Douglas W. Woods, Raymond G. Miltenberger - Tic Disorders, Trichotillomania, and Other Repetitive Behavior Disorders - Behavioral Approaches To Analysis and Treatment (2006)

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
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Printed in the United States of America.
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Contents
Contributors ix
Preface xi
Acknowledgements xiii
Chapter 1. Introduction to Tic Disorders, Trichotillomania, and

Other Repetitive Behavior Disorders: Behavioral
Approaches to Analysis and Treatment 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 97
Douglas W, Woods
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
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 Wisconsin-
Milwaukee, 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

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 Wisconsin-

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

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 Wisconsin-

Michael P. Twohig, Department of Psychology, University of Wisconsin-

David ?• Wacker, Department of Psychology, University of Iowa School of

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 Wisconsin-

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
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
with an emphasis on habit reversal, and finally, Woods and Twohig (Chapter
12) provide a session-by-session habit reversal treatment manual for oral-
digital 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
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 permanent-
product 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.
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).
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 semi-
structured behavioral interviews.
Examples of RB rating scales with psychometric properties reported in the
research literature include: the National Institute of Mental Health-
Trichotillomania 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 Obsessive-
Compulsive 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.
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. Permanent-
product 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].
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.
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).
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-by-
second) measurement of behavior. A number of studies have utilized real-
time 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 4-
year-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
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 self-
monitoring 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
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-to-
head behaviors. Thus, data can be collected in a variety of settings without
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
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
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.
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 4-
year-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 self-
stimulation. 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
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 age-
related 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 age-
equivalent peers). Likewise, for behaviors that result in visible products
(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 post-
treatment 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
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
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.
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Chapter 3
Physical and Social Impairment in Persons With
Repetitive Behavior Disorders
Douglas W. Woods
Patrick C. Friman
University of Nevada-Reno
Ellen J. Teng
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
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 35
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%
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 37
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
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 high-
frequency 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
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
40 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.

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 48-
77% 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
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.

In a study examining 67 adults diagnosed with trichotillomania, over 80%
of patients reported feeling depressed or unattractive as a result of their hair-
pulling, 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 self-
evaluation 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
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.

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
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.

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, &
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.
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
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
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.
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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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. 1072-
1075). 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
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 twelve-
month demarcation, this distinction has been made because tics are not
uncommon in childhood, and many children's tics spontaneously remit after
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 55
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 obsessive-
compulsive 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 health-
care 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).
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).
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
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 attention-
deficit hyperactivity disorder (ADHD) and OCD. In individuals wîth 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
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 co-
morbidity 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
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
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
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 freely-
moving 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.
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
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 obsessive-
compulsive 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 dextro-
amphetamine (DEX) on tic severity over a period of 1 - 3 years in boys with
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
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
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.
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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 non-
behavioral 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.
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).
Behavioral Interventions for Tic Disorders 75
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, open-
label 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,
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.
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 5-
minute 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
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).
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 self-
monitoring, 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,"
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
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 64-
87% 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
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).
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 (social-
positive). 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
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
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
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
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.
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
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, perceptual-
motor 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
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.
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.
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Chapter 6
Habit Reversal Treatment Manual for Tic Disorders
Douglas W. Woods
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).
98 Tic Disorders^ Trichotillomania, and Repetitive Behavior Disorders
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.
Habit Reversal Treatment Manual for Tic Disorders 99
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) RANKING
Figure 6.1. Identifying, Defining, and Ranking Tics

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
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
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
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, &
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.
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 in-
session 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
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 rank-
ordered 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.
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.
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'."
Habit Reversal Treatment Manualfor Tic Disorders 109
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.
"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
Habit Reversal Treatment Manualfor Tic Disorders 111
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 Competing Response
Arm Movements Push hand down on thigh or

abdomen and push elbow in
towards hip
Eye Blinking Systematic, voluntary, soft
blinking consciously main-tained
at a rate of one blink per 3-5
seconds
Hand/wrist Movements Push hands on arms of chairs,
desk, leg, etc.
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
Leg Movements Place feet flat on floor and push
downward. If standing, lock
knees
Mouth/facial Movements Clench jaw while pressing lips
together
Nose movements Pull upper lips down slightly and
press lips together
Copropraxia Make fists and push elbows into
side
Table 6.4. List of Alternative Competing Responses for Vocal Tics
Competing Response Description
Lip pursing Lips pressed firmly together

