Implications And Strategies For Dealing With Mouthing

1. Implications And Strategies For Dealing With Mouthing Geoff Bowen, Psychologist SVRC

2. “As a behaviourist, I am guided by the dead mans rule which says that dead men have no behaviors and no behaviors put the behaviourist out of business. What you want to do is to go to where the child is and let the child take you where the child needs to go. Along the way, you shape in the socially-appropriate behaviors that will lead to independent living and working.” Dr. Ed Hammer, Professor, Department of Paediatrics Texas Tech Health Sciences Centre in Amarillo

3. Object Mouthing • Object mouthing is a common problem among individuals with developmental disabilities. • When individuals both mouth and ingest items, object mouthing is often a component of pica (Piazza, Roan, Keeney, Bony, & Bat, 2002)

4. Hand Mouth - Definitions “Hand mouthing was broadly defined according to three topographies: (a) hand mouthing (HM), defined as the participant inserting the hand past the plane of the lips and not closing his or her teeth on the hand; (b) hand biting (HB), defined as the participant inserting the hand past the plane of the lips and closing his or her teeth on the hand; and (c) finger sucking (FS), defined as the participant inserting a single finger into the mouth past the plane of the lips and not closing his or her teeth on the finger.” (Canella, et al 2006)

5. HM: Prevalence/Concerns • Prevalence of hand mouthing, a form of stereotypic behavior, has been estimated to be between 7 and 16% for individuals with severe to profound developmental disabilities. • Engaging in hand mouthing can be detrimental to an individual’s health, adaptive behavior, and social functioning. • In terms of health, continuous hand mouthing can lead to tissue damage, hematoma, salivary dermatitis, scarring, and skin breakage.

6. Reference to adaptive behavior, hand mouthing interferes with participation in daily educational and living activities, because the individual’s hands are consistently in his or her mouth. • It is considered to be socially maladaptive because of the repulsive sights and smells it produces. (Treatment of hand mouthing in individuals with severe to profound developmental disabilities: A review of the literature, Helen I. Cannella et al, Research in Developmental Disabilities 27 (2006) 529–544)

7. Intervene??!! “Like you and I, children with deaf blindness have a need to participate in self-stimulatory activities. Because their behaviors appear very different from our own and can interfere with learning or become dangerous, they are viewed negatively by many people. Changing our perception about these behaviors may help us respond to them in a better way.” (Looking at Self-Stimulation in the Pursuit of Leisure or I'm Okay, You Have a Mannerism by Kate Moss, Family Specialist and Robbie Blaha, Teacher Trainer TSBVI, Texas Deafblind Outreach)

8. “There are a number of ways to intervene. Keep the child involved with others during the course of the day. Help him/her contain the behavior, or engineer the environment to make the behavior safer. Schedule times in the day for your child to engage in the preferred activity. Look at ways the behavior can be adapted, so it will appear more "normal." Use the information these behaviors tell you about your child's preferred channels of sensory input, to develop recreational and social pursuits that may be enjoyable for him/her, even if these activities will not entirely meet his/her "leisure" needs. Finally, accept that you will probably never completely extinguish the behavior without having it replaced by another self-stimulatory behavior. Self-stimulation is common to all humans and serves an important purpose.”

9. CHALLENGING BEHAVIORS “Behaviors of such intensity, frequency or duration that the physical safety of the person or others are placed in serious jeopardy, or behavior which seriously limits the person’s access to ordinary settings, activities and experiences.” Emerson et al 1988

10. CHALLENGING BEHAVIORS “It was originated by advocates of people with disabilities who were tired of terms like "behavior disorder", "disturbed behavior", "inappropriate behavior" and "behavior problem".They argued that such terms wrongly attributed ownership and blame to the person, as if they carried the behavior around as "symptoms" of their disability. Instead, the advocates argued, their behavior was a very understandable response to often unstimulating, inflexible, dehumanising and unresponsive services. Their behaviors in fact represented " symptoms " of a " sick system " and in this way "challenged" the system to improve and to become more responsive.”Radler 1990

11. Behavioural Interventions Quality Assurance Issues • Does the behaviour warrant intervention? • Have the physical/psychiatric aspects of the behaviour been assessed? • Have the situational aspects of the behaviour been assessed? • Has the function of behaviour been determined?

12. Have systematic influences on behaviour been determined? • Have the assessments led to a diagnostic hypothesis? • Is the recommended intervention consistent with the diagnostic hypothesis? • Is the intervention the least intrusive/restrictive option?

13. Is the intervention "crisis intervention" or "therapeutic intervention?“ • Has student (parent) provided informed consent for the intervention? • Arethe effects and side effects of the intervention monitored? • What is the time limit of the intervention?

