Assessment and Treatment of Habit Disorders Essay

Assessment and Treatment of Habit Disorders Essay

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Assessment and Treatment of Habit Disorders Essay

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Chapter 6

Assessment and Treatment of Habit Disorders

Habit behaviors are repetitive or stereotyped responses that serve no apparent social function yet appear to be maintained by operant contingencies (Adesso, 1990; Hansen, Tishelman, Hawkins, & Doepke, 1990; Woods & Miltenberger, 1995). When such behaviors result in direct (i.e., physical damage) or indirect (i.e., poor social acceptability by others) harm to a person, they are considered habit disorders.

Although habit disorders are thought to be maintained by automatic reinforcement in the form of self-stimulation or arousal reduction, they are typically defined topographically rather than functionally (Woods, Miltenberger, & Flach, 1996). Although many types of habit disorders can require treatment, in this chapter we only review the four that are likely to be encountered in a clinical setting: tic disorders, trichotillomania, thumb sucking, and nail biting.

Definition, Description, and Prevalence

Tic Disorders There are three types of tic behavior patterns. Motor tics are rapid, repetitive,

and often jerking muscle movements that are not caused by spasms, chorea, or tremors (Woods & Miltenberger, 1995). Examples include excessive or forceful eye- blinking, facial grimacing, and arm or neck jerking. Research suggests that approxi- mately 1% of the population has a motor tic disorder (Ollendick, 1981).

Vocal tics are “sudden, rapid, recurrent, nonrhythmic vocalizations” (American Psychiatric Association, 1994, p. 104; APA). Examples include barking sounds, coughing and throat clearing (unrelated to illness), snorting, and coprolalia (i.e., swearing; Woods & Miltenberger, 1995). The prevalence of vocal tics is unclear.

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However, Woods, Miltenberger, and Flach (1996) reported that as many as 6.5% of college students engage in throat clearing at least 5 times per day and identify it as a habit. Tourette’s syndrome (TS) is diagnosed when a person exhibits motor and vocal tics (APA). The prevalence of TS is approximately .04-.05% and is more common in males (APA).

Individuals with tic disorders (especially TS) sometimes have concurrent problems such as obsessive-compulsive behaviors, attention deficit/hyperactive.

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Behavior, aggression management problems, and sleep problems. In some cases the tic itself causes physical damage such as cuts, burns, and bruises (Shimberg, 1995). Research has also demonstrated that adults who exhibit tics are viewed more negatively than those who do not (Woods, Long, Fuqua, Miltenberger, & Outman, 1998).

These results extend to children (Friedrich, Morgan, & Devine, 1996) and developmentally disabled adults (Long, Woods, Miltenberger, Fuqua, & Boudjouk, in press). In addition, Long, Woods et al. demonstrated that individuals who exhibit tic behaviors are less likely to be hired for jobs than individuals who do not exhibit tics.

Trichotillomania Trichotillomania refers to chronic hair pulling which results in noticeable hair

loss (APA, 1994). Hair pulling (usually from the head) is sometimes followed by rubbing, chewing, or eating the pulled hair (Graber & Arndt, 1993). Individuals exhibiting trichotillomania often experience a feeling of tension/anxiety that is relieved after pulling the hair (APA).

Approximately 1-4% of the population is diagnosed with trichotillomania, and adult females are 3 times more likely to receive the diagnosis than males (Graber & Arndt). Chronic hair pulling can result in hair- follicle damage (Muller & Winkelmann, 1972) or severe gastrointestinal difficulties when the hair is ingested (Mouton & Stanley, 1996). In addition, individuals who engage in chronic hair pulling are at greater risk for negative social evaluation (Long, Woods et al., in press).

Thumb Sucking Thumb sucking occurs in up to 46% of children under the age of 4 (Traisman

& Traisman, 1958) and continues in 19% of children over the age of 5 (Infante, 1976). Thumb or finger mouthing occurs in approximately 2.8% of college-age adults (Woods, Miltenberger, & Flach, 1996). Females are more likely to engage in thumb sucking, although the exact sex ratio is unclear (Friman, Larzelere, & Finney, 1994).

Although typically harmless, chronic thumb sucking can cause physical damage such as dental malocclusion, atypical root resorption, and increased risk of acciden- tal poisoning (Friman & Schmitt, 1989). In addition, children who continue to suck their thumbs are perceived more negatively by their peers (Friman, McPherson, Warzak, & Evans, 1993).

Frequent thumb sucking is common in children under 4 years, and except in unusual cases, does not require clinical attention. However, a child who engages in chronic thumb sucking after the age of 4 is at greater risk of developing the problems mentioned above and should be considered for treatment (Friman & Schmitt).

Nail Biting Nail biting includes placing any digit into the mouth and biting either the nails

or the skin around the nails. Despite being a very common habit among children (41.6%; Massler & Malone, 1950) and adults (10%; Woods, Miltenberger, & Flach, 1996), chronic nail biting can result in damage or inflammation of the tissue around the nail, possible infection, and shortening of the roots of the teeth (Silber & Haynes,

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1992). There is also preliminary evidence that individuals who bite their nails are viewed as less socially acceptable than those who do not bite their nails (Long, Woods et al., in press).

