Behavior Modification recent issues

Context-Based Assessment and Intervention for Problem Behavior in Children With Autism Spectrum Disorder

Cale, S. I., Carr, E. G., Blakeley-Smith, A., Owen-DeSchryver, J. S. — Fri, 20 Nov 2009 12:49:33 PST

The present study used a context-based model of assessment and intervention to explore whether interventions that modify context result in reduction of problem behavior in ecologically valid settings (i.e., typical routines implemented by typical education personnel in neighborhood schools). The Contextual Assessment Inventory (CAI) and a postassessment interview were administered to parents and teachers of eight children with Autism Spectrum Disorder to identify problem contexts. Then, environmental modification techniques were implemented in three priority contexts: namely, transitions, termination of preferred activities, and presence of a feared stimulus. Our results demonstrated an almost complete elimination of problem behavior in the priority contexts as well as successful completion of activities and routines related to those contexts. We discuss the value of conceptualizing problem behavior as a function of context with respect to facilitating both assessment and intervention, and the need for enhancing breadth of effects to determine the larger impact of a context-based approach on promoting meaningful behavior change in the community.

Relationship of Exposure to Clinically Irrelevant Emotion Cues and Obsessive-Compulsive Symptoms

Allen, L. B., Barlow, D. H. — Fri, 20 Nov 2009 12:49:33 PST

Research has highlighted the role of emotion regulation as a common factor underlying emotional disorders. The current study examined the relationship of emotion regulation skills to obsessive-compulsive disorder (OCD) symptoms. Seven participants with a principal diagnosis of OCD in a multiple-baseline across subjects design were taught the skill of prevention of emotional avoidance in the context of emotion provocation procedures to clinically irrelevant (nonspecific) cues prior to practicing this skill with clinically relevant (OCD-specific) cues. Results suggested successful acquisition of emotion regulation skills (as evidenced by decreased thought suppression and increased acceptance of thoughts and feelings) in clinically irrelevant contexts. Acquisition of this skill was associated with decreases in obsessive-compulsive symptoms, even though clinically relevant cues were not introduced during this phase. Implementation of skills in clinically relevant contexts was associated with greater reductions in OCD symptoms. Discussion focuses on implications for emotion regulatory processes in the maintenance and treatment of emotional disorders.

Biased Processing of Threat-Related Information Rather Than Knowledge Deficits Contributes to Overestimation of Threat in Obsessive-Compulsive Disorder

Moritz, S., Pohl, R. F. — Fri, 20 Nov 2009 12:49:33 PST

Overestimation of threat (OET) has been implicated in the pathogenesis of obsessive-compulsive disorder (OCD). The present study deconstructed this complex concept and looked for specific deviances in OCD relative to controls. A total of 46 participants with OCD and 51 nonclinical controls were asked: (a) to estimate the incidence rate for 20 events relating to washing, checking, positive, or negative incidents. Furthermore, they were required (b) to assess their personal vulnerability to experience each event type, and (c) to judge the degree of accompanying worry. Later, participants were confronted with the correct statistics and asked (d) to rate their degree of worry versus relief. OCD participants did not provide higher estimates for OCD-related events than healthy participants, thus rendering a knowledge deficit unlikely. The usual unrealistic optimism bias was found in both groups but was markedly attenuated in OCD participants. OCD-related events worried OCD participants more than controls. Confrontation with the correct statistics appeased OCD participants less than healthy participants. Even in the case of large initial overestimations for OCD-related events, correct information appeased OCD participants significantly less than healthy participants. Our results suggest that OCD is not associated with a knowledge deficit regarding OCD-related events but that patients feel personally more vulnerable than nonclinical controls.

Group-Based Preference Assessment for Children and Adolescents in a Residential Setting: Examining Developmental, Clinical, Gender, and Ethnic Differences

Resetar Volz, J. L., Cook, C. R. — Fri, 20 Nov 2009 12:49:33 PST

This study examines developmental, clinical, gender, and ethnic group differences in preference in residentially placed children and adolescents. In addition, this study considers whether residentially placed youth prefer stimuli currently being used as rewards as part of a campuswide token economy system and whether youth would identify preferred stimuli that are not currently offered. The article discusses a survey devised specifically for the purpose of this study. Stimuli currently offered as rewards are listed and rated on a 5-point Likert-type scale. Results indicate that the majority of stimuli available within the token economy system were rated as preferred. Also, significant developmental, clinical, gender, and ethnic group differences are found, indicating the benefit of considering group-level characteristics when designing and implementing a groupwide token economy system. The implications of the results and directions for future research are discussed.

