Running head: MICHIGAN AUTISM TRAINING VIDEO TREATMENT MANUAL 1

Michigan Autism Training Video Treatment Manual:

Treating Habit Disorders
Created December 2015
Douglas W. Woods
Marquette University

Author Note

Address correspondence to Douglas W. Woods; Department of Psychology; Marquette

University; Milwaukee, WI 53233. (email: douglas.woods@marquette.edu).

Suggested Reference

Woods, D. (2015). Treating Habit Disorders. Archives of Practitioner Resources for

Applied Behavior Analysts. Western Michigan University, Kalamazoo, MI. Retrieved

from https://wmich.edu/autism/resources.
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Treating Habit Disorders

TABLE OF CONTENTS
A. Brief Description of Habit Disorders………………………………………………………..3
A. 1. Compulsive Quality Motor Behaviors…………………………………………....3
A. 2. Motor and Vocal Tics……………………………………………………………...3
A. 3. Evidentiary Support……………………………………………………………….3
B. Purpose and Appropriate Use of Habit Disorder Treatments…………………………….4
C. Applicability…………………………………………………………………………………..5
C. 1. Causes of HD and Relevant Treatment…………………………………………..5
D. Treatment Validity and Treatment Matching……………………………………………...5
D. 1. Function-Based Intervention……………………………………………………...5
D. 2. Habit Reversal Training…………………………………………………………..8
D. 3. Reinforcement and Other Ancillary Treatments……………………………….10
E. Recommended Personnel and the Role of Caregivers…………………………………….11

F. Challenges and Troubleshooting………………………………………………..…………..11

F. 1 Ability to provide response description…………………………………………..12
F. 2. Ability to do response detection………………………………………………….12
F. 3. Ability to implement HRT independently……………………………………….12
F. 4. Lack of interest in change………………………………………………………...12
G. Task analyses and Other Materials………………………………………………………..13

G. 1. Ongoing Assessment……………………………………………………………...13
H. References……………………………………………………………………………………14
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Treating Habit Disorders

A. Brief Description of Habit Disorders.

Habit disorders (HDs) involve a broad array of behavioral topographies characterized by

repetitive motor or vocal actions that have no clear socially-mediated or communicative
function. Various types of habit disorders exist in the psychiatric nomenclature and are fairly
common in persons with autism spectrum disorders (ASD). For example, stereotypies are
apparently non-functional, patterned, repetitive movements (American Psychiatric Association,
2000). Common examples include hand flapping, body rocking, and humming. Stereotypies are
quite common, occurring in up to 71% of children with ASD (Goldman, Wang, Salgado, Greene,
Kim et al., 2008). Relative to typically developing children, stereotypies are only slightly more
common in two year olds with ASD, but over time, children with ASD display relatively greater
levels of stereotypy (MacDonald, Green, Mansfield, Geckeler, Gardenier et al., 2007).
A. 1. Compulsive Quality Motor Behaviors

Compulsive quality motor behaviors (sometimes called body-focused repetitive

behaviors) are repetitive movements that seem driven and serve to reduce stress or
anxiety. Examples include body mouthing, hairpulling, nail biting, etc. Prevalence rates
for these behaviors in persons with ASD have not been widely examined, but recent
studies suggest they are much more common than in the typical population and occur as
often, if not more often than traditional stereotypies in ASD population (Long,
Miltenberger & Rapp, 1998; South, Ozonoff, & McMahon, 2005).

