behavioral interventions for rumination and operant vomiting in individuals with intellectual...

Research in Developmental Disabilities 32 (2011) 2193–2205

Contents lists available at ScienceDirect

Research in Developmental Disabilities

Review article

Behavioral interventions for rumination and operant vomiting inindividuals with intellectual disabilities: A systematic review

Russell Lang a,b,*, Austin Mulloy b, Sanne Giesbers c, Brooke Pfeiffer a,Elizabeth Delaune a, Robert Didden c, Jeff Sigafoos d, Giulio Lancioni e, Mark O’Reilly b

a Texas State University-San Marcos, Clinic for Autism Research Evaluation and Support, United Statesb The Meadows Center for the Prevention of Educational Risk, University of Texas at Austin, United Statesc Radboud University Nijmegen, The Netherlandsd University of Wellington, New Zealande University of Bari, Italy

A R T I C L E I N F O

Article history:

Received 15 June 2011

Accepted 16 June 2011

Available online 13 July 2011

Keywords:

Rumination

Vomiting

Emesis

Regurgitation

Developmental disabilities

Behavioral intervention

Systematic review

A B S T R A C T

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.

� 2011 Elsevier Ltd. All rights reserved.

Contents

1. Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2195

1.1. Search procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2195

1.2. Inclusion and exclusion criteria. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2195

1.3. Data extraction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2195

1.4. Reliability of search procedures and inter-coder agreement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2196

2. Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2196

2.1. Participants, intervention agents, and settings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2201

2.2. Dependent variables. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2201

2.3. Functional assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2201

2.4. Intervention procedures and outcomes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2201

2.5. Certainty of evidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2202

3. Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2202

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2204

* Corresponding author at: Texas State University-San Marcos, Department of Curriculum and Instruction, 601 University Dr, San Marcos, TX 78666,

United States.

E-mail address: [email protected] (R. Lang).

0891-4222/$ – see front matter � 2011 Elsevier Ltd. All rights reserved.

doi:10.1016/j.ridd.2011.06.011

http://dx.doi.org/10.1016/j.ridd.2011.06.011

mailto:[email protected]

http://www.sciencedirect.com/science/journal/08914222

http://dx.doi.org/10.1016/j.ridd.2011.06.011

R. Lang et al. / Research in Developmental Disabilities 32 (2011) 2193–22052194

Rumination is the deliberate regurgitation, chewing, and swallowing of stomach contents, and vomiting is the expulsionof regurgitated stomach contents from the mouth (Ellis, Parr, Singh, & Wechsler, 1997). Rumination can occur in typicallydeveloping children but is more common among individuals with intellectual and developmental disabilities (Tierney &Jackson, 1984). When rumination occurs in typically developing children, it often begins and ends early in life; however,rumination in individuals with intellectual disabilities often begins later in life and persists (Winton & Singh, 1983). Anestimated 6–10% of people with severe intellectual disabilities who live in residential treatment facilities engage inrumination (Singh, 1981; Winton & Singh, 1983).

Serious health risks related to vomiting and rumination include malnutrition, weight loss, dehydration, tooth decay,choking, gastrointestinal bleeding, and even death (Fredericks, Carr, & Williams, 1998; Kanner, 1972; Starin & Fuqua, 1987;Singh, 1981). Rumination is the primary cause of death in 5–10% of people who ruminate (Fredericks et al., 1998). In additionto adverse health effects, vomiting and rumination may also result in social isolation and reduced educational or vocationalopportunities by hindering a person’s appearance and causing foul odors due to frequent contact with vomitus (Starin &Fuqua, 1987).

Fredericks et al. (1998) provided an overview of the medical, psychiatric, and behavioral approaches used in thediagnosis and treatment of rumination and vomiting. Fredericks et al. emphasized that rumination and vomitingmaintained by operant contingencies should be distinguished from other types of regurgitation behaviors that arecaused by drug side effects, illness, and other physiologic etiologies. For example, some medications that are commonlyprescribed to individuals with disabilities may interfere with esophageal functioning and cause regurgitation thenrumination or vomiting (Rogers, Stratton, Victor, Kennedy, & Andres, 1992). In cases in which rumination and vomitingoccur due to medical or physiological problems, behavioral interventions may be ineffective and even dangerous if theprimary medical cause is ignored or not identified (Rogers et al., 1992). Therefore, prior to implementing a behavioralintervention for vomiting or rumination, medical causes should be systematically evaluated (Fredericks et al., 1998;Fredericks & Hayes, 1994).

When medical evaluations rule-out potential physiological causes, rumination is considered to be maintained byoperant contingencies and may be ameliorated via behavioral interventions (Weiss, 2002). Three known systematicreviews of behavioral interventions for rumination and operant vomiting have been published. Winton and Singh (1983)reviewed behavioral interventions and found that punishment (e.g., electric shock and liquid irritants) was the mostcommonly researched intervention for the treatment of rumination in pediatric populations. Tierney and Jackson (1984)reported that food satiation procedures and punishment were commonly used treatments, but that it was difficult toevaluate the effects of many of these treatment studies because of methodological weaknesses such as the lack ofexperimental design, inadequate reliability measures, and lack of generalization and maintenance data. Starin and Fuqua(1987) reviewed medical, psychiatric, and behavioral interventions and found that medical interventions were effectiveonly when a specific organic pathology was identified and that the psychiatric intervention research contained too manymethodological flaws to allow for definitive conclusions. Starin and Fuqua also reported methodological weaknesses inthe behavioral intervention research, but were still able to conclude that behavioral interventions may be effective insome cases.

Across the previous reviews on this topic, punishment interventions (e.g., electric shock and liquid irritants) wereamong the most commonly researched approaches to treatment. However, research involving punishment forrumination and operant vomiting has raised a number of concerns. For example, although contingent electric shock hasbeen found to be effective in immediately reducing rumination, failures to maintain reductions and negative side effects(e.g., crying and self injury) were often reported (Tierney & Jackson, 1984). Caution in use of liquid irritants (e.g., lemonjuice, liquid peppers) is also warranted due to concerns that these substances have the potential to exacerbate thecommon internal injuries (e.g., gastrointestinal bleeding) found in people who frequently regurgitate (e.g., Foxx, Snyder,& Schroeder, 1979).

Across the field of intellectual disabilities, intervention studies involving aversives have become less common over thepast 20–25 years (Matson & Taras, 1989). In the rumination and operant vomiting intervention research, there has been anincrease in the use of diet manipulations (e.g., increasing caloric intake, changing food texture, and/or restricting access tocertain foods or liquids) (Fredericks et al., 1998; Starin & Fuqua, 1987). Based upon previous reviews, when dietmanipulation and differential reinforcement interventions failed, clinicians attempting to treat rumination and/or operantvomiting may be left with very few desirable research-based treatment options. For example, Mudford (1995) describes acase in which a 31-year-old man was treated for life threatening operant vomiting maintained by automatic reinforcement.The treatment team applied for a court order to evaluate an intervention that included electric shock. The court denied therequest, but did not identify an alternative nonaversive intervention. Consequently, the man was subjected to an invasivemedical procedure (chronic nasogastric intubation), arguably more intrusive and restrictive than the electric shockprocedure that was denied by the New Zealand courts (Mudford, 1995).

This current systematic review addresses the need to identify research-based behavioral interventions for ruminationand operant vomiting and extends previous reviews in three ways. First, this review will cover the intervention researchpublished after Starin and Fuqua’s 1987 systematic review. Second, this review focuses solely on the use of behavioralinterventions with individuals with intellectual disabilities. Finally, this review is the first to calculate effect sizes forreductions in rumination. A review of this nature is intended to guide and inform clinicians in assessing and treating thesebehaviors and to identify areas in need of future research.

