Using Teacher Prompts and Habit Reversal to Reduce Fingernail Biting in a Student with Attention Deficit Hyperactivity Disorder and a Mild Intellectual Disability

Using Teacher Prompts and Habit Reversal to Reduce Fingernail Biting in a Student With Attention Deficit Hyperactivity Disorder and a Mild Intellectual Disability

Raymond J. Waller Susan Kent Miriam E. Johnson

An Article Published in TEACHING Exceptional Children Plus

Volume 3, Issue 6, July 2007

Copyright © 2007 by the author. This work is licensed to the public under the Creative Commons Attribution License. Using Teacher Prompts and Habit Reversal to Reduce Fingernail Biting in a Student With Attention Deficit Hyperactivity Disorder and a Mild Intellectual Disability

Raymond J. Waller Susan Kent Miriam E. Johnson

Abstract

Fingernail biting is a habit that is developed by numerous people, especially children and teenagers. Many clinicians believe that the habit of fingernail biting stems from nervous- ness or anxiety. Students, especially students with disabilities, can be easily distracted from instruction, can become the target of negative peer attention, and can get socially ostracized by habit problems such as fingernail biting. Although teachers often must pri- oritize severe behavioral problems that we see in the classroom, we think that teachers have dramatically improved the quality of life of some of our students by helping them to modify other, less severe behavioral issues like fingernail biting. This study investigated the effect of the simple, noninvasive, and nonpunitive approaches of using coded verbal prompts and habit reversal to reduce fingernail biting in a classroom setting. A significant reduction was observed.