A. 2. Motor and Vocal Tics

Tics are recurrent, sudden, stereotyped motor movements or vocalizations (APA, 2000;
Leckman, King, & Cohen, 1999). Tic disorders occur in as many as many as .6% of the
general population (Khalifia & von Knorring, 2003). Prevalence rates of co-occurring tic
disorders in ASD populations are much higher, ranging from 4.8%-48% (Baron-Cohen,
Mortimore, Moriarty, Izaguiree, & Robertson, 1999; Baron-Cohen, Scahill, Izaguirre,
Hornsey & Robertson, 1999; Cantitano & Vivanti, 2007; Gjevik, Eldevik, Fjaeran-
Granum & Sponheim, 2011; Simonoff, Pickles, Charman, Chandler, Loucas et al., 2008;
South et al., 2005) and are the third most common psychiatric comorbidity in children
with ASD, behind only specific phobia and ADHD-Inattentive type (Baron-Cohen,
Mortimore et al., 1999).

A. 3. Evidentiary Support
Evidentiary support for the treatment of HD in typically developing children is strong.
However evidence supporting the use of behavior therapy for HD in an ASD population
is more mixed. For the treatment of stereotypy, behavioral interventions primarily have
been studied using single-subject experimental design or open trials methodology (Ben
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Itzchak et al., 2008; Ben Itzchak & Zachor, 2009; Dawson et al., 2009; Miller, Singer,
Bridges & Waranch, 2005; Rapp & Vollmer, 2005). In the few randomized trials, that
have been conducted, HDs were not the primary focus of treatment (Ben Itzchak et al.,
2008; Ben Itzchak & Zachor, 2009; Dawson et al., 2009; Eldevik et al., 2006) studies
were limited to younger children, treatment lasted for as long as 12-40 hours per week for
up to two years, and outcomes are mixed. Summarizing the findings investigating
behavior therapy for stereotypies in ASD, Leekam and colleagues concluded in
2011…”To date, findings indicate that pharmacological interventions provide only
limited benefits; and while behavioral interventions are more promising, both types of
intervention need more development and evaluation with larger numbers for children.”
(Leekam, Prior, & Uljarevic, 2011; p. 587).

For HDs other than stereotypies, strong evidence exists to suggest behavior therapy is
effective in typically developing children, but very little is known about its efficacy in
children with ASD. In a recent review, habit reversal training was classified as the only
well established nonpharmacological intervention for tics (Cook & Blacher, 2007) and
other reviews have found HRT to be effective in treating other compulsive quality HDs
such as nailbiting, bruxism (Woods & Miltenberger, 1995), skin picking (Snorrason,
Belleau, & Woods, 2012), and trichotillomania (Bloch, Landeros-Weisenberger,
Dombrowski, Kelmendi, Wegner et al. (2007). Likewise our team recently completed
two large, NIH-funded, multi-site RCTs comparing 8 sessions (over 10 weeks) of and
HRT_based treatment called CBIT, to an identical-length psychoeducation and
supportive therapy control condition. Results of the child-focused study (N=126)
demonstrated that 53% of the CBIT group were treatment responders (CGI-I of 1 or 2)
compared to 19% in the control condition (Piacentini, Woods, Scahill, Wilhelm, Peterson
et al., 2010). Treatment responder status was generally maintained for the CBIT group at
the 6-month follow-up (87% of initial still responders remained responders at the 6-mo
follow-up), and treatment responders demonstrated decreases in disruptive behavior,
anxiety symptoms and general behavior problems at the 6-month follow-up (Woods,
Piacentini, Scahill, Peterson, Wilhelm et al., 2011). Unfortunately, the CBIT studies
excluded participants with ASD, and early HRT studies either did not report on their
patients comorbid diagnostic status or excluded the participation of those with ASD.
Thus, despite the fact that we have an effective treatment for HD and other HDs, it is
unclear if this manualized treatment package can be implemented to effectively manage
HDs in children with ASD.

