JOURNAL OF APPLIED BEHAVIOR ANALYSIS 2016, 49, 680–685 NUMBER 3 (FALL)

THE COMBINED EFFECTS OF NONCONTINGENT REINFORCEMENT

AND PUNISHMENT ON THE REDUCTION OF RUMINATION
NICOLE M. DEROSA, HENRY S. ROANE,
JAMIE R. BISHOP, AND ERICA L. SILKOWSKI
UPSTATE MEDICAL UNIVERSITY

The current study extends the literature on the assessment and treatment of rumination through
the evaluation of a combined reinforcement- and punishment-based intervention. The study
included a single participant with a history of rumination maintained by automatic reinforce-
ment, as identified via a functional analysis. Both noncontingent reinforcement (NCR) with
preferred edible items and punishment, in the form of a facial screen, were implemented sepa-
rately to evaluate their independent effects on the occurrence of rumination. The final treatment
package included both NCR and punishment procedures. Implementation of the combined
treatment resulted in a 96.5% reduction in rumination relative to baseline. Procedural modifica-
tions and integrity errors also were evaluated.
Key words: rumination, autism, noncontingent reinforcement, punishment

Rumination involves the repeated regurgita-
tion of previously ingested food, which then
may be rechewed, reswallowed, or spit out.
Rumination can develop throughout the life
span and is relatively common among indivi-
duals with intellectual disabilities (American
Psychiatric Association, 2013). Health risks
associated with rumination include malnutri-
tion, weight loss, esophageal damage, tooth
decay, and death (Vollmer & Roane, 1998).
Historically, punishment-based procedures were
used to treat rumination; however, the use of
certain punishment procedures (e.g., electric
shock) has raised ethical concerns (Lang et al.,
2011). More recent treatments for rumination
have been antecedent based, such as caloric
satiation procedures (e.g., Clauser & Scibak,
1990) or other dietary manipulations
(e.g., Johnston, Greene, Rawal, Vazin, &
Winston, 1991).
Lang et al. (2011) noted that the advent of
functional analysis methods produced an
Correspondence concerning this article should be
addressed to Nicole M. DeRosa, Family Behavior Analysis
Program, Department of Pediatrics, Upstate Medical Uni-
versity, 600 E. Genesee St., Suite 130, Syracuse,
New York 13202 (e-mail: derosan@upstate.edu).
doi: 10.1002/jaba.304
increase in the use of reinforcement-based treat-
ments for rumination, including the use of
noncontingent reinforcement (NCR; e.g.,
Lyons, Rue, Luiselli, & DiGennaro, 2007) and
differential reinforcement (e.g., Rhine &
Tarbox, 2009; Sanders-Dewey & Larson,
2006). However, consistent with other forms
of problem behavior, punishment procedures
may sometimes be a necessary complement to
reinforcement-based treatments for rumination
(e.g., Baker, Rapp, & Carroll, 2010). The cur-
rent study examined the effects of NCR and
punishment, both alone and in combination,
on the occurrence of rumination.
METHOD
Participant and Setting
Darnell was an 18-year-old man who had
been diagnosed with autism, rumination, and
several medical conditions. Previous medical
assessments ruled out biological causes for
rumination, suggesting that behavioral assess-
ment and treatment of rumination were safe.
Darnell had been hospitalized several times
before this study due to severe weight loss and
malnutrition, which medical examinations

