A food satiation and oral hygiene punishment program to suppress chronic rumination by retarded persons

Does the Arc of Science Bend Towards Impact? Four Decades of Empirical Research Published in JADD Since the DSM-III

The present study explored the shift from understanding to intervention to population impact in the empirical research published in this journal at five points of time over 40 years since the release of DSM-III. Two-thirds of the more than 600 original studies identified involved basic research, a pattern that is consistent with previous analyses of research funding allocations and that did not change over time. One of every eight studies involved intervention research, which occurred in community-based programs only about one-quarter of the time. These gaps in intervention research and community impact did not improve over time. The findings underscore the need to broaden the training and experience of researchers, and to re-consider priorities for research funding and publication.

Behavioral treatment of rumination: Research and clinical applications

This brief review describes research on rumination treatment that emphasizes functional analysis, recent intervention methods (supplemental feeding, fixed-time stimulus presentation, continuous access to preferred stimulation), clinical implications, and procedural recommendations.

Elimination of Self-Injurious Behaviour in an Autistic Child by use of Overcorrection

Mild punishment, overcorrection and reinforcement of an alternative behaviour were used to reduce and eliminate the incidence of severe self-injurious behaviour in an autistic 12-year-old boy who had sustained major damage to his wrists and fingers. Data were collected over 10 × 30-minute periods per day and showed that banging and touching of a protective cast and later the injured hand itself were reduced to zero in approximately three weeks. The injury had healed and self-injurious behaviour was still extinguished at 10-month follow-up.

Twenty years of applied behavior analysis in treating the most severe problem behavior: Lessons learned

This paper reviews some of the author's experiences during the past 20 years of treating severe problem behavior. Factors that represent barriers to success are identified and discussed, as are factors that contribute to the development of successful treatment programs. Barriers to success include the inherent reactive nature of human services and educational systems, expertise problems, systems problems, information gaps, programming problems, characteristics of problem behavior, and maintenance problems. Some new programmatic directions are suggested for overcoming the various treatment barriers. The paper concludes with strategies and factors to consider that will ensure long-term success in the treatment of severe problem behavior.

Behavioral interventions for rumination and operant vomiting in individuals with intellectual disabilities: a systematic review

We conducted a systematic analysis of studies that involved the treatment of rumination and operant vomiting in individuals with developmental disabilities. A total of 21 studies involving a combined 32 participants were identified and analyzed in terms of (a) participant characteristics, (b) dependent variables, (c) intervention procedures, (d) functional assessment procedures and results, (e) intervention outcomes, and (f) certainty of evidence. In comparison to previous reviews on rumination and operant vomiting, this review identified fewer studies involving punishment-based interventions and an increase in function-based reinforcement interventions. Preliminary guidelines for practitioners faced with assessing and treating these behaviors are offered and directions for future research are discussed.

The diagnosis of eating disorders in adults with learning disabilities: Conceptualisation and implications for clinical practice

OBJECTIVE

The literature suggests that less attention has been afforded to eating disorders (EDs) in adults with learning disabilities (LDs) than in adults of normal intellect. This review aimed to examine the methods, prevalence and implications of an ED diagnosis in adults with LDs.

METHOD

Key texts, journals and online databases were searched for literature examining disordered eating in adults with LDs.

RESULTS

A review of the extant literature revealed that a range of dysfunctional eating behaviours have been classified as 'eating disorders' and highlighted a lack of clarity about the distinction between feeding and EDs. A small body of research suggests that some individuals with LDs show the emotional and cognitive characteristics of typical EDs.

DISCUSSION

The lack of consensus about conceptualisation, assessment, diagnosis and treatment of EDs in individuals with LDs needs to be addressed in order to aid awareness and enhance clinical approaches for this population.

The relationship between rumination and eating disorders

OBJECTIVE

Rumination has been described as a symptom in association with eating disorders, but also as a separate disorder.

METHOD

A series of 8 female volunteers who reported rumination were systematically screened for the presence of eating disorders and other psychopathology.

RESULTS

Seven met current or prior criteria for an Axis I disorder and five had a current or prior eating disorder.

DISCUSSION

The importance of screening for eating disorders among women who ruminate, and for screening for rumination among eating disorder patients, is stressed.

Access to white bread as an intervention for chronic ruminative vomiting

Research has demonstrated that providing extra and sometimes unlimited food quantities following meals can be effective in reducing or eliminating ruminative vomiting in persons with developmental disabilities. In this study, providing access to white bread was evaluated as an alternative method of satiation-based treatment of rumination displayed by an 18-year old male with mental retardation. White bread was made available during 1-h periods following daily meals and this intervention produced a reduction in ruminating to near zero levels throughout the young man's waking hours. Long-term follow-up assessment revealed maintenance of low-frequency responding. Issues related to satiation treatment programs for ruminative vomiting are discussed.

Overview of the treatment of rumination disorder for adults in a residential setting

Rumination, or the chewing and re-swallowing of regurgitated stomach contents, can be found in up to 10% of institutionalized individuals with severe or profound mental retardation. Serious physical consequences, including death, can result from the disorder. Unfortunately, rumination can be subtle and difficult to observe and often continues untreated. Additionally, the research literature has provided divergent results without clear treatment guidance for clinicians. We present an overview of the history of rumination, a review of the literature on its etiology and treatment, and recommendations for future research.