R. Lang et al. / Research in Developmental Disabilities 32 (2011) 2193–2205 2195

1. Methods

A systematic review of studies that involved the treatment of rumination and vomiting in individuals with developmentaldisabilities was conducted.

1.1. Search procedures

Systematic searches were conducted within four electronic databases: Medline, Education Resources Information Center(ERIC), Psychology and Behavioral Sciences Collection, and PsycINFO. Publication year was restricted to studies publishedafter a previous review on the same topic in 1987 (i.e., Starin & Fuqua, 1987). The search was also limited to peer-reviewedstudies written in English. In all four databases, the terms ‘‘rumination’’ or ‘‘vomiting*’’ or ‘‘emesis’’ or ‘‘regurgitation’’ plus‘‘developmental disabil*’’ or ‘‘intellectual disabil*’’ or ‘‘developmental disorder’’ or ‘‘retardation’’ or ‘‘retarded’’ or ‘‘autis*’’ or‘‘syndrome’’ were inserted as free text into the keywords field. The abstracts of the resulting studies were reviewed toidentify studies for inclusion (see Section 1.2). The reference lists for studies meeting these criteria were also reviewed toidentify additional articles for possible inclusion. Hand searches, covering January to March 2011, were then completed forthe journals identified in the databases that had published studies included in the review. Searchers of databases, journals,and reference lists occurred during March and April 2011. A total of 114 abstracts were identified for possible consideration.

1.2. Inclusion and exclusion criteria

In order to be included in this review, a study had to meet the following three inclusion criteria. First, the study had tocontain at least one participant diagnosed with an intellectual disability. Second, the study had to implement a behavioralintervention intended to decrease vomiting and/or rumination. Behavioral intervention was defined as the implementationof procedures that involved one or more of the following changing a participant’s environment, programming specificcontingencies of reinforcement or punishment, and altering practices or routines related to mealtime or other relevantantecedent variables. Vomiting was defined as the regurgitation of stomach contents and expelling vomitus from the mouth(Baker, Rapp, & Carroll, 2010). Rumination was defined as the chewing, swishing, or swallowing of vomitus (Fredericks et al.,1998). Finally, the study had to be published after 1987 in order to avoid overlapping content with a previous review (i.e.,Starin & Fuqua, 1987).

Studies were excluded for the following three reasons. First, studies investigating only medications and/or surgicalinterventions were excluded unless delivered in comparison to or in tandem with a behavioral intervention (e.g., Wijetilleke,Sakran, & Kamat-Nerikar, 2009). This was done in order to focus on behavioral treatments that can be implemented bybehavior analysts and other similar professionals once medical causes for vomiting and rumination are ruled out. Second,studies investigating risk factors and/or describing prevalence of rumination were excluded if they did not also implement abehavioral intervention (e.g., Humphrey, Mayes, Bixler, & Good, 1989). Finally, studies in which data on vomiting andrumination were combined with other topographies of problem behavior were excluded, because the effect on vomiting andrumination alone could not be determined (e.g., Foxx & Garito, 2007).

1.3. Data extraction

Each study identified during the systematic search was first assessed for inclusion or exclusion. Studies selected forinclusion in this review were summarized in terms of the (a) participant characteristics, (b) dependent variables, (c)intervention procedures, (d) functional assessment procedures and results, (e) intervention outcomes, and (f) certainty ofevidence. Various procedural aspects were also noted, including experimental design, treatment fidelity, social validity, andinter-observer agreement (IOA). Because all of the studies that met inclusion criteria used single-case research designs(Hersen & Barlow, 1976), intervention outcomes were summarized by calculating the Nonoverlap of All Pairs (NAP; Parker &Vannest, 2009).

NAP is an index of data overlap between single-subject design phases similar to Percent of Nonoverlapping data (PND;Scruggs & Castro, 1987), Percent of All Overlapping Data (PAND; Parker, Hagan-Burke, & Vannest, 2007), and PercentageExceeding Median (PEM; Ma, 2006). However, NAP equals or outperforms PND, PAND, and PEM (Parker & Vannest, 2009). Forexample, NAP is more robust than PND, PAND, and PEM to the influence of outliers (e.g., maximum values appearing one timeduring baseline). The addition of a single outlier to a data set can greatly alter PND, PAND, and PEM values, while the NAPstatistic will not be substantially skewed. Consequently, NAP can more accurately represent the dominant trends in data.

NAP is calculated by comparing every baseline ‘‘A’’ data point with every intervention phase ‘‘B’’ data point. In studies oftreatments designed to decrease behavior (e.g., rumination), a ‘‘nonoverlapping pair’’ is an ‘‘AB’’ pair in which the ‘‘B’’ point islower than the ‘‘A’’ point. The NAP is calculated by summing the number of comparison pairs not showing overlap and one-halfthenumberof tiedcomparison pairs,and then dividingby the total number ofcomparisons. Mathematically, NAPisexpressedas:

NAP ¼ ðNA � NBÞ � ðO � :5½T�ÞNA � NB


where NA is the number of data points in the ‘‘A’’ or baseline phase, NB is the number of data points in the ‘‘B’’ or treatmentphase, O is the number of nonoverlapping pairs of data points from ‘‘A’’ and ‘‘B’’ phases, and T is the number of comparisons inwhich both data points have the same y-value/dependent score.

Using the guidelines for interpretation recommended by Parker and Vannest (2009), NAP scores between 0 and 65% canbe classified as ‘‘weak effects’’, 66–92% as ‘‘medium effects’’, and 92–100% as ‘‘strong effects’’. For more complete details onNAP calculation procedures and statistical validation see Parker and Vannest (2009).

Single-case designs for which the data could not be summarized with NAP calculations due to the nature of the grapheddata (e.g., no baseline phase) were classified via visual analysis of data trends as either ‘‘positive’’, ‘‘negative’’, or ‘‘mixed’’results (Lancioni, O’Reilly, & Emerson, 1996). These studies were considered to have positive results if a decrease in vomitingand rumination was observed for all participants in the study, negative if vomiting and rumination did not decrease for anyparticipants, and mixed if some participants experienced clinically significant reductions in vomiting and rumination andother participants did not (e.g., Rhine & Tarbox, 2009).

Certainty of evidence was evaluated by considering main findings in light of the research design and other methodologicaldetails. The ability of a study to provide certainty of evidence was rated as either ‘‘suggestive’’, ‘‘preponderant’’, or ‘‘conclusive’’(Schlosser, 2009; Simeonsson & Bailey, 1991; Smith, 1981). This classification system was applied in an effort to provide anoverview of the quality of evidence across the corpus of reviewed studies (Schlosser & Sigafoos, 2007). The lowest level ofcertainty is classified as suggestive evidence. Studies within this category might have used an AB or intervention-only designs,but did not involve a true experimental design (e.g., multiple-baseline or an ABAB design). The second level of certainty wasclassified as preponderance of evidence. Studies within this level had the following four attributes: (a) experimental designs, (b)adequate inter-observer agreement and treatment fidelity (i.e., 20% of sessions with 80% or better agreement), (c) operationallydefined dependent variables, and (d) enough detail to enable replication. However, studies classified at the preponderance levelalso had substantial limitation(s) in controls against alternative explanations for intervention outcomes. The final level ofcertainty was classified as conclusive. Within this level studies contained all of the attributes of the preponderance level, butalso attempted to control for alternative explanations of intervention effects such as controlling for the potential effect ofincreased attention from caregivers when providing longer meal times during diet manipulations.