Prediction of Exercise in Patients Across Various Stages of Bariatric Surgery: A Comparison of the Merits of the Theory of Reasoned Action Versus the Theory of Planned Behavior

Hunt, H. R., Gross, A. M. — Fri, 20 Nov 2009 12:49:33 PST

Obesity is a world-wide health concern approaching epidemic proportions. Successful long-term treatment involves a combination of bariatric surgery, diet, and exercise. Social cognitive models, such as the Theory of Reasoned Action (TRA) and the Theory of Planned Behavior (TPB), are among the most commonly tested theories utilized in the prediction of exercise. As exercise is not a completely volitional behavior, it is hypothesized that the TPB is a superior theoretical model for the prediction of exercise intentions and behavior. This study tested validity of the TPB in a sample of bariatric patients and further validated its improvement over the TRA in predicting exercise adherence at different operative stages. Results generally confirmed research hypotheses. Superiority of the TPB model was validated in this sample of bariatric patients, and Perceived Behavioral Control emerged as the single-best predictor of both exercise intentions and self-reported behavior. Finally, results suggested that both subjective norms and attitudes toward exercise played a larger role in the prediction of intention and behavior than previously reported.

Behavioral Activation Is an Evidence-Based Treatment for Depression

Sturmey, P. — Fri, 20 Nov 2009 12:49:33 PST

Recent reviews of evidence-based treatment for depression did not identify behavioral activation as an evidence-based practice. Therefore, this article conducted a systematic review of behavioral activation treatment of depression, which identified three meta-analyses, one recent randomized controlled trial and one recent follow-up of an earlier randomized control trial. Behavioral activation was consistently superior to wait list and treatment as usual control groups. Effect sizes were not different from cognitive behavior therapy or cognitive therapy, both post-treatment and at follow-up. Indeed, behavioral activation may be more effective than cognitive therapy and cognitive behavior therapy in terms of lower dropout. Behavioral activation, like cognitive behavior therapy, may be superior to paroxitine because it results in less relapse and recurrence, may be substantially cheaper, and does not have risks of pharmacotherapy. There is some evidence that behavioral activation may also be useful with some people for whom cognitive and cognitive-behavior therapy is less effective, such as those with severe, lifelong depression, people with substance abuse and people with dementia and severe depression. There is now sufficient evidence to conclude that behavioral activation is an evidence-based therapy.

The Validity of Virtual Environments for Eliciting Emotional Responses in Patients With Eating Disorders and in Controls

Ferrer-Garcia, M., Gutierrez-Maldonado, J., Caqueo-Urizar, A., Moreno, E. — Fri, 20 Nov 2009 12:49:33 PST

This article explores the efficacy of virtual environments representing situations that are emotionally significant to patients with eating disorders (ED) to modify depression and anxiety levels both in these patients and in controls. Eighty-five ED patients and 108 students were randomly exposed to five experimental virtual environments (a kitchen with low-calorie food, a kitchen with high-calorie food, a restaurant with high-calorie food, a restaurant with low-calorie food, and a swimming-pool) and to one neutral environment. In the interval between the presentation of each situation, anxiety and depressed mood were assessed. Results of several repeated measures analyses demonstrated that patients show higher levels of anxiety and a more depressed mood after eating, especially high-calorie food, and after visiting the swimming pool than in the neutral room. In contrast, controls only show higher levels of anxiety in the swimming pool. In the rest of the situations they presented a similar mood state as in the neutral room. We concluded that virtual reality is a useful vehicle for eliciting similar emotional reactions to those one would expect in real life situations. Thus, this technology seems well suited for use in experimental studies as well as in evaluative and therapeutic contexts.

