Taking Charge of Your Health

[MUSIC PLAYING] DR. WAYNE FUQUA: My name is Wayne Fuqua. I’m a professor of psychology at Western Michigan University. And I’d like to welcome you to another installment of the Michigan Autism Video Training series. And this is a series of videotapes
designed to illustrate the application of behavior analysis and psychological interventions
and assessment techniques to some of the problems experienced by children, adults,
and adolescents on the autism spectrum. And today we’re very fortunate to have with us Dr. Doug Woods, who is a professor of psychology at Texas A&M University. And Doug is going to be talking with us today about the assessment and treatment of habit disorders and tic disorders in children,
Including those on the autism spectrum. So Doug, welcome very much.
We’re very glad to have you here with us today. DR. DOUG WOODS: Thanks for having
me, Wayne. I appreciate the invitation. WAYNE: Absolutely. Can you start off
by telling us a little bit about what habit disorders entail and the range of activities? Because some people think of
habit disorders as– well, I’ve got a bad habit of staying up too late or eating too much.
But you’re thinking of something more specific. DOUG: Right. Habit disorders is a fairly broad term,
and you actually don’t find it in the psychiatric nomenclature. It’s an old term actually, but it’s still fairly
useful in terms of how we conceptualize things. So really when we talk about habit disorders,
we’re talking about things like tic disorders, which we’ll talk about
probably in a little bit more detail later. We’re talking about things
that are typically considered what we would call body-focused repetitive behaviors. Things like chronic hair pulling, which is
known as trichotillomania, or chronic skin picking, which is very closely
associated with trichotillomania, or things like nail biting or biting on
the insides of your cheeks, those kinds of things. WAYNE: OK. And this is distinctly different
than things like self-stimulatory behavior for a child with developmental disabilities or self-injury.
Is that correct, Doug? DOUG: Correct. Self-injury is
a much more severe form of behavior. Obviously by it’s very name of self-injury it’s
guaranteed to cause some damage physically to the body. Habit disorders can result in that– that can be one
negative effect, but it’s not kind of the defining feature. And stereotypy is just usually a little bit different,
because the form of the behavior in stereotypy really doesn’t change. It’s fixed. And that’s what makes stereotypy
a little bit different than a traditional habit disorder. And keep in mind that habit disorders in general
are fairly normal in typically developing kids. It’s not an uncommon behavior,
it’s just when it gets to be too frequent or too intense that it becomes problematic. WAYNE: It sounds like
a good distinction actually, Doug. Now, over the last decade or two
or however long, Doug, you’ve done extensive work in the area of habit disorders. Would you tell us something about how you
got involved and interested in the area? It’s kind of an interesting niche
that you’ve worked in over the last few years. DOUG: Yeah. It definitely hasn’t been
a common area in clinical psychology. I’m a trained clinical psychologist,
so it hasn’t been common in our area. Although people see it a lot, they just haven’t really
paid much attention to it in the realm of clinical psychology or behavior analysis for that matter. I got involved with this quite by accident. I was working as a master’s
student in North Dakota, where my advisor had started to do some
work on this or had done some work in the ’80s on this and continued doing it
when I was in North Dakota getting my master’s degree. And I started doing work on the disorder, and I found that
they were very treatable, and it was actually very interesting. And I realized that there was an area
there that nobody was doing much in, so it was an opportunity to make a difference in that field. WAYNE: Well, you certainly over the years made
a big difference for a lot of people in this particular field. You’ve talked about this broad range of behaviors,
maybe this is a good time to kind of begin to focus more specifically on some of the specific behaviors in this area. Is there a particular place you would like
to start with describing what the behavior is and something about what we know
about its etiology and development? DOUG: Sure. Why don’t we talk about tic disorders first.
We’ll cover that part of the habit disorder spectrum. So tic disorders are repetitive, recurrent,
non-rhythmic movement through vocalization, so very quick, rapid sounds or movements people make. Common ones are like eye blinking,
or nose twitching, or mouth stretching. Those are commonly what we call motor tics. And then there are vocal tics, which are–
or sometimes they’re called phonic tics– which are sounds people make. The popular one that gets all the media
attention is a swearing behavior called coprolalia. So when people think of something like a tic disorder
or Tourette’s syndrome, they think of the swearing thing. That’s actually a very rare symptom.
It happens in maybe 10% of the cases. And so these tics usually start around the age
of four or five in most cases when the tics develop. And then there’s for many kids a period of worsening
up until they’re about 11 to 13, 12 to 14, somewhere in there is the worst period of severity. And for many kinds the tics will just kind of fade away
if left untreated, but for about 2/3 of them the tics remain at some level. So that’s really what tics are.
Now, there are lots of different types of tic disorders. The one that gets the most attention
in the media is something called Tourette’s syndrome. And Tourette’s syndrome is where they have at least
two motor tics and one vocal tic that have been present for a year. WAYNE: So those tend to be pretty severe.
Don’t they, Doug? DOUG: They can be. It’s a range.
It’s probably the most severe of the tic disorder conditions. But even within Tourette’s, you can have very mild cases
of Tourette’s to the very, very extreme cases of Tourette’s, which in that domain you start
seeing self-injury from the tics themselves. People with very violent neck jerking tics
can become quadriplegic, those kinds of things. So it can be very intense, and you can have what
looks like self-injury in some cases because of the tic behavior. WAYNE: Wow. You described a range of behaviors there. What do we know about their kind of etiology
and development, and how does all this stuff emerge? Is it something that you see in a two or three-year old?
Or do you typically see it in an older child? What do we know about the things to watch for here? DOUG: We know that tics in general are normal. If you were to go into any random elementary school
and take a look at kids and observe them, you’d see about 25% of the kids engaging in tics. Now, most of those will never develop a tic disorder.
It’s just a normal part of motor development in many ways. And as people gain more inhibitory control over
their motor actions, then those tics start to reduce. But what we know in terms of the causes of tics–
we know that there are abnormalities in the parts of the brain that are responsible for the inhibition of movement. So the pathways that are responsible for controlling
that are actually smaller and less active in the level of the brain called the basal ganglia. And we also know that when people try to actively
stop their tics, when they use behavioral change strategies, that it activates a different part
of the brain that actually seems to be intact. So we know that it’s
a double-edged sword with kids with tics. The part of the brain that’s not
working well is the part that can give rise to the tics happening,
but they’re actually fortunate because the part of the brain that
they can inhibit the tics with often is quite intact. WAYNE: OK. So it sounds like that’s a pretty
good combination in terms of a course of treatment. Because it suggests there’s
neurological substrate there that would be responsive to some
sort of behavioral intervention. DOUG: What’s interesting about tics,
though, is the area of the brain that is not working, that gives rise to the tics,
is also the same area of the brain that’s very sensitive to
contextual or environmental influences. Which is why you get situations
where tics often become shaped very quickly by their environment, and they’re
very sensitive to environmental changes. That part of the brain that is
sensitive to environmental changes, like reinforcement or stimulus
control techniques, actually works perfectly well, maybe a little overactive in kids
with Tourette’s, which makes their symptoms get, like I said, shaped very heavily by the environment. We can use that to our advantage, too, in that
we can alter the environment so that tics can be made less frequent. And that’s what we do in behavior therapy in part. WAYNE: OK. Going back for just another
second to the neurology– do we know anything about the underlying pathology? Or is this just something
we don’t understand completely? We simply take it and go, OK, that’s part
of the underlying pathology, and let’s go from there. DOUG: We have some good ideas
of what’s happening. We don’t know for sure. But we know that there is an area of
the brain called the basal ganglia. It’s under the cortex.
It’s involved in the selection and inhibition of movement. So movement signals get sent down
from the cortex into the basal ganglia. The basal ganglia’s job is
to stop unwanted movements and allow desired movements to go through, in other words,
movements that are reinforced, allowed to go through. The problem is that area of the brain
we know is a little smaller in kids with Tourette’s. It’s about 10% volumetric differences on the MRI scans. And we know that there are some
neurochemicals in that area that are a little over active. And so what we think is happening is the inhibition
of those unwanted bits of movement isn’t happening, and so these little bits of movement
accidently slip through the filters that are built in. But once they slip through,
then they’re affected by the environment. And if the interaction is wrong, if people react to the tics,
or some kind of reinforcer is delivered after the tics occur, it can make those unwanted movements more likely
to happen over and over through the reinforcement cycle. WAYNE: It sounds like an interesting combination
of neurological genesis and shaping via environmental context. DOUG: Very much. It’s a very unique disorder in that
way that you get to see the symptoms so clearly. And it really does kind of sit at the center
of emotion and movement and operant respondent learning. The disorder is right there in that part of the biology. WAYNE: Is this something we see with
children in adolescence on the autism spectrum and those with developmental disabilities also? DOUG: Yes, absolutely.
Probably a little bit higher prevalence rate. So if you look at the prevalence rate
of Tourette’s syndrome in typically developing children, you see a prevalence rate of about 0.6%.
So it’s much more common than we used to think, where we used to think it was like
4 or 5 out of 10,000 that would have it. Now we’re thinking accurately
about 6 in 1,000 have this disorder. When you look at autism prevalence,
the prevalence of tic disorders in autism is much higher, up to I think around 5%. WAYNE: OK. So it is relatively common,
and it can be also somewhat, I suppose, stigmatizing and is worthy of consideration obviously. DOUG: Absolutely. There are studies
that have looked at the effects of tics. Now, obviously some of the other
problems that a child with autism has is probably to going to affect their social functioning,
their life satisfaction a little bit more than tics will. But there has been studies that show
evidence that there’s an independent negative effect of tics on life functioning
and satisfaction and success later on. So it’s not like– a lot of times people
look at a child who has autism, and they see a whole host of problems,
and the tics are the least of them. But the truth is there is some evidence
that tics alone can contribute additionally to the dissatisfaction or poor life
satisfaction these folks may end up having. WAYNE: Interesting. The other thing I was going
to ask you about is when do these tics tend to emerge, and is there a potential for
children just to outgrow them essentially? DOUG: Sure. There is some
evidence that children will outgrow them. They start, like I said,
between the ages of four and six. And as kids grow into adults, we do
believe that many cases could go away. The tics could just kind of go away,
or they’ll become less frequent. There aren’t great data on that.