Tensing Neck Muscles Lower chin slightly and tense neck muscles
Tensing Arms 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
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
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.
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.
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?"
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.
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)?"
"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.
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
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 self-
monitoring assignment and continue to work on awareness in-session weekly
until the client has achieved criterion level awareness. The self-monitoring
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
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.
4. REFERENCES
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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
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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
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evaluation in adolescents: The effects of tic disorders and trichotillomania. Child and
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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.
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syndrome. Neurologic Clinics of North America, 15, 429-450.
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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.
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).
Malatesta, V. J. (1990). Behavioral case formulation: An experimental assessment study of
transient tic disorder. Journal of Psychopathology and Behavioral Assessment, 12, 219-
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Miltenberger, R. G. (2001). Behavior modification: Principles and procedures (2'"^ ed).
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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).
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fraternal twin brothers. Child and Family Behavior Therapy, 21, 1-17.
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Clinical Handbook of Psychological Disorders, 2'"^ ed_ (pps. 189-239). New York: The
Guilford Press.
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manipulation. Journal of Psychopathology and Behavioral Assessment, 21, 1-18.
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avoidance response in a child who stutters: A case study. Journal of Fluency Disorders,
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Exposure and response prevention for an adolescent with Tourette's syndrome and OCD.
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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
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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

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

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'."
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."
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."
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 acknowledgement of correct CR

implementation
"(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

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
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, self-
directed 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
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).
Characteristics of Trichotillomania 13 5
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
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
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.
13 8 Tic Disorders, Trichotillomania, and Repetitive Behavior Disorders
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).
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.
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).
Characteristics of Trichotillomania 141
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
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)
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
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).
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
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 non-
hair 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
consequences. Researchers who have evaluated the biological basis of self-

injurious 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.
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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
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
Behavioral Interventions for Trichotillomania 153
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. Cognitive-
behavior 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 cognitive-
behavioral 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 multi-
component 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)
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
Behavioral Interventions for Trichotillomania 15 5
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
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 15 7
treatment if a reinforcement-based procedure proves ineffective in

alleviating hair pulling (e.g., Crawford, 1988).
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
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
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 cost-
effectiveness 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
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 self-
monitoring 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 follow-
up/booster sessions. As with most behavioral therapies, generalization and
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.
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 cognitive-
behavior 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
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 cognitive-
behavioral 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.
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
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
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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Chapter 9
Habit Reversal Treatment Manual for
Trichotillomania
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
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)
Habit Reversal Treatment Manual for Trichotillomania 173
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.
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.
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
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
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
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.
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 self-
monitoring 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.
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
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
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
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.
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;
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
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?"
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).
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).

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
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
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.
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.
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, 141-
145.
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.
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
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
twin brothers. Child and Family Behavior Therapy, 21, 1-17.
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.
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

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

SESSION 3-X
Collect and graph data
Review treatment
Practice treatment components
Problem solving
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
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
Characteristics of Oral-Digital Habits 199
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
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
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
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
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.
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;
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
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..
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).
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
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
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).
2.5.1 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
of social dimensions (Friman, McPherson, Warzak, & Evans, 1993).

Indirect support is also found in research showing that child behavior
problems can cause social distance betwêen 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).
2.6 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
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.
3.3 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
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 non-
existent 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
(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.
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Chapter 11
Behavioral Interventions for Oral-Digital Habits
Vincent J. Adesso
Melissa M. Norberg
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
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 225
2.1.1 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, self-
punishment, 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, self-
monitoring, 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
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 self-
monitored their nail biting and half did not. At the end of treatment and at 3-
month 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 self-
monitor. 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.
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
habit reversal and found substantial nail growth at posttreatment and 6-

