ERIC EJ964450: Direct and Distal Effects of Noncontingent Juice on Rumination Exhibited by a Child with Autism

2011·0.2 MB·English

by  ERIC

JOURNALOFAPPLIEDBEHAVIORANALYSIS 2011, 44, 955–959 NUMBER4 (WINTER2011)
DIRECT AND DISTAL EFFECTS OF NONCONTINGENT JUICE ON
RUMINATION EXHIBITED BY A CHILD WITH AUTISM
MEGAN L. KLIEBERT AND JEFFREY H. TIGER
LOUISIANASTATEUNIVERSITY
Previous research has demonstrated the efficacy of the noncontingent delivery of foods and
liquidsatsuppressingrumination,therepeatedregurgitationandrechewingofpartiallydigested
food.However,itisunclearhowlongthisreductionismaintainedaftercaregiversterminatethis
procedure. The current study examined the direct and distal effects of noncontingent juice on
rumination by measuring the duration of rumination during juice delivery and immediately
followingtheterminationofjuicedelivery.Noncontingentjuicesuppressedrumination,butthis
suppression was notmaintainedafter deliverytermination.
Keywords: autism, noncontingent reinforcement, rumination
_______________________________________________________________________________
Rumination is the regurgitation and rechew- meals to an 18-year-old man with intellectual
ing of partially digested food and is associated disabilities. Lyons et al. (2007) similarly reduced
with numerous health concerns including hali- the rumination of two children with develop-
tosis,toothdecay,electrolyteimbalances,abnor- mental disabilities by delivering small bites of
mal gastrointestinal symptoms, malnutrition, preferred edible items (i.e., cereal bars and
and social isolation (American Psychiatric Asso- pretzels) or 1-oz (about 30 ml) sips of preferred
ciation,2000;Chial,Camilleri,Williams,Litzinger, drinks(i.e.,fruitjuiceandfruitpunch)onafixed-
& Perrault, 2003; Ellis & Schnoes, 2009). Rumi- time (FT) schedule. This procedure requires
nation may occur in as many as 10% of relatively little effort to implement; however,
individuals with severe intellectual disabilities there are a number of important concerns
(Rogers, Stratton, Victor, Kennedy, & Andreas, regarding the distal effects of this intervention.
1992).Inthesecases,ruminationtypicallyoccurs For instance, it may not be healthy for an
within a few minutes after eating and may last individual to consume food continuously
several hours (Ellis & Schnoes, 2009). Recent throughout the day. In addition, it is unclear
evidence suggests that rumination may be from these results how long reductions would be
operant, most commonly maintained by auto- maintainedaftertheterminationoffooddelivery.
matic consequences of the behavior, and can be It is possible that noncontingent food simply
treated through operant mechanisms (Lyons, delays the onset of rumination.
Rue, Luiselli, & DiGennaro, 2007; Wilder, Two studies evaluated the maintenance of
Register, Register, Bajagic, & Neidert, 2009). reductions in rumination following interven-
Several studies have suggested that providing tion termination, both with favorable results.
noncontingent food or drink will suppress rumi- Wilder, Draper, Williams, and Higbee (1997)
nation. For example, Thibadeau, Blew, Reedy, measured rumination exhibited by an adult
and Luiselli (1999) suppressed rumination by man with profound intellectual disabilities and
providing free access to white bread following blindness during a 30-min period of noncon-
tingent gelatin or pudding (delivered in the
amount of 1 teaspoon on an FT 20-s schedule)
Correspondence concerning this article should be
addressedtoJeffreyH.Tiger,whoisnowatDepartment and during a 60-min extended data-collection
of Psychology, University of Wisconsin–Milwaukee, period after terminating delivery. The results
2441 E. Harford Ave., 219 Garland Hall, Milwaukee,
indicated that noncontingent food was effective
Wisconsin 53201(e-mail: [email protected]).
