Rumination is characterized by regurgitation of previously ingested food into the mouth, and re-chewing, re-swallowing or expelling that food (Chial, Camilleri, Williams, Litzinger, and Perrault, 2003). Although rumination is typically observed in infants and individuals with developmental disabilities, it does occur in adolescents, children, and adults with normal intelligence (Chail, Camilleri, Williams, Litzinger, and Perrault, 2003). It is estimated that an average of 6-10% of individuals with severe intellectual disability who are living in a residential treatment facility engage in rumination (Lang et al., 2011). There are several medical conditions/diagnoses that could result in ruminative behavior. These include gastro-esophageal reflux disease, upper gastrointestinal motility disorders (e.g., gastroparesis), and bulimia nervosa (Chial, Camilleri, Williams, Litzinger, and Perrault, 2003). The medical consequences of engaging in rumination over a prolonged period of time range from halitosis to malnutrition, dental erosion, and weight loss (Chial, Camilleri, Williams, Litzinger and Perrault, 2003). In addition to medical complications, several social consequences of ruminative behavior have been identified. These include, but are not limited to, unkempt personal appearance and foul odor, which can result in social isolation and/or decrease in educational or vocational opportunities (Lang et al., 2011). Thus, it is important that behavioral treatments for ruminative behavior, in conjunction with medical interventions (when applicable), are evaluated.
Since Iwata et al.’s (1982/1994) seminal article on the importance of determining the function of behavior prior to treatment, the use of functional analysis has become a cornerstone assessment in the field of applied behavior analysis. Functional analysis results allow clinicians to determine what types of environmental conditions evoke challenging behavior and what consequences maintain it. Functional analyses have been conducted for behaviors such as aggression, self-injury, property destruction, and more recently food refusal and rumination. Although not within the scope of this article, the majority of functional analyses of rumination conducted have revealed that, in most cases, rumination is maintained by an automatic reinforcer (Lyons, Rue, Luiselli, and DiGennaro, 2007; Wilder et al., 2009; Woods, Luiselli, and Tomasson, 2013), meaning that often the reinforcer for ruminative behavior is produced by the behavior itself and is not socially mediated. However, the use of functional analysis to determine the functional reinforcer of ruminative behavior is limited and more research is needed in this area.
Several treatment options have been used to treat ruminative behavior, including punishment, differential reinforcement of alternative behavior, differential reinforcement of other behavior, the delivery of a competing item, and manipulation of meal variables. Positive punishment, which involves the presentation of an aversive stimulus following a response, and a subsequent reduction in behavior, has been effective at decreasing rumination. Sajwaj, Libet and Agra (1974) were able to eliminate rumination in an infant, by squirting unsweetened lemon juice into the infant’s mouth at the first sign of rumination. The elimination of rumination also resulted in increased weight gain, babbling, smiling, reaching for objects, and interest in social attention. Another punishment procedure that has resulted in decreased rumination was reported by Singh, Manning, and Angell (1982). Singh, Manning, and Angell (1982) prompted twins, who engaged in ruminative behavior, to brush their teeth, for 2 minutes, with a toothbrush soaked in Listerine and wipe their lips with a face cloth dipped in Listerine. Results of the procedure showed a decrease in ruminative behavior and an increase in stereotypic and appropriate behaviors. Due to the rapid decrease in rumination and the serious medical and social concerns related to chronic rumination, positive punishment was historically used as an appropriate treatment for rumination. However, today clinicians evaluate the effectiveness of less restrictive procedures such as differential reinforcement of other behavior, the use of competing items, diet changes, and non-contingent access to stimuli prior to beginning a punishment-based procedure to decrease rumination.
Non-contingent delivery of food or drink has been shown to reduce ruminative behavior (Lyons, Rue, Luiselli, and DiGennaro, 2007). However, in order for these treatments to maintain low levels of rumination they often need to be delivered frequently, which can be impractical for caregivers and result in undesirable side effects for the client, such as weight gain. Therefore, researchers have also evaluated treatments which can be easily delivered frequently in a natural environment. Rhine and Tarbox (2009) decreased ruminative behavior, in a 6-year-old, by providing non-contingent access to chewing gum. Kliebert and Tiger (2011) decreased rumination, maintained by automatic reinforcement, by providing access to apple juice every 15 seconds, after lunch. These results, however, did not maintain in post non-contingent juice sessions, which were conducted right after the 15 second access to apple juice sessions. Similarly, Wilder et al., (2009) decreased rumination in a 37-year-old male by delivering an apple pie flavored spray every 10 seconds. The researchers used an audible tone to signal delivery of the spray, which they had taught the individual to self-administer. Although both of these treatments were found to be effective, one major limitation exists to extending these treatments to a residential or home setting. The juice and flavor spray were delivered on a dense schedule, which would be difficult to implement across a school day or residential hours. However, these may be viable treatment options if individuals are taught to administer the item themselves or rumination does not occur throughout the day (Wilder et al., 2009).
Due to the limited success and cumbersome nature of the treatments described above, researchers have begun manipulating antecedent variables which may result in decreased rumination. Researchers evaluated the effects of caloric intake and supplemental feedings for individuals who engage in ruminative behavior. These antecedent manipulations have shown promising results in decreasing rumination. In 1981, Rast, Johnston, Drum, and Conrin systematically evaluated the effect that food quantity. The researchers manipulated food quantity from regular portions to satiation portions. When the participants were eating satiation portions they were permitted to eat as many “potatoes, cream of wheat, unflavored grits, and/or bread” as they wanted. The authors found that when participants were given satiation portions the duration and frequency of rumination decreased. Other researchers have reported similar results (Johnston, Greene, Rawai, Vazin, and Winston, 1991). Thibadeau, Blew, Reedy, and Luiselli (1999) provided unlimited access to white bread for 1 hour post meal. The authors made the decision to use white bread because this was a preferred food for the participant and the starch content was similar to foods used in other satiation diet programs. This procedure resulted in significantly decreased levels of rumination. In follow-up observations the researchers found that these results were maintained up to 15 months after the conclusion of the study.
Future researchers and clinicians should evaluate different variables that may have similar effects on rumination. These variables include, food type (e.g., meat, starch, fruit), food texture (e.g., smooth versus crunchy), and food preference. For example, it is possible that an individual may be more likely to ruminate after eating a preferred food in comparison to a non-preferred food to gain additional access to its reinforcing qualities (e.g., taste, texture).
Although there are medical diagnoses where rumination is seen as a symptom (e.g., gastro-esophageal reflux), there are times when no medical basis for rumination is apparent. In these cases behavioral interventions, in conjunction with medical recommendations or as a primary treatment, may assist in decreasing or eliminating rumination. Early behavioral strategies emphasized the use of punishment, whereas more recent interventions have utilized reinforcement and antecedent modification. Behavior analysts have much to offer in the treatment of rumination given their adherence to ongoing data collection and the systematic exploration and analysis of variables that might influence rumination.
Jennie England, MA, BCBA, is Clinical Case Manager and James T. Chok, PhD, BCBA-D, is Director of Clinical Services at Melmark. For more information, please visit www.melmark.org.
References
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