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It is essential to understand that rumination and vomiting were once analogous but today are defined differently. Rumination involves contents from the stomach being brought back up and are typically described as tasting good or undigested (Talley, 2011). The content is then either re-swallowed or spat out. In comparison, vomiting refers to the forceful ejection of digested or partially digested gastric contents up from the stomach and out of the mouth (Talley, 2011). Vomiting is more forcible and spitting out the food that is regurgitated is described as uncontrollable. Rumination has always been defined to include both behaviors of regurgitating and re-swallowing.
In 1981, 6% of people institutionalized with a mental disorder were reported to be diagnosed with rumination syndrome (Singh, 1981). Due to the lack of recorded data, the prevalence of rumination today is unknown (Talley, 2011). Rumination has not always been considered a disorder that is harmful to individuals. We know today that rumination can cause esophagitis and tooth decay, severe weight loss, dehydration, gastric disorders, malnutrition, and in chronic cases, death (Rast, Johnston, Drum, and Conrin, 1981; Thibadeau, Blew, Reedy, & Luiselli, 1999). A study published in 1983 defined rumination as a benign disorder (Levine, Wingate, Pfeffer, & Butcher, 1983). The behavioral intervention used in the study was reported to be unsuccessful in all 8 out of 9 participants. The researchers were ignorant to the harmful effects of rumination and even told the participants who did not have significant results that the behavior was harmless (Levine et al., 1983). According to Talley (2011), professor of medicine, the cases of individuals diagnosed with rumination syndrome has increased. It was predicted that the increase in diagnoses is due to physicians noticing the disorder and asking patients about specific symptoms related to rumination and not because of an increase in people experiencing rumination. Individuals diagnosed with Autism Spectrum Disorder (ASD) are being treated for rumination with behavior analytical techniques after parents and caregivers report the symptoms to therapists and teachers. Without parents and caregivers speaking up, the behavior might never be treated for some individuals. Behavior analysts are expected to collaborate with families and stakeholders and without this collaboration, teachers and behavior analysts might not fully understand what the client needs (Leader Standards, 2013a). What behavior analytic intervention plans have been used to treat rumination and how successful were the interventions?
Researchers in the past have used different behavior analytic techniques to treat rumination. All researchers defined rumination to included re-swallowing of the regurgitated food, and thus the most common treatment interventions used in the recent literature were antecedent interventions involving food satiation for automatic reinforcement. According to Cooper et al. (2007), antecedent interventions can decrease the effectiveness of reinforcers that are maintaining the problematic behavior but alone they usually do not produce permanent changes in problem behavior and are most often paired with another intervention that will create more sustaining effects. Antecedent based food-related treatments alone have shown to be effective in past research studies. These are treatments that change the environment that the behavior occurs in such as removing or adding food to an individual’s meal. Researchers reported that antecedent interventions for rumination are particularly easy to implement and are often socially acceptable compared to other interventions such as punishment interventions (Wilder, Register, Register, Bajagic, & Neidert, 2009). Long term effects of these interventions have not been published.
One study used antecedent-based, satiation procedures to treat rumination maintained by automatic reinforcement. Kenzer and Wallace (2007) used both large portions and supplementary feedings in a treatment plan for Dan, a 59-year-old man diagnosed with profound mental retardation. There were four conditions. The first condition presented was baseline and involved Dan’s regular mealtime routine with data collection during the 30 minutes following meal completion. The next two conditions were supplemental feedings after meals for every minute either for 15 or 30 minutes. The last condition was labeled “large portion” where Dan was given a small portion of additional food following his meal. The results showed that frequency of rumination was lower following supplemental feedings (for 30 minutes) compared to baseline and the large portion condition. The researchers found that since the food consumed in both the supplementary feedings and the large portions conditions were the same number of grams, the critical variable to reducing the frequency of rumination for Dan was time (Kenzer & Wallace, 2007).