Effectiveness of Teacher-Child Interaction Training (TCIT) in a Preschool Setting

Fri, 20 Nov 2009 12:49:33 PST

This research addressed the need for trained child care staff to support optimal early social-emotional development in urban, low-income, ethnic minority children. We evaluated effectiveness of Teacher-Child Interaction Training (TCIT), an approach adapted from Eyberg’s Parent-Child Interaction Therapy (PCIT). TCIT focuses on increasing preschool teachers’ positive attention skills and consistent discipline in order to enhance children’s psychosocial functioning and prevent mental health problems. A total of 12 teachers participated in small-group workshop sessions with in vivo coaching on their use of skills in the classroom. A multiple-baseline design across four classrooms (3 teachers each) evaluated effects of training on teacher behaviors during weekly classroom observations. Findings indicated systematic increases in trained skills during intervention, and consumer evaluations showed that the training was rated positively. Our results suggest that TCIT is a promising approach for enhancing positive teacher-child interactions in a preschool setting and should receive further investigation.

Family Behavior Therapy for Substance Abuse and Other Associated Problems: A Review of Its Intervention Components and Applicability

Wed, 28 Oct 2009 11:23:00 PDT

A comprehensive evidence-based treatment for substance abuse and other associated problems (Family Behavior Therapy) is described, including its application to both adolescents and adults across a wide range of clinical contexts (i.e., criminal justice, child welfare). Relevant to practitioners and applied clinical researchers, topic areas include its theoretical and empirical background, intervention protocols, methods of enhancing motivation for treatment, and future directions.

Treatment Outcomes for Severe Feeding Problems in Children With Autism Spectrum Disorder

Laud, R. B., Girolami, P. A., Boscoe, J. H., Gulotta, C. S. — Wed, 28 Oct 2009 11:23:00 PDT

There is abundant research to support that children with autism spectrum disorder (ASD) exhibit challenging feeding behaviors. Despite increase in empirical evidence supporting the role of behavior analysis in treating severe feeding problems, evaluation of the short- and long-term effects of these treatments for a large group of children with ASD is warranted. The purpose of the current study was to evaluate treatment outcomes of an interdisciplinary feeding program for 46 children with ASD. A retrospective chart analysis indicated these children were treated successfully overall and follow-up data suggest gains were maintained following discharge from the program.

Using Descriptive Assessment in the Treatment of Bite Acceptance and Food Refusal

Wed, 28 Oct 2009 11:23:00 PDT

The feeding behaviors of two children who maintained failure to thrive diagnoses and displayed food refusal are assessed in their homes. Descriptive assessments are used to identify schedules of consequence provided by each child’s care providers for bite acceptance and food refusal behaviors. Assessments reveal rich schedules of praise and access to social interaction and preferred activities for bite acceptance and escape for food refusal. These schedule arrangements result in hypotheses that modifications to the schedule of praise and access to social interaction and preferred activities for bite acceptance would result in little to no effect and that modifications to the schedule of escape for food refusal would be necessary for treatment success. Successful interventions are subsequently implemented by manipulating the existing schedules of escape for food refusal by each child’s care providers. Implications for the use of descriptive assessments for feeding problems are discussed.

The Relation of Maternal Sensitivity to Children's Internalizing and Externalizing Problems Within the Context of Maternal Depressive Symptoms

Wed, 28 Oct 2009 11:23:00 PDT

Maternal depression has been linked to deficits in parenting that contribute to youth’s development of externalizing and/or internalizing problems. Maternal sensitivity has been implicated within the infant literature as a foundational aspect of parenting contributing to a child’s adjustment. This study examines the main and moderating effects of a construct labeled maternal sensitivity, within the context of depressive symptoms, on youth externalizing and internalizing problems in a sample of 65 mothers with a history of depression and their 84 children ages 9-15 years. Sensitivity was related to child externalizing problems. Although two-way interactions were not significant, exploratory moderation analyses indicated a significant three-way interaction among maternal depressive symptoms, maternal sensitivity, and youth gender for internalizing problems: among girls only, high depressive symptoms, low sensitivity, and the combination of these two variables were each associated with high levels of internalizing problems.

Identifying Evidence-Based Interventions for Children and Adolescents Using the Range of Possible Changes Model: A Meta-Analytic Illustration

De Los Reyes, A., Kazdin, A. E. — Wed, 28 Oct 2009 11:23:00 PDT

The article discusses a study involving a framework (range of possible changes [RPC] Model) developed and applied to identify patterns in consistent and inconsistent intervention outcomes effects by informant, measurement method, and method of statistical analysis to the meta-analytic study of trials testing two evidence-based interventions for children and adolescents (youth-focused cognitive-behavioral treatment for child anxiety problems; parent-focused behavioral parent training for childhood conduct problems). This article illustrates how findings gleaned from applying the RPC Model allow for unique opportunities for hypothesis generation based on the patterns of consistent outcomes effects. Based on the RPC Model, studies can be closely examined to identify the specific instances in which interventions yield robust effects, and the authors illustrate how examining effects in this way can lead to new understandings of interventions and the outcomes they produce. Findings suggest that researchers can employ previously underutilized patterns of consistencies and inconsistencies in outcomes effects as new resources for identifying evidence-based interventions.