It’s more of a clinical observation, a clinical phenomenon. Some studies that have tried to look
at that longitudinally have actually found that not nearly as many as we used
to think went away actually go away. What happens is people become
less aware that the tics are happening to them. So they still may be having them,
they just don’t recognize it anymore. Now, those same data
aren’t available in kids with autism. We really don’t know if the developmental
trajectory in terms of tics fading out or becoming less severe actually occurs in kids with autism. WAYNE: Interesting. So it still sounds like
there’s enough concern there that it’s worthy of monitoring, and in some cases intervening,
especially if they’re disruptive. Now, talk to me a little bit, Doug,
if you would, about the negative effects. What is the rationale
if we’re being concerned here? Do we have physiological damage?
Do we have social stigmatization? What’s going on?
Help us understand that a little bit. DOUG: There are a whole host of negative effects of tics. One can be physical. So imagine any kind of repetitive
strain injury or repetitive injury that occurs from doing the same motion over and over again– that could happen. I’ve worked with people who have had neck tics where
they’ve literally lost feeling in their arm, they’ve lost sensation in their hands. And I’ve seen people who have blinded themselves
from poking their own eyes out as a tic, a self-hitting tic. Which you might think of as self-injury,
and it could be, but it could also be a tic. So there are a host of different
problems that can emerge from the tic. People will do tics like punching themselves
in the stomach, completely typically developing kids– that is in your traditional self-injury case. So there can be physical effects. There can also be social effects–
teasing, people giving you odd stares, assuming things about you if they don’t
know what you’re doing, kids getting into trouble. There’s a lot of evidence of kids getting
into legal trouble for doing certain actions or saying certain things in the form of a tic. There’s plenty of evidence about
negative impact in work, in school, so there’s a whole host of social
problems that come with these movements as well. WAYNE: I would imagine that if it’s not resolved,
that as a person gets older and transitions into a job– could that also be a challenging situation in a lot of jobs,
especially when you’re interacting with the public? DOUG: Exactly. The more severe
tics could impact the jobs more, obviously. But even the subtle tics– if you have tics
and you’re trying to interact with someone on a customer basis or something like that,
it could be very distracting for the customer. And that can even cause subtle problems
and maybe diminishing your success as a salesperson for example. WAYNE: Well, Doug, that gives us a nice
overview of the tic end of the spectrum, but now you also mentioned
there are some other behaviors that we would include under habit disorders.
I think you talked about body-focused repetitive behaviors. Can you give us an overview
of what’s included there also? DOUG: Right. So that’s a broad term, obviously. It’s meant to encompass three primary
kinds of behaviors, but lots of other behaviors can be under that umbrella. It’s essentially any kind of habitual action
you’re doing that’s focused on a part of your own body. So common examples include
trichotillomania or chronic hair pulling, where you pull your hair to
the point of hair loss over and over again. Chronic skin picking, which is essentially the same thing,
except instead of pulling your hair, you’re picking your skin or using tweezers or a needle to pick
at your skin and remove it from your body. Nail biting is– everybody knows
what nail biting is, you chew your nails off. So those are the three major ones,
but then there are a bunch of other smaller ones. Thumb sucking that persists
into adulthood, which does happen. And you’ve got cheek biting,
like biting on the inside of your cheek to the point where you
have blood coming out of your cheeks. Lip biting– those kinds of actions too
are also considered body-focused repetitive behaviors. WAYNE: OK. Certainly many of us are
familiar with children who suck their thumb, but we’re concerned here
once again about well beyond childhood. And are these pretty prevalent behaviors? What goes on here, and why
should we be worried about them, Doug? DOUG: The behaviors in general–
if you don’t look at severity, and if you just look at– do these actions happen? They’re very common. We know up to 20% or 30% might
bite their nails at some point in their existence. A lot of kids suck their thumb.
A lot of kids tug at their hair and pull at their hair. And 70% of people play with
their hair on some kind of regular basis. That’s not what we’re talking about.
We’re talking about something where there’s actual loss of hair, scabbing and scarring of the skin
from picking, dental problems that come from chronic thumb sucking where you get buckteeth basically, or infections of your nail
bed that come from chronic nail biting. So we’re talking about things that
have much more of a permanent physical effect or a negative physical effect. WAYNE: OK. So we’re talking about
behaviors that are occurring of such frequency and such duration that
it’s really causing some physical damage. And how about on the social end of things?
Is that also a concern, too? DOUG: It is. It’s different than tics, because the social
effects don’t come from actually being seen doing the action. So with these body-focused repetitive behaviors,
at least in typically developing kids– it’s a little less true in kids on the autism spectrum. But in typically developing kids
you very rarely actually see them do the action. It’s done more covertly, usually because it’s
been socially punished, so people kind of hide that they’re doing it. The social effects, though, come from
embarrassment and feeling that they can’t do things or be seen. So for example, I child a might have trichotillomania
and be completely bald but can wear a wig and go out in public, but they can’t swim, or they can’t go out in windy weather. There are things– they don’t want to get dressed in gym,
because they’re afraid the wig might come off, things like that happen. So the social effects are more
of social avoidance than actually actively being teased. So it’s just a different kind of outcome. WAYNE: Now, what do we know about
the etiology of this set of behaviors? And do you typically see a person developing
one single body-focused repetitive behavior, or do they kind of come in groups essentially, Doug? DOUG: They cluster. Once you have one,
your chance of having the other ones are much higher. So if you have one behavior, there’s more than 50% chance
you’ll have another one of these things. So you’re likely to have clusters. And in terms of what causes it– we do know it’s genetic. We look at twin studies, if one identical twin has it,
there’s a 35% chance the other genetically identical twin will have it. Where that concordance rate is 0% if they’re not identical twins. So it’s really a pretty heavy genetic influence. In terms of what causes it, we don’t know nearly as much
about these things as we do typically developing Tourette kids, for example. But we do know a couple of interesting things–
there are lots of animal models about this. So any species with fur or covering
of any sort has some version of this. So birds have feather-picking disorder,
where they remove their own feathers. Dogs have acral lick dermatitis,
where they’ll lick at the same spot over and over again. Mice have something called barbering.
Cats have a very similar kind of thing, too. Chimpanzees do this, monkeys do it. So any species with fur has this,
which makes us think that there’s something potentially evolutionary
about this action at some level. And we do know in terms of where we think problems
show up in people with trichotillomania and skin picking, we look at some of the same areas
we actually look at in tic disorders. So we look at the basal ganglia,
which is that part that can inhibit movement. And really another way to think of
the basal ganglia is we think of that as habit circuitry. So it’s the circuits in the brain that are responsible
for habitual action, and those seem to have gone awry. And so people with trichotillomania have
a harder time stopping action once it’s started. They have a harder time getting out of a pattern of things. If once they start down a pattern, they have
a harder time switching and realizing that things have changed. So they kind of get stuck in these
habitual patterns much more easily than other people. WAYNE: Interesting. And how about the course
of action, does it resolve on its own essentially? Or is this something that tends to be
pretty persistent once you’ve developed it? DOUG: I should say there are actually two
times at which these kinds of repetitive behaviors start. I’m going to focus mostly on the hair-pulling piece. So there are really two ages of onset for trichotillomania. One is what we would call baby trichotillomania,
which happens usually after about the first year of life into the third year. And that’s a different kind of time-limited, usually,
hair-pulling action that’s usually associated with an attachment process. So the child is weaned off the bottle,
and they are self-soothing with hair as opposed to like a security blanket or something like that. And they do it so often that the hair comes out of their head. That’s a different process. Although it looks the same,
it’s functionally probably very different than a later onset. The other later onset age happens around
the age of 12 to 13, about the onset of puberty. And the disorder– once it starts there, it’s likely to keep going. It doesn’t just spontaneously remit very often,
and if it does, it usually comes back. So once you get this, it tends to be a very chronic,
life-long sort of thing that you end up having to deal with. WAYNE: Interesting. You’ve described the range of
body-focused repetitive behaviors. Let’s call them BFRBs, OK? For lack of a better word– that’s a mouthful otherwise. Why should we be concerned with them? In some ways those seem like they’re just normal things
that people do, or do they really create any problems for people, Doug? DOUG: Well, they can create problems. By definition, if they get to the point
where it’s a regular habit that has somehow caused a problem, that’s when
we would actually deal with it. So built in is the definition that there’s a problem. But what kinds of problems happen? So for trichotillomania, the obvious problem is hair loss. So sometimes people pull every hair out of their body,
sometimes they’re just big patches, sometimes it’s in a pattern. They pull eyelashes or eyebrows. So the hair loss itself is physically damaging.
But just like tics, you can get repetitive strain injuries. You can get carpal tunnel syndrome that
comes out of this because you’re using the same tweezers or whatever you might be using to remove the hair. So you can get that. You can get follicle damage,
which can end up resulting in your hair coming back gray, coming back distorted if you do enough follicle damage.
So you can have those kinds of problems. You can also get infections of the scalp from picking.
You can get skin infections from skin picking. You can get nail bed infections from nail biting.
You can do damage to your teeth. People with trichotillomania, after they pull,
a lot of times they’ll do things with the hair. One of things they’ll do is mouth the hair.
