JOURNAL OF APPLIED BEHAVIOR ANALYSIS 2013, 46, 328332 NUMBER 1 (SPRING 2013)

FUNCTIONAL ANALYSIS AND INTERVENTION

FOR CHRONIC RUMINATION
KATHRYN E. WOODS, JAMES K. LUISELLI, AND SHANON TOMASSONE
MAY INSTITUTE

We conducted a functional analysis and treatment evaluation of chronic rumination in a 19-year-old

man with intellectual disabilities. Outcomes of the functional analysis suggested that rumination
was maintained by automatic reinforcement. Results of the intervention evaluation suggested that
(a) noncontingent access to food after meals reduced rumination more effectively than did
noncontingent access to inedible stimuli, (b) a particular type of food was associated with lower
levels of rumination than other types of food, and (c) both presession and continuous access to food
reduced levels of rumination more effectively than did fixed-time access to food.
Key words: rumination, functional analysis, automatic reinforcement, noncontingent
reinforcement

Rumination is defined by repeated regurgitat-
ing, chewing, and reswallowing previously
ingested food. Serious medical problems can
result from chronic rumination, such as electro-
lyte imbalance, malnutrition, weight loss, esoph-
agitis, respiratory complications, and decreased
resistance to disease (Boris & Dalton, 2007).
Although the earliest behavioral intervention
research on rumination featured punishment
procedures (Sajwaj, Libet, & Agras, 1974), later
studies evaluated the effects of less restrictive
intervention by manipulating food quantity and
consumption (Rast, Johnston, Drum, & Conrin,
1981), supplemental feedings (Thibadeau, Blew,
Reedy, & Luiselli, 1999), and noncontingent
access to food or liquids (Kenzer & Wallace,
2007; Kliebert & Tiger, 2011). Despite the
importance of identifying maintaining rein-
forcers to inform intervention, relatively few
published studies on rumination included func-
tional analyses (Kenzer & Wallace, 2007; Lyons,
Rue, Luiselli, & DiGennaro, 2007; Wilder,
Register, Register, Bajagic, & Neidert, 2009).
This study was conducted at the May Center for Child
Development, Randolph, Massachusetts. We appreciate the
skilled participation of Adela Scancarova.
Direct correspondence to Kathryn E. Woods, May
Institute, 41 Pacella Park Drive, Randolph, Massachusetts
02368 (e-mail: kwoods@mayinstitute.org).
doi: 10.1002/jaba.24
Accordingly, the present study featured (a) a
functional analysis of rumination that suggested
automatic reinforcement as the source of control
and (b) a subsequent evaluation of stimuli that
were intended to compete with rumination.
METHOD
Participant and Setting
Aaron was a 19-year-old man who had been
diagnosed with congenital encephalopathy, glo-
bal developmental delay, gastroesophageal reflux,
and intellectual disability. He did not speak but
communicated through gestures, body language,
vocalizations, and a picture-point communica-
tion book. Aaron had displayed rumination for
many years. Although he was previously a parti-
cipant in earlier research (Lyons et al., 2007),
he required further intervention because the
problem had reemerged. He weighed 54 kg (3rd
percentile) and was 175 cm tall.
A classroom teacher with several years of
experience conducted functional analysis and
intervention sessions with Aaron each weekday.
Only the teacher and observers were present during
sessions, which were conducted in a partitioned
area of Aarons classroom at a private residential
school. Before the start of the study, the first
author trained the teacher to implement func-
tional analysis and intervention procedures using

