- Email: [email protected]
Differential reinforcement of other behaviors to treat chronic rumination of mental retardates
J. Behav. Thu. & Exp. Psychial. Vol. 13, No. 4, pp. 325.329, Printed in Great Britain.
1982
OCNX-7916/82/040325-05 $03.00/O 1982 Pergamon Press Ltd.
D1IFFERENTIAL REINFORCEMENT CHRONIC
OF OTHER BEHAVIORS
RUMINATION
OF MENTAL
JAMES CONRIN, H. S. PENNYPACKER, The University
of Florida,
JAMES JOHNSTON
Tinley Park
Mental
TO TREAT
RETARDATES
Health
and JAMES RAST
Center
Summary-Food rumination is a maladaptive, life-threatening behavior observed among infants and institutional populations for the mentally retarded. Differential reinforcement of other behaviors (IRT > LV) was experimentally studied as a method of reducing this behavior. Two mentally retarded clients emitted reduced rumination behaviors after implementation of the differential reinforcement procedure.
which preceded emesis. A shock administration belt was used by Galbraith, Byrick and Rutledge (1970) to eliminate chronic vomiting by a retardate. Lang and Melamed (1969) reported successful reduction of rumination by applying an electric shock contingent upon each rumination. Alteration of feeding methods has also been reported to be successful in reducing rumination (Ball, Hendricksen and Clayton, 1974). The reliance on aversive techniques to reduce rumination in the preceding studies poses ethical and legal problems in view of current statutes, resident bills of rights, and litigation regarding treatment of the mentally retarded. An alternative to punishment procedures seems appropriate as indicated in the study by Ball et al. (1974). This provided an example of successful results with a non-aversive procedure and a minimal amount of staff time when consideration was given ‘to the severity of the problem.
Rumination as a behavior problem among retardates can generally be described as emesis of previously ingested food, then chewing the food, and re-swallowing it. Rumination interferes with the digestive process by removing food from the stomach repeatedly before it can be digested. The retardate who chronically ruminates engages in a potentially lethal health hazard due to dehydration and malnutrition. Ball, Hendrickson and Clayton (1974) cited a study of California state hospital clients which indicated an incidence of 9.3% of vomiting not associated with illness or temperature. About 5.3% of clients exhibited moderate or severe vomiting problems. A 1979 survey of clients at Sunland Center, Gainesville, indicated that approximately 3% of clients exhibited rumination. Treatment of rumination has been approached from a psychoanalytic perspective (Wright and Menolascino, 1966). Contingency management procedures have also been utilized in treating rumination. Electric shock given after emesis resulted in almost total elimination of emesis within 5 days of treatment (Toister et al., 1975). Libet, Sajwaj and Agras (1973) eliminated persistent vomiting in a six-month-old infant by oral administration of lemon juice contingent on precurrent rolling motions of the tongue Requests for reprints should be addressed Pales Heights, Illinois 60463, U.S.A.
to James
Subjects
METHOD
John was a 23-yr-old non-verbal, blind and scoliotic male who was diagnosed as profoundly mentally retarded with an adaptive level of 5 (AAMD). He had ruminated for several years and weighed 79 pounds at the beginning of baseline, about 40 pounds under his estimated ideal weight range.
Conrin,
325
Pales
Neuropsychratric
Institute,
7600 W. College
Drive,
326
JAMES
CONRIN,
H. S. PENNYPACKER,
Bob was a 19-yr-old male about 53” tall and weighed 56 pounds at the beginning of baseline. No specific cause of developmental disability had been determined. Rumination first appeared at age 2 yr and continued thereafter. Bob was also diagnosed as profoundly mentally retarded, adaptive level 5. Staff reported that both clients began ruminating immediately after meals and continued to do so for a couple of hours. In addition, Bob was reported to vomit and expel all his food several times per week at various times after meals. Staff felt that liquids with meals aggravated the problem and accordingly presented Bob’s liquids between meals. Both clients were observed informally by the consultant during and after several meals prior to baseline. In addition, informational discussions were held with staff to familiarize the consultant with both clients prior to baseline.
