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Direct observation of scratching behavior in children with atopic dermatitis
BEHAVIOR THERAPY 19, 213-227, 1988
Direct Observation of Scratching Behavior in Children with Atopic Dermatitis KAREN
M. GIL, FRANCIS J. KEEFE
Duke University Medical Center
HUGH A. SAMPSON Johns Hopkins Hospital CYNTHIA C. MCCASKILL
Duke University Medical Center JUDITH RODIN
Yale University
JAMES E. CR1SSON Duke University Medical Center This study examines scratching behavior in children with atopic dermatitis (AD). Thirty children with severe A D and one parent of each child were observed for a 10minute observation period during a five-minute structured and five-minute unstructured task. Observers coded child and parent behaviors. Data analyses revealed that children engaged in more scratching behavior during the unstructured than structured task. Furthermore, regression analyses indicated that parent responses to scratching behavior in children were important predictors of scratching behavior even after controlling for demographic and medical status variables, such as serum lgE level and percentage of body area affected by AD. These results have important implications for health care professionals working with children who have AD. Suggestions for future behavioral treatment studies are discussed.
This research was supported in part by a grant (A124439) from the National Institute of Allergy and Infectious Diseases, a grant (RR-30) from the General Clinical Research Center Program of the Division of Research Resources, National Institute of Health, and a grant from the John D. and Catherine T. MacArthur Foundation Network on the Determinants and Consequences of Health Promoting and Health Damaging Behavior. Portions of these data were presented at the annual meeting of the Association for Advancement of Behavior Therapy, November, 1986. Request for reprints and all correspondence should be sent to Karen M. Gil, Ph.D., Department of Psychiatry, Box 3159, Duke University Medical Center, Durham, NC 27710. 213 0005-7894/88/0213-022751,00t0 Copyright 1988 by Association for Advancement of Behavior Therapy All rights of reproduction in any form reserved.
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Atopic Dermatitis (AD) is a condition which often begins in early infancy as an erythematous, intensely pruritic, maculopapular eruption and progresses to a more lichenfied dermatitis with time (Blaylock, 1976). The clinical course of AD is periodic and, during exacerbations of the disease, superficial inflammations of the skin can be clearly observed. The behavioral component of this disorder, that is, scratching, is especially problematic. Excessive scratching can lead to lichenification, excoriations, and serious skin infections. The etiology of itching and scratching in atopic dermatitis is not clearly understood. Pathophysiological mechanisms that have been described include an altered sweat response (Sulzberger & Herrmann, 1964), allergic reactions to food (Sampson, 1983), or a reduction in beta-adrenergic stimulation which leads to a deceased itch threshold (Busse & Lee, 1976). As early as 1857, however, authors recognized the importance of emotional factors in dermatological disorders (Wilson, 1857), and several psychological and behavioral mechanisms have been proposed as playing a significant role in maintaining scratching behavior in AD. Researchers with a psychophysiological perspective have postulated a role of stress and anxiety, whereby increased stress leads to increased sympathetic arousal, peripheral vascular changes, and a decreased itch threshold (Faulstich & Williamson, 1985). Data from several assessment and treatment studies lend support to such a perspective (Fabisch, 1980; Faulstich, Williamson, Duchmann, Conerly & Brantley, 1985; Fava, Perini, Santonastaso & Fornasa, 1980; Garrie, Garrie & Mote, 1974; Haynes, Wilson, Jaffe, & Britton, 1979; Lehman, 1978). These studies have found that anxiety and stressful life events are associated with AD symptomatology, and techniques such as relaxation training and hypnosis are effective in reducing symptoms of itching and scratching. A second conceptualization of scratching in AD considers scratching as a learned habit maintained by operant reinforcement; that is, scratching relieves itching and increases the probability of subsequent scratching (Bar & Kuypers, 1973; Jordan & Whitlock, 1972). Treatment studies which lend support to this perspective have found that the habit-reversal method (Azrin & Nunn, 1973) could be applied to decrease scratching by substituting a competing response such as tensing arm muscles (Rosenbaum & Ayllon, 1981) or folding hands in one's lap (Cataldo et ai., 1980) in response to itching. Social responses to scratching and other environmental factors may also play a role in maintaining scratching behaviors in individuals with AD (Gil, Keefe, Sampson, McCaskill, Rodin & Crisson, 1987). Informal observations of children with AD in our clinic reveal that children scratch more in some situations than in others. For example, many children scratch more at bedtime or during passive activities, such as watching TV, and less during active activities, such as playing games. Children not only scratch and rub affected areas, but express being itchy and request scratching from their parents. Parents have been informally observed to scratch and rub the child's skin as well as engage in verbal attempts and gestures to stop the child's scratching. The parent training literature provides a model for studying parent-child interactions in children having AD. The behavioral consequences provided by the parent are significant factors in a young child's environment (e.g., Her-
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bert & Baer, 1972). Extensive research has been conducted in the behavioral assessment of parent-child interactions using structured laboratory observation methods (Hughes & Haynes, 1978). These studies have found that certain problem behaviors in children, such as noncompliance and aggression (e.g., Budd, Green, & Baer, 1976; Hughes & Haynes, 1978; Patterson & Reid, 1973), are often inadvertently maintained through parental consequences such as attention to inappropriate child behavior. Researchers have also well documented that maladaptive behavior exhibited by children can be modified by training parents to alter their responses to the child (e.g., Forehand & McMahon, 1981). Taking the perspective that parental attention maintained inappropriate scratching behavior, Allen and Harris (1966) successfully treated a 5-year-old girl with AD by training her mother to ignore scratching and deliver token reinforcement for scratch-free periods. However, with the exception of case studies, there has been little controlled investigation of the role of social responses in maintaining scratching in children with AD. Furthermore, there has been insufficient study of the environmental circumstances which influence scratching in children with AD. It is our hypothesis that scratching behavior in children with AD differs as a function of the environmental demands as well as the consequences, that is, the parental response to scratching. This study had two major goals. The first goal was to investigate the effects of situational factors (i.e., level of structure) on scratching behavior in AD children and on a parental response to the child. The second goal was to examine parental responses to the child's scratching. Behaviors such as parental attention to scratching and attempts to get the child to stop scratching were examined to assess their impact on the child's behavior. Specifically, the study was designed to measure the extent to which these parent behaviors predicted child scratching over and above medical status variables, such as degree of dermatitis. Direct observation methodology adapted from the parent-training literature was used to help accomplish these two goals.
METHOD Subjects Thirty children (15 boys, 15 girls) with a mean age of 5.58 years (SD = 2.53 years, range = 3 to 13) participated in the study. Subjects were patients being evaluated for severe atopic dermatitis by one of the investigators (H.S.) on the Clinical Research Unit at Duke University Medical Center. All subjects fulfilled the criteria for AD established by Hanifin and Lobitz (1977). These criteria include several absolute features such as pruritus, typical morphology and distribution (i.e., facial and extensor involvement in infancy, flexural lichenification in adults), and tendency toward chronic or chronically relapsing dermatitis. In addition to the absolute criteria, several of a list of "optional" features are required to make the diagnosis. This list includes family history of atopic disease, immediate skin test reactivity, elevated serum IgE, and tendency toward repeated cutaneous infections. Most children in the study had a history of AD dating back to infancy. At
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the time of evaluation, patients had a median of 13% (range = 0 to 59%) area of their body surface affected by AD.
