Treatment of Habit and Tic
Disorders
Rachel Valleley, Ph.D.
Munroe-Meyer Institute
Overview
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Habits vs. Tics
DSM Criteria
Assessment
Treatment options:
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Medication
Habit Reversal
Case Example
Habits
“frequent, repetitive behaviors
that cannot be explained by
physiological causes and appear to
serve no identifiable physiological
function”
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Examples: nail biting, nail picking,
trichotillomania, thumb sucking,
hair twirling
Tics
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“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
DSM Diagnoses
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Habits:
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Stereotypic Movement Disorder
Trichotillomania
Tics:
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Transient tic disorder
Chronic motor or vocal tic disorder
Tourette’s disorder
Habits
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Stereotypic Movement Disorder
Trichotillomania
Stereotypic Movement Disorder
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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
Trichotillomania
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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
Demographics of Trichotillomania
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Prevalence: 0.6%
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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)
Scalp (80.6%)
Brow
(43.5%)
Lash
(47.3%)
Hair Pulling Episodes
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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
More often use dominant hand for
pulling
Consequences of Hair Pulling
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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
Comorbid Conditions
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Most Common
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Anxiety
Mood disorders
OCD: Some speculation that it is
related to OCD
Tic Disorders
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Transient tic disorder
Chronic motor or vocal tic disorder
Tourette’s disorder
Transient tic disorder
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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
Chronic motor or vocal tic disorder
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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
Tourette’s disorder
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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
Impairment from Habit or Tic
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Common impairments/distress
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Physical
Social
What causes or maintains habits/tics?
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Physical Trauma
Automatic reinforcement
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Positive
Negative
Social reinforcement
Very limited data on functional
analysis of habits and tics
Mechanisms involved in
Trichotillomania
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Negative reinforcement
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Tension
Arousal reduction
Negative affective states
Automatic reinforcement
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Sedentary (watching TV, getting ready
for bed)
Contemplative (homework, reading)
Assessment Considerations
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Rule out medical problem
Comorbid condition or habit?
Distress or impairment?
Observation
Self-monitoring
Permanent products
High probability situations
Ratings scales available
Empirically Supported Treatments
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Medication
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Haldol
Pimozide
Clonidine
Anafranil & Prozac for Trichotillomania
Behavioral Procedures
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Habit Reversal
Medication
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Haldol:
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Tourette’s
Relieves symptoms up to 70-80% of
patients.
Short term side effects
Long Term side effects
Pimozide
Clonidine
Behavioral Procedures
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Massed negative practice
Punishment
Reinforcement
Relaxation Training
Function-Based Treatments
Habit Reversal
Massed negative practice
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Requires the individual to perform
each tic accurately & effortfully for a
specified amount of time
Punishment
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Time out
Trichotillomania
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Topical creams
Sensory Extinction: e.g., gloves
Increasing effort: e.g., wrist weights
Reinforcement
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Differential reinforcement of other
behaviors or differential
reinforcement of alternative
behaviors
Relaxation Training
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Reducing tension before the
occurrence of tics
No data to support as sole
treatment for tics
Function-Based Treatments
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Determining the function of the tic
to tailor treatment.
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Is the tic occurring to escape
something aversive or
due to social attention provided, or
is it occurring due to the sensory
stimulation provided?
“Complete Habit Reversal”
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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
Simplified Habit Reversal
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Awareness Training
Competing Response Training
Relaxation Training (optional)
Social Support
Awareness Training
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Increase awareness of when habit is
occurring by:
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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
Competing Response Training
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Teach an incompatible behavior for
when habit occurs
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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
Relaxation Training
(optional)
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Reduce stress or anxiety if related to
habit
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Practice daily
Options
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Progressive muscle relaxation
Visual imagery
Breathing exercises
Social support
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Parents provide feedback and
encourage child to use habit reversal
procedure
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Provide feedback to child to become
aware of habit occurrence
Encourage competing response
Add reinforcement procedure if
necessary
Reinforcement
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Parents could reinforce:
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Awareness training practices
Use of the competing response
Habit free periods of time
Case Example
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11 year-old, 5th 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
Assessment of Motor Tic
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Interview of parent and child
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Description of tic, duration, frequency
Situations more likely to do it in
Awareness?
Parent response
Parent, Teacher Observation
Videotape at home
Treatment of Motor Tic
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Habit Reversal
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Awareness
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Watching videotape of self in session
Incompatible behavior
Social Support
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Reinforcement for practices
Assessment of Vocal Habit
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Assessment involved:
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Determining instructional reading level
(5th 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
Brief Experimental Reading Analysis
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Baseline conditions alternated with
treatment conditions
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Repeated Reading
Listening Passage Previewing
Word Error Correction
Reinforcement
Phrase Error Correction
PEC
Baseline
PEC
Reinforcement
WEC
Baseline
WEC
LPP
RR
Baseline
RR
Baseline
Habist Per Minute
Brief Experimental Reading Analysis
40
35
30
25
20
15
10
5
0
Intervention
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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
Results: Pre Integrity Feedback
30
25
Habits Per Minute
20
15
10
5
In Session Probe
0
1
2
3
4
5
6
Home Reading Sessions
7
8
9
10
Integrity Data: Pre-Feedback
100%
90%
80%
Percentage of Habits Caught
70%
60%
50%
40%
30%
20%
10%
0%
June 19th
June 27th
June 28th
Results
30
Home Reading Generalization Probes: Pre
Integrity Check
Home Reading Generalization Probes After In Session
Integrity Check
In Session
Follow up
25
Habits Per Minute
20
15
10
5
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
Home Reading Sessions
15
16
17
18
19
20
21
22
23
24
25
Results: Integrity data
100%
90%
Pre feedback
Post feedback
Percentage of correct steps completed
80%
70%
60%
50%
40%
30%
significantly few er habits in session
(5)
20%
10%
0%
June 19th
June 27th
June 28th
July 23rd
July 24th
Integrity session checks
July 26th
July 29th
July 30th
Results
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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)
Discussion
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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 &
References
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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 (2nd 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.
References
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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
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Treatment of Habit or Tic Disorders