“Help! My Brain’s Stuck!”
Repetitive Behaviours (RBs) in
Children and Adolescents
Drs. Kim Edwards, Holly McGinn, &
Sandra Mendlowitz
Ontario Psychological Association Conference
Friday February 20th, 2015
Conflicts of Interest
 None to disclose
Test YOUR Repetitive Behaviour IQ
1. Which is not an RB? (multiple choice: pick 1)
A. Trichotillomania
B. Onychiphagia
C. Autism
D. Dermatillomania
2. RB's are maintained by (multiple choice: pick 1)
A. A cycle of reinforcement
B. Elevated dopamine levels
C. School failure
D. Allergies
Test YOUR Repetitive Behaviour IQ
3. What are the two most common comorbid
disorders with Tourette Syndrome?
4. Hair pulling usually develops as a result of a
traumatic experience. (true/false)
5. In early childhood (e.g., 2-6 yrs old), many
children demonstrate some obsessive-compulsive
behaviors that are part of normal development.
(true/false)
Outline & Learning Objectives
 What are RBs?
 Why study RBs?
 What causes & maintains RBs? (Behavioural Model)
 Tourette Syndrome (TS)
 Trichotillomania (TTM)
 Obsessive Compulsive Disorder (OCD)
 Similarities & Differences among RBs
 Developmental Issues
 Leaky Brake Analogy
What are RB’s?
 Labels



Body Focussed RBs
Obsessive-Compulsive (OC) Spectrum Conditions
Impulse Control Disorders
 Behaviours






Dermatillomania/Excoriation (Skin Picking)
Onychiphagia (Nail Biting)
Trichotillomania (Hair Pulling)
Tics
Compulsions
Stereotypies (Autism)
 “Nervous Habits” or Actual Problems?
Why Study
RBs?
$
RBs: Myths and Facts
 Not
as severe as other psychiatric
conditions
 Uncommon
 Socially acceptable
 Purposeful
 Only impact the individual with the RB
Etiology
 Genetics
 Brain Circuits
 Cortico-striatal-thalamo-cortical (CSTC) circuits
 Neurotransmitters
 Dopamine, Serotonin, Noreepinephrine
 Environment
Behavioural Model of RBs
Internal Environment
Tics
TTM
OCD
Behavioural Model of RBs
External Environment
Negative Reinforcement
o absolved of expectations or demands
Positive Reinforcement
o attention, comfort, support, reward
Homework
Tics &
Tourette Syndrome (TS)
Meet Brad
Tics: Assessment & Diagnostic Issues
Sudden, rapid, recurrent, non-rhythmic motor
movements or vocalizations
Motor
Blinking
Simple
Complex Facial grimace + Head twist
Vocal
Throat clearing
 Tic Disorders (DSM 5):
 Tourette Syndrome
 Persistent (Chronic) Motor or Vocal Tic Disorder
 Provisional Tic Disorder
Echolalia
Tics: Assessment & Diagnostic Issues
 Premonitory Urge
 Relatively common (20%)
 More common in boys (4:1)
 Comorbid Conditions (The “+” in TS+)
 ADHD = 50%, OCD = 30 - 40 %
(Himle & Woods, 2005; Scahill et al., 2005; Scahill et al., 2009; Woods & Himle, 2004; Woods 2008)
Course
W
Peak Severity
X and
AgesA
10-12
W
E
AN
Decline in
severity for
most
Onset
Ages 4-7
(e.g., Leckman et al., 1998; Woods & Specht, 2013)
Comprehensive Behavioural Intervention for Tics
Internal Environment: Habit Reversal
Training
 Awareness Training
 Competing Response
External Environment:
 Positive and Negative Reinforcement
 Psychoeducation
(Woods et al., 2008)
CBIT Efficacy
European clinical
guidelines for TS & other
tic disorders, 2011
Canadian guidelines for
the evidence-based
treatment of tic disorders,
2012
Practice Parameters for the
Assessment & Treatment of
Children & Adolescents
with Tic Disorders, 2013
Tics: Tips & Tricks
 Education is often the only treatment needed
 Don’t forget about the comorbid conditions
 Shift in the way we think about tics
 Ignore vs. Increase awareness?
Brad Cohen
(Bennett et al., 2013)
Trichotillomania (TTM)
TTM (Hair-Pulling Disorder)
DIAGNOSTIC CRITERIA
DSM
4-TR
DSM
5
Recurrent pulling out of one’s hair resulting in hair loss
√
√
Increasing sense of tension immediately before pulling out the hair /
when attempting to resist behavior
√
Pleasure, gratification, or relief when pulling out the hair
√
DSM 4TR – Impulse Control Disorders Not Elsewhere Classif.
DSM-5: Obsessive Compulsive Disorders & Related Disorders
Repeated attempts to decrease or stop hair pulling.
√
The disturbance (hair pulling- DSM 5) is not better accounted for by
another mental disorder and is not due to a general medical
condition (e.g., a dermatological condition)
√
√
The disturbance (hair pulling- DSM 5) causes clinically significant
distress or impairment in social, occupational, or other important
areas of functioning
√
√
The hair pulling is not better explained by the symptoms of another
mental disorder (e.g., attempts to improve a perceived defect or flaw
in appears in body dysmorphic disorder)
√
Developmental Perspectives
Pulling/Picking Sites
Site
% Adults
% Children
Scalp
Eyebrows
79
65
85
52
Eyelashes
Legs
Arms
Pubic
59
59
30
17
38
27
18
9
other
More than one site
25
-
58
The Trichotillomania Impact Project: Exploring Phenomenology, Functional Impairment, & Treatment Utilization J Clin Psychiatry 67:12, December 2006
Developmental Perspectives
Pulling/Picking Characteristics
Pulling/Picking
Characteristic
Adults
Children
% of time
Unpleasant urges prior
71-89%
29% never/almost never
experienced pre-tension
To achieve a certain
bodily sensation
30-70%
13% never/almost never
“pleasure or relief”
Preceded by bodily
sensation
Preceded by anxiety
71-89%
-
0-10%
-
Urge increases when
resisting
71-89%
-
Post pulling anxiety
90-100%
-
Awareness of pulling
71-89%
4% never/almost never
The Trichotillomania Impact Project: Exploring Phenomenology, Functional Impairment, & Treatment Utilization J Clin Psychiatry 67:12, December 2006
TTM -Rituals
 Tactile stimulation of lips or face.
 A need to pull in a particular manner.
 Ritualistically placing, saving, or discarding hairs.
 Twirling, rolling, or examining the hair.
 Hairs that don’t feel right (i.e. coarse).
 Hairs that don’t look right (i.e. color).
 Compelled to achieve an absolutely even hairline.
 Need to extract an intact hair bulb.
 Need to bite or mince the hair or bulb
 Swallowing hair (trichophagy)
http://www.ohsu.edu/
TREATMENT
 Cognitive Behavioral Therapy
 Identify
distorted thinking and challenge
thoughts
 Relaxation training
 Behavioral – Habit Reversal
Training
Treatment
 Habit Reversal Training
Competing response
TREATMENT STEPS
 Monitoring of Symptoms (pulling/picking)
 CBT Intervention:
 Cognitive restructuring, coping thoughts
 Relaxation exercises, stress management
 Tactile Interventions:
 Finger tip bandages, gloves, bracelets, glasses, hats, etc.
 Silly putty, thinking putty, worry beads, soft brush
 Sensory Interventions:
 Numbing cream, brushing hair
 Gummy bears, sunflower seeds, dental floss, Khoosh balls, frayed
blankets, smurfs
 Environmental Interventions:
 Removing tweezers, covering mirrors
 Habit Reversal Training:
 Awareness training, stimulus control, competing response
CASE: “EMILY”
Initial Assessment:
 10 year old; intact family
 6 month history of eyelash pulling; no eyelashes at
assessment
 Several year history of nail biting
 Stressors:


