, and the child is failing the course. Whenever he engages in tics, the teacher dismisses him from the room to "take a break." In this case, it may be hypothesized that the removal
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from the aversive classroom setting negatively reinforces the tic. To assess for such possibilities the clinician should again ask about situations or persons around whom the tic is most likely to occur. If it appears the tic is localized to one or two situations, and if in those situations something aversive is often removed as a result of the tic, then socially mediated negative reinforcement can be hypothesized to play a role in maintaining the tic. Should this clearly be the case, interventions should focus on keeping the client in the aversive situation regardless of tic occurrence. If the tic(s) is not very clearly maintained by socially mediated negative reinforcement, the clinician should proceed with the protocol described below. The aforementioned use of the descriptor "socially mediated" may be considered strange by some readers. I use the term to distinguish between consequences provided by others and private consequences naturally produced by the tic. There are two primary private consequences of tics that may contribute to the maintenance of the behavior; automatic positive reinforcement and automatic negative reinforcement. Automatic positive reinforcement can come in many forms, but primarily involves a consequence produced by the tic which is added to the environment and results in a strengthening of the tic. For example a child with a whistling tic produces a certain sound when exhibiting the tic. Perhaps it is the case that the sound produced by the tic serves as a reinforcer for the tic. Although this is difficult to assess without conducting an extensive experimental analysis, the clinician should ask the client about the type of physical or emotional changes he or she experiences as an immediate consequence of the tic. Automatic negative reinforcement comes in two forms. Prior to engaging in a tic, persons with tic disorders often report a vague sensory experience similar to an itch that occurs in the area of the body associated with the tic. Upon completion of the tic, the uncomfortable sensation is alleviated. In a second form, the aversive experience is a specific physical discomfort which is alleviated by engaging in the tic. For example a person with a neck shaking tic may be experiencing muscle tightness in the neck which is temporarily relieved by the tic. To assess the possibility of automatic negative reinforcement, the clinician should ask the client if he or she is feeling anything uncomfortable prior to the tic, and if that sensation is relieved after the tic. Should a pattern emerge suggesting that the tic produces a reduction in an aversive private event, the clinician should assume the behavior is at least partially maintained by automatic negative reinforcement. Should the interview suggest an automatic reinforcement
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function or if no clear function emerges from the interview, the clinician should proceed with the protocol outlined below.
2.1.1.3 Identifying Comorbid Psychological Conditions The final segment of the interview involves determining the presence of other psychological conditions. As discussed in Chapter 4, tic disorders are often comorbid with other psychological conditions such as OCD, ADHD, other anxiety disorders, and depression. Although discussing general interview strategies is outside the scope of this book, the clinician should attempt to determine the presence of other psychiatric conditions and modify (as described later in this chapter) the habit reversal protocol as necessary. In summary, the interview will provide a good deal of vital information. However, there are supplementary standardized assessment strategies which may yield equally valuable information and should also be included during Session 1. These assessments include tic severity ratings and standardized assessments of psychological and social functioning. Each of the topics is described below.
2.1.2
Supplementary Standardized Assessment
Because the clinician often cannot observe the client outside of the session, he or she is required to rely on subjective reports or in-session observations to determine tic severity. The use of a standardized measure to determine tic severity is important for two primary reasons. First, more severe cases of tic disorders may require additional treatment time or adjunct pharmacotherapy. In such cases, standardized measures of tic severity will allow for meaningful communication between treatment providers. Second, a standardized pretreatment measure of tic severity will provide a baseline against which posttreatment measures can be compared to determine the effectiveness of intervention. Although this will be less important if an ongoing assessment plan is established and adhered to, the baseline severity rating can serve as a safety net for determining treatment outcome if the ongoing assessment plan fails. As discussed in Chapter 2, there are a variety of instruments to measure tic severity. The clinician should use such an instrument in Session 1. The second supplementary assessment deals with standardized assessments of social and psychological functioning. Although the initial
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interview provides a good deal of necessary information, standardized assessments have the advantage of being relatively easy and efficient to administer and include normative data for comparative purposes. The following areas should be addressed through the use of standardized assessments.
2.1.2.1 Intellectual Evaluation Intellectual assessment, though not necessary for diagnosing tic disorders, is useful in predicting the effectiveness of habit reversal. There is a growing body of research which suggests that habit reversal by itself is often ineffective for individuals with lower IQ's (Long, Miltenberger, Ellingson, & Ott, 1999; Woods, Fuqua, & Waltz, 1997). In such populations, habit reversal may be effective only in conjunction with additional contingency management plans. In general, if a client's IQ is under 70-80, one should consider modifying the treatment procedures by using the suggestions below in the section on Ancillary Procedures/Treatments.
2.1.2.2 Psychological Functioning During the initial interview, the clinician needs to assess the psychological functioning of the client. Though the interview may provide the information necessary to determine the presence of other psychiatric conditions, the clinician may also want to obtain additional information to confirm or rule out other diagnoses. If this is the case, disorder-specific standardized assessments (e.g.. Beck Depression Inventory [Beck, Ward, Mendelsohn, Mock, & Erbaugh, 1961]; Conners' Rating Scales [Conners, 1997]; or State Trait Anxiety Scale [Spielberger, Gorsuch, Lushene, Vagg, & Jacobs, 1983]) should be administered.
2.1.2.3 Social Functioning In addition to assessing the intellectual and psychological functioning of persons with tic disorders, the clinician should consider assessing the social problems the client may be experiencing. As discussed in Chapter 3, there is a growing body of research which suggests individuals with tic disorders are likely to experience social problems (Boudjouk, Woods, Miltenberger, &
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Long, 2000; Friedrich, Morgan, & Devine, 1996; Long, Woods, Miltenberger, Fuqua & Boudjouk, 1999; Woods, Fuqua, & Outman, 1999). The clinician should determine if an impairment in social functioning is present. This can be done with children using the Social Problems subscale of the Teacher Report Form (Achenbach, 1991b) and Child Behavior Checklist (Achenbach, 1991a). Likewise, for the child's perspective one might use the Assessment of Interpersonal Relations (Bracken, 1993) which allows the child to rate his or her perceptions of his or her social functioning within three different groups (parents, peers, teachers). Should the assessment support the presence of impaired social functioning, the clinician should refer below to the section marked Ancillary Procedures/Treatments.
2.L3
Establishing an Ongoing Assessment Plan
The final goal of the first session is to establish a plan for the client to collect baseline data throughout therapy. The collection of such data will allow the clinician to measure treatment effectiveness and to modify the intervention if acceptable improvement is not forthcoming. Before deciding on a data collection strategy, the clinician should ask a number of questions to determine the time of day and setting in which the data collection should take place. Ideally, data collection should occur at the time and place in which the tic(s) is most common. Table 6.1 offers a list of questions clinicians can ask to elicit this information.
Table 6.1. Questions for Determining Setting for Observation "Where are you most likely to do your tic?" "When are the tics worst for you?" "Is there a time of day that the tics get worse?" "What is happening when the tics are really bad?" "What one situation is guaranteed to make your tics happen?"
After the clinician has established the situation most likely to produce the tics, the clinician and the client need to determine an acceptable data collection strategy. Although various strategies are described in Chapter 2, some are more preferred than others as they provide information that is less reactive to observer bias. Table 6.2 presents a list of various assessment strategies. They are ordered from most preferred to least preferred.
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Table 6.2. List of Various Data Collection Strategies In-home videotaped observation In-home audiotaped observation (for vocal tics) Direct Observation by Significant Other Self-Monitoring Self-Report
After an assessment strategy is agreed upon, the specific steps (as outlined in Chapter 2) should be explained to the client. In addition, the client should understand that the assessment strategy is to continue throughout therapy. The clinician should provide a rationale for this such as, "We will need to keep collecting this information until the treatment is finished. We are doing this to track your progress and to decide if and when we need to modify the treatment." In addition to the assessment strategies listed in Table 6.2, the clinician should videotape record all treatment sessions (if possible) to capture insession occurrences of the tics. If the client refuses to participate in the ongoing assessment strategy, the clinician should explore the reasons for this resistance and help the client to work out an acceptable alternative. If the client still refuses, the clinician will need to rely on in-session recordings and baseline tic severity ratings to determine treatment efficacy. In summary, by the end of Session 1, the clinician should have completed the interview, a short assessment battery, and established a protocol for ongoing assessment. Between the first and second sessions, the assessments should be scored and the results interpreted. Depending on the results, habit reversal, to be implemented in Session 2, may be modified according to the suggestions described in the section marked "Ancillary Procedures/ Treatments."
2.2 Session 2 At the beginning of Session 2, the clinician should review the ongoing assessment data collected by the client during the previous week. The clinician should praise the client and ask the client if he or she discovered anything about the tic during the recording process. The primary objective of Session 2 is to implement habit reversal. As stated earlier, habit reversal consists of three phases including awareness training, competing response training, and social support. Each of these
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phases is described in detail below. For each phase the clinician should provide a rationale, describe the procedures used in the phase, model the client's task, have the client practice the procedures, and provide relevant feedback. Habit reversal is best implemented with one tic at a time. Thus, when introducing the procedure in Session 2, the clinician should refer to the rankordered list of problematic tics generated by the client in Session 1, and implement the intervention with the first tic on the list. Because that tic could be motor or vocal, the protocol written below uses examples of motor and vocal tics. However, the clinician should adapt the protocol to the needs of each individual client.
2.2.1
Awareness Training
The purpose of awareness training is to train the client to identify the occurrence of each tic and its preceding sensations. This needs to be accomplished because the intervention is essentially a self-management procedure. If the client is unable to state when he or she has a tic or feels one is about to occur, it is unlikely the procedure will be effective. Verbal awareness appears to be crucial to the effectiveness of habit reversal. The client should be given a rationale for doing awareness training prior to its induction. An example of a rationale follows. "The first thing we're going to do today is to teach you to know when you do the vocal tic. We are going to make you aware of when it is happening. Because the rest of the treatment depends on you knowing exactly when the vocal tic is about to happen or is happening, this is a very important part of the treatment. If you want to learn to manage something, you first have to know when it is happening. We'll do a number of exercises so that by the time you leave today, you will be very "aware" of your tic."
After providing the rationale, awareness training should be implemented. Awareness training involves describing the tic, describing the sensations and behaviors that precede the tic, acknowledging therapist simulations of the tic, and acknowledging the actual or simulated tic exhibited by the client. Each of these specific procedures is outlined below.
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2.2.1.1 Describing the tic The client should give a detailed description of what the tic sounds like and looks like. For example, if the client lifts his or her head and stretches his or her neck during a barking tic, the head lifting and neck stretching should be included in the description. If the client fails to describe a key feature of the tic, the therapist should point this out. Below is an example of how this procedure could be introduced. "One of the first things we need to do when we are becoming aware of something is to be able to describe it very well. What I'd like you to do is to describe, in as much detail as possible, what your tic sounds and looks like. Let's start with what it sounds like. Can you tell me what it sounds like? Is it loud or soft? Rapid or slow? Is it a word or is it more of a sound?" (Clinician allows client to answer) "I've also noticed that after each whistling sound you make, you immediately force air out through your nose. Do you recognize that you do that?" (This continues until the clinician feels the tic has been thoroughly described) "O.K., you did a nice job describing the tic itself Now let's spend a little bit of time talking about what other things your body is doing when the tic occurs. For example, what does your face look like when you do the tic? Do you grimace or squint? Do you stretch your neck?
Although there are no objective criteria to measure when the response description procedure has been implemented correctly, the clinician should feel that the person's tic and other behavior occurring at the time of the tic have been described in thorough detail. When this has been accomplished, the clinician and client should begin the next procedure, describing preceding sensations and behaviors. 2.2.1.2 Describing preceding sensations and behaviors The purpose of this procedure is to have the client recognize antecedent sensations and behaviors that may inform him or her the tic is about to occur. These sensations and behaviors should be called "warning signs," and the topic could be introduced as follows. "To be really aware of a problem, you not only need to be able to describe the problem, but you also need to be able to know when a problem Is about to happen.
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Tic Disorders, Trichotillomania, and Repetitive Behavior Disorders In the case of tics, your body is probably giving you warning signs before you tic to let you know it is about to happen. What I want you to do next is to really think about warning signs your body is giving you that let you know the tic is about to occur. These signs can either be things you do or things you feel."
Individuals who exhibit tics may do a number of precursory behaviors. For example, individuals who exhibit tics often describe an uncomfortable, vague itching sensation immediately prior to the tic. Likewise, the client may experience a tightness in the neck or a tickle in the throat. The "warning signs" do not necessarily need to be somatic. They can be as vague as "I get the feeling that I have to do it." Although the aforementioned examples all consisted of private events, warning signs do not necessarily have to be private. For example, if a person has an arm flapping tic, he or she may hold his or her elbows above his or head prior to the tic. In this case, the warning sign (elbows above the head) is public. Regardless of the warning sign, the clinician should work with the client to establish all warning signs the person may experience. If the client denies experiencing warning signs the clinician should point out a few of the examples listed above and ask the client if he or she engages in such behaviors or has such experiences. If the client still denies the presence of warning signs, the clinician should ask the client to try to be aware of them upon engaging in tics, and the clinician should proceed to the next awareness training procedure, acknowledging therapist simulated tics.
2.2.1.3 Acknowledging therapist simulated tics The purpose of this procedure is to help the client learn to acknowledge the tic. I have found it easier for clients to acknowledge another person's tic before acknowledging their own. In this procedure, the client is asked to verbally acknowledge occurrences of his or her own tic as simulated by the clinician. As the clinician will be mimicking the client's tic, the client needs to understand the purpose for this procedure. A rationale could be given as follows. "The next thing we're going to do is to begin the process of acknowledging your tic. We're going to start this by having you point out the tic in me. We're doing this because sometimes it's easier for people to get the hang of this when they're watching someone else instead of themselves. During the next few minutes of our discussion, I'll be acting out your tic. As soon as you see me do one, I want you to raise your right index finger and say 'There's one'."
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This process of awareness continues until the client has successfully acknowledged the presence of at least 4 of 5 therapist simulations. When the client correctly identifies the simulated tic, the therapist should provide praise for correct acknowledgement. When the clinician simulates a tic, but that simulation is not followed by the client's acknowledgement, the clinician should point out to the client that a tic had just occurred. The clinician should then remind the client of the instructions. After the client has successfully attained the 4 of 5 correct acknowledgements, the process should be repeated with the previously identified warning signs. Each warning sign need not be addressed separately. Rather, they can be interspersed with each other. The clinician could introduce this to the client as follows. Please note that therapist simulations of warning signs is only possible for the public warning signs. It would be impossible for the therapist to effectively simulate the private warning signs. "You did a great job identifying the tic. Now we're going to do the same thing with the warning signs you told me about. You also need to be able to point out warning signs because they will let you know the tic is coming. Again, during the next few minutes of our discussion, I'll be acting out your different warning signs. Do you remember what they were? As soon as you see me do any one of your warning signs, I want you to raise your right index finger and say There's one'."
Again, this process should continue until at least 4 of 5 warning signs are correctly identified. After the client has successfully acknowledged the presence of simulated vocal tics and warning signs, the client is ready to do the final step in awareness training; acknowledging self-tics.
2.2.1.4 Acknowledging Self-Tics This procedure is nearly identical to the previous procedure, but the client will be asked to point out occurrences of his or her own tic and warning signs. The most difficult part of this procedure is getting the client to exhibit the actual tic. Often, the client will not exhibit the tic during this procedure. In such cases, the clinician will need to find a situation that is likely to exacerbate the tic, leave the room and watch from behind a oneway mirror, or simply ask the client to simulate his or her own tic and warning signs. This latter solution is not ideal, but may often be necessary. The procedure can be introduced the client as follows.
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Tic Disorders, Trichotillomania, and Repetitive Behavior Disorders "You did an excellent job pointing out my *tic.' Now I want you to start pointing out your own tic. We're going to talk about different things for the next 10 minutes or so. Right after you do a tic, I want you to again raise your right index finger and say There's one.'
Again, the therapist should provide praise for correct acknowledgement and provide feedback and repeat the instructions when the client fails to acknowledge a tic that has occurred. This process should continue until the client has correctly acknowledged 4 of 5 tics. At this point, the clinician should ask the client to go through the procedure again, acknowledging his or her own warning signs rather than the tic. "You did a great job with identifying your tic. Now I'd like you to do the same thing with your warning signs. During the next few minutes of our discussion, I want you to point out your own warning signs. Do you remember what they were? As soon as you do any one of your warning signs, I want you to raise your right index finger and say 'There's one'."
Again, it is quite possible that the warning signs will not occur. If this is the case, the clinician will need to ask the client to simulate occurrences of the warning signs for acknowledgement. Upon completion of the awareness training procedures, the client is ready to begin competing response training. However, if awareness training appears to be exceptionally difficult or ineffective, the clinician should consider implementing an awareness enhancement procedure described below in the section marked "Ancillary Procedures/Treatments."
2.2.2
Competing Response Training
Competing response training is at the center of habit reversal. Within competing response training, there are three procedures. First, the client and clinician determine a competing response. Second, the clinician demonstrates the competing response and its correct implementation for the client. Finally, the client practices the correct implementation of the competing response while receiving feedback from the clinician.
2.2.2.1 Choosing the competing response The purpose of competing response training is to teach the client to engage in another behavior (called the competing response) for 1 minute
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contingent on the occurrence of the tic. Although it is unclear by what mechanism the competing response is effective, research suggests that it is of central importance in habit reversal (Woods, Miltenberger, & Lumley, 1996). Traditionally, the behavior chosen as the competing response is physically incompatible with the tic (Azrin & Nunn, 1973). A variety of different competing responses exist for the different topographies of tics. Although there is no "correct" competing response. Table 6.3 lists common competing responses for use with different motor tics. Choosing a physically incompatible competing response for vocal tics presents certain problems because vocal tics are so intimately tied to breathing. Although the ultimate competing response would be to stop breathing for one minute, this hardly seems appropriate. Rather, "controlled" breathing should be implemented for one minute as the first competing response. Controlled breathing involves inhaling through the nose and exhaling through the mouth. On the inhale, the client's abdomen should expand while their shoulders remain stationary. On the exhale, the client's abdomen should contract while their shoulders again remain stationary. Although controlled breathing is the ideal competing response for vocal tics, a number of other competing responses may be used if the client is uncomfortable with the breathing procedure. The alternative competing responses for vocal tics are listed in Table 6.4. It should be noted that not all competing responses listed in Table 6.4 are physically incompaitible with vocal tics. This is consistent with research by Woods et al. (1999) showing that physically similar and dissimilar competing responses may be equally effective in treating some repetitive behaviors.
Table 6.3. List of Alternative Competing Responses (Cam 1995) Motor Tic Arm Movements
Eye Blinking
Hand/wrist Movements
Competing Response Push hand down on thigh or abdomen and push elbow in towards hip Systematic, voluntary, soft blinking consciously main-tained at a rate of one blink per 3-5 seconds Push hands on arms of chairs, desk, leg, etc.
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Table 6.3., continued Motor Tic
Competing Response
Head Jerks/Movements
With head in centered position, contract the neck flexors so that the head tilts slightly downward and the neck appears shortened. If this is inadequate, push chin into sternum Place feet flat on floor and push downward. If standing, lock knees Clench jaw while pressing lips together Pull upper lips down slightly and press lips together Make fists and push elbows into side
Leg Movements
Mouth/facial Movements Nose movements Copropraxia
Table 6.4. List of Alternative Competing Responses for Vocal Tics Competing Response
Description
Lip pursing Tensing Neck Muscles Tensing Arms
Lips pressed firmly together Lower chin slightly and tense neck muscles Hold elbows firmly against side
When introducing the concept of the competing response, the clinician should be certain the chosen competing response will be acceptable to the client. Forcing the client to accept an unacceptable competing response may translate into poor treatment compliance. One way of introducing the competing response is as follows. "We're now at the main part of the treatment of the vocal tic. You're now going to learn something called the competing response. In here we'll call these your 'exercises.' The purpose of these exercises is to give you something to prevent your tic from happening. After you do this long enough, your body learns that the tic doesn't need to occur and the tic stops. For vocal tics, the best exercise to start with involves learning a new way to breath. I'll show you the new way of breathing in a few minutes. Basically, what will happen is that you will be expected to use
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this new type of breathing for 1 minute each time you have a vocal tic or notice one of the warning signs we talked about earlier." Clinician demonstrates competing response for client (described below) "Well, you've seen the competing response you'll be expected to do. Remember, you'll be asked to do this for 1 minute each time you do the tic or notice a warning sign. Before we continue, I want to make sure that you're comfortable with these exercises. I know the breathing exercise may not feel natural yet, and that is to be expected. You will feel more comfortable with time. What I'm more interested in is if you think it will work for you when you have to do it for real. Do you foresee any situations in which the breathing exercises won't be possible or would be embarrassing or uncomfortable?"
At this point, the clinician should listen carefully to the client's concerns. If there are none, the clinician should proceed. However if concerns are present, the client and clinician should try to develop strategies to manage the concerns and still use the controlled breathing as the competing response. If the problems with the chosen competing response are insurmountable, the clinician should choose another using the "Ancillary Procedures" section below, as a guide.
2.2.2.2 Therapist simulation of the competing response After the client and clinician have chosen the competing response, the clinician should model the competing response and its correct implementation for the client. As mentioned above, the client will be expected to use the competing response for one minute contingent on the occurrence of a tic or on one of the warning signs identified during awareness training. In describing the competing response to the client, the clinician could say something like this to the client as the clinician physically models the procedure. "Now I'd like to show you what your exercises will look like. I want you to inhale through your nose and exhale through your mouth. When you inhale, your shoulders should not move, but your abdomen should go out. When you exhale, your abdomen should go in, and your shoulders should still not move. Remember, inhale-abdomen goes out, exhale-abdomen goes in. These exercises will feel very strange at first because we are not used to breathing like this." "When we use these exercises to treat your vocal tic, I'm going to ask you to breathe like this for I minute each time you to the vocal tic or when you notice one
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Tic Disorders, Trichotillomania, and Repetitive Behavior Disorders of your warning signs we talked about earlier. As soon as you notice the tic or a warning sign, you need to stop doing the tic or warning sign and do your breathing for 1 minute. Let me show you what I mean.''
After this, the clinician should engage in a tic and then implement the competing response for one minute. This should be followed by the clinician demonstrating a warning sign followed by the competing response for one minute. This process should be continued until the client has seen the clinician use the competing response for one minute contingent on the tic and all of the clients warning signs. When this has been completed, the client is ready to learn the competing response and its correct implementation.
2.2.2.3 Teaching the client the competing response Usually the most difficult part of competing response training is getting the client to do the competing response correctly. One useful way to do this is to model the competing response for the client. The client should then practice the competing response in front of the clinician with the clinician providing feedback until the clinician is comfortable the client is doing the competing response correctly. When the client is correctly engaging in the competing response, he or she should be taught to implement it contingent on occurrences of the tic or upon occurrences of the warning signs. This can be introduced as follows. "Well, you've seen me do this, now it's your turn. We've already reviewed the exercises and you seem to be doing very well. Now, you need to use the exercises to reduce your motor tic. Remember the two times you are to use your exercises for one minute are (1) as soon as you start doing a tic, and (2) as soon as you notice one of your warning signs. As soon as either one of these two things happen, you should stop and do your exercises for 1 minute." "What I'd like you to do is to pretend to start a tic and then do the competing response for 1 minute. After that I'll ask you to go through each of your warning signs and show me how you would do the competing response."
The client should be asked to demonstrate the competing response after a simulated tic or warning signs. If the client does this correctly, the clinician should praise the client. However, if the clinician recognizes that the client is doing something incorrectly, he or she should provide corrective feedback to the client.
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After the client has correctly implemented the competing response contingent on the simulated tic and warning signs, the clinician should attempt to capture the correct implementation of the competing response after actual occurrences of the tic or warning signs, though if the tic is occurring at a low rate, continued practice with the simulated tics may be useful. Throughout the remainder of Session 2, the client should be praised for correctly implementing the competing response. However, when the client fails to use the competing response correctly, he or she should be prompted by the clinician to use the competing response and should be provided a description of why the competing response should be used. Ideally, the client should be able to correctly implement the competing response on 4 of 5 occasions. After this occurs, the client should be instructed to use the competing response in a contingent fashion at all times and in all situations until the treatment ends. This can be introduced to the client as follows. "You've done a wonderful job showing me that you know how to use your exercises. From now on I want you to use your exercises in the way we talked about. Whether you're in session with me or at work or school, you will always need to use your exercises until we are done with treatment. Throughout the rest of the session, I'll be watching to see if you're doing your exercises correctly. I'll remind you if you miss an opportunity to use your exercises, but I want you to try very hard to use them correctly."
2.2.3
Social Support Training
At this point, the client is ready to begin the third component of habit reversal; social support training. The purpose of this component is to recruit a person in the client's life to aid in the implementation of the procedures. Although some research suggests that the social support component may not be necessary (Woods et al., 1996), it adds relatively little time to the overall treatment implementation, and may be beneficial for some individuals. Thus, it is recommended that the component be included. Social support involves three procedures; (I) identifying the support person, (2) training the support person to praise/acknowledge correct implementation of the competing response exercises, and (3) training the support person to prompt the correct use of the competing response.
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2.2.3.1 Identifying the support person If the client is a child, the recruitment of a support person is relatively simple. In such cases, the support person should be a parent and if possible a sympathetic teacher. If the client is an adult; a spouse, adult child, relative, or close friend may serve as a useful support person. Ideally, the support person should come to the session, so it may be useful to discuss the idea of a support person in the first session so he or she is available for Session 2. After the awareness training and competing response training have been successfully implemented, the client should invite the support person into the therapy session and describe the basic idea of the intervention. In doing so, the clinician may say something such as... "Thanks for agreeing to help out Kylie (client) and I with treatment for Kylie's tic. Kylie and I have been working on making Kylie more aware of when she does her head shaking tic. We've also been working on doing exercises that help her stop the tic. This is what Kylie's exercises look like. She's been told to use these exercises for 1 minute each time she has a tic or when she has a feeling inside that others can't see."
At this point, the therapist should ask the client to demonstrate the competing response for the support person. When this has been done, the clinician should describe the responsibilities of the support person. This could be said as follows. "The support person has two main activities. One is to let Kylie know when she's doing a good job with her exercises and the other is to remind Kylie to do the exercises when she forgets about them. Let's start by talking about how to let Kylie know when she's doing well."
2.2.3.2 Praising correct implementation When the clinician gets to this point in treatment, he or she should tell the support person to acknowledge the correct implementation of the competing response by the client. The following instructions could be given. "(to support person).... When you see (the client) do the exercises, you should acknowledge his (or her) efforts by saying something like 'Nice job' or "Way to go', or provide praise in a way that is natural for you and (the client). Can you tell me what would be a natural way for you to provide praise?"
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The therapist should model this for the support person by asking the client to simulate a tic, begin the competing response and praising the client for doing it correctly. After the therapist has modeled the correct use of praise, the client should again be asked to simulate a tic and correctly implement the competing response. However, this time the support person will be asked to give feedback. The clinician should praise the support person for his or her efforts and offer corrective feedback if necessary.
2.2.3.3 Reminding the client After the support person has successfully learned to praise the correct use of the competing response, he or she should be instructed in how to prompt the client to use the competing response when the support person sees or hears the tic, but does not see the client use the competing response. This concept could be introduced as follows. "Right now, Kylie is supposed to start her exercise as soon as she starts doing a head shaking tic, but as with most people, she'll probably forget to use them every once in a while. When this happens, we need you to help her remember. If you see Kylie do a tic, but she doesn't do her exercises, then you need to remind her to do so."
As with training the support person to praise the correct use of the competing response, the clinician should again ask the client to simulate a tic. However, this time the client should be instructed not to use the competing response. When the client does the tic, but does not use the competing response, the clinician should model the behavior of prompting the client to use the competing response. The clinician should say something such as.... "Kylie, I just noticed that you had a tic, but didn't do your exercises. Don't forget to use your exercises."
After the therapist has modeled the correct way to prompt the use of the competing response, the support person should be asked to prompt the competing response after the client has simulated a tic, but not instigated the competing response. Again, the clinician should praise the support person for his or her efforts and offer corrective feedback if necessary. When these three treatment phases; awareness training, competing response training, and social support training have been implemented.
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Session 2 will be completed. This will also complete the habit reversal protocol for the first tic on the tic hierarchy established in Session 1. For tic disorders with single tic presentations, the third, and final session should be scheduled 2 weeks later. However, if the client presents with multiple tics, additional sessions should be scheduled in weekly increments for each tic over and above the initial tic (one session per additional tic). Although it would be helpful for the support person to attend each subsequent session, it is not essential. At the end of Session 2, the client should be reminded to continue data recording using the strategies outlined during Session 1.
2.3 Sessions 3-X For clients with a single tic, the purpose of Session 3 is to review the habit reversal procedures and to come up with solutions to various problems that may have arisen. For clients with multiple tics, the treatment should be reviewed for the first tic in the severity hierarchy, and the next tic on the list should be treated using the procedures outlined in Session 2. The clinician should collect and graph the data the client has collected since Session 2, praise the client for his or her efforts, and review with the client, his or her progress since the last session. The graphical representation of the data is often useful in demonstrating treatment progress and serves as a reminder to the client why data collection is important. At this point, the clinician should discuss any problems the client has had in implementing the procedure, and solutions to the problems should be found. When the data have been collected, progress discussed, and problems solved, the clinician and client should review the procedure. This will start by having the client state to the clinician the various "warning signs" identified in Session 2. The client should be able to state all warning signs. If he or she does not mention a warning sign identified in Session 2, the clinician should mention the sign to the client. After the warning signs are identified the clinician should ask the client to describe to the clinician how the competing response should be implemented. In reviewing this, the following questions should be asked. "During our last meeting we talked about when your breathing exercises should be done. When are you supposed to use your breathing exercises (contingent on the vocal tic or warning sign)?" "Can you describe the breathing exercises for me (breathe in -abdomen goes out, breathe out - abdomen goes in)?"
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"How long are you supposed to do the breathing exercises (1 min)."
If the client answers the question correctly, the clinician should praise the client. However, if the client answers incorrectly or seems confused, the clinician should review that component of habit reversal with the client. Next, the clinician should again have the client simulate the tic and ask him or her to demonstrate the correct use of the competing response. If this is done correctly, the clinician should praise the client. However, if this is done incorrectly, the clinician should review the Competing Response Training protocol covered during Session 2. The final part of the review is to address any concerns of the social support person. The support person should be asked if his or her participation is causing any hardship. Although unlikely, if concerns exist they should be addressed at this time. At this point, habit reversal is completed for the first tic on the hierarchy. If the tic has been eliminated or reduced to levels acceptable to the client and if the assessment during Day 1 did not show the presence of social difficulties or the presence of another psychiatric condition, treatment should be ended. If treatment is ended after Session 3, the clinician should still maintain periodic contact with the client to monitor treatment progress. If at a later time, the clinician or client believes the tic is increasing, the client should be brought in for booster sessions in which the Session 3-X protocol is reviewed. If the review of the data during Session 3 show the tic has not been eliminated or decreased to acceptable levels, the clinician should continue meeting with the client weekly using Sessions 2 and 3 protocols along with the possible modifications suggested below. If the client is in need of treatment for a separate problem, future appointments should be scheduled. Although addressing treatment concerns for all possible comorbid conditions is outside the scope of this book, a few suggestions for treating various other conditions are mentioned below.
3.
ANCILLARY PROCEDURES/TREATMENTS
A variety of situations and comorbid psychiatric conditions may complicate the implementation of habit reversal. Some of these issues are addressed below.
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3.1 Compliance Issues One of the primary concerns when implementing habit reversal is the client's failure to comply with the treatment requirements. Research has shown that one of the primary reasons habit reversal fails to produce behavior change is the failure of the client to implement the procedures (Carr, Bailey, Carr, & Coggin, 1996). Although the reasons for poor treatment compliance are numerous, they may include poor motivation, impaired intellectual ability, or the existence of competing activities. Regardless of the cause, two strategies may be of assistance for enhancing treatment compliance. The first involves the use of contingency management procedures. Specifically, reinforcement programs, managed by the social support person can be used to strengthen the correct use of the competing response. For example, children who use the competing response correctly may earn stars on a sticker chart which can then later be exchanged for tangible reinforcers. Likewise, adults may use a self-management or a reinforcement program, monitored by the social support person, to enhance compliance. For a thorough discussion on establishing supportive reinforcement programs, refer to Miltenberger (2001). The second compliance enhancement procedure involves remote detection of the tic and implementation of the competing response (Long et al., 1999; Rapp, Miltenberger, Galensky, Roberts, & Ellingson, 1999). One of the primary difficulties in implementing habit reversal is when the presence of the support person becomes the sole discriminative stimulus for engaging in the competing response. If this occurs, the client engages in the competing response only when in the presence of the support person. In such cases, habit reversal will only be moderately effective. To counteract this phenomena, remote detection procedures should be used in which the support person covertly observes the client when the client is unaware he or she is being observed. During this observation, if the support person views the client doing the competing response correctly, he or she should immediately enter the room and praise the client. Likewise if the support person observes the client fail to use the competing response correctly, the support person should enter the room and inform the client that it is now time to use the competing response. The remote detection procedure should continue until the covert observations consistently show the client is engaging in the procedure correctly. However, if the remote
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detection procedures seem to have little effect, the clinician may want to implement a contingency management program in conjunction with the remote detection procedures. In this case, tangible reinforcers would be joined with praise for correct implementation of the competing response, and a response cost procedure may be joined with a reminder to do the competing response when correct implementation of the competing response is not witnessed.
3.2 School Settings Although the aforementioned protocol was designed to be implemented in the home, the procedure should translate well into the school settings. The primary support person in the school will be the client's teacher. Although treatment should be easily implemented in the school, a few modifications may be necessary. The primary adjustment to the procedure is the fact that the child is in the room with other children who may or may not be privy to the child's problem. In such situations, it would be useful for the teacher and child to develop some type of inconspicuous "reminder" signal which will inform the child to engage in the competing response when he or she forgets to do so. For example, a teacher may tug at his or her own ear as a reminder for the child to use his or her competing response. Likewise, it would be useful to develop some strategy to communicate the child's successes with the home. Perhaps the teacher could keep track of the child's successful implementations of the competing response, and phone the child's parents daily with the information. The child's parents could then provide praise for the child's successes at school.
3.3 Awareness Enhancement & Self-Monitoring In some cases, habit reversal may fail due to the client's inability to achieve awareness of the target behavior (as may be the case with intellectually challenged clients). In such cases, the clinician should make special use of self-monitoring procedures. Incorporating self-monitoring into the aforementioned protocol can be done as follows. If the client is unable to achieve the in-session protocol, the clinician should assign a selfmonitoring assignment and continue to work on awareness in-session weekly until the client has achieved criterion level awareness. The self-monitoring
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assignment should consist of asking the client to record each time the tic occurs along with the antecedents of the behavior. Recording should occur for at least 1 hour per day.
3.4 Physically Compatible Competing Responses As mentioned earlier, the competing response should be physically incompatible with the target tic. However, the client must also agree to the competing response. If the clinician and client find it impossible to agree on a physically incompatible competing response, they may use a competing response that is physically compatible to the target response without losing treatment effectiveness (Woods, Murray et al., 1999). For example, a physically incompatible response for a head shaking tic would be to tighten the neck muscles. However, assume that the client does not like this competing response. In this case, the clinician may offer the physically compatible competing response of clenching the knees together for 1 minute contingent on the neck tic.
3.5 Treatment of Comorbid Conditions in Persons With Tic Disorders As discussed in Chapter 4 and mentioned in this chapter, persons with tic disorders are likely to have comorbid conditions. Although it is not within the scope of this book to provide detailed descriptions of such interventions, a few are worthy of note. Obsessive-compulsive disorder or obsessive compulsive behaviors are often seen in individuals with tic disorders. A common nonpharmacological treatment for OCD is exposure and response prevention in non-tic populations (Riggs & Foa, 1993). Although not well researched in the tic disordered population, preliminary evidence suggests that the same procedure can be used to treat comorbid obsessive behaviors in persons with Tourette's syndrome (Woods, Hook, Spellman, & Friman, 2000). ADHD is another common comorbid condition in persons with tic disorders. Unfortunately, common pharmacological treatments for ADHD (i.e., stimulants) are often not prescribed to individuals with tic disorders for fear that the stimulants will worsen the severity of the tic disorder (Chappell, Scahill, & Leckman, 1997). In such cases, the use of behavioral parent
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training strategies may be one of the few available strategies for the treatment of the ADHD symptom presentation. Examples of parent training protocols include Barkley (1987) and Forehand and MacMahon (1980). Should the client present with difficulties in social functioning, the clinician should consider further assessment to determine if the disruption is the result of a social skills deficit or is a direct result of the tic disorder. Should subsequent assessment show the functioning is a result of social skills deficit, the clinician should train the client in social skills. Gresham (1998) provides an example of a social skills training protocol. However, should the assessment show that the disruption of social functioning is not a result of a skills deficit in the client, but rather a peer group reaction to the tic disorder, two strategies could be employed. First, peer education could provide the education necessary to eliminate biases and stereotypes regarding the tic disorder. In fact, results of ongoing research in the author's lab is beginning to offer preliminary support the effectiveness of educational procedures in changing the attitudes toward persons with tic disorders. A variety of educational packages exist, though their effectiveness have not been evaluated. In addition to peer education, other strategies designed to increase positive peer interaction with the client can be utilized. Ervin, Miller, and Friman (1996) described a positive peer reporting procedure in which the target child's peers received reinforcement for making positive comments about the positive behavior of the target child. Results showed that the positive behavior and social status of the target child improved greatly as a result of the intervention. Subsequent studies have supported the generality of the procedure to children in group homes and family style homes (Bowers, McGinnis, Ervin & Friman, 1999; Bowers, Woods, Carlyon, & Friman, 2000; Jones, Young, & Friman, 2000).
3.6 Conclusions As you can see, habit reversal is a relatively uncomplicated procedure. However, like all clinical work it requires a good deal of flexibility in its implementation. Though success can never be guaranteed, research suggests that by following the procedures outlined in this protocol, the client should experience a significant reduction in symptoms that are maintained at rather lengthy follow-up periods.
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4. REFERENCES Achenbach, T. M. (1991a). Manual for the Child Behavior Checklist/4-J 8 and 1991 Profile. Burlington, VT: University of Vermont Department of Psychiatry. Achenbach, T. M. (1991b). Manual for the Teacher's Report Form and J 99 J Profile. Burlington, VT: University of Vermont Department of Psychiatry. Azrin, N. H., &Nunn, R. G. (1973). Habit reversal: A method of eliminating nervous habits and tics. Behaviour Research and Therapy, 11, 619-628. Azrin, N. H., &Nunn, R. G. (1977). Habit control in a day. New York: Simon and Schuster. Barkley, R. A. (1987). Defiant children: A clinician's manual for parent training. New York: Guilford Press. Beck, A. T., Ward, C. H., Mendelsohn, M., Mock, J., & Ergbaugh, J. (1961). An inventory for measuring depression. Archives of General Psychiatry, 4, 561-571. Boudjouk, P., Woods, D. W., Miltenberger, R. G., & Long, E. S. (2000). Negative peer evaluation in adolescents: The effects of tic disorders and trichotillomania. Child and Family Behavior Therapy, 22^ 17-28. Bowers, F. E., McGinnis, J. C, Ervin, R. A., & Friman, P. C. (1999). Merging research and practice: The example of positive peer reporting applied to social rejection. Education and Treatment of Children, 22, 218-226. Bowers, F. E., Woods, D. W., Carlyon, W. D., & Friman, P. C. (2000). Using positive peer reporting to improve the social interactions and acceptance of socially isolated adolescents in residential care: A systematic replication. Journal ofApplied Behavior Analysis, 33, 239-242. Bracken, B. A. (1993). Assessment of Interpersonal Relations: Examiner's Manual. Austin, TX: Pro-ed, Inc. Carr, J. E. (1995). Competing responses for the treatment of Tourette syndrome and tic disorders. Behaviour Research and Therapy, 33, 455-456. Carr, J. E., Bailey, J. S., Carr, C. A., & Coggin, A. M. (1996). The role of independent variable integrity in the behavioral management of Tourette syndrome. Behavioral Interventions, 77,35-45. Chappell, P. B., Scahill, L. D., & Leckman, J. F. (1997). Future therapies of Tourette syndrome. Neurologic Clinics of North America, 15, 429-450. Conners, C. K. (1997). Conners' Rating Scales-Revised. North Tonawanda, NY: MultiHealth Systems, Inc. Ervin, R. A., Miller, P. M., & Friman, P. C. (1996). Feed the hungry bee: Using positive peer reports to improve the social interactions and acceptance of a socially rejected girl in residential care. Journal ofApplied Behavior Analysis, 29, 251-253. Forehand, R. & MacMahon, R. (1980). Helping the noncompliant child: A clinician's guide to parent training. New York: The Guilford Press. Friedrich, S., Morgan, S. B., & Devine, C. (1996). Children's attitudes and behavioral intentions toward a peer with Tourette syndrome. Journal of Pediatric Psychology, 21, 307-319.
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Gresham, F. M. (1998). Social skills training with children: Social learning and applied behavioral analytic approaches. In T. S. Watson & F. M. Gresham (Eds.), Handbook of Child Behavior Therapy {pps. 475-491). New York: Plenum Press. Jones, K. M., Young, M. M., & Friman, P. C. (2000). Increasingpeer praise of socially rejected delinquent youth: Effects on cooperation and acceptance. School Psychology Quarterly 15, 30-39. Long, E. S., Miltenberger, R. G., Ellingson, S., & Ott, S. (1999). Augmenting simplified habit reversal in the treatment of oral-digital habits exhibited by individuals with mental retardation. Journal ofApplied Behavior Analysis, 52,353-365. Long,E. S., Woods, D. W., Miltenberger, R. G., Fuqua, R. W., & Boudjouk, P. (1999). Examining the social effects of habit behaviors exhibited by individuals with mental retardation. Journal of Developmental and Physical Disabilities, 11, 295-312. Malatesta, V. J. (1990). Behavioral case formulation: An experimental assessment study of transient tic disorder. Journal of Psychopathology and Behavioral Assessment, 12, 219232. Miltenberger, R. G. (2001). Behavior modification: Principles and procedures (2'"^ ed). Pacific Grove, CA: Wadsworth Publishing Company. Miltenberger, R. G., Fuqua, R. W., & Woods, D. W. (1998). Applying behavior analysis to clinical problems: Review and analysis of habit reversal. Journal of Applied Behavior Analysis, 31, 447-469. Peterson, A. L., &Azrin, N. H. (1993). Behavioral and pharmacological treatments for Tourette syndrome: A review. Applied and Preventive Psychology, 2, 231-242. Peterson, A. L., Campise, R. L., &Azrin, N. H. (1994). Behavioral and pharmacological treatments for tic and habit disorders: A review. Developmental and Behavioral Pediatrics, 75,430-441. Rapp,J. T., Miltenberger, R. G., Galensky, T. L, Roberts, J., & Ellingson, S. A. (1999). Brief functional analysis and simplified habit reversal treatment of thumb sucking in fraternal twin brothers. Child and Family Behavior Therapy, 21, 1-17. Riggs, D. S., &Foa, E. B. (1993). Obsessive Compulsive Disorder. In D. H. Barlow (Ed), Clinical Handbook of Psychological Disorders, 2'"^ ed_ (pps. 189-239). New York: The Guilford Press. Spielberger, C. D., Gorsuch, R. L., Lushene, R., Vagg, P. R., & Jacobs, G. A. (1983). State-trait anxiety inventory. Redwood City, CA: Consulting Psychologists Press, Inc. Woods, D. W., Fuqua, R. W., & Outman, R. C. (1999). Evaluating the social acceptability of individuals with habit disorders: The effects of frequency, topography, and gender manipulation. Journal of Psychopathology and Behavioral Assessment, 21, 1-18. Woods, D. W., Fuqua, R. W., & Waltz, T. J. (1997). Evaluation and elimination of an avoidance response in a child who stutters: A case study. Journal of Fluency Disorders, 22, 287-297. Woods, D. W., Hook, S. S., Spellman, D. F., & Friman, P. C. (2000). Case study: Exposure and response prevention for an adolescent with Tourette's syndrome and OCD. Journal of the American Academy of Child and Adolescent Psychiatry, 39, 904-907. Woods, D. W., Miltenberger, R. G., & Lumley, V. A. (1996). Sequential application of major habit reversal components to treat motor tics in children. Journal of Applied Behavior Analysis, 29, 483-493.
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Woods, D. W., Murray, L. K., Fuqua, R. W., Seif, T. A., Boyer, L. J., & Siah, A. (1999). 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, 30, 289-300.
5. APPENDIX A Habit Reversal Protocol-Tics Therapist Checklist Session 1 Interview Identify tics Rank order tics according to distress caused Operationally define tics
Determine possible function of tic Identify comorbid psychiatric conditions Supplemental assessments _ Tic Severity Ratings _ Intellectual Functioning _ Psychological Functioning _
Social Functioning
Establish an ongoing assessment plan
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Session 2 Awareness Training. Provide a rationale for awareness training. "The first thing we're going to do today is to teach you to know when you do the tic. We are going to make you aware of when it is happening. Because the rest of the treatment depends on you knowing exactly when the tic is about to happen or has happened, this is a very important part of the treatment. If you want to learn to manage something, you have to know when it is happening before you can do so. We'll do a number of exercises so that by the time you leave today, you will be very "aware" of your tic." Have client give a detailed description of tic and concurrent behaviors "One of the first things we need to do when we are becoming aware of something is to be able to describe it very well. What I'd like you to do is to describe, in as much detail as possible, what your tic looks like. Can you tell me what it looks (or sounds) like? What part of your body does it occur on? Is it rapid or slow? Clinician judges that client has described tic in thorough detail. Introduce discussion of "warning sign" description "To be really aware of a problem, you not only need to be able to describe the problem, but you also need to be able to know when a problem is about to happen. In the case of tics, your body is probably giving you warning signs before you tic to let you know it is about to happen. What I want you to do next is to really think about warning signs your body is giving you that let you know the tic is about to occur. These signs can either be things you do or things you feel."
Establish 1-3 different warning signs
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Disorders
Ask client to verbally acknowledge therapist simulated tics "The next thing we're going to do is to begin the process of acknowledging your tics. We're going to start this by having you point out tics in me. We're doing this because sometimes it's easier for people to get the hang of this when they're watching someone else instead of themselves. During the next few minutes of our discussion, I'll be acting out some of your tics. As soon as you see me do one, I want you to raise your right index finger and say 'There's one'." Continue until 4 of 5 therapist simulations have been acknowledged. Repeat process with previously identified warning signs. "You did a great job with identifying the tics. Now we're going to do the same thing with the warning signs you told me about. You also need to be able to point out warning signs because they will let you know the tic is coming. Again, during the next few minutes of our discussion, I'll be acting out your different warning signs. Do you remember what they were? As soon as you see me do any one of your warning signs, I want you to raise your right index finger and say There's one'." Continue until 4 of 5 therapist warning signs have been acknowledged. Acknowledge self-tics "You did an excellent job pointing out my 'tics.' Now I want you to start pointing out some of your own tics. We're going to talk about different things for the next 10 minutes or so. Right after you do a tic, I want you to again raise your right index finger and say 'There's one.' Continue until 4 pf 5 tics have been acknowledged. Repeat with warning sign acknowledgement "You did a great job with identifying your tics. Now I'd like you to do the same thing with your warning signs. During the next few minutes of our discussion, I want you to point out your own warning signs. Do you remember what they were? As soon as you do any one of your warning signs, I want you to raise your right index finger and say 'There's one'."
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Competing Response Training Choose a competing response "We're now at the main part of the treatment for the tic. You're now going to learn something called the competing response. In here we'll call these your 'exercises.' The purpose of these exercises is to give you something to prevent your tic from happening. After you do this long enough, your body learns that the tic doesn't need to occur and the tic stops. I'll show you the new behavior in a few minutes. Basically, what will happen is that you will be expected to do this new behavior for 1 minute each time you have a tic or notice one of your warning signs we talked about earlier." Clinician demonstrates competing response for client (described below) "Well, you've seen the competing response you'll be expected to do. Remember, you'll be asked to do this for 1 minute each time you do the tic or notice a warning sign. Before we continue, I want to make sure that you're comfortable with these exercises. I know that the behavior may not feel natural yet, and that is to be expected. You will feel more comfortable with time. What I'm more interested in is if you think it will work for you when you have to do it for real. Do you foresee any situations in which the new behavior won't be possible or would be embarrassing or uncomfortable?"