doi:10.1901/jaba.2011.44-955 at decreasing rumination relative to baseline; in
955
956 MEGAN L. KLIEBERT and JEFFREY H. TIGER
addition, rumination did not increase signifi- the therapist viewed Bennett’s mouth to ensure
cantly during the 60 min following treatment there was no food remaining from lunch. We
termination. Dudley, Johnson, and Barnes defined rumination as engaging in a rotary
(2002) evaluated a food satiation procedure in chewing motion, which was the most frequent
whichtheyprovidedfreeaccesstoricecakesand public accompaniment when Bennett ruminat-
otherstarches(e.g.,mashedpotatoes,pasta,and ed. We scored the onset of an episode immedi-
cereal) to a young girl with autism after her ately when chewing began and the offset when
meals and measured rumination for an addi- chewing ceased for 3 s. We divided the sum of
tional 50 min after she reached a satiation rumination durations by the total session
criterion (i.e., 3 min without approaching the duration to determine a percentage of session
food). This procedure reduced rumination with rumination.
during both the noncontingent food period A second observer simultaneously but indepen-
and the following 50 min. We extended this dentlyscoredtheoccurrenceofruminationduring
literature by evaluating the direct and distal 29% of functional analysis sessions and 33% of
effects of providing noncontingent juice on treatmentevaluationsessionstoassessinterobserver
ruminationexhibited byaboy withautism.We agreement.Wedividedeachobserver’srecordinto
measured the duration of rumination during 10-s intervals and compared observers’ records of
juicedeliveryandimmediatelyafterterminating the number of seconds with rumination on an
juice delivery. interval-by-intervalbasis.Weassignedeachinterval
inexactagreementascoreofoneandcalculateda
proportionalagreementscoreforallotherintervals
METHOD
by dividing the smaller number of seconds of
Participant and Setting
rumination by the larger number of seconds of
Bennett was an 11-year-old boy with multi- rumination. We then summed the scores across
ple diagnoses including autism, severe mental intervals, divided the sum by the total number of
retardation, blindness, septo-optic dysplasia, intervals, and converted this score to a percentage.
and a thyroid disorder. His teachers had The mean agreement score for the duration of
referred him due to his ongoing rumination; rumination was 83% (range, 61% to 94%)
we obtained parental consent for participation throughout functional analysis sessions and 86%
in this evaluation prior to initiating any (range, 54% to 100%) throughout treatment
procedures. Bennett presented with dental evaluationsessions.Attimes,Bennett’srumination
problems and chronically chapped lips and was difficult to detect due to subtle physical
was socially isolated from his peers; he was not accompaniments (i.e., minuscule rotary chewing
receiving any medical treatment for his rumi- motions). The low minimum ranges of interob-
nation.Therapistsconductedallassessmentand server agreement obtained during both the
treatment sessions in an unused classroom at functional analysis and treatment evaluation most
Bennett’s school. likely were due to this difficulty in detecting
rumination.
Measurement and Interobserver Agreement
Observersusedlaptopcomputerstorecordthe Procedure
continuousdurationofrumination.Weinitiated We conducted a functional analysis of rumina-
all assessment and treatment sessions at the tionusingproceduressimilartothosedescribedby
conclusion of Bennett’s school lunch period Iwata, Dorsey, Slifer, Bauman, and Richman
(within 10 min of lunch completion), which (1982/1994), including 5-min attention, escape,
teachers reported as the most frequent period of ignore,andtoyplayconditionsalternatedwithina
rumination. Prior to the first session each day, multielement design, to determine if rumination
EFFECTS OF NONCONTINGENT JUICE 957
was sensitive to social reinforcement. In addition,
we conducted a series of ignore sessions to verify
that Bennett’s rumination persisted in the absence
ofsocialconsequences.Weconductedfoursessions
per day. Following the functional analysis, we
initiated a treatment evaluation that examined the
direct and distal effects of noncontingent juice on
rumination.
We initially conducted a baseline phase
similartotheignoreconditionofthefunctional
analysis.Thatis,Bennett,thetherapist,andone
or two data collectors were present in the room
during 5-min sessions; Bennett did not have
access to any leisure materials or edible items;
and the therapist did not provide any pro-
grammed consequences for rumination. We
conductedfourconsecutivebaselinesessionsper
day following Bennett’s lunch period.