Development and Current Etiological Theories of Habit Disorders. In this section, we trace the history and describe the biological and behavioral

explanations for the etiology of each of the common habit disorders.

Tic Disorders TS and other tic disorders are believed to have occurred for a number of

centuries, although TS was not classified until 1885 when Georges Gilles de la Tourette described similar behaviors in nine individuals (Shimberg, 1995). Accord- ing to the biological perspective, tic disorders result from both genetic and neurological variables.

Genetic research has shown a 77% concordance rate among monozygotic twins as compared to a rate of 23% for dizygotic twins. Neurologically, an excess of the neurotransmitter dopamine may be responsible for tics, although this has not yet been clearly demonstrated (Bruun & Bruun, 1994). It appears that the etiology of tic disorders has some biological basis, despite the preliminary nature of the research database.

Behavioral theorists combine biological and learning explanations to suggest that some individuals with tic disorders are biologically predisposed for the occurrence of tics to be reinforced via tension reduction in the tic musculature. This view suggests that individuals experience heightened tension in specific muscle groups and that tics may be maintained by tension reduction in those muscles.

In such a case, the muscles are tense prior to the occurrence of the tic, and this tension is temporarily reduced following an occurrence of the tic (Evers & van de Wetering, 1994). Although there is little evidence in support of, or opposing this theory, studies have shown that tics can be increased by positive and negative reinforcement (Carr, Taylor, Wallander & Reiss, 1996; Scotti, Schulman, & Hojnacki, 1994) and the presence of an anxiety provoking person (Malatesta, 1990).

Trichotillomania Trichotillomania was first described in 1889 by the French dermatologist

Hallopeau (Franzini & Grossberg, 1995). Etiological explanations of the behavior began to be presented in the 1940s (Franzini & Grossberg). Biological theories have not established a causal link between neurological activity and trichotillomania.

However, the limited success of some psychoactive drugs such as fluoxetine and clomiprimine have led some theorists to posit that trichotillomania may be related to a seratonin deficiency (Iancu, Weizman, Kindler, Sasson, & Zohar, 1996). In addition, some studies suggest that differences in brain function are responsible for some hair pulling (e.g., Swedo et al., 1991).

The behavioral explanation of trichotillomania suggests that hair pulling produces automatic reinforcing consequences such as tactile stimulation resulting from stroking or manipulating the hair, or tension/anxiety reduction (Franzini &

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Grossberg, 1995). In addition, the behavior may be maintained through social consequences. Indeed, many people engaging in trichotillomania report a feeling of tension that is relieved following an episode of hair pulling (APA, 1994), and at least one study has shown that hair manipulation increases when individuals are anxious (Woods & Miltenberger, 1996b).

Thumb Sucking Biological theorists offer virtually no explanation for the etiology of thumb sucking. However, behavioral theorists have suggested that the behavior is learned (Friman, Finney, & Christophersen, 1984). Behavioral theorists suggest that thumb sucking begins in infancy as it modulates arousal (i.e., comforts the anxious child or arouses the bored child).

As the child’s verbal repertoire and other functional skills develop, more adaptive behaviors replace the functions of thumb sucking in most children, and thumb sucking gradually ceases (Friman & Schmitt, 1989). In cases where thumb sucking continues, the behavior seems to be maintained by an arousal modulation function (Rapp, Miltenberger, Galensky, Roberts, & Ellingson, in press).

Nail Biting Biological theorists have not been quick to address nail biting, although some studies suggest that there is a familial link among nail biters (e.g., Leonard, Lenane, Swedo, Rettew, & Rapoport, 1991). Additionally, Leonard et al. suggested that nail biting was maintained by the same biological processes affected by clomipramine.

The behavioral theory suggests that nail biting functions to reduce tension/anxiety or increase arousal in under-stimulating situations (Woods & Miltenberger, 1996b). Although there are little empirical data to support this hypothesis, a study by Hansen et al. (1990) found that nail biters reported being more likely to bite when alone and engaging in a passive activity (e.g., reading). These data seem to support the arousal increasing effect purported by Woods and Miltenberger (1996b).

Assessment of Habit Behaviors In this section, different strategies for assessing habit disorders will be discussed.

We start with a section on methods of data collection, discuss the importance of social validation, and conclude with a section on functional assessment of habit disorders.

Measuring Habit Behaviors The type of data collection procedures employed by the behavior analyst depends partly on the topography of the target behavior. Certain topographies lend themselves to certain types of measurement strategies.

Direct observation. Regardless of the habit behavior being measured, it is preferable to have direct (live or videotaped) observations of the habit behavior. The use of direct observation circumvents the possible methodological concerns en- countered when using self- or parental-report (Kazdin, 1992). The most desired

Assessment and Treatment of Habit Disorders 141 method of scoring data during direct observations however, depends on the type of behavior you are measuring. For behaviors with a relatively short duration (i.e., tic disorders), frequency or partial interval recording are best. The short duration of each tic occurrence and lack of a physical trace makes alternative scoring procedures difficult.