14. Is the intervention given an adequate treatment trial? • Is there increasing escalation of behaviour intervention?

15. Challenging Behavior: HM • As with all behavioural concerns, when working with our population of students we MUST consider the reasons for the observed behaviour, and question ourselves if the behaviour is: • Attention seeking (and why) • An avoidance behaviour • Providing sensory input and enjoyment • Response to presently occurring pain or discomfort • Organically based and it is the student's way to communicate their discomfort to you, the caregiver.

16. Functional Behavioral Analysis • Initially, a functional analysis should be conducted in order to obtain a detailed description of the person’s self-injurious behavior and to determine possible relationships between the behavior and his/her physical and social environment • The information obtained from a functional analysis should include: Who was present? What happened before, during and after the behavior? When did it happen? Where did it happen? • Hopefully, the answers to these questions may help reveal the reason's) for the behavior.

17. Prior To Data Collection • It is important to define the behavior of interest. • The focus of the functional analysis should be on a specific behavior (e.g., wrist-biting) rather than a behavior category (e.g., self-injury). • Combining several types of self-injury into one general behavior may make it difficult to determine different reasons for each behavior.

18. During Data Collection • Salient characteristics of the self-injurious behavior should be recorded, such as the frequency, duration, and severity. • Data collection should also include information about the person's physical and social environment. The physical environment should include: the setting (e.g., classroom, cafeteria, playground), lighting (natural light, florescent, incandescent), and sounds (e.g., lawn mower, another child screaming). • The names (or codes) of everyone in the person's environment should also be recorded, such as teachers, parents, staff, visitors and students/clients. • Other factors to be recorded are: time of day and day of the week

19. Reinforcement of SIB including HM Iwata and his colleagues (1994) identified four functions of self-injurious behavior using analogue functional analyses: • social-negative reinforcement (i.e., escape from demands or other situations), • social-positive reinforcement (i.e., access to attention or tangibles), • automatic (i.e., sensory) reinforcement, and • multiple controlling variables.

20. Automatically Maintained Behaviors • “For those behaviors maintained by social-negative or social-positive reinforcement, the method of treatment follows logically from the function. That is you stop rewarding or reward behaviors appropriately.” • “Unfortunately, between five and thirty-five percent of individuals with developmental disabilities engage in stereotypic, or automatically maintained, behaviors (Rojahn, Hammer, & Kroeger, 1997). Iwata and his colleagues (1994) found that nearly 26% of their participants’ challenging behavior was maintained by automatic reinforcement.”

21. Automatically Maintained Behaviors • “For those behaviors maintained by automatic reinforcement, determination of the method of treatment is not as logical, as there is often no clear indication of what aspect of the behavior is serving as the maintaining stimulus.” From: Assessment and Treatment of Automatically Maintained Hand Mouthing in Individuals with Developmental Disabilities, Helen Irene Cannella, August 2005

22. Differentiated V Undifferentiated Automatically Maintained Behaviors “With differentiated results, the challenging behavior occurs consistently more frequently in the alone condition and consistently less frequently in all other conditions. When a behaviour is differentiated, the conclusion is that the behavior is not being maintained by social reinforcement, but rather by the sensory stimulation provided by the behavior itself"

23. “With undifferentiated results, the challenging behavior occurs across all conditions. Undifferentiated results may occur for one of two reasons. One is that the behaviour may be maintained by both social and non-social forms of reinforcement (i.e., may be multiply maintained).” From: Assessment and Treatment of Automatically Maintained Hand Mouthing in Individuals with Developmental Disabilities, Helen Irene Cannella, August 2005

24. The following notes are primarily from Provincial Integration Support Program Website, funded by the B.C. Ministry of Education and hosted by B.C. School District #61 (Victoria , Canada). http://pisp.ca • The specific site on HM is: http://www.pisp.ca/?cx=017659047860420619755%3A-h1fsw-colw&cof=FORID%3A11&ie=UTF-8&q=hand+mouthing&sa=Search#182 • There is excellent material on VI students on the following part of the site: http://pisp.ca/inservice_training/index.html

25. Some Reasons, And Possible Solutions, To HM REFLUX: • Is a common symptoms of reflux is habitual mouthing of their hands. • If you suspect your student has reflux, you should ask for a medical opinion. • Monitor when your student's 'mouthing' behaviour occurs to see if it coincides with mealtimes (both oral and g-tube feedings). • You may wish to position your student in a more upright position and have smaller, more frequent meals until they are seen by a doctor. Medication usually works very well for this and should reduce the behaviour

26. DENTITION: • Always check your student's teeth to rule out dentition problems. • Sometimes fists in the mouth can help subdue pain. • Check with the dentist PAIN: • If this behaviour is new, rule out the possibility of pain. • Perhaps there are hip problems, seating and positioning • difficulties, changes in your student's physical state etc. Check with the doctor to rule out physical concerns.

27. GENETIC DISORDER: • Understand your students genetic disorder, it could be a sign/symptom of the disorder (e.g. lesh nyham disease). HUNGER/THIRST • Always check to be sure that your student is not hungry or thirsty. This is a way for them to • communicate a need. • If this is the case, the team will need to respond to the behaviour by providing food/drink. • This way of communicating needs to be added to the student's personal dictionary.