month 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 5-
month 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
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 habit-
reversal-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, self-
monitoring 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,
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
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 10-
week 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
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:
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 bitter-
tasting 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
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.
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
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
Behavioral Interventions for Oral-Digital Habits 23 5
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 near-
zero 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
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
Behavioral Interventions for Oral-Digital Habits 23 7
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 self-
monitoring, 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.
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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:
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competing response practice in the treatment of nervous habits. Journal of Behavior
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habit" in a profoundly retarded youth by increasing toy play. Journal of Behavior Therapy
Nunn, R. G., & Azrin, N. H. (1976). Eliminating nail-biting by the habit reversal procedure.
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analysis and simplified habit reversal treatment of thumb sucking in fraternal twin
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Chapter 12
Habit Reversal Treatment Manual for Oral-Digital
Habits
Douglas W. Woods
Michael P. Twohig
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 oral-

digital 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
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
Habit Reversal Treatment Manual for Oral-Digital Habits 243
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
244 Tic Disorders, Trichotillomania, and Repetitive Behavior Disorder
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 parent-
monitoring (if client is a child) may be utilized. When using self-
monitoring, 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.
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., 1:00pm-
3:00pm). 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?"
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.
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?"
"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
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."
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.
"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.
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?"
"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."
"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
think you will be comfortable with this competing response? If you are
uncomfortable, we can work on developing something different."
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.
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
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
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
"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
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
"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.
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?"
"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 self-
monitoring, 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).
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.

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
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
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
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.
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.
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 assessments of other conditions and social

functioning
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?"
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."
264 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
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
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

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.
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
Oral-Motor RBDs 271
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).
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
Oral-Motor RBDs 273
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 stuttering-
contingent 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
permitted to speak (e.g., Andrews, Howie, Dosza, & Guitar, 1982; Martin,
Kuhl, & Haroldson, 1972) James (1981), for example, used a 2 second time-
out, 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).
Oral-Motor RBDs 275
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 well-
known 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
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
Oral-Motor RBDs 111
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).

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
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.
Oral-Motor RBDs 279
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, five-
second 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
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.
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
Oral-Motor RBDs 281
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
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.
Oral-Motor RBDs 283
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).

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
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.
Oral-Motor RBDs 285
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
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
Oral-Motor RBDs 287
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 15-
month 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
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.
Oral-Motor RBDs 289
5. CONCLUSIONS
Although stuttering, bruxism, and rumination all involve repetitive oral-
motor 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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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
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 food-
seeking 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
RBDs in Persons with Developmental Disabilities 299
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
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
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
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
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
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
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 response-
reinforcer 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
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 07
3.3.2 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 self-
injurious behavior that was maintained by automatic reinforcement for 2 men
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 response-
reinforcer 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 ASSESSMENT AND TREATMENT

