“Help! My Brain’s Stuck!” Repetitive Behaviours (RBs) in Children and Adolescents Ontario Psychological Association Conference Friday February 20 th , 2015 Drs. Kim Edwards, Holly McGinn, & Sandra Mendlowitz
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“Help! My Brain’s Stuck!” Repetitive Behaviours (RBs) in
Children and Adolescents
Ontario Psychological Association Conference Friday February 20th, 2015
Drs. Kim Edwards, Holly McGinn, & Sandra Mendlowitz
Conflicts of Interest
None to disclose
Test YOUR Repetitive Behaviour IQ
1. Which is not an RB? (multiple choice: pick 1)A. TrichotillomaniaB. OnychiphagiaC. AutismD. Dermatillomania
2. RB's are maintained by (multiple choice: pick 1)A. A cycle of reinforcementB. Elevated dopamine levelsC. School failureD. Allergies
Test YOUR Repetitive Behaviour IQ
3. What are the two most common comorbid disorders with Tourette Syndrome?
4. Hair pulling usually develops as a result of a traumatic experience. (true/false)
5. In early childhood (e.g., 2-6 yrs old), many children demonstrate some obsessive-compulsive behaviors that are part of normal development. (true/false)
Outline & Learning Objectives
What are RBs? Why study RBs?What causes & maintains RBs? (Behavioural Model)
Tourette Syndrome (TS)Trichotillomania (TTM)Obsessive Compulsive Disorder (OCD)
Similarities & Differences among RBsDevelopmental IssuesLeaky Brake Analogy
What are RB’s?
Labels Body Focussed RBs Obsessive-Compulsive (OC) Spectrum Conditions Impulse Control Disorders
Behaviours Dermatillomania/Excoriation (Skin Picking) Onychiphagia (Nail Biting) Trichotillomania (Hair Pulling) Tics Compulsions Stereotypies (Autism)
“Nervous Habits” or Actual Problems?
Why Study RBs?
$
RBs: Myths and Facts
Not as severe as other psychiatric conditions
UncommonSocially acceptablePurposefulOnly impact the individual with the RB
Etiology
Genetics
Brain Circuits Cortico-striatal-thalamo-cortical (CSTC) circuits
Neurotransmitters Dopamine, Serotonin, Noreepinephrine
Environment
Behavioural Model of RBs
Internal Environment
TTM
Tics
OCD
Behavioural Model of RBs
External EnvironmentNegative Reinforcement
o absolved of expectations or demands
Positive Reinforcement o attention, comfort, support, reward
Homework
Because you have
tics
Tics & Tourette Syndrome (TS)
Meet Brad
Tics: Assessment & Diagnostic Issues
Tic Disorders (DSM 5): Tourette Syndrome Persistent (Chronic) Motor or Vocal Tic Disorder Provisional Tic Disorder
Motor Vocal Simple
Blinking Throat clearing
Complex Facial grimace + Head twist
Echolalia
Sudden, rapid, recurrent, non-rhythmic motor movements or vocalizations
Premonitory Urge
Relatively common (20%)
More common in boys (4:1)
Comorbid Conditions (The “+” in TS+) ADHD = 50%, OCD = 30 - 40 %
(Himle & Woods, 2005; Scahill et al., 2005; Scahill et al., 2009; Woods & Himle, 2004; Woods 2008)
Tics: Assessment & Diagnostic Issues
Course
(e.g., Leckman et al., 1998; Woods & Specht, 2013)
Onset Ages 4-
7
Peak Severity
Ages 10-12Decline
in severity for most
W A X and W A N
E
Comprehensive Behavioural Intervention for Tics
Internal Environment: Habit Reversal Training
Awareness TrainingCompeting Response
External Environment:Positive and Negative ReinforcementPsychoeducation
(Woods et al., 2008)
CBIT
CBIT Efficacy
European clinical guidelines for TS & other tic disorders,
2011Canadian guidelines
for the evidence-based treatment of tic
disorders, 2012
Practice Parameters for the Assessment & Treatment of Children & Adolescents with Tic
Disorders, 2013
Tics: Tips & Tricks
Education is often the only treatment needed
Don’t forget about the comorbid conditionsShift in the way we think about tics
Ignore vs. Increase awareness?
(Bennett et al., 2013)
Brad Cohen
Trichotillomania (TTM)
TTM (Hair-Pulling Disorder)
DIAGNOSTIC CRITERIADSM 4TR – Impulse Control Disorders Not Elsewhere
Classif.DSM-5: Obsessive Compulsive Disorders & Related
Disorders
DSM 4-TR
DSM 5
Recurrent pulling out of one’s hair resulting in hair loss √ √
Increasing sense of tension immediately before pulling out the hair / when attempting to resist behavior
√
Pleasure, gratification, or relief when pulling out the hair √
Repeated attempts to decrease or stop hair pulling.