In assessing longer duration behaviors (such as thumb sucking, nail biting, and hair pulling), it may be best to use a duration measure. Duration scoring procedures have been utilized with thumb sucking (Knight & McKenzie, 1974; Long, Miltenberger, Ellingson, & Ott, in press; Rapp, Miltenberger, Galensky, et al., in press; Skiba, Pettigrew, & Alden, 1971) and trichotillomania (Long, Miltenberger, & Rapp, in press; Miltenberger, Long, Rapp, Lumley, & Elliott, 1998; Rapp, Miltenberger, Long, Elliott, & Lumley, 1998).

Recently, Miltenberger, Rapp, and Long (1999) reported the use of real-time recording to assess the duration of hairpulling. Real time recording assesses the exact timing of each instance of the behavior within the observation period and results in a measure of the frequency and duration of the behavior.

Indirect observation procedures. Nail biting may be measured using physical trace procedures. Most often, nail biting is assessed by measuring the length of the fingernails (from cuticle to tip) on each digit (Davidson, Denney, & Elliott, 1980; Long, Miltenberger, Ellingson, & Ott, in press; Vargas & Adesso, 1976).

Physical trace measures have also been used to measure thumb sucking by placing a piece of litmus paper on the thumb which changes colors when the thumb is sucked (Hughes, Hughes, & Dial, 1979). Physical trace measures used in assessing trichotillomania include counting hairs removed from the head (Altman, Grahs, & Friman, 1982) and measuring areas of baldness in the participant (Tarnowski, Rosen, McGrath, & Drabman, 1987).

Although the physical trace measure appears to be a useful way to measure some habits, the occurrence of the behavior and the physical trace might not always correspond highly (e.g., a small amount of the behavior might produce a substantial amount of damage).

Perhaps the most popular (yet least desirable) data collection methods have been the use of self-report, self-monitoring, and parental report procedures. These procedures have been used to assess tic disorders, trichotillomania, nail biting, and thumb sucking (Woods & Miltenberger, 1996a).

Despite their widespread use, these procedures have been criticized for methodological problems such as proneness to bias and distortion, lack of specificity, and relatively poor correspondence with more objective assessment strategies (Barlow & Hersen, 1984).

In addition to these concerns, the act of self-monitoring may decrease the frequency of some habits (Woods & Miltenberger, 1996a). Because of these problems, we recommend using self-recording procedures only when direct observation or physical trace procedures are not possible.

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Assessing the Social Validity of Habit Disorder Treatments and Outcome

Assessing the actual occurrence of habit disorders is an important element of a good research or clinical evaluation. However, it is equally important to assess the social validity of the treatment procedures and results. Procedures that are not acceptable or decreases that are not noticed by individuals in the client’s natural environment are of little practical use.

The assessment of treatment acceptability using standardized measures has only been conducted extensively in evaluating the habit reversal procedure. Using the Treatment Evaluation Inventory-Short Form (Kelley, Heffer, Gresham, & Elliott, 1989), researchers have shown that parents or guardians find the simplified habit reversal procedures to be acceptable to treat motor tics (Woods, Miltenberger, & Lumley, 1996b), object chewing (Woods, Miltenberger, & Lumley, 1996a), stutter- ing (Elliott, Miltenberger, Rapp, Long, & McDonald, 1998; Wagaman, Miltenberger, & Arndorfer, 1993); thumb sucking (Rapp et al., in press), and other oral-digital habits (Long, Miltenberger, Ellingson, & Ott, in press).

Social validity of treatment outcome is typically assessed by taking randomly sampled videotaped segments from baseline and treatment conditions and showing them to independent raters (Wagaman et al., 1993; Woods, Miltenberger, & Lumley, 1996a, 1996b).

The rater rates each sample using an instrument such as the Social Validity Scale (Woods, Miltenberger, & Lumley, 1996b). Baseline and treatment ratings are then compared to determine whether the behavior change is socially valid. The use of interventions that do not produce socially valid results is, therefore, questionable.

A Functional Approach to the Assessment of Habit Disorders. Traditionally, the assessment of habit disorders (perhaps driven by the diagnos-

tic model) has been topographical. However, researchers have started assessing the function of habit behaviors. Functional assessment may provide two key pieces of information for those working with habit disorders. First, the information could provide data needed to modify etiological theories of the various habit disorders. Second, and perhaps more relevant to the clinician, the information could be used to alter treatment plans in an effort to maximize their effectiveness.

Malatesta (1990) used an alternating treatments design to demonstrate that the occurrence of a tic was increased by the mere presence of another person (a child’s father). Despite this effect, the author did not offer a possible operant function for the tic. In another evaluation of antecedent conditions, Woods and Miltenberger (1996b) showed that hair and face manipulation occurred more frequently when participants were made anxious while object manipulation occurred more frequently when participants were in an non-stimulating environment.

The authors hypothesized that habits involving the hair and face functioned to decrease arousal while object manipulation may have functioned to increase arousal.

Although these two studies identified possible antecedents, a number of studies evaluated the effects of manipulating the consequences of habits. Carr, Taylor et al.

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(1996) conducted a functional analysis of vocal tics. Exposing the participant to five conditions (alone, free play with a peer, tic-contingent social disapproval, tic- contingent escape from math, and high sensory stimulation), the experimenters found that tics were most likely to occur in the disapproval and escape conditions, suggesting that tics were maintained by attention and escape.