Keywords

attention deﬁcit disorders, ﬁngernail biting, habit reversal, mild disabilities

SUGGESTED CITATION: Waller, R. J., Kent, S., & Johnson, M. E. (2007). Using teacher prompts and habit reversal to reduce fingernail biting in a student with attention deficit hyperactivity disorder and a mild intellectual disability. TEACHING Exceptional Children Plus, 3(6) Article 3. Retrieved [date] from http://escholarship.bc.edu/education/tecplus/vol3/iss6/art3 Fingernail biting, clinically known as festation. For individuals affected by a high chronic onychophagia (Krejci, 2000), is a rate of fingernail biting, there can be addi- common problem that is largely dismissed as tional impact on the student as well. For ex- a minor nuisance, but can be observed as any- ample, severe fingernail biting may produce thing from a bad habit to an outward symp- root resorption of the teeth and lead to further tom of a medical or emotional disorder. Ac- dental problems or health complications. cording to Gale Research (1998), fingernail biting is in most cases harmless and may be Mild Intellectual Disabilities (MIID) best ignored. These researchers stated that the The most apparent educational issue most problematic side effect of fingernail bit- associated with MIID is cognitive deficits, ing is social ostracism, because the child may which we would observe as some level of be teased by his or her peers, and adults ob- lack of expected advancement in academic serving a child who bites their nails may con- achievement (Beirne-Smith, Ittenbach, & Pat- clude that he or she is insecure or stressed. It ton, 2006). We should not forget, though, that is also noteworthy that others may perceive MIID is also indicative of deficits in adaptive the sight of fingernails chewed to the ends of behavioral functioning (Luckasson et al., the fingers as unattractive, and additional 2002). Further, it is common to see behavioral negative attributions may be made about stu- issues in the classroom for students with this dents who engage in this behavior as well disability. These behavioral issues can occur (Long, Miltenberger, Ellingson, & Ott, 1999). on a continuum similar to that of fingernail Estimates suggest that 1/3 of young biting, ranging from minimal or no classroom children engage in fingernail biting (Veigle, impact to severely distracting problems that 1999), and boys seem to engage in this behav- can influence other areas, such as social and ior at a higher rate than girls after the age of academic inclusion. Teachers serving students 10. The causative agent in fingernail biting is with MIID can expect to work with students often thought to be anxiety. Situations that with a variety of needs that are similar to (al- cause fear, boredom, or pain are also corre- though often different in degree and fre- lated with fingernail biting (Doctor, 2000). quency) teachers working with other students Fingernail biting may give children a sense of with high incidence disabilities - including relief in response to these types of internal academic, behavioral, social, and transitional emotional turmoil (Veigle). Some researchers needs (see Sabornie, Cullinan, Osborn, & believe that there is a slight hereditary ten- Brock, 2005; Sabornie, Evans, & Cullinan, dency to biting fingernails, but recognize the 2006). difficulty in substantiating this theory because family members are prone to mimic each Attention Deficit Hyperactivity Disorder other’s habits (Doctor). However, specific Students who are diagnosed as having personality traits that are linked with finger- attention deficit hyperactive disorder nail biting have not been identified, and this (ADHD) display many characteristics that behavior, like other behavioral issues that we make the sustaining of attention problematic may observe, falls along a continuum that (Reis, 2002). According to the Diagnostic and ranges from a mild, occasional behavior that Statistical Manual of Mental Disorders has minimal impact on appearance to a fre- (DSM-IV-TR), characteristics of ADHD may quent, intense, and disfiguring clinical mani- include, but are not limited to: (1) often having difficulty sustaining attention in tasks or complicated steps, but it can also be simpli- play activities; (2) often does not seem to lis- fied to some simple, basic components: ten or gets easily distracted; (3) often avoids,  assessing the time, situations, and dislikes, or is reluctant to engage in tasks that other issues associated with the occur- require sustained mental effort, such as rence of the habit, schoolwork or homework; and (4) is often  identifying a reasonable replacement easily distracted by extraneous stimuli behavior, and (American Psychiatric Association, 2000).  teaching the student to replace the Approximately three to five percent of school habit with an incompatible response. children in the United States meet the diag- The effectiveness of habit reversal nostic criteria for ADHD (Bicard, Endo, & treatment for fingernail biting and other nerv- Neef, 2001). These statistics are suggestive of ous habits has been demonstrated by numer- the possibility of the placement of at least one ous researchers (e.g. Long, Miltenberger, El- child with ADHD in every classroom in lingson, & Ott, 1999) and has been reported America (Fabiano & Pelham, 2003). Stereo- to be helpful in reducing many behavioral typed behaviors such as fingernail biting problems, including skin picking (Teng, might serve as a distraction for students with Woods, & Twohig, 2006), compulsive hair ADHD, resulting in an exacerbation of atten- pulling (Woods, Wetterneck, & Flessner, tional, academic, and behavioral problems. 2006), and even reducing the tics associated with Tourette Syndrome (Watson, Dufrene, Classroom Intervention Planning Weaver, Butler, & Meeks, 2005). Several re- When designing interventions of any ports indicate that habit reversal techniques kind for students with a disability, diagnosis, have been used effectively in the classroom label, or challenging behavior, it is particu- setting (e. g. Gilman, Connor, & Haney, 2005; larly important to remember that each student Watson et al.). is first and foremost an individual, with his or her own particular pattern of strengths and Teacher Prompts needs for improvement (Forness, Sweeney, & We prompt students all the time. Wagner, 1998). Identifying effective interven- ‘Prompts’, used in this way, are no more tions for behavior problems exhibited by stu- complicated than reminders or suggestions. dents within school settings and within our Teachers must be careful about using prompts classrooms continues to be a high priority for excessively, because even when our inten- educators and other treatment providers, and tions are good, overusing prompts can lead to classroom teachers are increasingly seen as worsening – and in some cases even creating supportive, if not indispensable, in identifying – behavior problems. Another caution we and addressing behavioral issues that have a should consider with the use of prompts is negative impact on student quality of life. that they should not be something that will cause unwanted attention or shame to a stu- Habit Reversal dent. However, used with some attention, rea- Habit reversal training refers to a set son, and systematic application, prompts can of behavioral procedures used to eliminate be an important, not to mention uncompli- habits such as fingernail biting (Christopher- cated, component of an effective behavior sen, 1996). Habit reversal can consist of many intervention plan. In fact, prompts can be an invaluable tool to the classroom teacher both graders, three were seventh-graders, and three for behavior management and for promotion were eighth-graders. Recent educational test- of academic success (e.g. Brown, 2003; ing indicated that Thomas was performing Shukla-Mehta & Albin, 2003). below grade level in all academic areas. At the time of the study, he was taking stimulant Study purpose medication for ADHD, which was adminis- We hypothesized that the implementa- tered at home. He participated in two classes tion of coded teacher prompts and a simpli- outside of the MIID class, a band class and a fied habit reversal procedure would decrease resource class for social