Procedure Behavioral Observation System. A 10-minute videotaped observation session of the child's scratching behavior was obtained while the child was interacting with the parent. The session was divided into two conditions: 1) five-minute structured task and 2) five-minute unstructured task. During the five-minute structured task, the child and parent were instructed to work together building a Lego model. They were provided with a I_ego building set and instructed to work on building a model of their choice. The child and parent sat on a hospital bed in the child's room and worked on a table adjusted to a height that was comfortable for the child. During the unstructured task, the child and parent sat at the same hospital bed with an adjustable table in front of them; however, the five-minutes of free time had no specific task instructions. All toys were positioned out of the child's reach. The parents were instructed that the child should not play during this time, and they should encourage the child to sit in place in view of the camera. For both conditions, the video camera was placed in the doorway approximately 6-8 feet from the child. The experimenter interacted minimally with the child or parent and only gave instructions at the change of conditions. In a few cases, the experimenter requested that the parent have the child return to the bed if the child moved out of range of the video camera. The presentation for the two conditions was counterbalanced to minimize any potential order effects (Hughes & Haynes, 1978). Thirteen children participated in the structured task first followed immediately by the unstructured task, and 17 of the children participated in the unstructured task followed immediately by the structured task. Behavioral Coding Categories. The behaviors selected for coding were identified through interviews with nurses, physicians, and patient's families as well as informal observations of children with AD and their families. Child behaviors scored were scratching, rubbing, and verbal statements of itchiness or requests by the child for scratching by the parent. Parent behaviors scored were scratching, rubbing, attempts to stop the child from scratching, and attending. Definitions of the identified behaviors are presented in Table 1. Observer Training. Two observers scored the videotapes. The observers were trained in two stages. First, they studied a training manual that included definitions of the behavioral categories. Second, they practiced coding observations by scoring segments of videotapes. The segments illustrated the range of behaviors to be covered. Observers viewed segments and then received immediate feedback on their scoring. Observers practiced scoring until their percentage agreement scores routinely exceeded the 85°70 level. Recording and Scoring Procedure. Observers independently and simultaneously scored the videotapes for all 30 subjects. Behavioral categories were scored in an ongoing fashion using 20-second-observation record intervals. Child behaviors were scored for occurrence or nonoccurence in each interval. Parental
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TABLE 1 SUMMARYOF BEHAVIORALDEFINITIONSFOR THE OBSERVATIONSYSTEM Child Scratching (SCR):
Child Rubbing (RUB):
Child Request~Itch (REQ/IT):
Parent Stop (STOP):
Parent Scratching (SCR):
Parent Rubbing (RUB):
Parent Attend (ATT):
Child using nails of hand(s) or any sharp object or surface on any area of the skin. The skin does not have to have skin lesions. Child picking skin or scratching through clothes is scored as scratching. Child moving hand(s) or fingers(s) or any soft object across the skin. The area does not have to have skin lesions. The child makes a statement of physical discomfort such as "it hurts" or "it itches." The child asks or gestures the parent for "skin care" such as asking the parent to rub or scratch. Any motor behavior by the parent which attempts to stop the child from scratching, rubbing, or touching the skin such as physically removing the child's hand(s) or holding the child's hand(s). Any verbal command by the parent which directs child to stop scratching, rubbing, or touching the skin such as "Stop scratching," or "Don't touch your legs." Parent using nails of hand(s) or any sharp object or surface on any area of the child's skin. The skin does not have to have skin lesions. This category includes when the parent is picking at the child's skin. Parent moving hand(s) or finger(s) or any soft object or surface across the child's skin. The area does not have to have skin lesions. Parent is attending to child by looking at the child, the child's activity, or playing or speaking "on task" to the child.
b e h a v i o r s w i t h i n e a c h i n t e r v a l were s c o r e d as c o n t i n g e n t o r n o n c o n t i n g e n t . C o n t i n g e n t r e s p o n s e s were r e s p o n s e s t h a t o c c u r r e d d u r i n g a c h i l d b e h a v i o r o r were i n i t i a t e d b y t h e p a r e n t w i t h i n 5 s e c o n d s o f offset o f a c h i l d b e h a v i o r . N o n c o n t i n g e n t responses were responses t h a t were initiated by the p a r e n t m o r e t h a n 5 s e c o n d s a f t e r t h e offset o f t h e last s c o r e d c h i l d b e h a v i o r . T h i s a p p r o a c h to i n t e r v a l s a m p l i n g i m p l i e s a n o r d e r e d t e m p o r a l r e l a t i o n s h i p b e t w e e n c h i l d b e h a v i o r a n d p a r e n t a l response, a n d t h u s specific child b e h a v i o r - p a r e n t c o n s e q u e n c e c h a i n s c a n be m o r e p r e c i s e l y m e a s u r e d ( R o b e r t s & F o r e h a n d , 1978). T h i s m e t h o d is s i m i l a r to o t h e r o b s e r v a t i o n a l m e t h o d s c o m m o n l y u s e d in t h e p a r e n t t r a i n i n g literature to assess p a r e n t - c h i l d i n t e r a c t i o n p a t t e r n s ( F o r e h a n d & M c M a h o n , 1981; R o b e r t s & F o r e h a n d , 1978). A rate o f o c c u r r e n c e f o r t h e s t r u c t u r e d a n d u n s t r u c t u r e d c o n d i t i o n s was calculated for e a c h b e h a v i o r c o d i n g c a t e g o r y . T h u s , for e a c h c o n d i t i o n , t h e r e were t h r e e scores for t h e child, (rate o f scratching, r u b b i n g , r e q u e s t s / i t c h ) a n d eight m e a s u r e s for each child's p a r e n t (rate o f c o n t i n g e n t s c r a t c h i n g , c o n t i n g e n t r u b b i n g , c o n t i n g e n t stops, c o n t i n -
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AL.
gent attending, noncontingent scratching, noncontingent rubbing, noncontingent stops, and noncontingent attending). In addition, an overall total score was calculated for the child by summing the rate of scratching, rubbing, and requests/itch. Overall total scores for the child's parents were calculated for each condition: total contingent behavior (calculated by summing all the individual contingent behaviors) and total noncontingent behavior (calculated by summing all the individual noncontingent behaviors) in the structured and unstructured conditions. Observer Reliability. The reliability of observers was checked using a percentage agreement measure. Percentage agreement was calculated by dividing the number of intervals in which observers agreed on the occurrence of coding categories observed by the number of intervals in which disagreements plus agreements of occurrences occurred. Overall percentage agreement averaged 95.7%. The reliabilities for each category ranged from 71.2°70 for parent scratching to 98.2070 for parent attending. Medical Status and Demographic Variables. Two medical status variables were recorded because they are believed to be related to symptom severity in AD (Buckley, 1984). Serum IgE level was determined by a standard double antibody radioimmunoassay method (Gleich, Averbeck & Swedlund, 1971). Percentage of body area affected by AD was determined by an examining specialty nurse prior to videotaping; thus she was blind to actual videotape scores. Skin areas showing redness, rash, or other eczematous signs were mapped on
12
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FIG. 1. Mean rate of child scratching behaviors per five-minute observation for the structured versus unstructured conditions.
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a body chart, and, using age-modified norms for calculation of body surfaces area (Carson, 1981), an estimate of percentage of affected skin was determined. Age and sex were recorded for each child since these variables may be related to scratching behavior on the part of the child. R ES U LTS Figure 1 presents the mean rates of child behavior during the unstructured and structured tasks. As can be s e e n in the figure, children engaged primarily in scratching and rubbing. Figures 2 and 3 present the mean rates of parent behavior in the unstructured versus structured conditions. Attending (both contingent and noncontingent) was the primary behavior observed.
The Effects o f Structured Versus Unstructured Conditions As can be seen in Figure 1, children exhibited higher levels of each of the individuals behaviors during the unstructured as compared to structured conditions. In order to evaluate the effects of the manipulation of level of structure during the observation on child behavior, a one-way multivariate analysis of variance (MANOVA) was conducted. The overall MANOVA was significant [F 3,27) = 3.10, p < .05]. The multivariate effect was followed by univariate analysis of variance (ANOVA) on each of the child behaviors. The 1312-
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FIG. 2. Mean rate of contingent parent behavior per five-minute observation for the structured versus unstructured conditions.
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3. Mean rate of noncontingent parent behavior per five-minute observation for the structured versus unstructured conditions. FIG.
difference between structured and unstructured conditions was significant for child rubbing [F (1,29) -- 5.96, p < .05] and requests/itch [F (1,29) -- 5.19, p < .051. Parents exhibited differences in level o f behavior in the structured versus unstructured conditions (See Figures 2 and 3). In order to evaluate the effects of the manipulation o f level of structure on parent behavior, a one-way MANOVA was conducted. The overall MANOVA for parent behavior was significant [F (8,22) = 2.77, p < .05]. The multivariate analysis was followed by univariate analyses of variance for each of the parent behaviors. These ANOVAs revealed significant differences for contingent stop [F (1,29) = 6.92, p < .01], contingent attending IF (1,29) = 6.58 p < .051, noncontingent rubbing IF (1,29) = 7.95, p < .01], and noncontingent attending [F (1,29) = 6.67, p < .05].
