Augmenting simplified habit reversal with an awareness enhancement device: preliminary findings

Pilot trial of a technology assisted treatment for trichotillomania

The present study examined the usability, acceptability, feasibility, and preliminary efficacy of a prototype wrist-worn motion detection device and accompanying mobile app, developed by HabitAware®, as a system for delivering self-administered Habit Reversal Training (HRT). As an exploratory aim, the effect of the device and HRT app combination was compared to a reminder bracelet. The pilot trial included 15 adults with trichotillomania who interacted with the device and app system (n = 10) or reminder bracelet (n = 5) for 4 weeks. Participants in the device and app condition reported high usability, acceptability, and perceived efficacy of the system. The device and HRT app combination reduced hair pulling severity. Individuals in the reminder bracelet condition also showed a significant improvement in hair pulling. A future efficacy study with a larger sample size, longer timeframe, and improved gesture detection algorithm is warranted.

Preventing Undesired Face-Touches With Wearable Devices and Haptic Feedback

The alarming morbidity of COVID-19 has drawn the attention to the social role of hygiene rules, with a particular focus on the importance of limiting face-touch occurrences. To deal with this aspect, we present No Face-Touch, a system able to estimate hand proximity to face and notify the user whenever a face-touch movement is detected. In its complete setup, the system consists of an application running on the smartwatch and a wearable accessory. Its ease of implementation allows this solution to be ready-to-use and large-scale deployable. We developed two gesture detection approaches compatible with sensors embedded in recent smartwatches, i.e. inertial and magnetic sensors. After preliminary tests to tune target gesture parameters, we tested the two approaches and compared their accuracy. The final phase of this project consisted in exploiting the most robust approach in a daily living scenario during a 6-days campaign. Experimental results revealed the effectiveness of the proposed system, demonstrating its impact in reducing the number of face-touches and their duration.

Reducing risky behavior with habit reversal: A review of behavioral strategies to reduce habitual hand-to-head behavior

Habit reversal training (HRT) has been a mainstay of behavior analysts' repertoire for nearly the last 50 years. HRT has been effective in treating a host of repetitive behavior problems. In the face of the current coronavirus pandemic, HRT has practical public health importance as a possible intervention for reducing hand‐to‐head behaviors that increase the risk of viral infection. The current paper provides a brief review of HRT for hand‐to‐head habits that is designed for a broad audience and concludes with practical suggestions, based on HRT, for reducing face‐touching behaviors.

Awareness Enhancing and Monitoring Device plus Habit Reversal in the Treatment of Trichotillomania: An Open Feasibility Trial

Habit Reversal Therapy (HRT) is helpful for many persons suffering from trichotillomania. However successful habit reversal therapy requires awareness of hair pulling behaviors. Available methods to monitor hair pulling behaviors are less than ideal, particularly when sufferers are unaware of their pulling-related behaviors. This open feasibility trial included 20 persons with trichotillomania who were treated with nine weeks of HRT with experienced clinicians following a well-established HRT protocol. HRT was augmented with an electronic Awareness Enhancing and Monitoring Device (AEMD) designed to alert users of hand to head contact and to monitor the frequency of pulling-related behaviors. The AEMD included a neck unit and two wrist units, each equipped with vibrating alert functions. The results of the open trial revealed significant improvements in trichotillomania symptoms as measured by clinician and self-report rating scales. Most participants met study criteria for HRT completion and treatment effects were large. Participants reported that the AEMD, when operational, was effective in alerting participants to TTM-related behaviors. The monitoring function of the AEMD did not operate as designed. Subjective feedback focused on the AEMD concept was positive but AEMD reliability problems and complaints about the wearability the units were common. Recommendations for AEMD design modifications were included.

Habit Reversal Therapy for Body-Focused Repetitive Behaviors in Williams Syndrome: A Case Study

Williams syndrome (WS) is genetic neurodevelopmental disorder with a well-characterized cognitive and behavioral phenotype. Research has consistently demonstrated high rates of psychopathology in this population; however, little research has examined the use of empirically-supported psychosocial interventions in those with WS. The current case study reports on the use of Habit Reversal Therapy (HRT) to treat multiple body-focused repetitive behaviors in a child with WS. Although HRT is a well-established cognitive-behavioral intervention for body-focused repetitive behaviors, it has been infrequently used in populations with developmental disabilities. An etiologically-informed approach was used to adapt HRT to fit the known behavioral and cognitive phenotype of WS. Results suggest that HRT may be beneficial for this population. Modified treatment elements are described and future research areas highlighted.

