Understanding Habits: A Preliminary Investigation of Nail Biting

Function in Children.
Subject:
Human behavior (Psychological aspects)
Nail-biting (Analysis)
Oral habits (Analysis)
Children (Behavior)
Authors:
Woods, Douglas W.
Fuqua, R. Wayne
Siah, Adelene
Murray, Laura K.
Welch, Matthew
Blackman, Edward
Seif, Tory
Pub Date:
05/01/2001
Publication:
Name: Education & Treatment of Children Publisher: West Virginia University Press, University of West Virginia Audience: Professional
Format: Magazine/Journal Subject: Education; Family and marriage; Social sciences Copyright: COPYRIGHT 2001 West Virginia University
Press, University of West Virginia ISSN: 0748-8491
Issue:
Date: May, 2001 Source Volume: 24 Source Issue: 2
Geographic:
Geographic Scope: United States Geographic Code: 1USA United States

Accession Number:
79210381
Full Text:
Abstract

In this study, traditional functional analysis procedures were combined with results of a functional assessment interview and extant etiological
theories to construct conditions designed to test the function of nail biting. Environmental restriction appeared to primarily control nail biting
for one child. In the remaining children, environmental restriction in combination with a variety of other variables ranging from contingent
escape to contingent attention appeared to multiply control nail biting. Results of a habit reversal intervention suggested habit reversal was
effective for children whose nail biting was a function of environmental restriction, or for whom nail biting was a function of multiple variables.
Habit reversal appeared to be less effective for a child whose nail biting was partially controlled by contingent escape. Clinical and research
implications are discussed.

Nail biting is a common behavior in children. Prevalence estimates suggest up to 25% of 6 year olds may bite their nails (Foster, 1998).
Though typically benign, chronic nail biting may result in a variety of physical and social consequences such as malocclusions, atypical root
resorption, tissue damage to the fingers (Leonard, Lenane, Swedo, Rettew, & Rapoport, 1991; Hadley, 1984), and negative peer evaluation
(Long, Woods, Miltenberger, Fuqua, & Boudjouk, 1999). Because nail biting has a relatively high prevalence rate in children and may
produce unpleasant outcomes, it seems prudent to develop an understanding of the variables controlling the behavior.

Many theories have been proposed to explain the etiology and maintenance of nail biting. One common causal explanation suggests at nail
biting is evoked by states of "tension" or "anxiety" (Hadley, 1984). In fact, nail biting is typically referred to as a "nervous" habit, implying it is
a function of a specific physiological or emotional state. Unfortunately, little empirical research is available on the topic. Results of the few
existing studies have been mixed with respect to the relationship between anxiety and habit behaviors, a category that includes nail biting
(Deardorff, Finch, & Royall, 1974; Klatte & Deardorff, 1981; Woods, Miltenberger, & Flach, 1996).

A second theory, known as "environmental restriction" (Schendler, cited in Hadley, 1984), suggests that limiting motoric activity evokes
habits such as nail biting. Said another way, activity restriction is thought to function as an establishing operation (Michael, 1993) which
increases the reinforcing value of stimulation produced by any behavior, including that provided by nail biting. Thus, the environmental
restriction theory would predict an increase in nail biting under conditions of low motoric activity. Indeed, some research supports this theory.
For example, Harlow and Harlow (1962) found that a monkey raised in virtual isolation developed "compulsive habits" and would "chew and
tear at its body until it bled" (p. 138). In addition, Berkson and Mason (1963) found that individuals with mental retardation were more likely to
engage in stereotypic behavior or self-manipulation when in situations deprived of environmental stimuli. Although these studies seem to
support the environmental restriction theor y for habitual behaviors in some populations, the generality of the theory has not been tested with
respect to nail biting in typically developing humans.

Combining the two preceding theories, the "arousal modulation theory" suggests that nail biting calms the individual during periods of
autonomic arousal and provides stimulation in times of inactivity (Hansen, Tishelman, Hawkins, & Doepke, 1990). One study has
investigated this theory. Woods and Miltenberger (1996b) exposed nonreferred college students to experimental conditions postulated to
produce "anxiety," "boredom," and "emotional neutrality" while covertly videotaping the participants. Although the authors concluded that
emotional states of anxiety or boredom did not effect the occurrence of oral-digital habits, the use of nonreferred participants prevents
definitive generalizations to referred populations.

