J. Behov. Thu. & Exp. Psychiof. Vol. 13, No. I, PP. 49-54, 1982 Printed in Great Britain.

0005.7916/82/01,X,49-06$03.00/O @ 1982 Pergamon Press Ltd.

HABIT REVERSAL vs NEGATIVE PRACTICE TREATMENT OF

SELF-DESTRUCTIVE ORAL HABITS (BITING, CHEWING OR

LICKING OF THE LIPS, CHEEKS, TONGUE OR PALATE)

N. H. AZRIN, R. G. NUNN and S. E. FRANTZ-RENSHAW

Nova University and Anna Mental Health and Developmental Center

Summary-Ten patients with oral habits such as biting, chewing, licking, or pushing of the cheeks, lips, teeth, or palate were randomly assigned to either habit reversal treatment or to negative practice treatment. Treatment was given in a single 2-hr session. The patients receiving negative practice treatment showed a mean reduction of about 65%, those receiving the habit reversal treatment showed a mean reduction of about 99% during the 22.months of follow-up.

Relatively little study has been accorded to self-destructive oral habits such as lip picking, lip-biting, lip-licking, tongue-sucking, tongue- biting, sucking the roof of the mouth, and cheek-biting. One study which attempted to

ascertain the incidence of such habits by Nanda, Khan and Anand (1972) found that 3.4% of the 2500 children observed in India, age 2-6 years, were tongue thrusters and 0.2490 were lip suckers.

Treatment studies of these oral habits have consisted primarily of single-subject case studies usually lacking quantitative data regarding the results. In one psychotherapy study, Bonnard (1960) reported the elimination of a child’s thumbsucking after three sessions.

Oral appliances or surgery have occasjonally been used to treat oral habits. Daniel (1959) reported successful treatment of an 8-month old infant with a severe tongue biting habit by means of tooth extraction and a special mouth guard appliance. Walker and Collins (1971) reported successful treatment of’ three patients for tongue thrusting by a combination of an oral appliance, oral surgery, and tongue exercises. Moyers (1963) and Graber (1966) reported the use of an oral appliance and

exercises to treat their patients who had maloc- clusion, lip sucking, lip biting, or tongue thrust- ing habits. Hemley and Kronfeld (1961) reported a failure of treatment of a child’s tongue thrust- ing habit after use of an oral appliance for three months.

“Exercises” have often been advocated and used, such as by Walker and Collins (1971) and Graber (1966). Similarly, Teuschler (1940) reported the elimination of lip biting in a 4 year old child by teaching an incompatible response of whistling.

A small number of behaviorally based training procedures have been used to treat oral habits. Epstein and Hersen (1974) used a self-recording and coverant control procedure to reduce finger picking and lip biting by about 65% with one adult psychiatric patient. Kaufman, Hallahan and Ianna (1977) used contingent praise and contingent imitation to reduce tongue protrusion in a 12 year old retarded boy.

Almost all of the studies of oral habits may be characterised as case studies, usually in- volving only one person, lack of quantitative data, lack of systematic follow-up, and lack of controlled comparisons with alternative methods of treatment or with no treatment.

This research was conducted at the Anna Mental Health and Developmental Center. The present address of R. G. Nunn is Clairemont Medical Office, Kaiser Permanente, San Diego, CAL. The present address of N. H. Azrin is Nova University, Fort Lauderdale, FL. Grateful acknowledgement is due to R. deVito, R. C. Steck, and P. Levison for the support which made this study possible. Requests for reprints should be sent to N. H. Azrin, Department of Psychology, Nova University, Fort Lauderdale, Florida 33314, U.S.A.

49

50 N. H. AZRIN. R. G. NUNN and S. E. FRANTZ-RENSHAW

The present study attempted to provide a larger sample of subjects, greater quantification of the data, and a controlled comparison entailing random assignment of subjects to two different methods of treatment. One of the methods of treatment was the negative practice method (Dunlap, 1932) which has been used with a great variety of other types of nervous habits and tics (Yates, 1958; 1970). The second treat- ment procedure used in this study was the habit reversal procedure which also has been applied to many different habits, including tics (Azrin, Nunn and Frantz, 1980), thumbsucking (Azrin, Nunn and Frantz-Renshaw, in press), stuttering

(Azrin and Nunn, 1974; Azrin, Nunn and Frantz, 1979), nailbiting (Azrin, Nunn and Frantz, in

press), and hairpulling (Azrin, Nunn and Frantz, 1980). In the initial use of the habit reversal method (Azrin and Nunn, 1973), one patient was included who had the oral habit of gum sucking. The distinctive feature of the negative practice procedure is the deliberate practice of the habit in a massed practice man- ner, whereas the habit reversal procedure is characterized by teaching the person competing reactions.