Lyons, Rue, Luiselli, and DiGennaro (2007) also incorporated supplemental feeding on a fixed-time interval to treat rumination. There were two participants involved in the research. The first boy, Alex, was put through three conditions. Intervention 1 was 15 min in length and included a noncontingent presentation of a food or juice item on a fixed-time 30 s schedule. Intervention 2 involved a noncontingent presentation of only the juice on a fixed-time 30 s schedule for 30 min. The last condition was the control condition. The second boy, Tom, was put through three conditions as well. The first two conditions were 20 min in length and involved either the presentation of food or juice on a fixed-time 30 s schedule. The third condition was noncontingent access to a chew ring. The results showed that rumination that occurred after a meal was reduced when supplemental feedings were introduced (Lyons et al., 2007). The researchers stated that the reduction of rumination might be dependent on the type of food and liquid offered because rumination was eliminated when juice was an option for Alex in intervention 1. Then when water was offered, the behavior returned to baseline levels. For Tom, the supplemental presentation of food, liquid, and the chew ring eliminated the target behavior. But when the intervention was replicated, the frequency of rumination returned to baseline with the presentation of the chew ring, increased with the liquid, and stayed absent with the food presentation (Lyons et al., 2007). The researchers made it clear that even though the supplemental feedings were effective, the reason is not known. Their idea was that the extra food and liquid intake might have produced a satiation effect, or it provided sensory stimulation that was like rumination.
Other researchers have used the behavior analytical technique of fixed-time intervals to present supplemental feedings or liquids to treat rumination. Specifically, the duration of rumination was measured during juice delivery and immediately following the termination of juice delivery in a research study (Kliebert & Tiger, 2011). This study was different than others in the fact that rumination was measured by duration rather than by frequency. Kliebert and Tiger (2011) determined the behavior to be automatically maintained for an 11-year-old boy after finding out the behavior occurred across all FA conditions and was not influenced by social reinforcement. The results state that noncontingent delivery of juice on a fixed-time 15 s schedule resulted in an elimination of rumination in all but one of the sessions conducted (Kliebert & Tiger, 2011).
Researchers Rast et al., (1981) studied the relationship between food quantity and the frequency of rumination in three individuals with mental disorders. Rast et al. (1981) varied the quantity of food given to the participants and the amount of time it took the participants to eat. This resulted in mixed findings. For one of the three participants, the results showed that regular quantity meals spaced out over time correlated with a slightly reduced frequency and duration of rumination. Another participant’s results showed that spacing the meals out over time was not effective in reducing the frequency and duration of rumination.
Noncontingent access to white bread was used to treat rumination in a different study. Researchers Thibadeau et al. (1999) had tried different interventions for a client, Bill, who was engaging in rumination but were not able to find something long-lasting. They decided to implement a differential reinforcement of other behaviors (DRO) procedure that involved reinforcing the participant’s manding for “eat” with contingent access to white bread. In the baseline phase, the participant was engaged in rumination on average 14.5 times per day. After access to white bread for 1 h following a meal was in place, the rumination behavior decreased to an average of 1.6 times per day (Thibadeau et al., 1999). Dudley, Johnson, and Barnes (2002) found similar results when they gave a 9-year-old girl engaging in rumination access to unlimited quantities of starchy foods after she ate a meal.
Just like in Kenzer and Wallace’s (2007) study, satiation was the focus in the intervention used in 1975. Researchers Jackson, Johnson, Ackron, and Crowley (1975) were one of the first researchers to use a non-aversive procedure to treat rumination. The two participants in the study were introduced to a satiation procedure (i.e., double portions) until they met the satiation criteria. Jackson et al. (1975) defined the satiation criteria as the point in time when the participants refused food twice within a 1 min interval between food refusals. Unlike Kenzer and Wallace’s (2007) study, this study did not compare a satiation intervention with supplemental feedings on a fixed-time schedule. The results showed a 94% reduction of the target behavior for one participant and a 50% decrease for the other (Jackson et al., 1975).
Besides using food-based antecedent interventions, researchers have studied the effects of alternative antecedent-based interventions to treat rumination. Researchers Wilder et al. (2009) wanted to administer a flavor spray on a fixed-time interval while measuring the frequency of rumination. They, too, defined rumination to include re-swallowing of the regurgitated food and found that automatic reinforcement maintained the behavior. Dillion, a 37-year-old man, diagnosed with ASD, was taught to self-administer a flavor spray on a fixed-time 10 s interval. Therapists first administered the spray for Dillion until he was capable of doing it himself. The results concluded that the fixed-time delivery of a flavor spray could reduce rumination, but the researchers stated that because of the dense schedule (flavor spray every 10 s) and the reduction of rumination not being clinically acceptable, the intervention might not be practical to use when treating rumination (Wilder et al., 2009).
