Assessment and treatment of hand mouthing : a large-scale analysis

67 Pages·2001·2.6 MB·English

by  Roscoe, Eileen Michelle

ASSESSMENTANDTREATMENTOFHANDMOUTHING:
ALARGE-SCALEANALYSIS
By
EILEENMICHELLEROSCOE
ADISSERTATIONPRESENTEDTOTHEGRADUATESCHOOL
OFTHEUNIVERSITYOFFLORIDAINPARTIALFULFILLMENT
OFTHEREQUIREMENTSFORTHEDEGREEOF
DOCTOROFPHILOSOPHY
UNIVERSITYOFFLORIDA
2001
ACKNOWLEDGMENTS
Iwouldliketothankthoseindividualswhohelpedmakethisdissertation
possible. First,IthankDr.BrianIwata,mycommitteechairandadvisor,forhispatience
andsupportthroughoutmygraduateeducation. Hisprofessionalassistanceandadvice
throughoutthisprojectandothershavebeeninvaluable. Ialsothanktheothercommittee
members,Dr.JenniferAsmus,Dr.TimothyHackenberg,Dr.MarkLewis,andDr.
TimothyVollmer,fortheirassistance. AdditionalthanksareextendedtoAlonzoCole,
GeraldGoff,andLimingZhou,whoassistedinthedevelopmentandimplementationof
thisproject. Ialsothankmyfamilyfortheirunconditionalloveandsupport.
n
TABLEOFCONTENTS
page
ACKNOWLEDGMENTS ii
ABSTRACT iv
INTRODUCTION 1
Prevalence 2
Risk 3
Function 5
InterventionsforBehaviorMaintainedbyAutomaticReinforcement 10
EXPERIMENT1: PREVALENCEANDRISKOFHANDMOUTHING 16
Method 16
ResultsandDiscussion 20
EXPERIMENT2: FUNCTIONALANALYSISOFHANDMOUTHING 23
Method 23
ResultsandDiscussion 24
EXPERIMENT3: TREATMENT 29
ParticipantsandSetting 30
DataCollectionandReliability 30
PhaseI: FunctionalAnalysis 30
PhaseII: PreferenceAssessments 33
ResultsandDiscussionforPhaseII 34
PhaseIII: TreatmentEvaluation 36
ResultsandDiscussionforPhaseIII 39
DISCUSSION 50
REFERENCES 54
BIOGRAPHICALSKETCH 59
iii
AbstractofDissertationPresentedtotheGraduateSchool
oftheUniversityofFloridainPartialFulfillmentofthe
RequirementsfortheDegreeofDoctorofPhilosophy
ASSESSMENTANDTREATMENTOFHANDMOUTHING:
ALARGE-SCALEANALYSIS
By
EileenMichelleRoscoe
August,2001
Chairman: BrianA.Iwata
MajorDepartment: Psychology
Handmouthing(HM)isachronicprobleminindividualswithdevelopmental
disabilities. SomeformsofHMareclassifiedasself-injuriousbehaviorwhenlesions,
tissuebreakdown,andinfectionoccur. Althoughtheprevalenceofmouthinghasbeen
reported,dataonthefrequency,severity,orfunctionsofthebehaviorwerenotincluded.
ThepurposeofthepresentstudywastoconductsuchananalysisofHMinalarge
population. Thestudywasconductedattwopublicresidentialfacilitiesforpersonswith
developmentaldisabilities,withatotalpopulationof830individuals.
InExperimentI,theprevalenceandriskofHMwereassessedusingindirectand
directobservationmethods. Resultsobtainedfrominterviewsshowedthattheprevalence
ofHMintwoinstitutionalsampleswascomparabletothatreportedinearlierstudies,
whereasdirectobservationyieldedalowerestimateofprevalence. Inaddition,results
indicatedthatHM,whenitdidoccur,waslikelytoproducetissuedamageifleft
untreated.
IV
InExperimentII,modifiedfunctionalanalyses(FAs)wereconducted,during
whichalone,attention,anddemandsessionswerealternatedinmultielementdesignswith
a2:1ratioofalonetoattentionanddemandsessions. Resultsindicatedthat,in98.4%of
the64casesforwhichanFAwasconducted,HMwasmostlikelymaintainedby
automaticreinforcement.
InExperimentIII,14individualswhoseHMeitheroccurredatveryhigh-rates
duringtheFAorproducedseveretissuedamagetothehandsparticipated. InPhaseI,a
modifiedFAwasconductedthatdeterminedparticipants'HMwasmaintainedby
automaticreinforcement. InPhaseII,preferenceassessmentswereconductedthat
identifiedpreferredleisureand/oredibleitemsthatwereusedduringtreatment. InPhase
III,thefollowinginterventionswereimplementedinsequentialorder:(a)noncontingent
reinforcement(NCR),(b)eitherNCR+differentialreinforcementofalternativebehavior
(DRA)+responseblockingorNCR+responseblockingonly,and(c)NCR+brief
manualrestraint. NCR,NCR+DRA+responseblocking,NCR+responseblocking,
andNCR+briefrestraintresultedinincreasesinitemcontactandlargereductionsin
HM
forsix,five,two,andoneparticipant(s),respectively.