Predicting Child Behaviors from Parent Behaviors To examine the relation between parent and child behaviors, a series of regression analyses was conducted. A separate analysis was conducted for each of the child behaviors. A hierarchical model of regression was used (Cohen & Cohen, 1975). The hierarchical model enters each independent variable or set of independent variables into the equation in separate steps. Predictor variables were entered in three steps: 1) demographic variables (age and sex), 2)
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221
medical status variables (IgE levels, percentage of body area affected by AD), and 3) the total parent behavior scores (contingent parent total and noncontingent parent total). This hierarchical procedure allows one to assess the significance of R 2 (explained variance) for each of the three sets of variables. If the R 2 for a given set was significant, then the standardized regression coefficient (betas) for each predictor variable in that set was examined. An F test performed on each beta allows a test of whether the increase in explained variance (R 2) is significantly different from 0. At each step of the model, all variables contributing at the .15 or higher level were entered into the equation. If any one of the variables entered at one of the steps was found to be significant, then that variable was entered into subsequent steps of the regression analysis. This procedure is referred to as "pre-test estimation" (Cooley & Lohnes, 1971). This data analysis strategy insures that the effects of the parent behaviors were determined only after controlling for the effects of any significant demographic or medical status variables. Table 2 summarizes the results of the final step of the regression analyses for the child scratching-related behaviors. A total of 86°70 of the variance in total child scratching-related behaviors was explained by a combination of age, IgE, and total parent behaviors. The combination of contingent total and noncontingent total accounted for 52°70 of the variance in total child behavior above that accounted for by the demographic and medical status variables.
TABLE 2 SUMMARY OF THE REGRESSION ANALYSES FOR CHILD BEHAVIOR
Total child behavior
Total R2
df
F-ratio for R 2
.86
4,25
39.47***
Age IgE Contingent parent tot Noncontingent parent tot
ChiM scr
.74
2,27
.83
4,25
Sex ~< .05 ** p ~< .01 *** p ~< .001 * p
.19
1,28
.29 .05 .47 .05
1.42 0.25 62.26*** 9.96**
0.37 - 0.01 0.85 - 0.38
.17 .57
0.89 60.13"**
0.19 0.58
.42 .05 .24 .12
5.68* 0.85 19.42"** 17.08"**
0.41 - 0.01 0.26 - 0.27
.19
6.74**
30.20***
AGE IgE Contingent parent tot Noncontingent parent tot
Child req/itch
Beta coefficient
39.27***
Age Contingent parent tot
Child rub
R2 F-Ratio for change R 2 change
6.74** 0.67
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The relationship between parent totals and child behaviors is important to note. As can be seen by examining the beta coefficients in Table 2, the higher the level of contingent total, the higher the level of total child behavior; the higher the level of noncontingent total, the lower the level of total child behavior. The parent behaviors also accounted for a significant portion of the variance in two of the individual child behaviors over and above the variance accounted for by demographic and medical status variables. Higher contingent total scores were related to higher levels of scratching and higher levels of rubbing in children. Noncontingent total was also an important predictor of child rubbing. Higher levels of noncontingent total were related to lower levels of child rubbing. As can be seen in the table, some of the demographic and medical status variables were important predictors of variance in some of the child behaviors. Age was significantly related to child rubbing and marginally related to child scratching and child total. In this sample, older children tended to engage in significantly more rubbing and to engage in more scratching than younger children. This relationship maintains in the final step of the regression analysis even after controlling for medical status variables (percentage of body area affected and IgE level). Sex was a significant predictor of child requests/itch such that girls exhibited significantly more requests for parent behaviors and made more expressions of being itchy in comparison to the boys. A t-test of this sex difference revealed that the difference between girls and boys was significant at the .01 level [t (28) -- 2.60]. It is important to note that there were no significant differences observed between any of the child behaviors and percentage of body area affected.' Although IgE level appears in the final step of the regression analysis as contributing some variance to total child behavior and child rubbing, the contribution of this variable was not significant. Thus, the medical status variables were not significant predictors of variance in any of the child behaviors. In order to examine the relationship between the child's demographics and medical status variables and each of the parent behaviors, Pearson product moment correlations were computed. Several significant correlations were observed. As age increased, parental contingent attending increased (r = .54, p < .01). There was a negative correlation between age and parent noncontingent attending such that, as age increased, parental noncontingent attending decreased (r = -.48, p < .01). There were no significant relationships between parent behavior and the sex of the child. There were several significant relationships between percentage of body area affected by AD and parent behaviors. The more skin area affected by AD, the higher the level of contingent scratching (r = .47, p < .01) and the higher
' T h r e e subjects h a d missing d a t a o n affected area. Step 2 o f the regression analysis was d o n e twice, o n c e with affected a r e a i n c l u d e d (n = 27) a n d o n c e with affected a r e a r e m o v e d (n = 30). G i v e n t h a t affected a r e a was n o n s i g n i f i c a n t , the results a n d Table 2 r e p o r t d a t a o n p r e d i c t i o n with l g E o n l y (n = 30).
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the level of noncontingent stop (r = .40, p < .05). There were no significant relationships between IgE level and parent behaviors.
DISCUSSION Several previous researchers have postulated that social influences have a role in maintaining scratching-related behavior in patients with AD (Allen & Harris, 1966; Cataldo et al., 1980; Rosenbaum & Ayllon, 1981). Gil et al. (1987) recently found that features of the family environment, such as degree of independence/organization and moral/religions emphasis, were predictive of parent's report of scratching frequency in children. Parent attention has also been identified as a social influence related to scratching behavior in children with AD (Allen & Harris, 1966). These prior studies, however, have not systematically assessed social influences such as parental response through direct observation techniques. The findings of the present study lend support to a social learning perspective on scratching-related behavior in children with AD by directly observing both child and parent behaviors. Parent behaviors predicted a large and significant amount of variance in scratching-related behaviors in children with AD even after controlling for demographic and medical status variables. The parent behaviors that occurred during or immediately following the child's behavior accounted for the largest portion of variance in child's responses. These data suggest that when social responses, such as attention or actual physical contact (scratching, rubbing), are provided contingently in response to the child's behavior, these responses may actually reinforce the overall level of maladaptive child scratching behavior. The study also found that noncontingent parent behaviors played a significant role in predicting child scratchingrelated behavior. Although parents did initiate some spontaneous (noncontingent) scratching and rubbing of the child, noncontingent attention was the most frequent behavior. The higher the level of noncontingent attention, the lower the level of scratching. Thus, the data suggest that attention supplied when the child is n o t scratching, but engaged in some other behavior, may serve to reduce the overall level of child scratching through differential reinforcement of other behavior. Although the methodology used to predict child behavior is correlational (i.e., regression analysis) and causality cannot be inferred, several steps were taken in the development of the observation system to maximize the understanding of the nature of the relationship between child and parent behavior. The observation method used here was modeled after the interval sampiing/event recording method described by Roberts and Forehand (1978). In the observation system, the child problem behavior (B) and the parental response or the consequences that follow (C) were recorded in event sequences which implies an ordered and temporal relationship within the B-C chain (Roberts & Forehand, 1978). This procedure yields maximal information about specific behavior-consequence chains and thus helps identify the specific maladaptive parental responses that maintain problematic child behavior. A second interesting finding of this study was that the level of structure
