Why Define Behavior

A critical piece to every behavior plan or behavior intervention is the “target behavior”. In the majority of cases, this is the behavior of concern that the intervention is meant to decrease and it will often be paired with a functionally equivalent replacement behavior. For example, a target behavior labeled “Hits” may be defined as “forcefully swings an open or closed fist in the direction of her head or chin, swings objects in the direction of her head/chin, or swings her head in the direction of a wall or desk with or without making contact” (pulled from an actual behavior support plan referenced in the 2013 article by Smith, Lambert, & Moore). In contrast to this, a replacement behavior labeled “Places” may be defined as “gently places open palms on head or chin, places open palms on objects, or gently lowers and places head against object”.

In both examples, the target behavior and the replacement behavior are described such that a member of the team of interveners (staff, family, etc.) would be likely to identify the behavior as it is occurring such that it can be counted for data collection and responded to with a consequence procedure. With this in mind, we can generally state that we define behaviors so that interveners can count them and use them as a cue for when to implement a behavior change procedure.

The Trouble with Defining Behavior

Now that we’ve agreed on a general “why”, let’s revisit the target behavior labeled “Hits” used above. It reads, “forcefully swings an open or closed fist in the direction of her head or chin, swings objects in the direction of her head/chin, or swings her head in the direction of a wall or desk with or without making contact”. Take a moment and envision this behavior. Maybe even forcefully swing your arm a time or two being careful not to strike a person or object in your vicinity. Now take another moment and imagine someone is watching you as you swing your arm. Does that person also believe the speed of the arm was “forceful”? Does the arc of the arm fall within the definition of a “swing” or is it more of a “whirl”? Was the swing in the “direction” of the head or more towards the shoulder?

Here we see how a behavioral definition, which was pretty clear just a moment ago, can be rife with uncertainty. This is troublesome even when there is just one intervener who is unsure if a behavior “counts”. However, we often instill teams of interveners to measure behavior and intervene. If each person conceptualizes the target behavior differently, then how can we be sure it is counted reliably and accurately? Are there strategies to increase the likelihood that each subjective experience of the target behavior aligns with the actual event? If so, how can these increase agreement, decrease confusion, and ultimately improve treatment fidelity?

Considerations for Defining Behavior

While no source has established the “best” way to define target behaviors for intervention, there are several factors deemed valuable to the process. Several of these are reviewed below.

1. Present Tense, Active Voice – Use the present tense and an active voice form of a verb in your behavioral definition. Verbs that demonstrate action on an object ending in “s” usually meet this criteria. “Touches head”, “Throws ball”, “Sits bottom”, “Raises hand”, “Drops body”, etc. For those with experience with Celeration Charting and Precision Teaching, these may seem familiar.
2. Remove or Limit Adverbs – Adverbs can be great qualifiers in some behavior plans, especially ones that are specifically intervening on the intensity of a behavior. However, if intensity is not a qualifier, adverbs can create confusion. For example, “Quickly raises hand” introduces confusion to the observer. They may ask, “Did that count as quick enough?” when collecting data. Remove the confusion by removing the adverb. “Raises hand” is a fine target behavior without extra qualifiers.
3. Develop Exemplars – Within your team, demonstrate exactly what counts and does not count as an instance of the behavior and review these with all interveners. This is especially useful if the behavior may look different across various contexts or when adverbs cannot be removed from the definition. It is also especially useful when the behavior may not match the words. Even the phrase “raises hand” can lead to some confusion. Was the hand “high” enough? Was the bend to the arm within an “acceptable range”? Does it count if “both” hands are raised at the same time? Having staff review and observe various forms of the behavior can significantly improve detection and, therefore, increase both the quality of the data and correct implementation of the behavior change intervention.
4. Update Definitions regularly – It should come as no surprise that behaviors change over time. In most cases, the behavior is gradually shaped such that the most effective version of the response is selected more and more frequently. Because of this, we should expect changes in the behavior over time and update our definitions accordingly.
5. Build Directly into Interventions – Incorporating these pieces from the outset of designing an intervention can be quite helpful when training an intervener. While this can take many forms, consider the ABC Chart format below:

Notes:

– FR3 refers to a Fixed-Ratio schedule with delivery on the third response.

– FR1 refers to a Continuous schedule with delivery on every response.

Wrap-up

Again, it should be repeated that no “best” way to define a behavior has been established. In fact, if such a best way existed, the field as a whole would be in a very different place. The suggestions and discussion above offer one starting point to a larger discussion on defining behaviors. Hopefully, they are also useful in some way to you, the reader, regarding the creation of behavioral definitions, treatment planning, and intervention.

Until we meet again, happy definition writing!

Disclaimer:

Please note that the strategies and items discussed here do not constitute clinical advice and should not be used in place of treatment interventions developed by clinical professionals and multidisciplinary teams in your place of work. While some of the suggestions here may be incorporated into a well-designed treatment package, every treatment should be individualized to address the needs of the individual served.