METHOD Subjects

Ten persons participated as subjects in the study and were obtained in response to a newspaper advertisement. A coin flip was used to assign treatment status and resulted in five patients assigned to the habit reversal treatment and five to the negative practice treatment. Table 1 describes

Table 1. Demographic characteristics of the clients with oral habit problems who received either habit reversal or negative practice treatment

Habit reversal clients

Age at Duration Pre-treatment Description

Age onset of habit rate of habit Client Sex (yr) (yr) (yr) (episodes/day)

HRI F 26 12 14 1000 Biting and chewing inside of lips and cheeks while pressing lips or cheeks in with finger

HR2 F 20 18 12 125 Biting inside of cheek

HR3 F 27 9 18 50 Chewing on tongue

HR, M 9 infancy 9 40 Pushing and flicking tongue on roof and upper teeth

HRs M 48 21 21 1000 Jaw cracking

x 26 12 16 443

Negative practice clients

NPI

NP2

NP3

NP4

NPs

F 21 11 16 100

F 23 15 8 50

M 8 6 2 1400

M 11 9 2 900 F 65 3 62 125

Biting and picking lips Biting inside of cheeks, tongue Licking lips and skin around mouth Licking lips Sucking roof of mouth and tongue

x 21 9 18 540/day xof combined sample (N = 10) 26 yr IOyr 17 yr 492/day

HABIT REVERSAL vs NEGATIVE PRACTICE TREATMENT OF SELF-DESTRUCTIVE ORAL HABITS 51

several of the relevant characteristics of the imiividual patients. The mean age of the patients was 26 years and included three children under the age of 12. Fi’ve were male and five were female, and the mean reported age of onset was 10 years, with a reported mean duration of I7 years. The oral habits consisted, as shown in Table 1, of biting, chewing, licking, pushing or sucking of the tongue, cheeks, lips, and roof of the mouth, and were distinctive in topography for each of the patients. The number of episodes per day varied from 40 to 1400 prior to treatment, with a mean frequency of 492 episodes per day (median: 125). As seen in Table 1, the mean values of these relevant dimensions did not differ applreciably between the two samples. As shown in Table 2, 6 of the 10 patients had previously obtained professional consul- tation, primarily from dentists, but also psychiatrists, psychologists, and pediatricians. The primary problems

reported by the patients were either the physical problems caused by the habit or the unaesthetic appearance. All but one reported using home treatments, most commonly by concentrating on the habit or by such hopefully in- compatible behaviors as chewing gum.

Prior to treatment, each patient provided their best estimate of the daily frequency of occurrence of their oral habit. At the end of the treatment session, the patients were given recording sheets and were instructed to carry a card on their person on which to record each night the number of habit episodes that had occurred during that day. The records were used to read off the data to the counselor at the follow-up telephone contacts provided by the counselor. For the children, the counselor reviewed the recording sheets of the children with their parents to assure greater accuracy in the reporting. Since the study took place in a locale several hundred miles distant from

Table 2. Previous consultation, home treatments attempted, and stated problem of clients with ora. habits, presented separately for those who would receive habit reversal (HR) treatment vs those receiving negative

practice treatment (NP)

Habit reversal clients

Professional Problems caused by Client consultations habit Home treatments

HRI

HRz HR3

H%

HRs

Dentist

Dentist, doctor

Dentist

Irritation, pain, looks Chewing gum, great terrible, fear of concentration, smoking, disease eating, lipstick Rawness, looks bad Taping objects to hand Aching, embarrass- Concentration ment Causing teeth de- Telling self to stop formation, need braces Annoys others Concentration

Negative practice clients

NPI

NP2 Dentist, doctor

NP3 Pediatrician, doctors

NP4

NPs

Pediatrician, doctor, psychiatrist, psychologist

Fear of cancer, people make comments, pain, people staring, embarrassment Unflattering looking, may cause cancer

Appearance, self- consciousness, peer comments and st,aring, irritation, fear of infection Swollen mouth, red, chapped, soreness, looks silly, made fun of, annoying to others Soreness

Having friends comment on occurrences, folding hands

Gum chewing, biting nails, putting gauze in mouth

Reminders, appeals and talks from parents

Chewing gum, eating hard candy, drinking coffee, go to bed earlier, put finger in mouth

52 N. H. AZRIN, R. B. NUNN and S. E. FRANTZ-RENSHAW

the therapists’ usual office location, long term follow-up for all patients was difficult. However, follow-up was obtained for all patients for 4 weeks after treatment, and for the habit reversal patients, for a period up to 22 months.