A technology-based stimulation program to reduce hand mouthing by an adolescent with multiple disabilities

This study assessed the possibility of reducing hand mouthing, i.e., bringing fingers into or over the mouth, by an adolescent with multiple disabilities through a technology-based stimulation strategy. The strategy ensured that (a) the participant received 10 sec. of preferred stimulation contingent on the response of bringing both hands into a box with objects, and (b) the stimulation would be interrupted prematurely if the participant removed one or both hands from the box for 2 sec. The study involved an ABAB sequence (in which A represented baseline and B intervention phases) and a 3-mo. postintervention check. Data showed that the response of bringing both hands into the box increased from a mean frequency of about four per 10-min. session during baseline to a mean frequency of over 30 per session during the second intervention phase and the postintervention check. During these periods, the participant's mean hand-mouthing time per session was below 1.5 min. (compared to above 7 min. during baseline) and the mean stimulation time per session was about 4 min. Practical implications of the findings are discussed.

The phenomenology of hairpulling in a community sample

Assessment and treatment of trichotillomania (TTM) has evolved substantially over the past decade. However, standardized assessment and empirically supported treatment for TTM is still in early stages of development. We proposed that information important to the ongoing evolution of assessment and treatment could be obtained through the study of hairpulling across its range of severity. Hairpulling phenomenology was assessed in a large community sample across its range of presentation. Although the estimated prevalence rate of .6% for TTM is congruent with past studies, the 1.2% prevalence estimated for clinically significant hairpulling suggests that the current diagnostic criteria are overly restrictive. Overall, hairpulling occurred at a rate of 6.5%, while age of onset was 15.92 years. Symptoms of depression, anxiety, and history of teasing were positively associated with hairpulling, while self-esteem was negatively related to hairpulling. Cognitions most commonly associated with hairpulling were "feels coarse" (53.3%), "doesn't feel right" (30.0%), "is curly" (26.7%), and "doesn't look right" (23.3%). Environments most commonly associated with hairpulling included "while reading" (38.9%), "while watching television" (37.0%), and "in class" (35.25). Applications of findings to assessment and intervention formulation are suggested, and limitations and future directions are discussed.

Prototype awareness enhancing and monitoring device for trichotillomania

Trichotillomania is an impairing condition that involves repetitive hair pulling. Habit reversal therapy is helpful for many persons with this disorder. Unfortunately, habit reversal therapy is not helpful for everyone and maintenance of gains is often problematic. Successful habit reversal therapy requires the individual to be aware of hair pulling and handling. Unfortunately, most people with trichotillomania report that much of their plucking occurs outside of awareness. Monitoring of trichotillomania behaviors is also problematic. The present project involved a pilot study of a prototype awareness enhancing and monitoring device aimed at increasing the effectiveness of habit reversal therapy. The device included a watch, bracelet, magnetic necklace, and a pager that was hard-wired for remote activation of a vibrating alert when hair pulling behaviors occurred. Following structured diagnostic assessment, three female participants were randomly assigned to be initially observed for varied lengths of time without the device followed by observation with the device in place. The results indicated a marked reduction in trichotillomania behaviors when the device was in place. Semi-structured interviews revealed that the device was very effective in enhancing awareness and monitoring of trichotillomania related behaviors and enthusiastic acceptance of the device was provided by all participants.

Cognitive-behaviour therapy and skilled motor performance in adults with chronic tic disorder

The first aim of the present study was to compare performance of people with tic disorders (TD) and controls on executive function and a range of skilled motor tests requiring complex performance, guided movements, hand co-ordination, and fine control of steadiness. The second aim was to investigate the effect of cognitive behaviour therapy (CBT) on motor performance. A total of 55 patients with TD were recruited at baseline from participants in a behavioural management programme. A comparison group of 55 patients suffering from a variety of habit disorders (HD) involving complex manual movements, were matched on age and level of education to 34 non-psychiatric controls. Participants were evaluated pre- and post-treatment and post-waitlist with a neuropsychological evaluation focusing on executive function (Wisconsin Card Sorting Test, WCST) and skilled motor performance (Purdue Pegboard, Hole Steadiness Test, and the Groove Test). Results revealed WCST scores in the normal range, while motor performance differed significantly on the Purdue Pegboard Tests in both TD and HD as compared to the control group. Cognitive-behavioural treatment selectively improved motor performance in both clinical groups compared to waitlist control, and this improvement related to clinical outcome measures.

Behavior therapy in tic-disorders with co-existing ADHD

OBJECTIVES

To give an overview concerning the behavioral treatment approaches for Chronic Tic Disorder (CTD) and Attention-Deficit/Hyperactivity Disorder (ADHD) and to provide some suggestions for the behavioral treatment of children and adolescents with a combination of both disorders.