1.4. Reliability of search procedures and inter-coder agreement

In order to ensure the accuracy of the systematic search, co-authors screened the abstracts of the 114 studies that resultedfrom the initial database and hand searches. Of the 114 studies, 26 were selected for possible inclusion based solely upontheir abstracts. For these remaining 26 studies, co-authors independently evaluated the complete article using the inclusionand exclusion criteria. Agreement as to whether a study should be included or excluded was 88% (i.e., agreement wasobtained on 23 of the 26 studies). The three disputed articles were discussed until 100% agreement was reached.

Ultimately, five studies from the pool of 26 studies were excluded. Two studies were excluded because they weredesigned to identify variables associated with the occurrence of rumination, but did not implement an intervention(Humphrey et al., 1989; Johnston & Greene, 1992). Curtis (2005) was excluded because only a psychopharmacologicalintervention (i.e., fluvoxamine) was implemented. Foxx and Garito (2007) was excluded because the data on operantvomiting was combined with other topographies of problem behavior and the effect on vomiting alone could not bedetermined. Finally, Mudford (1995) was excluded because the details (data and experimental design information) were notincluded in the article. The purpose of Mudford’s case study was to describe the background and ethical issues surrounding atreatment team’s desire to use punishment and the consequences of a court decision that prevented the use of punishment.

After the final list of 21 studies was agreed upon, information was extracted by the first and second author to develop aninitial summary of each study. In order to ensure the accuracy of these summaries, co-authors who did not participate in theinitial data extraction, used a checklist designed to evaluate the accuracy of every summary. The checklist included sixquestions regarding various details of the study. Specifically: (a) Is this an accurate description of the participants? (b) Is thisan accurate description of the intervention procedures? (c) Is this an accurate description of the functional assessmentprocedures and results? (d) Is this an accurate description of the dependent variables? (e) Is this an accurate description ofthe outcomes? And, (f) is this an accurate description of the certainty of evidence? In cases where the summary was notconsidered accurate, the summary was edited to improve its accuracy. This process was continued until co-authors were in100% agreement regarding the accuracy of the summaries. The resulting summaries were then used to create Table 1.

This approach was intended to ensure accuracy in the summary of studies and to provide a measure of inter-coderagreement on data extraction and analysis. There were 126 items on which there could be agreement or disagreement (i.e.,21 studies with 6 checklist items per study). Initial agreement was obtained on 118 items (93.6%) and then corrected untilco-authors were in 100% agreement.

2. Results

The systematic search procedures and the application of the predetermined inclusion and exclusion criteria resulted inthe inclusion of 21 studies in this review. Table 1 summarizes: (a) participant characteristics, (b) dependent variables, (c)functional assessment procedures and results, (d) intervention procedures (e) intervention outcomes, and (f) certainty ofevidence of the 21 included studies.

Table 1

Summary of included studies.

Citation Participant characteristics Dependent variables Functional assessment (FA) and intervention

procedures (IP)

Outcomes and certainty of evidence (CoE)

Baker et al. (2010) 1 male, 8 years old, with

autism

Ma number of vomits per

week

FA: Vomiting was shown to persist in the absence

of social consequences during consecutive no-

interaction sessions (Iwata and Dozer, 2008).

Outcomes: NCRb with preferred items and

DROc + timeout were not successful. Contingent

mouthwash was briefly effective (NAP = 25.1),

but vomiting returned to baseline levels. Sensory

Extinction reduced vomiting to zero (NAP = 88.3).

Effects were maintained at 4 months and

generalized from home to school.

IP: Contingent mouthwash and sensory

extinction in which a visual screen was used to

block the participant’s view of his vomitus for 30

s.

CoE: Suggestive, due to pre-experimental design.

Clauser and Scibak

(1990)

3 males, ages 22, 33, and

40 years old, all with

profound intellectual

disability

Rate of ruminations per

hour for 2 participants

and number of 10 s

intervals with rumination

for 20 min following

meals for 1 participant;

frequency of other self

injurious behaviors

IP: During each meal participants were given

access to food until they stopped eating for 2 min

(food satiation). Over time, the intervention was

gradually faded so that less additional food was

used.

Outcomes: Rumination was reduced for all

participants (M NAPd = 84.8, range 72.8–92.4). A

decrease in other self injurious behaviors was

also reported. The intervention was still in place

and reported effective after 4 years.

CoE: Preponderance, due to a lack of additional

controls for alternative explanations (e.g.,

increased attention from staff during extra meal

time).

Dudly et al. (2002) 1 female, 9 years old, with

autism

Frequency of ruminations

during 50 min sessions

following meals

IP: A satiation procedure involving free access to

two types of foods high in starch was provided in

addition to regular meals until 3 min passed in

which the participant did not approach food.

Outcomes: Rumination was reduced (M

NAP = 98.6, range 91.7–100).

CoE: Preponderance, due to absence of additional

controls for alternative explanations (e.g., unclear

if effects were due to increased calories or

matched stimulation)

Dunn et al. (1997) 1 male, 24 years old, with

Down Syndrome and


disability

Percentage of intervals

containing rumination


following meals

IP: A satiation procedure in which free access to

foods high in starch (e.g., potatoes & pasta) and

then to fruits and vegetables was given in

addition to regular meals. Free access periods

lasted until 1 min without eating. Food quantity

was gradually reduced to control weight gain.

However, due to an increase in rumination, free

access was offered again after 2 years.

Outcomes: Starchy food access reduced

rumination. When switched to fruits and

vegetables rumination remained low (NAP = 100).

The intervention was still in place and reported

effective after 7 years.

CoE: Suggestive, baseline has only one data point

Greene et al. (1991) 4 males, 1 female, ages 22,

31, 37, 45, and 53 years

old, all with severe/


disability

Frequency of rumination


following meals

IP: Peanut butter was given during meals. To

determine whether the increased caloric intake or

the consistency of peanut butter reduced

rumination, participants were exposed to a

sequence of conditions that varied in caloric

content, quantity of peanut butter, and

consistency of peanut butter.

Outcomes: Results suggest an inverse relation

between rumination and quantity of peanut

butter consumed. Calories appeared to more

important than texture. The M NAP for reduction

in rumination using low calorie peanut butter

was 56.3 compared to M NAP of 82 for high

calorie.


controls for alternative explanations

Heering et al. (2003) 1 male, 19 years old, with

autism and profound

intellectual disability


during 1 h sessions

following meals and

consumption of liquid

IP: Results of a pre-intervention assessment

suggested rumination was less likely if the

participant did not consume liquid during meals

and when he did consume peanut butter during

meals. Liquids were withheld until 1.5 h after

mealtime.

Outcomes: Rumination was reduced during lunch

and breakfast (M NAP = 100).

CoE: Preponderance, due to AB design during

lunch (ABAB during breakfast), limited number of

data points, and no additional controls for

alternative explanations.

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Table 1 (Continued )


procedures (IP)


Johnston et al. (1991) 2 males, 1 female, ages 30,

40, and 44 years old, with


disability



following meals

IP: Increased caloric intake from 750 to 900

calories per meal to 2800–3000 calories per meal

by adding oils, sugars, and/or Polycose (a tasteless

calorie supplement).

Outcomes: Increased caloric intake reduced

rumination during lunch (M NAP = 69).

CoE: Conclusive, use of caloric additives allowed

for other variables (e.g., attention, and extended

mealtimes) to remain the same across phases.

Kelly and Heffner

(1988)

1 male, 24 years old, with


disability

Weight gained and

frequency of rumination

during 30 min meal

sessions

IP: Attention-based intervention involved: (a)

30 min of NCR staff attention, (b) 2 min of no

attention contingent on vomiting, and (c) 2 min

delay on cleaning and removing vomitus.

Outcomes: A food satiation intervention was

attempted first but had no effect on rumination.