328
 FUNCTIONAL ANALYSIS OF RUMINATION
instructions, written guidelines, demonstration,
rehearsal, and performance feedback (Moore et al.,
2002).
Response Measurement and Interobserver
Agreement
Rumination was defined as any instance of
gurgling (upward movement of throat), swishing
(side-to-side mouth movement with lips closed),
or gagging (retching sound) with or without
puffed cheeks or drooling. An observer collected
partial-interval rumination data during 5-min
functional analyses (three conducted per day)
and treatment sessions (one conducted per day)
that were divided into consecutive 15-s intervals.
Aaron typically ruminated immediately after
meals, so we began sessions approximately 2 min
after he consumed his lunch in the schools
cafeteria. Interobserver agreement was assessed
during 60% of functional analysis sessions and
27% of intervention evaluation sessions by having
a second person record rumination simultaneously
with the primary observer. Interobserver agree-
ment (interval agreements divided by interval
agreements plus disagreements and converted to a
percentage) averaged 98% (range, 80% to 100%)
for the functional analysis and 96% (range, 88% to
100%) for the intervention evaluation. Procedural
integrity was assessed during 38% of functional
analysis sessions and 34% of intervention evalua-
tion sessions by having a second person record the
teacher implementing the written procedural
guidelines. Procedural integrity (procedures im-
plemented correctly divided by procedures im-
plemented correctly and incorrectly and converted
to a percentage) was assessed for each session and
averaged 98% and 97%, respectively (range, 80%
to 100%).
Procedure and Design
Functional analysis. We exposed Aaron to five
experimental conditions in a multielement design
(Iwata, Dorsey, Slifer, Bauman, & Richman,
1982/1994). Three conditions were presented
each day based on a random sequence. In the
329
attention condition, Aarons teacher gave him a
preferred leisure activity (access to a computer)
for the duration of the session, did not interact
with him, and delivered a disapproving comment
when he ruminated. In the ignore condition, the
teacher sat out of Aarons view, did not interact
with him, allowed him free access to the
classroom, and did not react when rumination
occurred. During the escape condition, the
teacher presented Aaron with three learning tasks
(one task per session) from his individualized
educational program. When Aaron ruminated,
the teacher removed the task and stopped
interacting with him for 15 s. Finally, two toy
play conditions assessed whether different leisure
items that Aaron frequently chose during free
time would compete with rumination. During
the Play 1 condition, he had continuous access to
his most preferred leisure activity (computer) to
watch videos. The same computer that was used
during the attention condition was used in this
phase. During the Play 2 condition, he had
continuous access to puzzles, board games, and
letter and number books. In both play con-
ditions, the teacher spoke to Aaron every 30 s
(e.g., Youre watching a favorite video. You
have a blue letter.)
Preference assessment. Three staff members
who were familiar with Aaron were asked
independently to identify foods and liquids
that he liked to consume. During 10-min
preference assessment sessions (Pace, Ivancic,
Edwards, Iwata, & Page, 1985), Aarons teacher
presented him with a single food or liquid for
60 s. An observer recorded the percentage of food
that he consumed in quantities of 10 (e.g., 10
potato chips, a granola bar broken into 10 pieces).
Foods and liquids were randomized and pre-
sented once over a 2-day period. Liquid and
pureed food amounts were recorded in ounces,
and one ounce was presented to him at a time.
The following foods and liquids that had 100%
consumption were subsequently included in the
intervention evaluation: soft granola bar, cheese
crackers, applesauce, and graham crackers.
330 KATHRYN E. WOODS et al.
Intervention evaluation. Results of the func-