References

Smith, G. D., Lambert, J. V., Moore, Z. (2013). Behavior description affects accuracy and reliability. The Journal of General Psychology, 140(4), 269-281.

Some Habit History

Habits, habit behaviors, or habit disorders are often defined as repetitive, body-focused behaviors that serve no adaptive function and are often unwanted due to the stress or functional impairment they cause (Hansen, Tishelman, Hawking, & Doepke, 1990; Bate, Malouff, Thorsteinsson, & Bhullar, 2011). Such behaviors include: nail-biting, hair pulling (trichotillomania), skin picking, and teeth grinding (Miltenberger, Fuqua, & Woods, 1998); though other behavior such as saying “um” during pauses while speaking in public can be addressed within the same “habit” framework (Mancuso & Miltenberger, 2016). Prior to 1973, leading treatments of habit disorders included psychotherapy, drug interventions, shock-aversion therapy, and negative practice (Azrin & Nunn, 1973). These treatments vary in effectiveness and, in some cases, were not the most humane forms of behavioral intervention as they relied on punishment procedures. As such, several of these treatment approaches would not be used today. Fortunately, an effective approach to treating habits was developed and published by Azrin and Nunn in 1973.

Steps to Habit Change

Azrin and Nunn (1973) built on the work of Butcher (1968) who argued that nervous habits are maintained through operant reinforcement. In conceptualizing habits this way, Azrin and Nunn developed a five step treatment approach and recruited 12 participants to see if it worked. The intervention took place over  The results were astounding. Of the 12 participants, 10 of them displayed an average of zero habit behaviors three weeks after treatment had concluded. The seven participants who remained in the study for all follow-up activities collectively showed a 99% reduction in habit behavior at five months post treatment. The procedures used by Azrin and Nunn (1973) are described as steps below and can be utilized in your own life.

1. Self-Monitoring: To begin, the individual changing the habit selects a way of counting how often the habit behavior is occurring. This could be an exact count of each time it is happening or a statement regarding the percentage of time each day that the habit behavior is occurring. Various recording strategies can be used depending on individual preference.
2. Awareness Training: In this step, the individual changing the habit systematically increases their ability to detect when the behavior is occurring. Several separate systems for this are described by Azrin and Nunn (1973):
   • a.) Response Description Procedure: The individual is asked to describe in detail, perhaps using a mirror if necessary, each part of the behavior while engaging in the behavior; attaching the language to the movements.
   • b.) Response Detection Procedure: A third party informs the individual when the behavior is occurring and assists the individual in recognizing the behavior (e.g. a third party alerts the individual when their hand is in their mouth).
   • c.) Early Warning Procedure: The individual practices detecting the earliest sign of the habit behavior (e.g. when a nail biter first begins to move the hand closer to their mouth).
   • d.) Competing Response Practice: The individual is asked to tense the muscles involved in the habit behavior and, in doing so, consequently stop the habit behavior from occurring (e.g. as the individual moves the fingertips towards the mouth, the individual instead tenses the muscles along the length of the arm stopping the motion towards the mouth).
   • e.) Situation Awareness Training: The individual is asked to recall all situations, persons, and places where the habit has occurred or is likely to occur and what the habit looks like in that setting (e.g. the individual describes how they put their head down to bite their nails discreetly in a public setting).
3. Competing Response Practice: This builds on option “d” in Step 2. In this step, the individual selects a response that is incompatible with the habit behavior and includes all or some of the following characteristics:
   • a.) The movement is opposite that of the habit behavior (e.g. moving the hand away from the mouth rather than towards for nail-biting).
   • b.) The movement can be maintained for several minutes (e.g. holding an object tightly or pressing the hand into the leg rather than having it near the mouth for nail-biting).
   • c.) The movement results in muscles tensing and increasing awareness of the muscles involved in the movement (e.g. clenching fist of the hand that has been moved away from the mouth for nail-biting).
   • d.) The movement is inconspicuous in a public setting and allows for continued engagement in daily activities (e.g. the clenched fist of the hand away from the mouth is placed in the pocket of the individual for nail-biting).
   • e.) The muscles involved in the movement are strengthened through some level of exercise (e.g. grip strengthening exercises for nail-biting).
   • f.) The individual should engage in the competing behavior for three minutes every time s/he experiences the temptation to engage in the habit behavior and when s/he catches him-/herself engaging in the habit behavior. The Azrin and Nunn (1973) article provide some specific examples of competing behaviors for various nervous tics on pages 624-625.
4. Habit Control Motivation: This step involves several strategies to increase the individual’s motivation to actively engage in the Awareness and Competing Response pieces of the intervention. These strategies may be implemented by the individual or by a third party involved in the intervention and include:
   • a.) Habit Inconvenience Review: In this strategy, the individual reviews any embarrassment or inconveniences that that habit has resulted in. This strengthens the motivation to avoid embarrassment or inconvenience by either not engaging in the habit behavior or by engaging in the competing behavior.
   • b.) Social Support Procedure: In this strategy, family and friends of the individual strengthen the motivation by 1.) commenting favorably on efforts when habit-free periods are noted, 2.) offering reminders to “practice your exercises” when habits are overlooked by the individual, 3.) having a third party offer praise for the individual’s efforts at inhibiting habits.
   • c.) Special Procedures with Children who are not motivated: Parents either physically guided their children through the competing behaviors upon observing a habit behavior or instructed the child to practice the competing behavior in a bedroom if they failed to self-initiate the competing behavior.
5. Generalization Training: This step involves practicing the awareness and competing behavior steps in approximations of the natural settings that the individual spends time in. In some cases, these approximations only need to be imagined. Again, several procedures are available, including:
   • a.) Symbolic Rehearsal Procedure: In this strategy, the individual imagines common and habit-eliciting settings and that s/he has just engaged in the start of a habit behavior. The individual then engages in the appropriate competing response as if s/he had actually displayed the habit behavior.
   • b.) Additional Practice (Procedure not specified): In this strategy, the individual discusses topics that do not relate to habit behaviors with a third party, simulating an everyday conversation. When the individual begins to initiate a habit behavior, they will detect this and engage in the competing response. The third party is a confederate and will offer a subtle sign to the participant if s/he does not engage in the competing response after initiating the habit behavior.