Address client concerns about competing response (incompatible CR) (compatible CR) Clinician models the competing response. "When we use these exercises to treat your tic, I'm going to ask you to do the behavior for 1 minute each time you to the tic or when you notice one of your warning signs we talked about earlier. As soon as you notice the tic or a warning sign, you need to stop doing the tic or warning sign and do your exercises for 1 minute. Let me show you what I mean."
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Teach the client the competing response "Well, you've seen me do this, now it's your turn. We've already reviewed the exercises and you seem to be doing that very well. Now, we need to use the exercises to reduce your tics. Remember the two times you are to use your exercises for one minute are 1) as soon as you do a tic, and 2) as soon as you notice one of your warning signs. As soon as either one of these two things happen, you should stop and begin your exercises." "What I'd like you to do is to pretend to do a tic and then do the competing response for 1 minute. After that I'll ask you to go through each of your warning signs and show me how you would do the competing response."
Continue for remainder of session with 4/5 correct criteria "You've done a wonderful job showing me that you know how to use your exercises. From now on I want you to use your exercises in the way we talked about. Whether you're in session with me or at work or school, you will always need to use your exercises until we are done with treatment. Throughout the rest of the session, I'll be watching to see if you're doing your exercises correctly. I'll remind you if you miss an opportunity to use your exercises, but I want you to try very hard to use them correctly."
Social Support Training _ Identify the support person "Thanks for agreeing to help out (client) and I with (client's) motor tics. (Client) and I have been working on making (client) more aware of when she does her tics. We've also been working on doing exercises that help her stop the tics. This is what (client's ) exercises looks like. She's been told to use these exercises for 1 minute each time she has a tic or when she has a feeling inside that others can't see." __ Ask client to demonstrate the competing response "The support person has two main purposes. One is to let (client) know when she's doing a good job with her exercises and the other is to remind (client) to do the exercises when she forgets about them. Let's start by talking about how to let (client) know when she's doing well."
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Acknowledge the correct implementation of the competing response. "(to support person).... When you see (the client) do the exercises, you should acknowledge his (or her) efforts by saying something like 'Nice job' or "Way to go.'" Therapist models acknowledgement of correct CR implementation Have support person role-play praise Prompt the client to use the exercises "Right now, (client) is supposed to start her exercises as soon as she does a tic, but as with most people, she'll probably forget to use her exercises every once in a while. When this happens, we need you to help her remember. If you see (client) do a tic, but she doesn't do her exercises, then you need to remind her to do so." _
Therapist models implementation
acknowledgement
of
correct
CR
"(Client), I just noticed that you had a tic, but didn't do your exercises. Don't forget to use your exercises." Have support person role-play prompting Schedule Session 3 for 2 weeks later Remind client of data collection strategies
Session 3 Review client progress Collect data collected since Session 2 Discuss any problems the client has had
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Tic Disorders, Trichotillomania, and Repetitive Behavior Disorders Have client state various "warning signs" Have client describe implementation of CR "During our last meeting we talked about when your exercises should be done. When are you supposed to use your exercises (contingent on tic or warning sign)?" "Can you describe the exercises for me?" "How long are you supposed to do the exercises (1 min)." If incorrect, review that component of HR Have client demonstrate the correct use of the competing response If incorrect, review Competing Response Training protocol Ask support person about any problems If the client presents with more than one tic, Session 2 should be conducted again with focus on the second tic in the hierarchy identified in Session 1. Schedule follow-up contact (1 month later) or schedule next session.
Chapter 7 Characteristics of Trichotillomania Raymond G. Miltenberger North Dakota State University
John T. Rapp University of Florida
Ethan S. Long Kennedy Krieger Institute
1. INTRODUCTION Trichotillomania is generally defined as chronic hair pulling resulting in noticeable hair loss. Affected areas commonly include the scalp, eyebrows, eyelashes, beards, and pubic hair. As a result of hair loss produced by hair pulling, individuals may experience distress or stigmatization and may avoid social situations. The term trichotillomania was first described as a medical syndrome by the French physician Hallopeau in 1889. In a subsequent report published in 1894, Hallopeau elaborated on his characterization of trichotillomania, noting the essential characteristics of the disorder as including a "type of insanity" that leads the patient to seek relief from pruritus (intense itching) by chronic, selfdirected hair pulling. Despite Hallopeau's initial description of trichotillomania over 100 years ago, a relatively small body of research existed about the condition until recently. In the past 30 years, the body of behavioral literature regarding trichotillomania has grown, along with our understanding and ability to demystify this "type of insanity." Behavioral research has lead to the development of empirically based treatments for hair pulling, along with an improved awareness of the course and nature of the disorder Hallopeau labeled trichotillomania. The purpose of this chapter is to discuss diagnostic issues, demographics, characteristics, and theories of causation frequently associated
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with trichotillomania.
2.
DSM-IV CLASSIFICATIONS AND DISTINCTIONS
Trichotillomania was first categorized in the revised third edition of the Diagnostic and Statistical Manual of Mental Disorders in (DSM-III-R; American Psychiatric Association, 1987). The current diagnostic criteria (American Psychiatric Association, 1994) require that an individual experience clinically significant distress or impairment in important areas of functioning due to the hair pulling. In addition, the individual needs to exhibit or experience (a) recurrent pulling of one's hair resulting in noticeable hair loss, (b) an increasing sense of tension immediately prior to pulling out the hair or when attempting to resist pulling, and (c) a sense of relief, pleasure, or gratification when pulling hair (APA, 1994). Last, to receive the diagnosis, the disturbance should not be better accounted for by another mental (e.g., schizophrenia) or medical disorder (e.g., preexisting inflammation of the skin; APA, 1994). With respect to differential diagnosis, additional medical conditions (e.g., alopecia areata, male-pattern baldness) must be ruled out before diagnosing trichotillomania when individuals report hair loss but deny hair pulling (APA, 1994). Furthermore, the diagnosis of trichotillomania should not be made if the hair pulling occurs in response to a delusion or hallucination (APA, 1994). In addition, hair pulling should be distinguished from stereotypic movement disorder and obsessive-compulsive disorder (APA, 1994). In the DSM-IV, trichotillomania is classified under the general category of Impulse-Control Disorders Not Elsewhere Classified (APA, 1994). This general category consists of other diverse disorders (e.g., intermittent explosive disorder, pathological gambling, pyromania) characterized by impulsiveness and associated with tension prior to the behavior and relief subsequent to the performance of the behavior. Some researchers suggest that trichotillomania might be best conceptualized as an anxiety disorder, particularly in a spectrum of obsessive-compulsive disorders (Swedo, 1993; Swedo & Leonard, 1992). Other researchers have referred to trichotillomania as a "nervous habit" (e.g., Azrin & Nunn, 1973). These characterizations of trichotillomania share the assumption that a sense of anxiety or tension occurs prior to hair pulling, and relief occurs following performance of the behavior. Categorizations based on a tension reduction assumption infer that hair pulling is maintained through a process of negative reinforcement (Hansen, Tishelman, Hawkins, & Doepke, 1990; Woods, Miltenberger, & Flach, 1996).
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It is interesting that the diagnostic criteria for trichotillomania include a description of the behavior as well as the presumed function of the behavior based on the client's subjective experiences (tension prior to pulling with relief or gratification following pulling). Disorders in the DSM are typically defined according to the reported symptoms or behaviors rather than the function of the behaviors. As a result of the inclusion of the functional criteria, there can be some confusion in the diagnosis of trichotillomania. For example, there may be ambiguity in diagnosing trichotillomania when hair pulling with hair loss occurs without the subjective experience of tension and tension reduction or when individuals (especially children or individuals with mental retardation) are incapable of reporting such subjective experiences as tension or tension reduction.
3. DEMOGRAPHICS 3.1 Prevalence Although there is a general consensus that trichotillomania is rare, some have suggested that the disorder is relatively more common than once thought (e.g., Christenson & Mansueto, 1999; Swedo, 1993). Most investigations have examined the prevalence of trichotillomania in college-aged students. For example, Christenson, Pyle, and Mitchell (1991) surveyed 2524 college students and found that 0.6% of both the male and female students would have met the DSM criteria for trichotillomania at some point in there lives. Furthermore, the authors found that if the criteria regarding the urge to pull and subsequent tension reduction were excluded, prevalence estimates increased to 3.4% for females and 1.5% for males. In additional studies, Rothbaum, Shaw, Morris, and Ninan (1993) surveyed 490 college students and found that 10% of the students pulled their hair on a regular basis. However, only 2% pulled their hair with noticeable hair loss and only 2% reported distress due to hair pulling. Likewise, Woods et al. (1996) surveyed 246 college students and found that 10.5% endorsed hair pulling as a habit, but only 3.2% engaged in the behavior five or more times per day. Stanley, Borden, Bell, and Wagner (1994) surveyed 288 college students and found that 15.5% of the subjects reported pulling out their hair in the previous year. However, none of the subjects reported noticeable hair loss. In a second survey of 165 college students conducted by Stanley, Borden, Mouten, and Breckenridge (1995), 13.3% of the participants reported hair pulling that did
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not result in noticeable hair loss and distress. Stanley and colleagues (1995) referred to this form of hair pulling as "nonclinical hair pulling" and suggested that hair pulling may occur on a continuum, ranging from relatively benign forms of hair pulling to more severe forms that result in noticeable hair loss and distress. Surveys examining the prevalence of trichotillomania and hair pulling in populations besides college students are even more limited. Currently, no large epidemiological studies of younger children have been conducted, although it has been estimated that the percentage of children who hair pull is higher than that of the general population (Mehegran, 1970). However, Reeve (1999) suggested that hair pulling episodes exhibited by children are often transient and benign, thus not frequently referred for treatment. Few studies have examined hair pulling exhibited by individuals with mental retardation and other developmental disabilities. Long, Miltenberger, and Rapp (1998) surveyed direct care staff regarding 259 individual with disabilities and found that 5% of the clients were reported to engage in hair pulling resulting in noticeable hair loss. Dimoski and Duricic (1991) (cited in Christenson & Mansueto, 1999) found that 3.1% of 457 mentally retarded children and adolescents they evaluated had trichotillomania. In general, the variations between studies, along with inherent methodological limitations that accompany survey research, limit any conclusive prevalence estimates regarding the general population and specific sub-populations at this time (Christenson, & Mansueto, 1999).
3.2 Gender Differences With regard to gender differences in individuals diagnosed with trichotillomania, many clinical sample studies support the finding that trichotillomania primarily affects female adults. For example, Muller (1987) noted that 73.4% of 319 individuals diagnosed with trichotillomania seen for dermatological services were female. Likewise, Christenson, Mackenzie, and Mitchell (1991) found that 93.3% of a sample of 60 chronic hair pullers was female. Cohen et al. (1995) found similar results when they surveyed 772 individuals who responded to a nationally distributed magazine article on trichotillomania. Of the 131 respondents, 93% of the total sample was female. Although Christenson, Mackenzie, and Mitchell (1994) found no lifetime gender differences in a nonclinic sample of 2524 college students with regard to hair pulling resulting in hair loss, a higher percentage of females met full DSM trichotillomania criteria. Although it appears that more women than men
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experience trichotillomania, some researchers suggest that gender differences may reflect differences in help-seeking behavior between genders (Cohen et al., 1995) or the fact that males can more easily account for hair loss (e.g., alopecia due to male pattern baldness) or self-treat certain sites (e.g., shave facial hair; Christenson, Mackenzie, et al, 1991). Gender differences among children who pull their hair are less clear, although studies suggest a more balanced distribution (Cohen et al., 1995). In the Cohen et al. (1995) survey, it was found that, for children under the age of 18, 76% of hair pullers were female. In a survey of 36 individuals meeting DSM-III-R criteria, Chang, Lee, Chiang, and Lu (1991) found that 50% of the 28 children aged 12 and under were male. Finally, Muller (1987) found that 46.2% of a sample of 52 preschool children with trichotillomania was male. These findings suggest that gender differences in the prevalence of hair pulling may exist between adults and children (Cohen et al, 1995).
3.3 Onset of Hair Pulling The age of onset for adult, chronic hair pullers has been relatively well documented. Christenson, Mackenzie, et al. (1991) established a mean age of onset for 60 participants as 13 years (SD = ± 8 years), with hair pulling onset ranging from less than 1 year to 39 years. Similarly, Cohen and colleagues (1995) found that the mean age of onset for 123 participants was 10.7 years of age (SD = + 6.3; range, 2-46). In a study examining 14 male hair pullers, Christenson, Mackenzie, et al., (1994) found a slightly higher mean age of onset at 15.0 years (SD = + 7.9 years). Overall, additional studies generally have supported the mean age of onset at approximately 13 years (Christenson &Mansueto, 1999). Frequently, it is reported that the onset of hair pulling is precipitated by some stressful life event (Christenson & Mansueto, 1999) or a salient change in environmental conditions such as alterations in parental living conditions (e.g., Schnurr & Davidson, 1989; Weller, Weller, & Carr, 1989) and additional academic pressures (Oranje, Peereboom-Wynia, & De Raeymaecker, 1986; Weller et al., 1989). Stressful life events often include themes related to loss (e.g., death of family member). However, trichotillomania onset has been associated with childhood illness, change in residence, injury to the scalp, and entering college (Christenson & Mansueto, 1999; Christenson, Pyle, et al., 1991; Rosenbaum & Ay I Ion, 1981). Chang et al. (1991) noted that many child participants reported hair pulling onset related to encountering academic problems, parent-child conflicts, and changes in the home environment.
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In contrast, some individuals begin to pull their hair within the first year of their life (e.g., Altman, Grahs, & Friman, 1982; Christenson, Pyle, et al., 1991) in the absence of salient environmental changes. Individuals who develop hair pulling independent of a significant environment change seemingly comprise a subset of the hair pulling population. This subset (Swedo & Leonard, 1992; Winchel, 1992) is characterized by short durations of hair pulling (e.g., a few months) and/or remission without intervention. Some researchers suggest that when an individual is responsive to an intervention (i.e., re-growth in hair is noticeable) within 1 to 3 months, continued improvement is the probable outcome (Chang et al., 1991). Conversely, hair pulling that continues for 6 months or longer seems more resistant to intervention. Because young children are under the supervision of a parent, it is likely that this behavior is detected earlier, and thereafter treated more consistently, than it would be for an older child or an adult. Thus, the presence of a change agent (i.e., an individual to implement a behavioral intervention) may account for the shorter course of trichotillomania for younger children.
4. COMMON COMORBID CONDITIONS Interviews and surveys conducted with persons diagnosed with trichotillomania have shown that hair pulling is associated with a broad range of psychological disorders, particularly anxiety and mood disorders. In a sample of 22 adults with trichotillomania, Schlosser, Black, Blum, and Goldstein (1994) found that 27%, 23%, 23%, and 55%, were diagnosed (according to DSM-III criteria) with obsessive compulsive disorder (OCD), mood disorders, anxiety disorders, and personality disorders, respectively. Using a larger sample of persons with trichotillomania, Cohen et al. (1995) found that 13% were diagnosed with OCD, 14% were diagnosed with depressive disorder, and 15% were diagnosed with bipolar disorder. Swedo and Leonard (1992) found that among older children, adolescents, and adults with trichotillomania, 39% were diagnosed with depression, 32%) with generalized anxiety disorder, 16% with OCD, and 15%) with substance abuse. Christenson (1995) also found high rates of depression and anxiety disorders in a sample of 186 adults from a trichotillomania clinic. Less is known about comorbidity in children with trichotillomania. In a demographic study of 15 children who were diagnosed with trichotillomania, King and colleagues (1995) found that 2 children were diagnosed with affective disorders, while 7 were diagnosed with "disruptive" behavioral disorders (e.g., attention-deficit hyperactivity disorder, conduct disorder, oppositional defiant disorder).
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5. HAIR PULLING BEHAVIOR PATTERNS A variety of behaviors are often exhibited prior to hair pulling, such as touching or stroking (manipulation) of hairs in the target region. These behaviors are typically exhibited for a brief period of time and are eventually followed by the removal of the manipulated hair. Hair pulling is typically performed by wrapping longer strands of hair around the index finger or grasping shorter hair with the thumb and index finger and pulling the hand away from the scalp. A number of studies report that hair is most often pulled with the individual's dominant hand, whereas both hands are used to pull hair in only a small percentage of cases (Christensen, Mackenzie, et al., 1991; Schlosser et al., 1994). Aside from pulling hair with the fingers, there are several other topographies of hair pulling. A small percentage of individuals remove hair with the aid of cosmetic tools such as tweezers (Christenson & Mansueto, 1999). Researchers have also reported that some individuals entangle hair within a brush or comb and then forcefully remove the hair from the target region. Furthermore, behavior that does not actually include a "pulling" topography can also result in noticeable hair loss. A number of studies have described individuals who remove hair by vigorously rubbing the target area with their fingers (Greenberg & Sarner, 1965; Rapp, Miltenberger, Long, Lumley, & Elliot, 1998). After hair has been pulled, it may be discarded or it may become central to a series of post-pulling behaviors. Individuals often manipulate recently pulled hair in a number of ways, presumably to obtain some sort of sensory stimulation from contact with the hair. For example, Miltenberger, Long, Rapp, Elliott, and Lumley (1998) found that a woman with mental retardation rolled pulled hair between her index finger and thumb while staring at the hair. In a subsequent study (Rapp, Miltenberger, Galensky, Ellingson, & Long, 1999), another individual rolled pulled hair between her finger and thumb and also rubbed the hair against her lips and tongue. This type of hair manipulation has been reported in many cases across studies (e.g., Christenson, Mackenzie, et al., 1991). The repetitive chewing and biting of pulled-hair has also been reported in typically functioning adults (Christenson, Mackenzie, et al., 1991; Schlosser et al., 1994). The behavior of chewing hair is possibly a precursor to ingestion of hair, which can lead to a variety of serious medical conditions discussed in Chapter 3. Hence, clinicians should carefully evaluate post-pulling behavior to assess possible medical complications and the sensory consequences that may be maintaining the behavior.
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In the few studies that have directly assessed hair pulling and hair manipulation, researchers have demonstrated that hair pullers allocated an equivalent or a greater amount of time to the manipulation of a recently pulled hair (Miltenberger, Long, et al., 1998; Rapp et al., 1999; Rapp, Dozier, Carr, Patel, & Enloe, 2000). Rapp et al. (1999) suggested that the manipulation of hair positively reinforced hair pulling. In a brief experimental demonstration, Rapp et al. (1999) showed that a young woman with multiple disabilities engaged in the pulling of scalp-hair to gain access to hair that she later manipulated between her fingers and against her lips. The generality of the results from this study are limited because only one subject was studied; however, it is likely that the stimulus events (behaviors) that precede, as well as follow, the behavior of hair pulling will gain greater attention from researchers in the future. Although some variability in the sites from which hair is pulled is evident across individuals, there does appear to be a general consistency in the preference for hair located on the head. Separate survey studies conducted by Schlosser and colleagues (1994), Christensen (1995), and by Cohen and colleagues (1995) indicated that individuals overwhelmingly pulled hair from their scalp, followed by eyelashes, eyebrows, pubic regions, facial hair, and body hair (legs and arms). The general preference for hand-to-head topographies of hair pulling (e.g., hand-to-scalp, hand-to-eye) may be due to the availability of hair on the head and face relative to other parts of the body. Despite the apparent popularity of the scalp (for reasons that are unclear), it is not uncommon for individuals to pull from multiple sites. In terms of seeking treatment, individuals who pull hair from the scalp, as well eyelashes and eyebrows, may experience greater motivation as a result of negative social evaluation of the obvious hair loss (Boudjouk, Woods, Miltenberger, & Long, 2000). In addition to the pressures produced by potential social evaluation of hair loss, the amount of time the individual allocates to pulling hair may serve as a motivating factor to seek professional assistance. A large-sample study that employed indirect assessments (Koran, Ringold, & Hewlett, 1992) reported that individuals who pull hair often allocate as much as 8 hours a day to the behavior. However, few studies have directly evaluated the amount of time individuals engage in hair pulling. A few studies evaluated the percentage of time individuals engaged in hair pulling (and hair manipulation) by videotaping them during short periods of time (e.g., 10 to 20 minutes) while they were alone. Miltenberger and colleagues, found that individuals engaged in hair pulling for approximately 10% to 60% of the time they were alone (Miltenberger, Long, et al., 1998; Rapp et al., 1999; Rapp et al., 1998).
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The environment in which hair pulling occurs may influence the location from which hair is pulled. Pulling hair from the scalp is often reported to occur during sedentary activities such as lying on a couch or on a bed. The specific topography of hair pulling (i.e., hand to scalp behavior) may be chosen as a result of the effort required to engage in that topography given the context in which the hair removal occurs. In other words, pulling hair from one's scalp may require less physical effort when lying down than when standing. Similarly, one may be more likely to pull facial hair when positioning the elbows on a table or desk while sitting and resting the face in the hands. As previously indicated, direct assessment of hair pulling behavior in the literature is rare, thus the relative influence of body position and response effort on the site selected for hair pulling remains speculative.
6. AUTOMATIC VERSUS FOCUSED HAIR PULLING Some researchers have suggested that there are two subsets of hair pullers automatic and focused - who differ in terms of their awareness of each instance of the behavior. According to Christenson and Mackenzie (1994), automatic hair pulling is marked by the display of hair pulling during otherwise sedentary activities to which the individual's attention is diverted. With this of type of hair pulling event, the individual engages in hair pulling outside of his or her awareness while engrossed in an activity that requires concentration (e.g., reading a book or watching television). Although based primarily on patient reports, it is generally believed that 75% of referred individuals engage in automatic hair pulling. Because the individual who exhibits automatic hair pulling may not be overtly aware that she is engaging in this behavior, some interventions, such as habit reversal (Azrin, Nunn, & Frantz, 1980) or the use of an awareness enhancement device (Rapp, Miltenberger & Long, 1998), assist the individual to become more aware of hair pulling or the conditions during which hair pulling occurs. In a case study reported by Ristvedt and Christenson (1996), awareness of hair pulling was increased following the application of a topical cream (capsaicin) that increased sensitivity to the scalp. As the name implies, focused hair pulling is the category description reserved for the remaining 25% of hair pullers who evidence an overt awareness of, and an overwhelming urge (often described as intense "need") for, their hair pulling behavior (Christenson & Mackenzie, 1994). It is this intense need for and focus on the pulling of hair that has led some researchers to speculate that trichotillomania is a variant of Obsessive Compulsive
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Disorder (OCD; Lenane et al., 1992). In this same vein, individuals who engage in this type of hair pulling are reported to experience antecedent states of anxiety or tension that are reduced or attenuated as a consequence of their focused hair pulling. Despite the reported distinction between focused and automatic hair pulling, it should be noted that a method to evaluate this phenomenon has yet to be developed. Moreover, it should be emphasized that the behavior of hair pulling is rarely evaluated directly in clinical studies but rather is assessed through indirect methods such as interviews and questionnaires (e.g., Massachusetts General Hospital Hairpulling Scale, National Institute of Mental Health [NIMH] Trichotillomania Scales). Unfortunately, indirect assessment methods neither permit verification of internal states such as anxiety (Rapp et al., 1999) nor objective evaluation of relevant environmental conditions associated with hairpulling.
7. COVARYING HABIT DISORDERS: DIGIT SUCKING AND TRICHOTILLOMANIA A number of studies involving young children have shown that hair pulling and digit sucking (i.e., thumb or finger sucking) are often exhibited in close temporal proximity (e.g., Watson & Allen, 1993). As with hair pulling, digit sucking is also exhibited primarily when the individual is alone. Literature concerning the evaluation and treatment of digit sucking and hair pulling has focused primarily on the indirect treatment of hair pulling by applying an intervention for digit sucking. In many of these cases, the child first engages in digit sucking and then pulls hair while simultaneously continuing to suck the digit. In contrast, hair pulling rarely occurs in the absence of prior digit sucking. The combination of these two observations has led researcher to speculate that digit sucking and hair pulling are "links" in a behavioral chain. Thus, by eliminating the first behavior in the chain (digit sucking), subsequent behavior (hair pulling) is also eliminated. Extending this logic to treatment procedures, researchers have produced reductions in both digit sucking and hair pulling with the application of an aversive tasting substance to the target digit of the child (Altman et al., 1982; Friman & Hove, 1987; Knell & Moore, 1988). Although a number of studies have demonstrated effective interventions for digit sucking and hair pulling, the operant relationship between these two behaviors remains unclear. However, a recent study by Friman (in press)
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involving digit sucking and attachment objects (i.e., objects held by a child while engaging in digit sucking) may help explain this behavior-behavior relationship. Friman (in press) demonstrated that digit sucking could be made more or less probable by adding or removing the child's attachment object, respectively. Based on this outcome, Friman concluded that the attachment object served as an establishing operation (EO) that momentarily altered the reinforcing value of digit sucking (i.e., made digit sucking more probable) for the child such that digit sucking was more likely to occur in the presence of the object. Extending the logic of the results of Friman (in press), one might argue that digit sucking serves as an establishing operation that makes hair pulling more reinforcing or valuable. However, at least one study has demonstrated that hair pulling was displayed independent of digit sucking by a child who exhibited both behaviors (Long et al., 1999); thus, it appears that the EO explanation is not universally applicable. Alternatively, from the standpoint of behavior economics (e.g., Green & Freed, 1993) it is equally plausible that the reinforcing products of hair pulling and digit sucking are complementary such that an increase in one behavior is associated with an increase in another behavior. Therefore, consistent with the EO explanation, engaging in hair pulling remains a reinforcing activity only when it is permitted to occur in the presence of digit sucking. Correspondingly, withholding access to digit sucking typically results in covarying reductions in hair pulling (Altman et al., 1982; Friman & Hove, 1987; Knell & Moore, 1988). To date, however, no study has examined the effects of withholding access to hair pulling on covarying digit sucking.
8. OPERANT VARIABLES IN HAIR PULLING A majority of the research attempting to understand the conditions associated with hair pulling has relied primarily on indirect reports (e.g., interviews). A typical psychological evaluation of an individual includes questions concerning internal states (e.g., anxiety, boredom, sadness) prior to and after pulling hair. Christenson and Mansueto (1999) report that hair pulling occurs for many individuals in response to a number of negative affective states such as anxiety, anger, or depression. Likewise, Christenson, Ristvedt, and Mackenzie (1993) found that individuals with trichotillomania described hair pulling in two situations, when experiencing negative affect and when engaged in sedentary and contemplative activities. Negative emotional states that were frequently reported to be associated with hair pulling include
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sadness, anxiety, frustration and tension. Sedentary activities included doing homework, reading, and getting ready for bed. In a study of 60 adults, Christenson, Mackenzie, et al. (1991) found 57 participants reported an increase in "tension" prior to hair pulling and 53 participants reported a sense of relief or gratification as a consequence of pulling out hair. Examining a variety of affective states, Stanley and colleagues (1995) found 36% were bored, 25% were angry, 11% were anxious, and 23% were tense prior to pulling hair. Following hair pulling, 23%) of the sample reported a feeling of relief. Thus, self-report data from these two studies suggest that a common antecedent stimulus event for individuals who pull hair is anxiety or tension and the consequence of pulling hair is the alleviation or reduction in this internal state. Hair pulling that occurs during this type of context is likely maintained by automatic negative reinforcement. Data from Stanley et al. (1995) also suggest that hair pulling occurs during periods of low ambient stimulation (i.e., when the individual is bored) and that pulling hair results in an increase in some form of stimulation. As such, it seems that the behavior of hair pulling may also be maintained by automatic positive reinforcement. Nevertheless, it should be noted that none of the aforementioned studies experimentally manipulated the conditions (e.g., increasing an individual's anxiety with a difficult task or placing an individual into an environment devoid of stimulation) under which hair pulling was reported to have occurred. Only a small number of studies have systematically manipulated environmental conditions (i.e., antecedents and consequences) in an attempt to identify operant variables involved in the maintenance of hair pulling. Woods and Miltenberger (1996) created situations in the laboratory that produced anxiety or boredom and measured a number of habit behaviors as college students experienced the two conditions. They found that hair manipulation was more probable in the anxiety condition. Miltenberger, Long, et al. (1998) conducted functional analyses of the hair pulling exhibited by a woman with mental retardation and the hair pulling and digit sucking displayed by a young girl with typical intellectual functioning. These functional analyses involved several conditions where specific antecedents were present prior to hair pulling (e.g., low ambient stimulation, no attention, or an academic task) and specific consequences (e.g., contingent attention or escape from a task) were provided following occurrences of hair pulling. The results of the analyses indicated that hair pulling and digit sucking occurred most often when the individuals were alone. This led Miltenberger et al. to speculate that these behaviors were maintained by automatic positive reinforcement (i.e., sensory stimulation produced by the behavior was serving as a reinforcer).
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In a similar investigation, Rapp et al. (1999) showed that the hair pulling and hair manipulation of a woman with mental retardation also occurred most often when she was alone. Subsequently, Rapp et al. conducted two additional conditions where she had access to "free hair" (previously pulled or cut hairs) and then wore a thin rubber glove while in the presence of the free hair. This analysis indicated that she did not pull her own hair when she had access to free hair and, furthermore, that she did not manipulate free hair (or pull hair) when she wore the rubber glove. Based on these results, Rapp et al. concluded that this individual's hair pulling and hair manipulation were maintained by automatic positive reinforcement in the form of digital-tactile stimulation. Thereafter, this finding was replicated in an analysis of problematic hair manipulation (manipulation of scalp hair that did not result in removal of hair from the scalp) exhibited by a young boy with autism (Rapp et al., 2000). Although the results of these studies are promising, the generality of the results remains limited due to the small number of participants in these studies and the specific populations from which they were selected. In summary, considerable evidence, albeit indirect, has been accumulated supporting the position that hair pulling occurs to reduce antecedent levels of anxiety or tension (automatic negative reinforcement) in adults with typical intellectual functioning. Likewise, data suggest that hair pullers with and without developmental disabilities may engage in hair pulling to produce some form of stimulation (automatic positive reinforcement). To date, the most convincing data concerning the operant function of hair puller has been acquired using direct observation procedures in conjunction with single-subject methodology.
9. POSSIBLE GENETIC AND BIOLOGICAL FACTORS The extent to which other members within a hair puller's family also exhibit or have exhibited hair pulling may indicate a genetic basis or predisposition for the behavioral disorder. Following this assumption, a number of researchers have interviewed or surveyed the family members of adults and children diagnosed with trichotillomania. In a sample of 123 returned mail surveys, Cohen et al. (1995) found that 3% of those who were diagnosed with trichotillomania also reported a diagnosis of trichotillomania in a family member. Schlosser et al. (1994) conducted a similar assessment of the family history of 22 hair pullers and found that 5% of first-degree relatives had been diagnosed with this disorder. King and colleagues examined the family histories of 15 children diagnosed with hair pulling. They found that 20% of
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the parents from this sample exhibited some topography of "habit" behavior (e.g., nail-biting, hair pulling, motor tics). Similarly, in a sample of 65 first degree relatives of diagnosed hair pullers, Lenane et al. (1992) found that 6% had received diagnoses of obsessive compulsive disorder (OCD). There is also evidence to suggest that family members of individuals who chronically pull hair are more often diagnosed with depressive disorder, anxiety disorder, and substance abuse, among others (Cohen et al., 1995; Schlosser et al., 1994). In general, interview and survey data suggest that there is an increased probability of hair pulling, as well as other psychiatric disorders, in first-degree relatives of individuals diagnosed with trichotillomania. These outcomes, however, should be interpreted with caution as the data from these studies are merely correlational and do not demonstrate a definitive genetic link for trichotillomania. In addition to analyses of family histories, other researchers have examined possible biological factors that may contribute to repetitive hair pulling. Research on repetitive behaviors that are exhibited by animals, such as canine acral licking (Goldenberger & Rapoport, 1991; Rapoport, Ryland, & Kriete, 1992) and avian feather picking (Bordnick, Thyer, & Branson, 1994) has served as a biological analog to human habit behaviors such as hair pulling. Based on studies reporting reductions in acral licking following the administration of opiate antagonists (e.g., naltrexone; White, 1990), Christenson, Raymond, and colleagues (1994) hypothesized that hypoalgesia (higher pain threshold) may be a factor that permits hair pulling to occur without painful consequences. To evaluate this possibility, Christensen, Raymond, et al. (1994) subjected a group of hair pullers and a group of nonhair pullers to a procedure that involved the application of pressure to each individual's finger-tips. The results of this preparation showed no significant difference in pain threshold (point at which pain was first detected) and pain tolerance (point at which the individual could tolerate further pressure) between to the two groups. In terms of the selected dependent variable (i.e., finger sensitivity), it is difficult to evaluate the relevance of this study to the behavior of hair pulling. That is, it may have been more germane to evaluate sensitivity to pain in areas from which hair was pulled instead of pressure to finger-tips. Although differences in pain threshold or pain tolerance may be investigated as a way to understand the motivation for hair pulling, such differences are not sufficient to explain the occurrence of, or the motivation for, hair pulling. Rather, the behavior must be explained in terms of reinforcing consequences (contingent application or removal of a stimulus that results in future probability of the response) or conditions that increase the value of reinforcing
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consequences. Researchers who have evaluated the biological basis of selfinjurious behavior (SIB) have speculated that some individuals with severe disabilities evidence an increased tolerance for pain. Thereby, as a result of this tolerance for pain, individuals may exhibit topographies of self-injury (e.g., head-slapping) to gain access to socially mediated consequences (e.g., parental attention) (Cataldo & Harris, 1982). Thus, in this paradigm, the absence of pain is explained as a mediating variable, which indirectly enables the behavior to contact other forms of reinforcement, rather than a motivating factor that directly affects the probability of the behavior. Should future research identify increased tolerance for pain (related to hair removal) in individuals who pull hair, it may be fruitful to investigate the social consequences (e.g., attention) that are experienced as a result of the product(s) of hair pulling (recall that the behavior typically occurs while these individuals are alone) or the positively reinforcing consequences resulting from hair manipulation (Rapp et al., 1999). Regardless of the approach, further research on biological (as well as environmental) factors contributing to hair pulling is certainly warranted.
10. REFERENCES Altman, K., Grahs, C, & Friman, P. (1982). Treatment of unobserved trichotillomania by attention-reflection and punishment of an apparent covariant. Journal of Behavior Therapy and Experimental Psychiatry, 13, 337-340. American Psychiatric Association. (1987). Diagnostic and statistical manual of mental disorders (Srded.). Washington, D.C.: Author. American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, D.C.: Author. Azrin, N. H., & Nunn, R. G. (1973). Habit reversal: A method of eliminating nervous habits and tics. Behaviour research and Therapy, 11, 619-628. Azrin, N. H., Nunn, R. G., & Frantz, S. E. (1980). Treatment of hairpuiling (trichotiiimania): A comparative study of habit reversal and negative practice training. Journal of Behavior Therapy and Experimental Psychiatry, 11, 13-20. Bordnick, P.S., Thyer, B.A., & Branson, B.W. (1994). Feather picking disorder and trichotillomania: An avian model of human psychopathology. Journal of Behavior Therapy and Experimental Psychiatry, 25, J 89-196. Boudjouk, P. J., Woods, D. W., Miltenberger, R. G., & Long. E. S. (2000). Negative peer evaluation in adolescents: Effects of tic disorders and trichotillomania. Child & Family Behavior Therapy, 22, 17-28. Cataldo, M. F., & Harris, J. (1982). The biological basis for self-injury in the mentally retarded. Analysis and Intervention in Developmental Disabilities, 2, 21-39. Chang, C. H., Lee, M. B., Chiang, Y. C, & Lu, Y-C. (1991). Trichotillomania: A clinical study of 36 patients. Journal of the Formosa Medical Association, 90, 176-180. Christenson, G. A. (1995). Trichotillomania—From prevalence to comorbidity. Psychiatric Times, 12, 44-48.
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Christenson, G. A., & Mackenzie, T. B. (1994). Trichotillomania. In M. Hersen & R. T. Ammerman (Eds.), Handbook of prescriptive treatments for adults (pps 217-235). New York: Plenum. Christenson, G. A., Mackenzie, T. B., & Mitchell, J. E. (1991). Characteristics of 60 adult chronic hair pullers. American Journal of Psychiatry, 148, 365-370. Christenson, G. A., Mackenzie, T. B., & Mitchell, .1. E. (1994). Adult men and women with trichotillomania. A comparison of male and female characteristics. Psychosomatics, 35^ 142149. Christenson, G. A., & Mansueto, C.S. (1999). Trichotillomania: Descriptive characteristics and phenomenology. In Stein, M.B., Christenson, G.A., & Hollander, E (Eds.), Trichotillomania (pp. 1-41). Washington, DC: American Psychiatric Press. Christenson, G. A., Pyle, R. L., & Mitchell, J. E. (1991). Estimated lifetime prevalence of trichotillomania in college students. Journal of Clinical Psychiatry, 52, 415-417. Christenson, G. A., Raymond, N. C, Paris, P. L., McAllister, R. D., Crow, S. J., Howard, L. A., & Mitchell, J. E. (1994). Pain thresholds are not elevated in trichotillomania. Biological Psychiatry, 36, 347-349. Christenson, G.A., Ristvedt, S.L., & Mackenzie, T.B. (1993). Identification of trichotillomania cue profiles. Behavior Research and Therapy, 31, 315-320. Cohen, L. J., Stein, D. J., Simeon, D., Spadaccini, E., Rosen, J., Aronowitz, B., & Hollander, E. (1995). Clinical profile, comorbidity, and treatment history in 123 hair pullers: A survey study. Journal of Clinical Psychiatry, 56, 319-326. Friman, P. C. (in press). Transitional objects' as establishing operations for thumb sucking: A case study. Journal of Applied Behavior Analysis. Friman, P.C, & Hove, G. (1987). Apparent covariation between child habit disorders: Effects of successful treatment for thumb sucking on untargeted chronic hair pulling. Journal of Applied Behavior Analysis, 20, 421-427. Goldenberger, E., & Rapoport, J.L. (1991). Canine acral lick dermatitis: response to the antiobsessional drug clomipramine. Journal of the American Animal Hospital Association, 27, 179-182. Green, L., & Freed, D. E. (1993). The substitutability of reinforcers. Journal of the Experimental A nalysis of Behavior, 60, 141-158. Greenberg, H. R., & Sarner, C. A., (1965). Trichotillomania: Symptom or syndrome. Archives of General Psychiatry, 12, 482-489. Hallopeau, H. (1889). Alopecia par grattage (trichomanie ou trichotillomanie). Annales de Dermatologie et de Syphiligraphie, 10, 440-441. Hallopeau, H. (1894). Sur un nouveau cas de trichotillomanie. Annales de Dermatologie et de Syphiligraphie, 5, 541-543. Hansen, D.J., Tishelman, A.C., Hawkins, R.P., & Doepke, K.J. (1990). Habits with potential as disorders: Prevalence, severity, and other characteristics among college students. Behavior Modification, 14, 66-80. King, R. A., Scahill, L., Vitulano, L. A., Schwab-Stone, M., Tercyak, K. P., & Riddle, M. A. (1995). Childhood trichotillomania: Clinical phenomenology, comorbidity, and family genetics. Journal of the American Academy of Child and Adolescent Psychiatry, 34, 14511459. Knell, S. M., & Moore, D. J. (1988). Childhood trichotillomania treated indirectly by punishing thumb sucking. Journal of Behavior Therapy and Experimental Psychiatry, 19, 305-310. Koran, L.M., Ringold, A., & Hewlett, W. (1992). Fluoxetine for trichotillomania: an open clinical trial. Psychopharmacology Bulletin, 28, 145-149. Lenane, M. C, Swedo, S. E., Rapoport, .I.L., Leonard, H. L., Sceen, & Guroff (1992). Rates of
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obsessive compulsive disorder in first degrees relatives of patients witii trichotillomania: A research note. Journal of Child Psychology and Psychiatry, 33, 925-933. Long, E. S., Miltenberger, R.G., & Rapp, J.T. (1998). A survey of habit behaviors exhibited by individuals with mental retardation. Behavioral Interventions, 13, 79-89. Long, E. S., Miltenberger, R.G., & Rapp, J.T. (1999). Simplified habit reversal plus adjunct contingencies in the treatment of thumb sucking and hair pulling in a young child. Child and Family Behavior Therapy, 21, 45-58. Mehregan, A.H. (1970). Trichotillomania: A clincopathologic study. Archives of Dermatology, 102, 129-133. Miltenberger, R.G., Long. E.S., Rapp, J.T., Lumley, V.A., & Elliot, A.J. (1998). Evaluating the function of hair pulling: A preliminary investigation. Behavior Therapy, 29, 211-219. Muller, S. A., (1987). Trichotillomania. Dermatologic Clinics, 5, 595-601. Oranje, A.P., Peereboom-Wynia, J.D.R., De Raeymaecker, D.M.J. (1986). Trichotillomania in c\\\\d\\ood. Journal ofAmerican Academy of Dermatology, 15, 614-619. Rapoport, J. L., Ryland, D. H., & Kriete, M. (1992). Drug treatment of canine acral lick: An animal model of obsessive-compulsive disorder. Archives of General Psychiatry, 49, 517521. Rapp, J. T., Dozier, C. L., Carr, J. E., Patel, M. R., & Enloe, K. A. (2000). Functional analysis of hair manipulation: A replication and extension. Behavioral Interventions, 15, 121-133. Rapp, J. T., Miltenberger, R. G., Galensky, T. L., Ellingson, S. A., & Long, E. S. (1999). A functional analysis of hair pulling. Journal ofApplied Behavior Analysis, 32, 329-337. Rapp, J. T., Miltenberger, R. G., & Long, E. S. (1998). Augmenting simplified habit reversal with an awareness enhancement device: Preliminary findings. Journal of Applied Behavior Analysis, 31, 655-668. Rapp, J. T., Miltenberger, R. G., Long, E. S., Lumley, V. A., & Elliott, A. J. (1998). Simplified habit reversal treatment for chronic hair pulling in three adolescents: A clinical replication with direct observation. Journal ofApplied Behavior Analysis, 31, 669-672. Reeve, E. (1999). Hair pulling in children and adolescents. In Stein, M.B., Christenson, G.A., & Hollander, E (Eds.), Trichotillomania (pp.201-224). Washington, DC: American Psychiatric Press. Ristvedt, S. L., & Christenson, G. A. (1996). The use of pharmocologic pain sensitization in the treatment of repetitive hair-pulling. Behavior Research and Therapy, 34, 647-648. Rosenbaum, A.S., & Ayllon, T. (1981). The habit-reversal technique in treating trichotillomania. Behavior Therapy, 12, 473-481. Rothbaum, B.O., Shaw, L., Morris, R., & Ninan, P.T. (1993). Prevalence of trichotillomania in a college freshman population. Journal of Clinical Psychiatry, 54, 72. Schlosser, S., Black, D. W., Blum, N., Goldstein, R. B. (1994). The demography, phenomenology, and family history of 22 persons with compulsive hair pulling. Annals of Clinical Psychiatry, 6, 147-152. Schnurr, R. G., & Davidson, S. (1989). Trichotillomania in a ten year old boy: Gender identity issues formulated in terms of individual and family factors. Canadian Journal of Psychiatry^ 5^,721-724. Stanley, M. A., Borden, J. W., Bell, G.E., & Wagner, A.L. (1994). Nonclincal hair-pulling: Phenomenology and related psychopathology. Journal ofAnxiety Disorders, 8, 119-130. Stanley, M. A., Borden, J. W., Mouton, S. G., & Breckenridge, J. K. (1995). Nonclinical hairpulling: Affective correlates and comparison with clinical samples. Behavior Research and Therapy. 33, ]19-\^6. Swedo, S. E.(1993). Trichtotillomania. Psychiatric Annals, 23, 402-407. Swedo, S. E., & Leonard, H. L. (1992). Trichotillomania: An obsessive compulsive spectrum
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disorder? Psychiatry Clinics of North America, 15, 711-790, Watson, T.S., & Allen, K.D. (1993). Elimination of thumb-sucking as a treatment for severe trichotillomania. Journal of the American Academy of Child and Adolescent Psychiatry, 32, 830-834. Weller, E.B., Weller, R.A., & Carr, S. (1989). Imipramine treatment of trichotillomania and coexisting depression in a seven-year-old. Journal of the American Academy of Child and Adolescent Psychiatry 28, 952-953. White, S. D. (1990). Naltrexone for treatment of acral lick dermatitis in dogs. Journal of the American Veterinarian Medical Association, 196, 1073-1076. Winchel, R.M. (1992). Trichotillomania: Presentation and treatment. Psychiatric Annals, 22^ 8489. Woods, D.W., & Miltenberger, R.G. (1996). Are people with nervous habits nervous? A preliminary examination of habit function in a nonreferred population. Journal of Applied Behavior Analysis, 29, 259-261. Woods, D.W., Miltenberger, R.G., & Flach, A.D. (1996). Habits, tics, and stuttering: Prevalence and relation to anxiety and somatic awareness. Behavior Modification, 20, 216-225.
Chapter 8 Behavioral Interventions for Trichotillomania Amy J. Elliott Munroe-Meyer Institute, University of Nebraska Medical Center
R. Wayne Fuqua Western Michigan University
1. INTRODUCTION Trichotillomania (TCM) is a disorder characterized by chronic hair pulling. The initial conceptualization of TCM as a severe psychiatric disturbance (Hallopeau, 1889), guided treatment of the disorder for many decades and remains relatively common today. It was not until the 1970's that this notion was challenged with a behavioral approach. The behavioral approach to treating hair pulling focused on environmental influences and used empirically derived principles of behavior as the foundation for clinical interventions. This paper will provide a review of the behavioral treatments found effective in treating hair pulling, as well as a brief synopsis of the literature behind the medical management of TCM. Overall, literature on the treatment of TCM has been highly variable with respect to clinical presentation and prognosis. This variability can make interpretation of the research difficult and confusing. The current psychiatric literature characterizes TCM as a complex psychopathological disorder that is relatively resistant to treatment (see Graber & Arndt, 1993), whereas behavioral researchers tend to conceptualize TCM as a habit, without reference to an underlying psychopathology (Friman, Finney, & Christophersen, 1984). It has been suggested that the divergent treatment outcomes and conceptualizations reported across disciplines reflect different subject populations, with the more severe cases represented in the psychiatric literature (Friman et al., 1984). Although this theory remains
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untested, the self-selection of subjects to different treatment facilities cannot be ignored.
2. PHARMACOLOGICAL INTERVENTIONS FOR TRICHOTILLOMANIA Pharmacological interventions for TCM typically target biological mechanisms found responsible for disorders believed to be related to TCM. Among these treatments, antidepressants have been the most thoroughly researched (Christenson & O'Sullivan, 1996), because of the presumed relationship between TCM and Obsessive Compulsive Disorder (OCD). In a double-blind cross-over study, Swedo et al., (1989) reported significant improvements in self-report and physician ratings of TCM severity with clomipramine but not with desipramine, an antidepressant that does not affect obsessional activity (Swedo et al., 1989). A long-term follow-up to this study indicated that seven of the thirteen subjects were receiving clomipramine 4.3 years later, with only one showing a complete remission after medication was withdrawn (Swedo, Lenane, & Leonard, 1993). Stimulated by the positive results of the clomipramine study, open and controlled trials on the class of drugs known as selective serotonin reuptake inhibitors (SSRI) were conducted. Because OCD had proven responsive to SSRJs (e.g., fluoxetine; Mavissakalian, Turner, Michelson, & Jacob, 1985), it was hypothesized that TCM should respond in a like manner. Mixed results have been obtained with fluoxetine as some studies showed positive effects (e.g., Koran, Ringold, & Hewlett, 1992; Stanley, Bowers, Swann, & Taylor, 1991; Winchel, Jones, Stanley, Molcho, & Stanley, 1992), and others failed to document any effect (Christenson, Mackenzie, Mitchell, & Callies, 1991; Streichenwein & Thornby, 1995). The two studies that failed to show treatment results used self-monitoring procedures as the primary outcome measures (e.g., Christenson et al., 1991; Streichenwein & Thornby, 1995), whereas the studies reporting significant results used clinician-completed outcome measures; thus raising concerns about the adequacy of outcome measures. Attempts have also been made to improve treatment responsiveness to SSRJ's with the addition of a neuroleptic medication, namely risperidone and pimozide (Stein, Bouwer, Hawkridge, & Emsley, 1997; Stein & Hollander, 1992). One study identified five nonresponders to SSRI
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treatment and augmented that treatment with risperidone (Stein et al., 1997). Results indicated that of the five individuals, 3 reported significant clinical improvement, however, only 2 maintained this improvement while still on the medication regimen. The third individual had to discontinue the risperidone due to adverse side effects (Stein et al., 1997). Another study of seven individuals diagnosed with TCM and a variety of comorbid conditions showed greater responsiveness to pharmacological management as measured through self-report when pimozide was added to SSRI treatment (Stein & Hollander, 1992). Most recently, clomipramine was compared to cognitive-behavior therapy in a 9-week, placebo-controlled, randomized trial to treat TCM (Ninan, Rothbaum, Marsteller, Knight, & Eccard, 2000). Efficacy was evaluated using the Trichotillomania Severity Scale, the Trichotillomania Impairment Scale, and the Clinical Global Impressions-Improvement Scale, which were administered by an independent assessor blinded to the treatment condition. Twenty-three patients entered the study, with 16 completing it. Cognitivebehavior therapy with habit reversal resulted in statistically significant reductions on the outcome measures, while both clompiramine and placebo produced non-significant reducations (Ninan et al., 2000). The cognitivebehavioral treatment package used in this study to treat TCM will be discussed later in this chapter.