680
 RUMINATION
concluded to be secondary symptoms of rumi-
nation. A functional analysis suggested that
rumination was maintained by automatic rein-
forcement. Darnell was nonvocal and had
resided in a residential treatment center since
the age of 10 years. He was admitted to an out-
patient behavior clinic for 1 hr per day, 5 days
per week, for the treatment of rumination.
Clinical significance was determined at an ini-
tial goal meeting with his mother and the
clinic’s licensed psychologists (first and second
authors) and was set at an 80% reduction in
rumination from baseline levels.
One session of approximately 45 min (range,
30 min to 60 min) was conducted per day dur-
ing the NCR and combined treatment analyses;
sessions lasted 5 min, and four to six sessions
were conducted per day during the punishment
analysis. All sessions were conducted in a room
(3 m by 3 m) equipped with a one-way obser-
vation panel. Materials included a table, two
chairs, and three Chux pads (i.e., absorbent,
reusable pads to soak up vomit). Darnell wore
a smock throughout all sessions, and preferred
edible items (0.6 cm by 0.6 cm pieces of pre-
ferred foods identified via a paired-choice pref-
erence assessment; Fisher et al., 1992) were
present in the room during NCR sessions.
Before the start of daily sessions, Darnell was
provided with a snack prepared by his residen-
tial staff as part of his specialized diet. The
snack always included 236 ml of a high-caloric
shake, and the food items varied. Although the
snacks were determined by a dietician, we
documented the type of food he consumed
each day at clinic. Differences in rumination
across foods were not observed.
Response Measurement and Interobserver
Agreement
Rumination was defined as bringing previ-
ously consumed food or liquids into his throat
or mouth causing his cheeks to bulge out. An
instance of rumination was scored each time
681
one or both of Darnell’s cheeks bulged out
approximately 0.6 cm from its original resting
position. Darnell did not open his mouth dur-
ing rumination, so it was not possible to deter-
mine when food had been brought up or
reswallowed, although both response compo-
nents were likely due to his long history of
rumination that met that definition.
Frequency data were recorded and converted
to a response rate (responses per minute)
for data analysis. Interobserver agreement data
were collected during 33%, 36%, and 44% of
sessions for the NCR analysis, punishment
analysis, and combined treatment analysis,
respectively. Exact agreement intervals were
used to calculate interobserver agreement. The
mean agreement for rumination was 99.9%
(range, 99% to 100%), 93% (range, 83% to
100%), and 86% (range, 60% to 100%) for
the NCR analysis, punishment analysis, and
combined treatment analysis, respectively.
Procedure
NCR analysis. Baseline and NCR conditions
were evaluated using a reversal design. During
baseline a therapist was in the room with Dar-
nell but did not interact with him, no edible
items were present, and all instances of rumina-
tion were ignored. During the NCR condition,
Darnell was given noncontingent access to
three pieces of food placed on a plate within
arm’s reach and brief attention (e.g., head rub
and a neutral statement) on a variable-time
(VT) 45-s (range, 15 to 75 s) schedule. The
order of the time intervals was determined
before each session. As in baseline, rumination
was ignored during NCR.
Punishment analysis. A facial screen was iden-
tified as a potential punisher during a stimulus
avoidance assessment (Fisher, Piazza, Bowman,
Hagopian, & Langdon, 1994). Before imple-
mentation of the stimulus avoidance assess-
ment, a licensed psychologist (first author) met
with Darnell’s mother to review the procedures