Despite the increased occurrence of the tic in these conditions, it is unlikely that these were the only variables responsible for the behavior as the tic occurred frequently in all conditions. Similar procedures were conducted by Scotti et al. (1994) who found that the motor and vocal tics of an adult male were exacerbated by escape from demand situations.

In another study that manipulated the consequences of habits, Rapp et al. (in press) exposed a thumb-sucking child to 4 conditions (alone, social disapproval, free play, and demand). Results showed that the behaviors were most likely to occur when in the alone and free-play conditions, suggesting a self-stimulation function.

In addition, Miltenberger et al. (1998) exposed two participants who pulled their hair to alone, demand, and social disapproval conditions. Results showed that hair pulling and hair manipulation for one participant and hair pulling and thumb sucking for the other were most likely to occur in the alone condition (see Figure 1). These results suggest that both hair pulling and thumb sucking were maintained by some type of self-stimulation.

Although these studies have been an important start, two challenging questions remain. First, how can we conduct a functional analysis that manipulates the consequences purported to maintain habits when they might be automatic consequences of the behavior itself (i.e., tension reduction, relief from boredom, and self- stimulation)? Second, does the functional analysis provide useful information that cannot be obtained from a less time consuming, functional assessment interview?

Rapp, Miltenberger, Ellingson, Galensky, and Long (in press) addressed this first question in their functional analysis of hair pulling exhibited by a young woman with moderate mental retardation. The woman pulled her hair and then manipu- lated the pulled hair between her fingers.

After conducting a functional analysis similar to Miltenberger et al. (1998), the authors found that the hair pulling occurred predominantly in the alone condition and hypothesized a self-stimulatory function. To identify the specific source of sensory stimulation, the authors conducted further experimental manipulations and determined that the maintaining variable was the tactile stimulation produced by manipulating the hair once it was pulled.

Further research of this nature is important to help us better understand the variables maintaining hair pulling and other habit disorders. Within the constraints of the typical clinical setting, we recommend that the clinician conduct a functional assessment before a functional analysis (Iwata, Dorsey, Slifer, Bauman, & Richman, 1994/1982).

Using behavioral interviews and naturalistic observation, the clinician can usually establish hypotheses about the function of the habit behavior (Miltenberger, 1997). A functional analysis should be conducted if confusion remains about the function of the behavior after conducting the functional assessment.

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The course of any good assessment, whether it be for data collection, social validation, or to determine the function of the behavior, is to provide information that will evaluate or enhance the treatment procedure. A wide array of treatments has been used with habit disorders. In the next section, we briefly review the medical treatments (if any) used to treat each habit disorder, followed by the most common and effective behavioral treatments.

Figure 1. Percent duration of hair pulling, hair manipulation and thumb sucking across time for two participants who were repeatedly exposed to four different functional analysis

conditions (alone, social disapproval, demand/task, and control). From Miltenberger, Long et al. (in press). Copyright 1998 by the Association for Advancement of Behavior

Therapy. Reprinted by permission of the publisher.

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Treatment of Habit Disorders

Tic Disorders Medical treatments. The three most common medications used to treat tic

disorders are haloperidol, clonidine, and pimozide (Shimberg, 1995). In a review of pharmacological treatments for tic disorders, Peterson, Campise, and Azrin (1994) found that pimozide and haloperidol decreased tic frequencies by 50-60%. Clonidine did not appear to be effective. Despite their relative efficacy, drugs used to treat tics may have side effects such as dry mouth, constipation, sedation, and possible risk of developing permanent movement disorders such as tardive dyskinesia (Maxmen & Ward, 1995). Because of the limited efficacy and possibility of unwanted side effects, it would behoove researchers to seek alternatives to pharmacotherapy.

Behavioral treatments. A number of behavioral treatments have been applied to tic disorders. In this section, we review two common treatments; massed (negative) practice (MP) and habit reversal.

In MP, the participant intentionally engages in the target behavior rapidly and with great effort for a specified frequency or length of time (Peterson & Azrin, 1993). Despite its widespread occurrence in the literature, the efficacy of MP is question- able. Most studies evaluating MP have been case studies, thus limiting their interpretability (Peterson & Azrin, 1993). In studies using adequate methodology, 28.5% of the participants experienced tic decreases, 28.5% experienced no change, and 43% experienced increases in tic frequency. This suggests that MP may not be an effective treatment for tic disorders.

The second major treatment used in managing tic disorders is habit reversal (HR); a multi-component procedure originally developed to treat nervous habit and motor tics (Azrin & Nunn, 1973). In recent years, HR has received the majority of attention from researchers (Woods & Miltenberger, 1995).

The HR procedure consists of a number of components. To increase the awareness of the habit behavior, four techniques are used. With response description, the client gives a detailed description of the habit behavior (usually while in front of a mirror). The purpose is to describe the chain of behaviors that constitutes the habit. Response detection is implemented to teach the client to identify each occurrence of the behavior.

The clinician praises the client for correctly identifying an occurrence of the behavior, and provides corrective feedback if the client fails to identify an occurrence. This is continued until the client correctly identifies most of the habit behaviors.

Early warning is used to identify physical cues experienced by the client prior to the occurrence of the habit, such as a growing feeling of muscle tension in the area that is involved in the tic. The final awareness technique, situation awareness training, requires participants to identify the circumstances in which the habit behavior occurs most frequently.