Application of a Standardized Assessment Methodology Within the Context of an Evidence-Based Treatment for Substance Abuse and Its Associated Problems

Allen, D. N., Donohue, B., Sutton, G., Haderlie, M., LaPota, H. — Wed, 28 Oct 2009 11:23:00 PDT

Administrators of community-based treatment programs are increasingly being required to utilize psychometrically validated instruments to measure the effectiveness of their interventions. However, developers of psychometric measures have often failed to report strategies relevant to the administration of these measures in nontraditional settings outside the therapy office. Moreover, with few exceptions, developers of evidence-based treatments (EBTs) have insufficiently disseminated methods for integrating assessment measures into treatment planning. Therefore, the purpose of this article is to review an assessment methodology that may be utilized to support EBT for individuals who are identified for substance abuse or related problem behaviors. The application of this methodology is demonstrated utilizing Family Behavior Therapy to exemplify "real world" scenarios involving adolescents and adults. Although many of these strategies are evidence supported, most are based on clinical experiences occurring in clinical trials and dissemination efforts within community settings.

Are Children Diagnosed With the Combined Form of ADHD Pervasively Hyperactive?

Licht, C. A., Tryon, W. W. — Wed, 28 Oct 2009 11:23:00 PDT

Diagnostic criteria specified by the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR ; American Psychological Association [APA], 2000) require that motor excess be present across situations, at home and school, in order to establish that this condition is a characteristic of the child. The article discusses a study whose primary purpose was to use actigraphy to validate teacher and parent reports of hyperactivity at home and school. Continuous activity measurements were recorded for each minute of each 24-hr period (1,440 measurements per child per day) for a full 7-day week, during school and at home, on 9 children clinically diagnosed with the combined form of ADHD and 9 control children clinically examined at the same community mental health clinic and determined not to meet diagnostic criteria. The article highlights that the children with ADHD had not yet started medication, and the study findings reveal that only 1 of 9 children diagnosed with the combined form of ADHD was measurably pervasively hyperactive as DSM-IV-TR inclusion criteria require. Implications are discussed.

Identifying Stimuli that Alter Immediate and Subsequent Levels of Vocal Stereotypy: A Further Analysis of Functionally Matched Stimulation

Lanovaz, M. J., Fletcher, S. E., Rapp, J. T. — Wed, 28 Oct 2009 11:23:00 PDT

We used a three-component multiple-schedule with a brief reversal design to evaluate the effects of structurally unmatched and matched stimuli on immediate and subsequent vocal stereotypy that was displayed by three children with autism spectrum disorders. For 2 of the 3 participants, access to matched stimuli, unmatched stimuli, and music decreased immediate levels of vocal stereotypy; however, with the exception of matched stimuli for one participant, none of the stimuli produced a clear abolishing operation for subsequent vocal stereotypy. That is, vocal stereotypy typically increased to baseline levels shortly after alternative stimulation was removed. Detection of motivating operations for each participant’s vocal stereotypy was aided by the analysis of component distributions. The results are discussed in terms of immediate and subsequent effects of preferred stimuli on automatically reinforced problem behavior.

Description of a Standardized Treatment Center That Utilizes Evidence-Based Clinic Operations to Facilitate Implementation of an Evidence-Based Treatment

Fri, 24 Jul 2009 10:19:48 PDT

Developers of evidence-based therapies are enhancing methods of teaching therapists to implement "best practices" with integrity. However, there is a relative dearth of information available as to clinic operations and related contextual factors necessary to sustain successful implementation of these treatments. This article describes various evidence-based administrative strategies and methods utilized by clinic staff to effectively implement a comprehensive evidence-based treatment for substance abuse (i.e., Family Behavior Therapy). The basic structure of the clinic, standardized behavioral methods associated with its day-to-day operations, and maintenance of treatment integrity are delineated. Infrastructural systems are underscored, including clinical record keeping, quality assurance, and staff management.