Different from other research found Wagaman, Williams, and Camilleri (1998) wanted to study the effects of reinforcing an incompatible behavior on rumination. Explicitly, the researchers taught diaphragmatic breathing to a 6 year-old-girl diagnosed with rumination disorder. They stated that the behavior of diaphragmatic breathing would be incompatible with rumination and would provide a simplified habit-reversal intervention. Habit-reversal interventions are considered antecedent interventions that are usually used in conjunction with a different intervention (Cooper et al., 2007). Using the habit-reversal approach encompasses three components: awareness training, an incompatible behavior, and social support. Reinforcement was given contingent on diaphragmatic breathing during the intervention. The results indicated that the participant did not engage in the target behavior for 107 days in a row. Researchers Thomas and Murray (2016) also integrated self-monitoring and diaphragmatic breathing in an intervention for a 27 year old woman engaging in rumination and intermittent binge eating. The participant reduced rumination during both baseline and active intervention phases. A 23-week post intervention follow up showed that the reduction of rumination was maintained (Thomas & Murray, 2016). It is important to note that the participants in these two studies were estimated to have average intelligence. Awareness training may not be as attainable for some individuals in the ASD population.
Besides antecedent procedures, punishment procedures have also been used to treat rumination. Cooper et al. (2007) define punishment as a stimulus change following a response that decreases the future frequency of similar responses. Professors of gastroenterology and hepatology at the Academic Medical Center in Amsterdam used punishment in the form of a loud tone to treat rumination in their formal research study (Smout & Breumelhof, 1990). The loud tone was administered contingent on a detected pressure in the participant’s stomach. The researchers stated that the pressure in the gastric-fundus (upper part of the stomach) was a physiological marker of rumination (Smout & Breumelhof, 1990). The results were insignificant with no improvements in rumination for the participant.
Another study that used punishment as an intervention technique found significant results. Foxx, Snyder, and Schroeder (1979) looked at the effects of using both food satiation and an oral hygiene punishment program. The methods of the study included the presentation of a Listerine-soaked toothbrush contingent on rumination behavior. Two people, both institutionalized for mental delays, participated in three conditions after lunch. Besides baseline, the conditions consisted of food satiation and food satiation plus oral hygiene. The procedures for the oral hygiene condition were as follows for both participants; after the rumination occurred, a verbal reprimand was given along with the demand to brush their teeth for 2 min with the Listerine-soaked toothbrush, and then wipe their face with a Listerine-soaked facecloth. What they found was that when the participants were subjected to the satiation condition after baseline, rumination decreased by an average of 40.7% for participant 1 and decreased by an average of 42% for participant 2. During the satiation plus oral hygiene condition, rumination dropped to 3% for participant 1 and 1.4% for participant 2 (Foxx et al., 1979). Ethical considerations concerning using this punishment intervention for other clients could be debated since participant 2 only had an average difference of 6.5% between the satiation program and the punishment program used.
Researchers Singh, Manning, and Angell (1982) based their research design on Foxx et al.’s (1979) previous study. They used the same procedures previously in place for the oral hygiene intervention for two boys, Paul and David. Following the implementation of the oral hygiene procedures after breakfast, lunch, and dinner, rumination was reduced dramatically, and stereotyped behavior increased spontaneously for both participants. The researchers stated that they did not reinforce stereotyped behavior and did not know the exact cause for the increase after the intervention was in place. The results showed a dramatic decrease in rumination for both men. Paul’s behavior decreased an average of 79%, and David’s behavior reduced an average of 82% from baseline (Singh et al., 1982).