3. BEHAVIORAL INTERVENTIONS FOR TRICHOTILLOMANIA The development of behavioral interventions for TCM can be traced to Azrin and Nunn's (1973) landmark paper outlining habit reversal, a multicomponent treatment protocol for habit disorders. They reported a case study in which eyelash picking (a common site for hair pulling) was dramatically decreased after only a single session of habit reversal. Although there were many methodological flaws in this early work, the importance of the work cannot be understated as it inspired many future studies of TCM treatment. Behavioral interventions typically rely on the manipulation of one or more environmental factors in an effort to reduce or eliminate hair pulling. Many of the interventions are characterized by the arrangement of a contrived consequence (e.g., some type of "aversive" event or an effortful behavior)
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for instances of hair pulling. Others manipulate those events that seem to set the stage for higher levels of hair pulling or seek to develop skills and behaviors to displace the hair pulling. Over recent years, an impressive array of research has emerged demonstrating the validity of a behavioral approach to treating hair pulling. Positive results have been found with many behavioral interventions, however, habit reversal has the strongest empirical support (Elliott & Fuqua, 2000; Friman et al., 1984).
3.1, Punishment Procedures Punishment procedures have been used primarily to treat chronic hair pulling in both children and adults with developmental disabilities. A number of aversive consequences have been used to decrease hair pulling, including electric shock, topical cream application (to increase pain sensitization), the snap of a rubber band and response blocking/interruption. Again, most of the research in this area consists of single-subject designs. Studies have reported successful treatment of hair pulling when a mild electric shock was administered contingent on the hand movements involved in pulling hair (Corte, Wolf, & Locke, 1971; Crawford, 1988; Deshpande & Mehta, 1989). Two of these studies used self-monitoring data with normally functioning adults and found that contingent shocks in the clinic were sufficient to reduce hair pulling outside of the clinic setting (Crawford, 1988; Deshpande & Mehta, 1989). Generalization proved more elusive in a study evaluating the effects of contingent shock on hair pulling in an individual with mental retardation (Corte et al., 1971). In this study, it was necessary to implement the treatment protocol in various settings by different people to promote generalization. Aromatic ammonia (Altman, Haavik, & Cook, 1978) and facial screening (Barmann & Vitali, 1982) have also been used as consequences of hair pulling for children and adolescents with developmental disabilities. The aromatic ammonia procedure involved placement of an ammonia capsule (i.e., smelling salts) under the nose of a four year-old with severe mental retardation (Altman et al., 1978) contingent on hair-pulling. The facial screening procedure involved covering the subject's face with a terrycloth bib contingent on hair pulling (Barmann & Vitali, 1982). Each of the three children in this study reportedly spent time looking at and manipulating the hair after it was pulled, therefore, the facial screening was an attempt to systematically remove visual sensory reinforcement: a sensory extinction
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procedure (Barmann & Vitali, 1982). Whether the facial screening procedure also operated on the basis of punishment principles through the response contingent presentation of stimuli presumed to be "aversive" (e.g., the physical contact and restraint associated with facial screening) cannot be ascertained from the study. Another study systematically evaluated various treatment techniques to decrease hair pulling and hair manipulation based on functional analysis data suggesting the hair pulling was maintained by automatic reinforcement (Rapp, Miltenberger, Galensky, Ellingson, & Long, 1999; Rapp et al., 2000). Selected treatments were designed to increase the effort involved in pulling hair (wearing wrist weights), produce sensory extinction of digital-tactile stimulation (the subject wore a glove during the day and hand splints at night), and response interruption plus differential reinforcement of other behaviors. Neither the wrist weights nor the glove wearing during high risk times resulted in sustained decreases in hair pulling and manipulation across sessions. Sustained decreases were found with the combination of response interruption and differential reinforcement of the manipulation of objects other than hair. Although this study is limited by potential treatment ordering effects, it stresses the importance of measuring treatment effectiveness across time (Rapp et al., 2000). Punishment procedures have also been utilized when hair pulling occurred primarily outside of awareness and was not responsive to a commonly used self-management strategy, habit reversal. Ristvedt and Christenson (1996) had a subject apply an over-the-counter topical capsaicin cream to the scalp. Capsaicin cream makes the skin more sensitive, thereby increasing the pain associated with hair pulling. At a 4-month follow-up, the subject reported a significant decrease in her hair pulling (Ristvedt & Christenson, 1996). Despite the limitation of applying the cream daily, this intervention represents a novel use of an over-the-counter drug to facilitate awareness and management of hair pulling. Rapp, Miltenberger, and Long (1998a) also used an awareness enhancing device consisting of an alarm that sounded when the wrist came within a certain distance from the head of a developmentally delayed adult. This device was successful in decreasing hair pulling that had been unresponsive to other behavioral techniques. Contingent response prevention (Maguire, Piersel, & Hansen, 1995; Sanchez, 1979) has also been successful in reducing hair pulling in persons with developmental disabilities. Maguire et al. (1995) placed mittens on a 46-year-old female with profound mental retardation contingent on hair pulling. Ratings of photographs by individuals blind to the phase of
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treatment revealed a steady increase in hair growth. Although this treatment program took 3 years for its effects to become apparent, it systematically reduced hair pulling which had been previously resistant to treatment. This program was also rated as highly effective by the group home staff (Maguire et al., 1995). In a variation on the response prevention strategy, Barrett and Shapiro (1980) described parents who shaved the head of their 7-year-old girl with severe mental retardation who exhibited chronic hair pulling and trichophagia. Hair pulling decreased while the girl's hair was short but returned to baseline levels as the hair grew. An overcorrection procedure that required the girl to brush her hair for two minutes contingent on each hair pull (termed positive practice) decreased hair pulling but the effects did not maintain after the intervention was discontinued. Eventually, the inclusion of a verbal warning plus positive practice was successful in eliminating the hair pulling completely (Barrett & Shaprio, 1980). The above studies document the efficacy of a variety of punishment procedures for chronic hair pulling with children and adults with developmental disabilities. However, fewer studies have been done using punishment procedures with typically developing adults, thus raising concerns about the acceptability and generality of the treatment protocols. Only two studies have collected acceptability information on the use of a punishment procedure to decrease hair pulling (Barmann & Vitali, 1982; Rapp et al., 2000). The acceptability information on the use of a facial screening procedure to decrease hair pulling was collected from parents and care providers. These data indicated they were generally in support of the procedure, particularly with respect to its ease of use. Rapp et al. (2000) received treatment acceptability ratings from the mother of the individual receiving treatment and high ratings were obtained for both the hand splints and the combination of response interruption and differential reinforcement of other behaviors. However, further information regarding the treatment acceptability and treatment integrity of punishment procedures would be beneficial in making predictions about subject attrition and treatment adherence. There are also many ethical questions regarding the use of intrusive and restrictive procedures for a problem that is not an immediate threat to physical health (Elliott & Fuqua, 2000). However, trichophagy (ingestion of pulled hair) presents a significant health concern and may be a potential indicator for use of a punishment procedure. Therefore, punishment procedures may need to be considered as part of a treatment package which includes a reinforcement component or as a back-up
Behavioral Interventions for Trichotillomania treatment if a reinforcement-based procedure proves ineffective alleviating hair pulling (e.g., Crawford, 1988).
15 7 in
3.2. Hypnosis/Relaxation Procedures Habits have often been conceptualized as being maintained by negative reinforcement, because they reportedly produce reductions in tension, anxiety, or some aversive condition experienced by the individual (see Miltenberger, Fuqua, & Woods, 1998). One potential treatment avenue for decreasing tension involves training in relaxation procedures. This training may take the form of progressive muscle relaxation (e.g., DeLuca & Holborn, 1984) or a combination of relaxation and hypnotic suggestions. This latter technique has been referred to as hypnobehavioral treatment (Robiner, Edwards, & Christenson, 1999). Although the exact mechanisms underlying hypnosis are unclear, hypnobehavioral treatment for hair pulling often uses relaxation to relieve tension along with suggestions for behavior change (Fabbri & Dy, 1974; Galski, 1981; Rodolfa, 1986). The studies investigating the efficacy of hypnosis in treatment of hair pulling consist primarily of uncontrolled case studies without reports of quantifiable data. However, despite these limitations, the studies do document the success of hypnosis in reducing hair pulling in primarily normal functioning adults. Hypnotic induction has been used to both help increase awareness of instances of hair pulling, as well as perceptions of associated pain (Friman & O'Connor, 1984; Hall & McGill, 1986; Rodolfa, 1986). Hypnobehavioral techniques typically focus on normally-functioning adults and given the verbal nature of the techniques, they may be limited to use with those who exhibit highly developed verbal repertoires. Three studies investigating the use of hypnosis have reported rapid decreases in self-reported hair pulling with maintenance of these improvements over 2 (Fabbri & Dy, 1974; Friman & O'Connor, 1984), 6 (Hall & McGill, 1986), and 8 months (Rodolfa, 1986). These reports of treatment maintenance are impressive and have led some to speculate on the mechanisms by which maintenance might occur. Fabbri and Dy (1974) suggested that even if posthypnosis suggestions persist for only a limited time, this disruption in behavioral patterns may allow more adaptive patterns to develop. Unfortunately, most of aforementioned hypnosis studies relied exclusively on clinician or participant ratings and employed case study methodology. In the one hypnosis study to use a product measure to assess treatment
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effectiveness (hair length), more conservative results were reported (Barabasz, 1987). This study used hypnosis as the primary treatment intervention with 4 adult hair pullers (aged 19 to 34 years) and three of the 4 subjects were free of hair pulling at a 12-month follow-up session (Barabasz, 1987). Although these results are quite positive they suggest hypnosis techniques may not be effective for all individuals with chronic hair pulling. Although hypnosis may be a viable alternative to pharamcological and other behavioral approaches, it may also be a potential augmenting strategy when other treatment methods produce only partial improvements (Robiner et al., 1999). Relative to other treatments, hypnosis requires little response effort and may be well accepted by some individuals. Currently, the usefulness of hypnosis in treating hair pulling is hindered by a poor understanding of the underlying mechanisms of action, lack of guidelines for determining which individuals might be most responsive to this intervention, inadequate descriptions of hypnotic procedures, and a lack of controlled research in this area (Robiner et al., 1999). Future well-designed research is needed to explore the potential use of hypnosis both as a primary intervention for hair pulling and as a supplement to enhance awareness of hair pulling to facilitate the application of other response contingent interventions (e.g., habit reversal).
3.3. Habit Reversal Habit reversal, a multi-component treatment for habit behaviors, has been identified as the most efficacious treatment for TCM to date (Elliott & Fuqua, 2000; Friman et al., 1984) and is listed as a "probably efficacious" treatment for habits on the American Psychological Association's list of empirically validated treatments (Chambless et al., 1998). Habit reversal, as originally conceptualized by Azrin and Nunn (1973), contains 4 phases comprising a total of thirteen components. Generally, the 4 phases are categorized as awareness training, competing response training, motivation enhancement, and generalization training (see reviews by Miltenberger et al., 1998; Woods & Miltenberger, 1995; 1996). A number of variations of habit reversal have been used to treat hair pulling, including the original protocol, simplified versions, and group formats. Although the majority of studies have employed a small number of subjects, they have typically used appropriate small N experimental designs, characterized by relatively objective measures of the dependent variable for comparison across baseline
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and intervention phases. In the only group comparison study of habit reversal, Azrin, Nunn, and Frantz (1980) reported that individuals with TCM who used habit reversal decreased hair pulling by 91%, compared with a 50% decrease for a negative practice group. The individuals in the habit reversal group were also more likely to maintain these results at a 3-month follow-up (Azrin et al., 1980). The number of habit reversal components has also been manipulated, with successful outcomes documented using the complete habit reversal package (e.g., Tarnowski, Rosen, McGrath, & Drabman, 1987), as well as simplified packages (e.g., Rapp, Miltenberger, Long, Elliott, & Lumley, 1998b). In most research studies, the simplified treatment packages typically consist of awareness training, competing response training, and social support (e.g., Rapp et al., 1998b; Rosenbaum, 1982; Tarnowski et al., 1987). In a component analysis of habit reversal for motor and vocal tics, one study found equivalent results between groups, with one group receiving the entire package and another receiving only awareness and competing response training (Miltenberger, Fuqua, & McKinley, 1985). However, it has been speculated in a treatment study for stuttering in children that the social support component of habit reversal may be a necessary component to enhance motivation and promote generalization of treatment results, particularly in children (Elliott, Miltenberger, Rapp, Long, & McDonald, 1998). The necessity of each treatment component has yet to be studied in reference to chronic hair pulling. In many cases, very little therapy time was needed to achieve significant reductions in hair pulling (Friman & O'Connor, 1984; Rapp et al., 1998b; Rosenbaum, 1982). One case study treated a 7-year-old boy in a pediatric outpatient clinic in one 20-min session, with telephone follow-up sessions at 3, 12, and 18 months (Rosenbaum, 1982). Although this report is limited by the use of only one subject, its efficient application of habit reversal in a pediatric outpatient setting is novel. Obviously, these results may not be replicable with some individuals, but they do demonstrate the potential costeffectiveness of habit reversal in eliminating hair pulling in children. Maintenance of treatment effects has also been addressed in several studies. To help maintain treatment effects, Rapp et al. (1998b) administered booster sessions contingent on increases in hair pulling behaviors as shown in follow-up data. The contingent application of booster sessions may help to minimize the physical and psychological effects of relapse on the individual. Being able to administer timely booster sessions may be
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particularly beneficial when working with hair pulling, because a brief hair pulling binge can result in a rapid return to baseline levels of hair loss. Habit reversal has also been documented effective in decreasing hair pulling in individual therapy (e.g., Rapp et al., 1998b) and group therapy (Mouton & Stanley, 1996). Using a group therapy format, Mouton and Stanley (1996) reported improvements for 4 of 5 adult subjects, with 2 experiencing a minor relapse at a 6-month follow-up. Although this study is limited by the exclusive use of self-report measures to determine treatment effectiveness, it demonstrates a time- and cost-effective format for habit reversal. Follow-up sessions to help avoid or minimize relapse may have augmented the long-term effectiveness of the treatment (Mouton & Stanley, 1996). In general, habit reversal appears to be effective in decreasing and even eliminating chronic hair pulling in both children and adults. Follow-up data indicate that treatment effects can be long-standing, but active attempts to prevent or minimize relapse are necessary for some individuals. Although many studies achieved or maintained zero levels of hair pulling at follow-up (e.g., Tarnowski et al., 1987), not all individuals have responded to habit reversal in such a manner (Long, Miltenberger, & Rapp, 1999; Mouton & Stanley, 1996; Rapp et al., 1998a; Vitulano, King, Scahill, & Cohen, 1992). Further research is needed to discern the reasons why some fail to respond to habit reversal interventions. Once researchers have ruled out treatment integrity problems (i.e., failure to implement the habit reversal components, especially the response contingent competing response), then efforts should be made to identify circumstances in which the use of habit reversal would be the most promising and situations where its application would be contraindicated. Adjuncts to habit reversal have also been used to enhance treatment outcome. In one study, a 49-year-old woman was having difficulties remaining compliant with the treatment protocol (Rogers & Darnley, 1997). She reportedly derived much pleasure from manipulating and pulling hair. A self-identified contingent exercise component was added where she would do ten sit-ups each time she stroked or pulled a hair. Although selfmonitoring and habit reversal significantly decreased her hair pulling, the addition of contingent exercise helped to eliminate the behavior. Although habit reversal has the most empirical support, there is much work left to be done in the area. For example, one area for future research may be further delineation of approximate time intervals for followup/booster sessions. As with most behavioral therapies, generalization and
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maintenance of treatment effects are of concern. Furthermore, systematic attempts should be made to conduct the necessary research to meet the qualifications for habit reversal to be considered for the American Psychological Association's list of empirically validated treatments (Chambless et al., 1998).
3.4. Multi-Component Procedures Hair pulling has been treated with other behavioral procedures consisting of multiple components. These procedures are comprised of numerous interventions implemented simultaneously making it difficult to isolate the efficacy of individual techniques (Elliott & Fuqua, 2000). An example of such a treatment package was used by Blount and Finch (1988), who successfully decreased hair pulling in a 3-year-old by having the parents differentially reinforce non hair pulling behaviors, interrupt the behavior chain as soon as a hair pull was discernable, and apply a delayed aversive consequence (time-out) if it became noticeable that the child had pulled hair when alone. At a 12 month follow-up, the child was no longer pulling hair according to parental reports (Blount & Finch, 1988). In this study, the differential attention decreased hair pulling in the presence of another person, but the punishment aspect was needed to eliminate hair pulling when the girl was alone. Blum, Barone, and Friman (1993) also used differential reinforcement combined with other treatment techniques to treat hair pulling in 2 children. For one child, the treatment protocol included an increased number of positive interactions between the parents and child, time-out contingent on a hair pull, and placement of socks on the child's hands if she continued to pull hair in the time-out chair. Treatment for the second child also included increased positive interactions during high-risk times for hair pulling, verbal reprimands contingent on hair pulling, and an incompatible response contingent on a hair pull. As indicated by parental observations, both children had no hair pulling at 1- and 2-year follow-up sessions (Blum et al., 1993). Although these studies report dramatic results, it is unclear which components were the most effective.
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3.5. Cognitive-Behavioral Procedures In the past decade, an emergence of cognitive-behavioral conceptualizations and treatments for hair pulling have emerged. The emergence of cognitive-behavioral models is likely a reflection of a movement with mainstream psychology, but also concerns regarding the universal use of the habit reversal treatment package. Concerns specifically targeted the heterogeneity of individuals with hair pulling (Mansueto, Golomb, Thomas, & Stemberger, 1999), the lack of attention habit reversal gives to cognitive variables such as maladaptive thoughts (Stanley, 1999), as well as the overall acceptability of the procedure to adolescents and adults (Keuthen, Aronowitz, Badenoch, & Wilhelm, 1999; Robleck, Detweiler, Fearing, & Albano, 1999). Although the only data supporting these concerns resides in case studies and anecdotal reports (e.g., Robleck et al., 1999), recently published cognitive-behavioral conceptual models (Mansueto et al., 1999) and treatment manuals (Rothbaum & Ninan, 1999) have targeted the potential role of maladaptive thoughts and feeling states as triggers for hair pulling. The cognitive-behavioral treatment model proposed by Mansueto et al. (1999) includes four general phases, comprising a total often different steps. This model encourages the use of a functional assessment to help identify "triggers" for hair pulling that could be altered, avoided, or responded to with a more adaptive behavior, thus reducing hair pulling. The second phase divides the functional assessment information into five different modalities: cognitive, affective, motoric, sensory, and environmental. After the information has been categorized in such a way, the most prominent modalities are identified and treatments targeting those modalities are implemented in phase three (Mansueto et al., 1999). According to this model, most habit reversal components (e.g., awareness and competing response training) are relevant to the motor modality. The final phase of treatment is to evaluate treatment progress through self-monitoring. Relapse prevention strategies are also discussed, with an emphasis on a gradual fading of therapist support (Mansueto et al., 1999). In the only controlled empirical work on the efficacy of cognitivebehavior therapy to decrease hair pulling, Ninan et al. (2000) compared cognitive-behavior therapy to clomipramine and a pharmaceutical placebo. The cognitive-behavioral treatment package included components such as habit reversal, stimulus control, coping skills training, cognitive restructuring, and relapse prevention techniques. The cognitive-behavioral
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treatment package was demonstrated to be significantly more effective than either clomipramine or placebo. There was not a statistically significant difference between clomipramine and placebo. Efficacy of treatment outcome was measured by self-report ratings of severity and impairment, as well as clinician ratings of treatment improvement which were completed by a clinician blinded to the treatment condition. These results represent the first published account demonstrating the superiority of cognitive-behavioral techniques over pharmacotherapy to decrease hair pulling. However, the first treatment utilized in this cognitivebehavioral treatment package was habit reversal, therefore, the active components of the entire package cannot be easily delineated. The necessity of including additional treatment components to habit reversal has not been empirically verified. Although dissatisfaction with the acceptability and generality of habit reversal has been reported, it has not been demonstrated that additional cognitive components affect either of these variables. Furthermore, there is no evidence that cognitive variables cause, contribute to, or maintain hair pulling. Empirical work demonstrating that the addition of cognitive techniques to habit reversal significantly enhances outcome is necessary before adoption of these techniques can be recommended.
3.6. Treatment of Comorbid Thumb sucking Successful elimination of hair pulling has also been achieved by targeting treatment on a concurrent habit behavior, namely thumb sucking. Three studies examined the effects of applying an aversive taste treatment to the thumb and all obtained substantial decreases in both thumb sucking and hair pulling in children (Friman & Hove, 1987; Knell & Moore, 1988; Yung, 1993). Watson and Allen (1993) reported similar covariation between thumb sucking and hair pulling, noting a simultaneous reduction after the contingent application of a thumb splint. Although thumb sucking and hair pulling may reside in the same response class, this is not true for all individuals. In one study, a 6-year-old girl's thumb sucking was decreased to near zero levels with differential reinforcement and response cost procedures, but only a modest decrease was noted in her hair pulling (Long et al., 1999). Once the hair pulling was targeted directly, it also rapidly decreased to near zero levels (Long et al., 1999). Further research to clarify the nature of the observed response covariation is needed.
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There are many potential explanations of why hair pulling may decrease even when it is not the primary target of treatment. Friman and Hove (1987) speculated that the covariation between hair pulling and thumb sucking may be explained by both behaviors belonging to the same response class or as part of the same behavioral chain. Given this, one would expected that both behaviors would respond to the same deceleration techniques, as well as increase in response to the same exacerbating conditions (Elliott & Fuqua, 2000). Alternatively, interventions used to decrease thumb sucking may simultaneously increase the response effort necessary to pull hair (e.g., thumb splints). Finally, it is also possible that for some individuals, tactile stimulation (e.g., rolling the hair between fingers) is the primary sensory consequence that maintains hair pulling. Some of the interventions designed to reduce thumb sucking (application of a sticky substance to the thumb) may alter the sensory consequences for hair pulling, thus resulting in a decrease in both behaviors. Little is known about the effects of other comorbid conditions on decreasing hair pulling. Much of the work in this area has focused on pharamcological treatment of other diagnoses, such as Obsessive Compulsive Disorder. Further work on the effects of behavioral treatments targeting comorbid conditions, such as anxiety or depressive syndromes, would help elucidate any potential relationships between diagnostic categories as well as priorities for treatment planning.
4. FUNCTION-BASED TREATMENTS Selecting treatment strategies based on the presumed function of the target behaviors is a hallmark of behavioral approaches to treatment. However, there have been few reports of functional analyses of hair pulling in the literature. One study systematically manipulated conditions of social disapproval, demand, alone, and control with two hair puller's (Miltenberger, Long, Rapp, Lumley, & Elliott, 1998). During the alone condition, both individuals engaged in more hair pulling and were observed to manipulate hair after they pulled it, which suggests the behavior was maintained through automatic reinforcement by sensory stimuli (Miltenberger et al., 1998). Rapp et al. (1999) conducted a similar functional analysis and determined that hair pulling and hair manipulation occurred only when the participant, a 19 year old with mental retardation, was alone. Because hair manipulation
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always followed hair pulling, Rapp et al. hypothesized that the digital stimulation arising from hair manipulation was the reinforcing consequence for hair pulling. To test this hypothesis, Rapp et al. first provided previously pulled or cut hair for the participant to manipulate and then placed a latex glove on the participant's hand to attenuate the stimulation that resulted from hair manipulation. When hairs were available, the participant manipulated these hairs and did not pull her own hair. When the glove was worn, the participant ceased all hair pulling and hair manipulation. The results of this study demonstrated that hair pulling was maintained by digital stimulation arising from hair manipulation. Furthermore, the functional analysis conditions provide an avenue for two different functional treatments; the provision of alternative sensory stimulation to compete with hair pulling and the use of gloves to produce sensory extinction. Thus far, habit reversal has proven efficacious across a wide range of individuals, some of whom presumably had different controlling variables for hair pulling. This generality of treatment effectiveness could be a result of three processes. First, if treatment failures were not submitted or published in scholarly journals, then we might derive an inflated sense of the efficacy and generality of an intervention such as habit reversal. Second, for the vast majority of TCM cases, especially those treated with habit reversal, hair pulling may fall within the same functional response class (although this is seldom empirically tested in the treatment literature) thus producing reliable results. The limits of habit reversal would be discovered if it failed to produce treatment gains when applied to hair pulling that was maintained by contingencies that deviated from those found in past reliable research. Finally, it may also be the case that habit reversal is analogous to a punishment procedure that is superimposed over a set of unanalyzed contingencies maintaining the hair pulling. The latter situation would be a serious problem if 1) treatment effects were seldom maintained after termination of the habit reversal procedure thus suggesting that whatever contingencies were maintaining hair pulling prior to treatment were still operational or 2) if habit reversal were judged to be a highly intrusive intervention thus accentuating the need for less intrusive alternative treatments based on the function of the hair pulling.
5. CONCLUSIONS Based on the literature, hair pulling appears to be responsive to behavioral interventions, with habit reversal as the most promising intervention. Habit
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reversal has been shown to be effective with children and adults of varying levels of severity, but the limits of this treatment intervention have yet to be established. Some have questioned the generality and acceptability of the procedure and have suggested supplementing the procedure with additional treatment components (Rothbaum & Ninan, 1999). The necessity of these additional components has not been demonstrated empirically. The literature base on TCM is growing, however, the limitations of the majority of studies qualify the conclusions that can be drawn from this body of research. Attempts should be made to use direct observation or response product measures as the primary dependent variables whenever possible. Furthermore, the need for larger-scale clinical outcome trials is great. Although this type of research is difficult, given the prevalence of TCM, it should be considered a high priority. The next frontier for TCM research should be increased movement towards functional assessment and treatment of hair pulling. Information on the function of hair pulling could relate to prevention, early intervention, and matching treatment to various functional classes of hair pulling. This type of information could also answer questions about the underlying nature of TCM. In particular, questions about whether the disorder should be conceptualized along a continuum of severity or if distinct subtypes of hair pulling exist.
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Robleck, T. L., Detweiler, M. F., Fearing, T., & Albano, A. M. (1999). Cognitive behavioral treatment of trichotillomania in youth: What went right and what went wrong? Cognitive and Behavioral Practice, 6, 154-161. Rodolfa, E. R. (1986). The use of hypnosis in the multimodal treatment of trichotillomania: A case report. Psychotherapy in Private Practice, 4, 51-58. Rogers, P., & Darnley, S. (1997). Self-monitoring, competing response and response cost in the treatment of trichotillomania: A case report. Behavioural and Cognitive Psychotherapy, 25, 281-290. Rosenbaum, M. S. (1982). Treating hair pulling in a 7-year-old male: Modified habit reversal for use in pediatric settings. Developmental and Behavioral Pediatrics, 3, 241-243. Rothbaum, B. O., & Ninan, P. T. (1999). Manual for the cognitive-behavioral treatment of trichotillomania. In D. J. Stein, G. A. Christenson, & E. Hollander (Eds.), Trichotillomania (pp. 263-284). Washington, DC: American Psychiatric Press. Sanchez, V. (1979). Behavioral treatment of chronic hair pulling in a two year old. Journal of Behavior Therapy and Experimental Psychiatry, 10, 241-245. Stanley, M. A. (1999). Broadening the approach to treatment of trichotillomania in youth. Cognitive and Behavioral Practice, 6, 161 -163. Stanley, M. A., Bowers, T. C, Swann, A. C, & Taylor, D. J. (1991). Treatment of trichotillomania with fluoxetine. Journal of Clinical Psychiatry, 52^ 282. Stein, D. J., Bouwer, C, Hawkridge, S., & Emsley R. A. (1997). Risperidone augmentation of serotonin reuptake inhibitors in obsessive-compulsive and related disorders. Journal of Clinical Psychiatry, 58, 119-121. Stein, D. J., & Hollander, E. (1992). Low-dose pimozide augmentation of serotonin reuptake blockers in the treatment of trichotillomania. Journal of Clinical Psychiatry, 53, 123-126. Streichenwein, S. M., & Thomby, J. I. (1995). A long-term, placebo-controlled crossover trial of the efficacy of fluoxetine for trichotillomania. American Journal of Psychiatry, 152, 1192-1196. Swedo, S. E., Leonard, H. L., Rapoport, J. L., Lenane, M. C, Goldberger, B. A., & Cheslow, B. A. (1989). A double-blind comparison of clomipramine and desipramine in the treatment of trichotillomania (hair pulling). New England Journal of Medicine, 321, 497501. Swedo, S. E., Lenane, M. C, & Leonard H. L. (1993). Long-term treatment of trichotillomania (hair pulling). New England Journal of Medicine, 329, 141-142. Tarnowski, K. J., Rosen, L. A., McGrath, M. L., & Drabman, R. S. (1987). A modified habit reversal procedure in a recalcitrant case of trichotillomania. Journal of Behavior Therapy & Experimental Psychiatry, 18, 157-163. Vitulano, L. A., King, R. A., Scahill, L., & Cohen, D. J. (1992). Behavioral treatment of children and adolescents with trichotillomania. Journal of American Academic Child and Adolescent Psychiatry, 31, 139-146. Watson, T. S., & Allen, K. D. (1993). Elimination of thumb-sucking as a treatment for severe trichotillomania. Journal of the American Academy of Child and Adolescent Psychiatry, 32, 830-834. Winchel, R. M., Jones, J. S., Stanley, B., Molcho, A., & Stanley, M. (1992). Clinical characteristics of trichotillomania and its response to fluoxetine. Journal of Clinical Psychiatry. 53, 304-308.
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Woods, D. W., & Miltenberger, R. G. (1995). Habit reversal: A review of application and variation. Journal of Behavior Therapy & Experimental Psychiatry, 26, 123-131. Woods, D. W., & Miltenberger, R. G. (1996). A review of habit reversal with childhood habit disorders. Education and Treatment of Children, 19, 197-214. Yung, P. M. B. (1993). Treatment for trichotillomania. Journal of the American Academy of Child and Adolescent Psychiatry, 32, 878.
Chapter 9 Habit Reversal Treatment Manual for Trichotillomania Raymond G. Miltenberger North Dakota State University
1. OVERVIEW OF HABIT REVERSAL FOR TRICHOTILLOMANIA This chapter describes the use of habit reversal for the treatment of trichotillomania in children, adolescents, and adults. Azrin and Nunn developed habit reversal in 1973 for the treatment of a variety of habits including hair pulling (Azrin, Nunn, & Frantz, 1980). A number of studies have shown habit reversal to be an effective procedure for trichotillomania (for a review see Chapter 8 and Elliott & Fuqua, 2000). Habit reversal is comprised of three main treatment components: awareness training, in which the client learns to become aware of each instance of hair pulling; competing response training, in which the client learns to engage in an incompatible behavior contingent on hair pulling or antecedents to hair pulling; and social support, in which a significant other helps the client successfully use the competing response to control the hair pulling (e.g., Rapp, Miltenberger, Long, Elliott, & Lumley, 1998). The protocol outlined below describes the details of habit reversal applied to trichotillomania.
2. TREATMENT PROTOCOL Habit reversal is typically conducted in one or a small number of outpatient treatment sessions. The initial session is devoted to assessment. The habit reversal protocol is then implemented in the second session. The client learns the treatment protocol in session and implements the treatment
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procedures whenever hair pulling occurs outside of the sessions. Subsequent sessions (often referred to as booster sessions) are used to review the client's progress, review the treatment protocol, and engage in any problem solving related to the correct use of the procedures.
2.1 Session 1 In the first session, the therapist conducts a functional assessment interview with the client to better understand the nature of hair pulling, its antecedents, and consequences. Standardized assessment instruments may also be used to assess the hair pulling as well as to assess possible comorbid conditions. Finally, the therapist provides self-monitoring instructions for the client to record hair pulling outside of the session.
2.1.1 Functional Assessment Interview The goal of the functional assessment interview is to derive information from the client about the specific behaviors involved in hair pulling and the overt and covert antecedents and consequences associated with instances of hair pulling (e.g., Miltenberger, Long, Rapp, Lumley, & Elliott, 1998). This information will allow the therapist to better understand the circumstances in which hair pulling occurs, and the possible reinforcing consequences for hair pulling. In the initial interview the therapist will also ask about the onset of hair pulling, events associated with the onset, and the course of hair pulling since its onset. To assess the specific behaviors involved in hair pulling, the therapist asks the following types of questions: "Please describe how you pull your hair." "Are there any other ways that you pull your hair?" "Show me exactly how you pull your hair, without actually pulling one out." "Show me the behaviors involved in hair pulling from start to finish." "What do you do with the hair after you pull it?"
The therapist asks such questions until all of the behaviors involved in the hair pulling have been described objectively and demonstrated by the client. To assess the antecedents of hair pulling, the therapist asks the client to describe the circumstances in which hair pulling occurs (overt antecedents)
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and the client's subjective experiences prior to each instance of hair pulling (covert antecedents). Information on the antecedents is important for the correct implementation of treatment. To assess overt antecedents, the therapist asks the following types of questions: "When do you pull your hair?" "Where do you pull your hair?*' "What are you doing when you pull your hair?" "In what situations do you pull your hair?"
To assess covert antecedents, the therapist asks the following types of questions: "What are you feeling when you start to pull your hair?" "What feelings or emotions do you experience when you start hair pulling?" "What are you feeling or thinking when you get an urge to pull your hair?"
Because hair pulling is reported to occur when individuals experience negative emotions such as anxiety, worry, tension, or stress, the therapist should ask questions to assess these experiences. To assess the consequences of hair pulling, the therapist asks about the reactions of others and the client's own subjective experiences each time hair pulling occurs. Information on how others react to hair pulling will help determine whether hair pulling is being reinforced by attention, escape or avoidance of specific activities, or some other socially-mediated consequences. Information on the client's subjective experiences will help determine whether hair pulling provides relief from some negative experience such as tension or worry or whether hair pulling provides a type of pleasant sensory stimulation. To assess social consequences, the therapist asks the following types of questions. "How do people react to you when you pull your hair?" "What do people say or do when they observe you pull your hair?" "Do people react to you in any specific way when they see you pull your hair?"
Based on the answers to these types of questions about social consequences of hair pulling, the therapist can form hypotheses about possible social reinforcement for the behavior. For example, if the client receives reprimands or statements of concern each time she pulls her hair.
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the therapist may hypothesize that attention is a reinforcing consequence for hair pulling. To assess the covert consequences of hair pulling, the therapist asks the following types of questions. "How do you feel as you are pulling your hair?" "You said you were feeling (tense, worried, stressed) before pulling your hair. How do these feeling change as you are pulling your hair?" "How would you describe the sensation you get from hair pulling?"
Based on the answers to these types of questions about covert consequences of hair pulling, the therapist can form hypotheses about the automatic reinforcing function of the behavior. For example, if the client reports hair pulling when experiencing tension and reports some relief from the tension while hair pulling, the therapist may hypothesize that tension relief negatively reinforces hair pulling.
2.1.2 Assessment of Comorbid Conditions The therapist may decide to employ any of a number of standardized assessment instruments with the client to assess possible comorbid conditions that might influence treatment. The therapist could use a general screening instrument to assess a range of possible comorbid conditions or one or more instruments to assess specific disorders such as depression, generalized anxiety disorder, or obsessive-compulsive disorder (OCD).
2.1.3 Homework Before the first session is finished, the therapist assigns the client a number of assessment activities to be completed and brought to the second session. These include paper and pencil self-report measures of hair pulling and a self-monitoring assignment to record hair pulling that occurs outside of the sessions.
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2.1.3.1 Self-report Measures A number of self-report measures have been developed to assess the client's experience associated with hair pulling (e.g., Stanley & Mouton, 1996; Rothbaum, Opdyke, & Keuthen, 1999). These paper and pencil instruments provide a measure of a number of factors such as frequency of urges to pull hair, frequency of hair pulling, ability to resist urges, and distress associated with hair pulling. Two such measures are the Hair Pulling Survey (Stanley, Borden, Bell, & Wagner, 1994) and the Massachusetts General Hospital Hairpulling Scale (Keuthen et al., 1995). The therapist can assign one or more of these self-report measures for the client to complete and bring back to the second session. The therapist may then have the client complete such measures each week during the treatment period to assess changes associated with treatment.
2.1.3.2 Self-Monitoring Instructions Behavioral assessment of hair pulling is most often accomplished through self-monitoring by the client. Because hair pulling typically occurs when the client is alone, self-monitoring is often the only choice of direct behavioral assessment strategies. The goal of self-monitoring is for the client to record each instance of hair pulling as immediately as possible after it occurs. The client can carry out self-monitoring by writing down each hair pulling incident on a recording sheet or by using some other recording instrument, such as a wrist counter. The therapist provides the self-monitoring instructions and the recording sheet near the end of the first session. The recording sheet might simply have spaces to record the time involved in the hair pulling incident and the number of hairs pulled. Alternatively, the recording sheet might also have a space for recording the antecedents to hair pulling (e.g., Mouton & Stanley, 1996). The therapist needs to develop a recording sheet to match the ability and motivation of the client to engage in.self-monitoring. In most cases, the easier the recording assignment, the more likely the client is to complete the assignment successfully. An example of self-monitoring instructions the therapist might provide follows: *'It is important for us to get an accurate idea of exactly how many hairs you pull each day before we start treatment and during treatment so that we can determine how effective the treatment is. In order to do this, I am going to ask you to record
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Tic Disorders, Trichotillomania, and Repetitive Behavior Disorders your hair pulling each day. I have a recording sheet for you to use to record your hair pulling. Each time you pull your hair, write down the time you started, the number of hairs you pulled, and the time you stopped. Keep the recording sheet with you or in the location that you typically pull your hair, so that you can record your hair pulling immediately after you start. Recording immediately is important so that you don't forget or have to rely on your memory to record later."
2.1.3.3 ABC Recording In addition to recording the number of hairs pulled each day, it is also valuable for the client to periodically conduct recording of the antecedents and consequences of hair pulling. Recording antecedents and consequences (ABC recording) will help confirm the information received during the interview or provide new examples not disclosed in the interview. Because ABC recording is more time consuming than recording the frequency of hair pulling, the therapist will instruct the client to conduct ABC recording on a periodic basis such as once a day or a few times per week. To conduct ABC recording, the client writes down the overt and covert antecedents that were present when hair pulling occurred along with the overt and covert consequences of hair pulling. The therapist will provide the following type of instructions for ABC recording: "In addition to recording the number of hairs you pull each day, I also want you to record other experiences at the time you pull your hair. I want you to record what you are experiencing before and after hair pulling to better understand the factors that may contribute to your hair pulling. Because this type of recording will take more time, I am asking you to do it just once each day. During one hair pulling episode each day, I want you to record the situation in which you are pulling your hair. 1 also want you to record your thoughts and feelings just before you start to pull your hair. For example if you are alone in the living room with the TV on and you are worrying about an upcoming event, write this information down in this space under antecedents (therapist points to the space on the recording sheet). I also want you to record what you experienced after pulling your hair. For example, if you felt less worried or experienced some relief from stress, write this information down in the space under consequences."
2.1.4
Identifying the Social Support Person
Before the client leaves the first session, the therapist informs the client that the habit reversal treatment to be implemented in the second session involves the assistance of a social support person. The therapist asks the
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client to identify a social support person who can help the client implement the treatment. The therapist then indicates that the social support person should accompany the client to the next session. The client must choose a relative or friend who has frequent daily contact with the client. For a child, the social support person is typically a parent, and possibly an adult relative or older sibling living in the home. Sometimes, a teacher may serve as a social support person for the child at school. For an adult, the social support person may be a spouse, partner, or roommate. In some cases, a coworker may serve as a social support person. If the social support person does not already know about the client's hair pulling, the client must be comfortable disclosing the problem with hair pulling and asking the person to participate in the treatment. The social support person must be willing to assist in ways described below.
2.2 Session 2 In the second session, the therapist reviews the client's recording homework and begins implementing the habit reversal procedures with the client.
2.2.1 Collect and Review Homework Data The therapist starts by providing the client with an overview of the session to let the client know they will first review the recording assignments and will then begin treatment. Review of the client's homework emphasizes the importance of assessment in the therapy process. The therapist first reviews the self-report measures with the client by going through each questionnaire, reviewing the client's responses and asking the client if there are any questions. The therapist then reviews the client's self-monitoring of the number of hairs pulled each day. The therapist asks the client if there were any problems carrying out self-monitoring and whether the recording occurred at the time of hair pulling or at some later point in time. The therapist may ask the client questions about the circumstances in which hair pulling occurred and the client's experiences before and after hair pulling each day in order to complement the information on antecedents and consequences obtained in the interview. The therapist then graphs the number of hairs pulled each day so the client can see the results. Graphing further emphasizes the importance of accurate self-monitoring. Finally, the
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therapist reviews the client's ABC recording to gather further information on antecedents and consequences of hair puHing.
2.2.2 Implement Habit Reversal Procedures Once the review of homework is complete, if the behavioral assessment results do not indicate any social function for hair pulling, the habit reversal procedures are implemented. If a social function is identified, the therapist would implement the habit reversal procedures in conjunction with contingency management procedures described in section 4.1. The therapist starts by providing an overview of the habit reversal treatment components and then implements each treatment component in sequence.
2.2.2.1 Inconvenience Review Habit reversal starts with an inconvenience review as a way to motivate the client to comply fully with the treatment protocol in an attempt to eliminate the behavior. Inconvenience review simply involves the therapist asking the client to identify all of the ways in which the hair pulling has caused embarrassment, inconvenience, or distress, thus negatively impacting his or her life. For example some clients are embarrassed when others see the areas of hair loss resulting from their hair pulling. Some are inconvenienced on a daily basis as they spend substantial time fixing their hair or wearing hats in an attempt to cover the areas of hair loss. Some are distressed by their inability to control the behavior as they pull hair even though they want to stop. In most cases, the client will describe a variety of ways in which the hair pulling causes embarrassment, inconvenience, or distress. After this information is disclosed, the therapist helps the client see how life will improve after hair pulling is decreased or eliminated.
2.2.2.2 Awareness Training The goal of awareness training is to help the client identify each instance of hair pulling or the antecedents to hair pulling so he or she can successfully carry out the competing response component of habit reversal.
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2.2.2.2.1 Rationale The therapist must provide a rationale for the importance of awareness training to increase the likelihood that the client will comply with the procedure. A sample rationale for awareness training is provided below. "Because you report you are often not aware you are pulling your hair until after you have already pulled out a number of hairs, teaching you to become aware of the behavior is important in helping you control the behavior. I will be teaching you an alternative behavior to replace hair pulling and to use this strategy successfully, you must be aware each time you pull a hair or you are about to pull a hair. The success of this treatment depends on your awareness of each occurrence of the behavior."
2.2.2.2.2 Describing Hair Pulling After providing a rationale for awareness training, the next step in the process is to have the client describe the hair pulling. Because the client has already described the behavior in detail in the initial assessment interview, the therapist simply reviews the description of the behavior at this time. It is important for the therapist to understand all of the ways in which hair pulling occurs and the precursor behaviors to hair pulling (for example stroking or playing with hair before pulling). The client has an opportunity to add any further information after the therapist reviews the information obtained in the first interview.
2.2.2.2.3 Describing Preceding Sensations and Situations In addition to describing the hair pulling and precursor behaviors, the client is asked to describe any covert experiences (sensations, feelings, thoughts) that may precede hair pulling. At this time, the therapist will review any information obtained in the first interview or from the selfmonitoring and ask the client for confirmation or additional information about covert antecedents. The therapist also reviews the situations in which hair pulling occurs and asks for any further details to help the client understand all of the situations in which hair pulling is most likely. The therapist asks about covert and overt antecedents so that the client can become aware of thoughts and feelings (or other experiences) or situations that can serve as warning signs that hair pulling is likely to occur.
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1222A
Simulating Hair Pulling Movements
After the client has fully described the hair pulling movements and the sensations that precede the behavior (response description), the next step in awareness training is to practice detecting each occurrence of hair pulling (response detection). Because clients are not likely to pull their hair in presence of the therapist in the session, the client must simulate the behavior in the session. The therapist informs the client that simulating the hair pulling movements a number of times in session will make the client more aware of the behavior when it occurs outside of the session. The therapist then asks the client to act out an instance of hair pulling from start to finish in the exact way it typically occurs. After the client engages in the hair pulling movements, the therapist asks if there are any other ways in which the behavior occurs. If so, the client is asked to simulate the behavior to illustrate the different ways hair pulling might occur. After the client has simulated the full range of hair pulling movements, including the precursor behaviors, the therapist will have the client simulate different situations in session and demonstrate how hair pulling occurs in those situations. For example, the client will sit at a desk with elbows on the table and hands touching the face and simulate the behavior from this position. The client may then sit back in a chair with hands in lap as if watching television and simulate the behavior in this position. By simulating the hair pulling in as many different situations as possible, the client is more likely to be aware of the start of the hair pulling behavior when those situations arise outside of the session. The therapist will also ask the client to simulate covert antecedents to hair pulling and initiate the hair pulling movement. For example, if the client pulls her hair in response to thinking negative thoughts, the therapist will ask the client to engage in that pattern of thinking and begin the hair pulling movement. Likewise, if the client engages in hair pulling when experiencing certain feelings, the therapist will ask the client to imaging those feelings and begin the hair pulling movement. The point of this exercise is to increase the client's awareness of the covert antecedents to hair pulling in the hope that the client will recognize them when they occur outside of the session. While the client is simulating the hair pulling movements, the therapist will instruct the client to stop at various points in the movement to notice the sensations involved in the behavior. For example as the client first touches her hair with her fingertips, the therapist will have her stop and notice the
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sensations of her hair on her fingers. The therapist may tell the client to stop when the hand is just lifted off of the lap and have the client notice the feeling of the movement as the behavior is just starting. By stopping the hair pulling movements at many different points in time, the client should become more aware of the movement as soon as it starts, and thus be able to more successfully implement the competing response before a hair is actually pulled.
2.2.2.3 Competing Response Training Once awareness training is complete, the therapist implements competing response training. The goal of competing response training is to teach the client to engage in an incompatible behavior (the competing response) contingent on the occurrence of hair pulling or antecedents to hair pulling.
2.2.2.3.1 Rationale The first step in implementing competing response training is to provide a rationale so the client understands and is motivated to comply with the procedure. An example of a rationale follows: "Now that we have completed awareness training exercises, the hope is that you will be aware of each instance of hair pulling as soon as you begin to engage in the behavior outside of the session. In this next phase of treatment I am going to teach you to engage in a competing response to take the place of hair pulling. The competing response is a simple behavior involving your hands that is incompatible with hair pulling. If you engage in the competing response as soon as you catch yourself starting to pull your hair or before you actually pull a hair, then the use of the competing response will prevent hair pulling. Essentially, you replace hair pulling with this new behavior. First we will choose one or more competing responses and then practice the use of the competing response in the session until you are comfortable using it."