After awareness is established, competing response (CR) training is implemented. Contingent on the occurrence of the target behavior, the client engages in a behavior (for approximately 1-3 minutes) that is incompatible with the target habit behavior. Behaviors chosen for CRs typically involve isometric tensing of muscles that oppose

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the habit behavior. CRs are socially inconspicuous and do not interfere with ongoing activities (Azrin & Nunn, 1973).

After the CR is established, three techniques are used to increase motivation. With habit inconvenience review, the client reviews all the difficulties (social, occupational, physical) that result from the habit behavior. With public display, the client demonstrates control of the habit behavior in the presence of others.

In the social support procedure, significant others in the client’s life remind the client to use the CR when they see him or her engage in the target habit but fail to engage in the CR, and praise the client for correct implementation of the CR. The final technique, symbolic rehearsal, is used to promote generalization by asking the clients to imagine themselves controlling the habit behavior (by engaging in the CR) in the habit-prone situations.

The entire HR package was initially implemented by Azrin and Nunn (1973) in one, 2-hour session, but has since been implemented in varying amounts of time (Woods & Miltenberger, 1996a). In their initial evaluation of this procedure, Azrin and Nunn (1973) demonstrated a 99% reduction in self-reported tic and habit frequency at a 7-month follow-up in 10 of 12 clients.

These procedures were also evaluated by Azrin, Nunn, and Frantz (1980c) who found similar results. Although impressive, the results of these studies should be interpreted with caution due to the self-report method of data collection and the lack of an adequate research design. Finney, Rapoff, Hall, and Christophersen (1983) conducted a more internally valid evaluation of the HR procedures. In this study, the authors added relaxation training to the standard HR package, and with direct observation, demonstrated significant, socially valid decreases in the tic behavior of two children.

Azrin and Peterson (1988) further evaluated HR procedures to treat TS. Results showed that, at 6-8 months post-treatment, tic frequency was reduced by 93-95%. In a follow-up study by Azrin and Peterson (1990), a group of 5 participants with TS who received the same HR package were compared to a group of five TS patients on a waiting list. Tic frequency decreased significantly for the treatment group while the control group did not change until treatment was implemented for them.

Although the HR procedures of Azrin and Nunn (1973) had proven to be effective, the implementation of such a large number of techniques was seen by some as time consuming and of questionable clinical utility due to the increased response effort on both the part of the client and clinician (Miltenberger, Fuqua, & McKinley, 1985; Woods & Miltenberger, 1995; Woods, Miltenberger, & Lumley, 1996b).

Because of these concerns, studies were conducted to determine the active compo- nents of HR. Miltenberger, Fuqua, and McKinley (1985) evaluated the standard HR package (Finney et al., 1983) and a package consisting of only awareness training and CR training. Results showed that both packages were effective and produced socially valid results. The authors concluded that awareness training and the CR were the most important HR components.

Peterson and Azrin (1992) evaluated a number of behavioral treatments for TS in an alternating treatments approach. In a comparison of the differential effective- ness of relaxation training, self-monitoring, and CR training, the authors found that

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CR training produced the greatest decrease in tic frequency, although the three treatments did not differ statistically.

In another attempt to simplify the procedures, Woods, Miltenberger, and Lumley (1996b) sequentially implemented the components of awareness training, self-monitoring, social support, and CR in children with tics in a multiple baseline design (see Figure 2). Results showed that awareness training eliminated tics in one child and reduced them in another.

Self-monitoring further reduced the tics in that child and eliminated them in another. The simplified package of awareness training, CR, and social support greatly reduced tics in one child and further decreased tics in the child for whom awareness training and self-monitoring had produced

Figure 2. Percentage of intervals with tics across time for four children who were exposed to a sequential implementation of habit reversal treatment components in a multiple baseline across participants and behaviors design.

The treatment components included baseline (BL), awareness training (AT), awareness training and self-monitoring (AT&SM), awareness training, self-monitoring, and social support (AT&SM&SS), and awareness training, social support, and competing response training

(AT&SS&CR). From Woods, Miltenberger, and Lumley (1996b), p. 489. Copyright 1996 by the Society for the Experimental Analysis of Behavior, Inc. Reprinted by

permission of the author.

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moderate tic decreases. The improvements in the tics were seen as socially valid and the treatment was favorably evaluated by the participants’ parents.

As is suggested by studies evaluating simplified versions of HR, the effects of awareness training or self-monitoring seem to play a large role in the effectiveness of HR. A number of studies have shown awareness training (Wright & Miltenberger, 1987) and self-monitoring (Billings, 1978; Hutzell, Platzek, & Logue, 1974; Ollendick, 1981; Thomas, Abrams, & Johnson, 1971) to be effective in reducing tic frequency.

Although it may appear that increasing the awareness of the behavior (as is done in awareness training or self-monitoring) is responsible for the behavior change, this is unlikely for two reasons. First, there is evidence that some tic decreases reportedly caused by awareness training were actually produced by participants developing and using a CR without explicit training (Woods, Miltenberger, & Lumley, 1996b).

Second, Sharenow, Fuqua, and Miltenberger (1989) showed that a CR involving muscles not involved in the tic (a dissimilar CR) was as effective as a physically incompatible CR in reducing motor tics. This suggests that self-monitoring (e.g., making a checkmark on a card) may function as a dissimilar CR. Combined, these findings cast doubt on the beneficial effects of increased awareness as a sole treatment for tics.