Ethics and Integrity
The behavior analysis field is comparatively new when thinking about other helping fields such as psychology and education (Bailey & Burch, 2013). In the beginning, questions related to the ethics of the interventions used were not discussed. For example, literature published before 1980 relied heavily on using punishment to treat rumination. An astonishing number of articles published in the late 1960s and into the 1970s addressed treatment for rumination that primarily used electric shock punishment procedures (Galbraith, Byrick, & Rutledge, 1970; Kohlenberg, 1970; Lang & Melamed, 1969; Linscheid & Cunningham, 1976; Luckey, Watson, & Musick, 1968; Toister, Condron, Worley, & Arthur, 1975; White & Taylor, 1967). One could make the argument that by using punishment, the behavior analysts are following their obligation to provide individuals with the most effective treatment procedures available (Houten et al., 1988). Bailey and Burch (2010) would argue that using punishment is wrong in this situation because the client has the right to an effective, but most importantly, less restrictive treatment.
More recently, most of the research on rumination that has been published uses reinforcement and antecedent procedures instead of punishment. Ethically, researchers and practitioners in the field of behavior analysis know that using punishment when reinforcement produces significant results is wrong. Behavior analysts can damage the reputation of ABA if they practice unethical procedures to treat behaviors (Brodhead & Higbee, 2012). This not only includes refraining from using outdated procedures but also refraining from using scientific, critically analyzed methods.
Researchers in the field of behavior analysis have the ethical obligation to base all decisions for treatments and interventions on the science of behavior. Behavior analysts are required to keep up with new research that is being published and become familiar with past research that has already been published to stay compliant with both the PECC and the Teacher Standards (Behavior Analyst Certification Board, 2014; Missouri Department of Elementary & Secondary Education, 2013b). Subscribing to behavior analytical journals, keeping up with continuing education units, and attending conferences will help professionals stay current on outdated treatments and new interventions supported with statistically significant results.
After reviewing the published literature, it is evident that professionals in the fields of behavior analysis, psychology, and gastroenterology have all treated rumination. The assessments used depends on the researcher’s field of study. Gastroenterologists conduct tests to assess the functions of an individual’s livers, renal, abdomen, and blood before intervening in the behavior (Raha, Sarma, Thilakan, & Punnoose, 2017). Gastroenterologists such as Raha et al. (2017) might also look for esophageal obstructions, biliary tree obstructions, and pyloric stenosis. On the other hand, psychiatrists in the psychology field will use interviews, physical examinations, and a mental status examination (such as the Wechsler’s Intelligence Scale for Children) to assess what is causing the individual to engage in rumination (Raha et al., 2017; Wechsler et al., 2003). Behavior analysts use FBAs and FAs to assess rumination. The frequency of the behavior and the duration that an individual engages in the behavior have both been measured by professionals working with rumination. Kliebert & Tiger (2011) measured the duration of rumination for an individual they were working with to determine the percentage of the session with rumination. Duration data were collected at the onset of chewing and stopped 3 s after chewing ceased.
An FBA is systematic method used to gather information about the function of a problematic behavior (Cooper et al., 2007). It includes indirect assessments, descriptive assessments and experimental analyses. The assessment starts with interviewing key people involved including the client (if applicable), parents, teachers, personal care assistants etc. Behavior analysts will review medical history and treatment history to rule out medical reasons for the behavior. For rumination, individuals usually see gastroenterologists to see if there are other health reasons for the behavior. Next, behavior analysts or behavior technicians will collect ABC data. The ABC data may identify antecedent variables, reinforcement contingencies, and reinforcers for alternative replacement behaviors (Cooper et al., 2007). Sometimes the function of the behavior can be determined after collecting ABC data. Three strategies that are often used after FBA results are analyzed include altering antecedent variables, altering consequent variables, and teaching alternative behaviors (Cooper et al., 2007). With rumination, ABC data from current research was inconsistent and resulted in researchers relying on FA results.
An FA, the experimental analysis component of an FBA, is considered to be more scientific in that variables are manipulated. An FA usually consists of 4 conditions that reflect the different functions of behavior: attention, escape, alone (automatic), and control (Cooper et al., 2007). A control condition is used to set up an environment free from demands and with low reinforcement available. When rumination is assessed with an FA, researchers see the behavior occurring in all conditions. A behavior that occurs across all conditions is hypothesized to not be socially meditated and under automatic control (Cooper et al., 2007).
