Child Behavior and Sleep Disorders Quiz

Special Topics - Week #11

• Topic: Habit Disorders
• Presenter: Bev Graham, PhD, MPA, BCBA-D, LBA
• Source: Austin & Carr, Chapter 6
• Description: Habit disorders are repetitive responses with no apparent social function, but are maintained by operant contingencies.

Habit Disorders

• Examples: Tic disorders, trichotillomania, thumb sucking, nail biting
• Maintenance: Automatic reinforcement (self-stimulation or arousal reduction)
• Consequences: Physical damage, social unacceptability

Tic Disorders

• Prevalence: Approximately 1% of the population (motor tics); vocal tics are less clear, but 6.5% of college students engage in throat clearing at least 5 times per day; Tourette's syndrome is .04-.05%.
• Characteristics: Rapid, repetitive, jerking muscle movements (motor tics) or sudden, rapid, recurrent, nonrhythmic vocalizations (vocal tics).
• Concurrent Problems: Obsessive-compulsive behaviors, attention deficit/hyperactivity disorder, aggression management problems, and sleep problems

Development and Current Etiological Theories of Habit Disorders

• Biological: Excess dopamine may be responsible for tics.
• Behavioral: Heightened tension in specific muscle groups; tension reduction maintains tics; presence of an anxiety-provoking person reduces tension.
• Genetic: 77% concordance rate for tic disorders in monozygotic twins.

Trichotillomania

• Prevalence: Approximately 1-4% of the population; adult females are 3 times more likely to receive the diagnosis than males.
• Characteristics: Chronic hair pulling that results in noticeable hair loss; accompanied by tension or anxiety that is relieved by pulling hair.
• Consequences: Chronic hair follicle damage; severe gastrointestinal difficulties if hair is ingested.

Thumb Sucking

• Prevalence: Up to 46% of children under age 4; 19% over age 5; 2.8% of college-age adults.
• Characteristics: A learned behavior in infancy to modulate arousal.
• Consequences: Dental malocclusion, atypical root resorption, increased risk of accidental poisoning.

Nail Biting

• Characteristics: Placing any digit in the mouth and biting nails or skin around nails.
• Consequences: Tissue damage or inflammation around nails, possible infection, and shortening of tooth roots.

Development and Current Etiological Theories of Habit Disorders - Nail Biting

• Biological: Biological processes affected by clomipramine; clomipramine is effective in treating OCD.
• Behavioral: Maintained by tension/ anxiety or increased arousal in understimulating situations.

Assessment of Habit Behaviors

• Duration measures are best for longer behaviors like thumb sucking, nail biting, and hair pulling.
• Physical trace measures may not always directly correlate with the behavior's level of occurrence (damage).

Measuring Habit Behaviors

• Direct observation (live or videotaped) is preferred for habit behavior assessments.
• Physical trace procedures (e.g., measuring nail length) can be used for particular habit behaviors.

A Functional Approach to the Assessment of Habit Disorders

• Purpose: Provides data for modifying etiological theories and treatment plans.
• Method: Functional analysis that identifies functions of behavior through antecedent and consequence manipulation.

Treatment of Habit Disorders (Tic Disorders Medical Treatments)

• Medications: Haloperidol, clonidine, and pimozide
• Side Effects: Dry mouth, constipation, sedation, possible risk of developing permanent movement disorders like tardive dyskinesia

Behavioral Treatments

• Massed/Negative Practice (MP): Deliberately engaging in the target behavior rapidly and intensely for a set time or frequency.

• Habit Reversal (HR): Multi-component procedure for nervous habits and motor tics; increases awareness of the behavior via response description, detection, early warning, and situation awareness training.

• Competing Response (CR) Training: Client engages in a behavior incompatible with the target habit behavior.

• Motivation Training: Method to increase motivation, including habit inconvenience review, public display, social support procedure, and symbolic rehearsal.

• Relaxation Training: Useful for tics; functions as a dissimilar competing response.

Trichotillomania - Medical Treatments

• Medications: Fluoxetine, clomipramine, imipramine, haloperidol, and lithium.

Trichotillomania - Behavioral Treatments

• Habit reversal: Most effective in group settings (60% success rate).
• Simplified HR package: Consists of awareness training and reinforcement training with parental social support.
• Self-monitoring: Also shows positive results.
• Other Treatments: Aversive conditioning; elimination of co-occurring habits like thumb sucking; reinforcement/punishment procedures.

Thumb Sucking - Medical Treatments

• No medications are used for chronic thumb sucking.

Thumb Sucking - Behavioral Treatments

• Popular approaches: Bitter substance application, Habit reversal.

Nail Biting - Medical Treatments

• Clomipramine is the only attempted medical intervention.

Behavioral Treatments - Habit Disorders

• Self-monitoring: Demonstrated to be effective.
• Habit reversal: Evaluated in several studies.
• Other treatments: Electric shock (portable self-administered shock device), bitter substances, contingency contracting, covert sensitization.

Feeding Disorders

• Prevalence: Over 60% of children
• Causes: Neurological (62%), structural (53%), behavioral (43%), cardio-respiratory (34%), metabolic (12%).
• Complication: Usually multiple causes.
• Vulnerable groups: Children with autism spectrum disorder, cerebral palsy, and Down syndrome.

Causes of Feeding Disorders

• Direct effects on digestive system (e.g., GERD)
• Digestion problems (e.g., allergies, intolerances)
• Food reactions (e.g., discomfort, pain)
• Anxiety and reluctance to eat due to these causes.
• Taste aversions (single or repeated negative experiences).