RESULTS

Pharmacotherapy plays an important role in the treatment of both ADHD and CTD. However, behavior therapy has also been proven to ameliorate the core symptoms of both disorders. The most prominent behavioral technique to reduce tics is habit reversal training. In ADHD behavioral interventions, especially parent training and behavioral interventions in preschool/school, are effective in reducing ADHD core symptoms and comorbid problems. In children and adolescents with ADHD plus CTD both ADHD and tic symptoms can be treated by behavioral interventions alone or in combination with pharmacotherapy. However, most of the published studies on behavioral interventions in children with ADHD or CTD do not give detailed information on comorbidity and many studies excluded patients with comorbid problems.

CONCLUSIONS

Clinical experience suggests that in CTD+ADHD success may be easier to achieve using behavioral treatment of ADHD first. Adherence to the habit reversal procedure to reduce tics in daily living is the most important problem in the behavioral treatment of tics especially in children with comorbid ADHD. Practical suggestions to overcome these difficulties are presented.

Stereotypy I: a review of behavioral assessment and treatment

In this paper, we review definitional issues related to stereotypy, behavioral interpretations of stereotypy, procedures for determining operant function(s) of stereotypy, and behavioral interventions for stereotypy. In general, a preponderance of the assessment literature suggests that most forms of stereotypy are maintained by automatic reinforcement. Review of the treatment literature suggests that antecedent (e.g., environmental enrichment) and consequent (e.g., differential reinforcement of alternative behavior) interventions produce at least short-term reductions in stereotypy. Suggestions for further assessment and treatment of stereotypy are provided.

Functional analysis and treatment of problem behavior evoked by noise

We conducted a four-part investigation to develop methods for assessing and treating problem behavior evoked by noise. In Phase 1, 7 participants with developmental disabilities who were described as being hypersensitive to specific noises were exposed to a series of noises under controlled conditions. Results for 2 of the participants verified that noise was apparently an aversive event. In Phase 2, results of functional analyses indicated that these 2 participants' problem behaviors were maintained by escape from noise. In Phase 3, preference assessments were conducted to identify reinforcers that might be used during treatment. Finally, in Phase 4, the 2 participants' problem behaviors were successfully treated with extinction, stimulus fading, and a differential-reinforcement-of-other-behavior (DRO) contingency (only 1 participant required DRO). Treatment effects for both participants generalized to their home environments and were maintained during a follow-up assessment. Procedures and results were discussed in terms of their relevance to the systematic assessment of noise as an establishing operation (EO) and, more generally, to the identification of idiosyncratic EO influences on behavior.

Evaluation of an awareness enhancement device for the treatment of thumb sucking in children

An evaluation of the awareness enhancement device (AED) described by Rapp, Miltenberger, and Long (1998) was conducted with 2 children who engaged in thumb sucking past the age at which it was developmentally appropriate. The AED effectively suppressed thumb sucking for both children. Future research evaluating the AED is discussed.

Using real-time recording to enhance the analysis of within-session functional analysis data

Functional analysis methods have become standard practice for determining the maintaining variables of problem behavior. The analysis of within-session response patterns has been proposed as a useful adjunct to the functional analysis. Many within-session analyses have been conducted on data obtained from interval scoring methods. However, interval methods only provide an estimate of within-session data. The authors briefly describe a real-time recording method and provide a rationale for its use. The authors then provide descriptions of several research studies from their lab in which real-time data were crucial in determining behavioral function from experimental analyses.

The problem of parental nonadherence in clinical behavior analysis: effective treatment is not enough

Applied behavior analysts have developed many effective interventions for common childhood problems and have repeatedly demonstrated that childhood behavior responds to properly managed contingencies. The success of these interventions is dependent upon their basic effectiveness, as demonstrated in the literature, their precise delivery by the clinician to the parent, and adherence to or consistent implementation of the intervention. Unfortunately, arranging the consistent implementation of effective parenting strategies is a significant challenge for behavior analysts who work in homes, schools, and outpatient or primary care clinics. Much has been done to address issues of adherence or implementation in the clinic, but relatively little has been done to increase our understanding of the contingencies that affect parental adherence beyond the supervised clinic environment. An analysis of the contingencies that strengthen or weaken adherence might suggest strategies to improve implementation outside the clinic setting. What follows is an analysis of the variables associated with adherence by parents to recommendations designed to solve common childhood problems.

Analysis and treatment of finger sucking

We analyzed and treated the finger sucking of 2 developmentally typical children aged 7 and 10 years. The functional analysis revealed that the finger sucking of both children was exhibited primarily during alone conditions, suggesting that the behavior was maintained by automatic reinforcement. An extended analysis provided support for this hypothesis and demonstrated that attenuation of stimulation produced by the finger sucking resulted in behavior reductions for both children. Treatment consisted of having each child wear a glove on the relevant hand during periods when he or she was alone. Use of the glove produced zero levels of finger sucking for 1 participant, whereas only moderate reductions were obtained for the other. Subsequently, an awareness enhancement device was used that produced an immediate reduction in finger sucking.