Behavior analysts are taught to conduct assessments when addressing a new behavior or working with a new client. Instead of assuming an individual’s rumination behavior is maintained by automatic reinforcement because almost all past research articles stated that their participant’s behavior was maintained by automatic reinforcement, the researchers in the articles discussed above conducted original FAs that were individualized to their participants. An FA can be a long process that involves interviews, direct observations, and experimental analysis (Cooper et al., 2007). Guessing the function of the behavior and starting a behavior intervention plan would be quicker than going through with the formal intervention assessment process. This is neither ethical nor fair to the individual. Even if the function of the behavior seems clear based on brief observations or interviews, professionals in the field might miss if the behavior is multiply maintained or if different environmental factors contribute to the behavior. Beavers and Iwata (2011) conducted a meta-analysis and found that 16.9% of subjects in past research studies met the criteria for engaging in a behavior that was maintained by multiple sources of reinforcement. It is known that when a behavior is multiply maintained by two different functions, both functions need to be addressed in the intervention so that the behavior is not being reinforced (Smith, Iwata, Vollmer, & Zarcone, 1993). The intervention created could produce only a slight reduction in the problem behavior if only one function is addressed (Bachmeyer, Piazza, Fredrick, Reed, Rivas, & Kadey, 2009; Day, Horner, & O’Neill, 1994).
Even though there is no research supporting rumination behavior being maintained by multiple sources of reinforcement, professionals working with individuals with this behavior should always conduct a new assessment for their client. As discussed earlier, the most common interventions developed for rumination are based on the hypothesis that the behavior is likely maintained by direct access to positive reinforcement in the form of automatic sensory input. Behaviors were once thought to all be socially mediated. Then in the 1990’s, researchers discovered that some behaviors were not socially mediated and instead were being maintained by direct access to reinforcement (Mason & Iwata, 1990). Today, rumination is treated as a direct access behavior which means that reinforcement is obtained directly from the problem behavior (Cipani & Schock, 2011).
There were different types of interventions used to treat rumination with significant results. What is lacking is an intervention plan that decreases rumination altogether or research that follows up after an extended period (i.e., more than 1 year). Before researchers Thibadeau et al. (1999) used a DRO schedule of reinforcement using white bread, Bill participated in multiple other interventions with no lasting results. Treatments used in the past for Bill included different types of DRO schedules, increased fluid consumption, the presentation of gum, the presentation of peanut butter during meals, an oral hygiene punishment procedure, and contingent aversive stimulation (Thibadeau et al., 1999). Even though some of these treatment plans resulted in a decrease in rumination, none of them was a permanent fix. Access to white bread was successful for Bill when it came to maintaining a low frequency of rumination. After a 9 month, 12 month, and 15 months follow up, Bill was ruminating on average .43 times per day. Research involving the oral hygiene implementation contingent on the target behavior found success in the follow-up assessments for multiple participants (Foxx et al.; Singh et al., 1982). Other researchers did not see as good of results and stated that the interventions used were not applicable to the natural setting (i.e., dense schedules of reinforcement or shock therapy) or there was no follow-up assessment noted in the article (Wilder et al., 2009). Wagaman et al.’s (1998) study was the only one that conducted a follow-up assessment and rumination reduced to 0%. The relaxation techniques were thought to have caused the reduction in the target behavior, but it should be noted that this study relied on self-reported frequencies of rumination and may not be as reliable as direct observation.
Measurement and Assessment
Researchers studying rumination behavior used single-subject experimental designs. Single-subject designs are used to validate clinical interventions. Different from group designs, single-subject research focuses on the functional relationships between independent and dependent variables (Horner, Carr, Halle, McGee, Odom, & Wolery, 2005). Single-subject research is thought to be experimental compared to case studies and observational studies that are correlational and descriptive. A case study is different than a single subject design because non-experimental observations occur that happen due to natural or personal causes. Internal validity of single-subject research can be achieved by confirmation of experimental control (Horner et al., 2005). By using ABAB reversal designs, multiple baseline designs, and alternating treatment designs, researchers can verify that the changes to the dependent variable are controlled by the experimental independent variable.