They’ll put the hair in their mouth, and they’ll do things like run it through their teeth, clench it through their teeth. And that hair is very strong– tensile strength
is actually probably stronger than steel at the equivalent width. And you can actually run grooves in your teeth,
you can do a lot of dental damage by doing this. Sometimes people will actually ingest the hair,
and that actually can create a potentially fatal condition called a trichobezoar, which is a hairball that forms
in your stomach, which sounds strange, but it’s actually true. You can pull enough hair, and if you’re
ingesting it, hair doesn’t digest, and so it catches at the bottom of your stomach and forms a net. And as you keep eating it can actually shape
a hairball of indigestible mass in your stomach, which leads to malnutrition
and actually stomach pains, and eventually you could die from something like that. And that requires surgical intervention to be removed. So although it sometimes seems pretty
mild on the surface, in extreme cases it can actually be very dangerous
if you’re doing those kinds of things. WAYNE: Anything in terms of
the thumb sucking stuff? Because that’s also something the parents see all the time. And they always are going, should I do
something about it? Should I be concerned? When is it bad enough to say
you need to be concerned about it, Doug? DOUG: When you start seeing
the adult teeth come in, that’s really when you have to start worrying a little bit more. If the thumb is in the mouth
and the adult teeth are always coming in around that, you can actually
get the malocclusions of the teeth and you can get the buckteeth kind of thing. When it’s younger, below the age of
five or six, it’s probably not a big deal. WAYNE: OK. Well, that kind of covers
the range of BFRBs, and why they’re important. Can you give us a little orientation
to how you conceptualize treatment? I’m sure for a lot of people they’re hearing this
and going, well, a lot of this is neurological. Why don’t we just
use pharmacological interventions? Talk to us just a bit about that
and in particular also about what is the rationale for doing
behavioral interventions, behavior therapy. DOUG: Sure. So let’s start
with tics, how we conceptualize it. There are similarities between tics
and the BFRBs, but there are some differences. So when we look at tics,
we’re trying to do two things. The first thing we’re trying
to do is identify– first of all, we know that the environment is very
influential on how tics show up, which tics show up, how frequently
they occur, how intense they are. The environment has
a pretty profound impact on that. So one of the things we want to try
to understand is how the environment affects the tics. And we know that antecedent events
can affect tics, so different settings, different people, different activities, things people are doing. Those can make tics more or less frequent. And then we also know that reactions
to tics can make tics more or less frequent. So people can comment on or pay attention
to tics and give the child attention for doing the tics that make the tics more likely to happen. Or conversely, they can let the child out of
distressing activities because of the tics. So if a child, for example, is struggling with
reading and happens to start ticking a lot, the teacher might say,
oh, why don’t you just take a break. It looks like you’re struggling
with your tics. Why don’t you put your book down and go
out of the room and take a break. That’s all well intentioned, but what
ends up happening is the child’s tics get reinforced by not having to do the reading. And so you get these kinds of
social interactions surrounding the tics that can end up making
the tics worse than they need to be. The tics end up getting reinforced inadvertently. So that’s part of what we try to do in treatment
is to identify those situations in the environment that could be exacerbating the tics or maintaining them
and then try to change the environment accordingly. The other thing we’re trying to do–
and remember, the whole problem in tic disorders is that the kids don’t have proper inhibitory capacity. If you remember what I said earlier,
there’s the basic inhibition processes that don’t work, but there’s this sort of other
inhibition process that does work for kids. And so what we try to do is to target
that other process and teach the kids to intentionally consciously suppress their tics
when they start noticing they’re coming. It sounds pretty high-level
cognitive activity, but it’s really not. It’s basically you recognize
in your environment that you’re getting ready to do something,
and you try to do something to stop it. And so what we try to do
in that case is to make the child aware that they’re doing the action,
and then give them something to stop that action to inhibit that action
and make that activity, that catching oneself and inhibiting oneself a habit in its own right. And so we’re trying to build a new habit of
stopping one’s own tics, and there’s a procedure we use called habit reversal that tries to do that. WAYNE: Before we get to that,
let me just ask you one more question about that. The phenomenological precursor you’re
talking about, would you call that colloquially an urge? DOUG: Sure. A lot of kids with tics have,
before they do the action, they feel an uncomfortable, aversive sensation in their body that we call an urge. A way to think about it is if you
would open your eyes really wide and not blink. And if you do that long enough, you’ll start to
notice kind of an uncomfortable sensation around your eyes. Then once you blink, you’d notice that it goes away. Kids with tics experience that all day.
They feel this build up of a pressure or an urge, and then they do the movement,
and then it goes away for a short period of time. Now, not all children have that,
or not all children are able to report that. Whether or not they can report it really isn’t
important in terms of whether we do the treatments or not. Because the treatments can be done
with or without awareness of that sensation. It may get a little easier if they’re aware of that sensation. They might be able to do it a little bit more
independently if they’re aware of that sensation, but it’s not absolutely a precursor for doing the treatment. WAYNE: The urge is very interesting,
because if you begin to focus on those subtle body sensations, you begin to notice the urges there to– I want to scratch my forehead or something of
that nature, or I need to blink my eyes or whatever. So it is an interesting phenomenological observation really.
DOUG: Yeah, it is. WAYNE: Now, one thing I wanted to direct us back to,
though, you kind of gave us a little bit of preview on tics about kind of the way you think about it behaviorally. How about the pharmacological management? Before we get too deeply into the behavioral stuff,
is there a pharmacological approach? And if so, what are the pros and cons of that approach? DOUG: Absolutely. Up until probably about
three years ago, the most common first line treatment for kids with Tourette’s or tic disorders
was a pharmacological approach. That’s changed more recently as
the behavioral technologies have started to show up and be tested in larger trials,
the recommendations are changing. But still, pharmacology is a very common treatment
for kids with Tourette’s and adults with Tourette’s. There are really two classes of medication
that are used to treat Tourette’s. One are alpha-2 adrenergic agonists.
These are drugs like Clonidine and Guanfacine. And then are the atypical antipsychotics
which reduce dopamine levels, things like Risperdal or Haldol. Haldol is a traditional antipsychotic. But those are the medications that are typically used. Most of the time people will start on Clonidine or Guanfacine. Those can be effective, their side effects are pretty low. They seem to work by increasing
attentional capacity, not actually by reducing tics. Tic reduction almost seems
to be a secondary effect of them. Risperdal works a little bit better than
Clonidine or Guanfacine, except the side effects are worse– so weight gain, lethargy, cognitive dulling,
a lot of unpleasant physical side effects that often drive people off those medications. If that doesn’t work, then people will
try the traditional antipsychotics, like Haldol. And those actually work quite well,
but the side effect profiles are intolerable for many kids. WAYNE: And we’re talking about children here
that are taking fairly powerful medications, right? And my understanding is, and correct me if I’m wrong,
is that you take the medications that suppresses the tics, but it doesn’t cure them in the same sense
that an antibiotic might cure an infection, and you could go off the antibiotic
and never have to worry about the infection again. DOUG: Correct. WAYNE: It is an ongoing, active medication
that you have to take long enough to kind of solve the problem. DOUG: That’s very true. And the truth is we
don’t know what happens when they go off the medication. The long-term follow up studies after people
go after medications just haven’t been done– that I’ve seen. We do know there’s some safety
issues in terms of side effects. We don’t know about long-term durability. We know that in terms of the effectiveness
of the treatment, the behavioral procedures that we use are as effective as Risperdal, which is sort of
like the level two medication that you’d use for tics. WAYNE: So once you get a behavioral procedure
that’s equally effective as a medication but has no side effects, then that suggests then that it would be
the treatment of choice under those conditions most of the time. DOUG: And what’s happened actually, there have
now been three published guidelines across the world that talk about what treatment should
be used for the treatment of Tourette’s in kids. And these have been published–
the Canadian guidelines, the European guidelines, and then the US guidelines
published by the American Psychiatric Association. And all three of them suggest that
if it’s available and the patients want to do it, that the behavior therapy should be available
as the first line, or a first line, intervention for kids with Tourette’s. WAYNE: Doug, you just kind of gave us
a little overview about the kind of behavioral overview and rationale for doing
behavior therapy with tics and Tourette’s. How about the body-focused
repetitive behaviors, the BFRBs? Is it a similar rationale, or what else
goes into your thinking about the rationale for BFRBs? DOUG: Part of it is very similar in that
we know that people with trichotillomania and other body-focused repetitive behavior
problems have some core problems with response inhibition. They have a hard time stopping
things once they’ve started them. And so we still would use habit reversal
procedures for them, which we’ll talk more in detail about, and which we also use for Tourette’s. We also know that the environment, just like
it does in tics, affects body-focused repetitive behavior disorders in a very predictable and powerful way. So again, we are still thinking about
how the environment affects the behavior. But the things that we look at are a little bit different
in BFRBs, or body-focused repetitive behaviors, than in tics. So for example, we know that certain settings
that may not affect tics do affect BFRB frequency. So for example, tics or body-focused
repetitive behaviors, like hair pulling, are very common in boring situations, in situations where the patient
is alone, sometimes in anxious or stressful situations, in certain sittings, sitting in certain postures,
all those factors, those antecedent factors, really affect the frequency and intensity of these behaviors. We also know that people, before they do things,
like pull or pick, will do a lot of precursor actions. So they’ll do things like feeling the area
where they’re about to pick the skin from, and maybe finding a particular imperfection
in the skin or a ridge in the skin that they don’t like. And then they’ll try to find that
and take it off, and it will be that ridge in the skin that they find that actually triggers the action. Or for example, a person who does hair pulling
might have a particular hair that they want to get rid of, a particularly coarse hair, or gray hair,
or soft hair that is their target. And so they’ll search and search until they
find that stimulus, and then that will trigger the pulling. So we know there are a lot of
antecedent factors that can trigger the action. Likewise there are a lot of consequence
effects, a lot of things that come after the BFRB or the repetitive behavior that
can help maintain the action. So for example, people who pull
will get the hair out, after they pull the hair, they might have the hair, and they
might the run hair between their fingers. And what they’re actually seeking
is that tactile reinforcement of the ridge of the hair running between the fingertips. Sometimes they might run the hair
that they pull along the mouth. What they’re seeking, what the reinforcer
is there is that tactile stimulation of the soft, tickling feeling over the lips. Sometimes they’ll take the hair and they’ll
put it in the mouth, and they like to pull hairs that have roots. And so they can feel the ridge of the root
run between the ridge of the mouth and then the tongue, and it kind of creates a tickling
sensation in their mouth. Sometimes they like to twist
the pulled hair between the fingers. That kind of puts pressure on the fingers,
and there’s something tactile or rewarding about that. So there are a whole host of things. Sometimes it’s just visual stimulation.