Although all three of the aforementioned theories are plausible, no one has garnered more empirical support than the others. Taking this into
consideration, one could conclude that nail biting is not caused or maintained by one variable across all individuals. Indeed, nail biting may
be maintained by different variables across individuals. If this is the case, it would be necessary to determine nail biting function on an
individual basis.

Specific functional assessment/analysis technologies have been developed to assess variables maintaining self-injurious behavior in
persons with developmental disabilities (Iwata, Dorsey, Slifer, Richman,& Bauman, 1982). Using such procedures, individuals are exposed to
conditions designed to examine reinforcing variables associated with occurrences of a target behavior. In each condition a reinforcing
variable thought to maintain the target behavior is manipulated, and the effect of the reinforcement on the target behavior is observed.
Variables traditionally tested in the functional analysis of self-injury include social attention and escape from a demanding task. Automatic
stimulation produced by the target behavior (Iwata, et al., 1982) can also be evaluated by observing high levels of the target behavior when
the individual is left alone or when the target behavior is elevated across all functional analysis conditions.

Unfortunately, functional assessment/analysis technology has rarely been applied to oral-digital habits in children (Ellingson et al., 2000;
Rapp, Miltenberger, Galensky, Roberts, & Ellingson, 1999) and is nonexistent with nail biting in typically developing children. Likewise,
functional analysis conditions delineated by Iwata and colleagues were originally developed to assess the function of self-injurious behaviors
in persons with developmental disabilities. It may be the case that those same conditions are not entirely adequate for determining the
function of nail biting in typically developing children. Indeed, the standard conditions are not specifically designed to evaluate the variables
implicated in the extant theories of nail biting.

Clearly, the application of functional analytic technology to nail biting has not been well developed, a fact that may be partially explained by
the perception that nail biting is a relatively benign problem and by the presence of an effective intervention for nail biting, habit reversal,
which appears to have broad generality across participants (Woods & Miltenberger, 1996a). Despite the success of treatments such as habit
reversal, further investigation into the function of nail biting would be useful for a variety of reasons. First, though habit reversal is successful,
it does fail (Woods & Miltenberger 1996a). In such cases, it would be useful to determine whether the functions of nail biting predict poor
treatment outcome with habit reversal. Second, many procedures currently used to treat nail biting require a good deal of training and
compliance on the part of the parent, child, and therapist. Thus, gaining a better understanding of the variables responsible for controlling
nail biting may lead to prev ention of the problem or to less intrusive interventions. Third, given the rather widespread occurrence of nail
biting and the fact that it may have a variety negative consequences, it would be useful to develop a better understanding of the variables
controlling the behavior.
The current paper reports the results of a preliminary attempt to determine the function(s) of nail biting across six developmentally typical
children. Functional analysis conditions, designed to determine the function of nail biting for each participant, were developed based on three
sources of information: traditional functional analysis procedures (i.e., Iwata et al., 1982), results of a functional assessment interview with
participants and their parents, and the etiological theories of nail biting outlined above. Participants were exposed to each of the functional
analysis conditions (described below), and resulting data were used to identify a maintaining variable(s) for each participant's nail biting.
Next, 4 of 6 participants received habit reversal, which involved teaching the child to engage in a competing behavior contingent on nail
biting. Finally, an attempt was made to

identify maintaining variables that predicted treatment outcome.

Method

Participants

Six children and their parents responded to a newspaper article describing the current study. To qualify for participation, participants had to
(a) be between the ages of 5 and 15 years, (b) be free from reported psychopathology or developmental disabilities, and (c) have been biting
their nails for at least 1 year. A description of the participants can be seen in Table 1.

Assessments

Functional Assessment Interview. Upon qualifying for the study, participants and their parents were interviewed by graduate students in
clinical psychology. The children and their parents were asked to provide information regarding the history of the behavior, setting events
present when nail biting occurred, and social consequences that directly followed occurrences of nail biting. Table 1 shows the setting events
and consequences reported by each participant and/or his/her parent(s).