√
The disturbance (hair pulling- DSM 5) is not better accounted for by another mental disorder and is not due to a general medical condition (e.g., a dermatological condition)
√ √
The disturbance (hair pulling- DSM 5) causes clinically significant distress or impairment in social, occupational, or other important areas of functioning
√ √
The hair pulling is not better explained by the symptoms of another mental disorder (e.g., attempts to improve a perceived defect or flaw in appears in body dysmorphic disorder)
√
Developmental PerspectivesPulling/Picking Sites
Site % Adults % ChildrenScalp 79 85Eyebrows 65 52
Eyelashes 59 38
Legs 59 27
Arms 30 18
Pubic 17 9
other 25 -
More than one site
- 58
The Trichotillomania Impact Project: Exploring Phenomenology, Functional Impairment, & Treatment Utilization J Clin Psychiatry 67:12, December 2006
Developmental PerspectivesPulling/Picking Characteristics
Pulling/Picking Characteristic
Adults% of time
Children
Unpleasant urges prior 71-89% 29% never/almost never experienced pre-tension
To achieve a certain bodily sensation
30-70% 13% never/almost never “pleasure or relief”
Preceded by bodily sensation
71-89% -
Preceded by anxiety 0-10% -
Urge increases when resisting
71-89% -
Post pulling anxiety 90-100% -
Awareness of pulling 71-89% 4% never/almost neverThe Trichotillomania Impact Project: Exploring Phenomenology, Functional Impairment, &
Treatment Utilization J Clin Psychiatry 67:12, December 2006
Pulling se
verit
y
adults=child
ren
Children m
ore
likely
to pull/pick
other p
eople, dolls
,
pets
TTM -Rituals
Tactile stimulation of lips or face.A need to pull in a particular manner.Ritualistically placing, saving, or discarding hairs.Twirling, rolling, or examining the hair.Hairs that don’t feel right (i.e. coarse).Hairs that don’t look right (i.e. color).Compelled to achieve an absolutely even hairline.Need to extract an intact hair bulb.Need to bite or mince the hair or bulbSwallowing hair (trichophagy)
http://www.ohsu.edu/
TREATMENT
Cognitive Behavioral TherapyIdentify distorted thinking and
challenge thoughtsRelaxation training
Behavioral – Habit Reversal Training
Treatment
Habit Reversal Training
Awareness
training
Stimulus contro
l
Competing response
TREATMENT STEPS
Monitoring of Symptoms (pulling/picking) CBT Intervention:
Cognitive restructuring, coping thoughts Relaxation exercises, stress management
Tactile Interventions: Finger tip bandages, gloves, bracelets, glasses, hats, etc. Silly putty, thinking putty, worry beads, soft brush
Sensory Interventions: Numbing cream, brushing hair Gummy bears, sunflower seeds, dental floss, Khoosh balls, frayed
blankets, smurfs
Environmental Interventions: Removing tweezers, covering mirrors
Habit Reversal Training: Awareness training, stimulus control, competing response
CASE: “EMILY”
Initial Assessment:10 year old; intact family6 month history of eyelash pulling; no
eyelashes at assessmentSeveral year history of nail bitingStressors:
Increased parental conflict Bullying incident at school; largely resolved.
Good studentNo comorbid anxiety or mood issue
CASE: “EMILY”
Family History: Father suffers from OCD
Recommendations: “focus on catching herself when urge to pull” “talking to parents” “relaxation tapes” “marital therapy”
Result: Limited Effectiveness
CASE: “EMILY”
NOW 13 years old … REASSESSMENT
Lash pulling waxed and waned x 3 years
Currently no lashes
Parents used rewards with variable effectiveness
Emily expressed high motivation to change
Some anxiety in social situation (secondary to trich)
PLAN:
CBT + Monitoring + Habit Reversal Training
CASE: “EMILY”
CASE: “EMILY”
16 sessions CBT + Habit Reversal Training Session 5: eyelash regrowth Session 7: “more confident” Session10: healthy lashes Session 13: no pulling
Follow-up: 2 months later pulling apparentFollow-up: 4 months later no pulling/pickingSeen in periodic follow-up: 2 years later
no pulling/picking
TTM – Keys to Successful Outcomes
Thorough and knowledgeable assessment
Emphasize treatment is a process
Motivational for change
Use of first line treatments:Cognitive Behavioral (CBT) and Habit Reversal Training
Obsessive-Compulsive Disorder (OCD)
Meet Claire
OCD: Assessment & Diagnostic Issues
Obsessions and/or compulsions that take up more than an hour a day and cause significant distress or impairment
Obsessions Recurrent and persistent thoughts, urges, or
images that are intrusive and unwanted
Compulsions Repetitive behaviors or mental acts that one
feels driven to perform in response to an obsession or according to rules
OCD: Assessment & Diagnostic Issues
Common themes: Contamination and cleaning Checking or symmetry Ordering or counting Fear of harm to self or others
