TREATMENT OF SCAVENGING BEHAVIOR (COPROPHAGY AND PICA) BY OVERCORRECTION* R. M. Foxxt Psychology Department. University of Maryland at Baltimore County. 5401 Wilkens Avenue. Baltimore. Maryland 21128. U.S.A.
and E. D. Anna State Hospital. (Rxriued
MARTIN Anna. Illinois. U.S.A
19 Augusr 1974)
Summary-Scavenging behavior such as pica (ingesting non-nutritive substances) and coprophagy (ingesting fecal matter) represents a seritius health hazard in the care of the institutionalized retarded. The Overcorrection rationale was used to develop procedures for eliminating scavenging. The procedures were applied to 4 profoundly retarded adults who rumaged for and ate: paper. trash, garbage. cigarette butts. bits of cloth and feces. The 3 residents who habitually ate feces were chronically infested with intestinal parasites (Triclwris rrichra). The procedures emphasized correction of the scavenging act. as well as practice in alternative appropriate behavior in the situations in which scavenging normally occurred. The Overcorrection procedures reduced the scavenging of all 4 retardates to a near zero level within 1 week where it remained for the duration of the study. The results of biweekly stool specimens showed that all three coprophagic residents were free of parasites during the Overcorrection condition. The Overcorrection procedures were rapid. easily implemented. enduring and effective methods of reducing pica and coprophagic behavior.
Scavenging is a serious problem of the institutionalized retarded. Residents who rumage for and eat feces, trash, garbage and small objects are endangering their health. Pica, ingesting substances that have no nutritional value. can result in intestinal obstruction, frequent constipation, nutritional anemia and lead poisoning (Kanner. 1962). When the pica habit includes coprophagy, the ingestation of fecal matter. chronic infestation from intestinal parasites such as whipworms (7’1+cltu~istrichiur~) can result. Whipworms are commonly found in coprophagic retardates and can cause diarrhea or constipation, emaciation and anemia (Netter. 1962). Of all the maladaptive behavior of the institutionalized retarded, coprophagy is generally regarded by ward staff as the most disgusting. The coprophagic resident who digs in his rectum for feces to eat or eats the feces of others receives scant attention from ward staff. He smells bad. is generally quite messy and can be a source of infection and infestation. Frequently. the coprophagic resident is kept in isolation or his arm movements are restricted by restraints. At present, no method is in general usage for reducing or eliminating coprophagic or pica behavior. The recent success of Overcorrection procedures in reducing various types of maladaptive behavior suggests that scavenging behavior might be treated successfully by Overcorrection procedures. Overcorrection procedures have been used effectively to reduce or eliminate aggressive-disruptive behavior (Foxx and Azrin. 1972); self-stimulatory behavior (Foxx and Azrin. 1973a); stripping (Foxx, in press) and toileting accidents (Foxx and Azrin, 1973b, c). The general rationale of Overcorrection is: (1) to educate the person to accept responsibility for his misbehavior through Restitutional Overcorrection procedures that require him to restore the disturbed situation to a vastly improved state and (2) to require the offender to practice appropriate modes of responding through Positive Practice Overcorrection procedures that require him to behave appropriately in the situations in which he normally misbehaves (Foxx and Azrin, 1972). * Portions of the research were conducted at Anna State Hospital. t Author to whom reprint requests should be addressed. 153
Anna. 111
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An Overcorrection training program to treat scavenging would require the scavenger to accept personal responsibility for his actions. The scavenger would be required to expel1 ingested non-nutritive matter, expectorate foreign matter from his mouth and keep his mouth. hands and the ward free of debris. The ingestion of foreign substances is a possible source of self-infection. The Restitutional Overcorrection rationale dictates that this source of infection should be reversed by chemical, mechanical or tactile stimulation. Chemical stimulation could be accomplished by use of an emetic that would induce vomiting. Mechanical stimulation would require the use of a stomach pump. The primary disadvantage of both alternatives is that they could be used only once or twice per day, thereby rendering them unusable when the scavenging occurs at a high frequency as is often the case. However. tactile stimulation could be accomplished as frequently throughout the day as necessary. by use of an Oral 7 1973a). The Oral Hygiene procedure would Hygiene procedure (Foxx and Azrin, 197,. consist of cleansing the buccal area by requiring the scavenger to brush his teeth. tongue and gums with a toothbrush that had been soaked in an oral antiseptic. The scavenger would be instructed or coaxed to cough or spit out the foreign matter. If he refused or was unable to expel1 the object(s), the toothbrush could be used as a hygienic probe by inserting it into the mouth and moving it in a tickling manner to elicit coughing and spitting. Periodically, the scavenger would be required to expectorate the antiseptic. The handling of trash and feces also is a source of self-infection since the scavenger’s hands come into frequent contact with his mouth. The Restitutional Overcorrection rationale would dictate that the scavenger be taught the opposite behavior of keeping his hands clean. After each scavenging episode, the scavenger should be required to wash his hands thoroughly and for an extended period. Finally, a Positive Practice Overcorrection procedure should be instituted whereby the scavenger is required to practice alternative correct responses in the situations in which he usually scavenges. This training would consist of teaching the scavenger to rid the ward of debris that had been scavenged formerly by emptying trash recepticles and ashtrays, flushing toilets, and mopping or cleaning up feces from the floor. The coprophagic resident who digs in his rectum for feces would be required to keep his anal region clean and free of fecal matter. A combination of the above procedures should be applied immediately following each scavenging episode. The present study sought to use Overcorrection procedures to treat the pica and coprophagic behavior of institutionalized retarded persons.