They like to look at the hair. Sometimes they like to look at the root
and the bloody end of the root that they’ve pulled out. That’s visually reinforcing to them. So there are a whole host of things
that happen after the pulling occurs that can actually serve to reward or reinforce the pulling itself. So when we think about treatment, we’re not
only trying to teach them to do something to break the habit, break that automaticity that happens,
but we’re also looking for how can we change and substitute some of those tactile
reinforcers that they’re getting that make it less likely that they’re going to actually do the pulling behavior
to get those reinforcers where they could be doing something else. We’re also trying to do things that will block
or prevent the opportunity for pulling to start. So that’s another thing we look at in treatment. And then another thing to think about is
we also know that pulling, like a lot of repetitive behaviors, also has an emotion regulating function. So a repetitive action in general can help
soothe negative or unpleasant internal private experiences. So a lot of times pulling will be
triggered by a negative emotional state– distress, anxiety, whatever the term is you might use
to describe that, some kind of unpleasant, aversive, internal experience. And we know that during the active pulling
that actually can reduce that negative experience. So sometimes there’s a negative
reinforcement cycle that gets built in. People do this repetitive behavior in order to reduce
these negative experiences they’re experiencing internally. WAYNE: You said something I thought
was an interesting observation. You pointed out the way people handle things,
like the hair they pulled out, look at it, touch it. And in some ways it reminds me that our concept
of reinforcement needs to be functionally defined for the individual. What might be reinforcing for you– you might not
enjoy twirling your hair or anything like that, but it is highly reinforcing for somebody else potentially. And it just reflects the different, unique, individual
idiosyncrasies and the behaviors that sometimes get caught up in these unique, reinforcement concepts. DOUG: It’s really true. You see that
a lot in trichotillomania in particular. What’s true and reinforcing for one person
is not at all reinforcing for another. So for example, one person might really like
the ridge of the hair between their fingers, or might like to put the hair in their mouth. Another person would be completely grossed out
by that– wouldn’t do that, and the thought of doing that would turn them off of pulling itself. And you get other kinds of strange things that happen. So people who pull their eyelashes, for example,
I’ve had people who describe a very pleasurable feeling when they pull their eyelashes,
it’s just an automatic reinforcement function. And they might have removed
all of their top eyelashes. And you say, well, why don’t
you pull your bottom ones? And they say, I couldn’t imagine.
That would hurt. I couldn’t possibly do that. Ew. That kind of thing. The top ones
feel good, the bottom ones feel bad. It’s really interesting. It’s even within the individual–
you get topographical differences in reinforcement. It’s an interesting disorder that way. WAYNE: Yeah. It sounds fascinating. And you have to just be a good student
of behavior to understand things as best you possibly can. Well, taking a step back– you’ve given us
a pretty good overview about some of the behavioral, environmental, contextual factors that
influence tics, Tourette’s, and BFRBs. Can you now transition us a little bit to kind of
think about– how do you do clinical case formulation? Walk us through what
a clinical case might look like, Doug. And you can start wherever you want to,
and you may want to cover them separately if you want to. DOUG: So for tics, we’re trying to address
the environmental effects on tics, or the contextual influences on tics by a process of functional
assessment and then resulting function-based interventions. So what we do is we’ll interview the parents
and the child together, usually early on in treatment. And what we’re looking for are those factors
that are associated with exacerbations of tics. Now, in a traditional functional assessment
or functional analysis, every episode of the behavior you write down, you note the antecedents
and the consequences, the time of day, and so on. If you did that with tics, you would go crazy. Because tics can happen thousands of times an hour,
if you’re talking about rapid eye blinks or something like that. So we don’t use that specific strategy. What we do is we say, tell us when
your tics are worse during the day than usual, periods of time in which your tics are more frequent
or more intense than they typically are during the day. And we ask parents to think about those situations,
and then we ask them to think about antecedents that might be occurring in that situation, and then reactions to tics
or consequences to tics that might be occurring in those situations. And what we’re looking for are patterns that emerge,
similar situations where the tics are more likely to happen, similar reactions to tics in situations
in which the tics are more likely to happen. And once we’ve identified those factors,
then we come up with very simple function-based strategies that we can use to try to reduce the tics more effectively. So for example, let’s say a child is being interviewed. The clinician and the parent are sitting there, asking each other or talking about
this particular child’s tics. And we find out that the child tics
a lot right after school, which is actually fairly common. And with a little bit more inquiry what we
find out is that when the child comes home from school he’s always kind of anxious and uptight,
he goes downstairs into the den, watches TV with his sister. And we get a little bit more from the mom,
and we find out that when he goes outside and plays, he doesn’t tic much, or when he’s
helping Mom with dinner he doesn’t tic much. But when he goes down into the den
and gets quiet and watches TV, his tics tend to flare up. And while he’s down there with
his sister, he starts ticking very loudly. And his sister starts teasing him
or yelling at him, because she can’t hear the television. And we find out that that’s a pretty common
reaction to his tics, he gets a lot of attention for it. And this makes the mom upset,
because the child is getting teased. So she goes down and gets
after the sister a little bit. The sister gets in trouble,
gets sent out of the room. The kid then gets to watch TV by himself,
gets to watch his own shows. And so what we see is this pattern start to
emerge where he goes down into this quiet, dark place, starts ticking a lot, gets a reaction from it,
the reaction leads to his sister getting removed from the room, he gets access to the TV, lots of things can happen,
he gets rewarded in many ways for doing these behaviors. Now, he’s not doing these behaviors intentionally
in order to get things, but the circumstances of the environment are that when he tics, a series of rewarding things happen,
and you could believe that they would influence tics. So if we find that, then what we do
is we might offer particular strategies to the family. So we might say, look, let’s change his
routine a little bit, instead of sending him downstairs into the den after school when he’s
stressed out and he’s anxious, why don’t we give him a task to do– maybe it’s to go out
and sweep the driveway, maybe it’s help Mom with dinner, maybe it’s go outside and play.
So we just change his routine a little bit. Instead of having the sister react negatively
to his tics, we maybe educate her about what the tics are and how she can respond differently and reward
her for actually acting in a proactive way to help her brother. And so we try to eliminate those factors
that push tics or pull tics as a way to teach the family an effective management strategy. So that would be how we would
deal with the contextual factors that surround tics. And it could be different for everyone, obviously. WAYNE: You talked about doing what sounded
like an interview process to try to identify the contextual factors. Some of the children on the autism spectrum
and with developmental disabilities don’t have very good verbal skills and maybe not
very good self-observational skills. Can you get pretty good reports, mainly from
the parents, are they pretty accurate? Do you recommend that you try
to interview the children also, Doug? And what if you have a child with
kind of compromised verbal capabilities? Do you have any suggestions? DOUG: The truth is in most of our
interviews we always have the children there. The older ones in the typically
developing population, the older ones can be a little more reliable, the younger ones
tend not to be very reliable or sometimes have no idea. So a lot of times what we’ll do
is we’ll rely primarily on parent report. We might even call the school
and ask what the teachers are seeing and so on. So we rely on multiple informants
to try to develop this picture. We would do the same thing
in a child with autism. We would rely on whoever could give us
information that we could try to build an intervention based on. WAYNE: OK. Well, that sounds good. So it obviously works pretty well
at identifying all those contextual factors. So you’ve identified the contextual factors,
what are your next steps after that, Doug? DOUG: Again, it’s to look at those factors
and then set up interventions that are brief, that make sense for parents and the educators to do. Really, the purpose is to effectively manage the condition. So we don’t have a one-size-fits-all
recommendation, because everybody’s different. Everybody is going to be
influenced by different contextual factors. So what we do is we have just general guidelines. So one of our guidelines is if a child doesn’t
need to be in a particular situation that exacerbates his tics, then don’t put him in that situation.
That’s kind of a simple one, right? But sometimes there are situations where
a particular school session or school setting, like a classroom, does exacerbate his tics,
and you can’t not have him take that class. Well, then that’s not a viable option. In those kinds of cases what we do is we look at–
how can we modify the environment that he must stay in? How can we modify the environment
in a way that might minimize the effects on tics? So for example, let’s say we have a child who has
a tic that is exacerbated by nervousness, gets a little anxious. And we know that when he feels
like he’s the center of attention he gets anxious, or when people are looking at him he get’s anxious. This teacher happens to have
him sitting in the front of the class. Now, he can’t not take the class, but he can sit
in the back of the class where nobody is looking at him anymore. And that might be a modification to
the environment that we could use to reduce the activity. Let’s give another example that might be
a little more relevant to the autism spectrum. So let’s say it happens when the child
is inactive, is bored, there isn’t much going on for the child. One way would be to remove him from
the classroom, but another way might be to allow him to stand up and walk around every three minutes,
four minutes, sitting in the back of the classroom– not in a disruptive way, but every once in a while
he gets to stand up, get a little active, and then sit back down. That kind of breaking up the monotonous situation,
if the monotonous situation triggers the tics, might be an effective way to reduce the behavior. WAYNE: Doug, you’ve describe what sounds like
a really good strategy to identify those antecedent conditions that exacerbate the tics,
and either eliminate them or modify them. Are there some other components
here that you want to describe? Maybe you look at consequences also. DOUG: So there are a couple of different
main consequences that we’ll look at– social positive reinforcement
and then social negative reinforcement. Those are the two main categories. One of the things– if the kid
is getting a lot of attention for the tics, one of the things we’ll try to do is intervene
with people who are reacting to the tics in a verbal way. The best advice we have for
parents and teachers– ignore the tics. When they happen, act like they don’t happen. Sometimes that’s easier said than done,
because the tics can be annoying and so on. So we really encourage parents
not to talk about the tics in front of the kids, not to be the tic police,
not to say stop it every time they’re doing the tic. And we encourage the teachers to do the same thing. It gets a little harder sometimes
when you have peers that react to the tics. And so sometimes we’ll do peer interventions
in the classroom where we do education about tics and encourage them to help us
out by not reacting to the tics. And if done right, that can actually be very effective. So we try to eliminate those reactions to tics,
those social reactions to tics. The other thing we worry about and we look for is–
is the child somehow getting out of some kind of expectation or some kind of duty
or some kind of job because of the tics? So a common one is in school–
and I think alluded to this earlier– a child might be asked to do a task
in school, and they start ticking a lot, frequently. And the teacher’s reaction is, oh, just stop
doing that, and why don’t you go outside and take a break. And this makes sense if you’re the teacher,
you might think the kid is getting embarrassed, you might think the kid is distracting other students,
you might think that there are a lot other negative effects, so you send the child out of the room. The problem is kids with tics can sometimes
get in these patterns where they start getting out of things because of their tics,
and they’re not held responsible for that. So one of the things we want to do is
we want to say, OK, if your child starts to tic, and they’re doing some activity,
that’s not the time to stop that activity. You make them finish that activity
whether they’re ticking or not. Now, you might want to do it in a less
embarrassing way, so if a child is ticking a lot in front of his classmates, you don’t want to make him
sit in there and be embarrassed about it. But you might say, you know what? Why don’t you take that work,
go to the nurse’s office, and finish that work in the nurse’s office. That way they still have to hold
the responsibility, but they don’t have to suffer the embarrassing
consequences of it as well. But the problem is when you
get into this pattern of starting to allow escape from particular tasks because of the tics, you end up with adults with tics
who aren’t functioning very well. You can see some adults with Tourette’s
who have had that pattern of behavior, and they become kind of prisoners
to their own disability because of that. WAYNE: So you described several manipulations of
what you might call social or naturally occurring consequences out there in the real environment. And other things that you would do
in terms of your treatment model here? So those are great starting points,
is that your ending point? Or do you want to add in any other things
about self-initiated therapy strategies? DOUG: So remember, the functional assessment,
the function-based intervention, was the part that was dealing with more of the contextual factors
that were surrounding the tics. We’ve also got to deal with that inhibition piece.