We conducted treatment sessions (noncon-
tingent juice FT 15 s) similar to baseline except
the therapist provided a small sip (1-s access) of
apple juice every 15 s. We determined apple
juice to be a preferred liquid based on the
results of a prior preference assessment using
Figure 1. Percentage of session with rumination
procedures similar to those described by Pace,
during Bennett’s functional analysis (top) and treatment
Ivancic, Edwards, Iwata, and Page (1985). We
evaluation (bottom). NC5 noncontingent.
settheFTscheduleat50%ofthemeaninterval
between episodes of rumination during the last
between noncontingent juice sessions and
fivebaselinesessions(M530s).Weconducted
postnoncontingent juice sessions shares the
up to three 5-min treatment sessions per day
experimental logic of a multielement design.
but terminated treatment sessions early if
Bennett expelled the juice during three consec-
utive presentations within a session (i.e., we RESULTS AND DISCUSSION
considered this indicative of satiation; session
Bennett’s rumination occurred at similar
durationsareavailablefromthesecondauthor). durationsacrossallfunctionalanalysisconditions
After he met this expulsion criterion, we (Ms 5 17%, 23%, 14%, and 24% during
conducted the remainder of that session under ignore, escape, attention, and toy play condi-
postnoncontingentjuiceconditions,whichwere tions,respectively;Figure 1,top),indicatingthat
identical to baseline. We then conducted two the duration of rumination was not influenced
additional 5-min postnoncontingent juice ses- by social reinforcement. The extended series of
sions. Thus, we were able to evaluate the direct ignore sessions confirmed this; Bennett’s rumi-
effectsofnoncontingentjuice(duringtreatment nation not only maintained but increased (M5
sessions) and the distal effects (during the 54%) in the absence of social consequences.
sessions that immediately followed the termi- Bennett’s rumination increased across the
nation of juice delivery). The alternation baseline phase (M 5 24%; Figure 1, bottom).
958 MEGAN L. KLIEBERT and JEFFREY H. TIGER
During noncontingent juice sessions, the non- food easier to regurgitate and that simply
contingent delivery of juice eliminated rumina- restricting access to liquids prior to, during, and
tioncompletelyinallbutonesession,producinga immediately after meals can suppress rumination
98%reductionfrombaselinelevels(M50.3%). (Barton & Barton, 1985; Heering, Wilder, &
However, Bennett never completed three consec- Ladd, 2003; Wilder et al., 1997). Prior to this
utive treatment sessions prior to meeting our evaluation,weattemptedtoprovideBennettwith
satiation criterion. He met the liquid satiation preferred solid and starchy food items, but he
criterion within one to three 5-min sessions each refused to accept these during sessions. He did
day(i.e.,inlessthan15min),andweobserveda persist in accepting juice for longer periods; thus,
concomitant increase in rumination to baseline weevaluatedtheeffectsofjuiceonly.Thepossible
levels within the few minutes that followed differential effectiveness of foods and liquids in
maintaining suppressed rumination demands
treatment cessation each day (postnoncontingent
juice sessions; M 5 23%). additional research attention.
Theresultsofthecurrentstudydonotpreclude
These results are similar to those of Lyons
thepossibilitythatnoncontingentliquidssuppress
etal.(2007)inthatnoncontingentjuicedelivered
rumination in some cases but do draw attention
onanFTscheduleminimizedruminationduring
to the necessity of continuing data collection for
briefsessions.However,boththeresultsofLyons
periodsafterterminatingliquid(orfood)delivery.
et al. and the current results raise concerns
It is possible that thinning the FT schedule
regarding the use of FT juice delivery to produce
could result in greater maintenance (similar to
lasting decreases in rumination. Following their
that reported by Lyons et al., 2007) or could
initialintervention,Lyonsetal.fadeddeliveryby
identify the minimal amount of food or liquids
reducing the amount of juice from 1 oz (about
necessary to maintain low levels of rumination.