Habit reversal treatment All patients were treated individually in a single 2-hr

session. The first part of the session involved completion of a questionnaire and discussion to obtain information on habit frequency, origin, habit precursors, habit-prone Gtuations, and a list of significant others to assist in providing praise and gentle reminders. In the second part of the session, the counselor trained the patients to utilize two types of habit reversal procedures. The first procedure (competing responses) utilized specific behaviors that were incompatible with the habit and could provide immediate control. Whenever an episode of the habit occurred, or was likely to occur, the patients engaged in incompatible behaviors for about 3 min in order to interrupt, or prevent, habit occurrences. The patients were trained to perform these behaviors in a manner that wjould be inconspicuous. Further, the competing behaviors were to be used during conversational pauses, so that they were not disruptive of speech. The competing responses for the specific habits of the five habit reversal patients are described below:

Oral habit Competing response

HR, Biting insides of lips and cheeks and using finger to push lip and cheek to teeth.

HR2 Biting inside of cheek.

HRI Chewing tongue with mouth open.

HRJ Pushing and flicking tongue on upper teeth and roof of mouth with parted lips and making audible flicking noises.

HRs Jaw cracking.

Clench teeth lightly, part lips slightly, press fingers into palm/clenched fist

Clench teeth lightly, press lips together.

Clench teeth lightly, press tongue lightly on roof of mouth, keeping the lips closed.

Clench teeth lightly, press tongue lightly on roof of mouth, keeping the lips closed.

Press lips together, teeth barely parted.

Note: The jaw cracking patient also had trouble with teeth grinding, therefore teeth clenching was not appropriate for this patient.

The second set of procedures in the habit reversal treatment utilized general behavior therapy methods as described in Azrin and Nunn (1973; 1977) to increase motivation, identify habit-prone situations, rehearse im- plementation of the competing responses in all habit-prone situations, practice the competing reaction in a manner that was not apparent to others, rearrange social reinforce- ments, learn prevention procedures and positive care, and

plan ways to display immediately improvements in habit control. Patients were trained to use frequent naturally occurring events as signals to observe the presence of their oral habit. For example, when reading, the patients were trained to use the turning of a page as a signal for self- inspection of the occurrence of their oral habit at that moment. These procedures were modified slightly for use with children in that the competing responses were presented as an exercise game in which the child was responsible for performing the exercises; the parents pro- vided encouragement, praise, minimal reminders, and enforcement only if the child failed to initiate the competing response after a gentle reminder. These procedures for children are described in more detail in a habit reversal treatment study of children’s thumbsucking (Azrin e/ a/., in press).

The patients also were instructed to perform poGtive corrective actions at regularly scheduled times (waking, after meals, bedtime) each day, and also as a sequel to the competing exercise when convenient or feasible in the specific situation. The positive corrections included apply- ing lipstick, clear ointment, or mild antiseptic if the skin was broken. All patients were encouraged to make their mouth look as attractive as possible.

Behavioral rehearsal by the patient was used to insure understanding of all procedures. The last 20 min of the session involved casual conversation during which the patient was prompted, when necessary, to practice pre- ventive and competing responses so as to promote generaliz- ation to the natural everday situation. The counselor faded out the prompting responses and provided praise for the patient’s successful efforts.

Negative practice treatment The patient5 assigned to negative practice were also

treated in individual sessions of 2 hr duration. They completed the same intake questionnaires and discussion concerning origin of the oral habit, estimate of habit frequency, identification of habit-prone situations, previous treatments, assurance of effectiveness of proposed treat- ment, treatment rationale, and so forth, as did the habit reversal patients. Each patient received three pages of Smith’s (1957) instructions for negative practice treatment of nailbiting that were modified for use with other habits. The patients were instructed to set a timer and to practice their specific oral habit for 30 set every **aking hour. The patients were specifically instructed to simulate the habit motions, but not to do any damage. Further, the counselor emphasized the importance of consistency in the hourly exercises. Patients were instructed to maintain the regimen for 4 days after breaking the habit and then to fade out the exercises over a 2-week duration. The counselor asked questions to assure understanding and also had the patients perform several negative practice trials to demonstrate their understanding. The patients were given the same recording sheets and instructions as the habit reversal patients for recording daily progress.