tional analysis suggested that rumination was
maintained by automatic reinforcement. Accord-
ingly, the purpose of the intervention evaluation
was to examine the effects of noncontingent
access to preferred stimuli (Phases 1 and 2) and
different stimulus-presentation formats (Phase 3)
on rumination. As noted, we compared different
intervention conditions in an alternating treat-
ments design by scheduling one 5-min session
each day. Similar to the functional analysis,
intervention evaluation sessions started approxi-
mately 2 min after Aaron consumed his lunch. In
baseline, the procedures were identical to the
ignore condition of the functional analysis. The
purpose of Phase 1 was to compare the effects of
auditory, visual, and food stimuli on rumination.
During the auditory condition, Aaron had
continuous access to music played on a CD
player. In the visual condition, he used a DVD
player to watch brief clips from his favorite
movies and television shows. He could switch
between songs and video clips without restriction
in both conditions. In the food condition, Aaron
had continuous access to small pieces (5 g per
piece) of one of his highly preferred foods, which
was a soft granola bar.
Based on the results of the first intervention
phase, the purpose of Phase 2 was to evaluate
foods that differed in texture and taste. In
separate sessions, the teacher presented Aaron
with goldfish crackers, applesauce, granola bars,
and graham crackers. We selected these foods for
their nutritional content (i.e., lower calorie foods
preferred over high-calorie foods). As in all
conditions in Phase 1, the different foods were
available continuously throughout the session.
The purpose of Phase 3 was to compare
different formats for presenting the most effective
food identified in Phase 2 (soft granola bar). In
the presession presentation condition, which
occurred 2 min after Aaron consumed his lunch,
he had continuous access to food for 15 min,
followed immediately by a 5-min intervention
evaluation session without food. Under fixed-
time presentation, the teacher gave Aaron a piece
of the food every 60 s throughout the session.
The third condition, continuous presentation,
was identical to the continuous access to food
condition in Phase 1. The same brand-name
granola bar was used in Phases 2 and 3.
RESULTS AND DISCUSSION
In the functional analysis (Figure 1, top),
rumination was relatively stable across attention
(M 43%), ignore (M 50%), escape
(M 57%), Play 1 (M 31%), and Play 2
(M 35%) conditions. For the intervention
evaluation (Figure 1, bottom), rumination aver-
aged 53% in baseline. In Phase 1, rumination
decreased during the auditory stimulation condi-
tion (M 40%) and the visual stimulation
condition (M 25.5%), with the largest reduc-
tion during the food condition (M 4%). In
Phase 2, rumination was lowest for the soft
granola bar (M 6%), followed by applesauce
(M 10%), goldfish crackers (M 14%), and
graham crackers (M 20%). When the soft
granola bar was presented exclusively in Phase 3,
rumination occurred at similar low percentages
during the presession continuous access condi-
tion (M 2%) and the in-session continuous
access condition (M 3%) with an accelerating
trend in the fixed-time condition (M 33%).
Aaron consumed an average of 13 entire bars per
session (range, 3 to 17) during this phase.
As noted above, this study is one of only a few
that conducted a functional analysis of rumina-
tion. In addition, a caregiver implemented the
functional analysis in a real-world (nonsimulated)
setting, with good fidelity and high acceptability.
One potential limitation of our analysis is that we
concluded that rumination was maintained by
automatic reinforcement even though respond-
ing was undifferentiated across conditions (i.e.,
rumination was not highest in the ignore
condition, occurred in a condition of relatively
high stimulation [escape], and did not appear to
be stable in some of the test conditions; Hagopian
 FUNCTIONAL ANALYSIS OF RUMINATION 331