Data collection The basic data collection procedure involved observations after breakfast, lunch and dinner. As soon as the meal was completed, the trainer seated the client in a lounge chair or at a dining table. A stop watch was used to record the cumulative duration of rumination during the session. The total duration was recorded at the end of the session, also any observations of unusual behaviors such as crying, hitting others, or self-injurious behaviors. The general topography of the clients’ rumination involved an observable swelling of the cheeks and obvious chewing movements. The rumination was sometimes preceded by a bobbing of the head and upper body. Each episode of rumination was followed by swallowing in which a movement of the Adam’s apple occurred and the cheek swelling subsided. Observers were instructed to begin timing as soon as swelling of the cheeks occurred and to stop when the client swallowed.
Baseline Baseline observations were conducted for % hr after meals for John and for 1 hr after meals for Bob. During baseline, observers only recorded the rumination which occurred and made no effort to disrupt it. After formal observation sessions, staff were asked to observe the client informally and to report an estimated duration of rumination, though data were not collected. Staff were also directed to record whenever Bob completely vomitted his food, regardless of the time of day.
Treatment The general setting was the same as during baseline. Modification was scheduled after each meal on the regular workdays of the trainers. During modification, each trainer adhered to the following procedure. Upon removal of the dishes, staff escorted the client either to another table or to the cottage lounge. The data sheet, watch and edible reinforcers were prepared in advance so that the session could begin immediately after the meal. After seating the client, the trainer sat down within a few feet to the side or front of the client. Direct visual contact was maintained at all times. Whenever cheek swelling indicated the beginning of rumination, the trainer
JAMES
JOHNSTON
and JAMES
RAST
started the watch. Timing was stopped when chewing stopped and swallowing occurred. In Bob’s case, an entry was also made on a wrist-counter since his frequency as well as duration of rumination was being monitored. A differential reinforcement of other behaviors (DRO) procedure was implemented to reduce rumination. Baseline observations indicated that Bob initiated rumination as often as every 15 sec. John did not ruminate frequently, but each instance was of much longer duration. There were intervals of more than 20 or 30 set between rarely individual episodes of John’s rumination. Due to the high frequencies and durations of rumination, a DRO schedule of inter-response time greater than 10 set (IRT > 10 set) was implemented for both clients. This provided deliveries of food at sufficient frequency to maintain some food in the clients’ mouths almost continuously in addition to providing a consequence for appropriate behavior. Small pieces of cookie or bits of peanut butter presented on the end of a spoon were used as reinforcers for no rumination. The trainer terminated sessions after 1 hr in Bob’s program and after % hr in John’s program. Longer sessions were held for Bob since sometimes he vomited his food completely. Longer sessions allowed more time for digestion so less food was lost if he vomited after the session. The experimenter observed the projects, checked data and discussed program procedures with the trainers weekly. Changes in the reinforcement schedule were discussed, as were any client health problems. Changes in the schedule of reinforcement were made after observations had indicated no problem with rumination for several days. Reliability observations were held twice during baseline and weekly during modification. For frequency counts, reliability was calculated by the following formula: Reliability Agreements/Agreements + Disagreements. averaged 93% across the observations of frequency and ranged from 86 to 100%. For duration measures, overall durations of rumination observed by the two observers were simply compared, then the shorter duration was divided by the longer. Reliability on duration measures ranged from 94 to 100% and averaged 97%.
RESULTS Baseline data indicated that John ruminated about 30 min per session. Treatment produced an immediate reduction of rumination to less than a minute per half hour session for all but 4 of the first 82 sessions. The schedule of reinforcement was attenuated from IRT > 15 set to IRT > 10 min during the course of treatment. Rumination remained near zero throughout the modification phase. Rumination of at least 1 min occurred during 9 of 17 reversal sessions. Two minutes or more of rumination occurred during four reversal sessions.
RUMINATION
Resumption of an IRT > 2 min schedule decreased rumination to near zero duration again. Rumination averaged about 11 set per session when the schedule was changed to IRT > 10 min. More frequent sessions of no rumination occurred after 30 sessions of IRT > 10 min reinforcement. John’s weight increased from 79 pounds during baseline to 111 pounds by the end of the program. Table 1. Mean durations and standard rumination per session by John experimental phase
deviations of during each
Condition
Mean
S.D.
Baseline IRT > 15’ IRT > 1’ IRT > 2’ IRT > 5’ IRT > 10’ Reversal IRT > 2’ IRT > 5’ IRT > 10’
1758.0” 30.4” 22.5” 16.8” 7.1” 11.7” 55.0” 16.7” 7.3” 10.6”
25.1” 45.4” 34.0” 14.6” 18.3” 28.2” 49.0” 19.2” 10.9” 29.2”
Bob’s rumination averaged almost 7 min per session for baseline sessions. Durations up to 22 min occurred during 4 sessions. Frequencies of rumination were also recorded since Bob’s rumination consisted of brief but repeated episodes. Bob’s rumination frequencies were 56-417 individual episodes of rumination per hour. Table 2. Mean frequencies and standard deviations of rumination per session by Bob during each experimental phase Condition
Mean
S.D.
