Treatment of Chronic Breath-Holding in an Adult with Severe Mental Retardation: A Clinical Case Study

Breath-holding spells, or BHS, are uncommon in children, observed in only 4.6% of the childhood population (DiMario, 2001). Individuals demonstrating breath-holding episodes may experience cyanosis and, in some cases, death resulting from complications related to loss of consciousness (Paulson, 1963). To date, no prevalence information is available concerning the occurrence of breath-holding spells in adults. Childhood occurrences of breath-holding typically dissipate before the age of 2, even when no treatment has been implemented (MedlinePlus, 2005). The U. S. National Library of Medicine (MedlinePlus, 2005) suggests that children typically engage in breath-holding as a response to fear, trauma, or some other startling event. Other research has also suggested that breath-holding in adults may result from other psychological conditions such as somataform disorder (Inagaki, et al., 2001). While the U. S. National Library of Medicine alludes to a psychological component (i.e., emotion) of breath-holding, recent research suggests an additional biomedical explanation. Specifically, Bhat and colleagues (2007) found 35 cases of anemia in a sample of 59 children exhibiting breath-holding spells. Both the anemic and non-anemic breath-holding children were given oral iron therapy for 12 weeks. Results of the study indicated a 77% reduction for the anemic breath holders, with only a 29% reduction for the non-anemic breath holders, suggesting a possible medical explanation for at least some cases of breath-holding. While these aforementioned psychological and medical conditions offer insight into what may have caused the initial breath-holding episodes, they do not explain the maintenance of breath-holding when these conditions are either (a) absent in the individual, or (b) ameliorated due to previous treatment. A plausible hypothesis for the maintenance of breath-holding episodes under such conditions may be that initial occurrences of breath-holding were reliably followed by certain social consequences in the individual's environment. Under this philosophical framework, the breath-holding individual may not necessarily be cognizant of his/her reasons for engaging in this behavior, but it may have been shaped or conditioned over time. In recent years, some researchers have begun speculating that breath-holding, in at least some individuals, may be under operant control (Kern, Mauk, Marder, & Mace, 1995; Richman, Lindauer, Crosland, McKerchar, & Morse, 2001; Singh, 1979). Thus, given the effective use of behavioral technologies, the operant relationships governing the occurrence of breath-holding may be modified with simple consequence-based procedures and/or antecedent manipulations. One of the first documented operant treatments for breath-holding was published by Singh in 1979. In this study, a 15 month old boy presented with severe breath-holding, which maintained even after medical and psychodynamic approaches to treatment. Singh's operant approach consisted of aromatic ammonia presented to the boy contingent upon breath-holding episodes. Following implementation of this procedure, the breath-holding behavior quickly reduced to zero levels and maintained over an additional year of observations. Despite this procedure's clear effect, its application in applied settings may be met with skepticism and low social validity due to its sole reliance on punitive consequences. Moreover, Singh's procedure did not reinforce or promote appropriate breathing, which would likely be more effective for long-term maintenance. Recent advances in behavioral technology have allowed clinicians to identify the possible maintaining functions of aberrant behavior. One such approach has been the use of systematic manipulations of environmental events conducted within a multi-element research design to quickly identify function while retaining experimental control during the assessment process (i. …