Attention-based intervention reduced

rumination (N MAP = 83.3), weight increased

from 72 pounds (life threatening) to 97 pounds.

Effects were maintained at 2 months.

CoE: Suggestive, baseline has only one data point

Kenzer and Wallace

(2007)



disability and visual

impairment


during 30–60 min

sessions following meals

FA: An analogue functional analysis (Iwata et al.,

1994) suggested rumination was maintained by

automatic reinforcement.

Outcomes: Supplemental feedings reduced

rumination (M NAP = 100) and larger food

portions during regular mealtime did not (M

NAP = 0).

IP: Access to larger portions of food during meals

was compared to supplemental post-meal

opportunities to eat.

CoE: Preponderance, the functional analysis data

suggests that rumination may function to obtain

attention (instead of or in addition to an

automatic function). Staff gave attention when

delivering food during supplemental feeding,

however, no additional attention was provided

during the increased food portions phase.

Attention from staff may have been responsible

for the reduction in rumination.

Lockwood et al. (1997) 1 female, 34 years old,

with severe intellectual

disability

Daily frequency of

vomiting and average

monthly weight

FA: A descriptive functional analysis (Iwata et al.,

1990) using narrative event recording suggested

vomiting was maintained by escaping demands

made by staff.

Outcomes: Escape extinction and antecedent

control reduced vomiting (M NAP = 77.8) and

when choice making opportunities were added

vomiting was further reduced (M NAP = 100).

Effects generalized across settings and were

maintained at 3 years.

IP: Intervention components were implemented

in 3 phases; (a) a correction procedure involving

cleaning vomit and differential reinforcement, (b)

added escape extinction and antecedent control

(allowing participant arrange environment), and

(c) choice making opportunities for what foods to

eat

CoE: Suggestive due to pre-experimental design

Luiselli et al. (1993) 1 male, 13 years old, with

encephalopathy, atonic

diplegia, pseudobular

palsy, and severe


Daily frequency of

vomiting and rumination

IP: Treatment involved a combination of dietary

manipulations (i.e., limited liquid, removal of

dairy, and removal of spicy foods), medication

(i.e., antacid before and after meals and 5 cc of

Reglan and Cimetidine administered prior to

meals) and behavioral intervention strategies.

Behavioral intervention components included

individual attention during meal times, paced

access to food to slow consumption, and

contingent reprimand.

Outcomes: Rumination decreased (NAP = 74.5)

and vomiting decreased (NAP = 93.8). The pacing

between bites and liquid restriction procedures

were gradually reduced and in the final phase of

intervention rumination and vomiting were

further reduced (NAP = 95.7 and 98.5,

respectively). Results were maintained at 2 years.

CoE: Suggestive, due to pre-experimental design

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Luiselli et al. (1994) 1 male, 15 years old, with

autism and severe


Daily frequency of

rumination and vomiting

IP: A multicomponent medical and behavioral

intervention that included; (a) 40 mg of antacid

(Pepcid) for esophagitis (later reduced to 20 mg),

(b) dietery restrictions (i.e., reductions of fatty

foods and lactose), (c) increased portions of

acceptable foods, (d) change in eating

environment from a group setting to 1 on 1

setting, (e) pacing of food presentation to ensure

the participant ate at a slower rate, (f) attention

was denied or withdrawn following ruminating,

and g) participant was made to participate in

cleaning the vomitus.

Outcomes: Rumination was reduced (NAP = 89.7)

and vomiting was reduced (NAP = 75.5). Results

were maintained at 4 months.


Lyons et al. (2007) 2 males, ages 11 and 14

years old, 1 with severe

developmental delay, and

1 with autism and



with rumination during

15 to 30 min sessions.


1994) suggested rumination was maintained by

automatic reinforcement.

Outcomes: The chew ring was initially effective

with 1 participant but the effects were not

maintained (M NAP = 50). Supplemental feeding

reduced rumination (M NAP = 100). Intervention

was maintained at 3 months.

IP: Access to a chew ring intended to match the

automatic reinforcement plus a supplemental

feeding session that involved giving access to

food and liquids on a fixed schedule.

CoE: Suggestive, due to limited baseline data for

second participante and it was unclear if the

effects were due to matched stimulation or

increased caloric intake.

Rast et al. (1988) 3 females, ages 19, 23, and

24 years old, all with

severe intellectual

disabilities and 2 with

severe visual and hearing

impairment


minute for 30 min

sessions following meals

IP: The reinforcer maintaining rumination was

hypothesized to be the oropharyngeal

stimulation obtained via chewing. Sugarless

bubble gum was used to allow participants to

engage in chewing before meals. This was

intended to decrease the reinforcing effectiveness

of chewing (abolishing operation).

Outcomes: Premeal gum chewing reduced

rumination (M NAP = 92.2)f

CoE: Conclusive, the potential influence of

calories was controlled.

Rhine and Tarbox

(2009


autism


hour during in home

therapy sessions

IP: Participant was taught to chew gum and given

gum during sessions.

Outcomes: Visual analysis suggests that the

results were positive because sessions in which

gum was made available consistently contained

in less rumination.

CoE: Preponderance, NAP could not be calculated

due to absence of baseline data; alternative

explanations for reduction in rumination were

not controlled

Sanders-Dewey and

Larson (2006)

1 male, 20 years old,

severe intellectual


impairment



following meals

IP: Positive verbal attention plus access to a

preferred drink was provided contingent upon

periods of time without rumination and an

aversive (sour drink) was given contingent upon

rumination or pre-rumination behaviors.

Outcomes: Rumination was reduced (NAP = 96.5)

and aversive components of intervention were

gradually removed or reduced. Effects were

maintained at 8 days.


Thibadeau et al. (1999) 1 male, 18 years old, with

severe intellectual

disability, cerebral

gigantism, and described

as having ‘‘autistic

features’’

Daily frequency of

ruminating and vomiting

IP: A food satiation procedure that involved

giving the participant access to extra food (white

bread) upon request for 1 h following each meal.

Outcomes: Access to bread upon requested

reduced rumination (NAP = 95.2). At 15 months

the intervention was still effective and bread

consumption was reduced but not eliminated.


controls for alternative explanations

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99

Table 1 (Continued )


procedures (IP)


Wilder et al. (1997) 1 male, 46 years old, with

severe intellectual


impairment


containing rumination


Three interventions were compared; (a) NCR with

food every 20 s for 30 min following meals, (b)

competing stimulation (taking a shower where

participant normally would sing), and (c) reduced

liquid intake.

Outcomes: The most effective of the three

interventions was NCR with food every 20 s for

30 min immediately following meals (NAP = 100).

Competing stimulation via access to shower had

the weakest effect (NAP = 49.1). Liquid restriction

was associated with a medium effect

(NAP = 83.9).

CoE: Conclusive, the alternating treatment design

was embedded within an ABAB design

Wilder et al. (2009) 1 male, 37 years old, with

autism and severe




following meals


1994) that included sessions conducted pre and

post meals suggested rumination was maintained

by automatic reinforcement.

Outcomes: The flavor spray was first administered

every 20 s (NAP = 87.5), then every 2 s

(NAP = 100). Self administration occurred every

10 s (NAP = 100).

IP: Preference assessments were used to identify

a favorite flavor spray. The preferred flaor spray

was delivered on a fixed time schedule. The

participant was then taught to self administer the

spray.


controls for alternative explanations (e.g., the

flavor spray may have matched stimulation with

the taste of regurgitated food or may have been

incompatible with regurgitation).