Direct Observation Data Collection. Data collection took place in a 3m x 3m university research room over the course of 3 days for each
child. After obtaining informed consent from the parents and children, a researcher videotaped participants from behind a one-way mirror.
The children were not informed they were being recorded and with few exceptions, appeared to be unaware they were being observed.

Data Scoring. The presence of nail biting during each 5 mm condition (described below) was scored using a 10 s partial interval scoring
method. Nail biting was defined as placing any digit from either hand into the mouth. The dependent variable was the percentage of intervals
with occurrence of nail biting and was calculated by dividing the number of intervals containing an occurrence of the behavior by the total
number of intervals and multiplying by 100%. In addition, 16.7% of the segments were scored by a second independent observer. Reliability
was calculated using the Kappa correction for chance agreement and indicated excellent interobserver agreement, k=1.0.

Procedures

On each of three separate days, each participant was exposed to 8 conditions for 5 mm per condition. The conditions were presented in
random order during each day for each child. Building on traditional functional analysis procedures (Iwata et al., 1982), information provided
in the functional assessment interview (see Table 1) and the extant theories of nail biting etiology were used to create conditions designed to
test variables hypothesized to control nail biting.

There were three "alone" conditions that were characterized by having the child sit in a room with no other individuals present. In the Alone
(TV) condition, the child was asked to sit and watch a cartoon videotape. In the Alone (idle) condition, the child was asked to sit in the room
with nothing to do. In the Alone (game) condition, the child was asked to sit and play a hand-held video game. The child could play the game
with one or both hands, though data were not collected on the extent to which one or both hands were used. The three aforementioned
conditions were included to evaluate the role of environmental restriction, and to serve as a control to the socially mediated conditions
described below.

There were three "social" conditions characterized by the child interacting with an experimenter. In the Social (noncontingent attention)
condition, the child and experimenter talked about anything but nail biting. In the Social (contingent attention) condition, the experimenter
again talked with the child, but when the child engaged in nail biting, the experimenter immediately commented on the behavior (e.g., "Wow,
you really like to bite those nails, don't you?"). In the final condition, Social (Discuss Habit), the experimenter talked with the child only about
nail biting but the discussion was not contingent on occurrences of the behavior. The attention conditions were designed to determine if
contingent attention maintained nail biting in any of our participants. Although contingent attention has not been hypothesized as a
maintaining variable for nail biting, it was tested for two reasons. First, many of the parents reported that they made comments (e.g., "stop
that!") contingent on their child's nail bi ting. Second, in traditional functional analyses (Iwata, Dorsey, Slifer, Richman, & Bauman, 1982),
similar conditions are included to rule out contingent attention as a maintaining variable for self-injurious behavior in persons with mental
retardation.

Finally, to test the theory that nail biting was a function of tension/ anxiety, two "demand' conditions were included. Both conditions were
characterized by having the child complete age-appropriate math problems provided by his or her parent. Math problems were use to
increase tension because previous research has found math problems to increase autonomic arousal (Abel, Larkin & Edens, 1995). During
both demand conditions an experimenter prompted the child to keep working on the problems if he or she stopped. There were no other
interactions between the child and experimenter during these conditions. In he Demand (no escape) condition, the child was asked to
complete the problems in the presence of an experimenter. In the Demand (escape) condition, the child was asked to complete the problems
in the presence of an experimenter, but was allowed to stop for 15 s contingent on habit occurrence. It was decided to include separate
escape and no escape conditions to rule out a possible escape function as is typic al in traditional functional analysis methodology (Iwata et
al., 1982)

Results

For each of the six participants, the mean percentage of intervals with nail biting was calculated across the three assessment days for each
of 8 conditions. Results are displayed in Figures 1-6.