INTRODUCTION
Thepurposeofthecurrentinvestigationwastoconductalarge-scaleassessment
andtreatmentofhandmouthing,aformofbehaviorexhibitedbyindividualswith
developmentaldisabilitiesthatmayormaynotbeinjurious. InExperiment1,the
prevalence,frequency,andriskofHMwereassessedusingindirectand/ordirect
observationalmethods. InExperiment2,amodifiedfunctionalanalysis,basedonthat
describedbyIwataetal.(1982/1994a)wasconducted,toidentifytheextenttowhich
participants'HMwassensitiveto(maintainedby)socialcontingencies. InExperiment3,
aprogressiveseriesofinterventionswasevaluatedtodeterminewhichtreatment,or
combinationoftreatments,mosteffectivelyreducedHM.
Handmouthing(HM)hasbeendefinedastheplacingofoneormoredigitsofthe
handpasttheplaneofthelips(Lockwood&Williams,1994),insertionofthehandinto
themouthbeyondthefirstknuckle(Dorsey,Iwata,Ong,&McSween,1980),and/orany
contactbetweenthehandandthemouth(Lerman&Iwata,1996). RastandJack(1992)
madeadistinctionbetweenhandmouthingandthemouthingofobjects,notingthatthe
formerinvolvescontactofonlythehandsandthemouth,whereasthelattermayinclude
severalbehaviorsinvolvingcontactofthemouthwithotherobjects. HMis
topographicallyverysimilartohandbiting,oftenmakingtheseresponses
indistinguishabletoobservers. Forexample,Paisey,Whitney,andWainczak(1993)
conductedacasestudyofaparticipant'sself-injuriousHM. Althoughtheauthorsnoted
thattheparticipantfrequentlyengagedinhandbiting,theyonlyrecordedinstancesof
HM(definedasinsertionoffingersorhandintomouth). However,basedontheir
definition,occurrencesofHMmayhaveincludedinstancesofbiting. AssumingthatHM
andhandbitingmaybefunctionallyequivalent(i.e.,theyarebothmaintainedbythe
sameenvironmentalvariable),lumpingtheseresponsestogethermaynotprove
problematic. However,iftheresponsesaremaintainedbydifferentconsequences,clear
assessmentand/ortreatmentoutcomesmaybegreatlyimpeded. Giventhis,careshould
betakentousedefinitionsthatallowforaccuratediscriminationsbetweenhandmouthing
andhandbitingforparticipantswhoexhibitbothresponseforms.
HMthatoccursatahighfrequencyand/ordurationmayresultininjury.
Researchershavereportedsalivarydermatitisand/orassociatedinfectionsrequiring
medicaltreatmentasaresultofparticipants'HM(Ball,Campbell,&Barkemeyer,1980;
Lockwood&Williams,1994;McClure,Moss,McPeters,&Kirkpatrick,1986). HMhas
alsobeenclassifiedasaformof"stereotypy"becauseitisrepetitive,hasnoapparent
function,andmayinterferewithadaptivebehavior(LaGrow&Repp,1984). Regardless
ofwhetheraparticipant'sHMisinjurious,itmaygreatlyimpedeher/hisqualityoflife.
Mostnotably,theoffensiveodorassociatedwithHMmayserveasabarriertosocial
interactions(McClureetal.,1986). Inaddition,mouthingmayinterferewiththe
acquisitionofappropriatebehaviors(Balletal.,1980).
Prevalence
BecauseHMhasbeenclassifiedinseveraldifferentways,estimatingits
prevalencehasbeendifficult. Thatis,someauthorshavedescribedHMasaself-
injuriousresponseandhaveincludeditinstudiesontheprevalenceofselfinjury(Griffin
etal.,1986;Maurice&Trudel,1982),whereasothershaveconsidereditaformof
stereotypy(Bodfishetal.,1995;LaGrow&Repp,1984). Giventhatstudiesonthe
prevalenceofself-injuriousbehavior(SIB)typicallyexcludenoninjuriousresponse
topographies,andstudiesontheprevalenceofnoninjuriousstereotypyexcludeself-
injurioustopographies,reportsontheprevalenceofHMareusuallyincomplete.