The importance of single-subject designs when researching topics in special education has been discussed in the literature. Horner et al. (2005) stated it is helpful to look at participants as individual units rather than a sample of a larger population. By using single-subject designs, causal relationships can be determined without more complex analysis such as normal distribution (Horner et al., 2005). Alnahdi (2013) stated that single-subject designs are flexible and cost-effective.
The difficulties of running single subject design experiments is that the sample size is minute, and the procedures used for one individual may not work for an entire population of people. Since this is true, external validity increases when researchers operationally define the participants, the reason the study was conducted, and the known function of the behavior prior to the intervention (Horner et al., 2005). Replication of known successful research studies could also help increase the external validity for rumination interventions. With rumination research, behavior analysts can determine what research to replicate with their own clients based on the operational descriptions of the study details. A client engaging rumination maintained by attention may not benefit from an intervention derived from a study that studied rumination behavior maintained by a different function. Still, researchers state that external validity and generalizability are the main concerns of single subject research designs (Alnahdi, 2013).
Finding a behavioral intervention for rumination behaviors socially valid is important. In a school setting, rumination can be considered gross by peers, unsanitary, and interruptive causing an individual to have to be removed from their peers or be removed from learning. Some of the interventions that reduced rumination are not socially valid due to the procedures used or the lack of significant reduction in the behavior. Social validity can be measured by the extent to which an intervention is chosen by behavior analysts (Carroll, 2014). Before the 1980’s, least restrictive procedures were not the primary concern and interventions such as electric shock therapy were chosen most often (Bailey & Burch, 2013; Galbraith, Byrick, & Rutledge, 1970; Kohlenberg, 1970; Lang & Melamed, 1969; Linscheid & Cunningham, 1976; Luckey, Watson, & Musick, 1968; Toister, Condron, Worley, & Arthur, 1975; White & Taylor, 1967). Electric shock therapy would not be considered an acceptable procedure to use today even if the results from past research state the procedure reduces rumination. Interventions that involve supplemental feedings for an extended period following a meal may not be applicable when the behavior occurs in a setting where an individual cannot receive one-on-one care for extended periods of time. Likewise, interventions that reduce the frequency of rumination but not to a statistically significant percent may not be accepted as effective enough to implement in the applied setting therefore the intervention would not be chosen often and would have little social validity (Carroll, 2014).
Behavior analysts need to decide how they want to measure rumination before they start with an intervention. Almost all of the articles researching rumination measure the frequency of rumination behaviors. One article, instead, measured the duration of rumination to get a better understanding of the percent of the session that rumination occurs. Cooper et al. (2007) label the number of responses emitted during an observation period as the frequency of the behavior. Frequency is used to measure rumination behaviors because each instance of rumination behavior omitted is repeatable and countable. It is thought that measurement helps behavior analysts answer questions, operationalize empiricism, and gage progress (Cooper et al., 2007). Without measuring the frequency of rumination, behavior analysts would not fully understand what effects the intervention had on the behavior.
Behavior analysts will also need to decide behavioral goals for the student. These goals will help behavior analysts stay on track and show when the intervention is considered mastered. A goal written well will be measurable and objective (Visualrealm, 2018). Clarifying time frames, stating the intended frequency of the behavior, and using observable language ensures the goal is measureable and objective. Refrain from using vague language and instead use specific descriptors. A goal stating that “rumination behaviors will decrease to a frequency of 2 times a session by the end of the school year” is more specific than “The behavior will decrease”. Important to rumination behavior, the goal should be realistic. There is research that believes rumination behavior can be considered habit (Chitkara Tilburg, Whitehead, & Talley, 2006). A goal that states rumination behavior should decrease to 0 occurrences after 2 days of the intervention” may not be realistic or achievable when a student has been engaging in rumination for the last 9 years after every meal.