Increased parental conflict
Bullying incident at school; largely resolved.
 Good student
 No comorbid anxiety or mood issue
CASE: “EMILY”
 Family History:
 Father suffers from OCD
 Recommendations:
 “focus on catching herself when urge to pull”
 “talking to parents”
 “relaxation tapes”
 “marital therapy”
 Result: Limited Effectiveness
CASE: “EMILY”
 NOW 13 years old … REASSESSMENT
 Lash pulling waxed and waned x 3 years
 Currently no lashes
 Parents used rewards with variable effectiveness
 Emily expressed high motivation to change
 Some anxiety in social situation (secondary to trich)
 PLAN:
 CBT + Monitoring + Habit Reversal Training
CASE: “EMILY”
CASE: “EMILY”
 16 sessions CBT + Habit Reversal Training
 Session 5: eyelash regrowth
 Session 7: “more confident”
 Session10: healthy lashes
 Session 13: no pulling
 Follow-up: 2 months later pulling apparent
 Follow-up: 4 months later no pulling/picking
 Seen in periodic follow-up: 2 years later no
pulling/picking
TTM – Keys to Successful Outcomes
 Thorough and knowledgeable assessment
 Emphasize treatment is a process
 Motivational for change
 Use of first line treatments:
 Cognitive
Behavioral (CBT) and
Habit Reversal Training
Obsessive-Compulsive
Disorder (OCD)
Meet Claire
OCD: Assessment & Diagnostic Issues
Obsessions and/or compulsions that take up
more than an hour a day and cause significant
distress or impairment
 Obsessions
 Recurrent and persistent thoughts, urges, or
images that are intrusive and unwanted
 Compulsions
 Repetitive behaviors or mental acts that one
feels driven to perform in response to an
obsession or according to rules
OCD: Assessment & Diagnostic Issues
 Common themes:




Contamination and cleaning
Checking or symmetry
Ordering or counting
Fear of harm to self or others
 Lifetime prevalence = approx. 2%, chronic, fluctuates
 Mean age of onset is bimodal  peaks at 11 and 23 years
 Early-onset OCD