STUDY
I
METHOD
Dorris was a 30-yr-old profoundly retarded female who had been institutionalized for 20yr. Her gaunt and emaciated appearance made her seem much older than her years. Her retardation was diagnosed as resulting from encephalopathy. She habitually ate trash and feces and was considered to be the lowest functioning resident on the ward. She ate trash from the ward waste-baskets as well as any small objects she found on the floor. Her coprophagic behavior included digging in her rectum for fecal matter and eating the evacuated feces of herself and others. She was chronically infested with whipworms. Despite treatment by massive doses of antibiotics, she remained infested with the parasites since she invariably reinfected herself by eating the feces of other residents. There was no ward program in effect for treating her coprophagy or pica. Ward staff members studiously avoided any contact with Dorris other than providing her the very minimal custodial care.
A multiple baseline procedure was used (Baer, Wolf and Risley. 1968). The study contained three conditions: (1) Baseline recording of the frequency of coprophagic and pica
Treatment
of coprophagy
episodes; (2) Overcorrection for coprophagy Overcorrection for coprophagy and pica. Recording
and pica
155
and no treatment of pica episodes; and (3)
atld reliability
Scavenging was defined as the gathering and eating of any non-nutritive substance. e.g. trash or feces. A scavenging episode was defined as the presence of trash or feces around or in the mouth or on the hands. Dorris’s hands and mouth were inspected every 15 min throughout her waking hours and her scavenging recorded. Any scavenging episodes that were detected between inspections were recorded also. Each day two attendants were assigned to conduct the inspections; one on the morning shift, the other on the afternoon shift. On selected days within each condition a second observer was assigned on both shifts so that inter-observer reliability could be assessed. Reliability was calculated by dividing the number of daily observations in which the observers agreed by the total number of observations. times 100. The inter-observer agreement was never lower than 94 per cent. Stool specimens
Biweekly stool specimens were being collected when the study began. The specimens were analyzed at the hospital’s clinical lab for the presence of whipworm ova. Two specimens of Dorris’s stools continued to be sent to the lab each week throughout the study. Procedure
The Baseline condition lasted for 6 days. Whenever Dorris was found with trash or feces on her hands or around or in her mouth, she was admonished, encouraged to spit out the material. and required to wash her hands and mouth. This negative instruction and simple correction had been the standard ward procedure at the time the study began. The Overcorrection program for coprophagy began on the seventh day. Baseline conditions remained in effect for all instances of pica. After 2 weeks, an Overcorrection program for pica was instituted. All instances of coprophagy continued to receive Overcorrective consequences. Special trainers conducted the Overcorrection procedures for coprophagy and pica during the first week that each was instituted. The trainers were hospital attendants but were not assigned to the ward staff. During the first week, the special trainers instructed the entire ward staff in the proper conduct of the Overcorrection procedures. Once a staff member performed the procedure correctly, his name was added to a list of certified trainers that was conspicuously displayed on the ward (Foxx and Azrin. 1972, 1973b). Copr0phag.y
