1. Pica, Rumination, Drooling, and Hand Mouthing
AWS/Benchmark
Behavioral Clinicians Meeting October 2013
Presenter: Joe Darling

3. People do unusual things with their mouths
Pica, rumination, drooling, and hand mouthing
Definitions
Etiology
Health Risks
Interventions
Case reviews of pica, rumination, & drooling

4. PICA

5. pica definition
Compulsive, recurrent consumption of nonnutritive substances (Stiegler, 2005)
Swallowing inedible items

6. Pica terminology (Stiegler, 2005)
Acuphagia – sharp objects
Amylophagia – laundry starch
Cautopyreiophagia – burnt matches
Coprophagia – human feces, animal dung

7. Pica terminology (Stiegler, 2005)
Foliophagia – leaves, grass, acorns, pinecones
Geomelophagia – raw potatoes
Geophagia – dirt, sand, clay
Lignophagia – wood, bark, twigs
Lithophagia – rocks, gravel, pebbles

8. Pica terminology (Stiegler, 2005)
Pagophagia – ice, freezer frost
Plumbophagia – paint chips (lead)
Tobaccophagia – cigarette butts
Trichophagia – hair
wasps

9. Etiology Nutritional – iron/zinc deficiencies; pregnancy
Mental Health (OCD, anxiety, schizophrenia, depression)
Sensory stimulation/automatic reinforcement

10. Health risks Toxicity (lead poisoning) Parasitic infections
Malnutrition
Oral and dental health problems
Obstructions and perforations (metal/metal cans)
Risk of harm finding items (running into the street, eating lit cigarettes)

11. Treatment for pica
Well-established in behavioral literature (Hagopian, Rooker, & Rolider, 2011)
Reinforcement procedures
Response reduction procedures (response blocking, effort manipulations, punishment)
Combination procedures (Sr+ & resp. red. Proc.)

12. Treatment for pica
Environmental prevention (removing potential pica items from environment, restricting individual’s access to certain environments)
Pica Exchange: Essentially amounts to discrimination training. Teaching the individual to trade inedible items for edible items.

13. Case Review
46 year old male; Profound ID; DSM IV: OCD, pica, autistic D/O; Institutionalized at the age of 6

14. X ray data
Record review of x rays going back to the mid – 1980’s showed metal in most x rays
Screws, bolts, zipper tabs, pop tops, staples

16. Pica exchange sessions
One staff, one participant at the table; traded 10 inedible items for 10 preferred edible items
fading & generalization – traded with someone 5 feet away, then 10 feet, then at the door; probed throughout the day
During regular leisure time, metal objects were placed on the ground within 10 feet of the participant & observed for 10 minutes

17. Independent pica exchange

18. Pica data participant S

19. Rumination

20. Definitions
Repeated regurgitating, chewing, and reswallowing previously ingested food (Woods, Luiselli, & Tomassone, 2013)

21. Etiology Food allergies Infections Hiatal hernia
Medication side effects
Esophagitis
Automatic reinforcement

22. Health Risks Electrolyte imbalance Weight loss
Esophagitis/esophogeal cancer
Respiratory complications
Konarski, Favell, and Favell (1992) estimate rumination to be the cause of death for 5-10 percent of those who ruminate.

23. Treatment “Loving Care” – Wright, 1965
Electric shock - White & Taylor,1967; Bright & Whaley, 1968; Luckey, Watson, & Musick, 1968, others
Aversive taste – Becker, Turner, & Sajwaj, 1978; Hogg, 1982
Pinch – Minness, 1980

24. Treatment
oral hygiene punishment – Foxx, Snyder, & Schroeder, 1979; Singh, Manning, & Angell, 1982
Contingent exercise – Daniel, 1982; O’Neil, White, King, & Carek, 1979
Overcorrection – Azrin & Wesolowski, 1975; Duker & Seys, 1977

25. Treatment
Extinction – Mulick, Schroeder, & Rojahn, 1980; Wolf, Birnbrauer, Williams, & Lawler, 1965, 1970
Differential Reinforcement – Mulick, et. al., 1980; O’Neil, White, King, & Carek, 1979
Dietary manipulation (increased fiber, starch, or entire meal) – Rast, Ellinger-Allen, & Johnston, 1985; Rast, Johnston, Ellinger-Allen, & Drum, 1985)

26. Treatment
Liquid rescheduling – Wilder, Draper, Williams, & Higbee, 1997
Peanut butter – Greene, Johnston, Rossi, Rawal, Winston, & Barron, 1991
White Bread – Masalsky & Luiselli, 1998; Thibadeau, Blew, Reedy, & Luiselli, 1999

27. Case Review Supplemental feeding:
Five slices of bread offered one bite at a time spaced out over 20 minutes.
Procedure used an average of 6 meals per week (out of 21)
Participant: 27 year old male; Profound ID; DSM IV: pica, bipolar D/O NOS, PDD NOS; institutionalized in 1987 at the age of 7

28. Consents/Approvals
Approval for the procedure was obtained by the participant’s physician, dietician, the Behavior Management Committee, and the Human Rights Committee of the facility

32. Generalization & Follow-up
Two staff trained to carry out the procedure
One staff from day shift (breakfast and lunch)
One staff from evening shift (supper)
Each randomly assigned by supervisor to provide coverage
Procedure used 6 to 7 times each week.