B. Purpose and Appropriate Use of Habit Disorder Treatments

Behavior therapy for HDs involves a collection of treatment techniques designed to effectively
manage the behavior. Typically, these techniques are implemented over weekly sessions in an
outpatient setting, but the treatment itself occurs in multiple settings and is delivered by the
client, with the aid of the caregivers.
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Unfortunately, a manualized, well-tested intervention for habit disorders (HD) in Autism

Spectrum Disorders (ASD) does not exist, but numerous clinical reports have suggested that
effective behavior therapy for HDs in an ASD population typically includes three primary
components (Boyd, McDonough & Bodfish, 2012). The first involves the use of function-based
interventions, in which a clinician, client, and /or caregiver completes a functional assessment
interview designed to identify various environmental and sensory triggers for, and consequences
of the HD. Specific behavioral interventions are then designed to reduce, eliminate, or replace
the identified functions of the targeted behavior.

The second primary component in the treatment of HD involves teaching the person with ASD to
engage in an action designed to stop the HD. This component is often done in conjunction with
the third component, reinforcement for the absence of the HD. A combination of these latter two
components is typically referred to as habit reversal training (HRT; Azrin & Nunn, 1973). HRT
involves awareness training, competing response training, and social support. These procedures
make the client more aware of the HD through awareness enhancement practices, and the client
is then taught to do a behavior (called a competing response) that physically prevents the HD
from occurring when it starts. A parent or other caregiver is asked to prompt the client to use the
competing response when the HD occurs and to verbally praise the client for using the
competing response correctly. A final component involves a behavioral reward system that is
designed to reinforce compliance with treatment procedures.

Although data on the combination of function-based interventions with HRT in the treatment of
HD for children with ASD is scarce, similar components are utilized in the treatment of HDs in
typically developing populations and have shown significant promise. Below, we describe how
each of these treatment components are implemented.

C. Applicability

C. 1. Causes of HD and Relevant Treatment

The causes of all HDs are believed to be the result of two broad factors. At the biological
level, most individuals with HDs have demonstrated abnormalities in the basal ganglia,
which is a subcortical region in the brain responsible for the formation of habitual
behavior (Yin & Knowlton, 2006) and for the inhibition of unwanted movement (Mink,
1996). Similarly, it is believed that excessive dopamine activity yields
habitual/stereotypic behavior and because the basal ganglia is rich in dopaminergic
neurons, dopamine deficits are believed to be relevant to the biology underlying HDs
(e.g., Nakamura, Uramura, Nambu, Yada, Goto et al., 2000). It is also well understood,
and perhaps not surprising given the basal ganglia’s role in operant learning, that HDs are
highly influenced by both antecedent and consequence variables in the environment.
Research has clearly shown that habit disorders can be exacerbated by different settings,
emotional states, and other antecedent stimuli (e.g., Conelea, & Woods, 2008). Similarly,
research has demonstrated that HDs can be reinforced by social attention, escape from
demanding situations, and via the reduction of negative emotional experiences.
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Given these etiological factors underlying the expression of HDs, it is perhaps not
surprising to see that the most common pharmacotherapeutic approach involves the
delivery of a dopamine antagonist and the most common nonpharmacological therapy
involves the systematic manipulation of antecedents and consequences maintaining the
HD (function-based treatment) along with teaching the client a new method of inhibiting
the habitual behavior in context (HRT).
The presence and severity of HDs increase psychosocial burden. Negative effects of HDs have
been found in domains of receptive and expressive communication, domestic care, personal care,
interpersonal relationships, play and leisure time, daily living skills, socialization (Matson, Kiely
& Bamburg, 1997; Long, Woods, Miltenberger, Fuqua, & Boudjouk, 1999), and employability
(Erenberg, Cruse, & Rothner, 1987). Repetitive behavior in the form of tics can lead to
functional impairment (i.e., decreased social acceptability, peer relationship problems, poor self-
concept, and increased difficulty with academic and occupational functioning (Erenberg et al.,
1987; Storch, Lack, Simons, Goodman, Murphy et al, 2007; Woods, 2002; Woods, Fuqua &
Outman, 1999). Parents of children with these problems experience more family conflict,
marital difficulties, higher levels of parenting frustration, and a lowered quality of parent-child
interactions than parents of children without such behaviors (Cohen, Ort, Leckman, Riddle, &
Harin, 1988). In a study of the impact of tics in children with PDD, Gadow and DeVincent
found that persons with a PDD and comorbid tic disorder were at “greater risk of co-occurring
psychiatric symptoms and have greater severity of PDD symptoms, more medication use, and
experience more environment problems than children without either” (ADHD or tic disorder;
Gadow & DeVincent, 2005; p. 487). Combined, these data suggest the presence of HDs yields
additional burden beyond that already produced by other symptoms associated with ASD.
D. Treatment Validity and Treatment Matching