EXAMPLES
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
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
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.
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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Index
ABC recording, 22, 176, 178, 187, Child Behavior Checklist, 25, 27,
193, 194 104, 124
acral licking, 133 chorea, 54, 63
ADHD, 26, 29, 35, 36,44 58, 59,61, clomipramine, 30, 152, 153, 162,
63, 64, 67, 68, 70, 87-92, 102, 122, 168,169,224,239
222, 245 clonidine, 62, 75, 88, 89, 95
anxiety, 2, 7, 26, 30, 36,41,44, 59, clozapine, 75, 94
62,63,69,70,85,87,91,102, competing response, 79, 80, 82, 83,
125, 134, 138, 142-146, 157, 164, 86,105,110-122, 129-132,158-
173,174,188,191,200,215,218, 160,162,167,169,171,178, 181-
220, 222,243-245, 248, 270, 291, 190, 194, 217, 221, 226-229, 234,
299 237-241, 243, 246, 250-259, 261,
assertiveness training, 48, 76, 85, 86 264-267, 275, 279, 280, 287, 288
atypical root resorption, 42-43 competing response training, 82, 83,
automated recording, 10 159, 181, 183,228
avian feather picking, 133 contingency management, 103, 120,
awareness enhancement device, 30, 121,178,274,280,284,288
141, 168, 189, 192,236,240, 258, and oral-digital habits, 225, 226,
259,261 231-233
awareness training, 82, 83, 105, 106, and rumination, 285, 286
108,109,110,113,116,117, 127, and tics, 75-78
158, 159, 171, 178, 179, 180, 181, and trichotillomania, 154-158
184,226, 229, 234,241,244,246, coprolalia, 46
247,250,258, 263,275,280 copropraxia, 46
covert sensitization, 225, 238, 239
behavioral assessment, 1,9-11,15,
19,26,27,175,178,297 depression, 26, 30, 36, 44, 58, 69, 70,
behavioral interviews, 10-13, 21 102,124,138, 143,174,191,200,
behavioral seal, 19, 28 245
biofeedback, 76, 85, 86, 95, 272,278, descriptive assessment, 20-23
291-293 desipramine, 30, 88, 95, 152, 169,
bruxism, 1,6,26,223,269 224, 239
defined, 276 dextroamphetamine, 88, 89
and parasomnia, 276 diagnostic assessment, 9
prevalence, 276 differential reinforcement, 76-78, 83,
treatment, 277-281 87,91,95,155,156,161,163,
316 Index
225, 229, 232, 238, 242, 285, 293, habit reversal, 5-7, 27, 30, 71, 73, 76,
307, 309 86,91-95,97, 100, 102, 103, 105,
dyskinesias, 54,295 106,110, 111, 115,118-123, 125,
dystonias, 54 126,133,153-155,163,165-170,
221,224, 226-229, 231, 233-235,
early warning, 80 237-240,288, 289,294, 297
echoic speech, 297 and bruxism, 278,280,281
endogenous opiates, 297 and oral-digital habits, 226-229,
establishing operation, 143, 305-306 233-235
exposure and response prevention, and stuttering, 274, 275
66, 122 and tic disorder, 79-85
and trichotillomania, 158-161
finger sucking, 1, 16-19,23,24,26, treatment manual for oral-digital
28,42-44, 191, 197,205, 206, 207, habits, 241-267
214,216,218,219,221,232,235, treatment manual for tics, 97-132
236,238,241,251,261,308 treatment manual for
and clinical associations, 210-212 trichotillomania, 171-195
cross-cultural, 202,203,208-210 haloperidol, 60, 74, 89
definition, 198 homeostasis, 297
gender differences, 202 Hopkins Motor and Vocal Tic Scale,
genetics, 204 12,13
phenomenology, 199-203 hyperekplexias, 54
prevalence, 201,202 hypnosis, 74, 85, 157, 158, 169
and transitional objects, 203 hypoalgesia, 146
fluoxetine, 27, 93, 152, 167, 169
function based treatments, 83 inconvenience review, 80, 178, 280
functional assessment, 9, 10, 12, 20, informant Assessment, 12, 21
21,22,23,26,27,28,29,83,162,
166,172,187,242,243,258,286 "just right" perceptions, 58
generalization, 78, 80, 154, 158-160, massed practice, 76,93,278, 279,