33. Follow-up

34. Weight

35. Drooling (sialorrhea)

36. Definition
Inability to control oral secretions (Meningaud, Pitak-Arnnop, Chikhani, & Bertrand, 2006)
Loss of saliva from a person’s mouth (Lancioni, Singh, O’Reilly, Sigfoos,…Pichierri, 2011).

37. Acceptable Drooling Harris and Dignan (1980) 5 grams or less
Doesn’t show on clothes, doesn’t flow, and doesn’t smell.

38. Etiology
Neurological deficits (cerebral palsy, seizures, intellectual disability, Angleman’s syndrome, etc.)
Oral/dental problems (tongue thrust, GERD, lip incompetency, etc.)

39. Etiology
Diagnostically points to possible neurological impairments

40. Health Risks Increased risk of: aspiration
electrolyte and protein loss
Perioral infections

41. Treatments Medical: surgery, medications
Prompts to wipe mouth, lift chin, swallow
Suck & swallow prompt w/Sr+
Chewing gum

42. Reduction of drooling
People need saliva and it is more common for people to need intervention for not enough saliva
Too much saliva is not the problem, it’s saliva falling out of the mouth

43. Case Review

44. Case Review

45. Hand Mouthing

46. Definitions
The insertion of any part of the hand past the plane of the lips or the protrusion of the tongue out of the mouth onto the hand (Canella, 2005)

47. Etiology Automatic reinforcement
Some evidence of relationship to GERD (Swender, et al., 2006)

48. Health Risks Tissue damage Hematoma Salivary dermatitis Scarring
Skin breakage

49. Treatment Reinforcement-based – environmental enrichment; DRO/DRI/DRA
Prompt & redirect
Punishment, restraint, & medications (lazy therapist options)
(Canella, 2005; Canella, O’Reilly, & Lancioni, 2006; Rapp, 2007)

50. Overview take home points
Start with a good functional behavior assessment with preference assessment
Intervention takes patience and persistence
Involve medical professionals early on

51. Literature review suggests automatic reinforcement the most likely function after medical issues are addressed.
Relative inaccessibility of the sensory consequences thought to maintain behavior
(LeBlanc, Patel, & Carr, 2000; Rapp, 2007; Vollmer, 1994)

52. Automatic Reinforcement
This is important to consider as treatment will require finding something that is more preferred compared to the sensation of the target behavior as well as being easy for the individual to access OR blocks the stimuli that is reinforcing the behavior in a non-restrictive manner.

53. Pica Resources
Steigler, L.N. (2005). Understanding pica behavior: A review for clinical and eduational professionals. Focus on Autism and Other Developmental Disabilities, 20(1), doi: / Hagopian, L. P., Rooker, G.W., Rolider, N. U. (2011). Identifying empirically supported treatments for pica in individuals with intellectual disabilities. Research in Developmental Disabilities, 32 (6), doi: /j.ridd

54. Rumination Resources
Herring, P. W., Wilder, D. A., & Ladd, C. (2003). Liquid rescheduling for the treatment of rumination. Behavioral Interventions, 18, doi: /bin.137
Lyons, E.A., 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.
Rast, J., Johnston, J.M., Drum, C., & Conrin, J. (1981). The relation of food quantity to rumination behavior. Journal of Applied Behavior Analysis, 14 (2), 212 – 130.
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 (2), 137 – 144.

55. Drooling Resources
Ivancic, M. I. (1992). Drooling. In Konarski, E. A., Favell, J. E., & Favell, J. E. (1992). Manual for the assessment and treatment of the behavior disorders of people with mental retardation. North Carolina: Western Carolina Center Foundation. Lancioni, G. E., et al. (2011). Promoting mouth-drying responses to reduce drooling effects by persons with intellectual and multiple disabilities: A study of two cases. Research in Developmental Disabilities, 32, doi: /j.ridd

56. Handmouthing Resources
Cannella, H. I., O’Reilly, M. F., & Lancioni, G. E. (2005). Treatment of handmouthing in individuals with severe to profound developmental disabilities, Research in Developmental Disabilities, 27, doi: /j.ridd Swender, S. L., Matson, J. L., Mayville, S. B., Gonzalez, M. L., & McDowell, D. (2006). A functional assessment of handmouthing among persons with severe and profound intellectual disability. Journal of Intellectual & Developmental Disability, 31(2), doi: /

57. Preference Assessment
Fisher, W.W., Piazza, C.C., Bowman, L.G., & Amari, A. (1996). Integrating caregiver report with a systematic choice assessment to enhance reinforcer identification. American Journal on Mental Retardation. 101,

58. Questions/Comments