So how do we teach them to stop that ongoing action? That’s done through a behavioral procedure
called habit reversal training, which is a treatment that’s been around now for 42 years. I think it started in 1973 by Azrin and Nunn. Habit reversal has a few different components to it. There are three primary components. One is awareness training, the second one
is what we call competing response training, and the third one is what we call social support. And they’re all interacting together, working together. Generally what we do is
we make a list of the tics that the child has, and we teach them to inhibit the tics one at a time. So we get them very good at inhibiting one tic,
and then we move to the next tic and so on. Usually we do this once a week. And a kid with autism, depending on the severity,
it might take longer than that, but generally we try to go once a week. And what we do is we start with the tic
that we’re deciding that we’re going to work on that week, and we do the habit reversal procedure for that tic. Now, habit reversal starts with awareness training,
which is we’re trying to– remember, this is sort of a habitual kind of action that they’re doing, habit disorder.
So we’re trying to first make sure that they’re aware of it. A lot of times, by its very definition,
habit means it’s out of awareness. You’re just kind of doing it habitually. So we start by trying to get
the child to be more aware of the action. So you can establish awareness in a lot of ways,
but one of the ways habit reversal does it is by doing a particular set of techniques called awareness training. The first part of awareness training is to get
the child to describe, in any way that he or she can, the tic chain, the chain of– the description
of the behavior in very much detail. Now, a child without verbal abilities
isn’t going to be able to do this, and you just have to skip over
this particular section of it. But essentially it’s to try to get the child to think
a lot about and notice a lot about the action that they’re doing– From the minute the action starts,
until it’s completed, and everything they’re doing in between. So that’s the first part. After they’ve given a good description,
if they’re able to describe, then you move into the second part of it,
which is response detection. And in response detection,
the therapist and the patient sit together and talk about something or do an activity. And while they’re doing that,
the patient is asked to let the therapist know every time that they’ve
done the action– the tic, in this case. When they’ve done the action,
the client is asked to raise a finger and acknowledge that they’ve done it. And the therapist responds by praising
the client for appropriately being aware of the action. If the client does the action, does the tic,
but doesn’t raise their finger or doesn’t signal awareness, then the therapist will say to the patient,
don’t forget to raise your finger, and then they’ll continue discussion. So it’s basically discrimination training,
teaching the patient to discriminate their own behavior. And this discrimination training process
occurs over and over again until the patient can reliably discriminate correct episodes
of the tic at about 80% awareness. When they do, then we move on
to the next phase, which is competing response training. And in competing response training,
what we’re trying to teach the patient to do is to do something that physically prevents the tic from happening whenever
they notice the action has started, that the tic itself has begun. Preferably we do it as early as possible, so as soon
as they start the beginning of the chain of behaviors that is the tic, they can implement this competing response,
but we’ll take it at any point we can get it essentially. So this competing response is an action that they do,
and they’re asked to hold this action, this competing response, for a minute every time they notice the tic starting. Now, the competing response will be something
that prevents the tic from happening. So for example, if I’ve got a neck jerking tic,
a competing response might be dropping my chin slightly and tensing the sides of my neck gently. If I’m doing that, I can’t be
jerking my neck at the same time. And I’d be asked to hold that position
for a minute every time I feel that urge to do the tic, or if I even start to do the tic. Now, children with autism won’t be as likely
to notice an urge, but they can be trained to– when they do this, they go right into this,
and they have to hold it for a minute. That’s a very kind of shapeable response. And so that’s kind of the action we would take. Now, once we train that, teach the patient how
to do this, then we would have them practice it with us in session. Again, we’d sit there and talk with them,
or play a game with them, or do some activity. And every time they started to do the tic, or actually
even did the tic, they would be expected to use their competing action. If they did that correctly, they would be
praised or rewarded with some kind of reinforcer. And if they missed it,
they would be prompted to do it and then would be rewarded
for doing it correctly. And we would keep doing that until they could reliably
conduct that competing response whenever they started to do the tic. WAYNE: And I’m supposing you want them
to conduct it, obviously, not just in the session, but in all contexts in which
the tic might be occurring, right? DOUG: Correct. From there on out,
whenever they feel that tic coming on, or whenever that tic happens, they’re encouraged
to do this competing response for a minute. Now, the last part of habit reversal
is built to help that process out. That’s where a support person
comes in– a caregiver, a teacher. And that person is asked to do two things–
they’re asked to reward the child for doing the competing response correctly,
in other words, they’ve seen the child start to do the tic and then go into the competing response. And then the support person,
if they see that, is to praise the patient. Almost as important is if they see the patient
do the tic but not do the competing response, they’re asked to prompt the patient to do it–
so that constant training that goes on. And so that is how we establish the new habit,
if you will, the new action, the inhibition action in the patient. WAYNE: Well, that sounds like a nice use of kind of
social support systems that would obviously involve parents, teachers, other people,
as long as they had a little bit of training. DOUG: Correct. WAYNE: You now have trained the child to identify
the behaviors involved in the tics, obviously, and to apply the competing response, and to do it
with some level of consistency it sounds like. What sort of clinical progress do you
get in– and let me frame it in two questions. Do you begin to see that the competing response
interrupts the ongoing tics, and that’s what brings them down? Or do you begin to see that the onset of the tics
goes away dramatically as a result of that competing response? Is that a distinction there that’s useful to think about? DOUG: Yeah, I think so. If you really stay on top of it,
the first few days you’re catching yourself interrupting. But after about three days,
you’re actually seeing the urge to tic isn’t there. The tic’s just not happening so much– when it works. So the week is there– part of it’s arbitrary,
because we see people on week-to-week sessions, but it really does follow that pattern. Within a week you can significantly reduce
the frequency of a tic, if not completely eliminate it. That’s not terribly common– complete elimination–
but you can get very large reductions within a week. And then what you do is in the next week
you add another tic in while continuing to do the competing responses for the prior tic,
and so you’re building over time. WAYNE: So it sounds like you may have to treat
different tic topographies sequentially almost. One thing that people sometimes complain about
is you get rid of one behavior, and you get another symptom emerging. Is this an example of symptom substitution,
Doug, and you’re having to treat these? What is your take on all of that? DOUG: The symptom substitution, it really
comes out of this old Freudian way of looking at things, which we don’t hold as an effective model in Tourette’s,
but it’s a concern that’s been brought up in the literature. And the truth is, this idea of symptom
substitution that really behavior therapy is like a parlor trick– we just bring one symptom down,
and it just causes other ones to pop up. Really there’s absolutely no
empirical support for that in tics. What we see clinically actually, if we see anything,
is there’s a generalization of reduction in tics across untreated tics. So we find tics that we didn’t target actually reducing. There was one study that was looking at this,
and it had a control group and a behavior therapy group, and they were comparing them. And what we found was that
everybody can develop new tics. In fact, over a 10-week period– the very nature
of tic disorders is that new tics come and old tics go. And over a 10-week period, people developed
on average about 1.2 new tics over a 10-week period. But you’re not more likely to develop it if you have
behavior therapy than if you have a non-behavior therapy treatment. So what that tells us is the symptom
substitution idea really just isn’t true. What’s happening is it’s sort of spurious correlation. Because tics come and go, and people just
always develop new tics as the course of the disorder, we end up seeing people who get better,
whose one tic gets better, and then just by happenstance a new tic emerges, and people make
the assumption– a causal assumption erroneously– that the reduction in one tic
caused the increase in another tic. But there’s really no evidence to support that. WAYNE: The nice thing is if you replicate
the procedure with any new tic topographies that emerge, then you get some sort of results, right? DOUG: Very much so. Now, some tics don’t respond.
Not everybody is going to respond to everything. But generally we get some very good response actually. WAYNE: Could you talk about that just a bit?
What is your success rate? And it sounds like you oftentimes
get significant reductions within a week or so. What kind of success rate and what kind of
amount of reductions do you oftentimes see, Doug? DOUG: Sure. It depends on the kind of
metric that you use, the kind of measure that you use. But if you look at the biggest study on children to date– it was a study comparing behavior therapy, the procedures I described, that were spread out over 10 weeks. It was an eight-session treatment over 10 weeks versus a control condition– it was education about tics and supportive psychotherapy– those were the two conditions. And what we found was that there was a significant benefit for behavior therapy over psychoeducation and supportive therapy. People– half of them were essentially tic disorder free by the end of the eight sessions of treatment in the behavior therapy group. Significant reduction in tic frequency, according to a standardized, clinical scale– much more effective than the supportive therapy. And tic related life impairment was greatly reduced for behavior therapy relative to supportive therapy. On top of that, we followed them out six months later and found that of those who got better in
behavior therapy, over 80% were still better six months later. So there was a durability that we
don’t see in a lot of other kinds of interventions. It actually hasn’t been studied
in a lot of other interventions. In terms of percent symptom reduction,
if you would look at just symptom reduction, if you were to take direct observation data
from different studies, you would probably say the symptom reduction is 60% to 80% over a course
of treatment in terms of direct counts of the action itself. WAYNE: And that’s significant, obviously,
because a lot of these behaviors are behaviors that are not appropriate to get to zero, like eye blinking, you don’t want someone’s eyes
wide open all the time and never blinking. It has a base function,
a base rate that’s functional, obviously. So you just need to get it down to a certain level. DOUG: The way we start this with parents,
it’s important to understand, is we don’t sell this as a cure. When we talk to parents,
it’s like this is a management strategy. Much if like, as I said before, if you’re diabetic,
the goal of treatment isn’t cure of diabetes. It’s effective management and a healthy life with diabetes. And the same is true for Tourette’s,
Tourette’s is a neurological disease, we know that. What our behavior therapy does is to minimize the effect
of that neurological disease and give someone a healthy, functioning life. WAYNE: It sounds like it’s a very effective
and very fairly easy to implement intervention in reality, isn’t it? DOUG: It seems like it.