209, 231, 237, 238, 272, 275, 285, 281,289,290
288 medical interventions, 33
genetics, 4, 60, 67, 133 methylphenidate,
Gilles de la Tourette, 30,43, 67-71, Minnesota Trichotillomania
74, 92-95 Assessment Inventory, 12
Guanfacine, 88, 92 Motivation Assessment Scale, 13, 21
mouthing, 282, 290, 297
Index 317
nail biting, 1,14, 25,42-44, 167, 197, premonitory urge, 57, 62, 66
199,217, 218, 220-230, 236-240, prolonged exposure, 76, 85, 94
269 Psychiatric Institute Trichotillomania
clinical associations, 215,216 Scale, 13
gender differences, 214 psychoanalysis, 60, 74
phenomenology, 214 psychological impact
prevalence, 213,214 of oral-digital habits, 43, 44
nature vs. nurture, 4 of tic disorders, 35-39
negative practice, 27, 75, 76, 80, 81, of trichotillomania, 41, 42
92,94,159,166,191,217,226, psychotherapy, 4, 74
227, 292, 295 public display, 80
neuroleptics, 74, 75, 88, 90, 91 Punishment, 166, 278,279, 285
NIMH Trichotillomania Severity of bruxism, 279
Scale, 13, 153 of oral-digital habits, 225, 226,
232, 233
obsessive compulsive disorder, 55, of rumination, 285
69,87,92,133 of tics, 77
Obsessive Compulsive Foundation, of trichotillomania, 154-157
46,52
OCD, 34, 36, 57-61, 63,67, 87, 88, reactivity, 14, 16, 17,27,64
90,91,93,102,122,125,138, real-time recording, 17, 28, 29
142,146,152,174,191,200 regulated breathing, 274, 290, 291
Olanzapine, 75, 93, 95 reinforcement, 23, 65-67, 77, 78, 84,
86,95, 100,101,120, 123,133,
PANDAS, 63, 64, 69 154-157,164,173,187,189,208,
paroxysmal ataxia, 54 209, 213, 217, 224, 225, 229, 230-
paroxysmal tremors, 54 232, 235, 237, 242, 243, 244, 259,
peer education, 65, 123 271,272,283-287,296,302
periungual warts, 43 social-positive, 83
permanent products, 14 social negative, 83
pharmacological interventions, 83 automatic-positive 83, 300, 303,
physical impact 305
of bruxism, 277 automatic-negative, 83, 300, 301,
of oral-digital habits, 42,43 303
of rumination, 282 relaxation training
of tic disorders, 34, 35 and oral-digital habits, 229, 230
of trichotillomania, 40,41 and tic disorders, 78, 79
pica, 297 and trichotillomania, 157, 158
pimozide, 30, 74, 89, 152, 169
318 Index
75, 78, 79, 82, 167, 188, 226, 227, SSRI,88, 152
230, 238, 292 stereotypic movement disorder, 1, 2,
remote detection, 120 50,54, 134,245,261
repetitive behavior disorders, 1-6, 33, stereotypy, 54, 297
42,44-48,61,269,288,297 stuttering, 1, 6, 7, 167, 222, 269, 276,
response description, 80, 107, 180, 289
246, 247, 280 defined, 270
response detection, 80, 180, 246, 248, gender differences, 270
249, 275, 280 onset, 270
risperidone, 75, 92, 94, 152, 153, 169 prevalence, 270
rumination, 1, 6, 269, 289,291-296 recovery, 270
associated features, 282 treatment, 271-275
defined, 281 Sydenham's chorea, 63
etiology, 283 symbolic rehearsal, 80,280
prevalence, 282
treatment, 283-288 tardive dyskinesia, 45, 74, 75
tension reduction, 134, 135, 223, 237
self-injurious behavior, 6, 22, 23, 28, tic disorders, 1-6, 9, 12, 13, 26,27,
29, 133,166,167,297 33,34,41,42,44,48,57,73-76,
self-monitoring, 10, 18, 19, 27, 76, 87,89-92,94,97,98, 101-103,
77,79,82,83,121,152,154, 160, 118,122-124, 133,198-200
162, 172, 174, 175,177, 179, 185, and brain functioning, 61, 63
190, 225-228, 230, 237, 239, 244, cause, 60-67
258, 259, 275 chronic, 56
self-stimulation, 20, 23,297 clinical importance, 2, 3
sensory extinction, 154, 155, 165, comorbid conditions, 53-55, 58-60
188,297 defined, 53
Shapiro Tourette Syndrome Severity and environmental variables, 62-
Scale, 12, 13 67, 83-85
situation awareness training, 80 andgenetics, 60, 61
skin picking, 30,42-45,269 incidence, 55
social perceptions, 24, 25, 38, 39,41, onset, 56
42,44,215 prevalence, 55
social support, 11, 80, 82, 83, 105, research attention, 2,3
115,117,119,120,159,171, 176, simple vs. complex, 53
183-187,189,190,193,194,206, and stimulants, 64, 65
229,234,241,245, 246,254-256, tic-related conversations, 65, 66,
258, 259,265,266,275,280 84,85
Social validity, 31,81 transient, 53
Index 319
voluntary vs. involuntary, 54, 55 clinical importance, 2, 3

