ERIC EJ853190: Chewing Gum as a Treatment for Rumination in a Child with Autism

2009·0.11 MB·English

by  ERIC

JOURNALOFAPPLIEDBEHAVIORANALYSIS 2009, 42, 381–385 NUMBER2 (SUMMER2009)
CHEWING GUM AS A TREATMENT FOR RUMINATION IN
A CHILD WITH AUTISM
DENISE RHINE AND JONATHAN TARBOX
CENTERFORAUTISMANDRELATEDDISORDERS
Rumination involves regurgitation of previously ingested food, rechewing the food, and
reswallowingit.Inthecurrentstudy,achildwithautismdisplayedchronicrumination,resulting
inthe decay andsubsequent removal ofseveral teeth. Afterseveral treatments failed, including
thickenedliquidsandstarchsatiation,theparticipantwastaughttochewgum.Hisrumination
decreasedsignificantlywhengumwasmadeavailable.Resultssuggestthataccesstochewinggum
maybean effectivetreatment for rumination insome individuals.
DESCRIPTORS: autism,chewing gum, rumination
_______________________________________________________________________________
Rumination involves regurgitation of previ- METHOD
ously ingested food, rechewing the food, and
Client and Setting
reswallowing it. The potential negative effects
Reggie was a 6-year-old boy with a diagnosis
on the quality of life of individuals who display
of autism who attended a home-based behav-
rumination include weight loss, malnutrition,
dental decay, halitosis, and electrolyte abnor- ioral intervention program for children with
malities (Chial, Camilleri, Williams, Litzinger, autism during afterschool hours. Reggie was
& Perrault, 2003). Early research on the able to communicate his basic needs via three-
reduction of rumination in individuals with to four-word mands; other than that, he
developmental disabilities often involved aver- engaged in very little unprompted speech.
sive procedures, such as contingent delivery of According to a recent language assessment
aversivetastes(Sajwaj,Libet,&Agras,1974).A (Preschool Language Scales–4), Reggie scored
small number of less aversive procedures (e.g., in the 1st percentile on expressive and receptive
starchsatiation)havealsobeendemonstratedto language, indicating a very significant language
be effective. Starch satiation involves giving an delay. According to parental report, Reggie had
individual unlimited access to starchy foods, been ruminating regularly throughout each day
typically immediately after meals, and has been for approximately 1 year, and there were no
demonstrated to be an effective treatment in specific activities in which rumination did not
several studies (e.g., Rast, Johnston, Drum, & occur. No formal data were collected to assess
Conrin, 1981), in some cases producing long- which contexts rumination occurred in most
lasting effects (Dunn, Lockwood, Williams, & frequently, but his caregivers reported that it
Peacock, 1997). In the current study, we occurred in the morning, evening, and after-
evaluated the effects of a novel treatment noon; both in school and at home; and during
procedure, access to chewing gum, on the both educational activities and play time.
rumination of a young boy with autism for Reggie’s dentist asserted that the decay caused
whom starch satiation was ineffective. by his rumination had necessitated the removal
of five of his teeth. Prior treatments for
We thank Jennifer Purcell for her assistance with data
rumination included thickening of liquids and
collection.
AddresscorrespondencetoJonathanTarbox,Centerfor starch satiation, neither of which produced a
Autism and Related Disorders, 19019 Ventura Blvd, 3rd reduction in rumination. In the current study,
Floor, Tarzana, California 91356 (e-mail: j.tarbox@
all intervention procedures were implemented
centerforautism.com).
doi:10.1901/jaba.2009.42-381 and all data were collected as a part of his
381
382 DENISE RHINE and JONATHAN TARBOX
regularly scheduled behavioral intervention 93%, (range, 0% to 100%; only one session
sessions, which occurred in his home. The produced an agreement of 0%, which consisted
primary therapeutic activities during his regular of theprimaryobservertallyingonerumination
behavioral intervention sessions consisted of in a 30-min session and the secondary observer
naturalistic and discrete-trial approaches to tallying none).
teaching a variety of adaptive skills, including
language, socialization, preacademic skills, and Experimental Design and Sequence
activities of daily living. These regularly sched- A multielement design was used to compare
uled therapeutic activities continued for the the effects of continuous noncontingent access
duration of the study, and all procedures were to chewing gum to the absence of gum. Blocks
implemented by his regular therapy team. of sessions were scheduled several times per
week,basedontherapistandparentavailability.