Wrigley et al. (2010) 1 adult female, with

severe intellectual

disability, visual

impairment, and

gastroesophageal reflux

disease.



and weight of participant

IP: A multi-component intervention including;

(a) interruption of precursor behavior, (b) 10 min

periods of instruction and exercise, (c) 10 min

NCR with attention, and (d) DRO

Outcomes: The intervention package reduced but

did not eliminate rumination (NAP = 99.4). The

participant’s weight increased from a range of 88

to 103 pounds to a range of 103–109 pounds.

CoE: Preponderance, although a component

analysis was conducted to identify the effect of

individual intervention procedures, a potential

sequence effect prevents definitive conclusions.

One baseline point was taken during the second A

phase of the ABAB design.

Yang (1988) 1 male, 17 years old, with

severe intellectual

disability

Daily frequency of

rumination

IP: A food satiation procedure was implemented

followed by fading of food quantity

Outcomes: The initial food satiation reduced

rumination (NAP = 80) and this effect was

maintained following the gradual reduction of

food portions (NAP = 75). At 12 weeks rumination

was reported to be eliminated.


controls for alternative explanationsa Mean.b Noncontingent reinforcement.c Differential reinforcement of other behaviors.d Mean nonoverlap of all pairs across participants.e Intervention 1 data was used as baseline to calculate NAP.f NAP calculated for premeal gum chewing treatment only (Figs. 3–5).

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2.1. Participants, intervention agents, and settings

Collectively, the 21 studies provided intervention to a total of 32 participants. Twenty-four (75%) of the participants weremale. The ages of participants ranged from six to 59 years old (M = 27 years old). One participant was described as an ‘‘adult’’but her exact age was not reported (Wrigley, Kahn, Winder, Vollmer, & Sy, 2010). Twenty-nine participants were reported tohave a severe/profound intellectual disability. For the remaining three participants, the degree of intellectual disability wasnot explicitly stated (i.e., Baker et al., 2010; Dudly, Johnson, & Barnes, 2002; Rhine & Tarbox, 2009), however, the descriptionsof the participants (all three diagnosed with autism) were consistent with severe/profound intellectual disability (i.e.,extremely limited communication and self-help skills). In addition to severe/profound intellectual disability, severalcomorbid conditions were also reported. Specifically, seven participants were diagnosed with Autistic Disorder. Oneparticipant was described as having ‘‘autistic features’’ (, Thibadeau, Blew, Reedy, & Luiselli, 1999), and five participants had asevere visual impairment. Other comorbid diagnoses included severe hearing impairment, Down Syndrome, encephalopa-thy, atonic diplegia, pseudobular palsy, cerebral gigantism, and gastroesophageal reflux disease.

Three studies were conducted in school classrooms (Greene et al., 1991; Heering, Wilder, & Ladd, 2003; Johnston, Greene,Rawal, Vazin, & Winston, 1991). However, only in Heering et al. did school staff (instead of researchers) implement theintervention. In Baker et al. (2010) the mother of the participant implemented the intervention in the home. Rhine andTarbox (2009) utilized an applied behavior analysis therapy team to implement the intervention in the home. Kelly andHeffner (1988) was conducted in a hospital and implemented by nurses. Two studies were conducted in day treatmentfacilities and were implemented by direct care staff (i.e., Kenzer & Wallace, 2007; Wilder, Draper, Williams, & Higbee, 1997).The remaining studies were implemented in residential treatment facilities utilizing the facility staff to implement theintervention. The training of intervention agents (i.e., parents, facility staff, and school personnel) was not described in any ofthe studies.

2.2. Dependent variables

All of the included studies operationally defined vomiting and/or rumination and then either counted every occurrence ofthese behaviors or estimated the occurrence of the behaviors using an interval recording system. These direct observationdata were either collected during a specific period of time associated with vomiting and/or rumination or were collectedthroughout the participants’ entire day. For many participants, vomiting and/or rumination occurred only following a meal.Therefore, the most common data collection method involved collecting data within a preset period of time following meals.This method was used in 11 studies and the post-meal data collection periods ranged from 10 to 60 min (M = 36 min). Fivestudies collected data throughout the participants’ entire day and reported the daily frequency or rate of vomiting and/orrumination. The remainder of the studies collected data during meal times or other periods of times in which rumination wasknown to occur for a particular participant (e.g., during in home therapy sessions in Rhine & Tarbox, 2009). Three studies alsoreported the weight of participants measured in pounds as a dependent variable (Kelly & Heffner, 1988; Lockwood, Maenpaa,& Williams, 1997; Wrigley et al., 2010).

2.3. Functional assessment

Five studies attempted to identify the reinforcement contingencies maintaining vomiting and/or rumination by means ofa systematic functional assessment. Three of these studies implemented an analogue functional analysis (Kenzer & Wallace,2007; Lyons, Rue, Luiselli, & Digennaro, 2007; Wilder, Register, Register, Bajagic, & Neidert, 2009). In all three studies, theanalogue functional analyses included conditions to test for attention, escape from demands, and automatic reinforcementas well as a control condition (i.e., play or alone). In these three studies, the assessment procedures were similar to thefunctional analysis protocol and consistent with the logic originally presented by Iwata, Dorsey, Slifer, Bauman, and Richman(1982/1994); Baker et al. (2010) used consecutive no-interaction sessions to test for automatic reinforcement, but did notconduct tests for other potential socially mediated reinforcers (Iwata & Dozier, 2008). Lockwood et al. (1997) conducted adescriptive functional assessment using narrative event recording to identify antecedents and contingent consequences(Iwata, Vollmer, & Zarcone, 1990). Four of the five studies that conducted functional analyses concluded that vomiting and/orrumination was maintained by automatic reinforcement (i.e., the physical stimulation produced by the behavior wasreinforcing). However, Lockwood et al. concluded that vomiting was maintained by escaping the demands placed on theparticipant by the staff.

2.4. Intervention procedures and outcomes

Across the corpus of studies, three general approaches to intervention emerged. These intervention approaches included:(a) diet manipulations that involved either increasing the amount of food or calories consumed or withholding certain foodsor liquids, (b) sensory-based interventions in which the participant was either provided with an alternative means to obtainautomatic reinforcement or access to the automatic reinforcement was blocked, and (c) interventions based on sociallymediated reinforcers in which the participants’ access to attention from staff or escape from demands was manipulated.Each approach to treatment is described below and the mean NAP effect size for interventions containing each approach is


stated. However, because most of the studies utilized multi-component interventions involving more than one of theseapproaches, these effect sizes should be interpreted with caution.

The most common approach to intervention was to change the participants’ diets. Diet manipulations included: (a)pacing the presentation of food to ensure participants ate at a slower rate (e.g., Luiselli, Medeiros, Jasinowski, Smith, &Cameron, 1994), (b) increasing the calories and quantity of food the participant was given (e.g., Clauser & Scibak, 1990), (c)removing specific types of food or liquids from meals (Heering et al., 2003; Luiselli, Haley, & Smith, 1993), and (d) changingthe consistency or texture or food (e.g., Greene et al., 1991). Of these diet manipulations, the most common approach was toincrease the quantity of food consumed by providing additional food during meals or adding snack times throughout the day.Across the studies involving diet manipulations the mean NAP was 90.9%.

Five studies implemented sensory-based interventions. Three of these five studies hypothesized that automaticreinforcement was obtained from the oral stimulation of chewing vomitus and provided an alternative means to obtain thissensory stimulation by teaching participants to chew gum (Rast, Johnston, Lubin, & Ellinger-Allen, 1988; Rhine & Tarbox,2009) or a plastic chew ring (Lyons et al., 2007). Wilder et al. (2009) conducted a preference assessment to determine whatflavor a participant preferred and then taught the participant to spray a liquid with that flavor in their mouth as analternative form of automatic reinforcement. Baker et al. (2010) hypothesized that visual stimulation obtained by looking atvomitus maintained vomiting and implemented a visual screening procedure in which staff covered the participants eyes for30 s contingent upon vomiting. NAP could not be calculated for Rhine and Tarbox (2009) due to the absence of baseline data.Lyons et al. (2007) reported that the chew ring was initially effective, but that rumination eventually returned to baselinelevels. Ultimately, the mean NAP across studies involving sensory-based interventions was 82.6%.