Chelsea

Chelsea's data are presented in Figure 1. The alone-idle (M=5.8%, range, 0 -13.3%) and alone-tv (M=14.3%, range, 0 - 43%) conditions
were higher than the alone-game (M=0%) condition. Nail biting occurred more frequently in the social-discuss habit condition (M=15.9%,
range, 6.7 - 25%) than in either the social-noncontingent attention (M = 1.3%. range, 0 - 4%) or the social-contingent attention (M=3.7%,
range, 0 - 11.1%) conditions. Chelsea did not bite her nails in either demand condition.

Maggie

Maggie's data are presented in Figure 2. The alone-idle (M 13.3%, range, 3.3 - 26.7%) and alone-tv (M=5.6%, range, 0 - 16.7%) conditions
were higher than the alone-game (M=O%) condition. Maggie did ot bite her nails in any other conditions.

Linda

Linda's data are presented in Figure 3. The alone-idle (M 21.5%, range, 10 - 34.4%) and alone-tv (M=25.7%, range, 0 - 73.3%) conditions
were higher than the alone-game (M=0%) condition. Although all biting occurred in all three social conditions, it occurred more often in the
social-discuss habit condition (M=10.2%, range, 7.4 - 13.3%) than in either the social-noncontingent attention (M = 4.4%, range, 0 - 10% or
the social-contingent attention (M=4.4%, range, 0 - 10%) conditions. Linda bit her nails during a mean of 4.4% (range, 0-13.3%) of intervals
during the Demand-no escape condition, but did not bite her nails during the Demand-escape condition.

Kendra

Kendra's data are presented in Figure 4. The alone-idle (M 27.3%, range, 10 - 53.3%) and alone-tv (M=11.1%, range, 0 - 26.7%) conditions
were higher than the alone-game (M=0%) condition. Although nail biting occurred at low levels in the social-discuss habit (M=4.6%, range, 0
13.8%) and social-contingent attention (M=2.2%, range, 0 - 6.6%) conditions, the behavior did not occur in the social-noncontingent attention
condition. Kendra bit her nails during a mean of 3.3% (range, 3.3 - 6.6%) of intervals during the Demand-escape condition, but did not bite
her nails during the Demand-no escape condition.
Jerod

Jerod's data are presented in Figure 5. The alone-idle (M 35.4%, range, 16.7- 46.6%) and alone-tv (M=22.2%, range, 10-36.7%) conditions
were higher than the alone-game (M=4.4%, range, 0 - 10%) condition. Although nail biting occurred in all three social conditions, it occurred
more often in the social-discuss habit (M=18.9%, range, 6.7- 30%) and social-contingent attention (M=23.4%, range, 6.9 - 33.3%) conditions
than in the social-noncontingent attention (M = 7.8%, range, 0-13.3%) condition. Jerod bit his nails equally during the demand-escape
(M=4.6%, range, 013.8%) and demand-no escape (M=5.5%, range, 3.3 - 6.7%) conditions.

Rich

Rich's data are presented in Figure 6. The alone-tv (M=31.1%, range, 0 - 93.3%) condition was significantly higher than the alone-idle
(M=2.2%, range = 0 to 6.7%) condition. Nail biting did not occur or occurred at a very low level across all other conditions.

Treatment Outcomes

Upon completing the functional analysis described in this study, four participants (Chelsea, Linda, Maggie, and Kendra) received habit
reversal as part of a study evaluating the effectiveness of the procedure as a treatment for oral-digital habits (Woods et al., 1999).
Summarizing these results, the four participants showed varied responses to treatment. Chelsea's nail biting was eliminated, Linda's was
reduced 96% from baseline levels, and Maggie's was reduced 79%. However, Kendra's nail biting only decreased 20%.

Discussion

Chronic nail biting in children can produce a variety of physical and social consequences. Although procedures exist to treat nail biting there
is little understanding of the variables that maintain the behavior. The present study combined traditional functional analysis methodology
with results of functional assessment interviews and extant theories of nail biting etiology to create conditions designed to determine the
possible functions of nail biting in developmentally typical children.