Baseline IRT > 15” IRT > 30” IRT > 60” Reversal IRT > 30”
202.0 4.4 0 0 33.7 0.2
104.2 6.1 0 0 55.3 0.4
Treatment produced a reduction in rumination to zero frequency and duration after the first 18 sessions. Rumination remained at or near zero for 65 modification sessions.
321 Table 3. Mean durations and standard rumination per session by Bob experimental phase Condition Baseline IRT > 15” IRT > 30” IRT > 60” Reversal IRT > 30”
Mean 644.0” 11 .O” 0.0” 0.0” 162.0” 0.4”
deviations of during each
S.D. 356.0” 33.9” 0 ” 0 ” 208.0” 1 .O”
During reversal, rumination increased after the first five reversal sessions. Rumination of more than a minute occurred during 6 of 18 reversal sessions and approached 10 minutes per session just prior to reimplementation of treatment. Rumination decreased to zero of upon reimplementation or near-zero reinforcement on a schedule of IRT > 30 sec.
DISCUSSION One can only speculate about physiological or external environmental conditions that initially produce and then maintain rumination. This behavior problem is relatively uncommon among retarded clients. However, a client who does ruminate interferes with normal food digestion and nutrient utilization. A ruminating client will typically be severely underweight and possibly dehydrated. An especially serious and potentially fatal condition occurs where a ruminating client contracts a disease which causes a high fever or severe diarrhea. The sudden dehydration and physiological strain combined with malnutrition may cause death. This study involved applying a schedule of positive reinforcement as a method of controlling rumination. In both cases, the DRO schedule produced rapid reduction in rumination. The use of edible reinforcers in a very dense schedule also may have simply substituted an external food source for the internal food source involved in rumination. Gradually attenuating the schedule reduced the frequency and amount of food presented but did not produce increased rumination.
328
JAMES
CONRIN,
H. S. PENNYPACKER,
JAMES
JOHNSTON IRT
,ooo_BL
, IRT
15”
IRT
and JAMES
60”
30”
IRT
BL I
Oo”‘L~L I
0
IO
I
-L--i-
il_~
20
30
40
50
60
1. Count
per minute
90
IL A-A_-_1 100
of ruminations
after
60’ ”
I
0
Ill IO
20
I 30
I 40
I 50
11
1 60
70
Successive
Fig. 2. Duration
I
Ill 80
II0 I20
130
I40
90
100
meals
BL
Ill HO
by Bob.
IRT>30”
120
I 130
I 140
meals
of ruminations
However, withdrawal of the edible reinforcer did increase rumination and its reinstatement decreased it again. Simply presenting food noncontingently may have had the same effect. However, one would expect rumination to increase with longer intervals between reinforcers if external food simply substituted for internal food. The fact that rumination did
30”
I
meals
Succewve
Fig.
1 :
1 80
70
RAST
after meals by Bob.
not significantly with increase longer reinforcement intervals suggests that contingent presentation of food was a critical aspect of the procedure. In summary, presenting edible reinforcement contingent on other behaviors was successful in reducing rumination. This may be a rapid and easily implemented, nonaversive procedure
329
RUMINATION IRTH5’
IRT>Z’ ?T>
I’
R5>5’
EIL
I RTzIO’
lRT>Z
IRT
>5’
IRT>lO’
1
Fig. 3. Duration
of ruminations
which can be used by paraprofessional staff. Further research is needed concerning the variables contributing to the development and maintenance of rumination and related behaviors.
I
I
I
140
150
I60
‘0
/
1
180
190
1 200
after meals by John.