Six studies included socially mediated reinforcers in the intervention package (Kelly & Heffner, 1988; Lockwood et al.,1997; Luiselli et al., 1993, 1994; Sanders-Dewey & Larson, 2006; Wrigley et al., 2010). Three studies provided noncontingentreinforcement in the form of attention during or following mealtime (Kelly & Heffner, 1988; Luiselli et al., 1993; Wrigleyet al., 2010). Kelly and Heffner first attempted a food satiation procedure, but rumination was not reduced. They thensuccessfully reduced rumination with an attention-based intervention. Two studies provide positive verbal praise(attention) contingent upon periods of time in which vomiting and/or rumination was absent (Luiselli et al., 1994; Sanders-Dewey & Larson, 2006). Lockwood et al. (1997) hypothesized that rumination was maintained by escaping from demandsplaced on the participant by staff and implemented an escape extinction procedure. Lockwood et al. first implemented onlythe escape-based intervention and reduced rumination (NAP = 77.8): however, when a choice-making component wasadded (participant selected preferred foods) rumination was further reduced (NAP = 100). The mean NAP across studiescontaining socially mediated reinforcers was 86.3%.

2.5. Certainty of evidence

Eight studies were classified at the suggestive level of evidence, 10 at the preponderance level, and 3 at the conclusivelevel. The most common reason for classification as suggestive was the use of a single subject design that could notdemonstrate experimental control (e.g., AB or intervention-only designs). Studies were classified at the preponderance levelwhen multiple mechanisms of action could explain reductions and no design feature attempted to differentiate between thepossibilities. The three studies classified as conclusive (Johnston et al., 1991; Rast et al., 1988; Wilder et al., 1997) contained adesign feature that provided evidence related to the mechanism of action for the reduction in rumination. For example, inmany studies in which additional food was given, it was hypothesized that the increase in calories resulted in the reductionof rumination. However, because the participants also received additional attention from staff during the extra one-on-onefeeding times and/or longer breaks from other activities during mealtime, it is not possible to determine if it was theincreased caloric intake or socially mediated reinforcers that reduced rumination. Johnston et al. controlled for the influenceof socially mediated reinforcers by adding oils, sugars, and Polcose (a tasteless calorie supplement) to meals instead ofchanging the participants’ meal schedules or social interactions. Specific reasons for classification at a certain level areprovided in Table 1.

3. Discussion

This systematic review identified 21 studies involving behavioral interventions to treat rumination and operant vomitingin individuals with intellectual disabilities. Although reductions in rumination and operant vomiting were reported in all 21of the included studies, caution is warranted in the interpretation of these results. Specifically, only three of the includedstudies could be classified as providing a conclusive level of certainty. Although 13 of the included studies demonstratedexperimental control, the presence of multiple intervention components, ambiguous functional analysis data, and otherpotential confounds preclude definitive conclusions regarding the exact mechanism of action responsible for reductions inrumination and operant vomiting in most cases. Despite these limitations, the following approaches to assessment andtreatment of rumination and operant vomiting do emerge from this review.

After medical evaluations rule-out potential physiological causes (e.g., illness or drug side effects), a functionalassessment should be conducted to identify the reinforcement contingencies that may be maintaining these behaviors.Functional assessment may reveal that rumination or vomiting is maintained by either socially mediated reinforcement orautomatic reinforcement. Socially mediated reinforcement occurs when the behavior of another person reinforcers problem


behavior (Cunningham & Schreibman, 2008). For example, rumination may function to obtain attention from caregivers or toescape from demands, because both attention and escape are often provided when a person is cleaned following vomiting(e.g., Lockwood et al., 1997).

When a socially mediated reinforcer is identified, a variety of interventions demonstrated to be effective in the treatmentof problem behaviors may be effective (Lang, Rispoli, et al., 2009; Lang, White et al., 2009; Lang et al., 2010; Sigafoos, Arthur,& O’Reilly, 2003). Common strategies for treating problem behaviors maintained by socially mediated reinforcement includeteaching an alternative behavior with the same social function (e.g., Carr & Durand, 1985), restricting access to the socialreinforcer following the problem behavior (Wolf, Birnbrauer, Lawler, & Williams, 1970), and/or changing the environment toremove the discriminative stimuli that signal the availability of the reinforcer maintaining problem behavior (Sigafoos et al.,2003).

Automatic reinforcement was the most common hypothesized function of rumination and operant vomiting in thereviewed studies. The term automatic reinforcement is used when there is evidence that sensory consequences produced asa direct result of engaging in the problem behavior is reinforcing and the presence of another person is thus not needed forthe behavior to be maintained (Rapp & Vollmer, 2005). In the reviewed studies, several forms of automatic reinforcementwere hypothesized. The most common hypothesis involved sensory stimulation obtained via oral manipulation or chewingof vomitus (e.g., Rast et al., 1988; Rhine & Tarbox, 2009). Baker et al. (2010) hypothesized that automatic reinforcement in theform of visual stimulation obtained by viewing vomitus maintained vomiting. Clauser and Scibak (1990) hypothesized thatautomatic reinforcement may be obtained by chewing and swallowing previously ingested food in order to temporarilyrelieve hunger. Because automatic reinforcement is often difficult to directly observe and systematically manipulate,confirming the exact reinforcing stimulation is difficult (Rapp & Vollmer, 2005).

When automatic reinforcement is identified or suspected, this review suggests several approaches to treatment. First,food satiation procedures that involve increasing the amount of food consumed may reduce hunger and, consequently,reduce rumination maintained by the temporary relief of hunger (e.g., Clauser & Scibak, 1990). Interventions based on foodsatiation have been researched as potential treatments for rumination for over 30 years (e.g., Jackson, Johnson, Ackron, &Crowley, 1975), and food satiation was the most common approach to intervention in this current review. Johnston andGreene (1992) summarized 10 years of data from 10 clients who ruminated and found a strong relation between quantity offood consumed and rates of rumination. Additionally, even though their clients consumed up to six times their typicalquantity of food, no adverse health effects were identified (Johnston & Greene, 1992). The results of this review and previousreviews qualify food satiation procedures as ‘‘well-established’’ evidence-based practice (Odom et al., 2005).

Weight gain following food satiation was reported in several studies (e.g., Wrigley et al., 2010). In many cases, an increasein weight is desirable because rumination and vomiting may cause individuals to maintain low and unhealthy body weights(Johnston & Greene, 1992). However, in some cases weight gain may be unhealthy or stigmatizing. In the reviewed studies,several effective methods of reducing caloric intake (i.e., fading a food satiation intervention) were reported. Clauser andScibak (1990) originally provided additional food at all three meals but then faded the procedure by only providingadditional food during one meal. Dunn, Lockwood, Williams, and Peacock (1997) began food satiation by providing foodshigh in starch (e.g., mashed potatoes and pasta) but reduced caloric intake while maintaining low levels of rumination byproviding only fruits and vegetables. For some individuals the caloric intake is more important than the texture or type offood consumed and caution should be used when reducing calories in order to ensure problem behavior does not reemerge(e.g., Greene et al., 1991; Johnston et al., 1991). Input from a dietician, nutritionist, or similar expert should be sought beforeimplementing any substantial diet manipulation particularly when food satiation or calorie reduction is involved.