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of the setting for the observation was related to both child and parent behaviors. During the structured task, children consistently engaged in lower levels of scratching-related behavior as compared to the unstructured task. There are several possible reasons for this. First, children may be distracted by the task and therefore do not scratch. Second, it is possible that differences in parental responding during the structured task influence the child behaviors. Children engage in scratching and rubbing during structured times; however, parents do not respond with physical contact, i.e., scratching, rubbing. Parents do supply higher levels of noncontingent attending during the structured task. It may be that this higher level of attending to the child's appropriate task-related behavior serves to reinforce appropriate (nonscratching) behavior in the child. This finding is consistent with Allen and Harris' (1966) finding that scratching behavior is reduced when parents ignore scratching and reinforce scratch-free periods. The third interesting finding in this study was the relationship between the child's demographic and medical status variables and the parent behaviors. Parent behavior was associated with one of the medical status variables (i.e., percentage of body area affected). Although there was a nonsignificant relationship between the percentage of body area affected and the child's scratchingrelated behavior, parents of children with more observable body area affected engaged in higher levels of scratching. There are several possible reasons for this. The percentage of body area affected is observable to parents. In the case of young children, parents administered much of the medical care of AD, such as the application of topical lubricating creams or topical medications. Parents also closely inspected the child's skin to determine the status of AD. It may be that areas of AD on the child's body serve as a discriminative cue to the parent to administer care and thus promote parent scratching. Another possibility is that parents of children with more broken-out skin engage in more behavior in order to provide comfort to the child and alleviate the child's complaints. Taken together, the results of this study have important implications for the behavioral assessment and treatment of scratching behavior in children with AD. First, in addition to the child's behavior, the parent's behavior is critical to examine. Although several previous studies (Cataldo et al., 1980; Rosenbaum & Ayllon, 1981) recognized the importance of direct observation of the patient behavior, parent-child interactions have not been systematically observed. The behavioral observation system described in this study provides a reliable way to assess child scratching-related behavior as well as the response of the parent. Problem child behaviors as well as target parent responses can then be identified, which will assist in intervention planning and treatment evaluation. Parent training techniques (Forehand & McMahon, 1981) can be used to alter parental responses. In particular, parents can be trained to: (1) decrease contingent attention for scratching-related behavior, as well as contingent physical contact when the child is scratching, (2) increase overall attention for other appropriate behavior, (3) verbally reinforce task involvement through direct praise, and (4) minimize attempts to directly stop the child by gestures, physical restraint, or verbal commands. An obvious future research
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effort would be to actually train parents in these strategies and observe the treatment effects. Although several well-controlled case studies have been conducted along these lines (Allen & Harris, 1966), controlled group designs are needed. Second, situational factors, such as the level of structure, are important to define when assessing scratching. Although prior studies have controlled observational setting features (e.g., Cataldo et al., 1980), these factors have not been systematically manipulated in order to observe the effects of this manipulation on scratching. A limitation which should be mentioned is that the process of observing parents and child interact may have influenced their behavior possibly by inducing anxiety. The order of the conditions, structured versus unstructured, was counterbalanced to minimize any differential effect of these other possible variables on observed scratching. Future studies should include an adaptation period when child and parents are exposed to the videotaping for a longer period of time before observations are scored as a way to minimize reactivity of the observation. It should also be noted that, in this study, observational sessions were conducted in the patient's hospital room and this setting parameter may also have an influence on parent-child interaction. The patient's room was selected for the observation because it was considered less obtrusive than moving the patient to a hospital laboratory setting. In the Clinical Research Unit at Duke, it is common for parents to stay with their child in his or her room during the hospital stay. Thus, it was the most "natural" place in the hospital for the child and parent to typically interact. Future studies might conduct observations in other settings, such as home and school, and evaluate scratching behaviors in these settings. It should be noted that the conclusions of this study are restricted in part by the setting in which the observation were conducted. The present research suggests that distraction may also be a way to minimize scratching behavior. The manipulation in this study was a relatively simple, naturally occurring event in most children's environment, that is, a structured interaction between child and parent. Training parents to structure activities such as building a model, especially at times of the day that the child is at risk for increased scratching (e.g., before bedtime), may be a relatively simple means to reduce scratching behavior in AD children. Distraction through activity scheduling may be an even more useful strategy with young children than other strategies that have been used with adults, such as training in biofeedback (Haynes et al., 1979) and habit-reversal methods (Rosenbaum & Ayllon, 1981), since learning these self-control strategies may be difficult for young children.
REFERENCES Allen, K., & Harris, F. (1966). Elimination of a child's excessive scratching by training the mother in reinforcement procedures. Behaviour Research and Therapy, 4, 79-84. Azrin, N. H., & N u n n , R. G. (1973). Habit-reversal: A method of eliminating nervous habits and tics. Behaviour Research and Therapy, 11, 619-628.
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Bar, L. H. J., & Kuypers, B. R. M. (1973). Behavior therapy in dermatological practice. British Journal of Dermatology, 88, 591-598. Blaylock, W. K. (1976). Atopic dermatitis: Diagnosis and pathobiology. Journal of Allergy and Clinical Immunology, 57, 62-79. Buckley, R. H. (1984). Allergic eczema, in V. C. Kelley (Ed.), Practices in pediatrics, (pp. 1-29). Philadelphia: Hayes and Row Publishers. Budd, K. S., Green D. R., & Baer, D. M. (1976). An analysis of multiple misplaced parental social contingencies. Journal of Applied Behavior Analysis, 9, 459-470. Busse, W. W., & Lee, T. P. (1976). Decreased adrenergic responses in lymphocytes and granulocytes in atopic eczema. Journal of Allergy and Clinical Immunology, 58, 586. Carson, J. S. (1981). The treatment of burns. London: Chapman & Hall. Cataldo, M. E, Varni, J. W., Russo, D. C., & Estes, S. A. (1980). Behavior therapy techniques in treatment of exfoliative dermatitis. Archives of Dermatology, 116, 919-922. Cohen, J., & Cohen, P. (1975). Applied multiple regression~correlational analysis for the behavioral sciences. New York: Wiley. Cooley, W. W., & Lohnes, P. R. (1971). Multivariate data analysis. New York: Wiley. Fabisch, W. (1980). Psychiatric aspects of dermatitis artefacta. British Journal of Dermatology, 102, 29-34. Faulstich, M. E., & Williamson D. A. (1985). An overview of atopic dermatitis: Towards a biobehavioral integration. Journal of Psychosomatic Research, 29, 647-654. Faulstich, M. E., Williamson, D. A., Duchmann, E. G., Conerly, S. L., & Brantley, P. J. (1985). Psychophysiological analysis of atopic dermatitis. Journal of Psychosomatic Research, 29, 415-417. Fava, G. A., Perini, G. I., Santonastaso, P., & Fornasa, C. V. (1980). Life events and psychological distress in dermatological disorders: Psoriasis, chronic urticaria and fungal infections. British Journal of Medical Psychology, 53, 277-282. Forehand, R. L., & McMahon, R. J. (1981). Helping the non-compliant child." A clinician's guide to parent training. New York: Guilford Press. Garrie, E. V., Garrie, S. A., & Mote, T. (1974). Anxiety and atopic dermatitis. Journal of Consuiting and Clinical Psychology, 42, 742. Gil, K. M., Keefe, E J., Sampson, H. A., McCaskill, C. C., Rodin, J., & Crisson, J. E., (1987). The relation of stress and family environment to atopic dermatitis symptoms in children. Journal of Psychosomatic Research, 31, 673-684. Gleich, G. J., Averbeck, A. K., & Swedlund, H. A. 0971). Measurement of IgE in normal and allergic serum by radioimmunoassay. Journal of Laboratory and Clinical Medicine, 77, 690-698. Hanifin, T. M., & Lobitz, W. C., Jr. (1977). Newer concepts of atopic dermatitis. Archives of Dermatology, 113, 663-670. Haynes, S. N., Wilson, C. C., Jaffe, P. G., & Britton, B. T. (1979). Biofeedback treatment of atopic dermatitis. Biofeedback & Self-Regulation, 4, 195-209. Herbert, E. W., & Baer, D. M. (1972). Training parents as behavior modifiers: Self-recording of contingent attention. Journal of Applied Behavior Analysis, 5, 130-144. Hughes, H. M., & Haynes, S. N. (1978). Structured laboratory observation in the behavioral assessment of parent-child interactions: A methodological critique. Behavior Therapy, 9, 428-447. Jordan, J. M., & Whitlock, E A. (1972). Emotions and the skin: The conditioning of scratch responses in cases of atopic dermatitis. British Journal of Dermatology, 86, 574-585. Lehman, R. E. (1978). Brief hypnotherapy of neurodermatitis: A case with four-year follow-up. The American Journal of Clinical Hypnosis, 21, 48-51. Patterson, G. R., & Reid, J. B. (1973). Intervention for families of aggressive boys: A replication study. Behaviour Research and Therapy, 11, 383-394.