When you get in the weeds, it gets a little tougher. It’s based on very core, behavioral principles. If you understand behavioral principles,
this should be a treatment that you could take up fairly quickly. WAYNE: That’s a great synopsis, Doug, of the clinical
assessment interview and treatment and follow up process for tics. How about BFRBs? What do you do in the clinical
assessment and intervention for BFRBs that might be in any way different than what you’ve described for tics? DOUG: So it would probably be easier
to start where we look at similarities. So just like we did habit reversal with tics,
we would do habit reversal with the BFRBs. It’s not as complicated, because there’s usually
just one BFRB that they’re doing as opposed to doing multiple tics. So we’d start very early on in treatment
with giving them a tool to inhibit that action once it’s started. And again, we’d teach them to be aware of when
the action is happening, teach them a competing response to do to break that chain of action, and then we’d bring in
a support person to reinforce the use of that competing response, the correct competing response,
and to remind the patient to use the competing response. The truth is, though, for many BFRBs,
you don’t see it, it’s a solitary thing. So the social support person, a lot of times,
isn’t that helpful for that reason. So that part is still the same, and the same
techniques we would use in treating tics with habit reversal, we would treat BFRBs with habit reversal. The differences lie in more of
the function-based intervention approach. So in tics– in BFRBs just like in tics, we are trying
to identify situations where the BFRB is more likely going to happen and reduce contact with that situation
if appropriate, or change the situation if we can. But there’s usually a little bit more specificity to it. So for example, we’re trying to do something
in terms of antecedent control– we want to increase response effort. We want to make it difficult for these people
to do the BFRBs in the situations where they’re likely to do them. We want to do things like response blocking.
We want to try to interrupt behavior kind of by antecedent manipulation. So for example, if we know a person, like a child,
does a lot of BFRB before going to bed, we might put mittens on the child as they go
to bed, so they can’t actually pull their hair or pick their skin. So we might do something like that. We might put band aids on their skin, so they
can’t actually– it’s too much effort to actually try to get the hair. We might put jelly, like petroleum jelly, on their fingers,
so that when they try to pull the hair, they can’t, it just slides through. If they do– we might have them, for example,
take a koosh ball or something like that to manipulate. You get their hands occupied, so there’s
not enough free time to actually do the pulling. So there are a lot of kinds of activities
that would manipulate response effort or to otherwise disrupt the action from an antecedent perspective. We also look at the consequence perspective. Now, again, you don’t get a lot of
social reinforcement for these kinds of things. Sometimes kids with autism will
because they’re more likely to do it in front of other people. And if that’s the case, then you’d obviously
try to eliminate the social reinforcement for doing the action. But what we do look at are the tactile rewards,
the tactile reinforcers that can maintain these behaviors. So what kinds of things can we do to either
provide other sources of that tactile reinforcement, or to change the value of
the stimulation that they receive? So for example, if a child feels– gets tactile
reinforcement from running a pulled hair through the finger, we might give them long threads,
cut up a bunch of long threads that are very thin and just give it to them in their lap,
and they can manipulate those. You get them same exact
tactile reinforcement without having to pull. If it’s they like to run the root of the thread of
the hair through their mouth, and they like that tickling feeling on their tongue in the roof of their mouth,
we might tie little knots at the end of a thread and give them those tied up threads,
and they can just mouth those. That might be a substitute. We can also manipulate the establishing
operation of tactile reinforcement. So how do we do that? You can wear
latex gloves, and they can’t actually feel the feeling anymore. Or you can put Anbesol on the lips, it numbs
their lips and they can’t feel the hair in their mouth anymore. So those kinds of things can be done
to alter the reinforcing value of the tactile stimulation. So a lot of times we might do things like that. Keep in mind, also, that one of the main reinforcers
for BFRBs is that the repetitive action actually decreases internal distress. So one of the things we’ll look for–
what are the sources of internal distress? Can we look to the environment to see
if we can reduce those sources of internal distress? Can we teach the client skills that they can use? Relaxation training, for example,
alternative activities that bring down stress levels, because that, too, can eliminate
the negative reinforcer in that case. So we’ll look for those kinds of events in
the child’s environment as a way to try to bring down the activity. WAYNE: I imagine for some children on the autism
and developmental disability spectrum, making sure they have a functional communication skill to request a change
in their environment, or maybe an escape to a less anxiety provoking or distressing or sensory overloaded environment,
that also might be a useful adjunct essentially. DOUG: You won’t see this behavior serving that functional
communication function in typically developing people as often. But when you’re dealing with an autistic
population or other developmental disabilities population, that’s definitely something you need to keep in mind,
that this could actually be serving a communicative purpose. And you need to make sure that that repertoire
is established so they can communicate their desires. WAYNE: One thing that you mentioned is
changing the nature of the sensory consequence that’s maintaining the BFRBs. And every now and then I hear people
talking about thumb sucking as an example and using some tincture that
has kind of a bitter taste to it. Is that sometimes built in as part of
your protocol, or do you typically go with other strategies to deal with something of that nature? DOUG: Well, the interaction between
thumb sucking and hair pulling is actually interesting. So there have been a number of studies that have–
interestingly enough they actually co-occur fairly regularly. And there is a pretty decent amount of
evidence that if you can stop the thumb sucking, the hair pulling will disappear by itself. Now, there are a couple different products out there,
and the kind of stuff you can buy in the US is this product called Thum. You paint it on your fingernails.
It’s cayenne pepper based, and it tastes pretty nasty. My experience is that it doesn’t work terribly well. You put it in your mouth a few times,
and it rubs off, and you don’t really use it. There’s also a product that you can buy
on Amazon called Mavala, it’s out of Switzerland I think. It actually works really well in my experience.
It lasts longer on the fingernail, and it tastes much worse. And that I’ve used effectively to reduce
hair pulling actually by treating the thumb sucking. WAYNE: And if I’m understanding correctly,
though, that’s part of a treatment package. They’re not typically done
by itself. Is that correct? DOUG: Absolutely. WAYNE: OK. Good. Doug, this video contains
a wealth of information for people in terms of how you implement behavior assessment
and behavior therapy procedures. But I get the feeling there’s a number
of other resources that are out there that might be helpful. Can you give us some guidance as to other
things that therapists and/or parents or people afflicted with these sorts of movement disorder
problems might be referred to? DOUG: Sure. So for people who have tic disorders,
the best website that you can go to, the best resource is the Tourette Syndrome Association,
and the Tourette Syndrome Association is a national patient support organization.
It’s based out of New York City. And the website is For people with BFRBs– trichotillomania,
skin picking, nail biting– the best support organization out there, the primary support organization is
something called the Trichotillomania Learning Center. And the website for that is You can find a whole host of information. As for providers, treatment providers, they can
find a bunch of educational information on those websites. Patients can find support groups and access to providers
who have been trained in effective behavior therapy on those websites. So they’re really good websites. Therapists who are interested, for example,
for the Tourette’s stuff, can go on the Tourette’s website and find a whole host of demonstration videos
showing what this looks like, what behavior therapy looks like, and get more information about
additional training. So it can be very helpful. WAYNE: It sounds like a wonderful resource, Doug. DOUG: That’s right. WAYNE: And I’ll follow up with one more question. You mentioned these resources–
are there distance therapy resources that are out there? With the stuff we’ve described, all this face-to-face,
interpersonal sort of things, but are there other modalities of therapy that people might want to look at, Doug? DOUG: There are some self-help
programs that are coming online. There is a self-help website, whether this would be
appropriate for the population is not certain, but a self-help website called that treats trichotillomania,
a self-help website called, which treats skin picking. And we’re developing a new site called, which is a self-help treatment for
children and their parents with tic disorders. So we’re trying to do some distance work there. And there’s also, for therapist training,
there are more in depth trainings. On the trichotillomania website, you can
actually do an online in depth training there. The Tourette Association doesn’t have
an online therapist treatment training workshop, but they do have lists of workshops that
are available throughout the country for more in depth training in the treatment of Tourette’s. WAYNE: It sounds like there’s a marvelous
set of resources that are out there. That in combination with some of the video
we have right here should pretty well empower people that are therapists to then do some pretty
good evidence-based treatment for tics as well as BFRBs. DOUG: The truth is we need a lot more behavior
therapists trained in Tourette’s treatment in particular. And there are neurologists all over the place
looking for people to refer patients to. As this has gotten more and more popular,
one of the biggest problems we have is we have neurologists who don’t have anybody to refer to. Clinical psychologists, frankly, don’t seem
to be that interested in picking it up. I think it’s outside of what they
normally are trained to do. Behavior analysts, I think, are actually
in a prime position to pick at this and kind of run with it. They have the basic requisite skills and behavioral
technology that they should be able to pick this up quickly. I would encourage behavior analysts to sort of
pick this up and run with it, because I think they could get a lot of traction with it in the mainstream. WAYNE: Well, there’s certainly demand out there
and certainly treatment efficacy for making improvements in people’s lives, and that I would say is one of
the primary motivations, so that’s absolutely wonderful. Doug, you’ve provided a great description of
some of the assessment and treatment strategies for BFRBs. Assuming that you’ve been able to implement some
combination of those strategies that’s uniquely tailored to the individual, talk to us about the efficacy.