Williams
M. and
Conrin
J. (June,
1979) Assessing
Effects of Antecedent Environmental Events Behavior, Paper presented at the meeting of Association Michigan.
for Apolied
Behavior
Analysis,
the on
the Dearborn,
__
REFERENCES
REFERENCE
NOTES
Jackson G. M, Johnson C. R., Ackron G. S. and Crowley R. (1975) Food satiation as a procedure to decelerate vomiting, Am. J. Ment. Defic. 80, 223-227. Johnston J. M. and Pennypacker H. S. (1980) Strategies and Tactics of Human Research, Lawrence Erlbaum Associates, Hillsdale, N.J. Kohlenberg R. J. (1970) The punishment of persistent vomiting: A case study, J. Appl. Behav. Anal. 3,
241-245. Luckey R. E., Watson C. M. and Musick J. N. (1968) Aversive conditioning as a means of inhibiting vomiting and rumination, Am. J. Ment. Defic. 73, 139-142. Pennypacker H. S., Koenig C. H. and Lindsley 0. R. (1972) Handbook of the Standard Behavior Chart, Precision Media, Kansas City, KS. Sajwaj T., Libet J. and Agras S. (1974) Lemon juice therapy: The control of life threatening rumination in a six month old infant, J. Appl. Behav. Anal. I, 557-563. White J. C., Jr. and Taylor D. T. (1967) Noxious conditioning as a treatment for rumination, Ment.
Retard. 5, 30-33.
Ball T. S., Hendricksen H. and Clayton J. (1974) A special feeding technique for chronic regurgitation, Am. J.
Ment. Defic. 78 (4), 486-493. Galbraith D. A., Byrick R. J. and Rutledge J. T. (1970) An aversive conditioning approach to the inhibition of chronic vomiting, Can. Psychiat. Ass. J. 15(3), 3 1 l-3 13. Kanner L. (1957) Child Psychiatry, (3rd edn.) Charles C. Thomas, Springfield, Ill. Lang P. J. and Melamed B. G. (1969) Case report: Avoidance conditioning therapy of an infant with chronic ruminative vomiting, J. Abnorm. Psycho/. 74 (l), l-8. Libet J. M., Sajwaj T. and Agras W. S. (1973) Elimination of persistent vomiting in an infant by response contingent punishment using lemon juice, American Psychological Association, Slst Annual Convention. State of Florida Department of Health and Rehabilitative Services (1978) Behavior Management. Toister R. P., Condron C. J., Worley L. and Arthur D. (1975) Faradic therapy of chronic vomiting in infancy: A case study, J. Behav. Ther. Exp. Psychiat. 6,55-59. Wright M. M. and Menolascino F. J. (1966) Nurturant nursing of mentally retarded ruminators, Am. J. Ment. Defic. 71 (3), 451-459.
1982
OCNX-7916/82/040325-05 $03.00/O 1982 Pergamon Press Ltd.
D1IFFERENTIAL REINFORCEMENT CHRONIC
OF OTHER BEHAVIORS
RUMINATION
OF MENTAL
JAMES CONRIN, H. S. PENNYPACKER, The University
of Florida,
JAMES JOHNSTON
Tinley Park
Mental
TO TREAT
RETARDATES
Health
and JAMES RAST
Center
Summary-Food rumination is a maladaptive, life-threatening behavior observed among infants and institutional populations for the mentally retarded. Differential reinforcement of other behaviors (IRT > LV) was experimentally studied as a method of reducing this behavior. Two mentally retarded clients emitted reduced rumination behaviors after implementation of the differential reinforcement procedure.
which preceded emesis. A shock administration belt was used by Galbraith, Byrick and Rutledge (1970) to eliminate chronic vomiting by a retardate. Lang and Melamed (1969) reported successful reduction of rumination by applying an electric shock contingent upon each rumination. Alteration of feeding methods has also been reported to be successful in reducing rumination (Ball, Hendricksen and Clayton, 1974). The reliance on aversive techniques to reduce rumination in the preceding studies poses ethical and legal problems in view of current statutes, resident bills of rights, and litigation regarding treatment of the mentally retarded. An alternative to punishment procedures seems appropriate as indicated in the study by Ball et al. (1974). This provided an example of successful results with a non-aversive procedure and a minimal amount of staff time when consideration was given ‘to the severity of the problem.