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Roberts, M. W., & Forehand, R. (1978). The assessment of maladaptive parent-child interaction by direct observation: An analysis of methods. Journal o f Abnormal Child Psychology, 6, 257-270. Rosenbaum, M. S., & Ayllon, T. (1981). The behavioral treatment of neurodermatitis through habit reversal. Behaviour Research and Therapy, 19, 313-318. Sampson, H. A. (1983). Role of immediate food hypersensitivity in the pathogenesis of atopic dermatitis. Journal o f Allergy and Clinical Immunology, 71, 473-480. Sulzberger, M., & Herrmann, J. (1964). The clinical significance o f disturbances in the delivery o f sweat. Springfield: Thomas. Wilson, E. (1857). Diseases o f the skin. London: Churchill. RECEIVED: August 10, 1987 FINAL ACCEPTANCE: November 17, 1987
Direct Observation of Scratching Behavior in Children with Atopic Dermatitis KAREN
M. GIL, FRANCIS J. KEEFE
Duke University Medical Center
HUGH A. SAMPSON Johns Hopkins Hospital CYNTHIA C. MCCASKILL
Duke University Medical Center JUDITH RODIN
Yale University
JAMES E. CR1SSON Duke University Medical Center This study examines scratching behavior in children with atopic dermatitis (AD). Thirty children with severe A D and one parent of each child were observed for a 10minute observation period during a five-minute structured and five-minute unstructured task. Observers coded child and parent behaviors. Data analyses revealed that children engaged in more scratching behavior during the unstructured than structured task. Furthermore, regression analyses indicated that parent responses to scratching behavior in children were important predictors of scratching behavior even after controlling for demographic and medical status variables, such as serum lgE level and percentage of body area affected by AD. These results have important implications for health care professionals working with children who have AD. Suggestions for future behavioral treatment studies are discussed.
This research was supported in part by a grant (A124439) from the National Institute of Allergy and Infectious Diseases, a grant (RR-30) from the General Clinical Research Center Program of the Division of Research Resources, National Institute of Health, and a grant from the John D. and Catherine T. MacArthur Foundation Network on the Determinants and Consequences of Health Promoting and Health Damaging Behavior. Portions of these data were presented at the annual meeting of the Association for Advancement of Behavior Therapy, November, 1986. Request for reprints and all correspondence should be sent to Karen M. Gil, Ph.D., Department of Psychiatry, Box 3159, Duke University Medical Center, Durham, NC 27710. 213 0005-7894/88/0213-022751,00t0 Copyright 1988 by Association for Advancement of Behavior Therapy All rights of reproduction in any form reserved.
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Atopic Dermatitis (AD) is a condition which often begins in early infancy as an erythematous, intensely pruritic, maculopapular eruption and progresses to a more lichenfied dermatitis with time (Blaylock, 1976). The clinical course of AD is periodic and, during exacerbations of the disease, superficial inflammations of the skin can be clearly observed. The behavioral component of this disorder, that is, scratching, is especially problematic. Excessive scratching can lead to lichenification, excoriations, and serious skin infections. The etiology of itching and scratching in atopic dermatitis is not clearly understood. Pathophysiological mechanisms that have been described include an altered sweat response (Sulzberger & Herrmann, 1964), allergic reactions to food (Sampson, 1983), or a reduction in beta-adrenergic stimulation which leads to a deceased itch threshold (Busse & Lee, 1976). As early as 1857, however, authors recognized the importance of emotional factors in dermatological disorders (Wilson, 1857), and several psychological and behavioral mechanisms have been proposed as playing a significant role in maintaining scratching behavior in AD. Researchers with a psychophysiological perspective have postulated a role of stress and anxiety, whereby increased stress leads to increased sympathetic arousal, peripheral vascular changes, and a decreased itch threshold (Faulstich & Williamson, 1985). Data from several assessment and treatment studies lend support to such a perspective (Fabisch, 1980; Faulstich, Williamson, Duchmann, Conerly & Brantley, 1985; Fava, Perini, Santonastaso & Fornasa, 1980; Garrie, Garrie & Mote, 1974; Haynes, Wilson, Jaffe, & Britton, 1979; Lehman, 1978). These studies have found that anxiety and stressful life events are associated with AD symptomatology, and techniques such as relaxation training and hypnosis are effective in reducing symptoms of itching and scratching. A second conceptualization of scratching in AD considers scratching as a learned habit maintained by operant reinforcement; that is, scratching relieves itching and increases the probability of subsequent scratching (Bar & Kuypers, 1973; Jordan & Whitlock, 1972). Treatment studies which lend support to this perspective have found that the habit-reversal method (Azrin & Nunn, 1973) could be applied to decrease scratching by substituting a competing response such as tensing arm muscles (Rosenbaum & Ayllon, 1981) or folding hands in one's lap (Cataldo et ai., 1980) in response to itching. Social responses to scratching and other environmental factors may also play a role in maintaining scratching behaviors in individuals with AD (Gil, Keefe, Sampson, McCaskill, Rodin & Crisson, 1987). Informal observations of children with AD in our clinic reveal that children scratch more in some situations than in others. For example, many children scratch more at bedtime or during passive activities, such as watching TV, and less during active activities, such as playing games. Children not only scratch and rub affected areas, but express being itchy and request scratching from their parents. Parents have been informally observed to scratch and rub the child's skin as well as engage in verbal attempts and gestures to stop the child's scratching. The parent training literature provides a model for studying parent-child interactions in children having AD. The behavioral consequences provided by the parent are significant factors in a young child's environment (e.g., Her-
S C R A T C H I N G B E H A V I O R IN A T O P I C D E R M A T I T I S
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bert & Baer, 1972). Extensive research has been conducted in the behavioral assessment of parent-child interactions using structured laboratory observation methods (Hughes & Haynes, 1978). These studies have found that certain problem behaviors in children, such as noncompliance and aggression (e.g., Budd, Green, & Baer, 1976; Hughes & Haynes, 1978; Patterson & Reid, 1973), are often inadvertently maintained through parental consequences such as attention to inappropriate child behavior. Researchers have also well documented that maladaptive behavior exhibited by children can be modified by training parents to alter their responses to the child (e.g., Forehand & McMahon, 1981). Taking the perspective that parental attention maintained inappropriate scratching behavior, Allen and Harris (1966) successfully treated a 5-year-old girl with AD by training her mother to ignore scratching and deliver token reinforcement for scratch-free periods. However, with the exception of case studies, there has been little controlled investigation of the role of social responses in maintaining scratching in children with AD. Furthermore, there has been insufficient study of the environmental circumstances which influence scratching in children with AD. It is our hypothesis that scratching behavior in children with AD differs as a function of the environmental demands as well as the consequences, that is, the parental response to scratching. This study had two major goals. The first goal was to investigate the effects of situational factors (i.e., level of structure) on scratching behavior in AD children and on a parental response to the child. The second goal was to examine parental responses to the child's scratching. Behaviors such as parental attention to scratching and attempts to get the child to stop scratching were examined to assess their impact on the child's behavior. Specifically, the study was designed to measure the extent to which these parent behaviors predicted child scratching over and above medical status variables, such as degree of dermatitis. Direct observation methodology adapted from the parent-training literature was used to help accomplish these two goals.
METHOD Subjects Thirty children (15 boys, 15 girls) with a mean age of 5.58 years (SD = 2.53 years, range = 3 to 13) participated in the study. Subjects were patients being evaluated for severe atopic dermatitis by one of the investigators (H.S.) on the Clinical Research Unit at Duke University Medical Center. All subjects fulfilled the criteria for AD established by Hanifin and Lobitz (1977). These criteria include several absolute features such as pruritus, typical morphology and distribution (i.e., facial and extensor involvement in infancy, flexural lichenification in adults), and tendency toward chronic or chronically relapsing dermatitis. In addition to the absolute criteria, several of a list of "optional" features are required to make the diagnosis. This list includes family history of atopic disease, immediate skin test reactivity, elevated serum IgE, and tendency toward repeated cutaneous infections. Most children in the study had a history of AD dating back to infancy. At
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the time of evaluation, patients had a median of 13% (range = 0 to 59%) area of their body surface affected by AD.