What kind of response do you get to it? And how do you maintain that response? DOUG: So across the board, across most of
the BFRBs, there have been some studies done comparing to a control treatment
or to a wait list control for skin picking, for nail biting, thumb sucking, trichotillomania. And all those treatments that have at its core
habit reversal and then these kind of function-based interventions, that’s what we call stimulus control interventions. Those seem to work pretty well relative to the control conditions. Do you always get complete elimination of the behavior?
No– but you get significant reductions in the action. Now, one of the issues with BFRBs is
they’re habitual, and so they’re likely to come back. You never unlearn something, you just learn
something new, and sometimes the old learning can come back. And so we do have to be careful about relapse for
these kinds of conditions, they do relapse quite frequently actually. And so with those kinds of things, what we want to
think about doing is scheduling in follow up visits fairly regularly and then fading out those follow up visits.
That can help with the maintenance of those gains. WAYNE: So it sounds like you’re producing significant
results relatively fast, and you do need to do some sort of, what you might call booster sessions, to ensure
that they’re still implementing the treatment components that haven been identified as effective,
and then you get pretty good maintenance. DOUG: Correct.
WAYNE: Well, it sounds very good. Absolutely. How about non-responders, Doug? Call them treatment failures, non-responders,
whatever– what do you do about those folks? Do you have any troubleshooting hints
about why people might not respond as well? Because the clinicians are going to be out there,
and they’re going to hopefully get great results, but somewhere along the line they’re going to get
a non-responder, and I’d like to be able to say– what do you do about it? DOUG: The first– well, the most important
thing is– is the patient ready to do this? And you have to think of it– the tics, the BFRBs–
it’s not that they’re not being rewarded, they are. There’s a reinforcer for both of those actions,
and it’s an immediate reinforcer in most cases. The action happens and whatever it
is that’s maintaining it is delivered immediately. You have to start by understanding this–
those behaviors aren’t happening for nothing. The question is– is what you’re going to ask them
to do to stop it worth more than what they’re getting for it? And so if a child is not suffering because of these actions,
it doesn’t cost the child anything, the chance of the child doing the actions that they’ll need to to stop doing the habit are slim. The response effort’s way too great for the reward that
they get for stopping, so they’re going to continue to do it. And so that’s really kind of more
of a technical way of saying, if there’s really not a motivation to do this,
they’re probably not going to do it. And so my experience is that most treatment
failure is because people are pushing the child into something where there is no consequence– be it a physical
consequence, be it a social consequence, whatever. The child has not seen the consequence of this action
in a meaningful way, and they end up not putting in the effort. That’s my biggest experience in terms of treatment failure. And so what do I do for that?
What I try to do is to explain to parents or caregivers, if the child’s not distressed by these things,
it it’s not physically costing the child anything, if it’s not harming the child,
you really have to ask why you want to do this. If it’s just for you, because you don’t like
the way it looks, then it’s probably not going to work. But if it’s for the child, and the child can
actually get something out of the efforts to stop it, then you have a pretty good shot at making it work. So I think that’s the biggest predictor of a non-responder. WAYNE: That makes perfectly good sense.
And sometimes the best strategy is just to simply train parents to tolerate their child’s idiosyncratic behavior, if it’s not harmful or so socially
stigmatizing that that produces harm actually. Now, let me ask one more follow up related to that, though. Sometimes you probably get children
that the behavior really is harmful– DOUG: But they don’t see it. WAYNE: That’s it, exactly. But the child doesn’t see it. Do you have any thoughts about, well, how do you do
motivational operations for the child to get them to– DOUG: And that’s where we go really
kind of back to the basics of behavior analysis. That’s when we break out the hard contingencies. We really go into more of a DRA, DRO sort of model,
and we really make it about the tangible reinforcers. And we build in that hard reinforcement for doing the actions, because we can’t rely on the naturalistic reinforcers
of improvement to maintain those gains. And so ideally what we try to do is build in the external
rewards very heavily for doing the management strategies, hope that the naturalistic rewards will program themselves
in and eventually fade back the tangibles that we deliver. WAYNE: And that sounds like a good strategy.
In many ways it’s very similar to the way we learn to read. You don’t just learn to read naturally, you have oftentimes
some contrived reinforcers or even tangibles– ratings, and from grades, to special time away if you show reading mastery. And as you begin to acquire that skill,
then you find yourself reading everything– billboards, cereal boxes,
everything under the sun like that because there are some natural consequences
once you’ve gotten to a certain skill level that take over. So it sounds like you’re saying a very similar process
may indeed happen with respect to some of these tics and BFRBs. DOUG: Absolutely.
WAYNE: OK. Very good. Doug, you’ve described kind of a behavioral approach
to treatment of BFRBs that emphasizes change in contextual variables, including antecedents and consequences and also
implementing some of the competing response habit reversal packages. One thing I didn’t remember to ask you about
is alternatives to a behavioral approach to treating BFRBs. And I’m supposing there’s something out there
in the pharmacological end of the treatment continuum. What is your take on those
and pros and cons of pharmacological management? DOUG: There are things that
are out there that are used, but the evidence base behind them is weak. So one of the things that people look at,
they look at trichotillomania, skin picking, and they think, oh, that must be
a nervous habit or an anxiety problem. So they prescribe SSRI medications–
Zoloft, or Prozac, or something like that. The truth is, though, if you look at meta-analyses
of randomized trials done on those drugs, they don’t work. They do nothing, really,
over a placebo for those conditions. They might help a little bit in reducing
anxiety or depression, but they don’t do anything really for the BFRB itself. Clomipramine actually shows
a small effect over placebo pills. But the only drug that really has shown
a relatively robust effect at reducing these things is an over the counter
supplement called antecedal cystine. It’s a glutamate modulator that seems to be–
at least for adults effective, a trial in children failed. But it does seem to beat pill placebo
and is effective in about 56% of the cases. So the drug treatments, although they’re used
relatively frequently for some of these conditions, really there’s not much evidence that they do anything. WAYNE: And I suppose that like other drugs that
they work only as long as you take the medication and keep it at the therapeutic level, obviously. DOUG: We would assume, although there’s
really no evidence to tell us that either. The evidence base is sketchy. WAYNE: So it sounds like then that the preferred
alternative, in terms of evidentiary basis and lack of side effects, would be the behavioral treatment
package you’ve just described. DOUG: I think it’s safe to say that for those BFRBs
that behavior therapy really should be kind of the first line treatment. There really is not much
of an alternative pharmacologically. WAYNE: OK, great. Doug, we’ve arranged
for a clinical simulation using a child actor to play the role of a person with, in this case, a BFRB. I’ve asked you to kind of give us
a little demonstration about the treatment protocol. Would you give us a little introduction as to what
the therapist should be looking for in this clinical demonstration? What are you trying to accomplish,
and what should the person be looking for? DOUG: What we’re doing in this video
is to demonstrate habit reversal– at least two parts of habit reversal
in the treatment of trichotillomania. What we’re looking for is to do
awareness training and competing response training. And so what you’ll see in the video
is we’ll start by trying to get a good description of what this behavior looks like. So you’ll see me asking her to do
it over and over again, and slowing it down, describing it with her words. What we’re trying to do is to get
her to slow down and really think about what the action involves. That’s a part of habit reversal called
response description, that’s part of awareness training. The next thing we’re trying to do is
to get her to notice when she’s pulling in real time. So we’ll start talking about other
events in her life and asking her to tell me when she notices herself
either pulling or about to pull. We call that response detection, and early warning
training is when she tells us when she’s about to pull. It’s a version of response detection. So we have her practice that, and if she catches it,
I say, hey, good job. If she misses it, I say don’t forget. And over and over we practice until we can
get her to reliably detect when the action happens. WAYNE: And does that take
a long time of training typically? DOUG: For typically developing kids,
it doesn’t take more than usually 10 or 15 minutes. When you have a child with autism, the less verbal
they become, the more kind of time it takes to do that. So you should expect to spend a session or two
maybe even just doing that kind of discrimination training. WAYNE: Great. So let’s take a look at what
the video looks like on that particular area in terms of the awareness training component, OK?
DOUG: Sure. DOUG: So Elsa, I understand that you have
a little habit that we’re going to try to work on today. Is that right? What do you do?
What’s your habit? ELSA: I like pulling my hair.
DOUG: Pulling your hair. Is that what you were doing right there?
Were you pulling your hair? Do you always pull from that side,
or do you pull from the other side, too? ELSA: I pull from both,
but I mostly like my left side. DOUG: OK. Can you tell
when that pulling is going to happen? Do you know what’s going on? ELSA: I get really itchy where I want to pull it.
DOUG: Do you? OK. When you pull it–
and do you do anything with the hair? Do you pull it out of your head actually?
ELSA: Yeah. DOUG: What do you do with
the hair after you pull it? Anything? ELSA: I rub it between my fingers.
DOUG: Do you? OK. What do you feel when
you rub it between your fingers? ELSA: Softness.
DOUG: Softness. OK. Do you do anything with the hair after that? ELSA: Throw it on the ground.
DOUG: You throw it on the ground. OK. Do you know that you’re pulling?
Are you aware of it most of the time? ELSA: Yeah.
DOUG: Are you? OK. Well, we’re going to teach you something today,
and we’re going to teach you how to try to stop that action. We’re going to teach you to notice
when you’re starting to do the behavior. And then we’re going to try to give
you something else to do that helps you stop it. And the earlier we can catch it, the better. So we’re going to start by trying to get you
to be even more aware of when you do the pulling. We’re going to try to really get you
to focus in on when you’re doing it. So can you give me from the minute–
before you even start pulling– what it looks like when
you actually do the pulling? Can you describe that for
me just trying to use words? ELSA: Sometimes I aggressively pull. DOUG: Well, even before that.
Let’s say you’re sitting there just like this watching– Do you do it a lot when you’re playing sports,
or watching TV, or when do you usually do it? ELSA: When I’m just sitting around.
DOUG: Just sitting around. OK. So let’s just say you’re sitting around,
and you catch yourself doing it. Can you think of before you even
start to pull what your body is doing? ELSA: It starts tingling in
the spot that I want to start pulling. DOUG: So you start feeling that tingling.