Rumination syndrome

Rumination is a syndrome characterized by repetitive regurgitation of small amounts of food from the stomach. The food is then partially or completely rechewed, reswallowed, or expelled. This syndrome is relatively common in infants and mentally challenged persons, but it also occurs in adults with normal intelligence. The rumination syndrome is an underappreciated condition in adults who frequently receive a misdiagnosis of vomiting due to gastroparesis or gastroesophageal reflux. Difficulties in establishing the correct diagnosis may be caused by a lack of awareness of the condition among physicians. This syndrome must be considered in the differential diagnosis of a patient with regurgitation, vomiting (especially postprandial), and weight loss. Reassurance, explanations, and behavioral therapy are currently the mainstays of treatment in adults with normal intelligence who have the rumination syndrome. Appropriately controlled trials are needed to establish the best therapy.

The rumination syndrome: clinical features rather than manometric diagnosis

BACKGROUND/AIMS

Rumination is infrequent in adults of normal mental capacity. Upper gastrointestinal manometry reportedly confirms the diagnosis. Clinical characteristics, treatment(s), and outcomes of these patients are unclear.

METHODS

We assessed 38 adults and adolescents with rumination between 1987 and 1994. Esophagogastroduodenal manometric recordings (n = 36; 3-hour fasting and 2-hour postprandially) were reviewed; follow-up information was obtained from mailed questionnaires.

RESULTS

Patients saw a mean of five physicians and had symptoms for a mean of 2.75 years before diagnosis. Features included daily, effortless regurgitation of undigested food starting within minutes of meals. Weight loss was substantial (mean, 29 lb) in 42% of patients. Seventeen percent of female patients had a history of bulimia. Manometry confirmed the clinical diagnosis in 33% but was otherwise normal in all. Of 16 patients who responded to our questionnaires of 29 with > 6 months of follow-up (average, 35 months), 12 reported subjective improvement. In 14, the behavior persists.

CONCLUSIONS

The rumination syndrome is underdiagnosed. With typical clinical features, gastroduodenal manometry seems unnecessary to confirm the diagnosis. Diagnosis and reassurance are important in management to avoid unnecessary tests and treatments.

Behavioral medicine treatment of ruminative vomiting and associated weight loss in an adolescent with autism

Treated persistent ruminative vomiting of a 15-year-old boy with autism using a multicomponent behavioral medicine program within a residential facility. Preceding intervention the boy had lost 15 pounds associated with high-rate ruminating. The treatment program included a combination of dietary, nutritional, and behavioral procedures that emphasized food restrictions, satiation, and setting condition manipulations. Ruminative vomiting was reduced to near-zero levels and weight gain was achieved following treatment implementation. These therapeutic gains were sustained during a maintenance programming phase and at 1- through 4-month follow-up assessments. Issues related to functional assessment and treatment formulation in behavioral medicine intervention for ruminative vomiting are discussed.

The reinforcement of calm sitting behavior: a method used to reduce the self-injurious behavior of a profoundly retarded boy

The frequency and intensity of a 14-year-old profoundly retarded male's self-injurious behavior was significantly reduced by the reinforcement of calm sitting behavior. Social validation ratings confirmed the effectiveness of treatment, and showed that gains generalized across treatment and non-treatment settings and across people associated or not with treatment. Treatment gains were maintained at 6- and 12-month follow-ups.

Treatment of severe self-injurious and aggressive biting

The treatment of a 16-year-old severely mentally retarded and blind female client exhibiting severe biting of self and others consisted of the contingent application of an aversive gustatory stimulus (Tabasco Sauce), brief timeout, DRO, and contingent restraint against biting while in time-out. This is the first use of Tabasco as the aversive stimulus against biting. Deceleration of biting was rapid and maintained for 20 months after initiation of treatment.

The treatment of autistic children

The goals of treatment need to be decided on the basis of knowledge on the nature of autism. As with any developmental disorder, the first goal must be to foster normal development; with autistic children this involves a focus on intellectual, language and social development. The further goals include: the reduction of rigidity/stereotypy; the elimination of non-specific maladaptive behaviours; and alleviation of family distress. Research findings are used to translate these goals into a practical overall therapeutic programme with three main elements: a full diagnostic appraisal, special educational provision and a home-based programme for the family. Finally, the research findings are drawn together to derive inferences on the lessons to be learned and the questions that remain to be answered.

Effects of an oral hygiene punishment procedure on chronic rumination and collateral behaviors in monozygous twins

This study investigated the suppressive effects of an oral hygiene punishment procedure on the ruminative behavior of profoundly retarded monozygous twins. Rumination, fingers in mouth/tongue out, appropriate behavior, and stereotyped behavior were measured before and during treatment with oral hygiene. Treatment was introduced for each meal in succession across the twins in a multiple-baseline design. Results showed that the rate of rumination of both twins was dramatically reduced to very low levels and stereotyped behavior increased spontaneously with the introduction of oral hygiene. Maintenance data showed that response reduction was maintained over a six-month period and, when compared to baseline levels, increased rates of socially appropriate behavior were evident in both children.

Chronic ruminative vomiting: a comparison of four treatment procedures

An experimental analysis of a case of chronic ruminative vomiting in a 15-year-old, profoundly retarded, Down's syndrome boy addressed the consequences of vomiting in the postmealtime environment. The experiment compared four treatments in each hour-long session using a multiple reinforcement schedule with order of the following procedures counterbalanced over days in a Latin square design: differential reinforcement of any behaviors other than vomiting (DRO) in which periods of no vomiting were followed by reinforcement and vomiting postponed reinforcement; differential reinforcement of specific behaviors alternative to vomiting (DRI) in which conjoint periods of no vomiting and sustained toy play were followed by reinforcement and the lack of either postponed reinforcement; extinction plus reinforcement of alternative behavior in which vomiting was ignored but toy play was reinforced; extinction in which vomiting was ignored. Data revealed an orderly dual cyclical pattern of vomiting throughout the day, with increased vomiting in the morning and immediately following food ingestion. Postluncheon treatments emphasizing reinforcement of alternative behavior were more successful in decreasing vomiting than DRO or extinction alone.