The Impact of Children with High-Functioning Autism on Parental Stress, Sibling Adjustment, and Family Functioning

Rao, P. A., Beidel, D. C. — Fri, 24 Jul 2009 10:19:49 PDT

The article discuses a study conducted to investigate the impact of children with high-functioning autism (HFA) on parental stress, sibling adjustment, and family functioning; the study involves a sample of parents of 15 children with HFA and parents of 15 matched control children who completed questionnaires measuring the dependent variables. The results indicate parents of children with HFA experience significantly more parenting stress than parents of children with no psychological disorder, which was found to be directly related to characteristics of the children. The study further shows that the higher intellectual functioning in children with HFA does not compensate for the stress associated with parenting children with autism spectrum disorders. Because the intervention efforts directed at children with HFA will not eliminate the child's primary symptoms, treatment programs may need to address parental stress, which in turn will help optimize treatment outcome for the child and the family.

Behavioral Signs of Schizoidia and Schizotypy in the Biological Parents of Social Anhedonics

Emmerson, L. C., Miller, S. L., Blanchard, J. J. — Fri, 24 Jul 2009 10:19:49 PDT

A community sample of 88 putative schizotypes (48 social anhedonics, 40 controls), aged 18 to 19 years, and their biological parents (42 mothers of social anhedonics, 37 mothers of controls; 24 fathers of social anhedonics, 20 fathers of controls) receive videotaped diagnostic evaluations that serve as the basis for ratings of behavioral signs of schizoidia and schizotypy. Proband social anhedonics exhibit more atypical interpersonal behaviors characteristic of schizoid and schizotypal personality disorders than controls. Mothers of social anhedonics display more atypical interpersonal behaviors characteristic of schizotypal personality disorder than mothers of controls. In contrast, clinical symptom ratings of schizotypy do not differentiate mothers of social anhedonics from mothers of controls. Meaningful, though not statistically significant, effects are observed for behavioral sign ratings in the smaller sample of fathers of social anhedonics. Results provide preliminary support for the familiality of atypical interpersonal behavior in social anhedonics.

Behavior Modification of Aggressive Children in Child Welfare: Evaluation of a Combined Intervention Program

Nitkowski, D., Petermann, F., Buttner, P., Krause-Leipoldt, C., Petermann, U. — Fri, 24 Jul 2009 10:19:49 PDT

Children and adolescents with aggressive disorders are prevalent in child welfare settings. Therefore, the assumption is that child welfare services would benefit from a cognitive-behavioral intervention. This study investigates whether implementation of the training with aggressive children (TAC) could improve the outcome of child welfare. Twelve children (average age 10 years), diagnosed with an oppositional defiant disorder or a conduct disorder, are treated either with a child welfare program or with a combined intervention of child welfare program and TAC. Before and immediately after completion of the combined treatment, parent and teacher ratings are collected. Parents report children participating in child welfare and TAC to show a stronger decline in social and conduct problems as well as a clearer increase in prosocial behavior. Teachers see a better improvement in social problems and tended to report a decrease in aggressive behavior. Results confirm that the TAC can enhance effects of a child welfare program.

Booster Sessions Enhance the Long-Term Effectiveness of Spaced Retrieval in Older Adults with Probable Alzheimer's Disease

Cherry, K. E., Hawley, K. S., Jackson, E. M., Boudreaux, E. O. — Tue, 14 Apr 2009 13:19:02 PDT

Six older adults with probable Alzheimer's disease (AD) were trained to recall a name—face association using the spaced retrieval technique. In this study, we retested these persons in a 6-month follow-up program. For half of the participants, three booster sessions were administered at 6, 12, and 18 weeks after original training to promote long-term retention of the name— face association. Results yielded a mnemonic benefit of the booster sessions at retest. Participants were successful in transferring this association to the actual person in the target photograph. These data confirmed the positive effect of spaced retrieval on recall of a name—face association over a 6-month interval. Implications for memory remediation in cognitively impaired older adults are considered.