Response Measurement and For each block of sessions, a coin toss was used
Interobserver Agreement to determine the sequence of conditions within
Data were collected on the frequency of that block, with the rule that no condition
rumination throughout the study and were could be conducted more than three consecu-
summarized as an hourly rate. Rumination was tivetimes.Thesequenceof sessionswithineach
defined as the presence of food material in block of sessions was determined with a coin
Reggie’s mouth at a time other than when he toss so that inadvertent scheduling of particular
was eating. He was not prompted to open his conditions before or after meals could not bias
mouth in order to facilitate data collection; one condition or the other toward higher or
however, his mouth opened regularly through- lowerratesofrumination.Priortotheinitiation
out the day, typically to vocalize in some of the gum-chewing treatment, Reggie had
manner, so therapists were able to look into it reportedly never chewed gum and apparently
and observe regurgitated food frequently. did not possess the skill to do it (e.g., when
Reggie also frequently chewed and manipulated handed a piece of gum, he would look at it and
regurgitated food with his tongue, and his donothing).Therefore,beforethetherapyteam
mouth regularly opened during the course of initiated the gum-chewing treatment, the
such movements, thereby giving his therapists a speech and language pathologist in Reggie’s
natural opportunity to observe the presence or special education classroom designed and
absence of food. Data were collected on the implemented a skill-acquisition program to
presence of regurgitated food in the mouth, as teach him to chew gum. Instruction consisted
opposed to the act of regurgitating, because it of shaping the behavior by reinforcing compli-
was nearly impossible to detect regurgitation. ance with gradually increasing requirements,
Virtually no neck or head movement (i.e., starting with placing a piece of gum in the
retching) occurred when Reggie regurgitated. mouth, then biting it, then chewing it twice,
Twenty-two percent of sessions were video- andsoon,untilReggiewasabletochewapiece
taped, and a second observer viewed the of gum for several minutes.
videotapes at a later time and collected data
for the purposes of assessing interobserver Procedure
agreement. Interobserver agreement was calcu- During Sessions 1 through 17, in both gum-
lated using the total method, in which the chewing and no-gum conditions, the therapist
smaller frequency recorded across a whole gave Reggie a maintenance task, such as a book
session was divided by the larger frequency to look at or a worksheet to complete. The
recorded, and the resulting fraction was con- duration of these initial sessions depended on
verted to a percentage. Mean agreement was how long it took Reggie to complete the task
RUMINATION 383
Figure1. Hourlyratesofruminationingum-chewing(filledcircles)andno-gum(opensquares)conditions.Session
durationwasgraduallyincreasedto120minacrossthecourseoftreatment.Thefinalthreedatapointsrepresentfollow-
updataat 1,2, and3months posttreatment.
and ranged from approximately 3 min to noncompliant with the initial instruction to
approximately 10 min. Starting with Session chew the gum and rarely expelled the gum.
18,thedurationofsessionswasfixedat15 min The size of the piece of gum was gradually
and was then gradually increased to 120 min increased as session duration was increased,
over the course of the study. Sessions were movinguptoafullpieceofgumonSession27.
conducted 3 to 5 days per week, two to five Sessionsoftheno-gumconditionwereidentical
times per day. During gum-chewing sessions, in every way, except that Reggie was not given
Reggie’s therapist presented him with one gum to chew. Rumination produced no
quarter of a piece of chewing gum and told reaction from the therapists during any phase
him to chew it. If he did not accept the gum, of the study.
the therapist held it within 0.3 m of Reggie’s
mouth. The therapist again told him to chew
RESULTS AND DISCUSSION
the gum and repeated this prompt approxi-
matelyevery3 suntilReggieacceptedthegum. Figure 1 depicts rates of rumination in both
If he expelled the gum at any point during a the gum-chewing and no-gum conditions. The
session,thetherapistre-presentedthegum(orif gum-chewing condition produced consistently
the gum fell on the floor, the therapist re- lower rates of rumination than the no-gum
presented a fresh piece) and asked him to chew condition. Furthermore, rates of rumination
it. Systematic data were not collected on remainedlowwhenthedurationofsessionswas
compliance with the directive to chew gum, gradually increased to 120 min. Reggie contin-
but therapists reported that Reggie rarely was ued to demonstrate low rates of rumination
384 DENISE RHINE and JONATHAN TARBOX
duringfollow-upsessions at1,2,and3months therefore did not have the capacity to record
posttreatment.Hevisitedhisdentist1yearafter data across multiple intervals of short duration
this evaluation was completed, and his dentist (e.g., 10 s), as would be required for more
reported that Reggie’s tooth decay had ceased. stringent analyses. Due to the consistent and
This study provides initial evidence that often large differences in the rate of rumination
providing access to chewing gum may be an across conditions, we do not feel that any
effective treatment for reducing rumination in breachesinmeasurementagreementaffectedthe
some individuals with autism or other develop- validity of the relation demonstrated. Never-
mental disorders. Providing access to chewing theless, future research on treating rumination
gum is a relatively inexpensive, low-effort, and via chewing gum should attempt to employ
nonintrusive treatment. In addition, it may agreement procedures of greater rigor.