Rumination as a behavior problem among retardates can generally be described as emesis of previously ingested food, then chewing the food, and re-swallowing it. Rumination interferes with the digestive process by removing food from the stomach repeatedly before it can be digested. The retardate who chronically ruminates engages in a potentially lethal health hazard due to dehydration and malnutrition. Ball, Hendrickson and Clayton (1974) cited a study of California state hospital clients which indicated an incidence of 9.3% of vomiting not associated with illness or temperature. About 5.3% of clients exhibited moderate or severe vomiting problems. A 1979 survey of clients at Sunland Center, Gainesville, indicated that approximately 3% of clients exhibited rumination. Treatment of rumination has been approached from a psychoanalytic perspective (Wright and Menolascino, 1966). Contingency management procedures have also been utilized in treating rumination. Electric shock given after emesis resulted in almost total elimination of emesis within 5 days of treatment (Toister et al., 1975). Libet, Sajwaj and Agras (1973) eliminated persistent vomiting in a six-month-old infant by oral administration of lemon juice contingent on precurrent rolling motions of the tongue Requests for reprints should be addressed Pales Heights, Illinois 60463, U.S.A.
to James
Subjects
METHOD
John was a 23-yr-old non-verbal, blind and scoliotic male who was diagnosed as profoundly mentally retarded with an adaptive level of 5 (AAMD). He had ruminated for several years and weighed 79 pounds at the beginning of baseline, about 40 pounds under his estimated ideal weight range.
Conrin,
325
Pales
Neuropsychratric
Institute,
7600 W. College
Drive,
326
JAMES
CONRIN,
H. S. PENNYPACKER,
Bob was a 19-yr-old male about 53” tall and weighed 56 pounds at the beginning of baseline. No specific cause of developmental disability had been determined. Rumination first appeared at age 2 yr and continued thereafter. Bob was also diagnosed as profoundly mentally retarded, adaptive level 5. Staff reported that both clients began ruminating immediately after meals and continued to do so for a couple of hours. In addition, Bob was reported to vomit and expel all his food several times per week at various times after meals. Staff felt that liquids with meals aggravated the problem and accordingly presented Bob’s liquids between meals. Both clients were observed informally by the consultant during and after several meals prior to baseline. In addition, informational discussions were held with staff to familiarize the consultant with both clients prior to baseline.
Data collection The basic data collection procedure involved observations after breakfast, lunch and dinner. As soon as the meal was completed, the trainer seated the client in a lounge chair or at a dining table. A stop watch was used to record the cumulative duration of rumination during the session. The total duration was recorded at the end of the session, also any observations of unusual behaviors such as crying, hitting others, or self-injurious behaviors. The general topography of the clients’ rumination involved an observable swelling of the cheeks and obvious chewing movements. The rumination was sometimes preceded by a bobbing of the head and upper body. Each episode of rumination was followed by swallowing in which a movement of the Adam’s apple occurred and the cheek swelling subsided. Observers were instructed to begin timing as soon as swelling of the cheeks occurred and to stop when the client swallowed.
Baseline Baseline observations were conducted for % hr after meals for John and for 1 hr after meals for Bob. During baseline, observers only recorded the rumination which occurred and made no effort to disrupt it. After formal observation sessions, staff were asked to observe the client informally and to report an estimated duration of rumination, though data were not collected. Staff were also directed to record whenever Bob completely vomitted his food, regardless of the time of day.
Treatment The general setting was the same as during baseline. Modification was scheduled after each meal on the regular workdays of the trainers. During modification, each trainer adhered to the following procedure. Upon removal of the dishes, staff escorted the client either to another table or to the cottage lounge. The data sheet, watch and edible reinforcers were prepared in advance so that the session could begin immediately after the meal. After seating the client, the trainer sat down within a few feet to the side or front of the client. Direct visual contact was maintained at all times. Whenever cheek swelling indicated the beginning of rumination, the trainer
JAMES
JOHNSTON
and JAMES
RAST
started the watch. Timing was stopped when chewing stopped and swallowing occurred. In Bob’s case, an entry was also made on a wrist-counter since his frequency as well as duration of rumination was being monitored. A differential reinforcement of other behaviors (DRO) procedure was implemented to reduce rumination. Baseline observations indicated that Bob initiated rumination as often as every 15 sec. John did not ruminate frequently, but each instance was of much longer duration. There were intervals of more than 20 or 30 set between rarely individual episodes of John’s rumination. Due to the high frequencies and durations of rumination, a DRO schedule of inter-response time greater than 10 set (IRT > 10 set) was implemented for both clients. This provided deliveries of food at sufficient frequency to maintain some food in the clients’ mouths almost continuously in addition to providing a consequence for appropriate behavior. Small pieces of cookie or bits of peanut butter presented on the end of a spoon were used as reinforcers for no rumination. The trainer terminated sessions after 1 hr in Bob’s program and after % hr in John’s program. Longer sessions were held for Bob since sometimes he vomited his food completely. Longer sessions allowed more time for digestion so less food was lost if he vomited after the session. The experimenter observed the projects, checked data and discussed program procedures with the trainers weekly. Changes in the reinforcement schedule were discussed, as were any client health problems. Changes in the schedule of reinforcement were made after observations had indicated no problem with rumination for several days. Reliability observations were held twice during baseline and weekly during modification. For frequency counts, reliability was calculated by the following formula: Reliability Agreements/Agreements + Disagreements. averaged 93% across the observations of frequency and ranged from 86 to 100%. For duration measures, overall durations of rumination observed by the two observers were simply compared, then the shorter duration was divided by the longer. Reliability on duration measures ranged from 94 to 100% and averaged 97%.