D. 1. Function-Based Intervention

It is widely understood that HDs are impacted by contextual variables. Broadly these
variables include antecedents and consequences. With respect to antecedents, various
categories may be involved in eliciting the HD. Settings, ongoing activities, transitions,
emotional states, sensory states, particular people, demands, etc., can all occasion and/or
increase the intensity/frequency of an ongoing HD. Likewise, various consequences can
serve to reinforce the HD. Consequences can be social (i.e., attention for doing the
behavior, escape from a demanding task), tangible (e.g., having a pulled hair to
manipulate), or sensori-emotional (e.g., engaging in a tic decreases an internal “urge,” or
the act of stereotypy is automatically reinforcing via the visuotactile stimulation produced
by the behavior).

Given that such maintaining factors exist and are unique to the individual, behavior
analysts have developed a set of procedures designed to identify (i.e., functional
assessment) and alter (function-based interventions) HD-exacerbating stimuli in the
environment.
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Functional assessment, usually conducted in the first session, involves a clinical

interview conducted between the behavior analyst, the client and his or her caretakers.
Inclusion of additional caretakers in the assessment process will likely result in a more
comprehensive assessment of the problem and potentially more effective treatment
suggestions. Direct observation is sometimes utilized, as are analog functional analysis
procedures (Iwata, Dorsey, Slifer, Bauman, & Richman, 1982), but often these
procedures either result in little information (i.e., the client reacts to the observation by
not doing the HD) or results in a common “automatic reinforcement “ function.

Using standard functional assessment procedures for HD, the clinician asks the
interviewees about situations in which the HD is likely to occur. For each of these
situations, the clinician asks specific questions about the antecedents present in each of
the situations along with the consequences that may be functioning to reinforce the
behavior. After assessing multiple occurrence of the behavior, the clinician should look
for patterns among both the antecedents and consequences that are associated with
exacerbations of the HD. After HD-evoking and HD-reinforcing stimuli are identified,
the behavior analyst should work with the caretaker to develop function-based
interventions.

Function-based interventions are those changes to antecedent or consequence stimuli that

maintain HDs. The interventions recommended should attempt to diminish contact with
HD-evoking antecedents, alter the intensity of HD-evoking antecedents, or manipulate
motivating operations to decrease the reinforcing strength of automatically reinforced
behavior. Function-based interventions involve altering the identified stimuli believed to
be reinforce the HD. Typical interventions recommended involve extinction of socially
reinforced behavior and sensory extinction procedures for HDs that may be maintained
by automatic tactile reinforcement.

As an example, assume the frequency of stereotypic hand-waving increases in

environmentally restricted situations and is followed by significant caregiver attention. In
addition, the waving always occurs in front of the eyes, raising the possibility that visual
stimulation may also be reinforcing the behavior. In such a case, a series of function-
based interventions may be implemented that involve creating more enriched
environments, eliminating the social attention for the behavior, and providing an
alternative means of visual stimulation that mimics that of the hand waving in front of the
eyes (e.g., giving the client a socially appropriate visual stimulus to carry with them).

After the function- based interventions are identified, the behavior analyst, client, and
caretaker decide how the recommended interventions will be carried out and any training
required to do the intervention should be implemented. Following the initial functional
assessment and implementation of the relevant function-based interventions, the behavior
analyst should be mindful of the possibilities that additional behavioral functions of the
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HD may emerge over the course of the treatment. When additional behavioral functions
are observed or discovered throughout treatment, additional function-based interventions
should be implemented.