Lifetime prevalence = approx. 2%, chronic, fluctuates
Mean age of onset is bimodal peaks at 11 and 23 years
Early-onset OCD More common in boys than girls More likely comorbid with tics Generally more severe
1st PeakAge 11
2nd Peak
Age 23
Treatment Guidelines for OCD (CBT and SSRIs) Efficacy
CBT alone or CBT with
SSRI
Practice Parameters
for the Assessment & Treatment of Children & Adolescents with OCD,
2012
Cognitive Behavioural Therapy (CBT)
Controlled studies support the efficacy of Cognitive Behavioural Therapy (CBT) that emphasizes Exposure and Response Prevention (ERP)
Parental involvement is crucial for success
Child not responsible for
controlling symptoms
Child responsible for controlling
symptoms
Parents accept/tolerate
symptoms
Parents do not accept symptoms
CBT for OCD: Critical Components
Treatment Component
Operational Definition
Psychoeducation Both the child and the family need to have an accurate understanding of OCD
Symptom Monitoring Identify/track sx frequency and duration; Set targets to work towards
Relaxation Training Deep Breathing, Muscle Tension Relaxation, Imagery
Cognitive Strategies Generate and reinforce accurate thoughts to challenge obsessions and compulsions
Exposure & Response Prevention (ERP)
Confronting an OCD-eliciting situation (action, object, place, etc.) while preventing the associated compulsions and/or avoidance
Homework Change cannot occur exclusively through CBT sessions; strategies must be practiced at home
Childhood OCD: Tips & Tricks
Childhood and adult OCD are more similar than not. However, some differences exist :
Obsessions develop later that compulsions
Poor insight is more common in children
Children tend to under-estimate the impact of their OCD
Children are more likely to present with comorbid OCD and tics
Comparing & Contrasting RBs
Similarities vs. Differences
8 statements on the next 2 slides
Decide whether statement is a similarity (applicable across the RBs discussed – OCD,
TTM, TS) or
whether it is a difference (applicable to 0,1 or 2 but NOT all RBs
discussed)
Similarities vs. Differences
(1)Behaviour done in response to a sensation
(2)Comorbidities are common & frequent
(3)Competing responses are part of treatment
(4)Onset usually before age 10
Similarities vs. Differences
(5) Symptoms wax and wane
(6) Personal distress required for treatment
(7) More common in males
(8) Medications could be useful
How did you do?
Similarities Differences
(2) Comorbidities = common + frequent
(5) Symptoms wax & wane
(8) Medications could be useful
Similarities vs. Differences
(1) Behaviour done in response to a sensation(3) Competing responses are part of treatment(4) Onset usually before age 10(6) Personal distress required for treatment(7) More common in males
Comprehensive Comparison
Developmental Issues
“I’m not sure if I’m ready to change”
Unconcerned by RB
Lack of insight into RB
Parent involvement
Brake Shop Model
Welcome to the Leaky Brake ClubLeaky brakes over movements and/or sounds
(TICS)Leaky brakes over thoughts (OCD)Leaky brakes over urges (TTM)
Leaky brakes over attention +/or impulsivity (ADHD)
Leaky brakes over behaviour (ODD, CD, rage)Leaky brakes over senses (Sensory integration
disorder)
An Analogy for Understanding RBs
Welcome to the Leaky Brake Club!!
YOU = Driver
Welcome to the Leaky Brake Club!!
Welcome to the Leaky Brake Club!!
Welcome to the Leaky Brake Club!!
Welcome to the Leaky Brake Club!!
UH –OH!!!!
Welcome to the Leaky Brake Club!!
UH –OH!!!!
You Say….
BUT I DIDN’T DO IT!I TRIED TO STOPTHE BRAKES DIDN’T WORK…
I’m not a reckless individual.I shouldn’t lose my drivers licence.
Now imagine you had to drive around in a car that had leaky brakes ALL the
time.
Wouldn’t YOU be frustrated?
Take Home Messages
Leaky Brakes = Help child understand RBSociety: “Just Stop” vs. Patient: “I would if I
could”Awareness of behaviour & reinforcement
patternsRBs = a spectrumFunction of behaviour important differentialMore research needed!
Patient & Family Resources
Clinician Manuals/Resources
Woods & Miltenberger (2001). Tic disorders, trichotillomania, and other RB disorders: Behavioural Approaches to Analysis and Treatment. USA: Kluewer Academic Publishers
OCD OCD in Children and Adolescents: A Cognitive-Behavioral
Treatment Manual by John March and Karen Mulle
Tics Woods et al., (2008). Managing TS: A behavioural intervention for
children & Adults. Therapist Guide. USA: Oxford University Press.
TTM Golomb & Vavrichek ( 2000) The hair pulling habit and you: How
to solve the TTM puzzle. Maryland: Writers’ Cooperative of Greater Washington.
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