RESULTS Baseline data indicated that John ruminated about 30 min per session. Treatment produced an immediate reduction of rumination to less than a minute per half hour session for all but 4 of the first 82 sessions. The schedule of reinforcement was attenuated from IRT > 15 set to IRT > 10 min during the course of treatment. Rumination remained near zero throughout the modification phase. Rumination of at least 1 min occurred during 9 of 17 reversal sessions. Two minutes or more of rumination occurred during four reversal sessions.
RUMINATION
Resumption of an IRT > 2 min schedule decreased rumination to near zero duration again. Rumination averaged about 11 set per session when the schedule was changed to IRT > 10 min. More frequent sessions of no rumination occurred after 30 sessions of IRT > 10 min reinforcement. John’s weight increased from 79 pounds during baseline to 111 pounds by the end of the program. Table 1. Mean durations and standard rumination per session by John experimental phase
deviations of during each
Condition
Mean
S.D.
Baseline IRT > 15’ IRT > 1’ IRT > 2’ IRT > 5’ IRT > 10’ Reversal IRT > 2’ IRT > 5’ IRT > 10’
1758.0” 30.4” 22.5” 16.8” 7.1” 11.7” 55.0” 16.7” 7.3” 10.6”
25.1” 45.4” 34.0” 14.6” 18.3” 28.2” 49.0” 19.2” 10.9” 29.2”
Bob’s rumination averaged almost 7 min per session for baseline sessions. Durations up to 22 min occurred during 4 sessions. Frequencies of rumination were also recorded since Bob’s rumination consisted of brief but repeated episodes. Bob’s rumination frequencies were 56-417 individual episodes of rumination per hour. Table 2. Mean frequencies and standard deviations of rumination per session by Bob during each experimental phase Condition
Mean
S.D.
Baseline IRT > 15” IRT > 30” IRT > 60” Reversal IRT > 30”
202.0 4.4 0 0 33.7 0.2
104.2 6.1 0 0 55.3 0.4
Treatment produced a reduction in rumination to zero frequency and duration after the first 18 sessions. Rumination remained at or near zero for 65 modification sessions.
321 Table 3. Mean durations and standard rumination per session by Bob experimental phase Condition Baseline IRT > 15” IRT > 30” IRT > 60” Reversal IRT > 30”
Mean 644.0” 11 .O” 0.0” 0.0” 162.0” 0.4”
deviations of during each
S.D. 356.0” 33.9” 0 ” 0 ” 208.0” 1 .O”
During reversal, rumination increased after the first five reversal sessions. Rumination of more than a minute occurred during 6 of 18 reversal sessions and approached 10 minutes per session just prior to reimplementation of treatment. Rumination decreased to zero of upon reimplementation or near-zero reinforcement on a schedule of IRT > 30 sec.
DISCUSSION One can only speculate about physiological or external environmental conditions that initially produce and then maintain rumination. This behavior problem is relatively uncommon among retarded clients. However, a client who does ruminate interferes with normal food digestion and nutrient utilization. A ruminating client will typically be severely underweight and possibly dehydrated. An especially serious and potentially fatal condition occurs where a ruminating client contracts a disease which causes a high fever or severe diarrhea. The sudden dehydration and physiological strain combined with malnutrition may cause death. This study involved applying a schedule of positive reinforcement as a method of controlling rumination. In both cases, the DRO schedule produced rapid reduction in rumination. The use of edible reinforcers in a very dense schedule also may have simply substituted an external food source for the internal food source involved in rumination. Gradually attenuating the schedule reduced the frequency and amount of food presented but did not produce increased rumination.