1st Peak
Age 11
More common in boys than girls
More likely comorbid with tics
Generally more severe
2nd Peak
Age 23
Treatment Guidelines for OCD
(CBT and SSRIs) Efficacy
CBT alone or
CBT with SSRI
Practice
Parameters for
the Assessment
& Treatment of
Children &
Adolescents with
OCD, 2012
Cognitive Behavioural Therapy (CBT)
 Controlled studies support the efficacy of Cognitive
Behavioural Therapy (CBT) that emphasizes
Exposure and Response Prevention (ERP)
 Parental involvement is crucial for success
Parents do not
accept symptoms
Child not responsible
for controlling
symptoms
Child responsible
for controlling
symptoms
Parents
accept/tolerate
symptoms
CBT for OCD: Critical Components
Treatment Component
Operational Definition
Psychoeducation
Both the child and the family need to have an
accurate understanding of OCD
Symptom Monitoring
Identify/track sx frequency and duration; Set targets
to work towards
Relaxation Training
Deep Breathing, Muscle Tension Relaxation,
Imagery
Cognitive Strategies
Generate and reinforce accurate thoughts to
challenge obsessions and compulsions
Exposure & Response
Prevention (ERP)
Confronting an OCD-eliciting situation (action,
object, place, etc.) while preventing the associated
compulsions and/or avoidance
Homework
Change cannot occur exclusively through CBT
sessions; strategies must be practiced at home
Childhood OCD: Tips & Tricks
 Childhood and adult OCD are more similar than
not. However, some differences exist :

Obsessions develop later that compulsions

Poor insight is more common in children

Children tend to under-estimate the impact of their OCD

Children are more likely to present with comorbid OCD and
tics
Comparing & Contrasting
RBs
Similarities vs. Differences
 8 statements on the next 2 slides
Decide whether statement is a similarity
(applicable across the RBs discussed – OCD, TTM, TS)
or
whether it is a difference
(applicable to 0,1 or 2 but NOT all RBs discussed)
Similarities vs. Differences
(1) Behaviour done in response to a sensation
(2) Comorbidities are common & frequent
(3) Competing responses are part of treatment
(4) Onset usually before age 10
Similarities vs. Differences
(5) Symptoms wax and wane
(6) Personal distress required for treatment
(7) More common in males
(8) Medications could be useful
How did you do?
Similarities vs. Differences
Differences
Similarities
 (2) Comorbidities =
common + frequent
 (5) Symptoms wax &
wane
 (8) Medications could
be useful
 (1) Behaviour done in




response to a sensation
(3) Competing responses
are part of treatment
(4) Onset usually before
age 10
(6) Personal distress
required for treatment
(7) More common in males
Comprehensive Comparison
Developmental Issues
 “I’m not sure if I’m ready to change”
Unconcerned
Lack
by RB
of insight into RB
 Parent involvement
An Analogy for Understanding RBs
Brake Shop Model
Welcome to the Leaky Brake Club
 Leaky brakes over movements and/or sounds (TICS)
 Leaky brakes over thoughts (OCD)
 Leaky brakes over urges (TTM)
 Leaky brakes over attention +/or impulsivity (ADHD)
 Leaky brakes over behaviour (ODD, CD, rage)
 Leaky brakes over senses (Sensory integration disorder)
Welcome to the Leaky Brake Club!!
YOU = Driver
Welcome to the Leaky Brake Club!!
Welcome to the Leaky Brake Club!!
Welcome to the Leaky Brake Club!!
Welcome to the Leaky Brake Club!!
UH –OH!!!!
Welcome to the Leaky Brake Club!!
UH –OH!!!!
You Say….
BUT I DIDN’T DO IT!
 I TRIED TO STOP
 THE BRAKES DIDN’T WORK…
 I’m not a reckless individual.
 I shouldn’t lose my drivers licence.
Now imagine you had to drive
around in a car that had leaky
brakes ALL the time.
Wouldn’t YOU be frustrated?
Take Home Messages
 Leaky Brakes = Help child understand RB
 Society: “Just Stop” vs. Patient: “I would if I could”
 Awareness of behaviour & reinforcement patterns
 RBs = a spectrum
 Function of behaviour important differential
 More research needed!
Patient & Family Resources
Clinician Manuals/Resources
Woods & Miltenberger (2001). Tic disorders, trichotillomania, and other RB
disorders: Behavioural Approaches to Analysis and Treatment. USA:
Kluewer Academic Publishers
OCD
 OCD in Children and Adolescents: A Cognitive-Behavioral Treatment
Manual by John March and Karen Mulle
Tics
 Woods et al., (2008). Managing TS: A behavioural intervention for children
& Adults. Therapist Guide. USA: Oxford University Press.
TTM
 Golomb & Vavrichek ( 2000) The hair pulling habit and you: How to solve
the TTM puzzle. Maryland: Writers’ Cooperative of Greater Washington.
Thank You
Questions, Comments, Thoughts
Contact Information:
kim.edwards@sickkids.ca
holly.mcginn@sickkids.ca
sandra.mendlowitz@sickkids.ca