time-sampling recording, 15, 17 comorbid diagnoses, 138
Tourette syndrome, 27, 29, 34,46, defined, 133
54, 60, 63, 68-71, 92-95, 124, 125 differential diagnosis, 134-135
Tourette Syndrome Association, 46, and digit sucking, 142, 143
51 and environmental variables, 143,
Tourette Syndrome Global Scale, 12, 145
13 gender differences, 136, 137
Tourette Syndrome Symptom List, 13 genetics, 145-147
treatment compliance, 112, 120,251, onset, 137, 138
254,259,261 prevalence, 135, 136
Treatment Evaluation Inventory, 12, pulling patterns, 139-141
29 research attention, 2, 3
tremors, 54 Trichotillomania Impairment Scale,
trichobezoars, 45 13,153
trichophagia, 17,455, 156 Trichotillomania Learning Center,
trichotillomania, 1-6,9, 12, 13,27, 46,52
30-33, 124, 166-171, 187-189,
191-193,198,199,212,217,219, warning signs, 107-110, 113-115,
269 118,127-130,132,179,246-250,
in children, 136 252-255,257-259,263-265, 267

Douglas W. Woods, Raymond G. Miltenberger - Tic Disorders, Trichotillomania, and Other Repetitive Behavior Disorders - Behavioral Approaches To Analysis and Treatment (2006)

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Douglas W. Woods, Raymond G. Miltenberger - Tic Disorders, Trichotillomania, and Other Repetitive Behavior Disorders - Behavioral Approaches To Analysis and Treatment (2006)

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TIC DISORDERS,

TRICHOTILLOMANIA, AND OTHER

ISBN-10: 0-387-32566-2 softcover

ISBN: 0-7923-7319-7 hardcover

Printed on acid-free paper.

First softcover printing, 2006

Printed in the United States of America.

Chapter 1. Introduction to Tic Disorders, Trichotillomania, and

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

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

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

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

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

Chapter 14. Repetitive Beliavior Disorders in Persons

Joel E. Ringdahl David P. Wacker, Wendy K. Berg, and Jay W.

Keith D. Allen, Munroe-Meyer Institute, 600 S. 42"^ Street, Omaha, NE

Michelle R. Byrd, Department of Psychology, University of Nevada-Reno,

Wendy K. Berg, Department of Psychology, University of Iowa School of

James E. Carr, Department of Psychology, Western Michigan University,

Amy J. Elliott, Munroe-Meyer Institute, 600 S. 42""* Street, Omaha, NE

Patrick C. Friman, Department of Psychology, University of Nevada-Reno,

R. Wayne Fuqua, Department of Psychology, Western Michigan

Jay W. Harding, Department of Psychology, University of Iowa School of

Lorrie A. Howell, Department of Counselor Education and Educational

Raymond G. Miltenberger, Department of Psychology, North Dakota State

Melissa M. Norberg, Department of Psychology, University of Wisconsin-

Erin M. Oksol, Department of Psychology, University of Nevada-Reno,

Jodi Polaha, Munroe-Meyer Institute, 600 S. 42"^ Street, Omaha, NE 68198

John T. Rapp, Department of Psychology, University of Florida,

Joel E. Ringdahl, Department of Psychology, University of Iowa School of

Stephanie L. Smith, Department of Counselor Education and Educational

Ellen J. Teng, Department of Psychology, University of Wisconsin-

Michael P. Twohig, Department of Psychology, University of Wisconsin-

David ?• Wacker, Department of Psychology, University of Iowa School of

T. Steuart Watson, Department of Counselor Education and Educational

Douglas W. Woods, Department of Psychology, University of Wisconsin-

The goal of this book is to provide a comprehensive description of tic

We would like to thank the contributors to this book. Without their

2. IMPORTANCE OF THE BOOK

Unfortunately, tic disorders, trichotillomania, and other repetitive

Tic Disorders Trichotillomania SMD Schizophrenia Bipolar

Medline 2,118 370 87 37,934 12,472

PsychLit 177 309 14 32,741 2,489

3. PURPOSE OF THE BOOK

It may seem strange to some that we have decided to cover three