2.2.2.3.2 Choosing the Competing Response(s) To choose a competing response, the therapist tells the client that they need to decide on a behavior involving the hands that the client can carry out for about one minute wherever hair pulling typically occurs. The competing
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response should be easy to carry out, physically incompatible with hair pulling, and inconspicuous so that it does not draw attention to the client. Examples of competing responses include making a fist and holding the hand down at the side, folding the hands in the lap when sitting, grasping an object that is naturally found in the situation (e.g., a pencil for a student, a small toy for a child, the remote control for a person watching television), or putting the hands in pockets. The client may choose more than one competing response to be used in different situations. If the client pulls hair with only one hand, then the competing response will involve only that hand. If hair pulling occurs with either hand, then a competing response will involve both hands.
2.2.2.3.3 Practicing the Competing Response After the client has chosen one or more competing responses, the therapist has the client practice the use of the competing response in the session contingent on simulated hair pulling. "Now that you have chosen some competing responses to prevent your hair pulling, I am going to have you simulate hair pulling and practice using the competing response in session. I will have you simulate a variety of situations in which hair pulling occurs, start the hair pulling movements, and then immediately use the competing response instead. The point of this exercise is to catch yourself as you start to pull your hair, stop, and start the competing response to replace hair pulling. By practicing a number of times in session, it will become more natural for you, and you will be more likely to catch yourself outside of the session as you start to pull hair, stop, and use the competing response immediately to replace the behavior."
The therapist then describes a typical hair pulling situation for the client to simulate (e.g., sitting at a table reading a magazine) and has the client begin the hair pulling movement and use the competing response as soon as the client's hand touches her hair. The therapist will repeat this process by having the client simulate other situations (as indicated in the assessment interview), begin hair pulling movements, and use the competing response. In each practice, the client should use the competing response for about one minute to simulate how long the competing response should be used outside of the session. As the practice exercises continue, the therapist will have the client stop the hair pulling movements earlier and use the competing response. For example, the therapist will tell the client to stop as her hand is near her head but not yet touching it and use the competing response. In subsequent
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practice the therapist will have her stop as her hand is raised to her shoulder, as her hand is raised off of her lap, and finally before her hand even moves off of her lap after she thinks about starting to pull her hair. In each case, the client uses the competing response contingent on these incipient hair pulling movements. Continued practice of the competing response will occur in response to overt and covert antecedents to hair pulling. For example, if reading a magazine is an antecedent to hair pulling, the therapist will have the client practice the competing response while reading the magazine before any hair pulling movements occur. If worrying is an antecedent to hair pulling, the therapist will have the client think specific worrisome thoughts and then engage in the competing response for about one minute before any hair pulling movements occur. After the client has practiced the use of the competing response contingent on hair pulling, incipient hair pulling movements, and antecedents to hair pulling, the therapist provides instructions for the client to use the competing response outside of the session just as it was practiced in session. The therapist reminds the client that the success of the procedure in decreasing or eliminating hair pulling depends on the consistent use of the competing response outside of the session.
2.2.2.4 Social Support Training The purpose of social support is to enlist the assistance of a significant other to help the client use the competing response successfully outside of the session. The social support person reminds the client to use the competing response when hair pulling is observed, praises the client for correctly using the competing response, and praises the client for successfully refraining from hair pulling. After the therapist completes the competing response training component of habit reversal, the therapist asks the social support person to join the client in the therapy session. In some cases, the social support person may be present for the entire session. For example, if the client is a child, a parent may function as the social support person and be present in the entire session.
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2.1.2AA Rationale The rationale for the use of social support is that the client will be more successful using the competing response to control hair pulling if a significant other in the client's life can provide assistance. The therapist explains that the client may forget to use the competing response on occasion or may find it difficult if urges to engage in hair pulling are strong. In such cases, reminders from the social support person can help the client use the competing response more consistently. Furthermore, praise and approval from the social support person can motivate the client to continue using the procedures.
2.2.2.4.2 Practicing Social Support After providing the rationale for social support, the therapist tells the social support person how to implement the procedures and then asks the support person to practice the procedures with the client in session. At this point, the therapist asks the client to simulate hair pulling but fail to use the competing response so that the social support person has a chance to remind the client to use the competing response. Next, the therapist asks the client to simulate hair pulling, but to stop the behavior and use the competing response so that the social support person can practice praising the client for using the competing response. The therapist will also have the client simulate a situation in which hair pulling usually occurs and have the client refrain from hair pulling. This provides an opportunity for the social support person to praise the client. The therapist will have the client and social support person repeat this process a number of times so that the social support person gets practice delivering each of the components of social support approximately ten times. As they are practicing, the therapist will praise the social support person for correctly delivering social support and will provide corrective feedback when social support is not delivered correctly.
2.2.2.5 Homework After the therapist has provided awareness training, competing response training, and social support training in the session, the therapist will deliver the homework assignment. Homework consists of two components;
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instructions to use the habit reversal procedures outside of the session and continued self-recording. The therapist tells the client to work on identifying the occurrence of hair pulling movements as soon as they occur in all situations outside of session. The therapist also tells the client to be vigilant of antecedents to hair pulling, both covert antecedents (thoughts and feelings) and overt antecedents (situations or precursor behaviors). The therapist further tells the client to use the competing response whenever hair pulling movements occur, an urge to pull hair occurs, or any of the antecedents to hair pulling occur outside of the session. The therapist emphasizes the importance of catching hair pulling before it occurs and replacing it with the competing response. Finally, the therapist tells the social support person to consistently deliver reminders and praise at the appropriate time to help the client use the competing response successfully. Lastly, the therapist instructs the client to continue self-monitoring hair pulling as the client did between the first and second sessions. The therapist will provide the client with a new recording sheet for use in the upcoming week and will tell the client to bring the completed self-monitoring sheet to the next session. The therapist will also give the client the self-report questionnaires that the client completed previously. The therapist tells the client to complete these self-report instruments and return them at the next session. The therapist emphasizes the importance of the recording assignments for evaluating progress as the client is using the habit reversal procedures in the upcoming week.
2.3. Session 3 - X Session 3 and beyond are booster sessions in which the therapist reviews the client's progress, reviews and practices treatment procedures, and engages in any needed problem solving with the client.
2.3.1 Collect and Graph Data At the beginning of Session 3 (and each subsequent session), the therapist collects the client's homework recording assignments and reviews the data with the client. The therapist will compare the self-report questionnaire results with results of the questionnaires completed previously and discuss progress with the client. The therapist will also review the daily recording of
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hair pulling with the client and graph the number of hairs pulled each day using the graph from Session 2. At this point, the therapist discusses the client's self-recording, asking questions about the recording process and about the results. It is important for the therapist to identify any problems the client may be having carrying out the recording assignments so they can be fairly certain the client is recording consistently and presenting an accurate picture of the hair pulling. As the therapist and client review the results of self-recording, the therapist can identify any difficulties the client had in controlling the hair pulling. They will then discuss ways to address any difficulties the client may have experienced. 2.3.2 Review of Treatment / Problem Solving After reviewing the homework assignments, the therapist will review the habit reversal treatment components with the client (and possibly the social support person). After reviewing the procedures, the therapist will have the client simulate hair pulling and demonstrate the procedures in session a few times. The therapist will then ask the client (and social support person) to describe how she is implementing the procedures on a day-to-day basis and whether there are any difficulties implementing the procedures successfully. The therapist will ask questions such as: "Are you using the competing response each time you start to pull your hair?" "What are the circumstances in which you don't use the competing response consistently?" "Are there any situations or circumstances in which you don't catch yourself pulling your hair until you have already pulled out some hairs?" "Do you ever find that you catch yourself pulling your hair but fail to use the competing response immediately?' "I noticed on (specific day) that you pulled many more hairs than on the other days. Tell me what was happening on (specific day) when you pulled your hair. Tell me what you were thinking or feeling on this day when you pulled your hair." "I noticed on (specific day) that you didn't pull any hairs. Tell me what was happening on this day that may have contributed to your success." "Are there any situations in which the urge to pull hair is too strong to resist?" (To social support person) "Are you having any difficulties providing praise for using the competing response or reminders to use the competing response as we had discussed?"
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Depending on the answers to these and other questions, the therapist will help the client identify difficulties with the implementation of the competing response and social support procedures and will work with the client to find solutions.
3. THERAPIST CHECKLIST A checklist of the habit reversal procedures for use by therapists implementing the procedures with clients with trichotillomania is provided in Appendix A.
4. ANCILLARY PROCEDURES/CONCERNS In addition to the use of the habit reversal procedures described above, the therapist may choose to address other issues or implement a number of ancillary procedures as dictated by the needs of the particular client.
4.1 Focus on ABC's of Hair Pulling Information on antecedents and consequences of hair pulling is gathered from the functional assessment interview and the client's ABC recording. Information on the antecedents is incorporated into the habit reversal treatment as the client learns to become aware of the overt and covert antecedents and implement the competing response in those situations to prevent hair pulling. Information on the consequences may also be incorporated into treatment as an adjunct to the habit reversal treatment. If the therapist hypothesizes that some form of social reinforcement (i.e., attention, escape) is contributing to hair pulling, then procedures would be implemented to eliminate or attenuate this source of reinforcement. For example, if it appears that a parent is responding to a child's hair pulling with attention, then the therapist will instruct the parent to withhold attention following hair pulling and provide attention at other times (consistent with social support instructions). On the other hand if it appears that hair pulling is allowing the child to avoid or escape from some tasks or activities, the therapist will instruct the parent to require the child to engage in the task or activity regardless of the presence of hair pulling (thus eliminating the reinforcing consequence for hair pulling).
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If it appears that the client's hair pulling is being maintained by the sensory stimulation to the fingers (e.g., Rapp, Miltenberger, Galensky, Ellingson, & Long, 1999), then the therapist may implement procedures to mask the stimulation in an attempt to produce sensory extinction. For example, the therapist may have the client wear small adhesive bandages on the fingers involved in hair pulling in order to mask the stimulation arising to the fingers during hair pulling. Likewise, the therapist might instruct the client to manipulate another socially appropriate object to produce the same type of stimulation to the fingers produced by hair pulling. For example, a recent twelve-year old client who pulled his eyebrow and eyelash hair during school wore a name tag around his neck on a string (as required by the school) and manipulated the name tag as a competing behavior to hair pulling.
4.2 Relaxation Training Relaxation training may be a useful adjunct to habit reversal treatment for trichotillomania, especially when the client reports the presence of tension or anxiety as an antecedent to hair pulling. If the tension or anxiety can be alleviated through relaxation training, then the client will not need to pull her hair to produce relief from the tension or anxiety. The therapist should assess the role of tension or anxiety in the initial assessment and in the client's ongoing data collection to determine whether relaxation training appears warranted. There are a number of relaxation training approaches that the therapist can choose for use with the client, including progressive muscle relaxation, visualization exercises, breathing exercises, or attention focusing exercises (e.g., Miltenberger, 2001).
4.3 Compliance Issues Although research has shown that habit reversal can be an effective treatment for trichotillomania, some research has shown that it may be ineffective with younger children or individuals with mental retardation (Long, Miltenberger, Ellingson, & Ott, 1999; Long, Miltenberger, & Rapp, 1999; Rapp, Miltenberger, Galensky, Roberts, & Ellingson, 1999; Rapp, Miltenberger, & Long, 1998). In such cases, the ineffectiveness of habit reversal is likely due to the failure of the client to implement the competing response consistently. Noncompliance with the instructions to use the
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competing response may be due to a lack of motivation or inability to carry out the procedure. In such cases, ancillary procedures are warranted. One type of ancillary procedure is to provide additional social support in the form of contingencies for the correct use of the competing response. For example, Long and colleagues (Long, Miltenberger, Ellingson, et al., 1999; Long et al., 1999) used token reinforcement for the correct use of the competing response and for the absence of hair pulling with a young child and with adults with mental retardation after habit reversal failed to produce lasting decreases in hair pulling. Furthermore, Long and colleagues used a response cost procedure in which a token was removed whenever hair pulling was observed. The combination of reinforcement and response cost procedures produced lasting decreases in hair pulling. Finally, we have found that, when working with children who pull their hair while alone, the parents' use of social support can be enhanced if they frequently drop in on the child. Parents are instructed to make frequent unannounced checks on their child to record hair pulling and to provide praise and prompts as needed.
4.4 Awareness Enhancement In addition to the use of ancillary procedures that address the function of hair pulling, one other complementary treatment is to enhance the client's awareness of the hair pulling. If the client is acutely aware of each instance of hair pulling, then the use of the competing response is more likely to be successful. There have been two approaches to enhancing awareness. One approach involves the use of an awareness enhancement device that sounds an alarm each time the client reaches up to pull hair. Rapp et al., (1998) developed an electronic awareness enhancement device consisting of a unit worn near the neck and a unit worn on each wrist. When the client raised her hand to pull her hair, the proximity of the wrist unit to the neck unit activated an alarm in the neck unit. The alarm did not stop until the arm was lowered and the two units were no longer in close proximity. This device has been found to be effective in eliminating hair pulling exhibited by one woman with mental retardation (Rapp, Miltenberger, & Long, 1998) and thumb sucking exhibited by three children (Ellingson, et al., 2000, Strieker et al., 2000). Risvedt and Christenson (1996) utilized another approach to awareness enhancement. They applied a topical cream (capsaicin) to the scalp of a woman with trichotillomania. Capsaicin increased the sensitivity to the woman's scalp, thus increasing her awareness of each instance of hair
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pulling After finding that habit reversal was not effective, the use of capsaicin led to the elimination of hair pulling.
4.5 School Settings Habit reversal treatment for hair pulling may be more difficult to carry out for children in the school setting. The student may not be aware of some instances of hair pulling because he or she is concentrating on the teacher or on school work. Furthermore, social support cannot be implemented in the school setting if the parent is the sole social support person. In an attempt to overcome these difficulties, the therapist can have the student practice the competing response following hair pulling or antecedents to hair pulling in a variety of simulated school situations in the session. The therapist can also have the student enlist the assistance of a peer or the teacher as a social support person at school. Care must be taken to choose a peer that is reliable and sensitive to possible embarrassment that could result from disclosure of the student's hair pulling. If a teacher agrees to serve as a social support person, the therapist would ask the teacher to provide praise or prompts in an unobtrusive manner so that attention was not drawn to the student.
4.6 Self-Monitoring As indicated above, self-monitoring is typically used as a form of data collection so that changes in hair pulling can be documented over the course of treatment. In addition to self-monitoring the number of hairs pulled each day, the client could also monitor outcomes such as hair re-growth. For example, the client who pulls his eye brow hair could rate degree of fullness of the eyebrows using a 5 point rating scale (l=no hair at all, 5=hair completely filled in). A 12-year old client currently in treatment who pulls hair from his eyebrows and eyelashes is using such a scale on a daily basis. He and his mother complete the 5 point scale independently each evening after they both observe his eyebrows and eyelashes in the mirror. Their ratings have never varied by more than 1 point, suggesting that they are using the rating scale reliably. The client reports that he is less likely to pull his hair because he knows that he will be rating the appearance of his eyebrows and eyelashes every day. Thus self-monitoring can serve a motivational function as well as a data gathering function.
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4.7 Depression/Anxiety Disorders/OCD in Persons with Trichotillomania Because depression, anxiety disorders, and OCD are common comorbid conditions associated with trichotillomania (Christenson, 1995; Swedo & Leonard, 1992), a therapist providing treatment for trichotillomania may also need to provide treatment (or a referral) for one of these conditions as well. Fortunately, there is substantial empirical support for behavioral treatments for depression, anxiety disorders, and OCD (e.g., Barlow, 1993; Watson & Gresham, 1998). Although descriptions of behavioral treatments for depression, anxiety disorders, and OCD is beyond the scope of this book, the therapist is encouraged to be vigilant for symptoms of these (and possibly other) disorders and provide appropriate treatment or referral as needed. In many cases, the therapist may uncover the client's problem with hair pulling after the client has sought treatment for another psychological disorder. However, in some cases, the client may present with trichotillomania and the therapist may identify the presence of depression, anxiety disorders, OCD, or some other disorder in the process of providing treatment for trichotillomania. Concurrent treatment for the other identified disorder(s) is then warranted.
5. REFERENCES Azrin , N. H, & Nunn, R.G. (1973). Habit reversal: A method of eliminating nervous habits and tics. Behaviour Research and Therapy, 11, 619-628. Azrin, N. H., Nunn, R. G., & Frantz, S. E. (1980). Treatment of hair pulling (trichotillomania): A comparative study of habit reversal and negative practice training. Journal of Behavior Therapy and Experimental Psychiatry, 11, \ 3-20. Barlow, D. H. (1993). Clinical handbook of psychological disorders: A step by step treatment manual (2'"' edition). New York: Guilford. Christenson, G. A., (1995). Trichotillomania-from prevalence to comorbidity. Psychiatric Times, 12, 44-48. Ellingson, S., Miltenberger, R. G., Strieker, J., Garlinghouse, M., Roberts, J., & Galensky, T. (2000). Functional analysis and treatment of finger sucking. Journal of Applied Behavior Analysis, 33,41-52. Elliott, A., & Fuqua, R. W. (2000). Trichotillomania: Conceptualization, measurement, and treatment. Behavior Therapy, 31, 529-545.
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Keuthen, N. J., O'SuIIivan, R. L., Ricciardi, J. N., Shera, D., Savage, C. R., Borgman, A. S., Jenike, M. A., & Baer, L. (1995). The Massachusetts General Hospital (MGH) Hairpuiling Scale: 1. Development and factor analysis. Psychotherapy and Psychosomatics, 64, 141145. Long, E. S., Miltenberger, R. G., Ellingson, S., & Ott, S. (1999). Augmenting simplified habit reversal in the treatment of oral-digital habits exhibited by persons with mental retardation. Journal ofApplied Behavior Analysis, 32, 353-365. Long, E. S., Miltenberger, R. G., & Rapp, J. T. (1999). Simplified habit reversal plus adjunct contingencies in the treatment of thumb sucking and hair pulling in a young girl. Child and Family Behavior Therapy, 21, 45-58. Miltenberger, R. G., Long, E. S., Rapp, J. T., Lumley, V. A., & Elliott, A. (1998). Evaluating the function of hair pulling: A preliminary investigation. Behavior Therapy. 29, 211-219. Miltenberger, R. G., (2001). Behavior modification: Principles and procedures. Pacific Grove, CA: Wadsworth. Mouton, S. G., & Stanley, M. A. (1996). Habit reversal training for trichotillomania: A group approach. Cognitive and Behavioral Practice, 3, 159-182. Rapp, J. T., Miltenberger, R. G., Galensky, T., Ellingson, S., & Long, E. (1999). A functional analysis of hair pulling. Journal ofApplied Behavior Analysis, 32. 329-337. Rapp, J. T., Miltenberger, R. G., Galensky, T., Roberts, J., & Ellingson, S. (1999). Brief functional analysis and simplified habit reversal treatment of thumb sucking in fraternal twin brothers. Child and Family Behavior Therapy, 21, 1-17. Rapp, J. T., Miltenberger, R. G., & Long, E. S. (1998). Augmenting simplified habit reversal with an awareness enhancement device: Preliminary findings. Journal of Applied Behavior Analysis, 31, 665-668. Rapp, J. T., Miltenberger, R. G., Long, E. S., Elliott, A., & Lumley, V. (1998). Simplified habit reversal for chronic hair pulling in three adolescents: A clinical replication with direct observation. Journal ofApplied Behavior Analysis, 31, 299-302. Risvedt, S. L., & Christenson, G. A. (1996). The use of pharmacological pain sensitization in the treatment of repetitive hair pulling. Behaviour Research and Therapy, 34, 647-648. Rothbaum, B O., Opdyke, D. C, & Keuthan, N. J. (1999). Assessment of trichotillomania. In D. J. Stein, G. A. Christenson, & E. Hollander (Eds.), Trichouilomania (pps. 285-298). Washington, DC: American Psychiatric Press. Stanley, M. A., Borden, .1. W., Bell, G. E., & Wagner, A. L. (1994). Nonclinical hair pulling: Phenomenology and related psychopathology. Journal of Anxiety Disorders, 8, 119-130. Stanley, M. A., & Mouten, S. G. (1996). Trichotillomania treatment manual. In V. B. Van Hasselt & M. Hersen (Eds.), Sourcebook for psychological treatment manuals for adult disorders (pps. 657-687). New York: Plenum. Strieker, J., Miltenberger, R. G., Garlinghouse, M., Deaver, C, Anderson, C, & Tulloch, H. (2000). Evaluation of an awareness enhancement device for the treatment of thumb sucking in children. Manuscript submitted for publication. Swedo, S. E., & Leonard, H. L. (1992). Trichotillomania: An obsessive compulsive spectrum disorder. Psychiatric Clinics ofNorth America, 15,111'19\. Watson, T. S., & Gresham, P. M. (Eds.) (1998). Handbook of child behavior therapy. New York: Plenum.
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6. APPENDIX A Habit Reversal Checklist for Trichotillomania
SESSION 1
Functional assessment interview Describe and demonstrate hair pulling movements Identify overt and covert antecedents Identify overt and covert consequences Assessment of comorbid conditions Homework Trichotillomania questionnaires Self-monitoring instructions ABC recording Identify the social support person
SESSION 2
Collect and review homework data Review trichotillomania questionnaires Review the numbers of hairs pulled each day Graph the number of hairs pulled each day
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Review ABC recording Implement habit reversal procedures Inconvenience review Awareness training Provide rationale Have client describe and demonstrate hair puUing Have client describe preceding sensations and situations Have client simulate hair pulling movements Competing response training Provide rationale Have client choose the competing response(s) Have client practice the competing response Social support training Provide rationale Have social support person practice social support Homework Instruct client to continue self-recording Instruct client to implement habit reversal
Habit Reversal Treatment Manual for Trichotillomania SESSION 3-X
Collect and graph data Review treatment Practice treatment components Problem solving
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Chapter 10 Characteristics of Oral-Digital Habits Patrick C. Friman Michelle R. Byrd Erin M. Oksol University of Nevada, Reno
1.
INTRODUCTION
This chapter will discuss the two predominant forms of oral-digital habits, thumb/finger sucking (finger sucking hereafter) and onychophagia (nail biting hereafter) in terms of their demographics, phenomenology, causes, functions, and clinical associations. The two habits are obviously similar topographically. The extent to which this similarity extends to these other topics will be explored, but only briefly. The differential size and quality of their respective literatures present virtually insurmountable barriers to comprehensive comparisons. On the one hand, the literature we review on finger sucking is large, abidingly current, multidisciplinary, multicultural, and it includes many well-controlled studies. On the other hand, the literature we review on nail biting is small, dated, mostly psychological, culturally narrow, largely theoretical, and it includes few well-controlled studies. Our paper will mirror this disparity between the two literatures; we will devote the major portion to finger sucking. Review of the large literatures on nutritional sucking (suckling and bottle feeding) and the entire class of non-nutritional sucking (NNS) of which finger sucking is only one member is beyond the scope of this paper. Relevant aspects of both literatures will be subsumed into our review of finger sucking, however. In places throughout the paper and especially in our section on function, we
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will periodically refer to NNS in general rather than finger sucking in particular.
2.
FINGER SUCKING
Finger sucking, although historically regarded as clinically significant, has not been provided a diagnostic classification. Neither has it been defined in clinical terms as contrasted with other problematic repetitive behaviors such as tic disorders or trichotillomania (cf, Chapter 3). Sucking itself is an essential human activity that is inaugurated reflexively and perpetuated through processes to be discussed in our section on function. NNS, a virtually universal human activity in early life, occurs when children suck objects that are incapable of providing nutrition such as fingers, toes, portions of the caregivers body, or objects designed ad hoc, termed pacifiers in this culture and dummies in others (Larsson & Dahlin, 1985; Fox & Schaefer, 1996; Victora, Behague, Barros, Olinto, & Weiderpass, 1997). NNS, typically involving fingers, but sometimes other portions of the hand, has been observed in utero. Although pacifier usage is common and may even be increasing in industrialized cultures, finger sucking is by a wide margin the most commonly observed form of NNS. Finger sucking involves one readily observed core behavior (i.e., finger or fingers in mouth) and perhaps for this reason, definitions in the literature are relatively uniform and unambiguous differing mainly in terms of observable detail. Virtually all definitions proffered include the operation of two lips touching (Friman, Barone, & Christopersen, 1986) or closing over (Ellingson et al., 2000) at least one finger. Some add topographical detail describing where the finger is placed (against the roof of the mouth) or the location of adjacent fingers (curled over the bridge of the nose or fisted with the other fingers; Peterson, 1982). Lastly, some definitions include a temporal component in order to distinguish finger sucking of clinical significance from harmless sucking. For example, finger sucking can be considered chronic when it occurs in two or more molar environments (e.g., home and school) after the age of five (Friman & Schmitt, 1989). Unfortunately, research on the phenomenology of finger sucking is quite limited. There are few quantifiable specifics on thumbs versus fingers, single versus multiple fingers, and handedness. One early study did report that 80% of a finger sucking sample sucked only their thumb (Cerny, 1981). Generally, however, it appears as if the phenomenology of finger sucking
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has been all but ignored as a target of empirical inquiry, especially in contrast with the research on other habits such as trichotillomania (e.g., Christenson & Mansueto, 1999; Chapter 7 this book) tic disorders (e.g., Walkup et al., 1999; Chapter 4 this book), and even nail biting (e.g., Billig, 1941; Malone & Massler, 1952). Fortunately, some phenomenological information can be drawn from research on related habits. For example, the literature on the demographics of 'transitional object use' includes some data on finger sucking pertinent to phenomenology that we will discuss in subsequent sections. Additionally, although finger sucking has not been diagnostically classified, it does bear a sort of 'family resemblance' to other types of rhythmic, habitual behaviors that have been so classified and whose phenomenology has been more thoroughly studied. Relevant distinctions will be made in the section that immediately follows.
2.1
DSM-IV Distinctions and Related Phenomenology
Generally, most oral-digital habits do not meet criteria for a DSM-IV diagnosis (American Psychiatric Association, 1994) or that of other diagnostic systems. Finger-sucking in particular does not, of itself, constitute a medical or psychiatric disorder. The presence of finger sucking, however, can appear to meet (or at least resemble) select criteria for some actual diagnostic categories and the most likely example is Stereotypic Movement Disorder (SMD; American Psychiatric Association, 1994; Castellanos, Ritchie, Marsh, & Rapoport, 1996).
2.1.1 Stereotypic Movement Disorder A few important considerations enable a practical distinction to be made between finger sucking (even when chronic) and SMD. For example, to qualify for SMD the repetitive behavior must markedly interfere with normal activities and/or cause physical damage requiring medical treatment. Although it is possible for chronic finger sucking to do both, the vast majority of cases do neither (but see Castellanos et al., 1996). Additionally, behaviors composing SMD have a driven, seemingly purposeless quality (although they do have behavioral functions) and, as indicated by the nomenclature, they have a ritualized, stereotypical presentation. Although
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some uniformity of practice is often observed in finger sucking children, the habit does not typically occur in the strictly mannered fashion that is typical ofSMD.
2.1.2 Other Diagnostic Categories Other bona fide diagnostic categories into or under which finger sucking may appear to fit include obsessive-compulsive (OCD) and tic disorders. Regarding OCD, although the actual practice of some finger-sucking children appears to have compulsive qualities and some children's descriptions of their urge to practice can resemble an obsession, there has been no documented connection between finger sucking and anxiety, the establishing and maintaining condition for obsessive-compulsive disorders. On the contrary, this connection has been disconfirmed in the extant literature (e.g., Friman, Larzelere, & Finney, 1994; Tryon, 1968). Regarding tic disorders, finger sucking has a much more volitional and deliberate presentation than tics. Finger sucking is typically continuous over extended time periods in contrast to tics that tend to be discontinuous with 'burst' like presentations. Finger sucking is also not preceded by the mounting, often sensory urge (said to resemble the urge to sneeze) that is typical of tic disorders (cf. Woods, Hook, Spellman, & Friman, 2000). Lastly, finger sucking is significantly associated with sleep (e.g., Ozturk & Ozturk, 1977; Wolf & Lozoff, 1989), whereas the association between tics and sleep is nonexistent or at least very weak (Leckman & Cohen, 1999).
2.1.3 Categories With Regressive Features Finger sucking may also be observed in individuals who meet criteria for diagnostic categories with symptom clusters that have regressive features such as disintegrative disorder, major depression, anxiety disorder, or schizophrenia. Note the apparent but actually spurious contradiction with our assertion that finger sucking and anxiety are unrelated. On the one hand, it is possible and perhaps even likely that finger sucking has a statistically detectable significant presence in some samples of clinically anxious children, especially those exhibiting separation anxiety. On the other, attempts to detect the reverse possibility, that anxiety is significantly present in samples of finger sucking children, have been unsuccessful (e.g., Friman et al., 1994; Tryon, 1968). In the other types of disorders that can include
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regressive features, finger sucking is never a defining characteristic. Rather, it is merely one member of a constellation of regressive behaviors (e.g., incontinence, excessive crying, stereotypic movements) that occasionally accompany conditions with a potential to exert a retrograde influence on developmental functioning. In summary, finger sucking does not comprise a diagnostic category under any known system nor is it a defining symptom of any other diagnostic category. Nonetheless, finger sucking can and often does have clinical significance as we suggested above and as we shall describe more fully in the section on clinical associations below.
2.2
Demographics and Related Phenomenology
2.2.1
Prevalence
As indicated, finger sucking can begin in utero, but the supportive empirical evidence consists solely of select photographic images and we are aware of no quantified or quantifiable data that could be used to estimate prevalence at this early stage of development. From the neonatal stage and well beyond, however, finger sucking has long been the object of scientific study and multiple estimates of prevalence exist across ages and stages of development. In neonates estimated rates of finger sucking reach as high as 95% (Leung & Robson, 1991). In fact, finger sucking is so prevalent in newborns, that its absence is sometimes interpreted as a risk factor for physical or developmental problems. This interpretation is not without foundation. Finger sucking is often delayed or even non-existent in children with bona fide postnatal complications (e.g., extremely low birth weight, disease) (Cowett, Lipsett, Vohr, & Oh, 1978; Kravitz & Boehm, 1971). With its reflexive onset, almost universal early prevalence, and apparent salubrious properties for very young children, finger sucking is not typically even discussed as a habit until the toddler years. Various estimates place the prevalence of the habit at approximately 50% between the ages of 2 and 3 years (Klackenberg, 1949; Infante, 1976; Ozturk & Ozturk, 1977; Popovich and Thompson, 1974). One early (but large) study reported that the average age of stopping was 3.8 years (Traisman & Traisman, 1958). Other papers show that the habit remains common at later ages with an estimated prevalence of 25% at five years of age (Klackenberg, 1949; Mahalski & Stanton, 1992). Age ranges of target populations and related prevalence
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estimates vary widely for school age children. A relatively recent and reasonably rigorous study estimated 11% at 11 years (Mahalski & Stanton, 1992) but other estimates range as high as 28% for children that age (Popovich & Thompson, 1974).
2.2.2 Chronic Practice An important gap in the literature on prevalence of fmger sucking is information on the intensity or extent of the habit. Chronic practice is determined by age and number of environments in which sucking takes place (Friman & Schmitt, 1989). The literature summarized above provides abundant information on age and very little on where and how often the habit is practiced. Thus information on whether school-aged children are sucking a little before bed or a lot throughout the day and night is generally unavailable, which is unfortunate because frequency and intensity of the habit are central to the clinical significance of finger sucking.
2.2.3 Gender Most papers providing gender breakdowns report that a higher percentage of girls than boys suck their fingers, with the proportion of girls in various samples of finger sucking children averaging around 60% (Bakwin & Bakwin, 1972; Friman, 1987; Honzik & McKee, 1962; Infante, 1976; Larsson, 1985; Mahalski & Stanton, 1992).
2.2.4 Cross Cultural Findings There is some evidence, albeit far from conclusive, that finger sucking is more prevalent in industrialized cultures and in populations with higher socioeconomic status (SES). For example, children in New Guinea apparently exhibit finger sucking rarely if at all (Meade, 1935). The children of the Hopi exhibit some finger sucking very early but virtually none after the first year of life (Dennis, 1940). Analysis of skulls of children from an ancient agrarian culture did not reflect the dentition that is characteristic of prolonged NNS (Larsson, 1983). Lastly, comparative analyses of a sample of children from a poor agrarian culture in Africa and a middle class urban
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sample from Sweden revealed little NNS (finger or pacifier) in the former and high levels in the latter (Larsson & Dahlin, 1985).
2.2.5 Pacifiers With the exception of the two studies just cited, beyond indicating that the usage of pacifiers is widespread (possibly even increasing), papers on pacifiers are typically not specific about prevalence, ethnicity, or gender (e.g.. Fox & Schaefer, 1996). For the most part, pacifier usage is subsumed within the general class of NNS and is often collapsed with finger sucking (e.g., Larsson & Dahlin, 1985). Because of these limitations in the literature and because pacifier usage rarely achieves clinical significance, we will not develop the relevant demographics beyond the information above. Below, however, we will draw upon studies on pacifier usage to develop our section on the functions of finger sucking.
2.2.6 Transitional Objects Also relevant to this paper is the literature on the demographics of 'transitional' or 'attachment' objects (TO hereafter). These terms are not technical, rather, they are synonyms for a loosely defined category of treasured child possessions, the classic example of which is the blanket carried by the Linus character in the popular cartoon Peanuts (Friman, 1990). Qualification for TO status is typically based on the extent to which the objects accompany children in the transition between settings or to which children are 'attached' to the objects (e.g., Friman, in press; Mahalski, 1983; Passman & Holonen, 1979). As many as 60% of children in this culture have a TO at some point during their childhood. Two aspects of the demographics of TOs are pertinent here. First, as many as 50% of children with a TO also engage in finger sucking (Mahalski, 1983). Second, as with finger sucking, TOs may be much more prevalent in urban areas, industrialized cultures, or samples with higher SES (Litt, 1981; Gaddini & Gaddini, 1970; Hong & Townes, 1976). Both demographic aspects are relevant to an analysis of the function of finger sucking, as we shall argue in the section on function below.
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2.3
Causal Associations
2.3.1
Psychosexual
Freud was perhaps the first psychological theorist to hypothesize about the origins of finger sucking. In 1905, Freud interpreted "comfort sucking" as an autoerotic behavior and that digital sucking was associated with later masturbatory habits (Freud, 1953). Although never supported by data, repeatedly ignored or dismissed by advancing theories (e.g.. Bijou & Baer, 1965), and criticized in scientific presentations (Friman, 1993) this interpretation continues to have professional currency (e.g., Sperling, 1982). It seems safe to say, however, that the autoerotic interpretation has had an ample hearing and in the absence of a single supportive data set, it can be ignored here without penalty.
2.3.2
Genetics
As will be discussed further in this chapter, finger sucking is inaugurated reflexively and perpetuated through antecedent and consequent events. Whether genetic events increase the likelihood of perpetuated practice has never been established. An early study did show an increasing trend in monozygotic (over dyzygotic) twins, but it has not been replicated (Bakwin, 1971b). Rather than characterize this state of affairs as a failure to replicate, however, it would be safer to say that replications have not been attempted.
2.3.3
Feeding Practices and the 'Sucking Urge'
Among the many variables nominated as potentially causal over the years, the one that has received the most attention involves feeding practices, with special emphasis on breast-feeding. With few exceptions (e.g. Larsson,1975), the relevant studies have not detected a significant relationship between the timing and amount of breast-feeding and increases in finger sucking (Bowden, 1966; Hanna, 1967; Klackenberg, 1949; Popovich & Thompson, 1974; Sears, & Wise, 1950; Traisman & Traisman, 1958). This research has generally been predicated on the assumption that infants are born with an innate need to suck and if it is not satisfied naturally (i.e., through feeding) it will expend itself in other ways (i.e., through NNS;
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e.g., Levy, 1928). For example, one reason offered for why infants in rural, agrarian cultures tend to exhibit less NNS is that they have to suck more continuously and vigorously to obtain ample nourishment than their urban cohorts from industrialized cultures. Thus, the rural infants are said to be more likely to spend their 'sucking energy' on the procurement of food and less likely to exhibit NNS (Larsson, 1975; see also Larsson & Dahlin, 1985). Although a significant association between finger sucking and feeding practices is not supported by the literature, a few recent studies have shown that pacifier use is correlated with decreased breast-feeding (e.g., Barros et al., 1995; Victora et al., 1997). These findings notwithstanding, an innate need to suck as described in relation to NNS has not been established. Early sucking is reflexive but reflexive properties of behavior do not equal an innate need for its practice, especially after the reflex has decayed. These comments are not intended to diminish or deny the vaunted role sucking plays in the infant's behavioral repertoire. We merely believe a more parsimonious account of finger sucking can be achieved through an analysis of function than through an appeal to a hypothetically constructed innate 'need' for its practice. We will turn to this account in the section on function.
2.3.4
Other Variables
Other parental variables with potential for causal association with finger sucking include parents' occupation, number of siblings, mother working inside/outside the home, use of teething ring, parental attitudes regarding physical contact, and birth order (Johnson & Johnson, 1975; Larsson, 1975, Traisman & Traisman, 1958, Baalack & Frisk, 1971; Ozturk & Ozturk,1977; Popovich & Thompson, 1974). None of these has persuasively been associated with the onset of finger sucking. A few studies have shown that the parents of finger sucking children had higher levels of education (e.g., Ozturk & Ozturk, 1977; Popovich & Thompson, 1974) or higher SES (Infante, 1976). Whether these findings are chance correlations, contributors to true variance, or artifacts of the increased prevalence of NNS in urban, industrialized cultures is not clear. Generally, attempts to establish causes of perpetuated finger sucking have not been successful theoretically or empirically. Multiple lines of research relevant to the function of finger sucking, however, persuasively show a relationship between NNS and various dimensions of responsivity in infants
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and young children. As will be seen, these dimensions can be grouped into a general construct, arousal, that some may nominate as a causal variable. Such a theoretical move is beyond the scope of this paper. Description of the relevant findings, however, is central to the business at hand.
2.4
Analysis of Function
The cardinal function of finger sucking is alluded to in various colloquial descriptors that have been in wide use for decades. Foremost among these are 'self soothing' and 'self comforting' and the term 'pacifier' is obviously synonymous with them. The formal provenance of the descriptors and the term 'pacifier' seem to be lost to history (or at least to us). Their broad scale debut can, at minimum be traced to Spock (1945) for 'self soothing' and to Watson (1928) for 'self comforting'. As a cursory review of contemporary writing on child behavior will reveal, the terms are still used (very) widely in the lay community and are sometimes even employed in scientific papers (e.g., Lehman, Holz, & Aikey, 1995). This abiding use is likely due to the self-evident consonance between their shared meanings and the apparent result of sucking on distressed infants and children. Most adults have witnessed the cessation of demonstrative upset in infants who are provided something to suck, even (and often) when that something is non nutritive. Obviously assumptions drawn from informal observations, however widespread they may be, are insufficient to establish veracity at the level of science. History is rife with examples of science overturning what "everyone knows" (e.g., earth is flat, heavy objects fall faster, etc.). In this instance, however, science clearly supports the public view and we will marshal the evidence in the sections below.
2.4.1
External Sources
Implicit within the descriptive terms is the assumption that NNS is inaugurated and perpetuated non-socially. The photographic evidence of finger sucking in utero and the early reflexive properties of NNS reveal that social support is unnecessary for onset. Additionally, two recent studies of older children found no relationship between finger sucking and social variables such as demand and attention and demonstrated that sucking was especially likely to occur when the participants were alone (Ellingson et al..
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2000; Rapp, Miltenberger, Galensky, Roberts, & Ellingson, 1999). Although only a small number of subjects were used in these studies, they included rigorous time-series designs. For present purposes, the two studies provide empirical support for one aspect of the colloquial view of finger sucking: it does not appear to be directly mediated by external variables.
2.4.2
Arousal Reduction
However, ruling out a range of external variables does not 'rule in' internal variables; it merely establishes the likelihood that internal variables may be operating. Several strands of other research suggest arousal is a plausible possibility. For example, NNS reduces motor movements and crying in newborns. In a representative study, insertion of a rubber nipple quieted and stilled infants within 5 sec and within 25 sec of removal, motor movements returned to baseline levels and crying either began or resumed (Kessen & Leutzendorff, 1963). NNS also reduces infant responsivity to external stimuli, or more generally, distractibility. One representative study showed diminished responsivity to tickling in newborns sucking a pacifier (versus not). Those infants who had a pacifier in their mouth but were not sucking it responded to tickling by increased sucking with no effect on movement whereas infants without the pacifier responded with increased movement (Wolff & Simmons, 1967). Other studies have shown a relationship between NNS and reductions in crying, visual scanning, restlessness, and sleep latency (Bruner, 1973; Morley, Morely, Lucas, & Lucas, 1989; see also Pollard, Fleming, Young, Sawczenko, & Blair, 1999 for a brief but current review). Particularly relevant to the current argument is a small line of research showing the reductive (antinociceptive) effect NNS has on infant distress during invasive medical procedures such as heel sticks and gavage feedings (Field, 1992) and circumcision (Gunnar, Fisch, & Malone, 1984). The relevant literature is also not confined to infants. Parents rated children with a long term sucking habit as less distractible than other children in one early study (Lester, Bierbrauer, Selfridge, & Gomeringer, 1976). A related later study using a functional questionnaire also showed that finger sucking in older children (i.e., 9-12 years) was more likely to occur when the children were stimulated or excited than when they were bored (Lauterbach, 1990).
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2.4.3
Arousal and Negative Reinforcement
Generally, this evidence shows that NNS results in a reduction or modulation of anatomical and physiological events (e.g., movement, heart rate, respiration) that are associated with aversive states (e.g., hunger, fatigue, agitation, pain, etc.). As indicated above, a common summary term for these events is arousal (e.g.. Passman, 1976). Consequences that involve escape from, avoidance of, or reductions in aversive stimuli (or events) and that strengthen the responses that produce those consequences are said to do so through a process known as negative reinforcement (Catania, 1998). Therefore, early NNS appears to be maintained through the self-generation of negative reinforcement derived from modulations in arousal. Unfortunately, there is a large gap between the literatures on the functions of early NNS and of protracted finger sucking. Yet it seems safe to assume that the latter is functionally derived from the former, for at least two reasons. First, a small line of research shows that finger sucking (and TOs) can affect older children in ways very similar to the effects of NNS on younger children (e.g., Ozturk & Ozturk, 1977; Passman, 1976; Wolf & Lozoff, 1989). Second, although the function of a primitive simple response such as NNS decays as more complex, mature, and productive responses satisfying the same function emerge to take their place, the rate of exchange is different across children. Infants have few alternatives for minimizing distress on their own. Older children presumably have an increased repertoire of coping behaviors, but an initial high potency of finger sucking coupled with a delay in the development or availability of mature alternatives to finger sucking would very likely perpetuate the habit in susceptible children.
2.4.4
Cross Cultural Findings
Another line of evidence supporting the colloquial view of finger sucking (i.e., as self soothing) involves cross-cultural investigations. The relevant studies are fewer and much less rigorous than those on the arousal reducing functions of NNS. But the cross-cultural studies can be interpreted in a way that suggests the two groups of findings are logically consistent. The studies on cross cultural differences suggest that much less pacifier usage, finger sucking, and object attachment occurs in rural cultures with agrarian economies than in urban cultures with industrialized economies and that there is more direct caretaker-infant contact in the rural than in the urban
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cultures (Dennis, 1940; Gaddini & Gaddini, 1970; Hong & Townes, 1976; Larsson, 1975; Larsson & Dahlin, 1985; Litt, 1981; Meade, 1935; also see Dahl, 1988). As we have shown above, a plausible function of NNS (and TOs) is the production of negative reinforcement through the modulation of aversive levels of arousal. Perhaps NNS does not as readily or as potently acquire negative reinforcing functions in rural cultures because upset infants living therein are so readily soothed by abidingly present caretakers. As weaning from close contact with caretakers inevitably takes place, a selection of more complex, mature, and productive alternative responses with various levels of negative reinforcing functions become available to the children thus obviating the benefit of (need for) NNS. Obviously, this conclusion is speculative, as it should be given the small number of, and limited rigor in, cross-cultural studies. As indicated, however, the speculation is logically consistent with a highly rigorous large line of research on NNS and arousal.
2.4.5
Consonance With the Colloquial View
The upshot of the entire body of relevant research is a consonance between colloquial and empirically derived interpretations of finger sucking: it appears to be maintained through its capacity to modulate arousal (e.g., generate self-soothing, self-calming, or self-pacifying consequences). An important direction for new research is to determine whether the opposite can also be true; can finger sucking generate increases in arousal and, if so, are those increases reinforcing?
2.4.6
Ontogenesis of Arousal Reducing Functions
Before closing the section on function, some comments on how finger sucking achieves its functional properties seems in order. These comments will necessarily be speculative but converging lines of basic research underscore their plausibility. The cornerstones of the argument involve suckling, conditioned reinforcement, and stimulus generalization. Suckling is the nursing interaction between infant mammals and their mothers and it is the distinguishing mammalian behavior. The benefits of suckling for infants are profound. They include, but are not limited to, the provision of needed nutrition, the protective properties of proximity to the
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mother (e.g., heat, reduced energy usage, protection from predators, etc.), and other salubrious effects loosely categorized under the label of nurturing (Blass, 1990). The core component of infant suckling is sucking. Whether the act of sucking has any intrinsically reinforcing properties is unknown (e.g., why infants suck in utero is unknown). But with the inaugural suckling act, a multiplex of stimulation (e.g., tactile and kinesthetic stimulation of mouth, tongue, gums, and inside of cheeks) is produced by sucking and is also paired with and followed by the ingestion of milk (Bijou & Baer, 1965; Blass, 1990; Friman, 1987). The effect of milk (or at least the sucrose therein) on the neonate is very powerful (i.e., very reinforcing) and, in fact, is thought to follow an opioid pathway (Smith, Pillion, & Blass, 1990). In other words, in some respects the effects of milk (or more specifically, sucrose) on neonates resemble those that are produced by a group of the most powerful reinforcers known to man, narcotics (Blass, 1990; Smith et al., 1990). Powerful reinforcers have inductive functions, that is, they generate a spread of effects (Catania, 1998). The stimuli that are most susceptible to the spread of effects are those that are either coordinated with, or that are formally similar to, the core productive response. Hence, suckling in particular may condition sucking in general to become an automatically reinforcing practice. If, after this conditioning process has been in operation for a time, an infant Tmds her fmger' or is given a pacifier while she is in a aroused state (e.g., through pain, hunger, fatigue), the act of sucking itself may produce a reinforcing effect (e.g., through pain reduction, calming, comforting) and provide thereby the basis for perpetuated practice.
2.5
Clinical Associations
Although fmger sucking is neither a diagnosable disorder of itself nor a defining symptom of any other disorder, its chronic practice has been associated with a variety of clinically significant outcomes (as a reminder, chronic practice is defined as sucking in two or more environments after the age of five years—Friman & Schmitt, 1989). Empirical support for these proposed associations ranges from well established (i.e., through multiple replications) to merely suggested (i.e., through one cross-sectional sectional study or merely through theory).
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Dental
Foremost among the well-established outcomes are dental problems, the most common of which involves malocclusion in both primary ("baby") and permanent teeth (Johnson, 1939; Lewis, 1930; Kohler & Hoist, 1973; Leung & Robson, 1991). When the thumb or finger is sucked with intensity, imbalances of pressure occur between the teeth, tongue, hard palate, and floor of the mouth. These forces may cause problems in the child's bite pattern, including anterior misalignment, most commonly overbite and cross bite (Peterson, 1982). Children who suck their fingers chronically have almost three times the chance of developing a cross bite than those who do not (Infante, 1976). Malocclusions may not be self-correcting if the child's sucking behavior persists beyond approximately age 4 or when the permanent incisors erupt (Peterson, 1982) and may require orthodontic intervention. Additional oral risks of chronic finger sucking include trauma to the mucous membranes (Phelan, Bachara, & Satterly, 1979) and atypical root absorption (Rubel, 1986).
2.5.2
Medical
Less well documented and apparently less likely than dental problems is a diverse group of medically significant outcomes that have been reported to result from chronic finger sucking. The group includes abnormal facial growth (Moore, McNeill, & D'Anna, 1972), deformity in the sucked finger sometimes requiring corrective surgery (Rankin, Jabaley, Blair, & Fraser, 1988; Campbell-Reid & Price, 1984), infection of the skin (Vogel, 1998) and especially the cuticle (Schmitt, 1987), delayed speech development (Josell, 1995), and accidental poisoning (Turbeville & Fearnow, 1976) especially lead poisoning (because hand-mouth behavior is the leading cause of lead poisoning, Finney & Friman, 1988).