D. 2. Habit Reversal Training

Habit reversal training is typically implemented with one HD at a time. In some cases,
such as trichotillomania, there may be only one target topography involved in the HD
(e.g., only the hand is used to pull the hair). In such cases, HRT can be implemented
fully in one or more sessions with that specific target behavior. However, in other cases
(e.g., Tourette Syndrome), there may be multiple topographies that constitute the HD. In
such cases, HRT is implemented separately for each of the specific topographies
constituting the HD.

The pace at which HRT is implemented for any specific HD topography depends on the
client’s ability to successfully implement the procedures. Clients who quickly
demonstrate awareness of their target behavior and are reliably able to implement the CR
in session can address one new HD topography for every 60-90 minute session of HRT.
Those demonstrating less awareness of their HD or who have more difficulty
implementing the CR reliably will require additional sessions.

As a treatment package, HRT involves three primary components: awareness training,

competing response training, and social support. The procedure starts with awareness
training; which contains three elements; response description, response detection, and
early warning training. With response description, the client, the primary caretaker and
the clinician develop a very detailed operational definition of the HD. The definition
should entail all physical, somatic, and emotional aspects experienced from the onset of
the HD until it is completed. The clinician should keep in mind that the purpose of
response description is not necessarily to come up with an accurate definition for the
purposes of communication, but rather to develop a detailed definition that allows the
client to understand and describe in depth and at multiple levels (behavioral, sensory,
emotional), the target behavior as it occurs. After developing a response description, the
clinician implements response detection.

Response detection involves teaching the client, in real time, to tact the presence of the
HD. The clinician tells the client to “raise his or her finger” every time the client notices
the HD in the session. When the client successfully acknowledges the HD, the clinician
praises him or her. If the client does the HD, but does not acknowledge it, the clinician
should stop the session and prompt the client by saying something such as “don’t forget
to raise your finger when you do the HD.” This process should continue until the client
successfully acknowledges about 80% of the actual occurrences of the HD. During
response description and subsequent early warning training, the clinician and client
should not simply wait for the HD to occur. Rather, the dyad should be engaging in some
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other activity in order to promote generalization of the skills to settings outside of

therapy.

After successfully completing response detection, the client and clinician should practice
the client tacting the earliest parts of the behavioral chain that create the HD. For
example, before a person with trichotillomania actually pulls her hair, the hand will move
up toward the head. This early link in the chain is called a “warning sign.” The client and
clinician should practice the client tacting these warning signs in session. As in response
description, when the client engages in the agreed-upon warning sign, he or she should
raise a finger. If done correctly, the clinician should praise the client, and if the warning
sign is missed by the client, the clinician should point it out to him or her. This should be
continued until the client is accurately detecting approximately 80% of warning signs
displayed.

After the client has demonstrated reliable awareness of the target HD and its warning
signs, the clinician should implement competing response training. A competing
response is a behavior the client is taught to do for one minute immediately contingent on
(a) the target behavior occurring, or (b) the occurrence of a warning sign. Competing
response training involves two components; selecting the competing response and
implementing the competing response.
In selecting a competing response, the clinician and client should follow three rules.
First, the competing response should be a behavior that makes it more difficult, if not
physically impossible to concurrently do the target HD. For example, a client could not
pull hair from her head if she were also making a fist and holding her arms down at her
side. Second, the competing response should involve a behavioral topography that is not
more noticeable than the target HD, and can be implemented anywhere. Finally, the
competing response should be possible to hold for one minute. In selecting the
competing response, the clinician should describe these three rules to the client and
encourage him or her to come up with a competing response on his or her own. It the
client choose a competing response that does not meet all of the rules, then the clinician
should point out where the rules are not met and help the client choose something more
appropriate.
After a competing response is chosen, the client and clinician should practice
implementing the technique in session. The therapist should first model the correct
implementation of the competing response. Next, the clinician should ask the client to
demonstrate the competing response and provide corrective feedback. The therapist and
client should begin in-vivo practice of competing response implementation. During the
session, the client should be told to implement the competing response when appropriate.
If a tic or warning sign occurs and the client correctly implements the competing
response, the therapist should praise him or her. Conversely, if the client engages in a tic
or warning sign, but does not do the competing response, the therapist should stop the
ongoing activity and remind him or her to do the competing response. This should
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continue in-session until the client correctly implements the competing response
approximately 80% of the time without prompting.