RESULTS

The results of the two treatments are shown in Fig. 1. For the negative practice patients,

HABIT REVERSAL vs NEGATIVE PRACTICE TREATMENT OF SELF-DESTRUCTIVE ORAL HABITS 53

Fig. 1. Mean percentage reduction in the frequency of oral habits including cheek, lip and palate sucking, biting or chewing of 10 patients. The baseline pre-treatment level is designated by definition as 0% reduction. The dashed vertical line designates the single 2-hr treatment session. The follow-up data are presented weekly for the first 4

weeks and monthly thereafter except for the 22.month follow-up period.

the oral habits decreased by 66% during the first week following treatment and rernained at the general level of a 60% habit reduction during the 4 weeks. For the habit reversal patients, the oral habits decreased by 97.1% in the first week, by 99.6% in the second week, and this general level of reduction (99%100%) was maintained throughout all follow-ups for all five patients. One patient was not available after the second month, another after the fifth month, and another after the sixth month, leaving two patients for the 22-month follow-up. The patient (HR,) with the jaw cracking habit also eliminated his tooth grinding habit.

Individual data showed that no patient in the negative practice treatment was free from their habit at any point following treatment. At the last follow-up of one month, all five of the negative practice patients had five or more episodes per day. In the habit reversal procedure, each patient averaged less than one episode per day from the fourth week through the 6- month follow-up. All three habit reversal patients were free of the habit at the 6-month follow-up. At the 22-month follow-up, one patient, HR2,

stated that she had been experiencing about three minor and controlled episodes per day for the last 2 days after having been habit free for over 1 year; she was to be married in one

week.

DISCUSSION

The negative practice treatment reduced the oral habits to only a moderate degree of about 60%. This degree of reduction is roughtly com- parable to that obtained with this treatment when applied in large scale studies to other habits such as nailbiting (Smith, 1957), stuttering and nervous tics (Azrin, Nunn and Frantz, 1979; 1980). The habit reversal procedure reduced the oral habits by about 99% confirming the earlier result obtained by Azrin and Nunn (1973) with one gum-sucking patient whose oral habit was also eliminated. Four of the five patients receiving the habit reversal reported the habit to be absent at their last follow-up report which was as long as 22 months. The exception was a woman who had three minor episodes ascribed by her to “pre-wedding jitters”.

54 N. H. AZRIN. R. G. NUNN and S. E. FRANTZ-RENSHAW

The subjective reactions of the patients were recorded at each follow-up. At the last follow- up contact of the five negative practice patients, which was one month, two described their con- dition as somewhat improved and three as un- improved; all had five or more episodes per day. At the last follow-up contact of the five habit reversal patients, which varied from 3 to 22 months, four were habit free and all reported the habit was no longer a problem.

The present study offers a more systematic and larger scale evaluation of training procedures for treating oral habits than seems to have been available. The habit reversal procedure appears to offer an attractive alternative to some of the more drastic treatments such as surgery or intraoral appliances, lengthy psychotherapy, or to brief negative practice.

Response reliability measures present a special problem for intraoral habits since the behavior ordinarily is not visible to others, except for indirect signs such as puckering of the cheeks and folding in of the lips in some instances. Such signs were used in the present study to instruct parents in supporting practice by their children. The present study included quantitative measures of the behavior, in contrast to the non-quantitative reports of most previous studies. However, future research might well attempt to eliminate dependence on self-report data, perhaps by EMG recordings or by medical ratings of the tissue damage, when relevant. A similar caution exists regarding the general conclusions drawn from this study of 10 patients which, while based on a larger number than was included in most other studies, requires a larger sample in future research to provide population general- ity regarding the substantial benefit seen here. For at least one other type of oral habit, bruxism, a separate preliminary study resulted in a failure of the habit reversal treatment with some patients, due in part, perhaps, to the nocturnal nature of that habit. Definitive conclusions regarding the substantial efficacy of the present program must await further evidence with response reli- ability measures, a larger sample of patients and a greater variety of oral habits.

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