2.5.3
Social, Psychological, and Behavioral
Another group of outcomes includes social, psychological, and behavioral problems. Support for problematic social outcomes is derived directly from one study showing that first-grade children rated finger sucking peers as significantly less socially acceptable than non sucking peers across a number
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of social dimensions (Friman, McPherson, Warzak, & Evans, 1993). Indirect support is also found in research showing that child behavior problems can cause social distance betw^een the children with problems and their peers, especially if the peers perceive the problems as volitional (e.g., Sigelman & Begley, 1987). Regarding psychological and behavioral outcomes, the literature is divided. From the standpoint of psychoanalytic theory, psychological problems have been associated with finger sucking for most of this century (Freud, 1953; Sperling, 1982). From the standpoint of empirically derived evidence, support for the assumption is limited. A few studies have reported increases in psychological/behavior problems in finger sucking children (Mahalski & Stanton, 1992; Rutter, 1967; Singhal, Bhatia, Nigam, & Bohra, 1988), especially at later ages, but these studies do not indicate whether the increases are clinically significant. The most rigorous (and recent) of these studies used such a large sample that even slight differences between groups would have yielded statistically significant differences (Mahalski & Stanton, 1992). Furthermore, a much larger group of studies reports no significant increases in behavior or psychological problems in finger sucking children (e.g., Davidson, Haryett, Sandilands, & Hansen, 1967; Friman, Larzelere, & Finney, 1994; Tryon, 1968). A conclusion that appears to be supported by both lines of investigation is that finger sucking is not caused by detectable underlying psychopathology, but its prolonged and intensive practice may be a risk factor for psychological and behavioral problems (Friman, 1993).
2.5.4
Finger Sucking and Hair Pulling
Lastly, a small group of studies documents that finger sucking can covary with chronic hair pulling (trichotillomania). As indicated above, finger sucking is associated with TOs and in some children the TO appears to be their own hair (Friman, 1990; Friman, Finney, & Christophersen, 1984; Altman, Grabs, & Friman, 1982; Friman & Hove, 1987). Unfortunately, the ontogenic sequence of the two behaviors has not been established empirically. Clinical observations suggest that these children begin with finger sucking, gravitate to hair play, and subsequently begin pulling out their hair. Beyond the observation that treatment directed only at the finger sucking invariably reduces or eliminates the hair pulling, little else is documented (e.g., Friman & Hove, 1987).
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213
Finger Sucking Conclusions
Finger sucking is universal in infancy and very common almost up to middle school years. Its onset is usually reflexive and its perpetuation results from an amalgam of conditioning processes that include the inductive properties of early feeding experiences and sucking generated reinforcement (especially negative reinforcement). It is healthful in infancy, harmless in early childhood, and increasingly associated with harm if practiced chronically after school age. A topographically related habit also common in childhood is nail biting and we will address it in the next section.
3.
NAIL BITING
Nail biting (onychophagia) is a digital-oral habit involving repetitive biting and/or chewing of the finger (and sometimes toe) nails. Although the literature on treatment of nail biting is robust and reasonably rigorous (e.g., Allen, 1996; Azrin, Nunn, & Frantz, 1980) the research pertinent to this paper is limited in many ways, and thus our treatment of it will be brief. For example, clear operational definitions that supply topographical, frequency, and age criteria are either not used or are typically not reported.
3.1
Prevalence
The limited availability of operational definitions reduces the utility of, or at least confidence in, reports on prevalence. Furthermore, the prevalence data that are reported are often inconsistent. For example, an early study reported that 44% of children at age 13 were nail biters (Wechsler, 1931) and a later study reported a prevalence of only 12% in a similar age group (Deardoff, Finch, & Royall, 1974). The literature is also often highly derivative, with more current papers typically relying on earlier studies that supplied neither operational definitions nor information on research methods. For example, the figures supplied by Wechsler (1931) are central to an early review by Massler and Malone (1950) that is, in turn, central to a current review by Leung and Robson (1991). Additionally, some papers offer prevalence figures without supplying supportive citations (e.g., Peterson, 1982). One study (Malone & Massler, 1952), however, stands out
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from the rest in terms of its sample size (4587, ages 5 to 18 years), definitions (varied based on degree of nail biting) and methods (direct interview and observation of the participant's finger nails). Nonetheless, this study is dated. Based on our collective impressions of all the research, we offer the following tentative estimates of the prevalence of nail biting. Although it is very rare in children younger than three years, there appears to be a marked and sudden rise in incidence after that age. Between 20% and 40% of preschool children over the age of three years bite their nails. The prevalence appears to peak between the ages of 8-12 years of age, with estimates ranging from 25% to 60%. Prevalence declines through the teen years with estimates between 20% and 30% for late teens. Prevalence in young adults ranges between 10% and 25 % and declines to below 10% for adults over 35. The literature on gender is also inconsistent; some studies report a higher prevalence among females (DeFrancesco, Zahner, & Pawelkiewicz, 1989; Hadley, 1984) while others report a higher prevalence in males (Coleman & McCalley, 1948; Joubert, 1993). The safest conclusion we can draw here is that nail biting appears to be common habit across genders (but current, reliable quantitative specifics are unavailable).
3.2
Phenomenology
Surprisingly, and in contrast with other dimensions of their respective literatures, we found more empirically derived information on the phenomenology of nail biting than we did on finger sucking. The literature indicates that nail biting is typically confined to the fingernails but can involve toe nails (Leung & Robson, 1991). The Malone and Massler (1952) study showed that nail biters show little prejudice towards any of their fingers and bit all 10 with no apparent preference. Another study employing covert direct observation detected a series of four typical postures that include: 1) placement of the hand near the mouth; 2) placing the finger against the teeth; 3) beginning biting and chewing; 4) and the terminal stage involved withdrawal and inspection of the finger nail(s) bitten (Billig, 1941). An additional observation was that nail biting was highly responsive to audience variables; the participants in the Billig study immediately ceased the practice when they were observed.
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215
Cause and Clinical Associations
Beyond a single report that nail biting occurs more frequently in monozygotic versus dyzygotic twins (Bakwin, 1971a), thus suggesting a genetic etiology, there is no available research directly related to cause. Multiple papers, however, have correlated nail biting with a broad range of exotic psychological variables such as sociopathy (Walker & Ziskind, 1977), hostility (Coleman, 1950), bipolarity (Endicott, 1989) and suicide risk (Weinlander & Lee, 1978). A more pedestrian and frequently reported association involves anxiety or stress, but the supportive literature suffers from the types of contradictions and derivative problems that plague the literature on prevalence. For example, two early and influential papers asserted a relationship between nail biting and anxiety (or tension), but experimental controls were not employed in the research described nor were persuasive data presented (e.g., Massler & Malone, 1950; Wechsler, 1931). Nonetheless, a recent review reported that the relationship between nail biting and anxiety is well-documented and cited the two papers as supportive evidence (Leung & Robson, 1991). Confusing matters further are other papers that appear to refute the relationship (e.g., Deardoffet al., 1974; Joubert, 1993) with still others that appear to support it. Prominent among the supportive studies are two demonstrating that 'nervous habits' such as nail biting may indeed be associated with increases in anxiety (Woods & Miltenberger, 1996; Woods, Miltenberger, & Flach, 1996). However, in neither study was nail biting isolated from the other habits studied to determine whether it had independent functions. A few recent studies suggest that nail biting in older youth and young adults may have a detrimental effect on self-evaluation and social functioning. For example, college students who bit their nails were reported to perceive their appearance and health more negatively then persons who do not bite their nails (Hansen, Tishelman, Hawkins, and Doepke, 1990). Related (albeit less rigorous) research reported that adult nail biters were at risk for feeling shameful, experiencing low self-esteem, exhibiting social avoidance, and suffering occupational impairment (Joubert, 1993). These internalizing associations may (when present) be at least partly due to social consequences. Nail biters can be the victims of negative social perceptions by others because the habit is often believed to be associated with multiple types of disturbance such as inattention, deficient social skills and nervousness. In addition, some (perhaps many) persons can perceive nail
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biting as a socially unacceptable, undesirable, and repulsive habit (Silber & Haynes, 1992; Wells, Haines, & Williams, 1998). Some associations involving medical complications have also been documented. For example, nail biting can damage the cuticle, nail, and skin surface of the finger tip (Leung & Robson, 1990). Habitual biting can increase nail growth by as much as 20% (Bean, 1980). As with finger sucking, secondary bacterial infection, especially of the cuticle, can result from nail biting (Baron & Dawber, 1984). The emergence of peringual warts has also been documented (Samman, 1977). Lastly, as with finger sucking, chronic nail biting can inhibit oral hygiene and impair the dentition (e.eg., atypical root absorption; Odenrick & Brattstrom, 1985).
4.
CONCLUSIONS
In this chapter we reviewed several lines of research on two common repetitive human behaviors, finger sucking and nail biting. We described them in terms of their demographics, phenomenology, potential causes and functions, and clinical associations. The behaviors bear a strong topographical resemblance, one to the other. Additionally, they share some similar clinical associations. Prevalence rates differ, however, with finger sucking diminishing substantially in the teenage years and all but nonexistent in adults and with nail biting peaking near the teenage years and highly prevalent well into adulthood. Another point of divergence, and an unfortunate one, is the quality of their respective literatures. The nail biting literature is much more dated, culturally narrower, less rigorous, and ultimately less conclusive than the relevant finger sucking literature. Thus, empirically defensible accounts of finger sucking, arranged in terms of the topics of this paper (especially function) can be sketched, as we hope we have shown. In our view, however, it would be injudicious to take a strong stand on any of the topics as they pertain to nail biting, save possibly medical associations or possibly the phenomenology of nail biting in children The literatures on the remaining topics are simply insufficient to develop empirically defensible accounts. As one particularly salient example, the colloquial view is that both finger sucking and nail biting are associated with arousal and that both are considered to be inappropriate when practiced beyond early childhood. But an empirically derived argument that cogently explains the relationship between finger sucking and arousal can easily be drawn from the literature
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(e.g., negative reinforcement through reduction in arousal) and a rationale for gradually diminishing practice can be provided (e.g., socially acceptable, functionally equivalent practices emerge). But such arguments and rationales for nail biting cannot be persuasively posed because there are insufficient published data. Thus, we could not address why nail biting even begins, not to mention why it continues well into adulthood. There are many other important and unanswered questions for both behaviors, especially for nail biting. We hope this paper steers at least some interested researchers to them.
5.
REFERENCES
Allen, K. W. (1996). Chronic nail biting: A controlled comparison of competing response and mild aversion treatments. Behavior Research and Therapy, 34, 269-272. Altman, K., Grabs, C, & Friman, P.C. (1982). Treatment of unobserved trichotillomania by attention-reflection and punishment of an apparent covariant. Journal of Behavior Therapy and Experimental Psychiatry, 13, 337-340. American Psychiatric Association (1994). Diagnostic and Statistical Manual of Mental Disorders, 4'^ Ed. Washington, DC: Author. Azrin, N., Nunn, R.G., & Frantz, S. E. (1980). Habit reversal vs. negative practice treatment of nail biting. Behavior Research and Therapy, 75,281-285. Baalack, J. & Frisk, A. (1971). Finger sucking in children: A study in incidence and occlusal condition. Acta Odontics Scandinavia, 29, 499-512. Bakwin, H. (1971a). Nail-biting in twins. Developmental Medicine and Child Neurology, 13, 304-307. Bakwin, H. (1971b). Persistent finger-sucking in twins. Developmental Medical and Child Neurology, 13, 308-309. Bakwin, H. & Bakwin, R.M. (1972). Behavior Disorders in Children. Philadelphia: W.B. Saunders Co. Baron, R. & Dawber, R. P. R. (1984). Diseases of the nails and their management. Oxford: Blackwell Scientific Publications. Barros, F. C, Victora, C. G., Semer, T. C, Filho, S. T., Tomasi, E., & Weiderpass, E. (1995). Use of pacifiers is associated with decreased breast-feeding duration. Pediatrics, 95, 497499. Bean, W. B. (1980). Nail growth: Thirty five years of observation. Archives of Internal Medicine, 140, 13-16. Bijou, S., & Baer, D. M. (1965). Child development If: Universal stages of infancy. New York: Appleton, Century Crofts. Billig, A. L. (1941). Fingernail biting: Its incipiency, incidence, and amelioration. Genetic Psychological Monographs, 24, 123-218. Blass, E.M. (1990). Suckling: Determinants, changes, mechanisms, and lasting impressions. Developmental Psychology, 26, 520-533.
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Bowden, B.D. (1966). A longitudinal study of digital and dummy sucking. Australian Dentistry Journal, 11, 184-190. Bruner, .1. (1973). Pacifier-produced visual buffering in human infants. Developmental Psychobiology, 6, 45-51. Campbell-Reid, D. & Price, A. (1984). Digital deformities and dental malocclusion due to finger sucking. British Journal of Plastic Surgery, 37, 445-452. Castellanos, F. X., Ritchie, G. F., Marsh, W. L., & Rapoport, J. L. (1996). DSM-IV stereoptypic movement disorder: Persistence of stereotypies of infancy in intellectually normal adolescents and adults. Journal of the American Academy of Child and Adolescent Psychiatry, 57, 116-122. Catania, A. C. (1998). Learning (4^' ed.). Upper Saddle River, N.I: Prentice-Hall. Cerny, R. (1981). Thumb and finger sucking. Australian Dental Journal, 26, 167-171. Christenson, G. A., & Mansueto, C. S. (1999). Trichotillomania: Descriptive characteristics and phenomenology. In D. J. Stein, G. A. Christenson, & E. Hollander (Eds.), Trichotillomania (1-42). Washington, D. C: American Psychiatric Press, Inc. Coleman, J. C. (1950). The role of hostility in fingernail biting. Psychological Service Center Journal, 3. 238-244. Coleman, J. C, & McCalley, J. E. (1948). Nail biting among college students. Journal of Abnormal Social Psychology, 43, 517-525. Cowett, R. M., Lipsett, L. P., Vohr, B., & Oh, W. (1978). Aberrations in sucking behavior of low-birth weight infants. Developmental Medicine and Child Neurology, 20, 701-709. Dahl, E. K. (1988). Anthropological perspectives on the origins of transitional phenomena. In P. C. Horton, H. Gewirtz, and K. J. Kreutter (Eds.), The solace paradimgm: An eclectic search for psychological immunity (pp., 30\-319). Madison, CN: International University Press. Davidson, P.O., Haryett, R.D., Sandilands, M., & Hansen, F.C. (1967). Thumb sucking: Habit or symptom? Journal of Dentistry for Children, 34, 252-259. DeFrancesco, J. J., Zahner, G. E. P., & Pawelkiewicz, W. (1989). Childhood nail biting. Journal of Social Behavior and Personality, 4, 157-161. Deardoff, P.A., Finch, A.J., & Royall, L R. (1974). Manifest anxiety and nail-biting. Journal of Clinical Psychology, 30, 378. Dennis, W. (1940). The Hopi child. New York: Appleton, Century, Crofts. Ellingson, S.A., Miltenberger, R.G., Strieker, J.M., Garlinghouse, M.A., Roberts, J., Galensky, T.L., & Rapp, J.T. (2000). Analysis and treatment of finger sucking. Journal of Applied Behavior Analysis. 33, 41-52. Endicott, N.A. (1989). Psychophysiological correlates of *bipolarity.' Journal of Affective Disorders. 77,47-56. Field, T. (1992). Interventions in early infancy. Infant Mental Health Journal. 13._ 329-336. Freud, S. (1953). Three Essays on Sexuality. The Complete Psychological Works ofSigmund Freud. VII (1901-1905). (Translated by Strachey, J., Freud, An., Strachey, A., & Tyson, A.) Hogarth Press and Institute of Psychoanalysis: London. Fox, A., & Schaefer, C. (1996). Psychology, 33. 30-35. Finney, J. W., & Friman, P. C. (1988). The prevention of mental retardation. In D. C. Russo and J. H. Kedesdy (Eds.), Behavioral medicine with the developmentally disabled, (173200). New York: Plenum.
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Friman, P.C. (1987). Thumb sucking in childhood. Feelings and their medical significance, 29, 1-4. Friman, P. C. (1990). Concurrent habits: What would Linus do with his blanket if his thumb sucking were treated? American Journal of Diseases in Children, 144, 1316-1318. Friman, P. C. (1993). The relationship between routine child behavior problems and psychopathology: The possible influence ofBerkson's bias. Paper presented at the Fourth Florida Conference on Child Health Psychology, Gainesville, Florida. Friman, P. C. (in press). Transitional objects' as establishing operations for thumb sucking: A case study. Journal of Applied Behavior Analysis. Friman, P . C , Barone, V. J., & Christophersen, E.R. (1986). Aversive taste treatment of finger-and thumb-sucking. Pec?/a/nc5, 78, 174-176. Friman, P. C, Finney, J. W., & Christophersen, E. R. (1984). Behavioral treatment of trichotillomania: An evaluative review. Behavior Therapy, 15, 249-266. Friman, P.C. & Hove, G. (1987). Apparent covariation between child habit disorders: Effects of successful treatment for thumb sucking on untargeted chronic hair pulling. Journal of Applied Behavior Analysis, 20, 309-314. Friman, P.C, Larzelere, R., & Finney, J.W. (1994). Exploring the relationship between thumb-sucking and psychopathology. Journal of Pediatric Psychology, 19, 43\ -441. Friman, P.C, McPherson, K.M., Warzak, W.J., & Evans, J. (1993). Influence of thumb sucking on peer social acceptance infirst-gradechildren. Pediatrics, 91, 784-786. Friman, P. C, & Schmitt, B. D. (1989). Thumb sucking: Guidelines for pediatricians. Clinical Pediatrics, 28, 438-440. Gaddini, R., & Gaddini, E. (1970). Transitional objects and the process of individuation: A study in three different social groups. Journal of the American Academy of Child Psychiatry, 9, 347-365. Gunnar, M. R., Fisch, R.O., & Malone, S. (1984). The effects of a pacifying stimulus on behavioral and adrenocortical responses to circumcision in the newborn. Journal of the American Academy of Child and Adolescent Psychiatry, 23, 34-38. Hadley, N. H. (1984). Fingernail biting. New York: Spectrum. Hanna, J.C (1967). Breast-feeding versus bottle-feeding in relation to oral habits. Journal of Dentistry for Children, 34, 243-249. Hansen, D.J., Tishelman, A.C, Hawkins, R.P., & Doepke, K.J. (1990). Habits with potential as disorders: Prevalence, severity, and other characteristics among college students. Behavior Modification, 14, 66-80. Hong, K., & Townes, B. (1976). Infants' attachment to inanimate objects: A cross-cultural study. Journal of the American Academy of Child and Adolescent Psychiatry, 15, 49-61. Honzik, M. P., & McKee, J. P. (1962). The sex difference in thumb-sucking. Journal of Pediatrics, 61, 726-732. Infante, P.F. (1976). An epidemiological study of finger habits in preschool children , as related to malocclusion, socioeconomic status, race, sex, and size of community. Journal of Dentistry for Children, 43, 33-38. Johnson, L.F. (1939). The status of thumb sucking and finger sucking. Journal of the American Dental Association, 26, 1245-1254. Johnson, P.B. & Johnson, H.L. (1975). Birth order and thumb sucking. Psychological Reports, 36, 598.
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Josell, S.D. (1995). Habits affecting dental and maxillofacial growth and development. Dental Clinics ofNorth America, 39, 851-860. Joubert, C. E. (1993). Relationship of self-esteem, manifest anxiety, and obsessivecompulsiveness to personal habits. Psychological Reports, 73, 579-583. Kessen, W., & Leutzendorff, A. (1963). The effect of non nutritive sucking on movement in the human newborn. Journal of Comparative and Physiological Psychology, 56, 69-72. Klackenberg, B. (1949). Thumb sucking: frequency and etiology. Pediatrics, 4, 418-424. Kohler, L. & Hoist, K. (1973). Malocculsion and sucking habit of four-year-old-children. Acta Pediatrics ofScandinavia, 373-379. Kravitz, H. & Boehm, J.J. (1971). Rhythmic habit patterns in infancy: Their sequence, age of onset, and frequency. Child Development, 42, 399-413. Larsson, E. (1975). Dummy- and finger-sucking habits in 4-year-olds. Sven Tandlak Tidskr, 65.219-221. Larsson, E. (1983). Malocclusion in a juvenile medieval skull material. Swedish Dental Journal, 7, 185-190. Larsson, E. (1985). The prevalence and aetiology of prolonged dummy and finger-sucking hdhW^. European Journal of Orthodontics, 7, 172-176. Larsson, E, & Dahlin, K. G. (1985). The prevalence and the etiology of the initial dummyandfinger-suckinghabit. American Journal of Orthodontics, 87, 432-435. Lauterbach, W. (1990). Situation-response (S-R) questions for identifying the function of problem behaviour: The example of thumb sucking. British Journal of Clinical Psychology, 29, 5\-57. Leckman, J. F., & Cohen, D. J. (Eds.) (1999). Tourette's syndrome: Tics, obsessions, and compulsions. New York: John Wiley & Sons. Lehman, E. B., Holz, B. A., & Aikey, K. L. (1995). Temperament and self-soothing in children: Object attachment, thumb sucking and pacifier used. Early Education and Development, 6, 53-72. Lester, G., Biergrauer, B., Selfridge, B., & Gomeringer, D. (1976). Distractibility, intensity of reaction, and non-nutritive sucking. Psychological Reports, 39, 1212-1214. Leung, A.K.C. & Robson, W.L.M. (1991). Thumb sucking. American Family Physician, 44, 1724-1728. Leung, K. C, & Robson, W. L. (1990). Nail biting. Clinical Pediatrics. 29, 690-692. Levy, D. M. (1928). Finger sucking and accessory movement in early infancy. American Journal of Psychiatry, 7, 881-918. Lewis, S.T. (1930). Thumb sucking: A cause of malocculsion in the deciduous teeth. Journal of the American Dental Association, J 7, 1060-1073. Litt, C. J. (1981). Children's attachment to transitional objects: A study of two pediatric populations. American Journal of Orthopsychiatry, 5 J, 131-139. Mahalski, P. A. (1983). The incidence of attachment objects and oral habits at bedtime in two longitudinal samples of children aged 1.5-7 years. Journal of Child Psychology and Psychiatry. 24, 283-295. Mahalski, P.A. & Stanton, W.R. (1992). The relationship between digit sucking and behavior problems: A longitudinal study over 10 years. Journal of Child Psychology and Psychiatry, 33, 9\3'923. Malone, A. J., & Massler, M. (1952). Index of nail biting in children. Journal of Abnormal and Social Psychology, 47, 193-202.
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Massler, M. & Malone, A.J. (1950). Nail-biting-a review. Journal of Pediatrics, 36, 523. Meade, M. (1935). Sex and temperament in three primitive societies. New York: William Morrow. Moore, G. J., McNeill, R. W., & D'Anna, J. A. (1972). The effects of digit sucking on facial growth. Journal of the American Dental Association, 84, 592-599. Morley, R., Morley, C. J., Lucas, P. J., & Lucas, A. (1989). Comforters and night waking. Archives of Diseases in Children, 64, 1624-1626. Odenrick, L. & Brattstrom, V. (1985). Nail biting: Frequency and association with root resorption during orthodontic treatment. British Journal of Orthodontics, 12, 78-81. Ozturk, M & Ozturk, O.M. (1977). Thumb sucking and falling asleep. British Journal of Medical Psychology, 50, 95-103. Passman, R. H. (1976). Arousal reducing properties of attachment objects: Testing the functional limits of the security blanket relative to the mother. Developmental Psychology, 12, 468-469. Passman, R. H., & Halonen, J. S. (1979). A developmental survey of young children's attachment to inanimate objects. The Journal of Genetic Psychology, 134, 165-178. Peterson, J.E. (1982). Pediatric oral habits. In Pediatric Dentistry: Scientific Foundations and Clinical Practice. Stewart, R. E., Barber, T.K., Troutman, K.D., & Wei, S.H.Y., Eds. C.V. Mosby Company: St. Louis. Phelan, W. J., Bachara, G. H., & Satterly, A. R. (1979). Severe hemorrhagic complication from thumb sucking. Clinical Pediatrics, 18, 769-770. Pollard, K., Fleming, P., Young, J., Sawczenko, A., & Blair, P. (1999). Early Human Development, 56, 185-204. Popovich, F. & Thompson, G.W. (1974). Thumb and finger sucking: Analysis of contributory factors in 1258 children. Canadian Journal of Public Health, 65, 277-280. Rankin, E. A., Jabaley, M. E., Blair, S. J., & Eraser, K. E. (1988). Acquired rotational digital deformity in children as a result of finger sucking. Journal of Hand Surgery, 13, 535-539. Rapp, J.T., Miltenberger, R.G., Galensky, T., Robers, J., & Ellingson, S.A. (1999). Brief functional analysis and simplified habit reversal treatment of thumb sucking in fraternal twin brothers. Child and Family Behavior Therapy, 21, \-\l. Rubel, I. (1986). Atypical root resoprption of maxillary primary central incisors due to digital sucking: A report of 82 cases. Journal of Dentristy for Children, 53, 201-204. Rutter, M. (1967). A children's behavior questionnaire for completion by teachers: Preliminary findings. Journal of Child Psychology and Psychiatry, 8, 1-11. Samman, P. D. (1977). Nail disorders caused by external influences. Journal of the Society of Cosmetic Chemistry, 28, 351-353. Sears, R. R., & Wise, G. W. (1950). Relation of cup feeding to thumb sucking and the oral drive. American Journal of Orthopsychiatry, 20, 123-128. Schmitt, B. D. (1987). Your child's health. Toronto: Bantam Books. Sigelman, C. K., & Begley, N. L. (1987). The early development of reactions to peers with controllable and uncontrollable problems. Journal of Pediatric Psychology, 72, 99-115. Silber, K.P. & Haynes, C. E. (1992). Treating nail biting: A comparative analysis of mild aversion and competing response therapies. Behavior Research and Therapy, 30, 15-22. Singhal, P. K., Bhatia, M. S., Nigam, V. R., & Bohra, N. (1988). Thumb sucking: An analysis of 150 cases. Indian Pediatrics, 25, 647-653.
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Smith, B. A., Fillion, T. J., & Blass, E. M. (1990). Orally mediated sources of calming in lto 3-day-old human infants. Developmental Psychology, 26, 731-737. Sperling, M. (1982). The major neuroses and behavior disorders in children. New York: Jason Aronson. Spock, B. (1945). Baby and child care. New York: Pocket Books. Traisman, A.S. & Traisman, H.S. (1958). Thumb- and finger-sucking: A study of 2,650 infants and children. Journal of Pediatrics, 52. 566-572. Tryon, A. F. (1968). Thumb-sucking and manifest anxiety: A note. Child Development, 39, 1159-1163. Turbeville, D. P., & Pearnow, R. G. (1976). Is it possible to identify the child who is a high risk candidate for the accidentia! ingestion of a poison? Clinical Pediatrics, 15, 918-919. Victora, C. G., Behague, D. P., Barros, P. C, Olinto, M. T. A., & Weiderpass, E. (1997). Pacifier use and short breast feeding duration: Cause, consequence, or coincidence? Pediatrics, 99, 445-453. Vogel, L.D. (1998). When children put their fingers in their mouths: Should parents and dentists care? //ew York State DentalJournal, 64, 48-53. Walker, B. A. & Ziskind, E. (1977). Relationship of nail biting to sociopathy. The Journal of Nervous and Mental Disease, 164, 64-65. Walkup, J. T., Khan, S., Schuerholz, L., Paik, Y. S., Leckman, J. P., & Schultz, R. T. (1999). Phenomenology and natural history of tic-related ADHD and learning disabilities. In J.P. Leckman & D.J. Cohen (Eds.), Tourette's syndrome: Tics, obsessions, and compulsions (pp. 63-79). New York: John Wiley & Sons. Watson, J. B. (1928). Psychological care of the infant and child. New York: Norton. Wechsler, D. (1931). The incidence and significance of fingernail biting in children. Psychoanalytic Review, 75^201-209. Weinlander, M. M., & Lee, S. H. (1978). Suicidal age and childhood onychphagia among neurotic veterans. Journal of Clinical Psychology, 34, 31-32. Wells, J. H., Haines, J., & Williams, C. L. (1998). Severe morbid onychophagia: The classification as self-mutilation and a proposed model of maintenance. Australian and New Zealand Journal of Psychiatry, 32, 534-545. Wolf, A. W., Lozoff, B. (1989). Object attachment, thumb sucking and the passage to sleep. Journal of the American Academy of Child and Adolescent Psychiatry, 28, 287-292. Wolff, P. H., & Simmons, M. A. (1967). Non-nutritive sucking and response thresholds in young infants. Child Development, 38, 631 -639. Woods, D. W., Hook, S. S., Spellman, D. P., & Priman, P. C. (2000). Exposure and response prevention for an adolescent with Tourette's syndrome. Journal of the American Academy ofChild and Adolescent Psychiatry, 39, 904-907. Woods, D. W., & Miltenberger, R. G. A. D. (1996). Are persons with nervous habits nervous? A preliminary examination of habit function in a non referred population. Journal ofApplied Behavior Analysis, 29, 259-261. Woods, D. W., Miltenberger, R. G., & Plach, A. D. (1996). Habits, tics, and stuttering: Prevalence and relation to anxiety and somatic awareness. Behavior Modification, 20, 216-225.
Chapter 11 Behavioral Interventions for Oral-Digital Habits Vincent J. Adesso Melissa M. Norberg University of Wisconsin-Milwaukee
1.
INTRODUCTION
Nervous habits such as hair twirling, digit, lip, mouth, or tongue biting, bruxism, scratching, and object manipulation (Hansen, Tishelman, Hawkins, & Doepke, 1990; Woods & Miltenberger, 1995) have been defined as repetitive behaviors that serve no perceivable social function but may serve a tension reduction (e.g.. Woods & Miltenberger, 1995) or self-stimulatory function (Hansen et al., 1990). Oral-digit habits are likely the most prevalent of these behaviors, particularly among children. This chapter will focus on the behavioral treatment of the two primary oral-digital habits, nail biting and thumb sucking. For each, the review will start with a brief characterization of the problem, followed by a summary of methods for operationalizing the target behavior, and will proceed to a summary of the intervention research. The chapter will conclude with an overview of the current status of behavioral interventions for oral-digital habits.
2.
NAIL BITING
As nail biting in children is viewed as a behavior that will remit with age, relatively few studies have reported behavioral treatment of nail biting in
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preadolescent children (e.g., Azrin & Nunn, 1973; Barmann, 1979; Nunn & Azrin, 1976; Woods et al., 1999). However, nail biting is likely to be viewed as a problem if it occurs along with other habitual behaviors (e.g., DeLuca & Holborn, 1984), is severe, or occurs beyond the preadolescent years. In addition, motivation for treatment may be increased by the desire for better looking nails and the wish to avoid the embarrassment occasioned by nail biting as the individual moves into adolescence and adulthood. Nail biting may cause a number of problems, which can range from unattractiveness to skin infections, scarring, nail loss, and even dental problems such as temporomandibular disorders (Leonard, Lenane, Swedo, Rettew, 8L Rapoport, 1991). The target behavior in the treatment of nail biting includes (1) those occasions in which a biting response is actually performed, (2) instances in which a finger is inserted between the lips in such a way that contact between afingernailand one or more teeth is established (Adesso, Vargas, & Siddall, 1979) or (3) any movement of the hand that yields damage to the nails, cuticles, or skin area surrounding the nails (Nunn & Azrin, 1976). Several change indices have been used, including self-reports of nail biting frequency or number of nails bitten, photographs of nails, measures of nail growth or length, nail appearance, and expressed degree of self-control over biting. Smith (1957) developed a system for rating nail biting severity, and Malone and Massler (1952) developed a scale for rating skin damage and biting severity. Consistent results have been obtained across these different outcome measures.
2.1
Intervention Research
The only pharmacologically-based treatment study compared the effectiveness of clomipramine hydrochloride to desipramine hydrochloride (Leonard et al., 1991). Leonard et al. (1991) found clomipramine hydrochloride was superior in decreasing nail biting. However, the attrition rate was high (11 of 24 participants dropped out) and treatment gains were modest. A number of behavioral treatments has been used successfully for the treatment of nail biting. These treatments will be grouped into reinforcement procedures, punishment procedures, habit reversal, and a group of procedures using a diversity of approaches.
Behavioral Interventions for Oral-Digital Habits 2.1.1
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Reinforcement Procedures
Few studies have employed only reinforcement procedures to decrease nail biting. Rather, reinforcement procedures have often been compared to, or combined with punishment procedures. For example, Horan, Hoffman, and Macri (1974) combined sequential training in self-monitoring, selfpunishment, and self-reward across time for four subjects. They found reductions in biting for all subjects but no differences among treatment components. Adesso et al. (1979) found that subjects in their positive incentive group (earned credits for nail growth) produced changes in biting behavior equivalent to those in their other groups (response cost, selfmonitoring, nail measure, and minimal contact). Davidson, Denny, and Elliott (1980) included self-reinforcement training in their multi-component treatment package and found the group that received this training (along with various other components) obtained the best treatment outcome. Mulilck, Hoyt, Rojahn, and Schroeder (1978) reduced nail biting and finger picking in a profoundly retarded young man by prompting and reinforcing toy play. Long, Miltenberger, Ellingson, and Ott (1999) found that, in treating four mentally retarded adults, differential reinforcement for the absence of biting improved treatment outcome for three of these individuals. Long et al. also found that for one subject, differential reinforcement of nail growth decreased nail biting.
2.1.2
Punishment Procedures
A substantial number of studies has focused on the use of aversive contingencies to suppress nail biting. In a case study with an adult female client, Ross (1974) reported elimination of nail biting that was maintained at 6-month follow-up through the use of a response cost procedure in which the patient agreed to contribute money to a disliked organization for failure to increase nail length. Both Stephen and Koenig (1970) and Adesso et al. (1979) conducted controlled studies that found response cost (threatened loss of money or credits) equally effective to other treatments in the reduction of nail biting. Two case studies used covert sensitization (Daniels, 1974; Paquin, 1977) to reduce nail biting. In covert sensitization, an aversive image is paired with the target response to be reduced. Both case studies reported success in reducing biting. Davidson and Denny (1976) compared covert sensitization
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and information groups with a group that received both treatments and a wait-list control group. Their results indicated that only the information group had longer nails at the end of treatment than the other groups. However, at a five-week follow-up, no group differences were observed. Success in reducing nail biting has been reported with other aversive techniques (e.g., Butcher, 1968 with self-administered shock; Smith, 1957 with negative practice). Vargas and Adesso (1976) used four groups of college students to compare these aversive techniques (shock and negative practice) against the application of a bitter substance and an attention placebo control condition. Half the subjects in each of the four groups selfmonitored their nail biting and half did not. At the end of treatment and at 3month follow-up, all groups evidenced increases in nail lengths, but no group differences were observed. However, subjects who self-monitored experienced greater increases in nail length than those who did not selfmonitor. The failure to find differential outcome effects for different treatments led some authors (e.g., Adesso et al., 1979; Davidson & Denny, 1976) to conclude that nonspecific factors are the effective ingredients in nail biting reduction. Azrin, Nunn, and Frantz (1980a) indicated that the treatment components responsible for the improvements found in prior research were heightened awareness of nail biting (either through increased attention to one's nails, as in self-monitoring, or through contact with a therapist for measurement or other treatment regimen) and the expectation of treatment benefit.
2.1.3
Habit Reversal
In recent years, the most frequently studied approach to nail biting treatment has been the habit reversal treatment package developed by Azrin and Nunn (1973,1977), who originally conceived the treatment as consisting of 13 components divided into four phases. A number of the elements of the habit reversal package have been studied independently, such as relaxation training as a competing response (Barrios, 1977); overcorrection (Barmann, 1979), and awareness training (Adesso et al., 1979). Using the full habit reversal treatment, Azrin and Nunn (1973) eliminated nail biting in three adults and one child after a single day of treatment. Although one adult discontinued treatment, follow-up of the remaining subjects indicated that the gains were maintained after several months. Delparto, Aleh, Bambusch, and Barclay (1977) treated three subjects over 8 weeks using
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habit reversal and found substantial nail growth at posttreatment and 6month follow-up. The full habit reversal treatment package also has been evaluated in a number of controlled studies. Nunn and Azrin (1976) evaluated habit reversal against a wait list control group. At posttreatment all habit reversal subjects had stopped biting. Follow-up data, however, were available for less than half the subjects, some of whom had temporary relapses. Azrin et al. (1980a), comparing habit reversal with negative practice, found that at 5month follow-up negative practice produced a 60% reduction in nail biting and habit reversal yielded a 99% reduction. Further, 15% of the negative practice subjects had eliminated nail biting, while 40% of habit reversal subjects did so. As Azrin et al. (1980a) and others have suggested the importance of nonspecific factors in treatment outcome, the habit reversal package has been evaluated against nonspecific factors in several studies. Glasgow, Swaney, and Schafer (1981) compared Azrin and Nunn's (1977) self-help treatment manual for habit reversal and the self-help manual published by Perkins and Perkins (1976) with a self-monitoring only control condition. The treatments were either self- or therapist managed. Glasgow et al. (1981) found reductions in nail biting but no group differences at posttreatment or follow-up in either nail biting frequency or client satisfaction. Frankel and Merbaum (1982) used Azrin and Nunn's (1977) treatment manual across three therapist-contact conditions: weekly, individual meetings; weekly, brief phone calls; and, no therapist contact. Although all groups improved equally in nail length, cosmetic appearance, and self-control scale scores, the group with weekly therapist meetings evidenced the highest number of subjects who stopped nail biting at posttreatment and follow-up. Ladouceur (1979) compared habit reversal, habit reversal plus self monitoring, self monitoring alone, self monitoring plus daily graphing of nail biting, and a wait list control and found all treatments equally effective in reducing nail biting. Given these results which show habit reversal to be an effective treatment for nail biting and one that may be at least as effective as, if not superior to other methods, a body of research has focused on delineating the critical components of the habit reversal package. The component of the original habit reversal package that has received the most research attention is the competing response training, which typically involves training the subject to clench his or her fist for 3 min each time a biting response is about to occur or has occurred. DeLuca and Holborn (1984) applied relaxation training
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followed by the competing response training to a 17-year-old female who engaged in both hair pulling and nail biting. The relaxation was ineffective but the competing response training eliminated both behaviors nearly immediately. A 2-year follow-up revealed these changes were maintained. De L. Home and Wilkinson (1980) evaluated the effectiveness of the competing response (fist clenching) and positive practice (nail grooming) components of habit reversal along with the use of on-going nail-length target goals using four groups of subjects: a competing response plus positive practice group; a habit reversal, positive practice, and on-going target goals group; a positive practice and on-going target goals group; and, a waiting list control group. All subjects self-monitored nail biting and had minimal therapist contact. At posttreatment, the treatment groups improved equally and more than the control group. At 8-week follow-up, the habitreversal-only group (competing response plus positive practice) had the fewest relapses and the on-going target goals group had the most. Miltenberger and Fuqua (1985) compared using a competing response contingent on a habit's occurrence with noncontingent use of the competing response in a group of subjects with a variety of habit disorders. Of the three nail biters in the contingent response group, one reduced nail biting and reported reduced biting at one- and 6-month follow-up, one reduced biting but did not respond at follow-up, and one was given full habit reversal training in addition to the competing response training. The latter subject's reductions in biting were maintained at both follow-up intervals. For the two nail biters in the noncontingent competing response group, one reduced biting but the reductions were not maintained at follow-up and the other received contingent competing response training before biting was reduced. The latter subject maintained reduced biting at follow-up. Silber and Haynes (1992) compared self-monitoring alone, selfmonitoring plus a competing response, and self-monitoring with a bitter substance applied to the nails. The bitter substance and competing response groups showed significant improvements but the self-monitoring group did not. Competing response treatment also led to significant decreases in biting severity and skin damage, and left subjects feeling more self-control over their nail biting. All subjects reported that weekly contact with the therapist was an important element of treatment. Allen (1996) partially replicated the Silber and Haynes (1992) study but found that only the aversion group evidenced significant gains in nail length. The competing response group approached significant nail length gains, but self-monitoring alone group did not evidence improvements. No group differences,
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however, were found for measures of skin damage, urges to bite, acts of biting, or feelings of self-control over biting. The fact that Allen's subjects did not meet regularly with a therapist may explain the difference between his results and those of Silber and Haynes (1992), again suggesting the importance of regular therapist contact. Long et al. (1999) used a simplified habit reversal (SHR) treatment for the nail biting behavior of four mentally retarded adults. The SHR consisted of awareness training, competing response training, and social support. The treatment was effective with only one individual, so additional procedures were added to the treatment of the remaining three individuals, including remote prompting, remote contingencies involving differential reinforcement plus response cost, and differential reinforcement of nail growth). The addition of these treatment procedures reduced the behaviors substantially for all clients. Woods et al. (1999) compared SHR (training in awareness, competing response, and social support) with a wait list control for the treatment of the oral-digital habits of children. Half the SHR children were trained with a competing response that was physically incompatible with the target habit, half were trained with a dissimilar competing response (clenching the knees) was compatible with the target habit. Two children in each of the three groups were nail biters. The children in the incompatible competing response group showed posttreatment reductions of 99 and 96.3%, the one child for whom there were data reported in the compatible competing response group had a 79% reduction in biting, and the child in the wait-list control group had a 17.6% reduction. Although Woods et al. (1999) reported both treatment groups showed improvement and there were no differences between the incompatible and compatible groups overall, the nail biting subjects may have profited more from the use of a competing response incompatible with nail biting. Thus, these results would suggest that a physically incompatible competing response should be used to treat nail biting if possible. Finally, regardless of treatment group, all treated subjects found the treatment acceptable.
2.1.4
Other Behavior Change Procedures
Barrios (1977) found that using cue-controlled relaxation as a competing response was effective for nail biting reduction. Participants in this study maintained the substantial reductions at follow-up and reported using the
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competing response in situations unrelated to nail biting. DeLuca and Holborn (1984) found relaxation training alone did not reduce nail biting. McNamara (1972) compared various self-monitoring and incompatible response combinations with an attention-placebo control group and found no group differences. Barmann (1979) evaluated the treatment of nail biting in a person with mental retardation that involved the application of artificial nails and two types of overcorrection (Foxx, 1976): positive practice, where the hands are raised to the lips, without contact, then lowered and folded for 2 sec; and, restitution, immediately following positive practice, wherein the bitten nail, all remaining nails, and the nails of another person are groomed. Nail length increased and biting was nearly eliminated after 3 weeks of treatment. A 10week follow-up indicated these changes were maintained. Davidson et al. (1980) compared substitute skill training and training in suppression skills using five groups of subjects: a combined substitution and suppression group; a substitution group; a suppression group; a placebo control group; and, a wait list control group. Substitution training subjects received instruction in alternative behaviors, including relaxation, hand and finger exercises, hand massage, nail care and self-reinforcement. Suppression training consisted of stimulus control techniques, aversive imagery, negative self-verbalization, and self-punishment (e.g., burning a dollar bill or snapping a rubber band against the skin contingent on nail biting). Compared to the wait-list control group, all treatment groups experienced gains. Subjects who received the substitution training evidenced superior results to those who received the suppression training. Those who received both forms of training did better than those who received only suppression training but not as well as those who received only substitution training. The results support the importance of training in an alternative response and self-reinforcement to achieve an enduring behavior change.
3.
THUMB SUCKING
3.1
Intervention Research
In light of the potential problems associated with chronic thumb sucking (see Chapters 3 and 10), a variety of management techniques has been recommended to parents. To date, no treatment outcome studies have been
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published using pharmacological treatment for thumb sucking. However, a variety of behavioral procedures have been used to treat this behavior. These include reinforcement procedures, punishment procedures, habit reversal, and a host of other procedures with no clear behavioral mechanism operating. Below, the findings with each of these procedures are briefly reviewed.
3.1.1
Reinforcement Procedures
Differential reinforcement (DRO) involves delivering a reinforcer for the absence of the target behavior. DRO programs have been successfully employed with thumb sucking at home and school (Christensen & Sanders, 1987; Lichstein & Kachmarik, 1980; Ross, 1974; Ross & Levine, 1972; Skiba, Pettigrew, & Alden, 1971). Knight and McKenzie (1974) used reading stories at bedtime as reinforcement for the absence of thumb sucking in three girls. During baseline conditions, the experimenter read continuously to each child despite any occurrence of thumb sucking. However, during contingency conditions, the experimenter stopped reading when the child began to suck her thumb. The experimenter ignored any questions or responses made by the child and continued to look directly at the book, looking only peripherally at the child during the thumb sucking interval. Reading was resumed after the child removed her thumb from her mouth. When reading was made contingent on the absence of thumb sucking, the behavior was eliminated in all three subjects. Lichstein and Kachmarik (1980) analyzed generalization and maintenance of changes in thumb sucking following treatment with DRO across three treatment settings with two school-age children. For one child, the treatment settings included a quiet play period before lunch at school, prior to dinner at home, and just before bedtime. The treatment settings were similar for the second child. During the first treatment session, the researcher told the child that one token would be earned for each 5-minute interval with no thumb sucking. Tokens were exchanged for rewards and the interval needed to obtain a token was increased by 5 minutes each subsequent day until the entire session (30 minutes) was regarded as one interval. During the second phase of treatment, the half-hour sessions were terminated and the DRO schedule was divided into three intervals: the time spent at school, the time from the end of school until dinnertime, and from dinner time until bedtime. During the third phase, one of the child's schedules was condensed into two:
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the time at school and the time at home. Although the treatment produced immediate reductions in thumb sucking in each setting, the effects were short-lived as both returned to baseline levels of sucking within three months. However, both children showed generalization from one setting to another. Thus, it appears that treatment effects may be better when using immediate reinforcement (i.e., reading stories) rather than delayed reinforcement (i.e., token exchange).
3.1.2
Punishment Procedures
A number of aversive treatments have also been applied to thumb sucking. A common example of this technique is the application of bittertasting substances. Azrin, Nunn, and Frantz-Renshaw (1980b) conducted a controlled comparison with a bitter-tasting substance applied to the thumb and reported a 35% reduction in thumb sucking. However, more recent studies have found a bitter-tasting substance combined with extrinsic reinforcers is also successful at reducing thumb sucking. For example, in a randomized, wait-list controlled study, Friman and Leibowitz (1990) found that children who received aversive taste treatment plus differential reinforcement for the absence of thumb or finger sucking improved significantly more than the children in the wait list control group. Similar results were found by Friman, Barone, and Christopherson (1986) and by Friman (1990) who evaluated the treatment of concurrent thumb sucking and object attachment habits with a combination of aversive taste treatment and a motivational system (DRO). In this study, Friman (1990) asked parents of the participants to apply the aversive taste solution to the thumb once in the morning, once in the evening before bed, and when the child engaged in thumb sucking. Taste treatment was faded by first eliminating the morning application followed by the evening dose after a one-week period in which thumb sucking did not occur. When an entire day passed without thumb sucking, children under 7 years of age drew one slip of paper, on which the parents had written a reward, to be obtained from grab bag. Older children connected two dots on a connect-the-dot drawing of a toy (which the parents purchased when the drawing was complete). Treatment rapidly eliminated thumb sucking to zero levels and seven of the eight children subsequently lost interest in their attachment object. As the aforementioned study suggests, when thumb sucking covaries with another repetitive behavior, an effective treatment may merely involve
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treating only one of the behaviors. Friman and Hove (1987) observed that thumb sucking and hair pulling both decreased after sole treatment for thumb sucking in two young children. This study is important because it shows that hair pulling was eliminated through the successful aversive taste treatment of thumb sucking. However, research by Long, Miltenberger, and Rapp (2000) showed more limited treatment success among concurrent habits when using a simplified version of habit reversal. This study will be discussed below.