studies. While in the fingernail biting and related oral-digital habits MIID classroom, Thomas displayed no exhibited by a student diagnosed with atten- marked behavior problems and did not have a tion deficit hyperactivity disorder and a mild formal behavior intervention plan. Thomas intellectual disability. These interventions did, however, have the habit of biting his fin- were of particular interest to us because they gernails and the skin around his fingernails, were simple, easily managed within a class- along with “flicking” his teeth with his fin- room setting by teachers, and were relatively gers or fingernails. This fingernail biting was noninvasive (in the sense that they were con- severe enough to frequently distract him from sidered highly unlikely to bring undue atten- daily academic tasks, had a significant delete- tion to the student), and did not involve the rious cosmetic effect on his hands, and at- use of punishment. We chose to use a coded tracted a great deal of unwanted negative at- prompt, which in this case was a secret word tention from peers. agreed on by the student and classroom teacher, for a variety of reasons, including: Operationalization  to protect the student’s privacy, Thomas was observed throughout the  because we are opposed to using pun- school day in settings that involved a range of ishment and causing emotional duress activities including academic studies, com- in students, and puter projects, social enhancement periods,  because, if fingernail biting is affected lunch, and free time with classmates in the by stress, undesirable emotional stress school courtyard area. The target behavior could actually make the problem identified for intervention was fingernail bit- worse. ing. Fingernail biting was defined as placing one or more fingers into the mouth for the Method purpose of biting the fingernails or chewing Participant and target behavior on the skin around the fingernails. The defini- ! The participant in this study was a 14- tion also included “flicking” teeth with any year-old white male. For the purpose of this part of the finger or fingernail, operational- report, the participant will be referred to as ized as thumping, tapping, or drumming the Thomas. Thomas was in the eighth grade in a teeth with fingers with sufficient force to pro- public middle school and was served in a self- duce a sound audible to other people in the contained classroom for students with MIID. classroom. Thomas was one of eight students in the classroom, which contained four males and four females. Two of the students were sixth- Procedure and Experimental Design he heard the coded prompt that the stress ball An ABAB reversal design was used should be used, and it was said any time that for this study. With this type of single case the teacher observed his fingers in proximity research, the A phases represent a baseline to his mouth or whenever Thomas was ob- period, which is observation without interven- served biting his fingernails or “flicking” his tion. The B phases represent intervention pe- teeth. Upon hearing the prompt, Thomas was riods, and can also be thought of as the ex- taught to pick up the stress ball and begin perimental time frames that the independent squeezing it as a replacement behavior for variable(s) are being implemented. The inde- fingernail biting. Further, Thomas was told pendent variable we used in this study was a that he was free to squeeze the stress ball at coded teacher prompt combined with habit any time that he felt nervous or anxious, as a reversal, and the hypothesis being tested was replacement for fingernail biting or “flicking” that a combination of these two strategies with the hopes that the intervention, if effec- would result in a measurable decrease in the tive, may become self-managed with time and target behavior. Baseline data were collected practice. by the classroom teacher and paraprofessional ! The intervention was monitored for over two five-day school weeks to determine two five-day school weeks. After the first in- the number of times that Thomas bit his fin- tervention period, the stress ball was removed gernails. Baseline data consisted of tally to determine if Thomas would revert to fin- marks made on an index card by each of the gernail biting and “flicking.” The second two adults in the classroom independently. baseline data phase lasted for a five-day The teacher and paraprofessional conferred school week and then a second intervention regularly to compare the data, and reliability phase using the stress ball was implemented was consistently found to exceed 95%. The for a second five-day school week. adults collected data relative to specific academic periods to determine if a particular sub- Results ject or time of the day was associated with ! During the first baseline phase, Tho- increases in the target behavior. No effect was mas was biting his fingernails or “flicking” on identified, and it was determined that finger- an average of 11.9 times per day. With the nail biting occurred at a consistent rate first intervention phase, the occurrences throughout the school day. dropped to an average of 2.5 times per day. Thomas was asked about his finger- After this intervention period, the stress ball nail biting. He relayed that it was a habit that was removed, with Thomas’ permission, so caused him embarrassment and distress, that that we could better assess if it was the inter- he would like to stop, and indicated that he vention that had prompted the decrease in would welcome help if it didn’t result in other fingernail biting. Although fingernail biting students teasing him more than they already did not return to levels that were observed were. He was given a stress ball to squeeze as during the 1st baseline, the occurrences of fin- a replacement for fingernail biting or “flick- gernail biting and “flicking” began to increase ing.” A coded prompt was agreed upon by to an average of 3.2 times per day when the Thomas and his teacher that would serve as a stress ball was removed. In addition, a trend cue from the teacher that he should use the could be seen that indicated that this behavior stress ball. Thomas was instructed any time was increasing. During the second intervention phase, when the stress ball was returned, lead to additional problems in the physical, the occurrences of fingernail biting and social, and academic realms. Problems in “flicking” dropped to an average of 2.8 times these areas often translate into a decrease in per day, and a trend could be seen that indi- the students’ quality of life. cated that the behavior was decreasing. Over We were quite interested to see an- a 30-day study period, the number of occur- other behavior emerge during the second rences of fingernail biting and “flicking” de- baseline that we had not observed in Thomas creased from an average of 11.9 times per day previously. The new behavior was that of ex- to 2.8 times per day. The highest occurrence hibiting verbal aggression and rudeness to- of target behavior for one day was 30 and the ward classmates. Verbal aggression and rude- lowest occurrence for five separate days was ness were hypothesized to serve as a mecha- 1. These data are shown in figure 1. nism to assuage anxiety in the absence of the stress ball. These behaviors could be inter- Discussion preted to be suggestive evidence that supports ! Students can exhibit many behaviors the theory that fingernail biting, at least in that may negatively impact their quality of some people, is a behavioral coping mecha- life and/or their academic achievement. These nism to alleviate anxiety. behaviors can be as simple as a nervous habit, Many habits displayed by students considered meaningless by some educators, with intellectual disabilities or other disabili- especially when compared to severe disrup- ties further serve to alienate the students with tive or self-injurious behaviors that we some- disabilities from peers and give or may en- times see. Though easy to overlook, nervous courage the impression that students with dis- habits like fingernail biting can be indicative abilities cannot function adequately in social of inner turmoil and emotional duress that can situations. Though habit behaviors should not