Whenever Dorris was discovered eating feces or with traces of feces on her mouth and/ or hands she was given the following Overcorrection training: (1) The trainer manually guided her to a toilet bowl and verbally encouraged her to spit the feces into the toilet. (2) She then was given Oral Hygiene training during which she was required to brush her mouth, teeth and gums gently with a soft toothbrush that had been soaked in an oral antiseptic (mouthwash). The mouth cleansing lasted for 10 min and was conducted at the toilet bowl. (3) Following Oral Hygiene training, Dorris was guided to the bathroom sink and given Personal Hygiene training during which she was required to wash her hands and scrub her fingernails in warm soapy water with a soft fingernail brush. The Personal Hygiene training lasted 10 min. (4) She was required to clean her anal area with a cloth that had been soaked in tepid soapy water and then to wash her hands briefly. (5) Dorris was guided to the area where she was discovered eating and handling the feces and required to mop up the area with a disinfectant. If she had obtained the feces from an unflushed toilet, she was required to flush all unflushed toilets on the ward. The entire procedure lasted 30 min. The trainer wore rubber gloves and a hospital gown to protect his/ her health and clothing. A Graduated Guidance technique (Foxx and Azrin, 1972; Azrin and Foxx, 1974) was used. whenever necessary, to motivate Dorris to engage in the Overcorrective behavior. This guidance consisted of the trainer manually guiding Dorris’ hands whenever she failed
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to respond to an instruction. As Dorris began a requested movement voluntarily. the guidance was reduced to just a touch and then faded ultimately to where the trainer just ‘shadowed’ Dorris’ hands with his. The shadowing allowed the trainer to reapply guidance immediately should it be necessary. Pica
When Dorris was found eating or handling trash the following Overcorrection training was given: (1) The trainer guided Dorris to a trash can where she was required to spit out or throw away the material. (2) Dorris was guided to the toilet and given 1Omin of Oral Hygiene training. (3) Dorris was required to wash her hands and clean her fingernails in warm soapy water with a soft fingernail brush for 10 min. (4) The trainer guided Dorris throughout the ward where she was required to sweep portions of the floor where trash was found, empty all trash cans, and pick up trash and debris from the floor. Graduated Guidance was used whenever necessary. RESULTS
Figure 1 shows that Dorris’was scavenging for feces about ten times per day and for trash about eight times per day during the 6-day baseline period. During the next 2 weeks when Overcorrection training was given only following each coprophagic episode. coprophagy was reduced to about one episode every other day: a reduction of over 95 per cent. During this same 2-week period, Dorris scavenged for trash about nine times per day. On the first day that Overcorrection was given following pica behavior (Day 15) it was reduced by over 90 per cent. Thereafter, pica episodes occurred about once every other day. Coprophagy continued to remain suppressed with episodes occurring about every other day. Both types of scavenging behavior were ultimately reduced by Day 49 to a near zero level where they remained throughout the study. During the Overcorrection conditions, Dorris displayed several dramatic behavior changes. She began to have a hearty appetite at mealtimes, and had gained over 301b at the end of the study. She appeared to become more aware of her surroundings near the completion of the study and on one occasion was found hiding in the ward time-out room digging in her rectum. Before. she had always sat in the main hallways in a seemingly oblivious state whenever she dug for and ate her feces. During the sixth week of Overccorection for coprophagy (Days 35-42) the clincial lab reported that Dorris’ stool specimens were negative; they did not contain any whipworm ova. Thereafter, all biweekly lab reports continued to report negative findings during the
Overcorrection Overcorrection coprophogy
for and
pica
-
Feces -Trash
Fig. I. The effect of Overcorrection Training on the scavenging for feces and trash of a profoundly retarded woman. The circular data points represent the treatment of coprophagy by Overcorrection. The triangular data points represent the treatment of pica by Overcorrection. During the baselme no contingencies were in effect for scavenging. During the Overcorrection training for coprophagy. no contingencies were in effect for pica. The slash marks on the abscissa Indicate a period of 1 week.