After the competing response has been taught the therapist should identify the “social
support” person. Typically this is the primary caregiver. It is important to understand that
the social support person has a very circumscribed responsibility. He or she is asked to
do two things. First, he or she is asked to praise the client when the client is seen
correctly engaging in the competing response outside of session. Second, he or she is
asked to prompt the client to engage in the competing response when the client is seen
doing then HD, but not the competing response. In such a case, the support person is
asked to remind the client to “don’t forget your exercises.” In session, the therapist
should practice with the support person, both in delivering praise and in prompting the
correct implementation of the competing response. The therapist should provide
corrective feedback to the support person when necessary.

After awareness training, competing response training, and social support has been
conducted for a particular HD topography, the client should be instructed to use the
competing response outside of session whenever the HD or its warning sign occurs. The
support person is expected to prompt the action and praise its implementation when
appropriate.

D. 3. Reinforcement and Other Ancillary Treatments

In addition to the function-based interventions and habit reversal training, behavior

analysts often incorporate other therapeutic elements, including contingency management
and relaxation training.
Contingency management is useful in two ways. First, it can be useful in increasing
compliance to the function-based intervention and habit reversal treatment components.
In such cases, clinicians should identify specific behavioral targets to be reinforced,
primary or secondary reinforcers to be delivered, and the schedule of reinforcement on
which the reinforcers will be delivered.
Contingency management can also be used to directly reinforce the reduction of the
target HD. This is often used when the client exhibits lower functioning and when the
self-management elements of habit reversal are more difficult to implement. If used as a
direct treatment strategy a differential reinforcement of low-rate behavior (DRL)-based
shaping procedure is recommended. Using DRL, the clinicians select a window of time.
If the target behavior occurs at a rate below a prespecified level during that window of
time, the reinforcer is delivered. With continued success, the clinician continues to lower
the criterion rate until the target HD is occurring at a clinical acceptable level. It is
important to select reinforcers and schedules of reinforcement that are informed by an
effective preference assessment.
Another ancillary treatment strategy used in the treatment of HD involves relaxation
training. It is often the case that persons with HD engage in the behavior more frequently
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when experiencing anxiety or stress, as the HD is often negatively reinforced via stress
reduction. To reduce the reinforcing effects of the HD, relaxation training can be useful.
The particular type of relaxation strategy utilized is up to the treating clinician, but
progressive muscle relaxation procedures are typically utilized. Often the client is taught
the procedures and then instructed to practice them frequently throughout the week
between sessions. They client is then prompted to use the procedures during times of
heightened stress or anxiety.
E. Recommended Personnel and the Role of Caregivers
Research done on the use of behavior therapy for HD has primarily reported on the use of
doctoral or master’s level trained therapists. For this reason, we recommend that only BCBAs
implement the treatments described here. Nevertheless, it should be clear that the BCBA will
only be able to effectively implement the procedures fully with the assistance of caregivers and
perhaps BCABAs who are responsible for implementing the function-based interventions and for
providing the social support and reinforcement elements of the HRT intervention.