Procedure Behavioral Observation System. A 10-minute videotaped observation session of the child's scratching behavior was obtained while the child was interacting with the parent. The session was divided into two conditions: 1) five-minute structured task and 2) five-minute unstructured task. During the five-minute structured task, the child and parent were instructed to work together building a Lego model. They were provided with a I_ego building set and instructed to work on building a model of their choice. The child and parent sat on a hospital bed in the child's room and worked on a table adjusted to a height that was comfortable for the child. During the unstructured task, the child and parent sat at the same hospital bed with an adjustable table in front of them; however, the five-minutes of free time had no specific task instructions. All toys were positioned out of the child's reach. The parents were instructed that the child should not play during this time, and they should encourage the child to sit in place in view of the camera. For both conditions, the video camera was placed in the doorway approximately 6-8 feet from the child. The experimenter interacted minimally with the child or parent and only gave instructions at the change of conditions. In a few cases, the experimenter requested that the parent have the child return to the bed if the child moved out of range of the video camera. The presentation for the two conditions was counterbalanced to minimize any potential order effects (Hughes & Haynes, 1978). Thirteen children participated in the structured task first followed immediately by the unstructured task, and 17 of the children participated in the unstructured task followed immediately by the structured task. Behavioral Coding Categories. The behaviors selected for coding were identified through interviews with nurses, physicians, and patient's families as well as informal observations of children with AD and their families. Child behaviors scored were scratching, rubbing, and verbal statements of itchiness or requests by the child for scratching by the parent. Parent behaviors scored were scratching, rubbing, attempts to stop the child from scratching, and attending. Definitions of the identified behaviors are presented in Table 1. Observer Training. Two observers scored the videotapes. The observers were trained in two stages. First, they studied a training manual that included definitions of the behavioral categories. Second, they practiced coding observations by scoring segments of videotapes. The segments illustrated the range of behaviors to be covered. Observers viewed segments and then received immediate feedback on their scoring. Observers practiced scoring until their percentage agreement scores routinely exceeded the 85°70 level. Recording and Scoring Procedure. Observers independently and simultaneously scored the videotapes for all 30 subjects. Behavioral categories were scored in an ongoing fashion using 20-second-observation record intervals. Child behaviors were scored for occurrence or nonoccurence in each interval. Parental
SCRATCHING BEHAVIOR IN ATOPIC DERMATITIS
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TABLE 1 SUMMARYOF BEHAVIORALDEFINITIONSFOR THE OBSERVATIONSYSTEM Child Scratching (SCR):
Child Rubbing (RUB):
Child Request~Itch (REQ/IT):
Parent Stop (STOP):
Parent Scratching (SCR):
Parent Rubbing (RUB):
Parent Attend (ATT):
Child using nails of hand(s) or any sharp object or surface on any area of the skin. The skin does not have to have skin lesions. Child picking skin or scratching through clothes is scored as scratching. Child moving hand(s) or fingers(s) or any soft object across the skin. The area does not have to have skin lesions. The child makes a statement of physical discomfort such as "it hurts" or "it itches." The child asks or gestures the parent for "skin care" such as asking the parent to rub or scratch. Any motor behavior by the parent which attempts to stop the child from scratching, rubbing, or touching the skin such as physically removing the child's hand(s) or holding the child's hand(s). Any verbal command by the parent which directs child to stop scratching, rubbing, or touching the skin such as "Stop scratching," or "Don't touch your legs." Parent using nails of hand(s) or any sharp object or surface on any area of the child's skin. The skin does not have to have skin lesions. This category includes when the parent is picking at the child's skin. Parent moving hand(s) or finger(s) or any soft object or surface across the child's skin. The area does not have to have skin lesions. Parent is attending to child by looking at the child, the child's activity, or playing or speaking "on task" to the child.
b e h a v i o r s w i t h i n e a c h i n t e r v a l were s c o r e d as c o n t i n g e n t o r n o n c o n t i n g e n t . C o n t i n g e n t r e s p o n s e s were r e s p o n s e s t h a t o c c u r r e d d u r i n g a c h i l d b e h a v i o r o r were i n i t i a t e d b y t h e p a r e n t w i t h i n 5 s e c o n d s o f offset o f a c h i l d b e h a v i o r . N o n c o n t i n g e n t responses were responses t h a t were initiated by the p a r e n t m o r e t h a n 5 s e c o n d s a f t e r t h e offset o f t h e last s c o r e d c h i l d b e h a v i o r . T h i s a p p r o a c h to i n t e r v a l s a m p l i n g i m p l i e s a n o r d e r e d t e m p o r a l r e l a t i o n s h i p b e t w e e n c h i l d b e h a v i o r a n d p a r e n t a l response, a n d t h u s specific child b e h a v i o r - p a r e n t c o n s e q u e n c e c h a i n s c a n be m o r e p r e c i s e l y m e a s u r e d ( R o b e r t s & F o r e h a n d , 1978). T h i s m e t h o d is s i m i l a r to o t h e r o b s e r v a t i o n a l m e t h o d s c o m m o n l y u s e d in t h e p a r e n t t r a i n i n g literature to assess p a r e n t - c h i l d i n t e r a c t i o n p a t t e r n s ( F o r e h a n d & M c M a h o n , 1981; R o b e r t s & F o r e h a n d , 1978). A rate o f o c c u r r e n c e f o r t h e s t r u c t u r e d a n d u n s t r u c t u r e d c o n d i t i o n s was calculated for e a c h b e h a v i o r c o d i n g c a t e g o r y . T h u s , for e a c h c o n d i t i o n , t h e r e were t h r e e scores for t h e child, (rate o f scratching, r u b b i n g , r e q u e s t s / i t c h ) a n d eight m e a s u r e s for each child's p a r e n t (rate o f c o n t i n g e n t s c r a t c h i n g , c o n t i n g e n t r u b b i n g , c o n t i n g e n t stops, c o n t i n -
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AL.
gent attending, noncontingent scratching, noncontingent rubbing, noncontingent stops, and noncontingent attending). In addition, an overall total score was calculated for the child by summing the rate of scratching, rubbing, and requests/itch. Overall total scores for the child's parents were calculated for each condition: total contingent behavior (calculated by summing all the individual contingent behaviors) and total noncontingent behavior (calculated by summing all the individual noncontingent behaviors) in the structured and unstructured conditions. Observer Reliability. The reliability of observers was checked using a percentage agreement measure. Percentage agreement was calculated by dividing the number of intervals in which observers agreed on the occurrence of coding categories observed by the number of intervals in which disagreements plus agreements of occurrences occurred. Overall percentage agreement averaged 95.7%. The reliabilities for each category ranged from 71.2°70 for parent scratching to 98.2070 for parent attending. Medical Status and Demographic Variables. Two medical status variables were recorded because they are believed to be related to symptom severity in AD (Buckley, 1984). Serum IgE level was determined by a standard double antibody radioimmunoassay method (Gleich, Averbeck & Swedlund, 1971). Percentage of body area affected by AD was determined by an examining specialty nurse prior to videotaping; thus she was blind to actual videotape scores. Skin areas showing redness, rash, or other eczematous signs were mapped on
12
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FIG. 1. Mean rate of child scratching behaviors per five-minute observation for the structured versus unstructured conditions.
S C R A T C H I N G BEHAVIOR IN ATOPIC DERMATITIS
219
a body chart, and, using age-modified norms for calculation of body surfaces area (Carson, 1981), an estimate of percentage of affected skin was determined. Age and sex were recorded for each child since these variables may be related to scratching behavior on the part of the child. R ES U LTS Figure 1 presents the mean rates of child behavior during the unstructured and structured tasks. As can be s e e n in the figure, children engaged primarily in scratching and rubbing. Figures 2 and 3 present the mean rates of parent behavior in the unstructured versus structured conditions. Attending (both contingent and noncontingent) was the primary behavior observed.
The Effects o f Structured Versus Unstructured Conditions As can be seen in Figure 1, children exhibited higher levels of each of the individuals behaviors during the unstructured as compared to structured conditions. In order to evaluate the effects of the manipulation of level of structure during the observation on child behavior, a one-way multivariate analysis of variance (MANOVA) was conducted. The overall MANOVA was significant [F 3,27) = 3.10, p < .05]. The multivariate effect was followed by univariate analysis of variance (ANOVA) on each of the child behaviors. The 1312-
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FIG. 2. Mean rate of contingent parent behavior per five-minute observation for the structured versus unstructured conditions.
220
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3. Mean rate of noncontingent parent behavior per five-minute observation for the structured versus unstructured conditions. FIG.
difference between structured and unstructured conditions was significant for child rubbing [F (1,29) -- 5.96, p < .05] and requests/itch [F (1,29) -- 5.19, p < .051. Parents exhibited differences in level o f behavior in the structured versus unstructured conditions (See Figures 2 and 3). In order to evaluate the effects of the manipulation o f level of structure on parent behavior, a one-way MANOVA was conducted. The overall MANOVA for parent behavior was significant [F (8,22) = 2.77, p < .05]. The multivariate analysis was followed by univariate analyses of variance for each of the parent behaviors. These ANOVAs revealed significant differences for contingent stop [F (1,29) = 6.92, p < .01], contingent attending IF (1,29) = 6.58 p < .051, noncontingent rubbing IF (1,29) = 7.95, p < .01], and noncontingent attending [F (1,29) = 6.67, p < .05].