328
JAMES
CONRIN,
H. S. PENNYPACKER,
JAMES
JOHNSTON IRT
,ooo_BL
, IRT
15”
IRT
and JAMES
60”
30”
IRT
BL I
Oo”‘L~L I
0
IO
I
-L--i-
il_~
20
30
40
50
60
1. Count
per minute
90
IL A-A_-_1 100
of ruminations
after
60’ ”
I
0
Ill IO
20
I 30
I 40
I 50
11
1 60
70
Successive
Fig. 2. Duration
I
Ill 80
II0 I20
130
I40
90
100
meals
BL
Ill HO
by Bob.
IRT>30”
120
I 130
I 140
meals
of ruminations
However, withdrawal of the edible reinforcer did increase rumination and its reinstatement decreased it again. Simply presenting food noncontingently may have had the same effect. However, one would expect rumination to increase with longer intervals between reinforcers if external food simply substituted for internal food. The fact that rumination did
30”
I
meals
Succewve
Fig.
1 :
1 80
70
RAST
after meals by Bob.
not significantly with increase longer reinforcement intervals suggests that contingent presentation of food was a critical aspect of the procedure. In summary, presenting edible reinforcement contingent on other behaviors was successful in reducing rumination. This may be a rapid and easily implemented, nonaversive procedure
329
RUMINATION IRTH5’
IRT>Z’ ?T>
I’
R5>5’
EIL
I RTzIO’
lRT>Z
IRT
>5’
IRT>lO’
1
Fig. 3. Duration
of ruminations
which can be used by paraprofessional staff. Further research is needed concerning the variables contributing to the development and maintenance of rumination and related behaviors.
I
I
I
140
150
I60
‘0
/
1
180
190
1 200
after meals by John.
Williams
M. and
Conrin
J. (June,
1979) Assessing
Effects of Antecedent Environmental Events Behavior, Paper presented at the meeting of Association Michigan.
for Apolied
Behavior
Analysis,
the on
the Dearborn,
__
REFERENCES
REFERENCE
NOTES
Jackson G. M, Johnson C. R., Ackron G. S. and Crowley R. (1975) Food satiation as a procedure to decelerate vomiting, Am. J. Ment. Defic. 80, 223-227. Johnston J. M. and Pennypacker H. S. (1980) Strategies and Tactics of Human Research, Lawrence Erlbaum Associates, Hillsdale, N.J. Kohlenberg R. J. (1970) The punishment of persistent vomiting: A case study, J. Appl. Behav. Anal. 3,
241-245. Luckey R. E., Watson C. M. and Musick J. N. (1968) Aversive conditioning as a means of inhibiting vomiting and rumination, Am. J. Ment. Defic. 73, 139-142. Pennypacker H. S., Koenig C. H. and Lindsley 0. R. (1972) Handbook of the Standard Behavior Chart, Precision Media, Kansas City, KS. Sajwaj T., Libet J. and Agras S. (1974) Lemon juice therapy: The control of life threatening rumination in a six month old infant, J. Appl. Behav. Anal. I, 557-563. White J. C., Jr. and Taylor D. T. (1967) Noxious conditioning as a treatment for rumination, Ment.
Retard. 5, 30-33.
Ball T. S., Hendricksen H. and Clayton J. (1974) A special feeding technique for chronic regurgitation, Am. J.
Ment. Defic. 78 (4), 486-493. Galbraith D. A., Byrick R. J. and Rutledge J. T. (1970) An aversive conditioning approach to the inhibition of chronic vomiting, Can. Psychiat. Ass. J. 15(3), 3 1 l-3 13. Kanner L. (1957) Child Psychiatry, (3rd edn.) Charles C. Thomas, Springfield, Ill. Lang P. J. and Melamed B. G. (1969) Case report: Avoidance conditioning therapy of an infant with chronic ruminative vomiting, J. Abnorm. Psycho/. 74 (l), l-8. Libet J. M., Sajwaj T. and Agras W. S. (1973) Elimination of persistent vomiting in an infant by response contingent punishment using lemon juice, American Psychological Association, Slst Annual Convention. State of Florida Department of Health and Rehabilitative Services (1978) Behavior Management. Toister R. P., Condron C. J., Worley L. and Arthur D. (1975) Faradic therapy of chronic vomiting in infancy: A case study, J. Behav. Ther. Exp. Psychiat. 6,55-59. Wright M. M. and Menolascino F. J. (1966) Nurturant nursing of mentally retarded ruminators, Am. J. Ment. Defic. 71 (3), 451-459.