Five different theories were tested including environmental restriction, contingent attention, contingent escape, tension/anxiety, and arousal
modulation. The environmental restriction theory was supported in all six cases as the "alone-idle" and "alone-tv" conditions (in which motoric
activity was low) produced higher levels of nail biting than the "alone-game" conditions (in which motoric activity was more frequent). This
finding is consistent with findings from other studies showing that limited responding or opportunities for responding (Green & Striefel, 1988)
may produce increases in nonpurposeful, stereotypic behavior (Berkson& Mason, 1963; Harlow & Harlow, 1962).

In traditional functional analyses, an elevated level of the tar et behavior in the "alone" condition relative to the other conditions is interpreted
as an automatic reinforcement function (Iwata et al., 1982). Given the findings of the present study, one can speculate that automatic
reinforcement may maintain nail biting in some children, but only if the appropriate establishing operation (i.e., environmental restriction) is in
place. For these children, environmental restriction would appear to function as an establishing operation that increases the reinforcing value
of stimulation from motoric activity, hence producing an increase in nail biting. Were environmental restriction not an establishing operation,
one would expect to see nail biting occurring evenly across all "alone" conditions.

Though 3 of 6 parents reported asking their child to stop nail biting contingent on the behavior, contingent attention did not appear to be the
primary maintaining variable for any of the 6 children in this study. In only one case (Jerod) was the "social-contingent attention" higher than
the two remaining "social" conditions, though even in this case the difference between the "social-contingent attention" and "social-discuss
habit" conditions was negligible.

Another interesting, and unexpected finding from the "social" conditions involved the elevation of the "social-discuss habit" condition relative
to the remaining "social" conditions in 2 of the 6 children (Chelsea and Linda). This finding was unexpected and one can only speculate why
it occurred. Perhaps the children for whom this occurred were reprimanded in the past for nail biting. If true, adult presence may have
become an SD for nail biting suppression. By discussing the behavior in a non-threatening fashion, the stimulus value of adult presence may
have been temporarily altered, thus affecting the exhibition of the nail biting. Of course, this explanation is speculative.
Contingent escape did not appear to maintain the nail biting in 5 of the 6 participants. One participant (Kendra) did show greater levels of nail
biting in the "demand-escape" condition when compared to the "demand-no escape" condition, suggesting an escape function. However,
Kendra's entire data pattern (see Figure 4), indicates the behavior was not entirely controlled by contingent escape.

The constructs of "anxiety" or "tension" have also been hypothesized to be causally linked to nail biting. Typically referred to as a "nervous
habit," nail biting is often assumed to be a function of "anxiety" or "tension." In the present study, "demand" conditions were used to create a
state of anxiety in the participants by using a task shown to induce autonomic arousal in humans (e.g., Abel et al., 1995). If nail biting were a
function of "anxiety," one would have expected to see an increase in nail biting when in "demand" conditions relative to other conditions. As
the data clearly show, this pattern was not evident in any of the children. Though nail biting did occur during the "demand" conditions for
three of the children (Linda, Kendra, and Jerod), nail biting under these conditions was much less common than in conditions free of
"demands." Thus, the theory that nail biting is a primary function of "anxiety" did not appear to be supported for any children in the present
study.

Support for the arousal-modulation theory can only come from observing increased nail biting both when a child is in a restricted environment
and when that same child is experiencing a state of "anxiety." However, this did not occur, suggesting that the theory of arousal-modulation
was not supported.

This study produced a number of findings, each with various implications. First, the present study demonstrates that restricting activity may
primarily or partially control nail biting in some children. This finding offers empirical support for one of many theories of nail biting and
suggests that future interventions for nail biting should train children to engage in alternative behaviors when in environmentally restricted
situations. Although habit reversal does this to some extent, intentionally limiting the amount of environmental restriction experienced by the
child (e.g., by scheduling activities) may be a useful adjunct to the standard habit reversal protocol.

Second, findings from this study offer guidance with respect to the use of parental reports in determining the function of nail biting. In this
study, parents reported making contingent requests of their children to stop biting their nails. Based on these reports, it was hypothsized that
contingent attention may maintain nail biting in some children. However, the contingent attention used in the present study (which differed in
content from that provided parents) did not appear to control nail biting for any of the children, though parental reports of consequence
variables may have predicted otherwise. This finding is important because during initial assessments, clinicians are apt to rely on parental
report when determining the function of the target behavior. In such cases, clinicians may want to recognize that parental reports of
consequences may not be consistent with actual behavioral function.