682 NICOLE M. DEROSA et al.
and obtain her ratings and documented con-
sent. Any procedures that she opposed would
not have been included in the assessment; how-
ever, she consented to all procedures. Proce-
dures included a baskethold, chair time-out,
tidiness training, contingent exercise, contin-
gent demands, facial screen, hands down, and
quiet hands.
After the stimulus avoidance assessment,
baseline and facial screen (FS) conditions were
evaluated in a reversal design. Baseline was
identical to that in the NCR analysis. During
the FS condition, a 30-s FS was implemented
contingent on each occurrence of rumination
(fixed-ratio [FR] 1 schedule). The FS included
the therapist standing behind Darnell and
lightly placing one hand over his eyes, while
the therapist used her other arm to block
attempts to remove the FS. If Darnell turned
his head, the therapist followed with her hand
but refrained from using any force to stabilize
his head (to prevent injury). No additional con-
sequences were in place if rumination occurred
during the screen. After 30 s, the therapist
removed the screen until the next occurrence of
rumination.
Combined analysis. Baseline (described above)
and the NCR + FS conditions were evaluated
within a multielement design. During the
NCR + FS condition, procedures for the NCR
analysis and punishment analysis were com-
bined, with NCR and the FS delivered on the
same VT 45-s and FR 1 schedules described
above.
After the combined treatment analysis, both
integrity errors and procedural modifications
were evaluated to determine whether the com-
bined treatment would be effective at decreas-
ing rumination under less-than-ideal integrity.
All procedural modification and integrity-error
conditions were compared to baseline
(described above) within a multielement design.
During the 50% integrity condition, every
other programmed NCR delivery (based on the
VT 45-s schedule) was omitted and the FS was
implemented on an FR 2 schedule. During the
25% integrity condition, every fourth NCR
delivery occurred as intended, and the FS was
implemented on an FR 4 schedule.
Next, we implemented the combined treat-
ment with 100% integrity and modified the FS
procedures. The first modification included
moving the therapist’s hand from lightly touch-
ing Darnell’s face to holding her hand in place
approximately 3 cm from his eyes. The final
modification included the 3-cm proximity and
a reduction in the duration of the FS to 10 s.
RESULTS AND DISCUSSION
Results of the NCR analysis are depicted in
Figure 1 (top). The horizontal dotted line
represents an 80% reduction (1.6 responses per
minute) from the original baseline. Across base-
line phases, rumination averaged 7.5 responses
per minute (range, 4.4 to 13.2). Rumination
averaged 2.0 responses per minute (range, 0 to
5.2), with a slight increasing trend across NCR
phases.
Results of the punishment assessment are
depicted in Figure 1 (middle). The average rate
of rumination during the initial baseline was
7.7 responses per minute (range, 6.2 to 9.0).
An 80% reduction from this baseline was
1.5 responses per minute. After implementa-
tion of the FS condition, a reduction in rumi-
nation occurred (M = 2.1 responses per
minute; range, 0 to 6.6). During the return to
baseline, rumination increased to high but vari-
able rates (M = 6.1 responses per minute;
range, 0 to 24.4). During the final FS phase,
rumination again decreased relative to baseline
(M = 3.3 responses per minute; range, 0.2
to 8.8).
During the initial combined treatment,
rumination averaged 5.7 responses per minute
(range, 3.8 to 7.7) during baseline and 0.2
responses per minute (range, 0.1 to 0.5) during
NCR + FS. When integrity errors were intro-
duced, rumination remained consistent in the
 RUMINATION 683