TheonlystudytodatethathasassessedtheprevalenceofHMspecificallywas
conductedbyTroster,Bambring,andBeelmann(1991),whosurveyedparentsofchildren
(10mo.-to-6yr.)whowereblind. Parentswereaskedtoindicatewhichof11different
stereotypedbehaviors(e.g.,suckingthumbsorfingers,bodyrocking,repetitivehandand
fingermovements,etc.)theyhadobservedintheirchild;theywerealsoaskedtoindicate
thefrequencyofresponsetopographiesreportedtooccur. Resultsindicatedthatthe
prevalenceofHMthatoccurred(a)atleastonceperweekwas49.4%,(b)onceperday
was36.5%,and(c)hourlywas4.7%. AlthoughthisstudywasthefirsttoincludeHMas
aspecificresponsetopography,itwasconductedonlywithnormallydevelopingblind
children;thus,thegeneralityofthesefindingstoadultsortoindividualswith
developmentaldisabilitiesisunclear. Inaddition,theauthorsusedonlyindirect(survey)
methodsforassessingtheprevalenceofSIB,stereotypy,and/orHM,whichmayhave
beenunreliableorinaccurate. Inthepresentstudy,weassessedtheprevalenceofHMby
conductingaseriesofassessments,beginningwithindirectassessments(i.e.,interviews)
andendingwithdirectobservationtoverifytheresultsobtainedduringtheindirect
assessment. ByconductingbothindirectanddirectassessmentsofHM,moreaccurate
measuresmaybeobtainedwithrespecttoprevalence.
Risk
Asnotedpreviously,HMhasbeenreportedtoresultinsevereself-injury(Ballet
al.,1980;Lockwood&Williams,1994;McClureetal.,1986). RastandJack (1992)
notedthat,forHMtobeconsideredinjurious,mouthingshouldresultin"redorwhite
hands,chappedlipsorface,orlesionsonthehandsorface"(p.1). Inaddition,they
indicatedthatHM,wheninjurious,occursbothfrequentlyandforlongperiodsoftime.
Basedontheirdefinitionofinjury,anadequateassessmentofriskshouldincludeboth
thefrequencyandseverityofHM.
Fewstudieshaveassessedthefrequencyand/ordurationofstereotypicbehaviors.
Dura,Mulick,andRasnake(1987)assessedthefrequencyanddurationofvariousforms
ofstereotypy,includingrhythmicmovements,bizarreposturing,self-restraint,andobject
manipulation. Participants'directcarestaffwereinterviewedtodeterminewhetheror
notanindividual(a)engagedineachtypeofstereotypyand(b)engagedinthe
stereotypicresponsefor1min,1-to-1 min,orgreaterthan10min. Althoughassessing
thedurationofHMmayproveuseful,itwasunclearwhetherthedurationreportedwas
perepisode,perday,orperweek. Ifthedurationwasperepisode,itwouldhavebeen
helpfultoknowhowmanyepisodesoccurredperday. Rojahn(1986)determinedtherisk
ofparticipants'stereotypybyconductingasurvey,consistingofa3-pointscalefor
severityanda4-pointscaleforthefrequencyofoccurrence. Schroeder,Schroeder,
Smith,andDalldorf(1978)usedanindirectassessmenttodeterminetheseverityof
participants'SIB. AftersocialworkersreferredindividualswhoexhibitedSIB,a
pediatricianorpsychologistinterviewedthesocialworkertoassesswhethertheSIBwas
severe(itoccurredatleastonceadayandhadcausedbleeding,bruises,brokenbones,or
othertissuedamagethatrequiredinterventionbyamedicalstaff)ormild(thosereferrals
thatwerenotsevere). Thestudiesnotedabovearenoteworthyinthattheyassessedthe
frequencyand/orseverityofseveraldifferenttopographiesofSIBand/orstereotypy.
However,becauseonlyindirectassessmentswereused,thereliabilityofthefindingsis
uncertain. Second,noneofthestudiesreporteddataspecificallyonHM,makingit
unclearifHMoftenresultsininjury. AlthoughauthorshavenotedthatHMmayresultin
severetissuedamage,nostudiestodatehaveconductedasystematicassessment
indicatingthedegreeofinjuryassociatedwithHM. Inthepresentstudy,wesoughtto
determinetheriskofHMexclusivelybyconductingdirectobservationsofthefrequency
andseverityofparticipants'HM.
Function
Thedevelopmentoffunctionalanalysismethodologyisbasedonover30yearsof
researchindicatingthatbehaviorproblems(e.g.,aggression,noncompliance,andSIB)
areoftenlearnedperformances. Thatis,theyaremaintainedbycontingenciesofpositive
ornegativereinforcement. Iwata,Dorsey,Slifer,Bauman,andRichman(1982/1994a)
proposedageneralmodelforassessingbehavioralsensitivitytoavarietyof
contingencies. Inthisstudy,threetestconditionswereused,eachcontaininga
discriminativestimulus(SD),anestablishingoperation(EO),andasourceof
reinforcement. Afourthcondition,the"play"condition,wasdesignedtobeacontrol. In
thesocialdisapprovalorattentioncondition,toyswerecontinuouslyavailable,andthe
therapistsatinachairacrosstheroomreadingabook. Briefattentionwasdelivered
contingentuponthetargetbehavior,andallotherresponseswereignored. Thiscondition
servedasatestforbehaviormaintainedbysocialpositivereinforcement. Inthedemand
condition,atherapistpresentedinstructionaltasks,andproblembehaviorresultedin
escapefromthesetasks. ThisconditiontestedforSIBmaintainedbysocial-negative
reinforcement. Inalonecondition,theparticipantwasaloneinaroom,andnomaterials
werepresent. Persistenceofrespondinginthisconditionsuggestedthatproblem