Examining and Treating Habit Disorders Essay

Examining and Treating Habit Disorders Essay

Instructions/Descriptions

Examining and Treating Habit Disorders Essay

[Order Now]

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 approximately 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.

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.

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,

Assessment and Treatment of Habit Disorders 139

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). According 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 & 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.

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), stuttering (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 diagnostic 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 a 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. (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 manipulated 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.

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.

Assessment and Treatment of Habit Disorders 145

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.

[Order Now]

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.

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.

154 Chapter 6

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.

Examining and Treating Habit Disorders Essay

PLACE THE ORDER WITH US TODAY AND GET A PERFECT SCORE!!!