100

90
Escape
Percentage of Intervals with Ruminaon

80
Aenon
70

60 Ignore
50

40

30

20

10 Play Materials - 2
Play Materials - 1
0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25

Sessions

BL Phase 1 Phase 2 Phase 3

60
Percentage of Intervals with Ruminaon

50
Audio

40
Fixed Time

30
Visual
Goldsh Crackers
20 Graham
Cracker

10 Pre-Session
Gustatory Applesauce Connuous
Granola Bar
0
1 4 7 10 13 16 19 22 25 28 31 34
Sessions

Figure 1. Percentage of intervals with rumination during functional analysis (top) and intervention evaluation (bottom)
sessions.

et al., 1997). Nonetheless, the data suggested that access to different types of sensory stimulation,
rumination was not maintained by a social different types of one sensory stimulus (food),
variable. and different food presentation formats. The
Our intervention evaluation demonstrated a principal finding was that the participant
systematic approach for developing an effective ruminated less frequently when he had access
treatment via noncontingent access to preferred to a particular food (soft granola bars) that was
stimuli. We compared the effects of continuous available either during or immediately before
332 KATHRYN E. WOODS et al.
sessions. The presession condition in Phase 3 also
suggested that continuous access to food may
have a lingering reductive effect on rumination
notwithstanding the possible confounding effect
of passage of time. However, we did not isolate
the mechanisms responsible for the treatment
outcome. For example, continuous access to food
may have reduced rumination through satiation
or oral and pharyngeal stimulation.
Results should be interpreted cautiously for
several reasons. Specifically, we included only a
single participant, the amount of food he ate at
lunch was not documented, rumination was not
recorded during the presession condition, and the
intervention evaluation was confined to a brief
postlunch period rather than other times of the
day when rumination occurred. Continuous
access to food also could produce weight gain,
which, as with Aaron, may not be an early-stage
concern in cases of chronic rumination but a
possible treatment contraindication long term.
Despite these concerns, our findings demonstrate
the advantages of conducting a functional
analysis of rumination to select an effective
intervention that can be applied successfully by
caregivers outside a formal research setting.
REFERENCES
Boris, N. W., & Dalton, R. (2007). Vegetative disorders. In
R. M. Kliegman, R. E. Behrman, H. B. Jenson, & B. F.
Stanton (Eds.), Nelson textbook of pediatrics (18th ed.,
pp. 113115). Philadelphia, PA: Elsevier.
Hagopian, L. P., Fisher, W. W., Thompson, R. H., Owen-
De Schryver, J., Iwata, B. A., & Wacker, D. P. (1997).
Toward the development of structured criteria for
interpretation of functional analysis data. Journal of
Applied Behavior Analysis, 30, 313326. doi: 10.1901/
jaba.1997.30-313
Iwata, B. A., Dorsey, M. F., Slifer, K. J., Bauman, K. E., &
Richman, G. S. (1994). Toward a functional analysis of
self-injury. Journal of Applied Behavior Analysis, 27,
197209. doi: 10.1901/jaba.1994.27-197 (Reprinted
from Analysis and Intervention in Developmental
Disabilities, 2, 320, 1982)
Kenzer, A. L., & Wallace, M. D. (2007). Treatment of
rumination maintained by automatic reinforcement: A
comparison of extra portions during a meal and
supplemental postmeal feedings. Behavioral Interven-
tions, 22, 297304. doi: 10.1002/bin.249
Kliebert, M. L., & Tiger, J. H. (2011). Direct and distal
effects of noncontingent juice on the rumination
exhibited by a child with autism. Journal of Applied
Behavior Analysis, 44, 955959. doi: 10.1901/jaba.
2011.44-955
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, 743747. doi: 10.1901/jaba.2007.40-743
Moore, J. W., Edwards, R. P., Sterling-Turner, H. E., Riley,
J., DuBard, M., & McGeorge, A. (2002). Teacher
acquisition of functional analysis methodology. Journal
of Applied Behavior Analysis, 35, 7377. doi: 10.1901/
jaba.2002.35-73
Pace, G. M., Ivancic, M. T., Edwards, G. L., Iwata, B. A., &
Page, T. J. (1985). Assessment of stimulus preferences
and reinforcer value with profoundly retarded individ-
uals. Journal of Applied Behavior Analysis, 18, 249255.
doi: 10.1901/jaba.1985.18-249
Rast, J., Johnston, J. M., Drum, C., & Conrin, J. (1981).
The relation of food quantity to rumination behavior.
Journal of Applied Behavior Analysis, 14, 121130. doi:
10.1901/jaba.1981.14-121
Sajwaj, T., Libet, J., & Agras, S. (1974). Lemon-juice
therapy: The control of life-threatening rumination in a
six-month-old infant. Journal of Applied Behavior
Analysis, 7, 557563. doi: 10.1901/jaba.1974.7-557
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 &
Experimental Psychiatry, 30, 137144. doi: 10.1016/
S0005-7916(99)00012-9
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, 977882. doi:
10.1901/jaba.2009.42-877
Received May 16, 2012
Final acceptance December 17, 2012
Action Editor, Michael Kelley