Implications And Strategies For Dealing With Mouthing

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Implications And Strategies For Dealing With
Mouthing

• Geoff Bowen, Psychologist SVRC

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• 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

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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)

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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)

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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 individuals 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.

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• Reference to adaptive behavior, hand mouthing
  interferes with participation in daily
  educational and living activities, because the
  individuals 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) 529544)

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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)

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• 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.

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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 persons
  access to ordinary settings, activities and
  experiences.
• Emerson et al 1988

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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

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Behavioural Interventions Quality Assurance
Issues

1. Does the behaviour warrant intervention?
2. Have the physical/psychiatric aspects of the
   behaviour been assessed?
3. Have the situational aspects of the behaviour
   been assessed?
4. Has the function of behaviour been determined?

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• 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/restrictiv
  e option?

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

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

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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.

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Functional Behavioral Analysis

• Initially, a functional analysis should be
  conducted in order to obtain a detailed
  description of the persons 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.

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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.

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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

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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.

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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.

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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

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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"

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• 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

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• 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
  0176590478604206197553A-h1fsw-colwcofFORID3A1
  1ieUTF-8qhandmouthingsaSearch182
• There is excellent material on VI students on the
  following part of the site
• http//pisp.ca/inservice_training/index.html

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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

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• 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.

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• 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.

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• 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.

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• 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.

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• 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 Annettes recommendations re
  this area.

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• 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.

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• 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.

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• 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 Annettes recommendations re.
  this. Deep pressure can calm some of these
  students i.e. sand filled vests and massage

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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?

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• 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.

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• 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

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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

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• 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).