When rumination or vomiting is maintained by automatic reinforcement in the form of oral stimulation, interventionsdesigned to provide alternative means of stimulation may be effective. The alternative sensory stimulation interventionsincluded in this review involved chewing gum (Rast et al., 1988; Rhine & Tarbox, 2009) or a plastic chew ring (Lyons et al.,2007). Because automatic reinforcement is difficult to observe, it is often not possible to identify the exact type of stimulationreinforcing rumination or vomiting. It is possible that, for some individuals, food satiation procedures may successfullyreduce rumination because oral stimulation is provided and not because hunger is relieved. Therefore, in instances in whichweight gain is not desirable or additional food is unavailable, attempting to provide alternative oral stimulation in a mannerthat does not involve increased calories (e.g., gum or chew ring) may be a preferable first alternative to treatment. Futureresearch in which comparisons between increased food consumption and alternative forms of oral stimulation not involvingincreased calories could lead to a functional analysis procedure capable of distinguishing between automatic reinforcementin the form of relieving hunger and oral stimulation. Such a procedure might further elucidate the mechanism of action forreductions in rumination and operant vomiting maintained by automatic reinforcement.

In previous reviews, studies involving punishment represented a substantial portion of the available interventionresearch, and punishment was considered among the most effective intervention approaches. A comparison of the studiesincluded in this current review to the studies included in previous reviews reveals a shift away from punishment andtowards function-based interventions and diet manipulations (cf., Fredericks et al., 1998; Starin & Fuqua, 1987; Tierney &Jackson, 1984; Winton & Singh, 1983). The intervention research identified in this review includes only two studies involvingpunishment. Baker et al. (2010) involved contingent mouthwash as a type of overcorrection and Sanders-Dewey and Larson(2006) used a liquid irritant (sour drink) contingent upon rumination and pre-rumination behaviors. In both of these casesthe interventions also included additional non-aversive procedures (i.e., sensory extinction and positive reinforcement). Theremaining 19 studies did not involve punishment. Although these emerging non-punishment intervention alternatives are


promising, these interventions may not always be effective and punishment may need to be considered when ruminationand vomiting become life threatening and non-aversive treatment options have failed (cf., Mudford, 1995).

Previous reviews involving behavioral interventions for rumination and operant vomiting identified a lack ofmaintenance and generalization data as weakness within the literature base (e.g., Starin & Fuqua, 1987). In this currentreview, 10 studies collected maintenance data for at least 2 months (Baker et al., 2010; Dudly et al., 2002; Dunn et al., 1997;Kelly & Heffner, 1988; Lockwood et al., 1997; Luiselli et al., 1993, 1994; Rhine & Tarbox, 2009; Thibadeau et al., 1999; Yang,1988). Across those 10 studies, the mean length of time for maintenance probes was 22.6 months ranging from 2 months to 7years. Two studies addressed generalization across settings. Baker et al. (2010) reported generalization from home to schooland Lockwood et al. (1997) reported generalization across settings within a residential facility. Combined, the results suggestthat behavioral interventions for rumination and operant vomiting can produce sustained positive effects across time andsettings.

References*

*Baker, L. M., Rapp, J. T., & Carroll, R. A. (2010). Treating operant vomiting with visual screening. Clinical Case Studies, 9, 218–224.Carr, E. G., & Durand, V. M. (1985). Reducing behavior problems through functional communication training. Journal of Applied Behavior Analysis, 18, 111–126.*Clauser, B., & Scibak, J. W. (1990). Direct and generalized effects of food satiation in reducing rumination. Research in Developmental Disabilities, 11, 23–36.Cunningham, A. B., & Schreibman, L. (2008). Stereotypy in autism: The importance of function. Research in Autism Spectrum Disorders, 2, 469–479.Curtis, K. (2005). An unusual case of recurrent emesis in a patient with autistic disorder. Mental Health Aspects of Developmental Disabilities, 8, 1–4.*Dudly, L. L., Johnson, C., & Barnes, R. S. (2002). Decreasing rumination using a starchy food satiation procedure. Behavioral Interventions, 17, 21–29.*Dunn, J., Lockwood, K., Williams, D. E., & Peacock, S. (1997). A seven year follow-up of treating rumination with dietary satiation. Behavioral Interventions, 12,

163–172.Ellis, C. R., Parr, T. S., Singh, N. N., & Wechsler, H. A. (1997). Rumination. In N. N. Singh (Ed.), Prevention and treatment of severe problems: Models and methods in

developmental disabilities. Belmont, CA: Thomson Brooks/Cole Publishing Co.Foxx, R. M., & Garito, J. (2007). The long term successful treatment of the very severe behaviors of a preadolescent with autism. Behavioral Interventions, 22, 69–82.Foxx, R. M., Snyder, M. S., & Schroeder, F. A. (1979). A food satiation and oral hygiene punishment program to suppress chronic rumination by retarded persons.

Journal of Autism and Developmental Disorders, 9, 399–412.Fredericks, D. W., Carr, J. E., & Williams, W. L. (1998). Overview of the treatment of rumination disorder for adults in a residential setting. Journal of Behavior

Therapy and Experimental Psychiatry, 29, 31–40.Fredericks, D. W., & Hayes, L. J. (1994). Effects of drug changes and physician prescribing practices on the behavior of persons with mental retardation. Journal of

Developmental and Physical Disabilities, 7, 105–123.*Greene, K. S., Johnston, J. M., Rossi, M., Rawal, A., Winston, M., & Barron, S. (1991). Effects of peanut butter on ruminating. American Journal on Mental Retardation,

95, 631–645.*Heering, P. W., Wilder, D. A., & Ladd, C. (2003). Liquid rescheduling for the treatment of rumination. Behavioral Interventions, 18, 199–2003.Hersen, M., & Barlow, D. H. (1976). Single case experimental designs: strategies for studying behavior change. New York: Pergamon.Humphrey, F. J., Mayes, S. D., Bixler, E. O., & Good, C. (1989). Variables associated with frequency of rumination in a boy with profound mental retardation. Journal

of Autism and Developmental Disorders, 19, 435–447.Iwata, B. A., Dorsey, M. F., Slifer, K. J., Bauman, K. E., & Richman, G. S. (1982/1994). Toward a functional analysis of self-injury. Journal of Applied Behavior Analysis, 27,

197–209 (Reprinted from Analysis and Intervention in Developmental Disabilities, 2, 3–20, 1982)..Iwata, B. A., & Dozier, C. L. (2008). Clinical application of functional analysis methodology. Behavior Analysis in Practice, 1, 3–9.Iwata, B. A., Vollmer, T. R., & Zarcone, J. R. (1990). The experimental (functional) analysis of behavior disorders: Methodology, applications, and limitations. In A. C.

Repp & N. N. Singh (Eds.), Perspectives on the use of nonaversive and aversive interventions for persons with developmental disabilities (pp. 301–330). Sycamore. ILSycamore.

Jackson, G. M., Johnson, C. R., Ackron, G. S., & Crowley, R. (1975). Food satiation as a procedure to decelerate vomiting. American Journal of Mental Deficiency, 80,223–227.