Wrap-up

Currently, the field of Applied Behavior Analysis (ABA) is often considered synonymous with interventions related to autism and intellectual disabilities. Habit Reversal Training deviates from this common association and demonstrates the application of ABA outside of “traditional” populations (Rapp et al., 1998; Twohig & Woods, 2001). The application of Habit Reversal Training also extends across countries and languages such as seen in the work on Nail Biting by Singal and Daulatabad (2017) in India. Finally, it is recognized as a competitive treatment for habit behaviors and is acknowledged as such by practitioners outside of the field of ABA (see Schumer, Bartley, and Bloch’s article in the Journal of Clinical Psychopharmacology (2016) comparing the effects of pharmacological and behavioral interventions).

Disclaimer: While the strategies discussed above can be adapted and implemented in a self-monitoring approach, the use of “third-party” throughout the Blog references a clinician in the original study by Azrin and Nunn (1973). While the information provided offers a framework for decreasing habit behaviors, working with a professional skilled in habit reversal and behavior change is recommended.

Let’s make a habit of continued dialogue between QBS and you. See you again soon!

References

Azrin, N. H., & Nunn, R. G. (1973). Habit-reversal: A method of eliminating nervous habits and tics. Behavior Research and Therapy, 11, 619-628.

Bate, K. S., Malouff, J. M., Thosteinsson, E. T., & Bhullar, N. (2011). The efficacy of habit reversal therapy for tics, habit disorders, and stuttering: A meta-analytic review. Clinical Psychology Review, 31, 865-871.

Bucher, B. D. (1968). A pocket-portable shock device with application to nail biting. Behavior Research and Therapy, 6, 389-392.

Hansen, D. J., Tishelman, A. C., Hawking, R. P., & Doepke, K. J. (1990). Habits with potential as disorders: Prevalence, severity, and other characteristics among college students. Behavior Modification, 14, 66-80.

Mancuso, C. & Miltenberger, R. G. (2016). Using habit reversal to decrease filled pauses in public speaking. Journal of Applied Behavior Analysis, 49(1), 188-192.

Miltenberger, R. G., Fuqua, R. W., & Woods, D. W. (1998). Applying behavior analysis to clinical problems: Review and analysis of habit reversal. Journal of Applied Behavior Analysis, 31(3), 447-469.

Rapp, J. T., Miltenberger, R. G., Long, E. S., Elliott, A. J., & Lumley, W. A. (1998). Simplified habit reversal treatment for chronic hair pulling in three adolescents: A clinical replication with direct observation. Journal of Applied Behavior Analysis, 31(2), 299-302.

Schumer, M. C., Bartley, C. A., & Bloch, M. H. (2016). Systematic review of pharmacological and behavioral treatments for skin picking disorder. Journal of Clinical Psychopharmacology, 36(2), 147-152.

Singal, A. & Daulatabad, D. (2017). Nail tic disorders: Manifestations, pathogenesis and management. Indian journal of Dermatology, Venereology, and Leprology, 87(1), 19-26.

Twohig, M. P. & Woods, D. W. (2001). Habit reversal as a treatment for chronic skin picking in typically developing adult male siblings. Journal of Applied Behavior Analysis, 34(2), 217-220.

Keywords: habit disorders, habit reversal training, hair pulling, skin picking, self-monitoring