3.1.3
Habit Reversal
One of the most studied behavioral approaches to the treatment of thumb sucking has been habit reversal (Azrin & Nunn, 1973). Since the development of habit reversal, several studies have shown its effectiveness for childhood habit disorders (for a review, see Woods & Miltenberger, 1995). Using the original habit reversal procedures, Azrin et al. (1980b) compared the effects of habit reversal to a bitter tasting substance applied to the finger or thumb twice a day. The results showed that 47% of the habit reversal participants had eliminated thumb sucking at the three-month follow-up as compared to only 10% of the participants who received the bitter tasting substance treatment. In terms of absolute frequency, the habit reversal group had a mean of 1.8 episodes per day at the three-month follow-up compared to the baseline mean of 36 episodes per day, whereas the bitter tasting substance group had a mean of 21.2 episodes per day at the three-month follow-up compared to their baseline mean of 52 episodes per day. In a well-designed study by Christensen and Sanders (1987), behavioral treatment of thumb sucking was evaluated by randomly assigning 30 children (10 per group) to a habit reversal, DRO, or wait-list control condition. Results showed that there was no difference in thumb sucking between the habit reversal and DRO groups, but the wait-list control group differed from both the habit reversal and DRO groups. Habit reversal completely eliminated thumb sucking in three children at post-training and in two at follow-up, whereas DRO eliminated thumb sucking in two children at post-training and one at follow-up. Both procedures were associated with significant increases in oppositional behavior in the training setting although this behavior returned to baseline levels at follow-up. This finding is important to keep in mind because parents may view the oppositional
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behavior as more aversive than the target behavior and may abandon adherence to the treatment. Many of the parents actually commented that they viewed the habit reversal condition more favorably than DRO because withholding of privileges produced protests from the children, whereas both parties felt like they were working towards a common goal in the habit reversal condition. Although several studies have demonstrated the effectiveness of the original habit reversal package or slight variations of it, other studies have focused on determining the active components of the procedure. Miltenberger, Fuqua, and McKinley (1985) found that the awareness training and competing response training components used together were as effective as the entire habit reversal program in suppressing muscle tics. Unfortunately, this simplified procedure has rarely been evaluated as a treatment for thumb sucking. In a recent study, Rapp, Miltenberger, Galensky, Roberts, and Ellingson (1999) evaluated simplified habit reversal as a treatment for thumb sucking in 5 year olds twin brothers. SHR was effective for one child but not for the other. For the other child, the addition of surreptitious observation and enhanced social support by the parent reduced thumb sucking to near zero levels. In one of the few well controlled group evaluations of SHR, Woods et al. (1999) randomly assigned 26 children who engaged in an oral-digital habit to either a similar competing response group (i.e., competing responses involving similar muscle groups to those used in the target behavior), a dissimilar competing response group (i.e., competing responses involving muscle groups not involved in the target behavior), or a wait-list control group. Results showed that the similar and dissimilar groups did not differ in thumb sucking reduction from pretreatment to posttreatment, but that both showed greater reductions in thumb sucking than did the control group. Thus, it appears that although habit reversal is effective, the competing response does not have to be physically incompatible with thumb sucking as suggested by Azrin and Nunn(1973). In another study evaluating SHR, Long, Miltenberger, and Rapp (1999) showed limited treatment success among concurrent habits. In this study, the authors examined the effectiveness of SHR treatment consisting of awareness training, competing response training, and social support procedures in a girl who engaged in thumb sucking and hair pulling. Initially, the implementation of SHR plus booster sessions for thumb sucking produced only minimal reductions in thumb sucking and hair pulling. However, additional treatments involving DRO and response cost resulted in
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near zero levels of the behavior when implemented for thumb sucking and then hair pulling. Next, hair pulling was treated with the same procedures, which resulted in near zero levels of the behavior. Thus, treatment of thumb sucking might not result in the elimination of covarying hair pulling in all children. In a similar study. Long et al. (1999) examined whether a SHR procedure would eliminate thumb sucking in individuals with mild to moderate mental retardation. Although the SHR did little to decrease the finger/hand-to-mouth behavior, the addition of remote contingencies decreased the habit to nearzero levels for both participants who exhibited these target behaviors. These authors suggested that a limitation of SHR in persons with mental retardation might be the lack of reinforcement or negative social consequences. Even though all participants learned the necessary skills to control their habit, there were no reinforcement contingencies in place in their natural environment to maintain the use of their skills. Also, persons with severe mental retardation may be less responsive to the negative social consequences that result from engaging in their habit behaviors. Perhaps what facilitates the independent use of SHR is the experience of negative social consequences. Thus, for some individuals who do not experience negative social consequences, an additional motivational system based on external reinforcers may be a necessary adjunct to SHR.
3.1.4
Other Behavior Change Procedures
In addition to reinforcement, punishment, and habit reversal treatments, a number of other interventions have also been used to treat thumb sucking. Dentists have advocated the use of a variety of response prevention methods, including oral devices and a palatal crib with spurs so that insertion of the thumb into the mouth produces a painful sensation. Fortunately, the use of a simple removable orthodontic appliance in the upper arch, which prevents contact between the digit and the roof of the mouth, has been shown to eliminate thumb sucking. Campbell-Reid and Price (1984) reported that persistent finger sucking in four of five subjects stopped within six months of treatment with the insertion of a dental appliance. Ellingson et al. (2000) reported that application of adhesive bandages to the fingers, which diminished tactile stimulation, resulted in a decrease of finger sucking in one child and cessation of finger sucking in another child. Gloves were then assessed in both children, based on the implication that
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oral stimulation, digital stimulation, or both were maintaining fmger sucking. Gloves were chosen in place of adhesive bandages because they were reusable and did not leave residue on the fingers. No finger sucking was noticed in one child during 20 of the 22 checks. Both the child and the mother agreed that the treatment was acceptable. An awareness enhancement device (AED: Rapp, Miltenberger, & Long, 1998) was implemented into the treatment of the other child, due to the fact that only moderate decreases in finger sucking were observed during the use of gloves. The AED emitted a 65 to 70 dB tone dependent upon placement of the child's hands within 6 inches of her head and did not cease until the hand was lowered from the head. Employment of the AED resulted in suppression of finger sucking for nine sessions (M = 0%); however, finger sucking increased slightly after withdrawal of the AED 10 sessions later (M = 1.3%). Reimplementation of the AED phase resulted in near-zero levels of finger sucking (M = 0.2%) for 12 sessions. Both the child and the mother agreed both the glove and AED treatments were acceptable, however, the child preferred the AED (EUingson et al., 2000). In an earlier study, Friman (1988) treated a child who chronically sucked her thumb while holding a doll, by placing the doll out of her reach. During treatment, when the child asked her parents about the doll, she was told that she had outgrown her need for it and that she should seek out other objects to play with. During the withdrawal phase, the doll was placed on the child's bed and nothing was said about its return. In the third, and final withdrawal session, after the child had sucked her thumb for an extended period of time, the child angrily told her parents not to leave the doll on her bed because it made her suck her thumb. Three and six month follow-up observations were similar to the treatment conditions in that the doll was placed out of the child's reach. Thumb sucking was eliminated with treatment and the elimination was maintained across follow-up sessions.
4.
CONCLUDING COMMENTS
The good news for the clinician is that there are a number of highly successful treatments available for the reduction and elimination of nail biting and thumb sucking. However, long-term reduction and elimination of these habits seem to be achieved less often than reductions in the short-run. This suggests some directions for future research. First, a better understanding of the variables controlling these behaviors would facilitate
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development of improved treatments or treatments better targeted at the factors maintaining the behaviors in a given individual. It would be important to understand whether tension reduction, self stimulation, or some form of social reinforcement is involved in the maintenance of oral-digital habits in order to better treat these behaviors. Conducting functional analyses of these behaviors would aid in this process. Although habit reversal continues to be studied actively, the components of the treatment responsible for behavior change remain unclear. Is selfmonitoring, a competing response, social reinforcement or some other element crucial to the treatment's efficacy? There are still no studies on the role of the expectancy of treatment benefit in these literatures, despite Azrin et al.'s (1980a) suggestion of its importance. In fact, it remains to be determined whether the success of any treatment utilized to date is based on anything more than the influence of nonspecific factors. In addition, too few studies have examined the social validity and generalization of treatments and the effects on other behaviors, including other habit behaviors. Finally, work applying habit reversal to mentally retarded individuals suggests the further study of individual difference and environmental variables would be profitable. The assessment of nail biting and thumb sucking has been excessively reliant on self-reports by participants. Miltenberger, Fuqua, and Woods (1998) reviewed a number of innovative assessment strategies that are less reliant on client self-reports. These include videotaping clients in high risk situations in the natural environment and monitoring the target behavior by significant others in the client's life. Assessment of a variety of aspects of the target behavior and client reactions should become standard practice in evaluating treatments for these behaviors.
5-
REFERENCES
Adesso, V. J., Vargas, J. M., & Siddall, J. W. (1979). The role of awareness in reducing nailbiting behavior. Behavior Therapy, 10, 148-154. Allen, K. W. (1996). Chronic nail biting: A controlled comparison of competing response and mild aversion treatments. Behaviour Research and Therapy, 34, 269-272. Azrin, N.H., & Nunn, R.G. (1973). Habit-reversal: A method of eliminating nervous habits and tics. Behavior Research and Therapy, 11, 619-628. Azrin, N. H., & Nunn, R. G. (1977). Habit control in a day. New York: Simon & Schuster. Azrin, N. H., Nunn, R. G., & Frantz, S. E. (1980a). Habit reversal vs. Negative practice treatment of nail biting. Behavior Research and Therapy, 75,281-285.
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Azrin, N. H., Nunn, R. G., & Frantz-Renshaw, S. (1980b). Habit reversal treatment of thumb sucking. Behavior Research and Therapy, 18, 395-399. Barmann, B. C. (1979). The use of overcorrection with artificial nails in the treatment of chronicfingernailbiting. Mental Retardation, 77,309-311. Barrios, B. A. (1977). Cue-controlled relaxation in reduction of chronic nervous habits. Psychological Reports. 41, 703-706. Butcher, B. D. (1968). A pocket-portable shock device with application to nail biting. Behaviour Research and Therapy, 6, 389-392. Campbell Reid, D. A., & Price, A. H. K. (1984). Digital deformities and dental malocclusion due to finger sucking. British Journal of Plastic Surgery, 37, 445-452. Christensen, A. P., & Sanders, M. R. (1987). Habit reversal and differential reinforcement of other behavior in the treatment of thumb-sucking: An analysis of generalization and sideeffects. Journal of Child Psychological Psychiatry. 28. 281-295. Daniels, L. K. (1974). Rapid extinction of nail biting by covert sensitization: A case study. Journal of Behavior Therapy and Experimental Psychiatry. 5, 91 -92. Davidson, A. M., & Denny, D. R. (1976). Covert sensitization and information in the reduction of nail biting. Behavior Therapy, 7, 512-518. Davidson, A. M., Denny, D. R., & Elliot, C. H. (1980). Suppression and substitution in the treatment of nail biting. Behaviour Research and Therapy, 18, 1-9. DeL. Home, D. J., & Wilkinson, J. (1980). Habit reversal treatment for fingernail biting. Behaviour Research and Therapy, 18, 287-291. Delparto, D. J., Aleh, E., Bambusch, J., & Barclay, L. A. (1977). Treatment of fingernail biting by habit reversal. Journal of Behavior Therapy and Experimental Psychiatry, 8, 319. DeLuca, R. V., & Holborn, S. W. (1984). A comparison of relaxation training and competing response training to eliminate hair pulling and nail biting. Journal of Behavior Therapy and Experimental Psychiatry, 15, 67-70. Ellingson, S. A., Miltenberger, R. G., Strieker, J. M., Garlinghouse, M. A., Roberts, J., Galensky, T.L., & Rapp, J.T. (2000). Analysis and treatment of finger sucking. Journal of Applied Behavior Analysis, 33, 41-52. Foxx, R. M. (1976).The use of overcorrection to eliminate the public disrobing (stripping) of retarded women. Behaviour Research and Therapy, 14, 53-61. Frankel, M. J., & Merbaum, M. (1982). Effects of therapist contact and a self-control manual on nail biting reduction. Behavior Therapy, 13, 125-129. Friman, P. C. (1988). Eliminating chronic thumb sucking by preventing a covarying response. Journal of Behavior Therapy and Experimental Psychiatry, 19. 301-304. Friman, P. C. (1990). Concurrent habits: What would Linus do with his blanket if his thumbsucking were treated? American Journal of Diseases of Children, 144, 1316-1318. Friman, P. C, Barone, V. J., & Christopherson, E. R. (1986). Aversive taste treatment of thumb sucking. Pediatrics, 78, 174-176. Friman, P. C, & Hove, G. (1987). Apparent Covariation between child habit disorders: Effects of successful treatment for thumb sucking on untargeted chronic hair pulling. Journal ofApplied Behavior Analysis, 20, 421-425. Friman, P. C, & Leibowitz, J. M. (1990). An effective and acceptable treatment -alternative for chronic thumb- andfinger-sucking.Journal of Pediatric Psychology, 15, 57-65.
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Glasgow, R. E., Swaney, K., & Schafer, L. (1981). Self-help manuals for the control of nervous habits: A comparative investigation. Behavior Therapy, 12, 177-184. Hansen, D. J., Tishelman, A. C , Hawkins, R. P., & Doepke, K. J. (1990). Habits with potential as disorders: Prevalence, severity, and other characteristics among college students. Behavior Modification, 3, 179-186. Horan, J. J., Hoffman, A. M., & Macri, M. (1974). Self-control of chronic fingernail biting. Journal of Behavior Therapy and Experimental Psychiatry, 5, 307-309. Home, D. J. DeL., & Wilkinson, J. (1980). Habit reversal treatment for fingernail biting. Behaviour Research and Therapy, 18, 287-291. Knight, M. F., & McKenzie, H. S. (1974). Elimination of bedtime thumb sucking in home settings through contingent reading. Journal ofApplied Behavior Analysis, 7, 33-38. Ladouceur, R. (1979). Habit reversal treatment: Learning an incompatible response or increasing the subject's awareness. Behaviour Research and Therapy, J 7, 313-316. Leonard, H. L., Lenane, M. C, Swedo, S. E., Rettew, D. C, & Rapoport, J. L. (1991). A double-blind comparison of clomipramine and desipramine treatment of severe onychophagia (nail biting). Archives of General Psychiatry, 48, 821-827. Lichstein, K. L., & Kachmarik, G. (1980). A nonaversive intervention for thumb sucking: Analysis across settings and time in the natural environment. Journal of Pediatric Psychology, 5, 405-414. Long, E. S., Miltenberger, R. G., Ellingson, S. H., & Ott, S. M. (1999). Augmenting simplified habit reversal in the treatment of oral-digital habits exhibited by individuals with mental retardation. Journal ofApplied Behavior Analysis, 32, 353-365. Long, E. S., Miltenberger, R. G., Rapp, J. T. (1999). Simplified habit reversal plus adjunct contingencies in the treatment of thumb sucking and hair pulling in a young child. Child and Family Behavior Therapy, 21, 45-58. MacNamara, J. R. (1972). The use of self-monitoring techniques to treat nail biting. Behaviour Research and Therapy, 10, 193-194. Malone, A. J., & Massler, M. (1952). Indexof nail biting in children. Journal of Abnormal Social Psychology, 47, 193-202. Miltenberger, R. G., & Fuqua, R. W. (1985). A comparison of contingent vs non-contingent competing response practice in the treatment of nervous habits. Journal of Behavior Therapy and Experimental Psychiatry, 16, 195-200. Miltenberger, R.G., Fuqua, R.W., & McKinley, T. (1985). Habit reversal with muscle tics: Replication and component analysis. Behavior Therapy, /6,_39-50. Miltenberger, R. G., Fuqua, R. W., & Woods, D. W. (1998). Applying behavior analysis to clinical problems: Review and analysis of habit reversal. Journal of Applied Behavior Analysis, 31, 447-469. Mulick, J. A., Hoyt, P., Rojahn, J., & Schroeder, S. R. (1978). Reduction of a "nervous habit" in a profoundly retarded youth by increasing toy play. Journal of Behavior Therapy and Experimental Psychiatry, 9, 381-385. Nunn, R. G., & Azrin, N. H. (1976). Eliminating nail-biting by the habit reversal procedure. Behaviour Research and Therapy, 14, 65-67. Paquin, M. J. (1977). The treatment of nail biting compulsion by covert sensitization in a poorly motivated client. Journal of Behavior Therapy and Experimental Psychiatry, 8. 181-183.
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Perkins, D. J., & Perkins, F. M. (1976). Nail biting and cuticle biting: Kicking the habit. Richardson, Tx.: Self Control Press. Rapp, J., Miltenberger, R., Galensky, T., Roberts, J., & Ellingson, S. (1999). Brief functional analysis and simplified habit reversal treatment of thumb sucking in fraternal twin brothers. Child and Family Behavior Therapy, 21, 1-17. Rapp, J. T., Miltenberger, R. G., & Long, E. S. (1998). Augmenting simplified habit reversal with an awareness enhancement device: Preliminary findings. Journal of Applied Behavior Analysis, 31. 665-660. Ross, J. A. (1974). The use of contingency contracting in controlling adult nail biting. Journal of Behavior Therapy and Experimental Psychiatry, 5, 105-106. Ross, J. A., & Levine, B.A. (1972). Control of thumb sucking in the classroom: Case study. Perceptual and Motor Skills, 34, 584-586. Silber, K. P., & Haynes, C. E. (1992). Treating nail biting: A comparative analysis of mild aversion and competing response therapies. Behaviour Research and Therapy, 30, 15-22. Skiba, E. A., Pettigrew, L. E., & Alden, S. E. (1971). A behavioral approach to the control of thumb sucking in the classroom. Journal of Behavioral Analysis, 4, 121-125. Smith, M. (1957). Effectiveness of symptomatic treatment of nail biting in college students. Psychological Newsletter, 8, 219-231. Stephen, L. S., & Koenig, K. P. (1970). Habit modification through threated loss of money. Behaviour Research and Therapy, 8, 211-212. Vargas, J. M., & Adesso, V. J. (1976). A comparison of aversion therapies for nail biting behavior. Behavior Therapy, 7, 322-329. Woods, D. W., & Miltenberger, R. G. (1995). Habit reversal: A review of applications and variations. Journal of Behavior Therapy and Experimental Psychiatry, 26, 123-131. Woods, D. W., Murray, L. K., Fuqua, R.W., Self, T. A., Boyer, L. J., & Siah, A. (1999). 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, 30, 289-300.
Chapter 12 Habit Reversal Treatment Manual for Oral-Digital Habits Douglas W. Woods Michael P. Twohig University of Wisconsin-Milwaukee
1. INTRODUCTION This chapter provides a treatment manual for oral-digital habits in children, adolescents, and adults. Oral-digital habits include thumb and finger sucking, fingernail biting, and biting skin around the fingernails. The treatment described in this chapter is based on the habit reversal procedure outlined by Azrin and Nunn (1973). There is substantial evidence habit reversal is an effective therapy for oral-digital habits in typically developing persons, although its effectiveness in treating persons with developmental disabilities is less clear (Miltenberger, Fuqua, Woods, 1998).
2. HABIT REVERSAL TREATMENT PROTOCOL FOR ORAL-DIGITAL HABITS As outlined in this protocol, implementation of habit reversal for oraldigital habits requires a minimum of four sessions. During the first one-hour session the clinician conducts an interview, administers standardized assessments, and establishes a system for data collection. During the second one-hour session, habit reversal is implemented. Habit reversal includes awareness training, competing response training, and social support training. The third and fourth sessions are booster sessions whose
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purpose is to monitor progress, review treatment implementation, and develop solutions to problems that may have occurred since the previous session. Each booster session lasts approximately 30 minutes.
2.1 Session 1 During Session 1 the clinician should gain an understanding of the client's habit and assess for possible functions and comorbid conditions. This is accomplished through an initial interview in which the habit and the possible maintaining variables for the habit are identified, and sensory experiences surrounding the habit are discussed. Next, standardized assessments for comorbid problems are conducted. Finally, an ongoing assessment plan should be established and continued throughout treatment to monitor effectiveness. 2.1.1
Identifying the Habit
The interview should begin by having the client work with the clinician to define the behavior until both are clear about what is being targeted. Additionally, a definition will be needed for data collection purposes. The clinician should record the definition, for it will be needed later in treatment.
2.1.2
Identifying Possible Functions
After the habit has been defined, the clinician should determine any possible variables maintaining the habit, including any socially mediated environmental variables. Determining the maintaining variables can often be done through a functional assessment interview (see Chapter 2 for assessment procedures), and is important because the course of treatment may differ depending on the function of the habit (see Chapter 11 for alternate treatments). For example, if a client's habit is maintained through parental attention, the clinician may forgo habit reversal in exchange for a differential reinforcement of alternative behavior procedure in which attention is provided for a non-habit behavior and withheld contingent on the habit. In general, three primary variables may maintain oral-digital habits; socially mediated positive reinforcement, socially mediated negative reinforcement, or automatic reinforcement. Although these reinforcers will
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be briefly described in this section, Chapter 2 provides a more thorough coverage. Oral-digital habits will likely draw a reaction from those nearby. To some, this reaction will serve as a positive reinforcer that maintains the habit's occurrence over time. For example a child who sucks his or her thumb will likely draw attention from his or her parents in the form of reprimands, consolation, or other attempts to stop the habit. If a functional assessment interview suggests the behavior is maintained by attention, treatment may involve teaching the parents to respond differently to their child's thumb sucking. It is also possible that the oral-digital habit alleviates something aversive to the client. In this case, engaging in the habit may result in negative reinforcement. For example, assume we have an adolescent with social anxiety and a thumb sucking habit. When this adolescent sucks his thumb, peers may avoid him or her, which keeps potentially aversive social contact at a distance. In this case, habit reversal may not be needed and therapy would consist of training those in contact with the client to withhold reinforcement for his habit (i.e., reinforcing peers for social interaction with the client in the presence of thumb sucking) or training the client to deal with the underlying anxiety. Although some habits may be maintained by socially mediated consequences, most seem to occur in the absence of such stimuli. These habits are believed to be maintained by automatic reinforcement. Unfortunately, to say a habit is maintained by automatic reinforcement reveals little about the specific reinforcer maintaining the behavior. Even in cases where the client can report the function of the habit, behaviors maintained by automatic reinforcement are often best treated with an approach such as habit reversal, because "automatic" variables are often outside the control of the clinician or any other external agent of change. To assist in determining habit function, it is sometimes useful to interview the client about sensory experiences surrounding his or her habit.
2.1.3
Sensory Experiences Surrounding Habits
During this phase of the initial assessment the clinician and the client identify bodily sensations or behaviors the client experiences before, during, and after the habit because (1) such behaviors or sensations often point to possible functions and (2) the antecedent behaviors or sensations may be used later in treatment as warnings to engage in the competing response. For
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example, sensations that precede fingernail biting could include anxiety or a feeling of "need" to bite the nails. This urge could then be used to prompt the client to become more aware of the habit occurrence which is a key factor to the awareness training procedures described in Session 2. Likewise, the feelings experienced during and after the habit may provide useful information as to the function the habit serves. For example, if the client reports a feeling of "relief during or after the habit, it may be presumed that the habit is being maintained by automatic negative reinforcement. 2.1.4
Behavioral Observation and Setting up Ongoing Data Collection
After the sensory experiences surrounding the habit are identified, a method of data collection should be implemented at home and in the clinic. Data collection procedures are used for monitoring treatment effectiveness and to determine the necessity of procedural modifications. Data collection should ideally be implemented in situations where the habit is most likely to occur. Often, this is in the home. Clinic-based data collection should occur only for reliability and as a back-up if data collection procedures established elsewhere fail. In the following paragraphs, home-based and clinic-based methods for data collection will be discussed. 2.1.4.1 Home-based Methods As stated earlier, data should be collected on the rate of occurrence of the target behavior. Video recording is an excellent form of data collection, although many individuals may not feel comfortable being videotaped and may intentionally not engage in the habit. If video monitoring is acceptable to the client, the clinician should teach the client, a caregiver, or significant other how to videotape. The caregiver or significant other should collect frequent (e.g. 2-3 times per week) 10-20 minute video segments of the client. The segments can then be returned to the clinician and scored using a duration or partial interval scoring method (Barlow & Hersen, 1984). If video monitoring is not a viable option, self-monitoring or parentmonitoring (if client is a child) may be utilized. When using selfmonitoring, the client could be given a number of cards on which the date is printed on the front and the clinician's phone number is printed on the back.
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The client can be asked to carry the card with him or her at all times and mark the card each time the habit occurs. If continuous monitoring is too difficult, clients may collect data on the occurrence of the habit for a predetermined shorter period at the same time each day (e.g., 1:00pm3:00pm). Parent monitoring can be done in a similar fashion with parents counting the frequency of the habit during a given time period. At the end of each day, the client should call or e-mail the therapist and state the number of times the habit occurred. Daily client reports are recommended to increase compliance with data collection and to enhance motivation for treatment.
2.1.4.2 In-Clinic Methods Clinic-based data collection methods could be implemented in a number of ways. The suggested procedure is video recording, similar to that described in the previous section. Another clinic-based assessment measure involves photographing the client's hands throughout sessions and comparing the photographs on the amount of visible damage.
2.1.5
Standardized Assessments of Other Conditions
After all other components of Session 1 are completed the clinician should assess for the presence of any comorbid psychological conditions. A growing body of literature suggests those with habitual behaviors, or stereotypic movement disorder, are more likely to have comorbid psychological conditions such as ADHD, depression, and anxiety than those without habitual behaviors (Teng, Woods, & Twohig, 2000). Although assessment strategies and particular treatments for such comorbid conditions are outside the scope of this book, the clinician should attempt to determine the presence of these conditions and modify treatment accordingly. At the end of Session 1, the clinician should ask the client to identify a support person to bring with him or her during the next session. The support person will be needed for implementing a part of the treatment known as social support training. This could be introduced to the participant as follows. "There is a part of the treatment in which we teach a person close to you to help you with treatment outside of the therapy session. Can you think of a person who would be willing to help you with treatment?"
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2.2 Session 2 Prior to initiating treatment, the clinician and client should review the data collected thus far. The clinician should praise the client for collecting the data, which may then be used as a basis for comparing subsequent data to determine treatment effectiveness. After praising the client and reviewing the data, treatment should begin. The goal of Session 2 is to implement habit reversal. As a therapy for oral-digital habits, habit reversal includes three main components: awareness training, competing response training, and social support. The purpose of awareness training is to help the individual recognize the habit and somatic sensations or behaviors that precede the habit (referred to as "warning signs" throughout the chapter). After the client is able to recognize the habit and the warning signs, he or she is taught to use a competing response contingent on the habit and warning signs. A competing response is any behavior that makes it difficult to engage in the habit. After the client demonstrates an ability to recognize his or her warning signs, and can perform a competing response contingent upon them, he or she is asked to gain the assistance of someone in implementating the procedure. This is known as social support and involves having someone close to the client assist the client in using the competing response contingent on the habit or warning signs.
2.2.1
Awareness Training
The goal of awareness training is to teach the client to recognize his or her habit and warning signs. Self-awareness is deemed essential because habit reversal is essentially a self-management procedure that requires clients to implement the competing response contingent on the occurrence of these events. Awareness training is accomplished by helping the client isolate and acknowledge the warning signs that occur just prior to the habit and by helping the client recognize instances of the actual habit. Awareness is achieved through the use of two techniques: response description and response detection.
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2.2.1.1 Response Description Response description involves providing a description of the target behavior and warning signs. However, before starting response description, a rationale for awareness training should be given. An example of such a rationale is as follows. "The very first thing we are going to do today is figure out just what your habit is like, and what happens just before you do your habit. After we know exactly what your habit is, we will do some exercises to help you become more aware of when it is going to happen. This is very important because if you want to learn to manage something you must first know when it is happening."
After providing the rationale for awareness training, the clinician should ask the client to describe his or her habit. Although this was done to a certain extent during Session 1, the process of describing the behavior in Session 2 should involve more detail. Let us use an individual with a fingernail biting habit as an example. For this individual the definition of the habit may be, "when any finger passes the lips and the teeth press down on the nail." Below is an example of how the clinician would ask the client to describe the habit. "Before we begin helping you with your habit we must come up with a clear definition of what your habit is. This is important in treatment for two reasons. First, in order to become aware of your habit you need to know exactly what the habit entails. Second, it is important that I know exactly what your habit is for effective treatment and communication between the two of us. I would like you to do is describe to me in detail, your habit." (Clinician allows the client to answer) "You did not mention which nails you bite. Do you bite all of your nails?" (Clinician allows the client to answer) "Nice job describing the habit, I feel we both have a clear understanding exactly what your habit entails."
The clinician should continue to ask questions about the habit until he or she feels the client has provided an accurate description. Because criteria do not exist to determine if the description is accurate, the clinician must rely on his or her judgment. At this point in treatment, the clinician and the client should have a clear description of the habit. If this is not the case, the
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clinician and the client should continue to describe the habit until the behavior is clearly described. After the habit has been fully described, the client should describe his or her warning signs. An example of how this phase of the treatment could be introduced is as follows. "Next, I want you to describe any feelings or other things you do or experience before your habit. It is very likely that you have certain feelings or do certain things prior to your habit and if we can figure out what these are then you will be more likely to predict when you will do the habit and thus have a better chance of successfully treating your habit. Could you please tell me any feelings or things you do prior to the habit."
Individuals with oral-digital habits may present with a number of warning signs. People with a fingernail biting habit may rub their fingers together or rub their lips with their fingers prior to biting their nails. Likewise, these individuals may experience feelings of anxiety prior to biting or report an urge to bite their nails. As is evident, warning signs for a person's habit may be both private and public. Regardless, it is vital to the success of habit reversal that the person be able to state the covert or overt behaviors that occur prior to their habit. If the client reports he or she does not have any warning signs, the clinician should point out a few obvious behaviors that could occur. After determining the warning signs, response detection should be implemented.
2.2.1.2 Response Detection The purpose of response detection is to help the client acknowledge actual occurrences of the habit and its warning signs. This is accomplished in two steps. First, the client should acknowledge clinician simulations of the client's habit. The client should be made aware of the rationale for this procedure. A sample explanation is as follows. "We are going to help you continue to become more aware of your habit by having you acknowledge each time I simulate your habit. I would like you to say, "there's one" or raise your hand each time I simulate your habit. We do this because watching someone else do something is an effective way of becoming aware of your own behaviors. During the next few minutes I will be acting out your habit and would like you to inform me each time I do it."
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This process continues until the client acknowledges four of five clinician-simulated habits. Each time the client acknowledges a simulated habit, the clinician should provide praise. In instances where the clinician simulates a habit, but the client does not acknowledge it, the clinician should state that a habit had occurred and remind the client of the instructions. After the client has correctly acknowledged simulated occurrences of the habit, the clinician should repeat the process with the client's warning signs. This involves having the clinician simulate the overt warning signs, and having the client acknowledge each simulation via raising his or her hand or saying "there's one." Each warning sign does not need to be presented in separate simulation sessions, but rather presented randomly in one session until the client recognizes four of five clinician-simulated warning signs. This could be introduced as follows. "Good job at identifying your habit, now I would like to do the same thing with your warning signs." I am going to simulate the different warning signs that you reported, and each time I do one I would like you to raise your hand or say, "there's one." Do you remember what they are? If not, I can remind you. It is important for you to be able to recognize the warning signs for they are the best indicator that your habit is about to occur. If you don't have any questions, let's begin."
After the client has successfully acknowledged four of five clinician simulated habits and warning signs, the second step of response detection should be implemented; acknowledging client-simulated habits in session. This phase of response detection is similar to the previous one, except the client is asked to acknowledge occurrences of his or her own habits and warning signs. The clinician should instruct the client to acknowledge each time a warning sign or actual habit occurs. It is best if the client can practice by acknowledging actual occurrences, but because the client is in a therapy session, it is unlikely many actual occurrences of the habit will occur. Hence, the client may need to simulate the habit and the warning signs just as the clinician did earlier in the session. First, the clinician should ask the client to simulate the habit, and after each simulation, tell the clinician it occurred by raising his or her hand or saying, "that's one." After the client successfully simulates and acknowledges four of five habits, the process should be repeated with the warning signs. This is done to help the client become more aware of his or her own habit and warning signs. The procedure can be introduced to the client as follows.
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Tic Disorders, Trichotillomania, and Repetitive Behavior Disorders "You did a very good job at pointing out my examples of your habit. Now, I would like you to simulate your own habit and point out to me each time you do your habit by raising your hand or saying, "there's one."
Again, the clinician should provide praise for proper simulation and acknowledgement, and corrective feedback for failed acknowledgements of habits. This procedure should continue until the client can successfully acknowledge four of five simulated habits. After this has been successfully completed, the clinician should ask the client to repeat the procedure, but this time simulating the various warning signs. If the client does not remember all of the warning signs the clinician should remind him or her. This could be introduced in the following manner. "You did a good job demonstrating and acknowledging your habit. Now I would like you to use the same procedure with the warning signs for your habit. Over the next few minutes I would like you to demonstrate the different warning signs we talked about earlier, and after demonstrating each one I would like you to signal or tell me that you just did one. If you do not remember all the warning signs tell me, and I can remind you. If you are ready, you may begin."
At this point, the client will have completed awareness training. The client should now be able to better recognize occurrences of his or her warning signs and habits. Next, the clinician should implement competing response training.
2.2.2
Competing Response Training
Competing response training involves teaching the client to engage in a behavior that is incompatible with the habit, contingent on the occurrence of the habit or one of the warning signs. The competing response is believed to be essential to the effectiveness of habit reversal (Woods, Miltenberger, & Lumley, 1996) The competing response phase contains four main components: choosing a competing response, demonstrating the correct use of the competing response, teaching the client to use the competing response, and having the client demonstrate the proper use of the competing response.
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2.2.2.1 Choosing the Competing Response A competing response is any behavior which makes it difficult to engage in the habit. The client and clinician should seek a competing response that is effective, acceptable to the client, and generally socially acceptable. Although the clinician can suggest or lead the client toward a certain competing response, the clinician should ultimately let the client choose. There are many possible competing responses when treating oral-digital habits. However, the clinician and client must come up with one that will not draw attention, be too difficult, or be embarrassing for the client in a given situation. Forcing the client to use a competing response he or she dislikes may decrease treatment compliance. An example of an unacceptable competing response for finger sucking would be having the client sit on his or her hands. Although this may seem like an acceptable alternative because such a behavior would make it impossible for the person to suck his or her fingers, sitting on one's hands may actually be very noticeable and difficult to do in certain situations. For example sitting on one's hands during a family dinner may be very noticeable and intruding. A more acceptable competing response may involve having the client subtly clench his or her fists. This behavior would make it difficult for the client to suck his or her fingers and would be more socially appropriate. The following paragraph contains an example of how to introduce and choose an acceptable competing response for the client. "The next part of treatment involves you finding a different behavior to do for one minute instead of your habit. I will help you select an appropriate alternate behavior. We will call this your competing response. A competing response should make it impossible for you to do your habit. Likewise, your competing response should be something you are comfortable doing. Do you have any ideas for a behavior you would be comfortable doing and would prevent you from doing your habit?" (Clinician allows the client to answer) "Yes, crossing your arms is a good idea. But I wonder if it might draw attention to you if you do it often. Perhaps something more discrete would be less noticeable to others." (Clinician allows the client to answer) "That sounds like a good idea. Many people choose making fists as their competing response because it is not very noticeable, and easy when you are in a crowd of people. At first, you will probably have to do this many times a day, so do you
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If you are
To maximize the flexibility of treatment, it is sometimes useful to identify a variety of competing responses appropriate for different situations. For example, when talking with friends at work, putting one's hands in one's pockets for 1 min would be socially acceptable, whereas making a fist may be more noticeable. In this social situation, the clinician and client may agree that putting the hands in the pocket would be a better competing response, whereas subtly making a fist may be more appropriate when in a more reserved social setting (e.g., in class or during dinner). After the clinician and the client have identified and agreed upon appropriate competing response(s), the implementation of the competing response should begin.
2.2.2.2 Clinician Simulation of the Competing Response -After selecting a competing response, the clinician should demonstrate its correct use. The clinician should simulate the habit, stop, then perform the competing response for one minute. After properly demonstrating the competing response, the clinician should help the client understand how to use the competing response contingent on the occurrence of the habit. This could be introduced as follows. "Great, now that you have selected a competing response I want to make sure you know how to use it properly. The competing response should be used for one minute each time you start doing the habit or when one of the warning signs occurs. The reason you use a competing response is to give you something to do instead of your habit. After you use the competing response enough you should learn to undo the habit. In the same way you learned to do the habit, you can learn not to do the habit. Now, I am going to demonstrate how to properly use your competing response contingent on the habit." After the clinician demonstrates the proper use of the competing response and believes the client understands how to correctly use it, he or she can have the client practice the procedure.
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2.2.2.3 Teaching the Client the Competing Response During competing response training the client should demonstrate the proper use of the competing response contingent on the occurrence of his or her habit. The clinician should ask the client to start doing the habit, stop, and perform the competing response for one minute. The clinician should have the client do this until it is done correctly on four of five trials. This can be introduced as follows. "Now that you've seen me con*ectIy use the competing response, I would like you to do it. I would like you to start doing the habit, stop, and perform the competing response for one minute. If you don't have any questions, you can start at any time."
After the client has demonstrated the correct use of the competing response contingent on the habit four of five times, the clinician should teach the client to use the competing response contingent on the warning signs. This is taught in a similar fashion and can be introduced as follows. "Good job using the competing response. Now I want to show you how to use it when one of the warning signs occurs. It is done in exactly the same way, except, when one of the warning signs occurs you should perform the competing response. If you do not remember what the warning signs are I can remind you. I will demonstrate how to do this contingent on your warning signs."
The clinician should start doing one of the warning signs, stop, and do the competing response for one minute. Obviously, the clinician cannot simulate the client's private warning signs, so only the overt signs will be practiced in session. If there are multiple warning signs the clinician should alternate between them rather than teaching the procedure with only one warning sign. After the clinician feels the client understands how to use the competing response contingent on the warning signs he or she should have the client to practice. "I would like you to use the competing response after your warning signs. I want you to start doing one of the warning signs, stop yourself, and do the competing response for one minute. If you do not remember what the warning signs are I can tell you. If you don't have any questions, you many begin."
The clinician should ask the client to start doing one of the warning signs, stop and engage in the competing response for one minute. Each time the client engages in the competing response he or she should point it out to the
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clinician by saying, "that's one." If the client engages in one of the warning signs without doing the competing response, the clinician should acknowledge this by saying something like, "you just rubbed your fingers together, don't forget to use the competing response." The client should continue until he or she has successfully used the competing response contingent on the warning signs four of five times. At this point, the client should have demonstrated the correct use of the competing response contingent on the actual habit and the warning signs. The clinician should instruct the client to use the competing response for one minute when the client does either a warning sign or the actual habit. The client must understand this is crucial to the success of treatment, and that he or she must continue to implement the competing response outside of session throughout the course of treatment. These instructions could be presented in the following fashion. "It is very good to see that you know how to use the competing response correctly. I want you to use this every time you experience one of the warning signs or do the actual habit. When you go home you must continue to implement the competing response correctly. This will continue until we have completed treatment. If you have no further questions, I am now going to give you a way to help you remember to do the competing response."
2.2.3
Social Support Training
The purpose of the social support phase is to increase treatment compliance. Social support training involves identifying a person to help the client remember to use the competing response. If the support person views the client doing the habit and not using the competing response, he or she should to remind the client to use it, and conversely, the support person should praise the client for correctly using the competing response. The social support procedure involves identifying and training the support person.
2.2.3.1 Identifying the Support Person Many different circumstances affect who should be selected as the social support person. In the case of a child, the person would ideally be a parent. If the client is in a relationship, it would most likely be the significant other. Likewise, if a person shares a living space with another person, the
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roommate may be ideal. In the case where the person does not live with anyone and is not in a relationship, the clinician should ask the client to nominate a person willing to help with his or her treatment. Ideally the support person should be at Session 2, thus the idea of the support person should have been discussed during the first session. 2.2.3.2 Training the Social Support Person At this point in Session 2, the clinician should invite the support person into the room. If the social support person is unavailable, the clinician should teach the client what to teach the support person. The basic idea of the intervention and the role of the support person should be explained as follows. "Thank you for agreeing to help (the client) with the treatment. Your basic role is to help (the client) remember to use the exercise she has been taught. First I would like to tell you what (the client) has done so far. Before (the client) does her habit she will almost always do one of a number of warning signs, so (the client) and I did some exercises to help her recognize each time she does one of those signs. Now every time she catches herself doing one of the signs she is supposed to make fists with her hands. She makes fists with her hands because that makes it difficult for her to bite her fingernails. If she can keep making the fists instead, her habit will eventually go away. What I would like you to do is praise her when you see her making her fists, and remind her to make the fists every time you see her biting her fingernails."
At this point, the clinician should demonstrate the warning signs and teach the support person to correctly praise the use of the competing response. The support person should deliver praise in a way that is most comfortable to him or her. This is practiced by having the client properly use the competing response, then having the social support person praise him or her. This could be introduced as follows. "When you two leave the clinic, I would like you (social support person) to praise her for correct use of the procedure. You don't have to do anything special, just praise her as you would naturally. I will demonstrate it one time, so you get the idea."
The clinician should ask the client to demonstrate the correct use of the competing response and the clinician should then praise him or her. After correctly praising the use of the competing response, the clinician should have the support person practice delivering the praise. The clinician should
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have the client demonstrate the correct use of the competing response, but this time the support person should praise the client. This could be introduced as follows. "Okay, you saw me praise (the client) for the proper use of the competing response. Now, I would like you to do the same thing. Til ask her to demonstrate the proper use of the competing response and I would like you to praise her. Whenever you are ready (client), you may demonstrate the competing response and I would like you (social support person) to praise her. Please use praise that is comfortable to you."
After the support person has demonstrated the ability to praise the correct use of the correct competing response, the clinician should teach the support person to properly remind the client when the habit occurs. In this part of treatment, the client should perform the habit without using the competing response, and the clinician should demonstrate the correct way to prompt the client. The clinician should remind the client by saying something like, "don't forget to use your competing response when you do your habit." This could be introduced as follows. "Good job praising the correct use of the competing response (social support person). Now, I would like to demonstrate what you should do if you see (client) biting her fingernails, but not using the competing response."
At this point the client and support person should understand how the social support process works. The next phase is to have the support person demonstrate reminding the client. The clinician should ask the client to demonstrate the habit but not the competing response and have the support person remind him or her to use the competing response. This could be introduced by saying something such as... "Now I would like you to practice reminding her when she does not use it. Please (client), perform your habit but do not use the competing response, and (support person) demonstrate reminding her. Whenever you are ready, I would like you to perform your habit."
The clinician should provide praise to the support person for a correct prompt, and provide corrective feedback if needed. The support person should be able to properly praise the correct use of the competing response and prompt the client when he or she is seen performing the habit but not using the competing response.
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Finally, the clinician should ask the support person to continue the praise and prompt strategy for the remainder of treatment. The clinician should ask the client and support person if there are any questions about the treatment. If there are no questions, the clinician may excuse the client and support person.
2.3
Sessions 3 and 4
Booster sessions should occur at one and two weeks after Session 2. The purpose of Sessions 3 and 4 is to review the data, troubleshoot any problems that may have arisen, and to review the treatment. When reviewing the data, the clinician should look for evidence of treatment effectiveness and any trends in the behavior that could be explained by environmental events. An example of such a trend could be one in which the client shows consistent increases in the target behavior during the middle of the week. If this trend is consistent throughout time, it is likely that an environmental event is exacerbating the biting at this time. In such cases, the clinician should try to isolate and alter such variables. Second, the clinician should ask about any concerns with the procedure. The clinician should help solve these problems. An example of a problem could be that the client only uses the competing response when in the presence of the support person, or the client engages in the habit while he or she is sleeping. Possible solutions to these problems are included in the section on ancillary procedures and concerns. Finally, the treatment should be reviewed. The review begins by asking the client the warning signs identified in Session 2. If any are omitted from the description, the clinician should remind the client. After the warning signs are reviewed, proper use of the competing response should be reviewed. This can be accomplished in the following manner. "Could you please tell me all the instances when you are supposed to use the competing response?" (contingent on the habit or a warning sign) "Could you please describe the competing response for me?" (can differ for each person) How long are you supposed to do the competing response?" (for one minute) "Could you please simulate a habit and do the correct competing response?"
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Tic Disorders, Trichotillomania, and Repetitive Behavior Disorders "Could you please simulate your warning signs and do the correct competing response?"
If the client answers the questions and does the simulations correctly the clinician should praise him or her. However, if the client seems confused, answers incorrectly, or does not implement the role play accurately, the clinician should review that part of the procedure by using the training procedures outlined in Session 2. Next, the social support person (if available) should be called into the room, and his or her concerns should be addressed. At this point the first booster session is complete. The client and support person should return for the second booster session one week later. The following booster sessions should be conducted in the same manner. After the second booster session, treatment may be complete if the data show a significant decrease in the target behavior and the results are acceptable to the client. If there has not been a significant decrease in the target behavior or the results are not acceptable, another booster session should be scheduled and possible problems should be addressed or another functional assessment conducted.
3. ANCILLARY PROCEDURES/CONCERNS This section is included to assist the clinician with situations that may complicate the treatment or were not directly addressed in the treatment protocol. It includes sections on awareness enhancement and selfmonitoring, compliance issues, nighttime habits, and application of habit reversal in a school setting.
3.1 Awareness Enhancement and Self-Monitoring The purpose of awareness training is to increase the person's awareness of the habit and its antecedents, but in some cases awareness training is ineffective and thus habit reversal is likely to fail. If the awareness training procedure described in the protocol is ineffective, a self-monitoring procedure or the use of an awareness enhancement device could be implemented. In addition to the two previously stated procedures, weekly awareness training procedures (described in the protocol) should be implemented until the client is at criterion levels of awareness (i.e., 4 of 5 habits or warning signs recognized).
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The self-monitoring assignment should consist of having the client record each time the habit occurs along with the antecedent behaviors. These recordings should occur for at least one-hour a day, and should be done during a time or situation in which the habit is most likely to occur. Using this self-monitoring procedure should help uncover warning signs for the habit as well as increase the client's awareness of its occurrence. An awareness enhancement device is an electronic device worn by the client, that is designed emit a tone whenever the individual raises their hand above a certain point (Rapp, Miltenberger, &Long, 1998). The clinician should arrange such a device to emit the sound whenever the client raises his or her hand above his or her neck. This sound should serve as prompt to use the competing response or stimulus to help the client recognize his or her habit.
3.2 Compliance Issues As stated earlier, one of the primary reasons habit reversal may fail is because of poor treatment compliance. The client may not comply with treatment procedures for a number of reasons including social embarrassment, lack of motivation, or impaired intellectual ability. Regardless of the reasons, well-designed reinforcement procedures should increase compliance. The purpose of the support person is to increase the use of the competing response through praise. However, social support will only be beneficial to the client if praise functions as a reinforcer for him or her. Verbal praise is a conditioned reinforcer to most people, but there are certainly individuals for whom praise is not reinforcing. In such instances an alternative reinforcer should be presented immediately after the individual correctly uses the competing response. Another reason for treatment noncompliance is that the social support person may become a discriminative stimulus for the use of the competing response. In other words the frequency with which the client uses the competing response increases only in the presence of the support person. To increase the use of the competing response in the absence of the support person the support person should covertly observe the client or carry out unannounced checks. If the support person then observes the client correctly use the competing response, he or she could enter the room and praise the client for the correct use. Likewise, if the social support person sees the client engage in the habit and not use the competing response, he or she
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should enter the room and remind the client to use the competing response contingent on the habit. This is similar to a procedure used by Long, Miltenberger, Ellingson and Ott (1999), in which a remote prompting procedure in addition to habit reversal was used to treat an individual with two oral-digital habits. One or both of the aforementioned procedures could be used until the competing response is being implemented correctly and consistently.
3.3 Night-time Habits Many oral-digital habits (e.g. thumb sucking) occur when the individual is in bed. If the clinician is treating a nocturnal habit, a number of concerns become evident, including data collection and treatment implementation. First, the method of data collection must be changed. Data collection on a nocturnal habit could occur in a number of ways (see Chapter 2 for an extensive review). An effective method for recording the occurrence of a nighttime habit is by videotaping segments while the client is asleep. The client can position a camera near the bed and a certain period of time can be scored for the percentage of occurrence. These data are important for determining treatment effectiveness and planning for treatment modifications. After data are collected on the rate of occurrence, an intervention should begin. Because habit reversal will likely be ineffective for a nocturnal habit, two possible alternative treatments are described below. The first approach would be to apply an aversive (but safe) tasting substance to the client's target digits before going to sleep (Friman, Barone, Christophersen, 1986). The aversive taste should decrease the rate at which the habit occurs. A second intervention consists of having the client wear some type of glove or a splint over their hands while he or she is asleep (Ellingson, et al., 2000; Lewis, Shilton, & Fuqua, 1981). Wearing the glove or splint makes it very difficult to engage in the habit and subsequently decreases the rate at which it occurs.