From the research on simplified HR treatment of tic disorders, it appears that awareness training and consistent application of a CR (Carr, Bailey, Carr, & Coggin, 1996) are the necessary components, although more research needs to be done to investigate the necessity of awareness training and social support procedures.

Habit reversal has been the primary behavioral treatment for tic disorders, however a number of other behavioral interventions have met with some success. In one study, biofeedback reduced tics by at least 40% (O’Connor, Gareau, & Borgeat, 1995). Tics have been eliminated using differential reinforcement of other behavior (DRO) procedures (Alexander et al., 1973; Wagaman, Miltenberger, & Williams, 1995), assertiveness training (Mansdorf, 1986), and various contingency manage- ment procedures (for a complete review, see Peterson & Azrin, 1993).

Trichotillomania Medical treatments. Attempts to reduce trichotillomania with medications

have varied widely with respect to medication type and effectiveness. Medications used to treat trichotillomania include fluoxetine, clomipramine, imipramine, halo- peridol, and lithium (Peterson et al., 1994). Despite a number of case reports, there are few randomized, double-blind studies conducted to evaluate medication treatments of trichotillomania (Peterson et al., 1994).

Swedo et al. (1989) used self- and physician-report data to show that clomipramine was more effective than de- sipramine, reducing hair pulling by 50% in two-thirds of the participants. Two studies (Christenson, Mackenzie, Mitchell, & Callies, 1991; Streichenwein, & Thornby, 1995) found that fluoxetine was no more effective than a placebo condition. Although the research is limited, it appears that medications have not been proven effective in treating trichotillomania.

Behavioral treatments. Behavioral treatments have produced better results than medical treatments. Habit reversal has been the most extensively evaluated

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(Friman et al., 1984). Studies show that HR is more effective than MP (Azrin, Nunn, & Frantz, 1980b) and is effective in 60% of the cases when presented in a group format (Mouton & Stanley, 1996). Rapp et al. (1998) found that simplified HR procedures involving awareness and CR training with parental social support were effective and produced socially valid results when evaluated in a multiple baseline across participants design for three children.

In addition to these well-controlled studies, a number of case studies have demonstrated the effectiveness of the original HR procedures (Fleming, 1984; Rosenbaum, & Ayllon, 1981; Tarnowski et al., 1987) as well as the simplified procedures (Rosenbaum, 1982).

Although HR is an effective treatment for hair pulling, some research has suggested limitations. Long, Miltenberger, and Rapp (in press) and Rapp, Miltenberger and Long (1998) found that simplified HR alone did not reduce hair pulling in two participants. For one 7-year-old girl, additional contingencies (differential reinforce- ment and response cost) had to be placed on the hair pulling to eliminate the behavior (Long, Miltenberger and Rapp, in press).

In the second participant (who was diagnosed with a developmental disability) the simplified HR was not effective until a device created by the authors was used to enhance awareness. The device (a modified hearing aid) was placed on the participant so that when her hand came within 6 inches of her head, a tone was produced, prompting her to engage in the CR. The use of this device following simplified HR procedures greatly decreased the hair pulling (Rapp, Miltenberger and Long, 1998).

In addition to HR, a number of other behavioral treatments have been utilized for hair pulling. In one case study, Anthony (1978) found that self-monitoring was effective in reducing trichotillomania. In another case study, Bayer (1972) did not show an effect of self-monitoring until an aversive condition (saving pulled hairs and bringing them to the therapist) was added. Ristvedt and Christenson (1996) applied capsaicin (a local pain enhancer) to the scalp of a 38-year-old female after implement- ing simplified HR with her.

The authors reported an immediate decrease in hair pulling behavior. Other studies have decreased trichotillomania by eliminating a covarying habit behavior such as thumb sucking (Altman et al., 1982; Friman & Hove, 1987; Watson & Allen, 1993), or using various reinforcement and punish- ment procedures (Peterson et al., 1994).

Thumb sucking Behavioral treatments. No medications have been used to treat chronic thumb

sucking. However, one of the most popular and effective treatments has been the use of a bitter substance applied to the thumb. When the substance is on the thumb, the act of placing the thumb in the mouth produces an unpleasant taste. The bitter substance alone or in conjunction with a reinforcement program usually results in a reduction, if not complete elimination, of thumb sucking (Altman et al., 1982; Friman, 1990; Friman, Barone, & Christophersen, 1986; Friman & Hove, 1987; Friman & Leibowitz, 1990).

The second most popular behavioral treatment for thumb sucking is habit reversal. Azrin, Nunn, and Frantz-Renshaw (1980) compared a group of children

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receiving HR procedures to a group of children using a bitter substance. Results based on parental reports showed that HR procedures were more effective than the bitter substance though the results of statistical tests were not presented to support these conclusions.

Rapp et al. (in press) found that a simplified package of awareness training, CR, and social support nearly eliminated thumb sucking in one child, while the package plus a “remote detection” procedure eliminated the behavior in a second child. In the remote detection procedure, the child was observed via video while alone in a room, and prompts to use the CR were delivered when thumb sucking was observed.