Caregivers have two primary roles in behavior therapy for HD in children with ASD. First, they
are often responsible for implementing many of the elements of the function-based interventions
designed for a particular client. In this context, they may be asked to alter the client’s settings,
change their own behavior toward the client, or encourage the change of behavior in others that
may be eliciting or reinforcing the HD. Caretakers are also asked to serve the social support
function in the HRT component. As described above, these responsibilities will include
prompting the client to use the competing response when he or she is seen doing the HD, but not
using the appropriate competing response. The caretaker will also be asked to reinforce, either
through verbal praise or through the delivery of a tangible reinforcer, the correct implementation
of the competing response.

F. Challenges and Troubleshooting

A number of challenges exist to the implementation of behavioral procedures to treat HDs in
persons with autism and related disorders. The primary concern for clinicians should involve
determining whether or not HDs targeted for treatment are important. Persons with autism have
numerous difficulties, including many language-based and social difficulties. While HDs are
common, the effective behavior analyst must make sure the HD is a clinically valid target of
change in the context of the clients other difficulties.
Assuming the HD is a clinically valid target, a number of other barriers to the procedures
described in this paper/presentation exist. If the client has low intellectual functioning or
diminished verbal abilities, the procedures may require greater involvement of caregivers than
what was described. Particular areas in which such clients may exhibit additional difficulties are
described below.
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F. 1. Ability to provide response description

Individuals with low verbal ability may have a difficult time creating an effective
description of their target response. In such cases, it may be helpful to simply skip this
step of treatment and move directly into response detection. Although this may extend the
duration of treatment, in the long run, it will likely diminish frustration for the client.
F. 2. Ability to do response detection
Sometimes the clients display a diminished ability to accurately detect his or her own
HD. In such cases, it can be helpful to have the clinician start by mimicking the client’s
HD, while asking the client to watch the therapist and detect the HD in the therapist.
Accurate detection should praised and incorrect detection should be prompted. Another
useful strategy prior to implementing traditional response detection involves utilizing a
video recording of the client doing the HD and then asking him or her to point out
occurrences of the behavior as they happen in the video. Upon successfully completing
these tasks, the client should then be exposed to traditional response detection
procedures.
F. 3. Ability to implement HRT independently
In some cases, the client does not demonstrate the ability to independently implement the
competing response. In such cases, the caretaker should engage in behavioral prompting
procedures to enhance compliance. These procedures should then be faded as the
patients demonstrate greater and greater success.
F. 4. Lack of interest in change
As with many automatically reinforced behavior, the motivation in place for the client to
change his or her behavior is limited. If the client does not display a strong tendency to
change his or her behavior, then a back-up reinforcement plan is suggested.
The different classes of HDs have differentially effective treatments. For the treatment of
stereotypies, the two most common types of medications include atypical neuroleptics (i.e.,
risperidone) and SRI medications such as clomipramine (Brodkin, McDougle, Naylor, Cohen, &
Price, 1997; Leekam et al., 2011; McCracken, McGough, Shah, Cronin, Hong et al., 2002;
Sanchez, Campbell, Small, Cueva, Armenteros et al., 1996). In a recent review of the literature,
it was suggested that risperidone may have some short term effectiveness in reducing RBs
(McCracken et al., McDougle, Scahill, Aman, McCracken, Tierney et al., 2005; Shea, Turgay,
Carroll, Shulz, Orlik et al., 2004), but the effects may not be durable (Research Units of Pediatric
Psychopharmacology Autism Network, 2005). SRI medications have also been evaluated. Some
results have been promising (Hollander, Phillips, Chaplin, Zagursky, Novony et al. (2005),
whereas others have shown no effects (King, Hollander, Sikich, McCracken, Scahill et al., 2009).
Research on the treatment of tics in typically developing populations have focused primarily on
the efficacy of traditional (e.g., haloperidol) and atypical (e.g., risperidone) neuroleptics and
alpha-adrenergic agonists (e.g., clonidine, guanfacine). Various reviews of pharmacotherapy
trials for tics, have concluded that the atypical antipsychotic risperidone, and α-2 adrenergic
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agonists clonidine and guanfacine have the greatest degree of empirical support (Pringsheim,
Doja, Gorman, McKinlay, Billinghurst et al., 2012; Roessner, Plessen, Rothenberger, Ludolph,
Rizzo et al., 2011). These medications have not been tested in children with ASD and tics.
Overall, the effectiveness of medication for RBs in children with ASD is unclear. Not only is the
effectiveness of pharmacotherapy in question for RBs in children with ASD, but there is concern
about side effects (King et al., 2009; Williams, Wheeler, Silove, & Hazell, 2010) and about the
possibility of over-medicating children with ASD (Mandell, Morales, Marcus, Stahmer, Doshi et
al., 2008). Given these concerns, nonpharmacological treatment options are often considered.

