1. Treatment of Habit and Tic Disorders Rachel Valleley, Ph.D. Munroe-Meyer Institute

2. Overview  Habits vs. Tics  DSM Criteria  Assessment  Treatment options: Medication Habit Reversal  Case Example

3. Habits “frequent, repetitive behaviors that cannot be explained by physiological causes and appear to serve no identifiable physiological function”  Examples: nail biting, nail picking, trichotillomania, thumb sucking, hair twirling

4. Tics  “sudden, brief, involuntary, rapid, nonrhythmic, repetitive movements or utterances that are purposeless and stereotypic”  Examples: eye blinking, facial grimacing, shoulder shrugging, throat clearing, coughing, growling, sniffing

5. DSM Diagnoses  Habits: Stereotypic Movement Disorder Trichotillomania  Tics: Transient tic disorder Chronic motor or vocal tic disorder Tourette’s disorder

6. Habits  Stereotypic Movement Disorder  Trichotillomania

7. Stereotypic Movement Disorder  Repetitive, seemingly driven, & nonfunctional motor behavior  Interferes with normal activities or results in self-inflicted bodily injury  Not accounted for by other disorders (e.g., OCD, tics, trichotillomania)  Not due to substance or general medical condition  Lasts longer than 4 weeks

8. Trichotillomania  Recurrent pulling out of one’s hair, resulting in noticeable hair loss  Sense of tension immediately before pulling out the hair or resisting the behavior  Pleasure, gratification, or relief when pulling out hair  Not better accounted for by other disorder or medical condition  Causes clinically significant distress or impairment

9. Demographics of Trichotillomania  Prevalence: 0.6% Non-clinical hair pulling (10-13%)  Age of Onset: 13.1 yrs  More frequent in females  Onset if often precipitated by stressful life event (e.g., divorce, loss, academic pressures)

10. Scalp (80.6%)

11. Brow (43.5%) Lash (47.3%)

12. Hair Pulling Episodes  Touching, manipulating region before pull  Can range from brief sessions with only a few hairs lost to sessions lasting several hours with hundreds of hairs pulled  Occurs in solitude but children do in front of family  Increased pulling during periods of stress, relaxation, or distraction  May be unaware they are pulling their hair and thus do not experience tension or relief

13. More often use dominant hand for pulling

14. Consequences of Hair Pulling  Post pull: play with hair  Result in total absence of hair, bald spots, or thinning of hair  Most serious consequence occurs when patients eat the hair and form hairballs in the stomach. Results in all kinds of complications like anemia, loss of appetite, nausea, vomiting

15. Comorbid Conditions  Most Common Anxiety Mood disorders  OCD: Some speculation that it is related to OCD

16. Tic Disorders  Transient tic disorder  Chronic motor or vocal tic disorder  Tourette’s disorder

17. Transient tic disorder  Single or multiple motor &/or vocal tics  Occur many times a day, nearly every day for at least 4 weeks but not longer than 12 consecutive months  Causes marked distress or impairment  Onset prior to 18  Not due to substance/medical condition  Do not meet criteria for other tic disorder

18. Chronic motor or vocal tic disorder  Single or multiple motor OR vocal tics but not both  Occur many times a day, nearly every day or intermittently for over 1 year, no more than 3 consecutive months tic free  Causes marked distress or impairment  Onset prior to 18  Not due to substance or medical condition  Do not meet criteria for Tourette’s

19. Tourette’s disorder  Both multiple motor & one or more vocal tics have been present but do not have to be at same time  Occur many times a day (usually in bouts), nearly every day or intermittently for over 1 year, no more than 3 consecutive months tic free  Causes marked distress or impairment  Onset prior to 18  Not due to substance or medical condition

20. Impairment from Habit or Tic  Common impairments/distress Physical Social

21. What causes or maintains habits/tics?  Physical Trauma  Automatic reinforcement Positive Negative  Social reinforcement  Very limited data on functional analysis of habits and tics

22. Mechanisms involved in Trichotillomania  Negative reinforcement Tension Arousal reduction Negative affective states  Automatic reinforcement Sedentary (watching TV, getting ready for bed) Contemplative (homework, reading)

23. Assessment Considerations  Rule out medical problem  Comorbid condition or habit?  Distress or impairment?  Observation  Self-monitoring  Permanent products  High probability situations  Ratings scales available

24. Empirically Supported Treatments Medication  Haldol  Pimozide  Clonidine  Anafranil & Prozac for Trichotillomania Behavioral Procedures  Habit Reversal

25. Medication  Haldol: Tourette’s Relieves symptoms up to 70-80% of patients. Short term side effects Long Term side effects  Pimozide  Clonidine

26. Behavioral Procedures  Massed negative practice  Punishment  Reinforcement  Relaxation Training  Function-Based Treatments  Habit Reversal

27. Massed negative practice  Requires the individual to perform each tic accurately & effortfully for a specified amount of time

28. Punishment  Time out  Trichotillomania Topical creams Sensory Extinction: e.g., gloves Increasing effort: e.g., wrist weights

29. Reinforcement  Differential reinforcement of other behaviors or differential reinforcement of alternative behaviors

30. Relaxation Training  Reducing tension before the occurrence of tics  No data to support as sole treatment for tics

31. Function-Based Treatments  Determining the function of the tic to tailor treatment. Is the tic occurring to escape something aversive or due to social attention provided, or is it occurring due to the sensory stimulation provided?