Christensen and Sanders (1987) compared HR, DRO, and wait-list control groups consisting of children who sucked their thumbs. Both procedures decreased thumb sucking to the same degree and the results were maintained over time.

Other successful contingency management procedures for reducing thumb sucking include a program using social praise to reinforce behaviors incompatible with thumb sucking (Skiba et al., 1971), DRO with edible reinforcers (Hughes et al., 1979), and a negative punishment procedure in which reading to a child was stopped contingent on thumb sucking (Knight & McKenzie, 1974).

Other treatments include using a splint on the thumb to treat nocturnal thumb sucking (Lewis, Shilton, & Fuqua, 1981; Watson & Allen, 1993) and preventing a covarying response (i.e., holding a doll; Friman, 1988). It appears that the two most common and effective treatments for thumb sucking are HR and aversive treatments although both may be supplemented by contingency management procedures.

Nail biting Medical treatments. Only one medical intervention has been attempted with

nail biting. Leonard et al. (1991) compared a group of nail biters who received clomiprimine to a group receiving desiprimine. Following a two-week placebo period where no change was evidenced, the drugs were administered and results showed clomiprimine was more effective than desiprimine. However, there was a 50% dropout rate and the clinical validity of the procedures is questionable.

Behavioral treatments. In contrast to the paucity of research on medical interventions, successful behavioral interventions for nail biting have been reported in the literature quite frequently. The three most common types of behavioral treatments are HR, aversive treatments (e.g., electric shock, bitter substance applied to the fingers, or MP), and self-monitoring.

Bucher (1968) eliminated nail biting in 65% of participants using a portable self-administered shock device. However, the data were self-reported for both nail- biting episodes and use of the shock device. Vargas and Adesso (1976) compared groups of participants randomly assigned to MP, bitter substance, and control groups.

Using nail length as the dependent variable, results showed that the three aversive conditions were more effective than no treatment, but the interventions did not differ from each other. Vargas and Adesso (1976) also had one-half of the participants self-monitor while the other half did not. Results showed that self- monitoring resulted in increased nail length. A number of other studies have

Assessment and Treatment of Habit Disorders 151

demonstrated the effectiveness of self-monitoring as a treatment for nail biting (Adesso, Vargas, & Siddall, 1979; McNamara, 1972).

Ladouceur (1979) compared the effects of four treatments in a group format. Fifty people received HR, HR plus self-monitoring, self-monitoring, self-monitoring plus daily charting of progress, or no treatment. Results showed that all of the treatment groups improved over the control group, but that the groups did not differ from each other. The author concluded that the CR was an unnecessary component. However, as discussed earlier, self-monitoring could have simply been functioning as a dissimilar CR, thus producing the same results in all groups.

Habit reversal procedures have been evaluated in a number of studies. DeLuca and Holborn (1984) found that the CR alone was more effective than a relaxation technique in reducing nail biting. Frankel and Merbaum (1982) found that a HR self- help manual (Azrin & Nunn, 1977) was more effective in reducing nail biting than a wait-list control condition. Glasgow, Swaney, and Schafer (1981) found the HR manual and a self-help manual describing a self-monitoring/contingency manage- ment program to be equally effective. Nunn and Azrin (1976) demonstrated that HR was more effective than a wait-list control, though the data were self-reported, and the results of statistical tests were not reported. De La Horne and Wilkinson (1980) found that HR produced more long-term gains than a standard information treatment.

In a study evaluating simplified HR procedures for individuals with develop- mental disabilities who bit their nails, Long, Miltenberger, Ellingson, and Ott (in press) found that the HR package failed to produce clinically acceptable results in any of the participants until additional procedures (i.e., remote prompting, differential reinforcement) were added to increase treatment compliance. Miltenberger and Fuqua (1985) also found that HR was effective in treating nail biting based on the participants’ self-monitoring. In addition, the authors evaluated the CR used contingently and noncontingently (scheduled daily practice) and concluded that a contingent CR was more effective than a noncontingent CR.

In a study comparing MP to HR, Azrin, Nunn, and Frantz (1980a) demon- strated that self-reports of nail biting were decreased 99% in the CR group compared to 60% in the MP group. Silber and Haynes (1992) compared three common techniques (bitter substances, self-monitoring, and HR) used to treat nail biting. Participants were randomly assigned to one of the three treatment groups. Using nail length as the dependent variable, results showed that while self-monitoring was ineffective, both the CR and the bitter substance produced significant improve- ments. The CR training proved to be more clinically valid. Allen (1996) replicated these three procedures, but demonstrated that the bitter substance was the only treatment to produce significant improvements.

Other treatments used for managing nail biting include the threat of response cost (Stephen & Koenig, 1970), contingency contracting (Ross, 1974), and covert sensitization (Daniels, 1974; Davidson, & Denney, 1976; Paquin, 1977). Although these treatments were demonstrated to be effective, there is little reason to believe they would be more effective than the HR or aversive procedures.

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Conclusions A number of different behaviors are included under the label of habit disorders.

Habit disorders are repetitive behaviors that have negative physical consequences (e.g., nail damage or hair loss) and/or negative social consequences for the individual (e.g., stigma or decreased social acceptance) and thus warrant treatment in many cases. Because the negative social consequences for the individual exhibiting a habit disorder have received little attention from researchers, further study of these potential negative effects is warranted (e.g., Woods et al., 1998).