30ml)to0.5oz(about15ml)andextendedthe
Future research should include a parametric
session duration from 15 min to 30 min for one
manipulation of liquid levels and delivery sched-
participant.Althoughruminationdecreasedcom-
ules during and after treatment sessions. Given
pared to levels seen during baseline, treatment
that delivering noncontingent food and liquids
effectswerenotasrobustasthoseobservedduring
continuously throughout the day would be
the initial intervention. In the current study, we
neither desirable (due to excessive caloric intake
directly evaluated satiation and maintenance
and dental problems) nor possible (due to
effects by setting a termination criterion and
satiation), it will be important to continue to
measuring rumination following the systematic
evaluate the maintenance of behavior change for
withdrawal of treatment, but results were not
this and similar procedures.
favorable,indicatingthatcontinuousprovisionof
foodorliquidmaynotbefeasibleoreffectivefor
REFERENCES
longer periods (i.e., satiation may occur and
disrupt treatment effects). American Psychiatric Association. (2000). Diagnostic and
statistical manual of mental disorders (4th ed., text
Thecurrentstudyproduceddifferentoutcomes
rev.).Washington, DC:Author.
than previous research that evaluated rumination
Barton, L. E., & Barton, C. L. (1985). An effective and
after treatment termination. This difference in benign treatment of rumination. Journal of the
AssociationfortheSeverelyHandicapped,10,168–171.
outcomes may be due to the items delivered
Chial,H.J.,Camilleri,M.,Williams,D.E.,Litzinger,K.,
duringtheintervention.Dudleyetal.(2002)and
& Perrault, J. (2003). Rumination syndrome in
Wilderetal.(1997)providedsolidfoods,whereas children and adolescents: Diagnosis, treatment, and
we provided Bennett with liquids. Some research prognosis. Pediatrics, 111,158–162.
Dudley, L. L., Johnson, C., & Barnes, R. S. (2002).
suggeststhatincreasedliquidconsumptionduring
Decreasing rumination using astarchy food satiation
mealtime may facilitate rumination by making procedure. BehavioralInterventions, 17,21–29.
EFFECTS OF NONCONTINGENT JUICE 959
Ellis, C. R., & Schnoes, C. J. (2009). Eating disorder, Rogers, B., Stratton, P., Victor, J., Kennedy, B., &
rumination.Retrievedfromhttp://emedicine.medscape. Andreas, M. (1992). Chronic regurgitation among
com/article/916297-overview personswithmentalretardation:Aneedforcombined
Heering, P., Wilder, D., & Ladd, C. (2003). Liquid medical and interdisciplinary strategies. American
reschedulingforthetreatmentofrumination.Behav- Journal onMentalRetardation, 96,522–527.
ioralInterventions,18,199–207. Thibadeau, S., Blew, P., Reedy, P., & Luiselli, J. K.
Iwata,B.A.,Dorsey,M.F.,Slifer,K.J.,Bauman,K.E., (1999). Access to white bread as an intervention for
& Richman, G. S. (1994). Toward a functional chronic ruminative vomiting. Journal of Behavior
analysis of self-injury. Journal of Applied Behavior Therapy and Experimental Psychiatry, 30,137–144.
Analysis,27,197–209. (ReprintedfromAnalysisand Wilder,D.,Draper,R.,Williams,W.L.,&Higbee,T.S.
Intervention in Developmental Disabilities, 2, 3–20, (1997). A comparison of noncontingent reinforce-
1982) ment, other competing stimulation, and liquid
reschedulingforthetreatmentofrumination.Behav-
Lyons,E.A.,Rue,H.C.,Luiselli,J.K.,&DiGennaro,F.D.
ioral Interventions,12,55–64.
(2007). Brief functional analysis and supplemental
Wilder, D. A., Register, M., Register, S., Bajagic, V., &
feeding for postmeal rumination in children with
Neidert,P.L.(2009).Functionalanalysisandtreatment
developmental disabilities. Journal of Applied Behavior
ofruminationusingfixed-timedeliveryofaflavorspray.
Analysis,40,743–747.
JournalofAppliedBehaviorAnalysis,42,877–882.
Pace,G.M.,Ivancic,M.T.,Edwards,G.L.,Iwata,B.A.,
& Page, T. J. (1985). Assessment of stimulus
preference and reinforcer value with profoundly Received December 20, 2010
retarded individuals. Journal of Applied Behavior Final acceptanceApril 12, 2011
Analysis, 18,249–255. Action Editor,David Wilder