3.4 School Settings Although this treatment manual is described for use in a clinic, it may be equally or more effective when implemented with children or adolescents in
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a school setting. First, schools represent a more natural environment than a clinic setting. Second, psychologists, therapists, social workers, or counselors have a great deal of control over the client's environment in a school setting. As stated in the compliance section, one of the main reasons habit reversal may be ineffective is due to a lack of treatment compliance. Treatment compliance may be increased in a school setting by having the teacher properly reinforce the use of the competing response. Finally, teachers are also in an excellent position to gather direct observation data on the child or adolescent's habit. Although teachers can be a great asset to implementing the procedure, it is important that teacher assistance be carried out in a way that does not draw unnecessary attention to the child for his or her habit. It would be of little benefit to eliminate the habit at the expense of the child being singled out in front of his or her peers.
4. REFERENCES Azrin, N. H., & Nunn R. G. (1973). Habit reversal: A method of eliminating nervous habits and tics. Behaviour Research and Therapy, 11, 612-628. Barlow, D. H., & Hersen, M. (1984). Single case experimental designs: Strategies for studying behavior change (2"^ ed). New York: Pergamon Press. EUingson, S. A., Miltenberger, R. G., Strieker, J. M., Garlinghouse, M. A., Roberts, J., Galensky, T., & Rapp, J. T. (2000). Analysis and treatment of finger sucking. Journal of Applied Behavior Analysis, 33, 41-52. Friman, P.C., Barone, V. J., Christopherson, E. R. (1986). Aversive taste treatment of finger and thumb sucking. Pec/w/nc5, 78, 174-176. Lewis, M., Shilton, P., Fuqua, R. W. (1981). Parental control of nocturnal thumbsucking. Journal of Behavior Therapy and Experimental Psychiatry, 12, 87-90. Long, E. S., Miltenberger, M. G., EUingson, S. A., Ott, S. M. (1999). Augmenting simplified habit reversal in the treatment of oral-digital habits exhibited by individuals with mental VQiaxddiion. Journal ofApplied Behavior Analysis, 32, 353-365. Miltenberger, M. G., Fuqua, R. W., & Woods D. W. (1998). Applying behavior analysis to clinical problems: Review and analysis of habit reversal. Journal ofApplied Behavior Analysis, 31, 447-469. Rapp, T. J., Miltenberger, R. G., Long, E. S. (1998). Augmenting habit reversal with an awareness enhancement device: Preliminary findings. Journal ofApplied Behavior Analysis, 31. 665-668. Teng, E. J., Woods D. W., & Twohig M. P. (2000). Is stereotypic movement disorder a simple habit? An investigation ofcomorbid conditions and the validity ofDSM-lV criteria. Manuscript under review. Woods D. W., Miltenberger R. G., & Lumley V. A., (1996). Sequential application of major habit-reversal components to treat motor tics in children. Journal ofApplied Behavior Analysis, 29, 483-93.
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Disorders
5. APPENDIX A Habit Reversal Treatment Protocol-Oral-Digital Habits Therapist Checklist
Session 1 Interview Identifying the habit definition
Identifying possible functions Sensory experiences surrounding habits Behavioral observation and setting up ongoing data collection Home-based methods In clinic methods Standardized functioning
assessments of other conditions and social
RESULTS
Discuss support person "There is a part of the treatment in which we teach a person who is close to you to help you to remember to use the treatment procedure outside of the therapy session. Can you think of a person who would be willing to help you with treatment?"
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Session 2 Awareness Training Provide a rationale for awareness training "The very first thing we are going to do today is figure out just what your habit is like, and what happens just before you do your habit. After we know exactly what your habit is, we will do some exercises to help you become more aware of when it is going to happen. This very important because if you want to learn how to manage something you first need to know when it is happening."
Operationally define the oral-digital habit "Before we begin helping you with your habit we must come up with a clear definition of what your habit is. This is important in treatment for two reasons. First, in order to become aware of your habit you need to know exactly what the habit entails. Second, it is important that I know exactly what your habit is for effective treatment and communication between the two of us. I would like you to do is describe to me in detail, your habit."
Identify "warning signs" "Next, I want you to describe any feelings or other things you do or experience before your habit. It is very likely that you have certain feelings or do certain things prior to your habit and if we can figure out what these are then you will be more likely to predict when you will do the habit and thus have a better chance of successfully treating it. Could you please tell me any feelings or things you do prior to the habit."
Have client acknowledge clinician-simulated habit "We are going to help you continue to become more aware of your habit by having you acknowledge each time I simulate your habit. I would like you to say, "there's one" or raise your hand each time 1 simulate your habit. We do this because watching someone else do something is an effective way of becoming aware of your own behaviors. During the next few minutes I will be acting out your habit and would like you to inform me each time I do it."
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Tic Disorders, Trichotillomania, and Repetitive Behavior Disorder Continue until correctly acknowledged 4 of 5 times Have client acknowledge clinician simulated "warning signs" "Good job at identifying your habit, now I would like to do the same thing with your warning signs." I am going to simulate the different warning signs that you reported, and each time I do one I would like you to raise your hand or say, "there's one." Do you remember what they are? If not, I can remind you. It is important for you to be able to recognize the warning signs for they are the best indicator that your habit is about to occur. If you don't have any questions, let's begin."
Continue until correctly acknowledged 4 of 5 times Have client acknowledge own habits "You did a very good job at pointing out my examples of your habit. Now, I would like you to simulate you own habit and point out to me each time you do your habit by raising your hand or saying, "there's one."
Continue until client correctly demonstrated 4 of 5 times Have client acknowledge own, or self-simulated "warning signs" "You did a good job demonstrating and acknowledging your habit. Now I would like you to use the same procedure with the warning signs for your habit. Over the next few minutes 1 would like you to demonstrate the different warning signs we talked about earlier, and after demonstrating each one I would like you to signal to me that you just did one. If you do not remember all the warning signs tell me, and I can remind you. If you are ready begin you may begin."
Continue until client correctly demonstrates 4 of 5 times Competing Response Training Choosing the Competing Response "The next part of treatment involves you finding a different behavior to do for one minute instead of your habit. I will help you select an appropriate alternate behavior. We will call this your competing response. A competing response should make it impossible for you to do your habit. Likewise, your competing response should be something you are
Habit Reversal Treatment Manual for Oral-Digital Habits comfortable doing. Do you have any ideas for a behavior you would be comfortable doing and would prevent you from doing your habit?"
Clinician simulates the competing response "Great, now that you have selected a competing response I want to make sure you know how to use it properly. The competing response should be used for one-minute each time you start doing the habit or when one of the warning signs occurs. The reason you use a competing response is to give you something to do instead of your habit. After you use the competing response enough you should learn not to do the habit. In the same way you learned to do the habit, you can learn not to do the habit. Now, I am going to demonstrate how to properly use your competing response contingent on the habit."
Clinician demonstrates how to use the competing response contingent on the habit Continue until correctly demonstrated 4 of 5 times Clinician demonstrates use of competing response contingent on warning signs Client demonstrates use of the competing response contingent on warning signs Continue until correctly demonstrated 4 of 5 times Instruct client to use competing response whenever the warning sign occurs Social Support Training Identifying the Support Person Training the social support person "Thank you for agreeing to help (the client) with the treatment. Your basic role is to help (the client) remember to use the exercise she has been taught. First I would like to tell you what (the client) has done so far. Before (the client) does her habit she will almost always do one of a number of warning signs, so (the client) and I did some exercises to help
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her recognize each time she does one of those signs. Now every time she catches herself doing one of the signs she is supposed to make fists with her hands. She makes fists with her hands because that makes it difficult for her to bite her fingernails. If she can keep making the fists instead, her habit will eventually go away. What I would like you to do is praise her when you see her making her fists, and remind her to make the fists every time you see her biting her fingernails."
Clinician demonstrates how to correctly praise the correct use of the competing response "When you two leave the clinic, I would like you (social support person) to praise her for correct use of the procedure. You don't have to do anything special, just praise her as you would naturally. I will demonstrate it one time, so you get the idea."
Have support person demonstrate praising the client "Okay, you saw me praise (the client) for the proper use of the competing response. Now, I would like you to do the same thing. I'll ask her to demonstrate the proper use of the competing response and I would like you to praise her. Whenever you are ready (client), you may demonstrate the competing response and I would like you (social support person) to praise her. Please use praise that is comfortable to you."
Clinician demonstrates how to correctly remind the client to use the competing response "Good job praising the correct use of the competing response (social support person). Now, I would like to demonstrate what you should do if you see (client) biting her fingernails, but not using the competing response."
Clinician has the support person demonstrate reminding the client when not using the competing response "Now I would like you to practice reminding her when she does not use it. Please (client), perform your habit but do not use the competing response, and (support person) demonstrate reminding her. Whenever you are ready, I would like you to perform your habit."
Schedule Session 3 for one week later
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Sessions 3 & 4 Collect data collected since Session 2 Review client progress Discuss any problems the client has had Review main components of habit reversal "Could you please tell me all the instances when you are supposed to use the competing response?" (contingent on the habit or a warning sign) "Could you please describe the competing response for me?" (can differ for each person) "How long are you supposed to do the competing response?" (for one minute) "Could you please simulate a habit and do the correct competing response?" "Could you please simulate your warning signs and do the correct competing response?"
If incorrect, review component
Chapter 13 Analysis and Treatment of Oral-Motor Repetitive Behavior Disorders Keith D. Allen Jodi Poiaha Munroe-Meyer Institute for Genetics and Rehabilitation University of Nebraska Medical Center
1. OVERVIEW Repetitive behavior disorders represent a large class of responses that encompass more than the familiar tics, trichotillomania, thumb sucking or nail biting. Surveys of care providers in residential settings have frequently found other stereotypic behaviors such as lip biting, skin picking, skin scratching and head banging (Troster, 1994). Similar results have been found in college students, where nearly 10% endorse repetitive occurrences of behaviors such as knuckle cracking, lip and mouth biting, object chewing, and scratching or picking (Woods, Miltenberger, & Flach, 1996). Most of these, however, are "subclinical" in that they do not typically interfere with adaptive functioning or present frequently in outpatient clinical settings (Arndorfer, Allen, & Aljazireh, 1998). Yet there are several oral-motor repetitive behaviors that are stable, "automatic" and appear to serve no social function (Hansen, Tishelman, Hawkins, Doepke, 1990), that do have a significant presence both in the extant literature and in the clinic; these include stuttering, bruxism, and rumination. All three involve oral-motor behavior of some kind but have no apparent common etiology, topography or function. Like other repetitive behavior disorders, however, each has been or could be targeted for intervention using common behavioral interventions for repetitive behavior disorders.
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2. STUTTERING 2.1 Description Stuttering involves disfluencies in the production of speech, including repetitions of word sounds, words, or phrases; prolongation of a word sound; or a hesitation when attempting to speak (Miltenberger & Woods, 1998; Leung & Robson, 1990). Stuttering occurs in all nationalities with an incidence of approximately 1% and a prevalence of 4 to 5% (Ingham, 1990). Recent studies suggest that there is a continuous diminution in the frequency and severity of stuttering over time as many children progress toward recovery, with an overall conservative estimate of a 74% recovery rate (Yairi & Ambrose, 1999). Stuttering typically begins between the ages of 2 and 6 years, with a mean age of onset of 5 years (Andrews et al., 1983). The ratio of males to females is about 2-3:1 in childhood and 4-5:1 by adulthood (Bloodstein, 1987).
2.2 Impairments in Social Functioning In the absence of effective treatment, stuttering can be disabling socially and vocationally. Stutterers have been found to evidence increased anxiety (Craig, 1990) and also to have more difficulty securing job promotions or upgrades in occupation (e.g., Craig & Calver, 1991). Indeed, research suggests that although employers often conclude that stuttering does not interfere with job performance, they also acknowledge that stuttering does decrease employability, can interfere with promotion possibilities, and is generally a vocationally handicapping condition (Hurst & Cooper, 1983). In addition, negative perceptions by others of a stutterer's communication ability can result in more difficulties with social adjustment (Andrews et al., 1983). Thus, it appears that stuttering has a direct impact on general social adjustment.
2.3 Causes The causes of stuttering are still uncertain. There is, however, growing acceptance that genetic factors play a prominent role in explaining the onset
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of the disorder. In addition, physiological studies present a disorder that is characterized by unusual hemispheric processing and a speech motor control system that has an impaired timing and/or coordinative function. In sum, recent studies have strengthened the argument that stuttering has a physiological rather than environmental origin (Ingham, 1990). However, this conclusion does not rule out environmental variables as important in the maintenance of stuttering. Unfortunately, the basic research is this area is scant and efforts to identify environmental variables are often drawn from treatment outcome studies. For example, there is some evidence that stuttering is the result of disrupted airflow involved in speech production, caused by increased tension in the vocal musculature (Brutten & Shoemaker, 1967; Healy, 1991). This tension in the vocal musculature is typically decreased following a stutter (Ingham, 1984), and behavioral models of stuttering then account for the maintenance of stuttering through a process of automatic negative reinforcement (Miltenberger & Woods, 1998). However, treatment studies have not typically measured changes in vocal musculature tension as a function of treatment so it is unclear whether observed differences in vocal musculature tension in stutterers are a cause or an effect of stuttering.
2.4 Behavioral Treatments and Effectiveness There is now reasonable consensus that routinely treating every individual soon after onset of stuttering is unnecessary (Onslow & Packman, 1999). However, recovery rates are suspect, range from 40-80%, and make it far from certain that most stutters recover spontaneously (Ingham, 1990). Given that stuttering can be successfully treated in young children, there are some who believe that there is an urgent need to counter the widely held belief that stuttering will resolve if ignored (Prins & Ingham, 1983.) There are numerous protocols for treating stuttering and research over the past 20 years has relied heavily on behavioral treatment programs. The most favored techniques for treating stuttering fall into three categories; mechanical aids for modifying stuttering, prolonged speech or some variant, and response contingent stimulation (Ingham, 1990).
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2.4.1 Mechanical Aids Mechanical aids are basically limited to two types of feedback devices; delayed auditory feedback (DAF) and electromyographic (EMG) feedback. In DAF, electronic equipment is used to deliver the sound of ones own voice slightly after words have been spoken, requiring a slower rate of speech, thereby assisting the speaker in producing a prolonged speech pattern. However, it was soon discovered that the functional variable in reducing stuttering was the use of prolonged speech, not the device. Because prolonged speech can be achieved without a mechanical aid (Ingham, 1984), the device is rarely used. EMG biofeedback involves using electronic equipment to give individuals information about vocal muscle tension levels which can then be used to reduce muscle tension believed by some to be associated with stuttering. Moore (1978) found that EMG biofeedback alone was not effective in reducing stuttering, however, Craig and Cleary (1982) did find reductions in stuttering after 15 EMG biofeedback training sessions for some subjects. However, treatment also included a self-management and generalization component, making it difficult to determine the independent effects of EMG biofeedback. In general there simply is not enough research on the efficacy of EMG biofeedback to draw reasonable conclusions.
2.4.2
Prolonged Speech
Prolonged speech procedures are based on the original behavioral work of Israel Goldiamond, who used delayed feedback in a negative reinforcement paradigm (Goldiamond, 1965) to teach subjects to speak in a slow, prolonged, fluent pattern (e.g., Webster, 1980). In Goldiamond's method, a controlled stutter-free speech pattern was achieved by reducing the speaking rate and using extended vowels, reduced articulation, and gentle initiation of phonation. Numerous variations of this method have been developed and have been called smooth speech, delayed auditory feedback, prolonged speech, and Gradual Increase in Length and Complexity of Utterance (GILCU) treatment. In GILCU, subject starts with one-word utterances that are gradually increased in length during reading, speaking, and conversation (e.g, Costello, 1980). The program often consists of upwards of 50 steps designed to gradually increase fluent speaking in reading, then monologue, then
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conversation. As with all prolonged speech programs, the speech is gradually and progressively replaced by faster speech and speech rate until speech has been normalized. Treatments modeled after the prolonged speech style of intervention have dominated stuttering treatment programs for decades (Onslow, 1992) and recent studies continue to investigate and report variations of prolonged treatment as an intervention for stuttering (e.g, Druce, Debney, & Byrt, 1997; Ryan & Van Kirk-Ryan, 1995). Indeed, prolonged speech methods are at the heart of most methods reported in the literature (Ingham, 1993). Generally, results have found that 1) prolonged speech produces significant reductions in stuttering immediately after treatment, 2) drop-out rates are low, 3) results are generally maintained up to a year, and 4) relapse is about 30%, especially for those who were most severe in baseline (Ingham, 1993). Unfortunately, the total time to establish effects, transfer and maintain them across settings range from 32 to 90 hours of total treatment time. In addition, although these treatment have been found to be of value with adults, their value with early stutterers is less clear (Ingham, 1993; Onslow, 1992). Many of the investigations with children are poorly controlled and do not permit reasonable conclusions to be drawn about effectiveness. On a more practical level, the treatment is arduous and is notorious for producing unusual sounding speech (Onslow & Ingham, 1987; 1989).
2.4.3
Response Contingent Stimulation
Early theories of stuttering had suggested that punitive behavior by parents may have been the cause of stuttering and that making individuals aware of stuttering could make the impairment worse (Van Riper, 1973). In spite of these concerns, researchers began looking at whether the response contingent consequences of stuttering could have a beneficial impact on the rate of stuttering. Reed and Godden (1977) found that a verbal correction procedure delivered contingent on stuttering (i.e., "slow down") significantly reduced stuttering in two preschool children. Christensen and Lingwall (1982) found that simply delivering a response contingent "No", was not effective, however, Salend and Andress (1984), found that a stutteringcontingent response-cost procedure was effective in significantly reducing stuttering. A series of other studies have modified this approach and added a brief "time-ouf period contingent on stuttering during which the subject is not
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permitted to speak (e.g., Andrews, Howie, Dosza, & Guitar, 1982; Martin, Kuhl, & Haroldson, 1972) James (1981), for example, used a 2 second timeout, signaled by a therapist, and then a self-administered time-out and found significant reductions in stuttering, although the effects were not maintained. In a more recent study, Onslow et al. (1997) also evaluated the time-out procedure and found similar results. Another type of response-contingent stimulation has involved having parents deliver praise and tangibles for stutter-free speech while identifying a stuttering utterance and requesting the child to correct the utterance (Lincoln, Onslow, Lewis, & Wilson, 1996; Onslow, Andrews, & Lincoln, 1994;). Unfortunately, many of these studies have used only quasi-experimental designs. Thus, although the time-out procedure and its variants have been described as "the most profitable area of study regarding response contingent stimuli (Ingham, 1993), there have been few well controlled empirical investigations, little evidence of long term benefit, and even now, the "potential has not been realized experimental ly"(Onslow, 1992). A final form of response contingent stimulation that was originally developed in 1974 by Azrin and Nunn, commonly called "habit reversal," involved 12 components designed to help stutters identify, anticipate, and regulate stuttering through a controlled or regulated breathing procedure. The initial results were impressive, with a reported 98% reduction in stuttered words after as little as two, 2 hour sessions. Follow up studies, however, have not produced nearly that level of success (e.g.. Cote & Ladouceaur, 1982; Ladouceur & Martineau, 1982). In addition, early studies were criticized for failure to demonstrate sustained benefits (Ingham, 1990). Perhaps this explains why much of the speech literature has ignored recent research on habit reversal treatment of stuttering as a form of response contingent stimulation. Reviews in the speech literature (now 10-15 years old but still prominent) of the regulated breathing procedure suggest that it represents an example of a vaguely described therapy with unsubstantiated claims of success (Ingham, 1984). Although many speech researchers view contingency management procedures as fundamental to much of stuttering therapy, simplified habit reversal has not typically been discussed as one viable alternative (Ingham, 1990; Ingham, 1993; Onslow, 1992). Recent research invest-igations of habit reversal, however, have refined and simplified the procedure arid have consistently found significant reductions in stuttering (e.g. Caron & Ladouceur, 1989; de Kinkelder & Boelens, 1998; Elliot et al., 1998; Wagaman, Miltenberger, & Arndorfer, 1993) that can be sustained across several years (Wagaman, Miltenberger, & Woods, 1995).
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The procedure, in its simplified form, typically involves 1) awareness training, including teaching the subject to describe and detect each occurrence of stuttering, 2) a competing response, including teaching the subject to use a diaphragmatic breathing and gentle onset technique contingent on each occurrence of stuttering , and 3) social support, involving home practice along with praise and feedback regarding use of the competing response. Although it is unclear at this point which of these components or combination of components are critical, it seems unlikely that any one component is responsible in every case. Of course, use of a competing response is impossible without response detection, so its independent effects may be hopelessly confounded by awareness training. Social support may not be critical in treatment implementation with motivated adult stutterers, but treatment with children has frequently relied on parents to implement home practice sessions and deliver supporting consequences (e.g., Budd, Madison, Itzkowitz, George, Price, 1986; Elliott et al, 1998). In addition, the use of social support systems to run home practices and facilitate generalization may improve outcome and reduce restrictiveness of the procedures. Finally, self-monitoring (awareness training) alone is a wellknown intervention in the behavioral literature and has been found to be, in some cases, effective as an independent intervention for stuttering (Bray & Kehle, 1998). Regardless, the simplified habit reversal procedure, with its three components, can be implemented in such a parsimonious and unrestrictive fashion (Elliott et al., 1998) that it makes clinical sense to use the procedure as a package until research suggests otherwise.
2.5 Conclusions Regarding Behavioral Treatment of Stuttering There are numerous behavioral treatment options for treatment of stuttering. Mechanical aids such as EMG simply need more research and do not seem practical. Prolonged speech interventions are supported as a viable treatment option for adults but are not supported for use with children. In addition, they are time consuming and may result in unusual speech patterns. Variations of response contingent treatment such as time-out, SHR, and even awareness training having growing empirical support, are easily learned and taught, and can be incorporated into home-based training
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procedures. None of the studies, however, has demonstrated sustained effectiveness with all stutterers and it remains unknown the extent to which these procedures are differentially effective with different types of disfluencies. Recent research studies typically do not identify how specific types of disfluencies respond to treatment. In one exception, time-outs were reported to not be as effective for individuals whose stuttering was characterized by blocks rather than sound, syllable or whole word repetitions (Onslow et al., 1997). Onslow and colleagues suggested that this procedure may not be effective for blockers just because the procedure requires starting and stopping again, which is the principal deficit in fluency with an individual who blocks. From a clinical perspective, the SHR procedure is attractive because it has growing empirical support, is efficient, and generally acceptable. But it is certainly not the only option, although guidance regarding how to match treatment with individual clients is, as yet, unavailable. In the mean time, SHR would appear to be the treatment of choice in dealing with uncomplicated stuttering in children and adults, particularly those with partial or whole word repetition disfluencies.
3. BRUXISM 3.1 Description Bruxism refers to the nonfunctional clenching, gnashing or grinding of the teeth, that can occur when awake or during sleep (Cassisi & McGlynn, 1988; Glaros & Melamed, 1992). It is often considered a parasomnia because it is an "undesirable physical phenomena that occurs predominantly during sleep (American Sleep Disorders Association, 1997). Prevalence estimates vary widely and are likely due to disparities in defining the condition (Long & Miltenberger, 1998). Reports range from 5 to 20% in adults without disabilities (Hublin, Kaprio, Partinen, & Koskenvuo, 1998) and 7 to 88% in children without disabilities (Glaros, 1981; Glaros & Rao, 1977). More recent reports have found prevalence rates of approximately 10-20% in nondisabled children from 3 to 13 years of age (Laberge, Tremblay, Vitaro, & Montplaisir, 2000). Incidences in individuals with disabilities have been reported in 13 to 41% of the population (Long & Miltenberger, 1998; Richmond, Rugh, Dolfi, Wasilewsky, 1984). There have been no consistent
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gender or age differences observed (Cherasia & Parks, 1986; Laberge et al., 2000).
3.2 Physical Damage The adverse effects of bruxism may include excessive tooth wear, periodontal problems, temporomandibular joint disturbances, and facial or head pain (Glaros & Rao, 1977). In addition, bruxism reportedly can result in hypertrophy of the masticatory muscles, resorption of the alveolar bone, and muscle and tooth sensitivity.
3.3 Causes The prominent etiological view of bruxism highlights a CNS origin and a correlated role of sleep (Cassisi, McGlynn & Belles, 1987). Bruxism is thought to be differentially associated with REM sleep (Clarke & Townsend, 1984) and with transitions between sleep stages (Satoh & Harada, 1973) and has been found to be associated with distinct EEG changes (Rugh & Ware, 1986). Bruxism has also been thought to result from occlusal irregularities, from stress, and frequently from a combination of the two (Cassisi, et al., 1987). Finally, there is some physiological evidence that nocturnal bruxism is linked to daytime stressful events, suggesting that bruxism may be a learned behavior associated with stress reduction (Cash, 1988; Rugh & Harlan, 1988). However, there is increasing evidence that rather than malocclusion or stress, the primary etiology is found in an abnormally low arousal threshold during sleep (Parker, 1990; Westrup, Keller, Nellis, & Hicks, 1992).
3.4 Behavioral Treatments and Effectiveness Treatment typically involves dental interventions and/or behavioral interventions. Oral splints are characterized by devices that protect or guard the teeth. A thin piece of hard plastic is made from an impression of the teeth and then worn to protect the teeth from wear (Christensen & Fields, 1994). However, the guard does not eliminate the grinding or clenching or the jaw joint and muscle pain that may arise from bruxism. Recent case
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reports of dental interventions have also described an expensive botulinum toxin injection as an alternative for those with disabling bruxism that is refractory to other dental interventions (Tan & Jankovic, 2000) and an aversive taste treatment used along with a dental appliance (Nissani, 2000). Behavioral treatments have typically involved either biofeedback, punishment techniques, massed practice, or habit reversal.
3.4.1 Biofeedback Treatments Biofeedback treatments have typically involved surface electromyographic (EMG) electrodes measuring masseter and/or temporalis EMG signals, which are then amplified to provide either an audible signal that varies with the frequency or intensity of muscular activity or triggers an alarm. Early studies involving auditory bruxing feedback found reductions in duration but not frequency of bruxing (e.g., Kardachi & Clarke, 1977). Later studies introduced an "arousal task" in which, for example, a subject would be required to walk across a room (to insure wakefulness) and record the time of the awakening (e.g., Clark, Beemsterboer, & Rugh, 1981; Feehan & Marsh, 1989). Across studies, data have suggested that auditory feedback of bruxism during sleep has differential effects depending on the presence or absence of a correlated arousal task requirement (Cassisi et al., 1987). On the whole, alarms plus arousal tasks reduce both durations and frequencies of bruxism. Additional studies have compared EMG biofeedback treatment with occlusal treatment (i.e., grinding away tooth surfaces that interfere with gliding contacts between teeth; Kardachi, Baily & Ash, 1978), stress management (Casas, Beemsterboer, & Clark, 1982), and muscle relaxation (Moss et al., 1982) and have found that nocturnal alarms are similar in effectiveness to these other treatments (Cassisi et al., 1987). Unfortunately, biofeedback interventions rarely eliminate bruxing and long term follow up have not been conducted. In addition, this intervention typically requires portable equipment that can be expensive and difficult to access. Patients must also be able to properly attach electrodes and set feedback thresholds to appropriate levels.
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3.4.1 Punishment Techniques Punishment techniques have been used more often with the developmentally disabled and have relied on contingent icing, contingent pressure, and overcorrection. Kramer (1981) had a teacher use her fingers to apply 2-3 seconds of pressure, contingent on bruxing, to the jaw of a child with mental retardation. Rudrud and Halaszyn (1981) also used contingent pressure, calling it a "massage" of the masseter, but they described a procedure that appeared functionally similar to the procedure used by Kramer. Blount, Drabman, Wilson, and Stewart (1982), applied ice briefly to the faces of two individuals with mental retardation, contingent on bruxing and Gross and Isaac (1983), used an overcorrection procedure with 2 children with mental retardation that required forced arm exercise contingent on bruxing. Although each of these studies produced reductions in bruxing, bruxing was not eliminated, and long term benefits are unclear. Given increasing concerns about the acceptability of aversive behavioral treatment procedures (Sidman, 1989) and the availability of nonaversive alternatives, it seems prudent to avoid these types of punishment procedures when possible.
3.4.3 Massed Practice Massed practice typically involves having the patient voluntarily clench his or her teeth for a specified time interval several times a day and is similar to noncontingent competing response procedures have been studied with other habits disorders (Miltenberger & Fuqua, 1985). Early studies by Ayer and colleagues found that instructing patients to clench their teeth for 5, fivesecond intervals six times a day would produce reports of reductions in nocturnal bruxing, although no direct measures were taken (Ayer, 1976; Ayer & Levin, 1973). Other studies of massed practice have found no effects (Heller & Forgione, 1975), with these authors suggesting that the practice interval might have been too short for some patients. Another study investigated the use of 15 second clenching intervals alternated with 15 seconds of resting, repeated 10 times just before bed (Vasta & Wortman, 1988). These authors found, in an ABAB design, marked and sustained reductions in bruxing, although the bruxing was never eliminated. Although it is difficult to reconcile the effects of this technique with proposed etiologies involving REM sleep and sleep transitions, the massed practice may have a relaxing effect on the masseter muscles, as in a progressive
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muscle relaxation procedure. Regardless, evidence suggests that it can be effective. This effectiveness, combined with being inexpensive, convenient and simple, makes massed practice a treatment worthy of consideration.
3.4.4 Habit Reversal Habit reversal procedures have included variations of the original Azrin and Nunn (1973) procedure with components such as awareness training, competing responses and social support or contingency management. Watson (1993), found that bruxism was reduced simply by having patients aroused from sleep for 15-20 seconds by their spouses when bruxing was heard. Although this was called "arousal training" by the author, the procedure is described very much like one of the "awareness training" components of habit reversal. Although a 10 minute overcorrection procedure was then added (wash face, brush teeth, rinse mouth, repeat) and corresponded with the complete elimination of bruxing, the frequency of bruxing had already begun to show a significant trend toward elimination just from the awareness training. Studies involving both awareness training and contingent competing responses have also shown promising results. Rosenbaum and Ay I Ion (1981) treated three college-age bruxers using a habit reversal protocol that included awareness training (response description, response detection, situation awareness, and habit inconvenience review), competing response (closing the mouth and clenching teeth for two subjects, opening the mouth until tension was felt for the other), and symbolic rehearsal (visualize situations in which bruxing occurs and practice the competing response). The subjects showed, in an AB design, marked reduction in bruxing with the treatment, although bruxing was not eliminated. Bebko and Lennox (1988) used a simplified habit reversal procedure with two children with autism who were bruxing. Treatment simply involved providing a verbal cue ("no grinding"), delivered contingent on bruxing and then a prompt to engage in a competing response involving opening the mouth for 10 seconds. Finally, the children were provided social support in the form of rewards for appropriate behavior. In a multiple baseline across settings, bruxing was markedly reduced for both subjects and completely eliminated for one. No follow-up measures were provided. Finally, Peterson, Dixon, Talcott and Kelleher (1993), demonstrated that a habit reversal procedure could markedly reduce the temporomandibular pain experienced by 2 out of 3
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adult bruxers, but they did not collect data on actual teeth grinding or clenching. Overall, habit reversal and its various components have offered promising results in several small n studies, however, the literature on habit reversal treatment for bruxism is quite limited and dated and firm conclusions about the applicability of habit reversal treatment and variations would be premature.
3.5. Conclusions Regarding Behavioral Treatment of Bruxism In sum, bruxism is a difficult problem to eliminate. A variety of behavioral treatments have been attempted and almost all have shown some evidence of positive impact on bruxism. Yet there is no well developed, systematic program of research demonstrating any one procedure as the treatment of choice. Habit reversal is attractive because it is noncoercive and can be implemented without expensive equipment, but the few studies that have been done are only promising, not convincing. Interestingly, given that bruxism is proposed by many to be a disorder of sleep involving REM or sleep transition difficulties, it is surprising that no researchers have explored the use of interventions that have traditionally been used with other sleep transition problems, such as scheduled awakenings for night terrors (e.g., Lask, 1993). Until then, variations of habit reversal, such as massed practice, may be the treatment of choice.
4. RUMINATION 4.1 Definition and Prevalence Rumination is the repeated regurgitation of previously ingested food (Johnston & Greene, 1992). It has been observed to occur most often after meals and often includes chewing and re-swallowing. Moreover, many authors further delineate that ruminative behavior seems to be "deliberate" in that individuals will engage in behaviors that induce regurgitation (e.g., Kedesdy & Budd, 1998; Sajwaj, Libet, & Agras, 1974). In contrast, Fredricks, Carr, and Williams (1998) report that the voluntary nature of ruminative behavior can be difficult to identify because the behavior can
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appear "effortless" as it is practiced over time. In fact, various authors have described antecedents to rumination as behaviors ranging from obvious forms of digital stimulation, mouthing the hand, or gagging motions of the neck region, to more subtle behaviors involving tongue movements, contractions of the abdominal muscles, or even postural changes (Glassock, Friman, O'Brien, & Christopherson, 1986; Konarski, Favell, & Favell, 1992). It is generally well-accepted that although ruminative behavior is observed to some extent in normally developing individuals, especially infants beginning at three to six months of age (APA, 1994), it is most commonly seen in individuals with mental retardation. Prevalence in institutionalized individuals with mental retardation has been estimated at 6 to 10% (Fredericks et al., 1998); however, the prevalence and incidence of ruminative behavior among this population at large has not been studied. Moreover, no estimates are available for typically developing individuals (Parry-Jones, 1994) although recent case studies have documented the occurrence of rumination in normally-developing adults (Amarnath, Abell, & Malagelada, 1986), adolescents (Khan, Hyman, Cocjin, & DiLorenzo, 2000), and school-age children (Reis, 1994). It is suggested that prevalence is equal for males and females (APA, 1994) but there is some evidence that it is more common in males (Mayes, Humphrey, Handford, & Mitchell, 1988).
4.2 Associated Features Historically, sequelae to chronic rumination in infants have been thought to include malnutrition, weight loss, failure to thrive, and death (Sloan & Kaye, 1991). More recently, however, medical advances and early identification are leading to declining mortality and morbidity rates among infants with rumination behaviors. In addition, there is increasing evidence that not all infants who ruminate experience impairments in growth and nutrition (Mayes, 1992). Among children and adults, associated features may include halitosis, dehydration, heartburn, lowered resistance to disease, malnutrition, esophageal inflammation, and dental complications, (Fairburn & Cooper, 1984; Kedesdy & Budd, 1998; Sajwaj et al., 1974). Moreover, Johnston and Greene (1992) point out that ruminative behavior is socially undesirable and may cause social rejection or, in the case of adults with mental retardation, may present a barrier to less restrictive placements.
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4.3 Etiology A behavioral account of the etiology suggests that rumination is a behavior of organic etiology that is maintained through contact with reinforcing environmental contingencies. Original organic mechanisms that can produce regurgitation can include temporary illness (Starin & Fuqua, 1987), higher gastric sensitivity, and/or a decreased threshold for lower esophageal sphincter relaxation during gastric distention (Khan et al., 2000; Thumshirn et al., 1998). An individual who exhibits frequent vomiting and/or regurgitation as a consequence of one of these organic mechanisms then has an increased opportunity to "discover" that the behavior produces social and/or sensory reinforcement (Kedesdy & Budd, 1998). For example, ruminative behavior might be strengthened and maintained when caregivers provide increased social attention (e.g., parent looks at individual and says "stop!") when the behavior occurs (e.g., Lavigne, Burns, & Cotter, 1981). Similarly, ruminative behavior may be strengthened and maintained if escape from an aversive stimulus (e.g., an unwanted meal or unpleasant activity) is provided when the behavior occurs. Finally, it has been suggested that ruminative behavior may be strengthened if it produces a reinforcing sensory experience such as tactile or gustatory reinforcement. The latter explanation is supported by the observation that ruminative behavior often occurs in the absence of a caregiver who might deliver reinforcement in the form of escape or social contact (Ball, Hendricksen, & Clayton, 1974).
4.4 Behavioral Treatments and Effectiveness Given that rumination can often have an organic etiology, behavioral intervention should always be preceded by a thorough medical evaluation. Studies have shown that endoscopy and radiological studies can rule out as many as 50 to 90% of referrals for rumination disorders as due to congenital anatomic defects or oral-motor dysfunction. (Kuruvilla & Trewby, 1989; Rogers, Stratton, Victor, Kennedy, & Andres, 1992). In these cases, medical or surgical intervention can often successfully and rapidly solve the problem (Fredricks et al.,1998). However, even in cases where medical or surgical intervention is appropriate, behavioral intervention may be
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necessary to manage environmental contingencies that come to bear on the rumination. Understanding which contingencies are most salient in the maintenance of rumination may require an assessment of the function of the behavior. Indeed, considerable individual differences have been hypothesized as the controlling variables across individuals who ruminate, including social, escape, or automatic reinforcing functions (Johnston & Greene, 1992). Yet, little research has been conducted directly analyzing the potential multiple functions of rumination. In one of the few exceptions, Humphrey, Mayes, Bixler, and Good (1989), examined the environmental variables associated with ruminating in a boy with mental retardation. The investigators recorded the frequency of rumination throughout the day over a four-week period. Results showed rumination behavior increased after meals and over the course of the day overall and decreased during periods when individual attention was provided (as opposed to independent play or non-school hours). The authors suggested that for this individual, rumination may have been effectively decreased if attention and structured programming were provided immediately after meals (when ruminating was most problematic), however, there was no actual intervention to evaluate the utility of the assessment. In another assessment of possible fimction, Applegate, Matson, and Cherry (1999) used a Questions about Behavioral Function (QABF) interview to assess 417 institutionalized persons with mental retardation. The QABF was used to examine potential variables associated with five severe problem behaviors, including rumination. Applegate et al. (1999) determined the most common function of ruminative behavior in this sample was automatic reinforcement. Although the investigators recommended the QABF to clinicians as a means of developing more effective treatment programs, there was no actual demonstration of the use of the QABF in this capacity. Indeed, we were unable to find investigations relying on functional assessments to guide the development of interventions with rumination. Instead, the literature on behavioral intervention for rumination has relied on the development of treatments independent of behavioral function, resulting in two principle types of procedures; contingency management procedures and modified feeding/satiation procedures.
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4.4.1 Contingency Management The efficacy of contingency management interventions including both punishment and reinforcement procedures have garnered substantial empirical support. Punishment procedures were the first to be investigated and predominated the treatment literature through the 1980's. The use of aversive procedures has been generally well-researched, and a wide variety of aversive interventions have been identified as having some beneficial effect upon the frequency of ruminative behavior in adults with mental retardation. Starin and Fuqua (1987) reviewed the data from 18 studies investigating punishment procedures for treatment of rumination. Aversive procedures included the use of contingent pinching (e.g., Minness, 1980), delivery of noxious tastes such as lemon juice (e.g., Marholin, Luiselli, Robinson, & Lott, 1980), and overcorrection procedures (e.g., requiring subject to brush with oral antiseptic after ruminating) (e.g., Foxx, Snyder, & Schroeder, 1979). In all cases a single-subject design or case-study method was employed, and the aversive consequence was delivered contingent upon the patient exhibiting ruminative behavior or, in some cases, specific behaviors antecedent to ruminating. In all of the studies, immediate reductions in ruminative behavior were observed subsequent to the intervention. However, generalization to meals outside the treatment setting was examined in only 4 of these 18 studies and was demonstrated in 3. In 8 of 9 studies, maintenance at 6 to 10 months was found to be at or near 0, however, of 5 studies examining maintenance at 10 to 12 months, 2 found ruminative behavior had returned to baseline levels. Although interventions involving the presentation of aversive stimuli seem to offer some immediate benefit, data regarding long-term maintenance are more equivocal. Moreover, many service settings prohibit the use of aversive interventions, given concerns about misuse or even abuse of punishment procedures. Perhaps not surprisingly, few (if any) studies investigating punishment procedures have been conducted since the Starin and Fuqua review over a decade ago. More surprising, however, is the fact that contingency management alternatives to punishment have also not been extensively researched. Several single case investigations exploring extinction and differential reinforcement procedures were conducted over 20 years ago, finding mixed results. For example, two studies investigated extinction procedures in which access to proposed reinforcers such as escape and social attention was denied contingent upon rumination. These authors
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found inconsistent outcomes and reported significant increases in other undesired behaviors during treatment (Wolf, Birnbrauer, Williams, & Lawler, 1970; Mulick, Schroeder, & Rojahn, 1980). Note, however, that because the success of an extinction procedure is dependent upon the accurate identification of the reinforcer for rumination, the functional assessment must be suspect in studies where the procedure is found to be ineffective. Studies of differential reinforcement procedures (e.g., delivering a reinforcer whenever ruminative behavior has not occurred for approximately 30 seconds with the interval being gradually lengthened as the rate of rumination decreases) have also found mixed results, have been conducted on a total of three subjects (Mulick et al., 1980; O'Neil, White, King, & Carek, 1979; Barmann, 1980) and have been criticized for significant methodological flaws (Starin & Fuqua, 1987). Finally, a procedure involving the delivery of noncontingent reinforcement found that social attention delivered before, during, and after mealtimes significantly reduced rumination (Whitehead, Drescher, Morrill, Corbin & Cataldo, 1985). Overall, however, too few studies with too few subjects have been conducted to draw firm conclusions about the wide applicability of these contingency management procedures and virtually no recent investigations have pursued this line of research.
4.4.2 Satiation/Modified Feeding Another group of studies has examined the effects of satiation and/or modified feeding procedures for reducing rumination. The impetus for these interventions was the work of Johnston and his colleagues who demonstrated that feeding individuals to the point of satiation corresponded to significant decreases in the frequency of ruminative behavior after a meal (Rast, Johnston, Drum, & Conrin, 1981) and in subsequent meals (Rast, Johnson, & Drum, 1984). The satiation procedure utilized by Johnston and his colleagues involves presenting clients with a meal containing "at least a double portion" of food and, as the client eats, adding more food to keep the tray full (Johnston & Greene, 1992). These authors emphasize that any foods may be presented but should be varied to avoid satiation on any one flavor. Moreover, in research protocols described above, clients were encouraged to continue to eat when their feeding slowed down, and the meal was discontinued only after the client refused more food on three successive prompts. These
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authors report that none of the research to date has shown that the consumption of food at this rate has adverse effects on health, though it does often lead to substantial weight gain. A similar protocol involving the use of modified feeding has also been described, wherein the noncontingent presentation of foods are provided to patients for a certain period of time after a meal. Specifically, Wilder, Draper, Williams, and Higbee (1997) demonstrated reduced ruminative behavior in a man with mental retardation by giving him a teaspoon of gelatin/pudding every 20-seconds for 30 minutes after a meal. Similarly, Thibadeau, Blew, Reedy, and Luiselli (1999) decreased rumination to near zero levels in a man with mental retardation by providing him with white bread for one hour after meals over 20 treatment days. Specifically, slices of white bread were presented "conspicuously" to the client during the hour following a meal, and was given to him whenever he signed, "eat". This procedure was superior to a DRO procedure, and rates were at zero at a 15month follow up. The authors note that the client had gained a significant amount of weight as measured one year after the study, but that the supervising physician did not believe this gain posed a health threat or outweighed the benefits of the treatment for rumination. In summary, satiation/modified feeding procedures provide a nonaversive alternative to management of rumination. The findings regarding the satiation procedures have been fairly robust; across a number of studies involving approximately 25 individuals with mental retardation, investigators have consistently observed marked and sustained decreases in ruminative behavior in the context of satiation (Johnston & Greene, 1992). In addition, recent research continues to demonstrate the benefits of this approach. It is, however, somewhat perplexing that the specific function served by the satiation procedure has not yet been identified in the literature. Johnston and his colleagues (Johnston & Greene, 1992) report that caloric density and oropharyngeal and esophageal stimulation (i.e., sensory reinforcement) associated with the satiation procedure may be important components in explaining treatment effectiveness, but the functional mechanism is still not well understood. An alternative hypothesis might view the continued consumption of food as a competing response, thereby disrupting the ruminative behavior. However, both Thibadeau et al., (1999) and Wilder et al. (1997) argue that it was actually the "satiation" (perhaps a type of disestablishing operation) that was the mechanism responsible for decreasing ruminative behavior in their study because rumination decreased throughout the day and not only during the hour when noncontingent feeding
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engaged the client in an "incompatible behavior." Indeed, studies have shown that the satiation procedure appears to have an impact not only on the meal in which the extra food is presented but on the subsequent meal as well (Johnston & Greene, 1992).
4.5 Conclusions Regarding Behavioral Treatment of Rumination Current behavioral treatments for rumination can be grouped into contingency management and satiation procedures. Overall, punishment procedures appear to have significant immediate benefits but can increase the frequency of other negative behavior, have questionable social acceptability, and have little supportive data in terms of generalization and long-term maintenance. Non-punishment contingency management procedures have some mixed empirical support, but have received little recent attention and have often been used in multi-component treatment packages so that their specific effects have not been isolated. Finally, satiation/modified feeding protocols have a strong body of empirical support with good follow-up data. Although it is unclear what specific function is addressed by this intervention, the data are fairly robust, the procedure is easily implemented, and the health risks are limited to associated weight gain. Interestingly, in spite of the strong support for habit reversal procedures with numerous other repetitive behavior disorders, we were unable to find any controlled investigations of this procedure in the management of rumination. One case study did report the complete elimination of rumination using a simplified habit reversal procedure with a typical 6 year old girl who had exhibited rumination for over a year (Wagaman, Williams, & Camilleri, 1998). The investigators used diaphragmatic breathing as a competing response, reasoning that controlled breathing might be incompatible with regurgitation. Although not a controlled study, this report adds support to the notion that the use of habit reversal procedures with individuals who ruminate warrants additional investigation.
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5. CONCLUSIONS Although stuttering, bruxism, and rumination all involve repetitive oralmotor behavior, they have no apparent common function. Perhaps most surprising is that in spite of the emphasis on the importance of function in applied behavior analysis, effective treatments have been developed for these three problems almost without regard to behavioral function. Procedures such as habit reversal, massed practice, and satiation have demonstrated marked improvements in stuttering, bruxing, and rumination behaviors respectively, yet we are no closer to understanding the principle function(s) of these behaviors. One might conclude that research efforts to assess and define the function(s) of repetitive oral motor behavior disorders are not important. But consider that each of these three treatments was only one of many behavioral interventions that have been explored across several decades for treatment of repetitive oral-motor behaviors. That is, the search to effective treatments for these oral-motor behaviors has not been efficient. Perhaps systematic research efforts to better understand and assess the function of repetitive oral-motor behaviors would have led more quickly to the identification and refinement of viable treatment options. It is our belief that it still can.
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Onslow, M. (1992). Choosing a treatment procedure for early stuttering: Issues and future directions. Journal ofSpeech and Hearing Research, 35, 983-993. Onslow, M., Andrews, C, & Lincoln, M. (1994). A control/experimental trial of an operant treatment for early stuttering. Journal ofSpeech and Hearing Research, 37, 1244-1259. Onslow, M. & Ingham, R.J. (1987). Speech quality measurement and the management of stuttering. Journal ofSpeech and Hearing Disorders, 52, 2-17. Onslow, M. & Ingham, R.J. (1989). Whiter prolonged speech? The disquieting evolution of a stuttering therapy procedure. Australian Journal of Human Communication Disorders, 17, 67-81. Onslow, M. & Packman. (1999). Treatment recovery and spontaneous recovery from early stuttering: The need for consistent methods in collecting and interpreting data. Journal of Speech, Language, and Hearing Research, 42, 398-402. Onslow, M., Packman, A., Stocker, S., van Doom, J., et al. (1997). Control of children's stuttering with response-contingent time-out: Behavioral, perceptual, and dicousixc ^dX?L. Journal ofSpeech, Language, and Hearing Research, 40, 121-133. Parker, M.W. (1990). A dynamic model of etiology in temporomandibular disorders. Journal of the American Dental Association, 120, 283. Parry-Jones, B. (1994). Merycism or rumination disorder: A historical investigation and current assessment. British Journal of Psychiatry, 165, 303-314. Peterson, A.L., Dixon, D.C., Talcott, G.W., & Kelleher, W.J. (1993). Habit reversal treatment of temporomandibular disorders: A pilot investigation. Journal of Behavior Therapy and Experimental Psychiatry, 24, 49-55. Prins, D. & Ingham, R.J. (1983). Issues and perspectives. In D. Prins & R.J. Ingham (Eds), Treatment of stuttering in early childhood: Methods and issues (ppl41-145). San Diego: College-Hill Press. Rast, J., Johnston, J. M., Drum, C, & Conrin, J. (1981). The relation of food quantity to rumination behavior. Journal ofApplied Behavior Analysis, 14, 121 -130. Rast, J., Johnston, J. M., & Drum, C. (1984). A parametric analysis of the relationship between food quantity and rumination. Journal of the Experimental Analysis of Behavior, 41, 121-130. Reed, C. G., & Godden, A. L. (1977). An experimental treatment using verbal punishment with two preschool stutterers. Journal of Fluency Disorders, 2, 225-233. Reis, S. (1994). Rumination in two developmentally normal children: Case report and review of the literature. Journal of Family Practice, 38, 521-523. Richmond, G., Rugh, J.D., Dolfi, R., & Wasilewsky, J.W. (1984). Survey of bruxism in an institutionalized mentally retarded population. American Journal of Mental Deficiencies, 55,418-421. Rogers, B., Stratton, P., Victor, J., Kennedy, B., & Andres, M. (1992). Chronic regurgitation among persons with mental retardation: A need for combined medical and interdisciplinary strategies. American Journal on Mental Retardation, 96, 522-527. Rosenbaum, M.S. & Ayllon, T. (1981). Treating bruxism with the habit reversal technique. Behavior Research and Therapy, 19, 87-96. Rudrud, E., & Halaszyn, J. (1981). Reduction of bruxism by contingent masssage. Special Care in Dentistry, 1, 122-124.