Baseline NCR (BL) NCR NCR (BL) NCR

14
13 (BL)
12
11
Rate of Rumination

10
9
8
7
6
5
4
3
2
1
0

0 5 10 15 20 25 30 35

26 FS Baseline FS
24
22
20
Rate of Rumination

18
16
14
12
10
8
6
4
2
0

0 5 10 15 20 25 30 35 40 45 50 55 60 65

100% 50% 25% FS 3 cm FS 3 cm

24 Integrity Integrity Integrity +10 s
22
20
Rate of Rumination

18
16
14
Baseline
12
10
8 NCR
6 + FS
4
2
0

0 5 10 15 20 25 30 35
Sessions

Figure 1. Rate of rumination during the NCR analysis (top), punishment analysis (middle), and combined treat-
ment (bottom).

50% (M = 0.2 responses per minute) and 25% per minute (range, 0.07 to 0.36) when the FS
integrity conditions (M = 0.1 responses per was placed 3 cm from Darnell’s face. Finally,
minute). Rumination averaged 13.3 responses rumination remained low (M = 0.04 responses
per minute (range, 6.8 to 23.4) during baseline per minute) when the duration of the FS was
but decreased to an average of 0.1 responses reduced to 10 s.
684 NICOLE M. DEROSA et al.
The current study examined the effects of
NCR and punishment, alone and combined,
on the occurrence of rumination. Results indi-
cated that the implementation of NCR and FS
alone was insufficient for reducing rumination
to clinically significant levels (80% reduction
from baseline). However, implementation of
the combined treatment resulted in a 96.5%
reduction from baseline. Clinically significant
effects were maintained when the combined
treatment was implemented with 50% and
25% integrity. Effects were maintained when
the FS was modified to be less intrusive and
was implemented for a shorter duration. Given
these results, it is possible that an aspect of the
procedural arrangement (e.g., session room,
therapist proximity) exerted stimulus control
over rumination. Previous studies have evalu-
ated stimulus-control procedures for the main-
tenance of treatment effects in the absence of
caregivers (Piazza, Hanley, & Fisher, 1996).
Although we did not program for stimulus con-
trol, rumination rarely occurred during the
combined treatment. Thus, contact with the
punisher was limited, which may provide evi-
dence of an inhibitory stimulus-control effect.
The current study, combined with previous
research (e.g., Baker et al., 2010), extends the
literature on the need for combinations of
punishment- and reinforcement-based proce-
dures to treat rumination. Although punish-
ment is subject to ethical considerations, it
should be noted that Darnell had been exposed
to 22 different reinforcement-based procedures
before the current study, none of which was
effective. Only when a systematically identified
punishment procedure was added to the
reinforcement-based treatment did significant
reductions in rumination occur and maintain,
demonstrating the necessity of this component.
Despite these findings, there are limitations
that should be considered. The combined treat-
ment phase was relatively brief before the integ-
rity errors and procedural modifications were
introduced. Furthermore, integrity and
procedural modifications may have been sub-
ject to sequence effects. It is also unknown
whether the modification procedures would
have been immediately effective (i.e., if the ini-
tial treatment parameters were necessary to
obtain effectiveness). Future investigations
should conduct parametric assessments of pun-
ishers before implementation to ensure the least
intrusive procedure. Our ability to draw defini-
tive conclusions about the relative effects of
integrity levels may be limited, given that Dar-
nell rarely contacted the punishment contin-
gency during the combined treatment. In
addition, the programmed integrity schedules
may not be representative of those present in
the natural environment. Specifically, it is prob-
able that errors in the natural setting occur on
variable, rather than fixed, schedules. Neverthe-
less, these results add to the literature by
demonstrating the effects of combining empiri-
cally derived reinforcers and punishers in the
treatment of rumination.
REFERENCES
American Psychiatric Association. (2013). Diagnostic and
statistical manual of mental disorders (5th ed.).
Washington, DC: Author.
Baker, L. M., Rapp, J. T., & Carroll, R. A. (2010). Treat-
ing operant vomiting with visual screening. Clinical
Case Studies, 9, 218–224. doi: 10.1177/
1534650110372253
Clauser, B., & Scibak, J. W. (1990). Direct and general-
ized effects of food satiation in reducing rumination.
Research in Developmental Disabilities, 11, 23–36.
doi: 10.1016/0891-4222(90)90003-Q
Fisher, W., Piazza, C. C., Bowman, L. G.,
Hagopian, L. P., & Langdon, N. A. (1994). Empiri-
cally derived consequences: A data-based method for
prescribing treatments for destructive behavior.
Research in Developmental Disabilities, 15, 133–149.
doi: 10.1016/0891-4222(94)90018-3
Fisher, W., Piazza, C. C., Bowman, L. G.,
Hagopian, L. P., Owens, J. C., & Slevin, I. (1992).
A comparison of two approaches for identifying rein-
forcers for persons with severe and profound disabil-
ities. Journal of Applied Behavior Analysis, 25,
491–498. doi: 10.1901/jaba.1992.25-491
Johnston, J. M., Greene, K. S., Rawal, A., Vazin, T., &
Winston, M. (1991). Effects of caloric level on
 RUMINATION
ruminating. Journal of Applied Behavior Analysis, 24,
597–603. doi: 10.1901/jaba.1991.24-597
Lang, R., Mulloy, A., Giesbers, S., Pfeiffer, B.,
Delaune, E., Didden, R., … O’Reilly, M. (2011).
Behavioral interventions for rumination and operant
vomiting in individuals with intellectual disabilities: A
systematic review. Research in Developmental Disabil-
ities, 32, 2193–2205. doi: 10.1016/j.ridd.2011.06.011
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. doi:
10.1901/jaba.2007.743-747
Piazza, C. C., Hanley, G. P., & Fisher, W. W. (1996).
Functional analysis and treatment of cigarette pica.
Journal of Applied Behavior Analysis, 29, 437–450.
doi: 10.1901/jaba.1996.29-437
Rhine, D., & Tarbox, J. (2009). Chewing gum as a treat-
ment for rumination in a child with autism. Journal
685
of Applied Behavior Analysis, 42, 381–385. doi:
10.1901/jaba.2009.42-381
Sanders-Dewey, N. E., & 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 Exper-
imental Psychiatry, 37, 140–145. doi: 10.1016/j.
jbtep.2005.03.001
Vollmer, T. R., & Roane, H. S. (1998). Rumination. In
L. Phelps (Ed.), Health-related disorders in children
and adolescents: A guidebook for understanding and
educating (pp. 564–570). Washington, DC: Ameri-
can Psychological Association. doi: 10.1037/
10300-079
Received June 22, 2015
Final acceptance November 5, 2016
Action Editor, Terry Falcomata