Collaboration with Families and Stakeholders
Based on current and past research, rumination is commonly seen as a problem behavior for children with developmental disabilities such as ASD. Required by the Individuals with Disabilities Education Act (IDEA), students with disabilities between the ages of 3 and 21 are given an individualized education program (IEP) based on their needs (Felix & Tymeson, 2017). In an IEP, the student’s functional and academic levels are presented along with annual goals and the different educational services that will be provided. An IEP is comprised of many content areas depending on the special education and related services provided to the student (Felix & Tymeson, 2017). Typically, a BIP for rumination would be included into a student’s IEP. With annual goals and meetings, the IEP helps professionals work together on common goals to increase skills and appropriate behaviors for students.
Since BIPs are included in IEPs, after an intervention plan has been created for a client, behavior analysts will need to communicate with the other professionals who are a part of the IEP team. This typically includes paraprofessionals, parents, speech-language therapists, and occupational therapists. Behavior analysts will be in charge of providing training and materials needed to implement the intervention. To make sure that care providers and other professionals follow through with intervention plans, behavior analysts need to be flexible. Flexibility is appreciated in applied settings, and inflexibility is often punished with personnel failing to follow through on your requests and avoiding you in future circumstances (Cipani & Schock, 2011). The behavior is less likely to decrease if it receives reinforcement in other environments while one environment is using an intervention plan (Cipani & Schock, 2011).
Even after paraprofessionals and teachers are trained on intervention plans that should be followed, staff are prone to treatment drift. Treatment drift is defined as a person failing to implement the intervention as they were trained to do (McIntyre, Gresham, DiGennaro, & Reed, 2007). Therapist are also susceptible to observer drift which is defined as a decline in performance during data collection compared to during training (Taplin & Reid, 1973). Reid (1970) described the drift in therapist’s behavior has not as a continuous decline but rather a drop in performance followed by a stable level of performance (as cited in Taplin & Reid, 1973). Performing treatment integrity spot checks with the professionals in charge of implementing the treatment procedures and data collection can prevent treatment and observer drift. Results from a study looking at the effects of observer reliability conducted by Taplin & Reid (1973) found that reliability of the therapists to collect correct data and implement the treatment plan appropriately significantly increased when a supervisor conducted a spot check. Taplin & Reid (1973) also recommend to take into consideration that therapists may understand the treatment procedures during training with simple stimulus procedures but then could get confused when they are in the applied setting. Teaching antecedent intervention procedures may be more difficult to apply in the natural setting when working with rumination. Making sure that the definition is objectively defined, clearly written, and completely includes all “boundaries” (including exclusions) will help therapists when they are working in the natural, applied setting (Cooper et al., 2007).
Keeping up data collection and following through with the intervention plan until goals are met is important for individuals with any problem behavior and not only rumination behaviors. It is common for behavior analysts to incorporate reinforcement during behavior skills training to ensure that therapists and paraprofessionals are implementing the intervention appropriately and consistently. Examples of reinforcement schedules include a paraprofessional getting their name entered in a drawing to win a gas card contingent on passing a treatment integrity spot check. Another example of reinforcement used is paraprofessionals receiving company fake money when interventions are implemented consistently over a large time period. The company fake cash is then exchanged for goods or abstract things like extra breaks.
Working closely with the community and families can also bring about available resources that might not have been known otherwise. Other people might have resources or leads to ideas when they know what you are interested in. An individual diagnosed with ASD, engaging in rumination behaviors, and attends a special education classroom has a team of individuals who are impacted by this individual’s behavior. This could include parents, behavior analysts, speech therapists, occupational therapists, physician, gastroenterologist, paraprofessionals, teachers, camp counselors. If all these stakeholders networked with each other to collaborate about rumination, the amount of resources and ideas being shared would be dramatic.
Not only do behavior analysts have valuable skills and diverse knowledge that could be helpful to other professionals in the community and other stakeholders, but the other professionals have specific skills and knowledge that could benefit behavior analysts. Behavior analysts may also need to shift priorities and resources after they discover what has already been researched or what other people are already doing to address the problem. After bringing up the topic of rumination at a meeting with psychology professors at Lindenwood University, a professor shared names of researchers that she knows has worked with rumination. Networking researchers Provan, Veazie, Staten, and Teufel-Shone (2005) state that collaboration with the public can help people understand the range of problems and needs that the community faces. Community leaders and public and nonprofit organizational administrators are responsible for working towards building and sustaining networks that addresses health, social, and other problems in the community (Provan et al., 2005). Provan et al. (2005) recommend using network analysis to examine the relationship between organizations. Network analysis is defined as a data collecting procedure that compares individuals and organizations and how they are connected (Provan et al., 2005). Lindenwood University’s Student Learning Outcome Standard 4 states that community resources are necessary not only for student achievement but also for the achievement of the behavior analysts’ goals. Understanding what other stakeholders already know about the behavior, what they have already done to understand the behavior, and what problems they face with people engaging in the behavior is a crucial part of fully understanding the impact of rumination and what can be researched to help people afflicted with it.