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Rugh, J.D. & Harlan, J. (1988). Nocturnal bruxism and temporomandibular disorders. In J. Jankovic & E. Tolosa (Eds.), Advances in neurology 49: facial dyskinesias (pp. 329-341). New York: Raven Press. Rugh, J.D., & Ware, J.C. (1986). Polysomnographic comparison of nocturnal bruxists with and without facial pain. Journal of Dental Research, 65, 181. Ryan, B. P., & VanKirk-Ryan, R. B. (1995). Programmed stuttering treatment for children: A comparison of two establishment programs through transfer, maintenance, and follow-up. Journal ofSpeech and Hearing Research, 38, 61-75. Salend, S. & Andress, M. (1984). Decreasing stuttering in an elementary-level student. Language, Speech, and Hearing Services in Schools, 15, 16-21., Sajwaj, T., Libet, J., & Agras, S., (1974). Lemon juice therapy: The control of life-threatening rumination in a six-month-old infant. Journal of Applied Behavior Analysis, 7, 557 - 563. Satoh, T., & Harada, Y. (1973). Electrophysiological study on tooth grinding during sleep. Electroencephalography and Clinical Neurophysiology, 35, 267-275. Sidman, M. (1989). Coercion and its fallout. Authors Cooperative, Inc. Publishers. Sloan, T. B. & Kaye, C. I. (1991). Rumination risk of aspiration of gastric contents in the Prader-Willi Syndrome. Anesthesia and Analgesia, 75,492-495. Starin, S. P., & Fuqua, R. W., (1987). Rumination and vomiting in the developmentally disabled: A critical review of the behavioral, medical and psychiatric treatment research. Research in Developmental Disabilities. 8, 575-605. Tan, E. & Jankovic, J. (2000). Treating severe bruxism with botulinum toxin. Journal of the American Dental Association, 131, 211-216. Thibadeau, S. Blew, P., Reed, P., & Luiselli, J. K. (1999). Access to white bread as an intervention for chronic ruminative vomiting. Journal of Behavior Therapy and Experimental Psychiatry, 30, 137-144. Thumshim, M., Camilleri, M., Hanson, R. B., Williams, D. E., Schei, A. J., & Kammer, P. P., (1998). Gastric mechanosensory and lower esophageal sphincter function in rumination syndrome. American Journal of Physiology, 275, 314-321. Troster, H. (1994). Prevalence and functions of stereotyped behaviors in nonhandicapped children in residential care. Journal ofAbnormal Child Psychology, 22, 79-97. Van Riper, C. (1973). The treatment of stuttering. Englewood Cliffs, NJ.: Prentice Hall. Vasta, R., & Wortman, H.A. (1988). Nocturnal bruxism treated by massed negative practice. Behavior Modification, 12, 618-626. Wagaman, J.R., Miltenberger, R.G., Arndorfer, R.E, (1993). Analysis of a simplified treatment for stuttering. Journal ofApplied Behavior Analysis, 26, 53-61. Wagaman, J.R., Miltenberger, R.G., Woods, D. (1995). Long term follow-up of a simplified treatment for stuttering in children. Journal of Applied Behavior Analysis, 28. 233-234. Wagaman, J.R., Williams, D.E., Camilleri, M. (1998). Behavioral intervention for the treatment of rumination. Journal of Pediatric Gastroenterology and Nutrition, 27, 596598. Watson, T. S. (1993). Effectiveness of arousal and arousal plus overcorrection to reduce nocturnal bruxism. Journal of Behavior Therapy and Experimental Psychiatry. 24, 181185. Webster, R. (1980). Evolution of a target-based behavioral therapy for stuttering. Journal of Fluency Disorders. 5, 303-320.
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Westrup, D.A., Keller, S.R., Nellis, T.A., & Hicks, R.A. (1992). Arousability and bruxism in male and female college students. Perceptual and Motors Skills, 75, 796-798. Whitehead, W. E., Drescher, V. M., Morrill-Corbin, E., Cataldo, M. F. (1985). Rumination syndrome in children treated by increased holding. Journal of Pediatric Gastroenterology and Nutrition, 4, 550-556. Wilder, D. A., Draper, R., Williams, W. L., Higbee, T. S., (1997). A comparison of noncontingent reinforcement, other competing stimulation, and liquid rescheduling for the treatment of rumination. Behavioral Interventions, 12, 55-64. Wolf, M. M., Bimbauer, J. S., Williams, T., & Lawler, J. (1970). The operant extinction, reinstatement and re-extinction of vomiting behavior in a retarded child. In R. Ulrich, T. Statnick, & J. Mabry, (Eds.), Control of human behavior: From cure to prevention: Vol 2. (pp. 146-149). Glenview, IL: Scott Foresman. Woods, D.W., Miltenberger, R.G., & Flach, A.D. (1996). Habits, tics and stuttering. Behavior Modification, 20, 216-225. Yairi, E, & Ambrose N. (1999). Early childhood stuttering I: Persistency and recovery rates. Journal of Speech, Language, and Hearing Research, 42(5), 1097-1112.
Chapter 14 Repetitive Behavior Disorders in Persons with Developmental Disabilities Joel E. Ringdahl David P. Wacker Wendy K. Berg Jay W. Harding The University of Iowa
1. INTRODUCTION In this chapter, we summarize some of the issues related to repetitive behavior disorders exhibited by individuals with developmental disabilities. For the purposes of this chapter, we will focus exclusively on behavior that occurs independent of any observable effects on the immediate environment. We provide (a) an overview of theories regarding the etiology and maintenance of such behavior (with a focus on operant explanations), (b) a description of operant-based assessment and treatment procedures, and (c) clinical examples of operant treatments derived from behavioral assessments. Repetitive behavior disorders in persons with developmental disabilities are typically referred to as stereotypy and include such broad classes of behavior as habits, motor and vocal tics, obsessive/compulsive behaviors, and some forms of repetitive self-injurious behavior (SIB). Very specific topographies or forms of this behavior have been described in the literature, and include hair pulling (Friman & Hove, 1987; Rapp, Miltenberger, Galensky, Ellington, & Long, 1999; Rapp, Miltenberger, Long, Elliot, & Lumley, 1998), mouthing (Vollmer, Marcus, & LeBlanc, 1994), pica (Goh, Iwata, & Kahng, 1999; Mace & Knight, 1986), and echoic speech (Charlop, 1983). Sequalae of these behaviors range from social stigma to tissue damage. Two general definitional classes for stereotypic behavior have been proposed in the behavioral
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literature. First, Lovaas, Newsom, and Hickman (1987) defined these disorders as constituting stereotyped and repetitive movements that persist in the absence of social consequences and that appear to produce some type of sensory stimulation (e.g., visual, tactile, or vestibular). Thus, some researchers refer to stereotyped behavior as "self-stimulatory" behavior or as "self-stimulation," implying that the function of the behavior is to produce some unknown type of sensory stimulation. The second definitional class is based more on the structural properties of stereotypy and does not presume a self-stimulatory function. For example, Baumeister (1978) defined stereotypy as behavior characterized by "highly consistent and repetitious motor or posturing responses which are excessive with respect to rate, frequency, and/or amplitude and which do not appear to possess any adaptive significance" (p. 354). Regardless of the definition, a rather large percentage of individuals with developmental disabilities exhibits stereotypy. For example, Berkson and Davenport (1962) estimated that over two-thirds of the institutionalized population of individuals with developmental disabilities exhibited some form of stereotypy. Displays of stereotypy can also vary across subgroups not only in overall amount but also in the most common form or topography (e.g., individuals with Prader-Willi syndrome often display obsessive-compulsive behavior related to food seeking; DiMitropoulos et al., 2000).
2. THEORETICAL MODELS Numerous theories regarding the etiology and maintenance of stereotypic behavior have been postulated in the literature, with psychoanalytic, organic, and operant explanations representing distinct perspectives. To the extent that treatment is often based on the theory used to explain the behavior, it is important to understand the function of each theory. It should also be noted that various theories might be useful for explaining the same behavior at separate points in time. Thus, the etiology of behavior, and its maintenance, may be explained by contrasting theories. For example, obsessive foodseeking behavior may emerge primarily due to organic reasons but may persist because of operant mechanisms. Thus, although distinct, the organic and operant theories are not always incompatible. Psychoanalytic explanations were among the earliest attempts to explain stereotypy. According to Spitz and Wolfe (1949), stereotyped movements, such as body rocking, are grouped into a class of behavior termed autoerotic. Autoerotic behaviors are "manifestations of sexual impulses .. .not yet directed
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at any outer object. Each individual component of the sexual impulse works for a gain in pleasure and finds its gratification in its own body" (p. 85). Other psychoanalytic explanations of stereotyped behavior focus on the behavior as a way to express and relieve anxiety and tension (Klaber & Butterfield, 1968) or as a manifestation of poor ego identity or lack of a well-developed sense of self (Baumeister & Forehand, 1973). Although these hypotheses provide potential explanations regarding etiology, they are difficult to substantiate, and do not address how stereotypy is maintained over time. In addition, they do not address the distinct forms of stereotypy often found in specific subgroups. For these reasons, few current studies of stereotypy are based on psychoanalytic models. An increasing number of studies are currently being published that evaluate the behavioral phenotypes associated with specific genetic disorders (e.g., Denckla, 2000). Several subtypes of organic-based explanations have been posited in the literature, and the following three subtypes provide examples of this theory. One class of organic explanations posits that stereotyped behavior can be traced to chemical or structural brain pathology (Baumeister, 1978). This view is supported indirectly by findings that stereotyped behavior is often negatively correlated with IQ scores. The fact that stereotypy occurs more frequently among persons classified as severely to profoundly retarded than among persons with more mild disabilities (Davenport & Berkson, 1963) supports a relation to overall central nervous system pathology. Other evidence of an organic explanation comes from studies showing that certain genetic syndromes (e.g., Prader-Willi) are highly correlated with stereotypic behavior and that lesions in the brains of animals can produce stereotyped movements (Baumeister, 1978). A second organic explanation is based on the supposition that a certain level of stimulation is optimal for the organism (homeostasis). When this level is not achieved, the organism engages in stereotypy, which serves to either increase or decrease stimulation (Baumeister & Forehand, 1973). For example, several researchers have posited that, due to the high degree of monotony associated with institutional settings, stereotypy develops in an attempt to achieve optimal levels of stimulation (Berkson & Davenport, 1962). A related view is that stereotypic behavior serves as a stimulus filtering function. Hutt and Hutt (1965), for example, found that stereotyped responding in mentally retarded children was positively correlated with environmental complexity. That is, the more complex the environment in terms of available stimuli, the more likely the occurrence of stereotypic behavior. One inference from this study is that the individuals were engaging
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in stereotypy in order to "filter" extraneous environmental stimuli. A third organic explanation posits that stereotyped responding leads an individual to experience altered states of consciousness. According to this view, the functional significance of stereotypy is that it decreases arousal, leading the individual to experience EEGs similar to those accompanying normal drowsiness (Stone, 1964). Another process through which behavior might lead to altered states of consciousness is through the response-contingent release of endogenous opiates. This process results in a state of euphoria and may also attenuate pain, such as that originating from ear or sinus infections (Thompson, Hackenburg, Cerutti, Baker, & Axtell, 1994). Opioid-related accounts of the development and maintenance of stereotypic behavior are especially compatible with an operant theory, because it is possible to describe the change in biological events that results from stereotypy as automatic response products that reinforce operant behavior. For example, if the release of endogenous opiates is produced directly by a specific behavior, this constitutes a response-consequence relationship and, therefore, represents an operant contingency. As mentioned previously, the etiology of the behavior might be organic, but the maintenance might be operant. In the operant literature, stereotypic behavior is often described as behavior that directly produces its own reinforcement (e.g., Ringdahl, Vollmer, Roane, & Marcus, 1997). Thus, reinforcement occurs automatically when the behavior occurs, and the behavior is described as serving an automatic function. As such, stereotypy constitutes a distinct functional class of behavior that is separate from behavior that is maintained by social functions (i.e., access to socially mediated reinforcers). Some researchers have demonstrated that stereotypy can be influenced by social reinforcers (e.g., Durand & Carr, 1987; Mace & Belfiore, 1990); however, the majority of studies concerning stereotypy have focused on behaviors that serve an automatic function. Within the functional classification of automatic reinforcement, there are two major subcategories: automatic positive reinforcement (e.g., production of sensory stimulation) and automatic negative reinforcement (e.g., escape from intense stimulation or biologic events such as pain). The maintaining role of automatic positive reinforcement has been supported by studies demonstrating the effects of treatments designed to interrupt or replace the sensory products of stereotypy. Rincover (1978) reduced aberrant behavior exhibited by several individuals with developmental disabilities via a sensory extinction procedure. For example, to reduce the stereotypic plate spinning exhibited by 1 individual, a table was carpeted to eliminate the auditory feedback (the hypothesized variable responsible for
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maintenance). This simple change reduced the occurrence of behavior and thus supported the hypothesis that plate spinning was maintained by automatic positive reinforcement. An alternative approach is to "enrich" the environment in order to provide stimulation that competes with the sensory stimuli maintaining stereotypy. Favell, McGimsey, and Schell (1982), for example, reduced SIB that had been resistant to socially mediated treatments by placing alternative stimuli in competition with the products of SIB. For 2 participants, allowing noncontingent access to popcorn reduced pica (ingestion of inedible objects). The fact that behavior evaluated in these sensory-based studies was resistant to socially mediated treatments, but was responsive to sensory extinction or alternative sensory stimulation, suggests that stereotypy was maintained by the production of sensory events (i.e., automatic positive reinforcement). An automatic negative reinforcement explanation of stereotypic behavior is usually inferred when behavior serves to escape or avoid certain biologic states (e.g., discomfort) or to attenuate stimuli in the environment (e.g., auditory stimuli). Cataldo and Harris (1982) hypothesized that stereotypic self-injurious behavior (SIB) might emerge initially due to the production of endogenous opiates in response to pain. Evidence for an automatic negative reinforcement explanation comes from the finding that individuals with biologic conditions such as otitis media exhibit differentially higher levels of stereotypic behavior than individuals without this condition (de Lissovoy, 1963). Other biologic events, such as gastric discomfort, have also been demonstrated to be correlated with stereotypic behavior (Wacker, Harding, et al., 1996). It is important to note that operant explanations of stereotypic behavior do not necessarily preclude other potential factors. For example, operant explanations can incorporate the production of organic compounds (endogenous opioids) or the cessation of organic processes (pain) for the maintenance of stereotypy. Indeed, although successful drug interventions with opiate blockers, such as naltrexone and naloxone, provide evidence that aberrant behavior is maintained through biological processes (e.g., Sandman et al., 1990; Thompson et al., 1994), it may be that the results are also obtained as either a function of extinction (i.e., no opiate high) or punishment (i.e., increased sensitivity to pain). The above example illustrates the complex interaction that can occur between biologic and automatic reinforcement variables. Similar interactions can occur between social reinforcement and biologic variables (e.g., aberrant behavior occurs to escape demands whenever the person is sleep deprived [Kennedy & Meyer, 1996] or has pain [O'Reilly, 1997]), and possibly between
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different categories of operant variables such as social and automatic reinforcers (e.g., stereotypy occurs to increase stimulation and to avoid social contact). However, a comprehensive examination of these types of complex interactions is beyond the scope of this chapter. In the following sections, we describe behavioral assessment and treatment of one category of operant variables: automatic reinforcement. Although a few studies have shown social functions for stereotypy (e.g., Durand & Carr, 1987; Mace & Belfiore, 1990), most studies have identified automatic reinforcers as maintaining stereotypy. In addition, stereotypy maintained by automatic reinforcement has proven to be highly resistant to behavioral treatment and has not been studied as extensively as socially maintained aberrant behavior. Recent operant research has begun to increase our understanding of the behavioral mechanisms underlying stereotypy and, therefore, has led to successful behavioral treatment.
3. AUTOMATIC REINFORCEMENT MODELS 3.1 Identifying Automatic Functions of Behavior Iwata et al. (1982/1994) noted that behavior maintained by automatic reinforcement, by definition, is not controlled by social events and, therefore, should occur in the absence of social reinforcers. To test this hypothesis, they constructed an alone condition within a functional analysis in which participants were placed in a room without social contact or extraneous materials. In this condition, no social contingencies (i.e., attention, materials, or escape from task demands) were provided. Thus, if behavior occurred at steady rates across alone sessions, a variable other than social reinforcement was, by default, responsible for maintenance. Behavior that occurred at high rates during the alone condition (relative to a free play and other test conditions) was described as serving an automatic function. A number of variations of the functional analysis methodology have been posited to identify automatic reinforcement. For example, several investigators (Iwata, Pace, Dorsey et al., 1994; Ringdahl et al., 1997; Vollmer et al., 1994) suggested that an undifferentiated pattern across all test conditions of a functional analysis was indicative of an automatic function. If behavior was observed to occur at comparable levels across all conditions (social and nonsocial) of the functional analysis, this suggested that the presentation and
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removal of social contingencies did not influence the occurrence of behavior. In a review of 152 functional analyses conducted for SIB displayed by individuals with developmental disabilities, Iwata, Pace, Dorsey, et al. (1994) found that the functional analyses of 39 individuals (25.7%) fit one of these two patterns (responding highest in the alone condition or across all conditions), suggesting that for about one-fourth of the sample, SIB was maintained by automatic reinforcement. Of this number, SIB exhibited by 30 individuals was hypothesized to be maintained by sensory stimulation (automatic positive reinforcement), and SIB exhibited by 2 individuals was hypothesized to be maintained by pain attenuation (automatic negative reinforcement). No hypotheses were generated for the SIB exhibited by the remaining 7 individuals.
3.2 Matching Treatment to Functional Analysis Outcome Typically, the results of functional analyses are used to allow clinicians to "match" reinforcement-based treatment to the function of a target behavior. For behavior maintained by social functions such as attention or escape from demands, treatment often consists of two components: (a) disrupting the response-reinforcer relationship maintaining a target behavior and (b) presenting that same reinforcer following a more acceptable, appropriate response. The results of the functional analysis are important because they identify the reinforcer that will be discontinued for target behavior and differentially provided for appropriate behavior. Unlike behaviors maintained by social reinforcement, the reinforcers responsible for behavior maintained by automatic reinforcement are not readily identifiable via a functional analysis. Thus, the particular reinforcers to include in treatment are not apparent. However, in some cases, the various patterns of automatic behavior exhibited during a functional analysis (e.g., only during the alone condition; across test and control conditions) coupled with other assessment methods (e.g., stimulus preference assessments) can provide information that is critical to treatment. For example, the absence of problem behavior in conditions where alternative stimuli are available (e.g., free play) may indicate that the presence of alternative stimuli suppresses behavior. Thus, treatment might include some sort of exposure (either contingent or noncontingent) to alternative stimuli. Steege, Wacker, Berg, Cigrand, and Cooper (1989) provided a demonstration of the use of alternative stimuli to decrease behavior maintained
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by automatic reinforcement. During assessment, SIB occurred only during alone sessions in which no alternative stimuli were present. Following assessment, the participant was taught to press a microswitch that activated a fan. This stimulus was then provided as an alternative during alone sessions. Results indicated that the individual activated the switch to the exclusion of SIB. That is, access to the alternative stimulus suppressed engagement in SIB. Ringdahl et al. (1997) and Shore, Iwata, DeLeon, and Kahng (1997) described similar results. In each of these studies, providing access to alternative stimuli identified via a systematic preference assessment decreased automatically maintained SIB exhibited by individuals with developmental disabilities. Taken collectively, the results of Steege et al. (1989), Ringdahl et al, (1997), and Shore et al. (1997) suggest that if alternative sensory stimuli can be identified, they can be used to decrease stereotypy maintained by automatic reinforcement. A logical question, then, is how to best select the alternative stimuli. Smith, Iwata, Vollmer, and Zarcone (1993) and Kuhn, DeLeon, Fisher, and Wilke (1999) evaluated the effects of two treatment procedures, one that matched the hypothesized function of behavior and one that did not, to clarify further the results of functional analyses. In both investigations, the results for 1 participant suggested a possible automatic function (behavior occurred within an alone condition) and one additional function: attention for Smith, Iwata, Vollmer, and Zarcone (1993) and escape for Kuhn et al. (1999). Two treatments, one that matched an automatic function and one that matched the alternative function, were compared for their effectiveness in reducing the occurrence of target behavior. In both investigations, the treatment procedure that matched an automatic function for behavior was more effective than the alternative treatment, indicating that the behavior was maintained by automatic rather than social reinforcement. Thus, for durable treatment effects to occur, it might be important that the variability in behavior attributed to automatic reinforcement be identified and that alternative stimuli are available during treatment. Piazza, Adelinis, Hanley, Goh, and Delia (2000) demonstrated that the problem behavior of three individuals with developmental disabilities was maintained by automatic reinforcement. Treatment consisted of providing ongoing access to alternative stimuli. However, treatment varied in effectiveness depending on the nature of the stimuli available. Specifically, positive treatment outcomes were observed only if the alternative stimuli matched the putative sensory reinforcer provided by the problem behavior. For example, with 1 individual, saliva play was reduced only when matched stimuli (i.e., liquids such as shaving cream and shampoo) were available. When unmatched, yet preferred, stimuli (e.g., a
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plastic ball) were available, saliva play continued to occur at high levels. The results of current behavioral studies show that behavior maintained by automatic reinforcement occurs only in the absence of social contingencies or across social contingencies. It is currently unclear whether these represent distinct categories of functional behavior. Additional assessment procedures, such as stimulus preference assessments, are often required to identify competing sensory stimuli. Based on these results, distinct models of behavioral treatment have been suggested in the literature.
3.3 Models for Addressing Behavior With an Automatic Function Vollmer (1994) described three categories of behavioral treatment for behavior maintained by automatic reinforcement. In the first category, treatment is achieved by attenuating the establishing operations associated with problem behavior. This treatment approach may be indicated when the behavior is putatively maintained by automatic positive reinforcement and is observed only during the alone condition of a functional analysis (or under conditions where no alternative stimuli are available). These assessment results would indicate that deprivation of distinct sensory stimuli increases the value of automatic reinforcers produced by stereotypy. Thus, treatment might consist of noncontingent access to competing stimuli. A second approach has been used to reduce aberrant behavior by providing alternative stimuli contingent on the absence of problem behavior or following an appropriate response. This approach may be indicated when problem behavior occurs across conditions of a functional analysis, but is relatively less preferred than engaging in some other, more acceptable behavior (Ringdahl et al., 1997). Finally, a third approach, extinction, involves disruption of the responsereinforcer relationship. Extinction typically involves blocking the response or blocking the sensation (i.e., the hypothesized reinforcer) produced by the response. This approach may be indicated when other treatment approaches are determined to be unsuccessful.
3.3.1
Attenuate Establishing Operations
Michael (1982) defined establishing operations as environmental events that momentarily influence (a) the effectiveness of a reinforcer and (b) the
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frequency of responses associated with obtaining the reinforcer. In applied work with individuals with developmental disabilities, establishing operations have been studied within two distinct categories: (a) deprivation or satiation of a reinforcer (e.g., Vollmer & Iwata., 1991) and (b) the biological status of the individual (e.g., sleep, infections, or allergies; O'Reilly, 1995) that appear to be correlated with behavior maintained by negative reinforcement. The absence of alternative activities and stimuli within the alone condition appears to function as an establishing operation for problem behavior. Ringdahl et al. (1997) demonstrated that problem behavior occurred in the absence of social reinforcement and alternative stimuli. When preferred items were available on a noncontingent basis, individuals participating in two of the four analyses engaged in the preferred stimuli almost to the exclusion of problem behavior. Rapp et al. (1999) demonstrated that noncontingent access to hair, collected from an individuals bed and after a haircut, reduced the level of automatically reinforced hair pulling exhibited by that individual. In each investigation, the presence of alternative stimuli appeared to alter the establishing operation (an absence of alternative sources of stimulation) associated with problem behavior, thus resulting in a reduction in the occurrence of problem behavior. In the previous examples, problem behavior was most likely to occur when alternative sources of stimulation were not available. For some individuals, access to specific types of sensory stimulation appears to maintain problem behavior. In these cases, providing an alternative source of similar stimulation may reduce problem behavior. Goh, Iwata, Shore, DeLeon, and Kahng (1995) hypothesized that hand mouthing that served an automatic function was maintained by sensory stimulation to either the hand or the mouth. To test these two hypotheses, 4 women with a history of hand mouthing were given free access to a toy that could be manipulated as a substitute for hand mouthing. Data were recorded on the percentage of time each woman made contact with the toy with her hand, made contact with the toy with her mouth, and made contact with her mouth with her hand. The results of this analysis revealed that contact between the toy and hand was the most frequent response for each woman. These results indicated that stimulation to the hand was the predominant reinforcer for each woman's behavior. Treatment then consisted of having the women manipulate items with their hands to increase alternative, more appropriate stimulation to compete with hand mouthing. This approach was successful in reducing hand mouthing for 3 of the 4 women.
RBDs in Persons with Developmental Disabilities 3.3.2
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Differential Reinforcement Procedures
In each of the preceding examples, access to alternative stimuli was provided on a noncontingent basis, and the participant was able to engage in problem behavior without losing access to those stimuli. An alternative approach would be to make access to the alternative stimuli contingent on the absence of problem behavior (differential reinforcement of other behavior [DRO]) or the exhibition of some appropriate alternative behavior (differential reinforcement of alternative behavior [DRA]). For a differential reinforcement approach to be successful, two factors have to be present: (a) the alternative reinforcer competes effectively with the automatic reinforcers, and (b) the individual is able to "wait" or to engage in alternative behavior that is distinct from stereotypy. Ringdahl et al. (1997) used a combination of DRO and DRA to decrease the stereotypic SIB displayed by a young child with developmental disabilities. Specifically, a low frequency response, reaching, resulted in 20 to 30 s access to a preferred item (as identified by a stimulus preference assessment) if problem behavior did not occur for a 10-s period immediately prior to the reach response. During a functional analysis, the individual displayed SIB across all conditions (including free play). However, during a preference assessment, toy engagement was more likely to occur than SIB. Thus, it was hypothesized that access to toys could be made contingent on an alternative response plus the absence of SIB. The combination of DRO and DRA was effective in reducing the occurrence of problem behavior for this child, even though the same toys were not sufficient to reduce problem behavior when they were provided noncontingently.
3.3.3
Extinction
In the case of problem behavior maintained by automatic reinforcement, extinction requires that the automatic reinforcement provided by the stereotypy be discontinued. This disruption is typically accomplished by either preventing the behavior from occurring (i.e., blocking) or reducing the sensation provided by the behavior (sensory extinction) through the use of protective equipment such as gloves. This treatment approach is indicated when other, reinforcement-based approaches to treatment have been ineffective. Lindberg, Iwata, and Kahng (1999) used response blocking to reduce selfinjurious behavior that was maintained by automatic reinforcement for 2 men
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who were diagnosed with profound mental retardation. For each participant, the noncontingent presentation of alternative sources of stimulation was not sufficient to reduce the occurrence of problem behavior. Response blocking was then implemented for both participants and resulted in decreased levels of self-injury for 1 participant. Sensory extinction like response blocking is used to disrupt responsereinforcer relations. A common example is the use of protective equipment that reduces any sensations that are produced through the completion of the problem behavior. For example, Iwata, Pace, Cowdery, and Miltenberger (1994) and Kuhn et al. (1999) used helmets to reduce the sensations produced by head banging and face hitting for 2 males with severe mental retardation. These types of findings are not unique to persons with developmental disabilities. For example, Ellingson et al. (2000) used gloves to reduce the sensations provided by finger sucking for 2 normally developing children. Either stimulation to the mouth or stimulation to the fingers may have maintained finger sucking. The use of gloves attenuated both types of sensations and was effective for reducing finger sucking for 1 of the children.
4. CLINICAL EXAMPLES
ASSESSMENT
AND
TREATMENT
In this section, we briefly describe case examples from our inpatient and community-based programs. Our purpose is to describe how various functional analysis response patterns indicative of an automatic function, coupled with the use of other evaluations, led to effective behavioral treatment. For two of the following case examples, problem behavior occurred across all functional analysis conditions and appeared to serve an automatic positive reinforcement function (i.e., access to stimulation). The result of subsequent analyses suggested different treatment approaches for the respective participants. For the third individual, problem behavior appeared to serve an automatic negative reinforcement function (i.e., escape from discomfort). Alleviating the discomfort, in turn, resulted in us being able to identify social functions that also maintained aberrant behavior. The community-based outreach service was funded, in part, by the National Institute of Child Health and Human Development (Wacker, Berg, & Harding, 1996). The child's primary care provider (usually parents) conducted all assessment and treatment procedures with coaching from therapists during visits to the child's home. The inpatient program was a component of a
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hospital unit that provided comprehensive assessment and treatment for individuals with developmental disabilities. Both programs involved a multiphase model of assessment, treatment, and treatment evaluation. During the assessment phase, a functional analysis was conducted to identify the reinforcer(s) maintaining aberrant behavior. In cases where the results of the functional analysis were undifferentiated, further evaluation was conducted. This process included either an analysis of the response patterns during the functional analysis, preference/choice assessments, or a second functional analysis during which antecedents correlated with problem behavior were altered. During the treatment phase, parents and/or clinic staff conducted a treatment program (e.g., functional communication training) based on assessment outcomes. In our home-based treatment, we conducted weekly to monthly probes to evaluate treatment efficacy. For the vast majority of the individuals seen by our services (approximately 80% of the inpatients and 90% of children in our home project), distinct social functions for aberrant behavior were identified and treatment involving differential reinforcement was used to successfully reduce problem behavior (Wacker, Berg, Harding, et al., 1998). In the remaining cases, social functions were not identified. Specifically, undifferentiated patterns of responding occurred across all the functional analysis conditions including free play. When these types of results were obtained on the inpatient unit, treatment was developed either based on the pattern of inappropriate behavior exhibited during assessment or on the results of stimulus preference/choice assessments. When these types of results were obtained in the community-based program, antecedent analyses provided information regarding antecedent variables correlated with problem behavior.
4.1 Case Example 1: Derek (inpatient) Derek was a 2-year-old boy with mild developmental delays admitted for assessment and treatment of mouthing (placing inappropriate items such as hairs and carpet fibers in his mouth). During the functional analysis, a brush with hairs on it was available. Parents had reported that Derek would seek out brushes in the home, pull off a piece of hair, and hold it in his mouth. The functional analysis consisted of the following conditions: free play, alone, and ignore (functionally similar to the alone condition, except a therapist was present). Results of the functional analysis indicated that mouthing occurred primarily during the alone and ignore conditions. Thus, automatic
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reinforcement was implicated as the maintaining variable. This response pattern suggested that stimuli available during the free-play condition might effectively compete with problem behavior. A choice assessment was conducted to evaluate which components of free play (access to toys or attention) competed with mouthing. This evaluation was done by making alternative stimuli (toys, attention, or both) available on one side of the room and materials for mouthing (hair in a hairbrush) available on the other side. In another condition, Derek was allowed to choose between the side with materials for mouthing and being alone. His time allocation to each side was recorded (based on Harding et al., 1999). Results of this evaluation indicated that Derek preferred any combination of toys and attention to the brush. In addition, the only time Derek chose the side with the brush was when neither toys nor attention were available on the other side. Thus, for Derek, we recommended noncontingent access to preferred items (i.e., toys) and attention as treatment.
4.2 Case Example 2: Sharon (inpatient) Sharon was a 51-year-old woman diagnosed with severe to profound mental retardation. She was admitted to the inpatient program for assessment and treatment of SIB (self-scratching). The behavior had caused lacerations to her hands and forearms. Interviews with her care providers indicated the behavior occurred across all situations in her daily routines. During the functional analysis, problem behavior occurred across assessment conditions. In reviewing Sharon's response pattern during the functional analysis, it was noted that, in addition to occurring across all test conditions (including the alone condition), SIB occurred during the free-play condition while Sharon was engaged in a preferred activity (pulling a wagon). Given that the preferred activity did not compete with problem behavior, a blocking procedure was implemented as treatment during both alone (i.e., no alternative stimuli) and free-play conditions. The results of the treatment evaluation suggested that blocking was an effective treatment during both the alone and free play conditions. Thus, we recommended to Sharon's careproviders that an ongoing blocking procedure be implemented in her living environment.
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4.3 Case Example 3: Tanya (home) Tanya was a 5-year-old girl diagnosed with severe to profound mental retardation, cerebral palsy, and visual and hearing impairments (Harding, Wacker, & Berg, 2000). She was referred to the in-home project for assessment and treatment of SIB in the form of head and chin hitting, eye pressing, and hitting her knuckles together. During an initial functional analysis, Tanya was seated in her wheelchair during the free-play, attention, tangible, and escape conditions. The results of this analysis were undifferentiated in that Tanya displayed high levels of self-injury across all assessment conditions. Overall, across all conditions, she appeared to be uncomfortable. The functional analysis was then repeated with Tanya positioned on the couch. The results of this analysis showed that SIB was at zero, or near zero, levels during the free-play condition, but consistently elevated across attention, escape, and tangible conditions. Thus, Tanya's SIB appeared to be socially mediated when she was not seated in her wheelchair, but appeared to have an automatic function when seated in the wheelchair perhaps because of discomfort. Collectively, these case examples demonstrate that the results of functional analyses can indicate when behavior is likely maintained by automatic reinforcement. However, it is often necessary to conduct further evaluation in order to clarify the initial results (e.g., Tanya) or identify successful treatment strategies (e.g., Sharon).
5. SUMMARY Repetitive behavior disorders in persons with developmental disabilities are likely produced and maintained by a complex interaction of biologic and operant variables. We have described some of these variables and suggested that even if behavior is related to biologic variables, operant mechanisms may still be maintaining the behavior. Based on this supposition, we suggest that behavioral treatment be considered. A difficulty with behavioral treatment for behavior maintained by automatic reinforcement is that we are often unable to match treatment to the specific variables that maintain repetitive behavior. A combination of functional analysis and assessments of stimulus preferences or antecedent events may be a good approach for clarifying both the operant mechanisms underlying behavior and the behavioral treatment components that may be effective in reducing the behavior.
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Naltrexone, attenuates self-injurious behavior. American Journal on Mental Retardation, 95, 84-92. Shore, B. A., Iwata, B. A., DeLeon, I. G., & Kahng, S. W. (1997). An analysis of reinforcer substitutability using object manipulation and self-injury as competing responses. Journal oj Applied Behavior Analysis, 30, 21-41. Smith, R. G., Iwata, B. A., Vollmer, T. R., & Zarcone, J. R. (1993). Experimental analysis and treatment of multiply controlled self-injury. Journal of Applied Behavior Analysis, 26, 183196. Spitz, R. A., & Wolf, K. M. (1949). Autoerocticism. Psychoanalytic studies of the child. 3, 85120. Steege, M. W., Wacker, D. P., Berg, W. K., Cigrand, K. K., & Cooper, L. J. (1989). The use of behavioral assessment to prescribe and evaluate treatments for severely handicapped children. Journal ofApplied Behavior Analysis, 22, 23-33. Stone, A. A. (1964). Consciousness: Altered levels in blind retarded children. Psychomatic Medicine, 26, 14-19. Thompson, T., Hackenberg, T., Cerutti, D., Baker, D., & Axtell, S. (1994). Opiod antagonist effects on self-injury in adults with mental retardation: Response form and location as determinants of medication effects. American Journal on Mental Retardation, 99, 85-102. Vollmer, T. R. (1994). The concept of automatic reinforcement: Implications for behavioral research in developmental disabilities. Research in Developmental Disabilities, 15, 187-207. Vollmer, T. R., Marcus, B. A., LeBlanc, L. (1994). Treatment of self-injury and hand mouthing following inconclusive functional analyses. Journal of Applied Behavior Analysis, 27.331-344. Vollmer, T. R., Iwata, B. A. (1991). Establishing operations and reinforcement effects. Journal ofApplied Behavior Analysis, 24, 279-291. Wacker, D. P., Berg, W. K., & Harding, J. W. (1996). Promoting stimulus generalization with young children. Department of Health and Human Services, National Institute of Child Health and Human Development. Wacker, D. P., Berg, W. K., Harding, J. W., Derby, K. M., Asmus, J., & Healy, A. (1998). Evaluation and long-term treatment of aberrant behavior displayed by young children with disabilities. Journal of Developmental and Behavioral Pediatrics, 19, 26-32. Wacker, D. P., Harding, J., Cooper, L. J., Derby, K. M., Peck, S., Asmus, J., Berg, W. K., Brown, K. A. (1996). The effects of meal schedule and quantity on problematic behavior. Journal ofApplied Behavior Analysis, 29. 79-87.
Index
ABC recording, 22, 176, 178, 187, 193, 194 acral licking, 133 ADHD, 26, 29, 35, 36,44 58, 59,61, 63, 64, 67, 68, 70, 87-92, 102, 122, 222, 245 anxiety, 2, 7, 26, 30, 36,41,44, 59, 62,63,69,70,85,87,91,102, 125, 134, 138, 142-146, 157, 164, 173,174,188,191,200,215,218, 220, 222,243-245, 248, 270, 291, 299 assertiveness training, 48, 76, 85, 86 atypical root resorption, 42-43 automated recording, 10 avian feather picking, 133 awareness enhancement device, 30, 141, 168, 189, 192,236,240, 258, 259,261 awareness training, 82, 83, 105, 106, 108,109,110,113,116,117, 127, 158, 159, 171, 178, 179, 180, 181, 184,226, 229, 234,241,244,246, 247,250,258, 263,275,280 behavioral assessment, 1,9-11,15, 19,26,27,175,178,297 behavioral interviews, 10-13, 21 behavioral seal, 19, 28 biofeedback, 76, 85, 86, 95, 272,278, 291-293 bruxism, 1,6,26,223,269 defined, 276 and parasomnia, 276 prevalence, 276 treatment, 277-281
Child Behavior Checklist, 25, 27, 104, 124 chorea, 54, 63 clomipramine, 30, 152, 153, 162, 168,169,224,239 clonidine, 62, 75, 88, 89, 95 clozapine, 75, 94 competing response, 79, 80, 82, 83, 86,105,110-122, 129-132,158160,162,167,169,171,178, 181190, 194, 217, 221, 226-229, 234, 237-241, 243, 246, 250-259, 261, 264-267, 275, 279, 280, 287, 288 competing response training, 82, 83, 159, 181, 183,228 contingency management, 103, 120, 121,178,274,280,284,288 and oral-digital habits, 225, 226, 231-233 and rumination, 285, 286 and tics, 75-78 and trichotillomania, 154-158 coprolalia, 46 copropraxia, 46 covert sensitization, 225, 238, 239 depression, 26, 30, 36, 44, 58, 69, 70, 102,124,138, 143,174,191,200, 245 descriptive assessment, 20-23 desipramine, 30, 88, 95, 152, 169, 224, 239 dextroamphetamine, 88, 89 diagnostic assessment, 9 differential reinforcement, 76-78, 83, 87,91,95,155,156,161,163,
316 225, 229, 232, 238, 242, 285, 293, 307, 309 dyskinesias, 54,295 dystonias, 54 early warning, 80 echoic speech, 297 endogenous opiates, 297 establishing operation, 143, 305-306 exposure and response prevention, 66, 122 finger sucking, 1, 16-19,23,24,26, 28,42-44, 191, 197,205, 206, 207, 214,216,218,219,221,232,235, 236,238,241,251,261,308 and clinical associations, 210-212 cross-cultural, 202,203,208-210 definition, 198 gender differences, 202 genetics, 204 phenomenology, 199-203 prevalence, 201,202 and transitional objects, 203 fluoxetine, 27, 93, 152, 167, 169 function based treatments, 83 functional assessment, 9, 10, 12, 20, 21,22,23,26,27,28,29,83,162, 166,172,187,242,243,258,286 generalization, 78, 80, 154, 158-160, 209, 231, 237, 238, 272, 275, 285, 288 genetics, 4, 60, 67, 133 Gilles de la Tourette, 30,43, 67-71, 74, 92-95 Guanfacine, 88, 92
Index habit reversal, 5-7, 27, 30, 71, 73, 76, 86,91-95,97, 100, 102, 103, 105, 106,110, 111, 115,118-123, 125, 126,133,153-155,163,165-170, 221,224, 226-229, 231, 233-235, 237-240,288, 289,294, 297 and bruxism, 278,280,281 and oral-digital habits, 226-229, 233-235 and stuttering, 274, 275 and tic disorder, 79-85 and trichotillomania, 158-161 treatment manual for oral-digital habits, 241-267 treatment manual for tics, 97-132 treatment manual for trichotillomania, 171-195 haloperidol, 60, 74, 89 homeostasis, 297 Hopkins Motor and Vocal Tic Scale, 12,13 hyperekplexias, 54 hypnosis, 74, 85, 157, 158, 169 hypoalgesia, 146 inconvenience review, 80, 178, 280 informant Assessment, 12, 21 "just right" perceptions, 58 massed practice, 76,93,278, 279, 281,289,290 medical interventions, 33 methylphenidate, Minnesota Trichotillomania Assessment Inventory, 12 Motivation Assessment Scale, 13, 21 mouthing, 282, 290, 297
Index nail biting, 1,14, 25,42-44, 167, 197, 199,217, 218, 220-230, 236-240, 269 clinical associations, 215,216 gender differences, 214 phenomenology, 214 prevalence, 213,214 nature vs. nurture, 4 negative practice, 27, 75, 76, 80, 81, 92,94,159,166,191,217,226, 227, 292, 295 neuroleptics, 74, 75, 88, 90, 91 NIMH Trichotillomania Severity Scale, 13, 153 obsessive compulsive disorder, 55, 69,87,92,133 Obsessive Compulsive Foundation, 46,52 OCD, 34, 36, 57-61, 63,67, 87, 88, 90,91,93,102,122,125,138, 142,146,152,174,191,200 Olanzapine, 75, 93, 95 PANDAS, 63, 64, 69 paroxysmal ataxia, 54 paroxysmal tremors, 54 peer education, 65, 123 periungual warts, 43 permanent products, 14 pharmacological interventions, 83 physical impact of bruxism, 277 of oral-digital habits, 42,43 of rumination, 282 of tic disorders, 34, 35 of trichotillomania, 40,41 pica, 297 pimozide, 30, 74, 89, 152, 169
317 premonitory urge, 57, 62, 66 prolonged exposure, 76, 85, 94 Psychiatric Institute Trichotillomania Scale, 13 psychoanalysis, 60, 74 psychological impact of oral-digital habits, 43, 44 of tic disorders, 35-39 of trichotillomania, 41, 42 psychotherapy, 4, 74 public display, 80 Punishment, 166, 278,279, 285 of bruxism, 279 of oral-digital habits, 225, 226, 232, 233 of rumination, 285 of tics, 77 of trichotillomania, 154-157 reactivity, 14, 16, 17,27,64 real-time recording, 17, 28, 29 regulated breathing, 274, 290, 291 reinforcement, 23, 65-67, 77, 78, 84, 86,95, 100,101,120, 123,133, 154-157,164,173,187,189,208, 209, 213, 217, 224, 225, 229, 230232, 235, 237, 242, 243, 244, 259, 271,272,283-287,296,302 social-positive, 83 social negative, 83 automatic-positive 83, 300, 303, 305 automatic-negative, 83, 300, 301, 303 relaxation training and oral-digital habits, 229, 230 and tic disorders, 78, 79 and trichotillomania, 157, 158
318 75, 78, 79, 82, 167, 188, 226, 227, 230, 238, 292 remote detection, 120 repetitive behavior disorders, 1-6, 33, 42,44-48,61,269,288,297 response description, 80, 107, 180, 246, 247, 280 response detection, 80, 180, 246, 248, 249, 275, 280 risperidone, 75, 92, 94, 152, 153, 169 rumination, 1, 6, 269, 289,291-296 associated features, 282 defined, 281 etiology, 283 prevalence, 282 treatment, 283-288 self-injurious behavior, 6, 22, 23, 28, 29, 133,166,167,297 self-monitoring, 10, 18, 19, 27, 76, 77,79,82,83,121,152,154, 160, 162, 172, 174, 175,177, 179, 185, 190, 225-228, 230, 237, 239, 244, 258, 259, 275 self-stimulation, 20, 23,297 sensory extinction, 154, 155, 165, 188,297 Shapiro Tourette Syndrome Severity Scale, 12, 13 situation awareness training, 80 skin picking, 30,42-45,269 social perceptions, 24, 25, 38, 39,41, 42,44,215 social support, 11, 80, 82, 83, 105, 115,117,119,120,159,171, 176, 183-187,189,190,193,194,206, 229,234,241,245, 246,254-256, 258, 259,265,266,275,280 Social validity, 31,81
Index SSRI,88, 152 stereotypic movement disorder, 1, 2, 50,54, 134,245,261 stereotypy, 54, 297 stuttering, 1, 6, 7, 167, 222, 269, 276, 289 defined, 270 gender differences, 270 onset, 270 prevalence, 270 recovery, 270 treatment, 271-275 Sydenham's chorea, 63 symbolic rehearsal, 80,280 tardive dyskinesia, 45, 74, 75 tension reduction, 134, 135, 223, 237 tic disorders, 1-6, 9, 12, 13, 26,27, 33,34,41,42,44,48,57,73-76, 87,89-92,94,97,98, 101-103, 118,122-124, 133,198-200 and brain functioning, 61, 63 cause, 60-67 chronic, 56 clinical importance, 2, 3 comorbid conditions, 53-55, 58-60 defined, 53 and environmental variables, 6267, 83-85 andgenetics, 60, 61 incidence, 55 onset, 56 prevalence, 55 research attention, 2,3 simple vs. complex, 53 and stimulants, 64, 65 tic-related conversations, 65, 66, 84,85 transient, 53
Index voluntary vs. involuntary, 54, 55 time-sampling recording, 15, 17 Tourette syndrome, 27, 29, 34,46, 54, 60, 63, 68-71, 92-95, 124, 125 Tourette Syndrome Association, 46, 51 Tourette Syndrome Global Scale, 12, 13 Tourette Syndrome Symptom List, 13 treatment compliance, 112, 120,251, 254,259,261 Treatment Evaluation Inventory, 12, 29 tremors, 54 trichobezoars, 45 trichophagia, 17,455, 156 trichotillomania, 1-6,9, 12, 13,27, 30-33, 124, 166-171, 187-189, 191-193,198,199,212,217,219, 269 in children, 136
319 clinical importance, 2, 3 comorbid diagnoses, 138 defined, 133 differential diagnosis, 134-135 and digit sucking, 142, 143 and environmental variables, 143, 145 gender differences, 136, 137 genetics, 145-147 onset, 137, 138 prevalence, 135, 136 pulling patterns, 139-141 research attention, 2, 3 Trichotillomania Impairment Scale, 13,153 Trichotillomania Learning Center, 46,52 warning signs, 107-110, 113-115, 118,127-130,132,179,246-250, 252-255,257-259,263-265, 267