entail the ingestion of fewer calories than a Third, no systematic data were collected
starch satiation procedure in cases when while Reggie was initially taught how to chew
excessive weight gain is a concern. gum, and a precise technological description of
Several limitations of the current study the teaching procedure is not available. Thus,
warrant discussion. First, functional assessment replication of that procedure is likely to be
of challenging behaviors prior to implementa- difficult for future investigators. In future
tion of behavioral interventions is widely studies, researchers should document and
considered best practice (Hanley, Iwata, & provide a more technological description of
McCord, 2003), and we did not conduct a procedures used to teach gum chewing to
functional analysis of Reggie’s rumination prior facilitate replication.
to the intervention. The rumination displayed Fourth, the procedures used in this study do
by some individuals may be maintained by not allow any definitive conclusions regarding
automatic reinforcement; until recently, rumi- the behavioral processes that were responsible
nation research generally did not include for the reduction in rumination observed in the
functionalanalyses(foranexception,seeLyons, gum-chewing condition. It seems most likely
Rue, Luiselli, & DiGennaro, 2007), but the that chewing the gum produced an alternative
lack of a functional assessment in the current formoforalstimulationthatcompetedwiththe
study makes any assumption regarding main- oral stimulation produced by ruminating. This
taining reinforcers tenuous. However, the fact possible interpretation is supported by previous
that rumination did not decrease over the research on other automatically reinforced
course of 62 no-gum sessions, in which there behaviors that has shown that providing access
were never any socially mediated consequences to an alternative behavior that results in oral
for rumination, provides evidence that rumina- stimulation similar to that produced by the
tion was at least partially maintained by target problem behavior reduces the target
automatic consequences. behavior (Piazza et al., 1998).
Second, the method of interobserver agree- Finally, we did not extend the duration of
ment calculation employed in this study, the sessions beyond 120 min to an all-day analysis
total method, is generally considered to be of the effects of gum chewing on rumination
an insensitive measure of agreement (Repp, (see Lindberg, Iwata, Roscoe, Worsdell, &
Deitz,Boles,Deitz,&Repp,1976).Weelected Hanley, 2003, for an example of this sort of
tousetotalagreementbecausethetherapistwho temporally extended evaluation). Nevertheless,
collected data was also responsible for the the use of 120-min sessions may be viewed as a
implementation of teaching trials and data strength of the current study, considering the
collection for a variety of other behaviors, and common practice of 10- or 15-min session
RUMINATION 385
durations common in applied behavioral re- Dunn,J.,Lockwood,K.,Williams,D. E.,&Peacock,S.
(1997).Aseven-yearfollowupoftreatingrumination
search. Chewing gum also may not be a viable
with dietary satiation. Behavioral Interventions, 12,
interventionduringmanyeducationalactivities, 163–172.
inwhichthepresenceofguminthemouthmay Hanley, G. P., Iwata, B. A., & McCord, B. (2003).
interfere with oral motor activities (i.e., those Functional analysis of problem behavior: A review.
Journal ofAppliedBehavior Analysis, 36,147–186.
that require vocal behavior). Although no
Lindberg,J.S.,Iwata,B.A.,Roscoe,E.M.,Worsdell,A.
formal data were collected to evaluate this S., & Hanley, G. P. (2003). Treatment efficacy of
possible relation, a large proportion of Reggie’s noncontingent reinforcement during brief and ex-
tended application. Journal of Applied Behavior
educational activities that occurred during this
Analysis,36,1–19.
study required vocal responses on his part, and
Lyons,E.A.,Rue,H.C.,Luiselli,J.K.,&DiGennaro,F.
his therapists did not report any increased D.(2007).Brieffunctionalanalysisandsupplemental
difficultieswiththesetasksduringgum-chewing feeding for postmeal rumination in children with
developmentaldisabilities.JournalofAppliedBehavior
sessions.
Analysis,40,743–747.
In conclusion, the primary contribution of Piazza, C.C., Fisher, W.W.,Hanley, G.P.,LeBlanc,L.
this study is that a treatment for intractable A., Wordsell, A. S., Lindauer, S. E., et al. (1998).
Treatment of pica through multiple analyses of its
rumination that was novel, nonintrusive, and
reinforcing functions. Journal of Applied Behavior
highly effective for our participant was identi-
Analysis,14,121–130.
fied. Future researchers should continue to Rast,J.,Johnston,J.M.,Drum,C.,&Conrin,J.(1981).
investigate treatments for rumination that are Therelationoffoodquantitytoruminationbehavior.
Journal ofAppliedBehavior Analysis, 14, 121–130.
practicalinreal-lifesettingsandshouldbeginto
Repp,A.C.,Deitz,D.E.D.,Boles,S.M.,Deitz,S.M.,
identify the behavioral processes that occur & Repp, C. F. (1976). Differences among common
when these interventions effect appreciable methods for calculating interobserver agreement.
Journal ofAppliedBehavior Analysis, 9,109–113.
changes in rumination.
Sajwaj, T., Libet, J., & Agras, S. (1974). Lemon-juice
therapy:Thecontroloflife-threateningruminationin
a six-month-old infant. Journal of Applied Behavior
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