Predicting Child Behaviors from Parent Behaviors To examine the relation between parent and child behaviors, a series of regression analyses was conducted. A separate analysis was conducted for each of the child behaviors. A hierarchical model of regression was used (Cohen & Cohen, 1975). The hierarchical model enters each independent variable or set of independent variables into the equation in separate steps. Predictor variables were entered in three steps: 1) demographic variables (age and sex), 2)
SCRATCHING BEHAVIOR IN ATOPIC DERMATITIS
221
medical status variables (IgE levels, percentage of body area affected by AD), and 3) the total parent behavior scores (contingent parent total and noncontingent parent total). This hierarchical procedure allows one to assess the significance of R 2 (explained variance) for each of the three sets of variables. If the R 2 for a given set was significant, then the standardized regression coefficient (betas) for each predictor variable in that set was examined. An F test performed on each beta allows a test of whether the increase in explained variance (R 2) is significantly different from 0. At each step of the model, all variables contributing at the .15 or higher level were entered into the equation. If any one of the variables entered at one of the steps was found to be significant, then that variable was entered into subsequent steps of the regression analysis. This procedure is referred to as "pre-test estimation" (Cooley & Lohnes, 1971). This data analysis strategy insures that the effects of the parent behaviors were determined only after controlling for the effects of any significant demographic or medical status variables. Table 2 summarizes the results of the final step of the regression analyses for the child scratching-related behaviors. A total of 86°70 of the variance in total child scratching-related behaviors was explained by a combination of age, IgE, and total parent behaviors. The combination of contingent total and noncontingent total accounted for 52°70 of the variance in total child behavior above that accounted for by the demographic and medical status variables.
TABLE 2 SUMMARY OF THE REGRESSION ANALYSES FOR CHILD BEHAVIOR
Total child behavior
Total R2
df
F-ratio for R 2
.86
4,25
39.47***
Age IgE Contingent parent tot Noncontingent parent tot
ChiM scr
.74
2,27
.83
4,25
Sex ~< .05 ** p ~< .01 *** p ~< .001 * p
.19
1,28
.29 .05 .47 .05
1.42 0.25 62.26*** 9.96**
0.37 - 0.01 0.85 - 0.38
.17 .57
0.89 60.13"**
0.19 0.58
.42 .05 .24 .12
5.68* 0.85 19.42"** 17.08"**
0.41 - 0.01 0.26 - 0.27
.19
6.74**
30.20***
AGE IgE Contingent parent tot Noncontingent parent tot
Child req/itch
Beta coefficient
39.27***
Age Contingent parent tot
Child rub
R2 F-Ratio for change R 2 change
6.74** 0.67
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The relationship between parent totals and child behaviors is important to note. As can be seen by examining the beta coefficients in Table 2, the higher the level of contingent total, the higher the level of total child behavior; the higher the level of noncontingent total, the lower the level of total child behavior. The parent behaviors also accounted for a significant portion of the variance in two of the individual child behaviors over and above the variance accounted for by demographic and medical status variables. Higher contingent total scores were related to higher levels of scratching and higher levels of rubbing in children. Noncontingent total was also an important predictor of child rubbing. Higher levels of noncontingent total were related to lower levels of child rubbing. As can be seen in the table, some of the demographic and medical status variables were important predictors of variance in some of the child behaviors. Age was significantly related to child rubbing and marginally related to child scratching and child total. In this sample, older children tended to engage in significantly more rubbing and to engage in more scratching than younger children. This relationship maintains in the final step of the regression analysis even after controlling for medical status variables (percentage of body area affected and IgE level). Sex was a significant predictor of child requests/itch such that girls exhibited significantly more requests for parent behaviors and made more expressions of being itchy in comparison to the boys. A t-test of this sex difference revealed that the difference between girls and boys was significant at the .01 level [t (28) -- 2.60]. It is important to note that there were no significant differences observed between any of the child behaviors and percentage of body area affected.' Although IgE level appears in the final step of the regression analysis as contributing some variance to total child behavior and child rubbing, the contribution of this variable was not significant. Thus, the medical status variables were not significant predictors of variance in any of the child behaviors. In order to examine the relationship between the child's demographics and medical status variables and each of the parent behaviors, Pearson product moment correlations were computed. Several significant correlations were observed. As age increased, parental contingent attending increased (r = .54, p < .01). There was a negative correlation between age and parent noncontingent attending such that, as age increased, parental noncontingent attending decreased (r = -.48, p < .01). There were no significant relationships between parent behavior and the sex of the child. There were several significant relationships between percentage of body area affected by AD and parent behaviors. The more skin area affected by AD, the higher the level of contingent scratching (r = .47, p < .01) and the higher
' T h r e e subjects h a d missing d a t a o n affected area. Step 2 o f the regression analysis was d o n e twice, o n c e with affected a r e a i n c l u d e d (n = 27) a n d o n c e with affected a r e a r e m o v e d (n = 30). G i v e n t h a t affected a r e a was n o n s i g n i f i c a n t , the results a n d Table 2 r e p o r t d a t a o n p r e d i c t i o n with l g E o n l y (n = 30).
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the level of noncontingent stop (r = .40, p < .05). There were no significant relationships between IgE level and parent behaviors.
DISCUSSION Several previous researchers have postulated that social influences have a role in maintaining scratching-related behavior in patients with AD (Allen & Harris, 1966; Cataldo et al., 1980; Rosenbaum & Ayllon, 1981). Gil et al. (1987) recently found that features of the family environment, such as degree of independence/organization and moral/religions emphasis, were predictive of parent's report of scratching frequency in children. Parent attention has also been identified as a social influence related to scratching behavior in children with AD (Allen & Harris, 1966). These prior studies, however, have not systematically assessed social influences such as parental response through direct observation techniques. The findings of the present study lend support to a social learning perspective on scratching-related behavior in children with AD by directly observing both child and parent behaviors. Parent behaviors predicted a large and significant amount of variance in scratching-related behaviors in children with AD even after controlling for demographic and medical status variables. The parent behaviors that occurred during or immediately following the child's behavior accounted for the largest portion of variance in child's responses. These data suggest that when social responses, such as attention or actual physical contact (scratching, rubbing), are provided contingently in response to the child's behavior, these responses may actually reinforce the overall level of maladaptive child scratching behavior. The study also found that noncontingent parent behaviors played a significant role in predicting child scratchingrelated behavior. Although parents did initiate some spontaneous (noncontingent) scratching and rubbing of the child, noncontingent attention was the most frequent behavior. The higher the level of noncontingent attention, the lower the level of scratching. Thus, the data suggest that attention supplied when the child is n o t scratching, but engaged in some other behavior, may serve to reduce the overall level of child scratching through differential reinforcement of other behavior. Although the methodology used to predict child behavior is correlational (i.e., regression analysis) and causality cannot be inferred, several steps were taken in the development of the observation system to maximize the understanding of the nature of the relationship between child and parent behavior. The observation method used here was modeled after the interval sampiing/event recording method described by Roberts and Forehand (1978). In the observation system, the child problem behavior (B) and the parental response or the consequences that follow (C) were recorded in event sequences which implies an ordered and temporal relationship within the B-C chain (Roberts & Forehand, 1978). This procedure yields maximal information about specific behavior-consequence chains and thus helps identify the specific maladaptive parental responses that maintain problematic child behavior. A second interesting finding of this study was that the level of structure