In this chapter, we described the possible behavioral explanations for habit disorders, as well as assessment and treatment procedures commonly used with them. Although it is speculated that habit behaviors are maintained by automatically reinforcing consequences involving self-stimulation, tension reduction, or modula- tion of arousal (e.g., Woods & Miltenberger, 1996b), socially reinforcing conse- quences may also play a role in some cases. Future research is needed to understand the variables responsible for the etiology and maintenance of habit disorders.

A variety of techniques is available for the assessment of habit disorders. Direct observation is preferred when possible, although the private nature of some habits (e.g., trichotillomania) makes direct observation difficult. Videotape recording provides a way to obtain direct observation of habits that occur in private (Long, Miltenberger, & Rapp, in press; Miltenberger et al., 1998; Rapp et al., 1998). Physical trace methods such as recording bald areas of hair pullers and nail length of nail biters are valuable for recording the outcomes of some habit disorders. Finally, social validation of treatment procedures and outcome is important.

In this chapter, we described functional analysis and functional assessment as an emerging area of habit disorder research. Due to the time intensive nature of a functional analysis, we recommended that a functional assessment be conducted in lieu of a functional analysis prior to clinical treatment of habit disorders when possible. Future research should compare the utility of both approaches in the assessment variables maintaining habit disorders. From assessment, our attention turned to the treatments of habit disorders. In comparing medical and behavioral treatments for habit disorders, it appears that behavioral treatments have been better researched and have produced better results than medical treatments. A possible area of future research would be to directly compare the effectiveness of medical treatments to behavioral treatments for various habit disorders.

Of the behavioral treatments, it appears that HR, in either the original or the simplified form, is the most effective treatment across the spectrum of habit disorders. Although we only discussed the effectiveness of HR with four habit disorders in this chapter, the procedure has been shown to be effective with other behaviors such as stuttering (Miltenberger, Wagaman, & Arndorfer, 1996; Miltenberger & Woods, 1998; Wagaman et al., 1993; Wagaman, Miltenberger, & Woods, 1995), object chewing (Woods, Miltenberger, & Lumlay, 1996b), and other “nervous habits” (Woods & Miltenberger, 1995; 1996a). As specified throughout the chapter, studies comparing different behavioral techniques to habit reversal would

Assessment and Treatment of Habit Disorders 153

be useful. Specifically, we need to determine the differential effectiveness of aversive treatments and habit reversal in the treatment of thumb sucking and nail biting.

In summary, applied behavior analysis has provided an excellent solution to the sometimes-puzzling area of habit disorders. The assessment methodology, research design, and treatments developed in the field of applied behavior analysis have proven most successful in addressing habit disorders. Though a number of questions remain, continued diligence by researchers using the tools of applied behavior analysis will result in empirically sound answers.

Reading Objectives 1. Define habit disorders and identify four different types. 2. Describe behavioral theories for each of the four habit disorders discussed in the

chapter. Discuss the adequacy of support for these theories. 3. Know for which habit disorders event recording and duration recording are most

appropriate. Also, know the advantage of real-time recording offers. 4. Describe the use of physical-trace data collection procedures with trichotilloma-

nia. 5. For each habit disorder described in the chapter, discuss the problems that develop

as a result of the behavior (physical and social). 6. Describe the habit reversal procedure for any habit disorder (original as well as

simplified version). 7. For each habit disorder discussed in the chapter, name the most effective

procedure (behavioral or biological) along with other procedures investigated in the literature.

8. Know what evidence exists suggesting that self-monitoring may not involve an active awareness component.
9. Know the methods that have been used to measure treatment acceptability and social acceptability of habit disorder treatments.
10. Given a habit disorder, describe how to conduct a functional assessment/analysis of the behavior by incorporating methods discussed in the chapter.

References Adesso, V. J. (1990). Habit Disorders. In A. Bellack, M. Hersen, & A. Kazdin (Eds),

International handbook of behavior modification and therapy (2nd ed.). New York: Plenum Press.

Adesso, V. J., Vargas, J. M., & Siddall, J. W. (1979). The role of awareness in reducing nail-biting behavior. Behavior Therapy, 10, 148-154.

Alexander, A. B., Chai, H., Creer, T. L., Miklich, D. R., Renne, C. M., & Cardoso, R. (1973). The elimination of chronic cough by response suppression shaping. Journal of Behavior Therapy and Experimental Psychiatry, 4, 75-80.

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Allen, K. W. (1996). Chronic nailbiting: A comparison of competing response and mild aversion treatments. Behaviour Research and Therapy, 34, 269-272.

Altman, K., Grahs, C., & Friman, P. (1982). Treatment of unobserved trichotilloma- nia 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 (4th ed.). Washington, D.C.: Author.

Anthony, W. Z. (1978). Brief intervention in a case of childhood trichotillomania by self-monitoring. Journal of Behavior Therapy and Experimental Psychiatry, 9, 173-175.

Azrin, N. H., & Nunn, R. G. (1973). Habit reversal: A method of eliminating nervous habits and tics. Behaviour Research and Therapy, 11, 619-628.

Assessment and Treatment of Habit Disorders Essay

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