Then what do your hands do? Is it always with your left hand
or your right hand that you pull? ELSA: Sometimes both but usually
the one that is on the side that I pull from. DOUG: So you notice that–
let’s say it’s on your left side and you notice that feeling. What does your hand start to do?
How does your arm go up to your head? Does it go really fast,
or does it go really slow? ELSA: Kind of in the middle.
DOUG: Kind of in the middle. OK. And when your hand goes up there,
does it go right and pull out a hair right away? Or does it do something else? ELSA: It twirls it and then starts
pulling on it and trying to pull it out. DOUG: Well, let’s do a couple of examples. Let’s pretend you’re going to do it
a little bit, just so we can see what it’s like. And I want you to pay attention
as you’re doing that movement. I want you to pay attention to
what your body is doing the whole time. So feelings that you’re getting in your arms,
feelings that you’re getting in your fingers. So just go ahead and do that movement really slow. So where’s the hair right now? ELSA: In between my fingers.
DOUG: It’s in between your fingers. It runs between your fingers.
Put your arm back down, and let’s do that again. Watch what your hands are doing as
you slowly go up to your head and get ready to pull. That’s the second time in a row you’ve
grabbed it between these two fingers. So let’s try it again.
Is that a pattern for you? Is that a habit for you? ELSA: No. I just do it random.
DOUG: OK. Let’s go again. Do you ever– you don’t ever go up and just
grab it with your fingers. You always play with it first. And do you always rub it between
your fingers and then rub it like that? Let’s do it again and watch,
see what else you’re doing. So right now you’ve got
a bunch of hairs in your hand. Do you ultimately ever get– do you always
pull out groups of hairs, or do you pull out just one at a time? ELSA: Sometimes groups and sometimes one. DOUG: You don’t ever pull out that much
that you had in your hand right now, do you? Because that would be a lot of hair at one time. So once you get a big hunk of hair in your hand,
how do you get it down to like one or two? ELSA: Just by taking them
and throwing them on the ground. DOUG: Try to get like one
or two that you might actually pull. OK. Good.
And then you’d rub it between your fingers. Do you play with it like that a lot of times?
ELSA: Yeah. DOUG: One of the things I noticed is when
you had it over to the side, you were looking at it. Is that something you do
a lot before you pull it? ELSA: Yeah, just to make sure
I’m grabbing the right one. DOUG: The right one– what makes
it the right one, do you know? ELSA: It’s just really, really soft.
DOUG: OK. The soft one– good. So just to make sure I have this right,
you’re sitting there and you’re maybe kind of bored, you’re not doing much else, and your hand–
you feel a little tingling in your head. And you get your hand up there,
and you probably grab a bunch of hairs. You kind of run them through your
fingers a little bit, maybe feel them a little bit like that. And then you’ll pull it over and find one that
looks really soft to you, maybe one or two, and then pull that one or two out.
Is that right? Now, when you pull it out,
is it a really fast or is it a really slow kind of pull? ELSA: I pull it out a little slower.
Like when I’m picking out the one, I pick it out slow. And then when I’m pulling it,
I do it fast, so it’s a little bit painless. DOUG: OK. So when it pops out,
you just get it out fast. OK. Good. I’m going to have you try to tell me
when your hand is going up to your head. So we’re going to call that your warning sign.
When you notice that you’re– like that. When your hand starts to go up
to your head, that’s a warning sign. And that will tell us that your pulling is coming. And what I want you to do is
every time you notice that, like your hand starting
to go toward your head, I want you to just raise a finger
and let me know that you caught it, that you noticed that that happened. If you miss it, I’m going to say,
hey, Elsa, don’t forget– raise your finger. Your hand started to go to your head. And if you catch it, I’ll say, hey,
you got it. That’s great. OK? Now, while we’re doing that, all I want
to do is sit here and talk with you about stuff. I’m going to ask you questions about
what you do with your friends, what kind of movies you like, what your TV shows are that you like to watch. But remember, if your hand starts to go
up to your head, I want you to raise a finger and let me know that you caught it. OK? Are you ready?
What are your favorite subjects in school? ELSA: Reading.
DOUG: Reading. Do you have a favorite book series that you like? ELSA: Yeah. I kind of like the “Dork Diaries” series. DOUG: The what?
ELSA: “Dork Diaries.” DOUG: Oh, the “Dork Diaries.”
Oh, don’t forget– your hand’s up there. Remember, the next time your hand
starts to even go up, I want you to catch it and bring it down
and tell me that you caught it. So what’s that series about? ELSA: It’s just about a middle school girl
who has trouble at her new school, because the only person that knows why
she’s there is because she’s on a bug extermination scholarship is the one who’s really mean to her. DOUG: Good. Nice job.
That’s catching it early– the earlier, the better. How many books are in that series? WAYNE: Great, Doug. I see how
the awareness training component works. Now, the next component is
the competing response training component. Tell us what we should be looking for in this
next component, the next part of the video demonstration. DOUG: Sure. So remember, the competing
response is an action that we teach the patient to do whenever they notice that
the habit is getting ready to start. And so we want the competing response
to be something that the patient can do in all different settings, that they don’t rely on anything else to have. And we don’t want to get her to think too much
about what she has to do in one circumstance versus the other, so we try to find something that she can do
that doesn’t require anything else on her body at the time. So we, in this case, had her make
a fist and hold a fist, and it’s a pretty common competing response for hair pulling. Because when you’re doing that,
you actually can’t do the pulling. What we ask them to do is hold that
competing response for a minute whenever they notice that the tic, or in this case, hair pulling, is about
ready to start or actually has even already happened. We’re trying to get them into that new habit
of stopping the action as it’s getting ready to go. And then we practice that in session,
we, again, will talk with her about whatever kinds of events might be happening in her life. And if she notices her hand going up,
she is to go into the competing response and hold that. And if she does that correctly, I praise her. If she misses it, I remind her to use that
competing response when appropriate. At the end of that training, again, for typically
developing kids that can be done usually within the same session as awareness training. For kids with developmental disabilities,
it might take a longer time, a number of sessions sometimes to get that trained up. But once the patient is able to do that, then we want
to make sure that that’s transferring out to the environment. So we send them out with homework assignments of,
look, from here on out, whenever you feel the urge to do that action, or whenever you start that action, you’re to go into
your competing response and hold that for a minute. And then we build in reinforcement– in most
cases that’s the social support piece of habit reversal. But in some cases we actually build in
more obvious reinforcers, more tangible reinforcers. WAYNE: That sounds fantastic. So it looks it’s
a pretty complex– not complex– a pretty east to implement treatment component, and once again, producing
pretty good effects in terms of the impact on tics or BFRBs. DOUG: Yes.
WAYNE: Fantastic. DOUG: OK. Elsa, you did a pretty good job
of catching your pulling before it happened. And remember, the earlier you catch it, the better
it’s going to be, because then you can do something about it. And what we’re going to teach you to do
about it is something called your competing response. We’re going to call it your exercise,
because it’s easier to understand. When we’re trying to stop these
kinds of habits like this, one of the things we want to do is give you something that
you can do that will make your habit impossible to do. And so we’re going to ask you to do this
special exercise whenever you feel like have to pull or even when you start pulling. So if you find your hands up at your
head already, we’re giving to give you an exercise to do then so it stops your pulling cold. So we want to think of something that’s going
to be really hard– it will make it really hard for you to pull your hair when you’re doing
this behavior, when you’re doing this exercise. So if you’re doing this exercise,
it’s almost impossible for you to pull your hair. So we should also have something that you
can do anywhere that you might start pulling your hair. So we want to make it something that you
don’t have to carry a lot of stuff with you to do this exercise, you don’t need anything else to do this exercise,
you can kind of just do it no matter where you’re at. So can you think of something that might be
a good exercise that you could to do that would prevent your pulling from happening, like an exercise
where you couldn’t do the pulling? ELSA: Maybe if I had like–
I don’t know. DOUG: Well, here’s one
that’s pretty common. Go like this. Go like this and now try
to pull your hair without letting that fist go. Can you do it? It gets pretty hard, doesn’t it? You maybe get a little,
but you can’t get them both, right? And you can’t do the thing that you were doing. So that’s one of the things we want to do.
We call this exercise the making a fist. We want you to make a fist whenever you
start to notice that your hand is going up towards your head, or even if you’ve gotten some hair in your hand,
we want you to pull your hands down and hold this fist. Now, we want you to hold this fist like this for a minute. So here’s what it would like.
Let’s say I’m sitting there, and I’m not doing anything. I’m just kind of hanging out, sitting on the couch. And I notice that my hand starts to go up to my
head like this, oh, I caught myself. I want to go right into this fist. And then I’ll hold that for a minute. And then at the end of the minute,
I say, OK, I can let my hands go. And then let’s say I’m sitting there again
and I start to notice my hand going up again. And I catch it, and I’m like, oh–
right back into it. All right? And what you’re doing when you do this
is you’re training your brain to start noticing that you’re going to do the habit,
and then you’re going to try to keep it from happening. And that will become a new habit. So that’s an example
of what that would be like. Now, can you show me
what you understand what that would be? So show me when
you would do this kind of exercise. ELSA: Just sitting.
DOUG: OK. So you’re just sitting. You wouldn’t do it just when you’re sitting.
You would it when you start the action, like your hand starts to go up,
or when you actually start pulling your hair. So show me an example of it when
you catch yourself with your hand going up. Can you show me what that would look like? Oh, caught it.
Now bring your fist down. And let’s do both fists, because remember,
both hands are involved in this, right? So then you would hold that,
and how long would you hold that position? ELSA: A minute.
DOUG: Right, perfect. Now let’s do another time where let’s say you’re
sitting there, and you don’t realize that your hand has gone up. You weren’t paying attention to it. But then all of a sudden you realize
that you had your hair in your fingers, and you were running it through your fingers. Then you would let your hair
go and go right into the exercise. So can you show that to me? Good. And how long do you hold it? ELSA: A minute.
DOUG: Perfect. WAYNE: Well, thank you very much, Doug.
I certainly enjoyed talking with you. And thanks again for your
contributions to this video training series. DOUG: Thank you, Wayne.

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