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of the setting for the observation was related to both child and parent behaviors. During the structured task, children consistently engaged in lower levels of scratching-related behavior as compared to the unstructured task. There are several possible reasons for this. First, children may be distracted by the task and therefore do not scratch. Second, it is possible that differences in parental responding during the structured task influence the child behaviors. Children engage in scratching and rubbing during structured times; however, parents do not respond with physical contact, i.e., scratching, rubbing. Parents do supply higher levels of noncontingent attending during the structured task. It may be that this higher level of attending to the child's appropriate task-related behavior serves to reinforce appropriate (nonscratching) behavior in the child. This finding is consistent with Allen and Harris' (1966) finding that scratching behavior is reduced when parents ignore scratching and reinforce scratch-free periods. The third interesting finding in this study was the relationship between the child's demographic and medical status variables and the parent behaviors. Parent behavior was associated with one of the medical status variables (i.e., percentage of body area affected). Although there was a nonsignificant relationship between the percentage of body area affected and the child's scratchingrelated behavior, parents of children with more observable body area affected engaged in higher levels of scratching. There are several possible reasons for this. The percentage of body area affected is observable to parents. In the case of young children, parents administered much of the medical care of AD, such as the application of topical lubricating creams or topical medications. Parents also closely inspected the child's skin to determine the status of AD. It may be that areas of AD on the child's body serve as a discriminative cue to the parent to administer care and thus promote parent scratching. Another possibility is that parents of children with more broken-out skin engage in more behavior in order to provide comfort to the child and alleviate the child's complaints. Taken together, the results of this study have important implications for the behavioral assessment and treatment of scratching behavior in children with AD. First, in addition to the child's behavior, the parent's behavior is critical to examine. Although several previous studies (Cataldo et al., 1980; Rosenbaum & Ayllon, 1981) recognized the importance of direct observation of the patient behavior, parent-child interactions have not been systematically observed. The behavioral observation system described in this study provides a reliable way to assess child scratching-related behavior as well as the response of the parent. Problem child behaviors as well as target parent responses can then be identified, which will assist in intervention planning and treatment evaluation. Parent training techniques (Forehand & McMahon, 1981) can be used to alter parental responses. In particular, parents can be trained to: (1) decrease contingent attention for scratching-related behavior, as well as contingent physical contact when the child is scratching, (2) increase overall attention for other appropriate behavior, (3) verbally reinforce task involvement through direct praise, and (4) minimize attempts to directly stop the child by gestures, physical restraint, or verbal commands. An obvious future research
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effort would be to actually train parents in these strategies and observe the treatment effects. Although several well-controlled case studies have been conducted along these lines (Allen & Harris, 1966), controlled group designs are needed. Second, situational factors, such as the level of structure, are important to define when assessing scratching. Although prior studies have controlled observational setting features (e.g., Cataldo et al., 1980), these factors have not been systematically manipulated in order to observe the effects of this manipulation on scratching. A limitation which should be mentioned is that the process of observing parents and child interact may have influenced their behavior possibly by inducing anxiety. The order of the conditions, structured versus unstructured, was counterbalanced to minimize any differential effect of these other possible variables on observed scratching. Future studies should include an adaptation period when child and parents are exposed to the videotaping for a longer period of time before observations are scored as a way to minimize reactivity of the observation. It should also be noted that, in this study, observational sessions were conducted in the patient's hospital room and this setting parameter may also have an influence on parent-child interaction. The patient's room was selected for the observation because it was considered less obtrusive than moving the patient to a hospital laboratory setting. In the Clinical Research Unit at Duke, it is common for parents to stay with their child in his or her room during the hospital stay. Thus, it was the most "natural" place in the hospital for the child and parent to typically interact. Future studies might conduct observations in other settings, such as home and school, and evaluate scratching behaviors in these settings. It should be noted that the conclusions of this study are restricted in part by the setting in which the observation were conducted. The present research suggests that distraction may also be a way to minimize scratching behavior. The manipulation in this study was a relatively simple, naturally occurring event in most children's environment, that is, a structured interaction between child and parent. Training parents to structure activities such as building a model, especially at times of the day that the child is at risk for increased scratching (e.g., before bedtime), may be a relatively simple means to reduce scratching behavior in AD children. Distraction through activity scheduling may be an even more useful strategy with young children than other strategies that have been used with adults, such as training in biofeedback (Haynes et al., 1979) and habit-reversal methods (Rosenbaum & Ayllon, 1981), since learning these self-control strategies may be difficult for young children.
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Bar, L. H. J., & Kuypers, B. R. M. (1973). Behavior therapy in dermatological practice. British Journal of Dermatology, 88, 591-598. Blaylock, W. K. (1976). Atopic dermatitis: Diagnosis and pathobiology. Journal of Allergy and Clinical Immunology, 57, 62-79. Buckley, R. H. (1984). Allergic eczema, in V. C. Kelley (Ed.), Practices in pediatrics, (pp. 1-29). Philadelphia: Hayes and Row Publishers. Budd, K. S., Green D. R., & Baer, D. M. (1976). An analysis of multiple misplaced parental social contingencies. Journal of Applied Behavior Analysis, 9, 459-470. Busse, W. W., & Lee, T. P. (1976). Decreased adrenergic responses in lymphocytes and granulocytes in atopic eczema. Journal of Allergy and Clinical Immunology, 58, 586. Carson, J. S. (1981). The treatment of burns. London: Chapman & Hall. Cataldo, M. E, Varni, J. W., Russo, D. C., & Estes, S. A. (1980). Behavior therapy techniques in treatment of exfoliative dermatitis. Archives of Dermatology, 116, 919-922. Cohen, J., & Cohen, P. (1975). Applied multiple regression~correlational analysis for the behavioral sciences. New York: Wiley. Cooley, W. W., & Lohnes, P. R. (1971). Multivariate data analysis. New York: Wiley. Fabisch, W. (1980). Psychiatric aspects of dermatitis artefacta. British Journal of Dermatology, 102, 29-34. Faulstich, M. E., & Williamson D. A. (1985). An overview of atopic dermatitis: Towards a biobehavioral integration. Journal of Psychosomatic Research, 29, 647-654. Faulstich, M. E., Williamson, D. A., Duchmann, E. G., Conerly, S. L., & Brantley, P. J. (1985). Psychophysiological analysis of atopic dermatitis. Journal of Psychosomatic Research, 29, 415-417. Fava, G. A., Perini, G. I., Santonastaso, P., & Fornasa, C. V. (1980). Life events and psychological distress in dermatological disorders: Psoriasis, chronic urticaria and fungal infections. British Journal of Medical Psychology, 53, 277-282. Forehand, R. L., & McMahon, R. J. (1981). Helping the non-compliant child." A clinician's guide to parent training. New York: Guilford Press. Garrie, E. V., Garrie, S. A., & Mote, T. (1974). Anxiety and atopic dermatitis. Journal of Consuiting and Clinical Psychology, 42, 742. Gil, K. M., Keefe, E J., Sampson, H. A., McCaskill, C. C., Rodin, J., & Crisson, J. E., (1987). The relation of stress and family environment to atopic dermatitis symptoms in children. Journal of Psychosomatic Research, 31, 673-684. Gleich, G. J., Averbeck, A. K., & Swedlund, H. A. 0971). Measurement of IgE in normal and allergic serum by radioimmunoassay. Journal of Laboratory and Clinical Medicine, 77, 690-698. Hanifin, T. M., & Lobitz, W. C., Jr. (1977). Newer concepts of atopic dermatitis. Archives of Dermatology, 113, 663-670. Haynes, S. N., Wilson, C. C., Jaffe, P. G., & Britton, B. T. (1979). Biofeedback treatment of atopic dermatitis. Biofeedback & Self-Regulation, 4, 195-209. Herbert, E. W., & Baer, D. M. (1972). Training parents as behavior modifiers: Self-recording of contingent attention. Journal of Applied Behavior Analysis, 5, 130-144. Hughes, H. M., & Haynes, S. N. (1978). Structured laboratory observation in the behavioral assessment of parent-child interactions: A methodological critique. Behavior Therapy, 9, 428-447. Jordan, J. M., & Whitlock, E A. (1972). Emotions and the skin: The conditioning of scratch responses in cases of atopic dermatitis. British Journal of Dermatology, 86, 574-585. Lehman, R. E. (1978). Brief hypnotherapy of neurodermatitis: A case with four-year follow-up. The American Journal of Clinical Hypnosis, 21, 48-51. Patterson, G. R., & Reid, J. B. (1973). Intervention for families of aggressive boys: A replication study. Behaviour Research and Therapy, 11, 383-394.
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Roberts, M. W., & Forehand, R. (1978). The assessment of maladaptive parent-child interaction by direct observation: An analysis of methods. Journal o f Abnormal Child Psychology, 6, 257-270. Rosenbaum, M. S., & Ayllon, T. (1981). The behavioral treatment of neurodermatitis through habit reversal. Behaviour Research and Therapy, 19, 313-318. Sampson, H. A. (1983). Role of immediate food hypersensitivity in the pathogenesis of atopic dermatitis. Journal o f Allergy and Clinical Immunology, 71, 473-480. Sulzberger, M., & Herrmann, J. (1964). The clinical significance o f disturbances in the delivery o f sweat. Springfield: Thomas. Wilson, E. (1857). Diseases o f the skin. London: Churchill. RECEIVED: August 10, 1987 FINAL ACCEPTANCE: November 17, 1987