Johnston, J. M., & Greene, K. S. (1992). Relation between ruminating and quantity of food consumed. Mental Retardation, 30, 7–11.*Johnston, J. M., Greene, K. S., Rawal, A., Vazin, T., & Winston, M. (1991). Effects of caloric level on ruminating. Journal of Applied Behavior Analysis, 24, 597–603.Kanner, L. (1972). Child psychiatry. Springfield, IL: Charles C Thomas.*Kelly, M. B., & Heffner, H. E. (1988). The role of attention in the elimination of chronic life-threatening vomiting. Journal of Mental Deficiency Research, 32, 425–431.*Kenzer, A. L., & Wallace, M. D. (2007). Treatment of rumination maintained by automatic reinforcement: A comparison of extra portions during a meal and

supplemental post-meal feedings. Behavioral Interventions, 22, 297–304.Lancioni, G. E., O’Reilly, M., & Emerson, E. (1996). A review of choice research with people with severe and profound developmental disabilities. Research in

Developmental Disabilities, 17, 391–411.Lang, R., Didden, R., Machalicek, W., Rispoli, M., Sigafoos, J., Lancioni, G., et al. (2010). Behavioral treatment of chronic skin-picking in individuals with

developmental disabilities: A systematic review. Research in Developmental Disabilities, 31, 304–315.Lang, R., Rispoli, M. J., Machalicek, W., White, P. J., Kang, S., Pierce, N., et al. (2009). Treatment of elopement in individuals with developmental disabilities: A

systematic review. Research in Developmental Disabilities, 30, 670–681.Lang, R., White, P. J., Machalicek, W., Rispoli, M., Kang, S., Aguilar, J., et al. (2009). Treatment of bruxism in individuals with developmental disabilities: A

systematic review. Research in Developmental Disabilities, 30, 809–818.*Lockwood, K., Maenpaa, M., & Williams, D. E. (1997). Long-term maintenance of a behavioral alternative to surgery for severe vomiting and weight loss. Journal of

Behavior Therapy and Experimental Psychiatry, 28, 105–112.*Luiselli, J. K., Haley, S., & Smith, A. (1993). Evaluation of a behavioral medicine consultative treatment for chronic, ruminative vomiting. Journal of Behavior

Therapy and Experimental Psychiatry, 24, 27–35.*Luiselli, J. K., Medeiros, J., Jasinowski, C., Smith, A., & Cameron, M. J. (1994). Behavioral medicine treatment of ruminative vomiting and associated weight loss in

an adolescent with autism. Journal of Autism and Developmental Disorders, 24, 619–629.*Lyons, E., Rue, H. C., Luiselli, J. K., & Digennaro, F. D. (2007). Brief functional analysis and supplemental feeding for postmeal rumination in children with

developmental disabilities. Journal of Applied Behavior Analysis, 40, 743–747.Ma, H. H. (2006). An alternative method for quantitative synthesis of single-subject research: Percentage of data points exceeding the median. Behavior

Modification, 30, 598–617.Matson, J. L., & Taras, M. E. (1989). A 20 year review of punishment and alternative methods to treat problems behaviors in developmentally delayed persons.

Research in Developmental Disabilities, 10, 85–104.Mudford, O. (1995). An intrusive and restrictive alternative to contingent shock. Behavioral Interventions, 10, 87–99.

* Studies included in the review.


Odom, S. L., Brantlinger, E., Gersten, R., Horner, R. H., Thompson, B., & Harris, K. R. (2005). Research in special education: Scientific methods and evidence-basedpractices. Exceptional Children, 71, 137–148.

Parker, R. I., Hagan-Burke, S., & Vannest, K. (2007). Percent of all non-overlapping data (PAND): an alternative to PND. Journal of Special Education, 40, 194–204.Parker, R. I., & Vannest, K. (2009). An improved effect size for single-case research: Nonoverlap of all pairs. Behavior Therapy, 40, 357–367.*Rast, J., Johnston, J. M., Lubin, D., & Ellinger-Allen, J. (1988). Effects of premeal chewing on ruminative behavior. American Journal on Mental Retardation, 93, 67–74.Rapp, J. T., & Vollmer, T. R. (2005). Stereotypy I: A review of behavioral assessment and treatment. Research in Developmental Disabilities, 26, 527–547.*Rhine, D., & Tarbox, J. (2009). Chewing gum as a treatment for rumination in a child with autism. Journal of Applied Behavior Analysis, 42, 381–385.Rogers, B., Stratton, P., Victor, J., Kennedy, B., & Andres, M. (1992). Chronic regurgitation among persons with mental retardation: a need for combined medical and

interdisciplinary strategies. American Journal on mental Retardation, 96, 522–527.*Sanders-Dewey, N. E. J., & Larson, M. E. (2006). Chronic rumination in a severely developmentally disabled adult following combined use of positive and negative

contingencies. Journal of Behavior Therapy and Experimental Psychiatry, 37, 140–145.Schlosser, R. (2009). The role of evidence-based journals as evidence-based information sources.. Applied behavior analysis international annual convention

(Conference).Schlosser, R., & Sigafoos, J. (2007). Editorial: Moving evidence-based practice forward. Evidence-Based Communication Assessment and Intervention, 1, 1–3.Scruggs, M., & Castro, B. (1987). The quantitative synthesis of single-subject research. Remedial and Special Education, 8, 24–33.Sigafoos, J., Arthur, M., & O’Reilly, M. (2003). Challenging behavior and develop-mental disability. London: Whurr Publishers.Simeonsson, R., & Bailey, D. (1991). Evaluating programme impact: Levels of certainty. In D. Mitchell & R. Brown (Eds.), Early intervention studies for young children

with special needs. New York: Chapman and Hall.Smith, N. (1981). The certainty of evidence in health evaluations. Evaluation and Program Planning, 4, 273–278.Singh, N. N. (1981). Rumination. In Ellis, N. R. (Ed.). International review of research in mental retardation (Vol. 9, pp. 139–182). New York: Academic Pres.Starin, S. P., & Fuqua, W. (1987). Rumination and vomiting in the developmentally disabled: A critical review of the behavioral, medical, and psychiatric treatment

research. Research in Developmental Disabilities, 8, 575–605.*Thibadeau, S., Blew, P., Reedy, P., & Luiselli, J. K. (1999). Access to white bread as an intervention for chronic ruminative vomiting. Journal of Behavior Therapy and

Experimental Psychiatry, 30, 137–144.Tierney, D. W., & Jackson, H. J. (1984). Psychosocial treatments of rumination disorder: A review of the literature. Australia & New Zealand Journal of Developmental

Disabilities, 10, 81–112.Weiss, J. (2002). Self-injurious behaviours in autism: A literature review. Journal on Developmental Disabilities, 9, 129–143.Wijetilleke, A., Sakran, M., & Kamat-Nerikar, R. (2009). Vomiting in a girl with autism. Clinical Pediatrics, 48, 224–227.*Wilder, D. A., Draper, R., Williams, W. L., & Higbee, T. S. (1997). A comparison of noncontingent reinforcement other competing stimulation, and liquid

rescheduling for the treatment of rumination. Behavioral Interventions, 12, 55–64.*Wilder, D. A., Register, M., Register, S., Bajagic, V., & Neidert, P. L. (2009). Functional analysis and treatment of rumination using fixed-time delivery of a flavor

spray. Journal of Applied Behavior Analysis, 42, 877–882.Winton, A. S., & Singh, N. N. (1983). Rumination in pediatric populations: a behavioral analysis. Journal of the American Academy of Child Psychiatry, 22, 269–275.Wolf, M. M., Birnbrauer, J., Lawler, J., & Williams, T. (1970). The operant extinction, reinstatement and re-extinction of vomiting behavior in a retarded child. In

Ulrich, R., Stanik, T., & Mabry, J. (Eds.), Control of human behavior: From cure to prevention (Vol. 2, pp. ). ). Glenview, III: Scot, Forseman.*Wrigley, M., Kahn, K., Winder, P., Vollmer, T. R., & Sy, J. R. (2010). A multi-component approach to the treatment of chronic rumination. Behavioral Interventions,

25, 295–305.*Yang, L. (1988). Elimination of habitual rumination through the strategies of food satiation and fading: A case study. Behavioral Residential Treatment, 3, 223–224.

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