Third, findings from this study seem to indicate that classifying nail biting as a "nervous" habit is incorrect. Although it is always possible that
an individual's nail biting is a function of "anxiety," evidence produced in this study is consistent with other studies (e.g., Woods &
Miltenberger, 1996b) in not supporting nail biting as a function of anxiety or anxiety-provoking situations. Clinically, this is relevant in that nail
biting may actually indicate the lack of opportunity to respond rather than an overt manifestation of some underlying condition labeled
"anxiety." Understanding this conceptualization may dissuade clinicians from using probably ineffective interventions such as relaxation
training in exchange for interventions focusing on the manipulation of external events (e.g., event scheduling or habit reversal).

Fourth, it should be noted that in only one case (Maggie) and perhaps another (Rich), was environmental restriction dearly the primary
controlling variable. Although environmental restriction appeared to have a large affect on nail biting in the other children, other variables also
appeared to influence the behavior. Thus, it is important for clinicians and researchers to be aware that nail biting may be controlled by
multiple variables that can differ from person to person.

In addition to determining the function of nail biting across the six children, an attempt was made to determine if behavioral function could
predict treatment outcome. In this study, habit reversal was effective for treating children who exhibited nail biting primarily evoked by a
restricted environment (Maggie) or when the function appeared to be multiply controlled (Chelsea and Linda). Although it is not clear why
Kendra's behavior did not decrease further as a result of treatment, her pattern of responding suggested that nail biting was evoked by
environmental restriction and a pattern (although relatively weak) consistent with an additional escape function. Perhaps because habit
reversal does not allow escape from an ongoing task, compliance with the procedure may be compromised by someone exhibiting an
escape-related target behavior. Future research should continue to investigate the extent to which different behavioral functions predict the
efficacy of standard treatment protocols such as habit reversa l.

From this study, we were able to reach a number of conclusions about variables maintaining nail biting. However, a variety of methodological
limitations must be considered in interpreting the results. First, the demand conditions may not have produced adequate levels of "tension"
necessary to test the anxiety/tension and arousal modulation theories. Although previous studies have used arithmetic tasks to produce
"stress" or "tension" in participants (e.g., Abel et al., 1995), it is unclear if a subjective state of "tension" or "anxiety" was produced in this
case. Second, the alone-game and demand conditions required that the child engage in a behavior that was incompatible with nail biting
(with at least 1 hand). Despite this potential confound, many of the children and their parents reported that the behavior was likely to occur
under similar conditions.

Third, not all possible maintaining variables were tested. For example, some researchers believe that human habit behaviors are byproducts
of certain reinforcement schedules (e.g., Foster, 1978). Although the adjunctive behavior hypothesis was not tested in the present
investigation, its possible application to nail biting in children seems worthy of further study and may explain the large amount of variability
found in the participants' behavior. A fourth limitation involves the external validity of the findings. Although conditions were constructed
based on participant report, the findings were still obtained under analogue conditions with a small number of participants and limited
observations. Future research should replicate this study with more individuals in natural conditions with longer observation periods.

In summary, this preliminary investigation has taken the first steps in investigating the possible variables maintaining nail biting (and possibly
other habitual behavior disorders) in children. The conditions tested in this study provide a strong basis for future research. Only through
further inquiry and investigation will a more complete understanding of this common, but potentially damaging behavior be obtained.

References

Abel, J. L., Larkin, K T., & Edens, J. L. (1995). Women, anger, and cardiovascular responses to stress. Journal of Psychosomatic Research,
39, 251-259.

Berkson, G., & Mason, W. A. (1963). Stereotyped movements of mental detectives: III: Situation Effects. American Journal of Mental
Deficiency, 68, 409-412.

Deardorff, P. A., Finch Jr., A. J., & Royall, L. R. (1974). Manifest anxiety and nail biting. Journal of Clinical Psychology, 30, 378.