Figure 1. be considered to have the same priority for promoting children’s mental health and in- intervention as many of the behaviors that we cluding teachers as key participants in the in- may confront in the classroom, we contend tervention process (see Waller, 2006). This is that assisting students to change lower inten- particularly important as concerns among sity behaviors that are distressing, distracting, many professionals about issues like medica- or that negatively impact the students’ quality tion use for behavioral problems with chil- of life is a valuable endeavor. dren are growing (e.g. Waller, Lewellen, & This study provides evidence that Bresson, 2005). Habits should not intimidate stereotyped habit behaviors can be amenable teachers or be ignored as immaterial, espe- to change using simple assistive strategies cially if it is possible that they could lead to that are manageable within the instructional or further a social, physical, or academic setting and are noninvasive. The teacher was problem. Previous studies have shown nonin- surprised that the participant was so willing to vasive behavioral strategies to be successful cooperate with the attempt to change his be- in reversing negative habits, both in students havior and actually desired to discontinue the with disabilities and in students without dis- habit of fingernail biting. If fact, he went as abilities. In fact, teachers may be the only far as expressing appreciation for her concern help that is realistically available for some and desire to help. During the first interven- children with habit problems. It should further tion phase, he remarked that he actually had a be considered that these types of problems fingernail growing on one finger. tend to worsen and become more difficult to ! Obviously, this study has methodo- change the longer they occur. You may find logical weaknesses. Thomas’ strong desire to that you and your student are the right treat- stop his habit could have influenced the de- ment team at the right time to have even more crease in fingernail biting, as could other fac- of an impact in the lives of students than the tors. One obvious weakness is that both inter- immeasurable impact that you already exert. ventions, using coded teacher prompts and habit reversal, were implemented at once, making it impossible to determine the relative effect of each intervention individually. 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About the authors:

Raymond J Waller is the Coordinator of the MA/MAT programs in special education at Piedmont College/Athens and an active school consultant for children with behavioral problems.

Susan Kent and Miriam E. Johnson are graduates of the MAT program in special education at Piedmont College.