Teaching and Learning
Personal learning and academic growth does not end when a student walks across the stage at their graduation. Specifically to behavior analysts, additional training beyond the requirements for graduation from a behavior analysis program is required in order to maintain certification through the Behavior Analyst Certification Board (“Maintaining BCBA Certification”, 2018). The specific number of Continuing Education Units (CEUs) needed depends on the level of education the practitioner has. CEUs guarantee that behavior analysts continue expanding their behavior-analytical skills (“Continuing Education”, 2018). Even though academic development may seem like it has come to an end, professional development will be more prominent and still require learning. Continuing to research the topic of rumination to increase the awareness of different intervention options available for individuals engaging in rumination behaviors will not only increase one’s professional development but also improve the education experience for the student (“Student Learning Outcomes”, n.d.).
Professional development with other professionals that behavior analysts will work with is also important to continue working on.It has been seen in the field that school professionals and home therapists currently do not have a set of rigid collaboration standards. Developing a new set a guidelines for more meetings (other than an Individualized Education Program meeting) and communication could potentially increase a student’s progress. Something that sets up more days that the different therapists can share the student’s progress together, and a stronger communication system to share program ideas and what has and has not worked with the student would benefit all involved. Currently, there are strategies used to increase the collaboration between speech-language pathologists (SLPs) and occupational therapists (OTs) in the school setting but the collaboration between different therapists in different settings is not strong (Jordan & Lofland, n.d.). All professionals involved with a student have the same goal, to increase the student’s success in a targeted skill. As long as the student and the student’s caregivers give permission to discuss information, why not increase the communication and update other people involved on progress and regression?
There has been an initiative to use more behavior analytical techniques in a school wide settings. Researchers Sprague and Horner (2007) have developed a practice based on research to use positive behavioral supports to increase students’ appropriate positive behaviors. This idea, termed School Wide Positive Behavioral Supports (SWPBS), revolves around faculty teaching and modeling expected behavior to students school wide. This approach incorporates prevention, multi-tiered support, and data-based decision making (Sprague & Horner, 2007). It is amazing to see that the approach incorporates ABA fundamental techniques such as: using incentives, incorporating motivational systems, providing staff training with constructive feedback, systems in place to measure and monitor effectiveness, scheduled instruction and assistance to students based on their individualized needs and differences, and long term staff commitment. This system does talk about how office referrals and suspensions may work short term but are not long term solutions to antisocial behavior. Sprague and Horner (2007) back up their opinion about punishment by referencing research articles that have found when punishment is used alone in school settings, antisocial behaviors such as vandalism, aggression, truancy, and dropout increase.
Rumination behaviors could also benefit from the SWPBS approach. More research could look at the effects of explaining the consequences of rumination to the individual engaging in the behavior. A key practice to SWPBS is clear definitions of the behavior and the consequences involved (Sprague & Horner, 2007). This may not be beneficial for some individuals who have low levels of communication or awareness of cause and effect.
There is more research published than expected studying effective interventions to treat rumination disorders. The behavior falls into different categories of treating physicians including behavior analysis, psychology, and gastroenterology. The interventions discussed in current literature have not been replicated (or at least no replication has been published) and the interventions do not significant longevity results. The need for an effective treatment for rumination is critical to individuals engaging in the behavior considering that the effects of rumination are damaging to one’s health and have even been life threating. When individuals engage in rumination, they stand out from their peers. Regurgitating previously swallowed food is not socially acceptable behavior and is often considered repulsive to witnesses. More research needs to be conducted on interventions effective in treating rumination.
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