Virtual Reality Cognitive Behavior Therapy for Public Speaking Anxiety: A Randomized Clinical Trial

Wallach, H. S., Safir, M. P., Bar-Zvi, M. — Tue, 14 Apr 2009 13:19:02 PDT

Public speaking anxiety (PSA) is a common phobia. Although cognitive behavior therapy (CBT) is preferred, difficulties arise with the exposure component (lack of therapist control, patient's inability to imagine, self-flooding, loss of confidentiality resulting from public exposure). Virtual reality CBT (VRCBT) enables a high degree of therapist control, thus overcoming these difficulties. This study examined whether VRCBT is an alternative to CBT. Participants with PSA were randomly assigned to VRCBT (28 participants), CBT (30 participants), and wait list control (WLC; 30 participants). VRCBT and CBT were significantly more effective than WLC in anxiety reduction on four of five anxiety measures, and on subject's self-rating of anxiety during a behavioral task. No significant differences were found on observer ratings of the behavioral task. However, twice as many participants dropped out from CBT than from VRCBT. Our results demonstrated that VRCBT is an effective and brief treatment regimen, equal to CBT.

The Effectiveness of Intervention on the Behavior of Individuals With Autism: A Meta-Analysis Using Percentage of Data Points Exceeding the Median of Baseline Phase (PEM)

Ma, H.-H. — Tue, 14 Apr 2009 13:19:02 PDT

The aim of the present study is to demonstrate the percentage of data points exceeding the median of baseline phase (PEM) approach using data on autism treatment for illustrative purposes to compare the effectiveness of different interventions on the problem behaviors of individuals with autism. Electronic databases such as The ProQuest and Google were searched. A total of 163 articles were located, producing 1,502 effect sizes. The results demonstrate that five highly effective intervention strategies were priming, self-control, training, positive reinforcement and punishment, and presenting preferential activities. The least effective strategy was to teach perspective-taking skills. The PEM approach is recommended for use in meta-analysis for single-case experimental designs.

Evaluation of a Self-Instructional Manual for Conducting Discrete-Trials Teaching With Children With Autism

Thiessen, C., Fazzio, D., Arnal, L., Martin, G. L., Yu, C.T., Keilback, L. — Tue, 14 Apr 2009 13:19:02 PDT

Discrete-trials teaching (DTT) is commonly used to implement applied behavior analysis treatment for children with autism. The authors investigated a revised self-instructional manual for teaching university students to implement a 21-component DTT procedure to teach three tasks to confederates role-playing children with autism. Also, as a motivational contingency, for each DTT session in which a student scored at or above 90% accuracy, they received US$10. After an average of 4.5 hr to master the training manual, students' average DTT performance improved from 52% in baseline to 88% while teaching a confederate. Students averaged 77% DTT performance during subsequent generalization sessions with a child with autism.

Adapted Behavior Therapy for Persistently Depressed Primary Care Patients: An Open Trial

Uebelacker, L. A., Weisberg, R. B., Haggarty, R., Miller, I. W. — Tue, 14 Apr 2009 13:19:02 PDT

Major depressive disorder is commonly treated in primary care settings. Psychotherapy occurring in primary care should take advantage of the unique aspects of the setting and must adapt to the problems and limitations of the setting. In this open trial, the authors used a treatment development model to adapt behavior therapy for primary care patients (n = 12) with persistent symptoms of depression, despite antidepressant medication treatment. Ten of 12 participants completed 10 sessions of therapy over the course of 4 months, and all endorsed high levels of treatment satisfaction. Participants' depression scores declined significantly over time, and 75% of participants experienced at least 50% change on a self-report measure of depression symptoms. There were trends for social functioning, pain, and general health perceptions to improve over time. These results highlight the acceptability and feasibility of adapting behavior therapy for primary care, and support the continuation of this research.

Affective and Sensory Correlates of Hair Pulling in Pediatric Trichotillomania

Meunier, S. A., Tolin, D. F., Franklin, M. — Tue, 14 Apr 2009 13:19:02 PDT

Hair pulling in pediatric populations has not received adequate empirical study. Investigations of the affective and sensory states contributing to the etiology and maintenance of hair pulling may help to elucidate the classification of trichotillomania (TTM) as an impulse control disorder or obsessive-compulsive spectrum disorder. The current study aimed to examine children's self-reported affective and sensory states associated with hair pulling. Fifteen participants completed a questionnaire assessing children's experiences during first and recent hair pulling episodes. Results revealed that pulling hair for the first time was associated with pleasure and pain whereas recent hair pulling was associated with pleasure only, suggesting that the punishing quality of hair pulling may diminish over time. The findings also support the notion that hair pulling may be maintained primarily through positive reinforcement, which is consistent with its classification as an impulse control disorder.