Ellingson, S., Miltenberger, R., Stricker, J., Garlinghouse, M., Roberts, J., Galensky, T., & Rapp, J. (2000). Functional analysis and treatment
of finger sucking. Journal Applied Behavior Analysis, 1, 41-51.

Foster, L. G. (1998). Nervous habits and stereotyped behaviors in preschool children. Journal of the American Academy of Child and
Adolescent Psychiatry, 37, 711-717.

Foster, W. S. (1978). Adjunctive behavior. An under-reported phenomenon in applied behavior analysis. Journal of Applied Behavior
Analysis, 11, 545-546.

Green, G., & Striefel, S. (1988). Response restriction and substitution with autistic children. Journal of the Experimental Analysis of Behavior,
50, 21-32.

Hadley, N. H. (1984). Fingernail biting: Theory, research, and treatment. Spectrum Publications: Jamaica, New York.

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

Harlow, H. F., & Harlow, M. K. (1962). Social deprivation in monkeys. Scientific American, 207, 137-146.

Iwata, B., Dorsey, M. F., Slifer, K. J., Bauman, K. E., & Richman, G. S. (1982). Toward a functional analysis of self-injury. Analysis and
Intervention in Developmental Disabilities, 2, 3-20.

Klatte, K. M., & Deardorff, P. A. (1981). Nail biting and manifest anxiety of adults Psychological Reports, 48, 82.

Leonard, H. L., Lenane, M. C., Swedo, S. E., Rettew, D. C., & Rapoport, J. L. (1991). A double-blind comparison of clomipramine and
desipramine treatment of severe onychophagia (nail biting). Archives of General Psychiatry, 48, 821-827.

Long, E. S., Woods, D. W., Miltenberger, R. G., Fuqua, R. W., & Boudjouk, P. J. (1999). Examining the social effects of habit behaviors
exhibited by individuals with mental retardation. Journal of Developmental and Physical Disabilities, 11, 295-312.

Michael, J. (1993). Establishing operations. The Behavior Analyst, 16, 191-206.

Rapp, J., Miltenberger, R., Galensky, T., Roberts, J., & Ellingson, S. (1999). Brief functional analysis and simplified habit reversal treatment
of thumb sucking in fraternal twin brothers. Child and Family Behavior Therapy, 21, 1-17.

Woods, D. W., & Miltenberger, R. G. (1996a). A review of habit reversal with childhood habit disorders. Education and Treatment of Children,
19, 197-214.

Woods, D. W., & Miltenberger, R. G. (1996b). Are persons with nervous habits nervous? A preliminary examination of habit function in a
nonreferred population. Journal of Applied Behavior Analysis, 29, 259-261.

Woods, D. W., Miltenberger, R. G., & Flach, A. D. (1996). Habits, tics, and stuttering: Prevalence and relation to anxiety and somatic
awareness. Behavior Modification, 20, 216-225.

Woods, D. W., Murray, L. K., Fuqua, R. W., Seif, T. A., Boyer, L. J., & Siah, A. (1999). Comparing the effectiveness of similar and dissimilar
competing responses in evaluating the habit reversal treatment for oral-digital habits in children. Journal of behavior Therapy and
Experimental Psychiatry, 30, 289-300.

[Graph omitted]

[Graph omitted]

[Graph omitted]

[Graph omitted]

[Graph omitted]

[Graph omitted]
Table 1.
Description of Participants and Reported Setting Events and
Consequences of Nail Biting.
Participant Gender Age Time engaged in Setting &
nail biting Consequences
Chelsea Female 9 8 years a,b,c,d,e,g
Maggie Female 10 2 years a,f,h,i,j,k
Linda Female 9 3 years a,g,j
Kendra Female 15 10+ years a,b,c,g
Jerod Male 11 5 years a,b,d,f,g,j
Rich Male 7 5 years a,b
Note. a = watching television,
b = reading,
c = doing math,
d = taking tests,
e = thinking hard,
f = playing,
g = bored/not doing anything,
h = waiting for things,
i = nervous,
j = parents tell or signal child to stop contingent on nail biting,
k = other children say mean things contingent on biting.