32. “Complete Habit Reversal”  Originally developed by Arin & Nunn (1973)  Consisted of 10-13 steps components  Simplified Habit Reversal: only 4 components necessary  90-100% reduction of tics that maintained over 12 months  Has been found effective for many types of habits and tics

33. Simplified Habit Reversal  Awareness Training  Competing Response Training  Relaxation Training (optional)  Social Support

34. Awareness Training Increase awareness of when habit is occurring by:  Practice habit/tic in front of mirror  Focus on how muscles/body feels while engaging in habit  Have child identify times when habit occurs  Prompt child when habit occurred  Keep data on habit occurrence

35. Competing Response Training Teach an incompatible behavior for when habit occurs  Select competing response  Practice competing response in front of mirror  Use competing response when urge for habit occurs  Use competing response in situations when habit is likely to occur  After habit occurs, practice competing response for one minute

36. Relaxation Training (optional) Reduce stress or anxiety if related to habit  Practice daily Options  Progressive muscle relaxation  Visual imagery  Breathing exercises

37. Social support Parents provide feedback and encourage child to use habit reversal procedure  Provide feedback to child to become aware of habit occurrence  Encourage competing response  Add reinforcement procedure if necessary

38. Reinforcement  Parents could reinforce: Awareness training practices Use of the competing response Habit free periods of time

39. Case Example  11 year-old, 5 th grade Caucasian male  Tourette’s Disorder  Special Education for LD in Written Expression  Motor Habit: Tensing face, pulling arms up, anticipation antecedent  Vocal Habit: ‘ah’ added between words, occurred both in conversation & oral reading

40. Assessment of Motor Tic  Interview of parent and child Description of tic, duration, frequency Situations more likely to do it in Awareness? Parent response  Parent, Teacher Observation  Videotape at home

41. Treatment of Motor Tic  Habit Reversal Awareness  Watching videotape of self in session Incompatible behavior Social Support  Reinforcement for practices

42. Assessment of Vocal Habit  Assessment involved: Determining instructional reading level (5 th grade, 91-106 WPM & 95% Comprehension) Determining base rate of vocal habit while reading (28-29 VHM) Sampling conversation (13 VHM) Conducting a Brief Reading Experimental Analysis

43. Brief Experimental Reading Analysis  Baseline conditions alternated with treatment conditions Repeated Reading Listening Passage Previewing Word Error Correction Reinforcement Phrase Error Correction

44. Brief Experimental Reading Analysis

45. Intervention  Phrase error correction chosen as intervention  Mother trained  Home reading practices (10-20 minutes of preferred reading & one minute generalization probe) conducted over 2 months  Reading sessions recorded for reliability & treatment integrity  Tokens earned for participation

46. Results: Pre Integrity Feedback

47. Integrity Data: Pre-Feedback

48. Results

49. Results: Integrity data

50. Results  Decreased rate of oral habit from 28 per minute to 0-1 per minute while reading  Did not impact reading fluency (109 WPM at two month follow up)  Generalized to conversation speech (13 to 1 per minute)

51. Discussion  Vocal habit conceptualized as dysfluency  PEC intervention resembles awareness training and practice of competing response  Important to collect treatment integrity data  Parents can be trained to conduct these types of interventions & collect data for reliability & treatment integrity

52. References  Christopherson, E. R., & Mortweet, S. L. (2001). Treatments that work with children: Empirically supported strategies for managing childhood problems. Washington, DC: American Psychological Association  Glaros, A. G., & Epkins, C. C. (1995). Habit Disorders: Bruxism, Trichotillomania, and Tics. In M.C Roberts (Ed.), Handbook of Pediatric Psychology (2 nd ed., pp.558-574). New York: The Guilford Press.  Miltenberger, R. G., Fuqua, R. W., & Woods, D. W. (1998). Applying behavior analysis to clinical problems: Review and analysis of habit reversal. JABA, 31, 447-469.

53. References  Valleley, R. J., Shriver, M. D., & Rozema, S. (2005). Using brief experimental assessment of reading interventions for identification and treatment of a vocal habit. Journal of Applied Behavior Analysis, 38, 129-133  Woods D. W., Miltenberger, R. G. (2001). Tic Disorders, Trichotillomania, and othr repetitive behavior disorders. Norwell, MA: Kluwer Academic Publishers