28. INDUCE VOMITING: • Inducing vomiting can be a sign of discomfort or may be a sign of reflux. Check with the doctor to rule out medical concerns. Also check positioning: If your student is in a chair or is wearing a TLSO or some truncal restraint, there may be pressure on the stomach that is making them uncomfortable, especially after a meal. Monitor when this behaviour occurs. • GB: Induced vomiting can be used to escape a request, a situation or an environment.

29. AVOIDANCE: • Your student may be trying to avoid an activity or may be unprepared for the activity you are about to begin. • Try to determine if your student is avoiding the activity because it is uncomfortable for him/her: If so and if appropriate, eliminate the stimulus (activity). If not, then help prepare your student for the activity. To give them some control you may wish to introduce tactile calendar boxes to help develop some understanding and control of routines within the day. Once the routine is understood and the activity is part of the day, the 'hands in mouth' avoidance behaviour may be reduced.

30. DEVELOPMENTAL PHASE: • Some students with significant developmental delays, and mouth their hands as part of their developmental stage. Try redirecting using chewellery, hard toys, chew stick etc. • GB: See Marion and Annette’s recommendations re this area.

31. BORED: • Sometimes our student is bored. Try redirecting the student's focus to a motivating activity, music, vibrations, vestibular activities (e.g. swing, ball activities etc). FRUSTRATED: Are they trying to tell us something? • Rule out pain or medical concerns and check the environment; perhaps there is something in the immediate environment that is bothering your student, noise, lights, the need for a position change, etc. Try removing/changing the stimulus.

32. If the behaviour does not change, then try redirecting (e.g. chewellery, more stimulation, using a motivating activity etc.). You might also try relaxation techniques or strategies, e.g. pressure, massage, brushing, music etc. ORAL STIMULATION: • Many students who age tube fed or fed only soft foods may be trying to give themselves oral stimulation. • Try using oral stimulation techniques e.g. Beckman exercises (http://www.beckmanoralmotor.com), NUK brushing, chew bags etc. talk to your OT for extra (and student specific) ideas.

33. SENSORY NEEDS: • Many students with sensory losses (e.g. vision, hearing etc.), find it hard to meet their sensory needs especially if they are confined to a wheelchair/and or blind. • Mouthing their hands is a way to provide some sensory input. A sensory diet of motivating activities may help reduce the incidence of mouthing. Talk to • Occupational therapists can help establish a 'student specific sensory diet' or redirect your student to one of their motivating sensory activities. • GB: See Marion and Annette’s recommendations re. this. Deep pressure can calm some of these students i.e. sand filled vests and massage

34. Sensory Homunculus • Illustrating the projection of various body regions on the sensory cortex. • The length of each line represents the proportion of the somato-sensory cortex devoted to the part indicated by the adjacent label. • The diagram shows that the size of the body part is less important than the density of enervation in determining how much space is needed in the cortex. • Does blindness/physical disability change the homunculus placing even greater emphasis on the mouth and hands?

37. TACTILE DEFENSIVE: • Some students who keep their hands fisted put their hands in their mouth (dorsal - back of hand) to avoid touching objects with the palms of their hands. • They may also be tactile defensive to other stimuli in their environment and mouth to reduce the stress of the stimulus. • Always check to determine if tactile defensiveness is a concern and work with the student to reduce (e.g. using a sensory program), or eliminate (e.g. rough textured t-shirt, removed), the defensive reaction.

38. HABIT: • Redirecting the behaviour • Adding more sensory input into the student's routines • Activity boxes to keep your students hands busy • Use of arm splints to keep hands away from mouth • Using mitts to cover the hands, although sometimes the hand, mitt and all, will go into their mouth • Use of relaxation techniques • Use of chewellery • Oral stimulation programs

39. Social Reinforcement • The hand mouthing of 2 subjects was maintained by social-positive reinforcement, one in the form of attention, and the other in the form of access to materials. • These data suggest that hand mouthing can be sensitive to social contingencies. • Thus, an a priori assumption that hand mouthing in a given individual is a self-stimulatory response may be incorrect and could have detrimental effects on treatment. ANANALYSIS OF THE REINFORCING PROPERTIES OF HAND MOUTHING HAN-LEONG GOH et al, JOURNAL OF APPLIED BEHAVIOR ANALYSIS 1995, 282 269-283 NUMBER3

40. HAN-LEONG GOH et al suggested an effective intervention for individuals whose hand mouthing was maintained by social reinforcement, might be: • Discontinue access to attention or materials for hand mouthing (i.e., extinction) while providing these consequences independent of hand mouthing (non-contingent reinforcement), • Contingent on the non-occurrence of hand mouthing (differential reinforcement of other behavior) • Or contingent on the occurrence of a different behavior (differential reinforcement of alternative behavior).