G. Task Analyses and Other Materials

G. 1. Ongoing Assessment

Progress in the treatment of HDs can be measured in numerous ways, but the one most
familiar to behavior analysts, direct observation, may be particularly problematic. Often,
children with stereotypy or some compulsive quality behaviors exhibit the behavior most
frequently when alone, thus making direct observation a potentially unreliable mode of
assessment.

Various self-report instruments exist for the different HDs. For example the parent-
reported Parent Tic Questionnaire (Chang, Himle, Tucker, Woods, & Piacentini, 2009)
can be used to assess tic severity, and the parent- completed Trichotillomania Severity
Scale for Children (TSC-C; Tolin, Diefenbach, Flessner, Franklin, Keuthen et al., 2008)
is useful in assessing hairpulling.

In addition, a number of other clinician-rated scales exist. For example, the Interview for
Repetitive Behaviors (IRB; Bodfish, 2005) is a clinician-rated scale designed to assess the
severity of three different domains of repetitive behavior; motor stereotypies, insistence
on sameness, and circumscribed interests. Each of these three domains are separately
rated on each of five subscales. The subscales assess the frequency (0 to 4 points),
intensity (0 to 4 points), interference (0 to 4 points), accommodation (0 to 4 points) and
peculiarity (0 to 4 points) of the repetitive action. For each of the three domains a total
score ranging from 0-20 is calculated. The three domain totals are then summed to create
a 0-60 total RB severity score. Likewise, the Yale Global Tic Severity Scale (YGTSS;
Leckman, Riddle, Hardin, Ort, Swartz et al., 1989) is a clinician-rated scale used to assess
tic severity in the past week. Motor and phonic tics are rated separately from 0 to 5 on
several scales including number, frequency, intensity, complexity, and interference. Total
Tic Score ranges from 0 to 50. The YGTSS has demonstrated excellent psychometric
properties with solid internal consistency, excellent inter-rater reliability, and excellent
convergent and divergent validity.

Finally, the NIMH Trichotillomania Scale (Leonard, Rapoport, Lenane, Goldberger et al.,
1989) is a semi-structured clinical interview that consists of two IE-rated scales: NIMH-
MICHIGAN AUTISM TRAINING VIDEO TREATMENT MANUAL 14

TTM Symptom Severity Scale (NIMH-TSS) and the NIMH Trichotillomania Impairment
Scale (NIMH-TIS). The NIMH-TSS is comprised of five items assessing time spent
pulling, problems thinking about pulling, attempts to resist the urge to pull, general
distress about the pulling, and the interference of pulling on one’s life. The NIMH-TIS is
a 10 point IE-completed rating scale measuring impairment produced by the time spent
pulling or concealing damage, ability to control pulling, severity of alopecia, interference,
and incapacitation caused by the pulling. Although little data exist for the psychometric
properties of the NIMH-TTM Scales, the interrater reliability scores for the measure have
been found to range from .78 to .81 when the scales were administered to the same
participants by different raters. In addition, these scales appear to be sensitive to change
in symptom severity as a result of treatment (Swedo, Lenane & Leonard, 1993).

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