Maintaining Factors in Feeding Disorders

• Access to adult attention or tangible items reinforce negative behaviors.
• Escape from food presentation/mealtime demands.
• Environmental events reinforce inappropriate behaviors.

Treatment of Feeding Disorders

• Stimulus fading: Gradual introduction to new textures and eating methods.
• Utensil manipulation: Increasing mouth cleanliness and decreasing food packing.
• Applied Behavior Analysis (ABA): Treatment for feeding challenges, including increasing food variety, utensil use, restaurant eating, and improving swallowing, and reducing mealtime tantrums.
• Chewing and swallowing coordination: Crucial for eating development; a mismatch can worsen issues.

Behavioral Pediatrics

• Exploration of how children's behavior connects to their health needs.
• Focus: Psychological and emotional well being alongside physical health.
• Role: Early intervention and support.

Rates of Behavioral Disorders in Pediatrics

• Prevalence: Approximately 25% of children exhibit symptoms of behavioral disorders in primary care.
• Other symptoms: 40% or more of children display subclinical behavior concerns.

Key Principles of Behavioral Pediatrics

• Behavior is influenced by current and past circumstances and contexts.
• Interventions are tailored to the individual needs of each child and addressing issues like discipline, incontinence, sleep, and ADHD.

Bedtime Problems

• Prevalence: 30% of families experience sleep issues.
• Difficulties: Resistance, fussing, crying, night waking.
• Treatment: Use of soporific drugs (but with side effects and limited long-term efficacy).

Understanding and Treating Sleep Problems of Children with Autism

• Significance: Sleep disruption significantly impacts family dynamics and children's health and emotional stability.
• Importance: Recognizing the needs of children with autism is crucial for treatment.
• Factors: Irritability, fatigue, unintentional injuries, difficulty following instructions or learning concepts, problem behaviors.

How Prevalent Are Sleep Problems in Children?

• Young children: 35-50%
• Autism: 63-73%

Treatment Options for Children's Sleep Problems

• Medication: Commonly prescribed without FDA approval for pediatric insomnia.
• Issues: Inconsistent or limited effectiveness, often with noticeable side effects.

Common Sleep Problems

• Nighttime routine noncompliance: Difficulty following instructions
• Sleep-interfering behavior: Behaviors that hinder sleep.
• Delayed sleep onset: Difficulty initiating sleep.
• Night awakenings: Waking up during the night
• Early awakenings: Waking up too early.

Assumptions Regarding Sleep

• Sleep behavior is influenced by past and present events, motivation, environmental cues, and other competing reinforcers.
• Assessment Methods: Open-ended, indirect assessment to identify factors influencing sleep.
• Tool: Sleep Assessment and Treatment Tool (SATT).
• Implementation: Support of parents in applying assessment-based treatment via communication.

Steps to Treat Children's Sleep Problems

• Develop ideal sleep schedule
• Routinize bedtime routine
• Optimize bedroom conditions (e.g., cooler temperature, minimal noise, indirect lighting).
• Regularize sleep dependencies (e.g., reduce reliance on specific stimuli).
• Address sleep-interfering behavior (e.g., eliminate or reduce negative behaviors).
• Age-based sleep averages (1-18)
• Sleep Scheduling and Cautions: Adjusting bedtime slightly and making gradual transitions, considering sleep total, consistency.

Encopresis

• Fecal retention: Primary driver of encopresis.
• Contributing Factors: Gastrointestinal transit time, dietary choices, pain during stool passage, negative reinforcement.
• Related conditions: Trauma, other neurological issues.

Encopresis - Medical Factors

• Constipation: Major role in developing encopresis due to fecal impaction
• Neurological conditions, such as Hirschsprung's disease.
• Anatomical defects: May necessitate medical intervention.

Encopresis - Behavioral Assessment

• Interviews: Identify factors related to constipation.
• Essential questions:
  • Length of intervals between bowel movements?
  • Size and presence of foul odor in stools?
  • Difficulty, pain, discomfort during bowel movements?
  • Awareness of the urge to defecate?
  • Hiding soiled underwear?

Incentive Programs

• Structure: Breaks comprehensive regimens into smaller, manageable steps.
• Rewards: Tokens/points earned for completing steps, creating clear links between effort and reward.
• Consistency reinforcement: Removing tokens/points for non-compliance underlines the importance of consistency.

Rapid Toilet Training (Azrin & Fox, 1971)

• Population: Incontinent males with profound disabilities.
• Procedure: Treatment protocol (Appendix) and automated system for immediate reinforcement for successful toileting.
• Apparatus: Moisture sensitive shorts, alarm system that sounds via urination/defecation, for immediate reinforcement to be successful.

Social Validity of Procedures

• Positive Reinforcement: Residents received significant positive reinforcement.
• Noncompliance: Residents often resisted exiting the toilet area at the end of training sessions
• Aggression/Disruptive behaviors: No reported instances.

Toilet Training

• Prevalence: 30-50% of children with ASD.
• Developmental milestone: Typically begins between 18-30 months.
• Collaborating Roles: Childcare centers and pediatricians can help initiate the training program.

Comparison of Toilet Training Methods (Underwear, Dense Sit, Differential Reinforcement)

• Detailed description of procedures used.

Toilet Training Participants

• 20 children across three classrooms with varied teacher-child ratios.
• Training conducted by undergraduate students participating in a practicum course.

Toilet Training Procedures

• Detailed reporting of assessments and procedures

Baseline Procedures

• Subjects wore disposable diapers/pull-up training pants.
• Prompted to sit on the toilet regularly, and rewarded with preferred items after successful bowel movements.

Conclusions

• Implications for future research on toilet training
• Discussion of areas for improvement, including specific behaviors and additional factors, to measure the success of the program and collect additional data