Treatment
of coprophagy
and pica
157
remaining 6 weeks of the study. The negative lab reports indicated that the near elimination of coprophagy by Overcorrection had interrupted the life cycle of the whipworms, since Dorris was no longer introducing ova-laden feces into her mouth. STUDY II
In Study I, Overcorrection procedures were employed in the successful treatment of coprophagy and pica. A major question that remained was the generality of the procedures. In Study II, two additional retarded residents who engaged in pica and coprophagy were treated by Overcorrection procedures as a further assessment of the utility of the procedures. METHOD
Subjects
Susan was a 31-yr-old profoundly retarded female with an assessed IQ of 16. She had been institutionalized for 25 yr. Susan was coprophagic, eating her own feces and any feces that she found in the ward toilets. She was chronically infested with whipworms. Susan also ate any bits of paper and cloth that she found lying on the floors. Marie resided on the same ward with Susan. Marie was 20-yr-old, profoundly retarded and had been institutionalized since the age of 11 yr. Her assigned IQ was 18. She was coprophagic, infested by whipworms, and would eat any small objects that she found on the floor. To control Susan and Marie’s scavenging, the ward treatment staff periodically kept them in continuous physical restraints. This restraint consisted of placing a mesh restraining bag over the body which was tied at the shoulders and between the legs thereby restricting any arm movements while still allowing the resident to walk. The restraint effectively eliminated scavenging but had several undesirable side effects: (1) Marie and Susan were very vulnerable to attacks by other residents. They often were pushed and fell down or lost their balance themselves and fell down. Both of them had numerous scars and open lacerations on their heads; (2) they could not be taught self-help skills such as toileting. feeding or dressing themselves; and (3) they presented even the most hardened institutional employee, and justifiably so, with the overwhelming impression that they were being subjected to inhumane treatment. Esperirnental
design
Study II contained three procedures: (1) a baseline condition, (2) a physical restraint condition in which a modified version of the existing ward procedure for scavenging followed each scavenging episode and (3) an Overcorrection procedure. The sequence of the conditions was: Susan: (1) Baseline, 3 days; (2) Physical Restraint. 5 days; and (3) Overcorrection. Marie: (1) Baseline, 3 days; (2) Baseline, 5 days: (3) Physical Restraint, 5 days; and (4) Overcorrection. The initial baseline period lasted 3 days. Susan then was placed in the physical restraint condition while Marie remained under baseline conditions. When Susan was switched to the Overcorrection condition. Marie was switched to the physical restraint condition. After 5 days, Marie was placed in the Overcorrection condition. The women were assigned to a specific treatment sequence on the basis of a coin flip. This design permitted a within-subjects comparison. as well as a between-subjects comparison. Recording
and reliahilitj
Scavenging was defined and recorded in the same manner as described in Study I. However. observations were made only between 8:00 a.m. and 4:OO p.m. each day. The observers were hospital attendants. Inter-observer reliability was obtained and calculated in the same manner described in Study I. The inter-observer agreement was above 97 per cent for Marie’s scavenging episodes and 100 per cent for Susan’s scavenging episodes. Procedure
Marie and Susan had been kept in the mesh restraining bags on an on-and-off basis for several years. Since they were in the bags at the beginning of the study, the bags were
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removed and they were allowed to adapt to their new freedom for 3 days. During the 3-day period. no contingencies were in effect for coprophagic or pica behaviors. Following the initial 3-day baseline period, baseline records of Marie’s scavenging were kept for an additional 5 days while Susan was assigned to the physical restraint condition. Whenever either woman was found scavenging or to have scavenged. she was admonished. required to wash her mouth and hands and encouraged to spit out any material in her mouth. Susan was then placed in a mesh restraining bag for 30 min. Marie received no further treatment. After 5 days, Susan was assigned to the Overcorrection condition and Marie assigned to the Physical Restraint condition. The Overcorrection program began immediately following both physical restraint conditions. Special trainers conducted the Overcorrection program throughout the study. These special trainers also served as observers. The Overcorrection procedures for pica and coprophagy were the same as described in Case I and were 30min in duration. Biweekly stool specimens were taken throughout the study. RESULTS
The lower portion of Fig. 2 shows that Susan was scavenging about 4 times per day during the 3 days of baseline recording. Scavenging was reduced by 35 per cent to between 2 and 3 episodes per day during the physical restraint condition. The Overcorrection procedures reduced scavenging to about 1 episode every other day within the first week. Scavenging was at zero level after 4 weeks of Overcorrection training (Day 35) with only two instances of scavenging occurring thereafter during the remaining 3 weeks of the study. Both instances involved the ingestion of trash.
Boseiine 71
f,
PhYS.l
~
Overcorrection
;y+/
Fig. 2. The effect of physical restraint and Overcorrection training on the scavenging for feces and trash of two profoundly retarded females. During the baseline conditions no contingencies were in effect for scavenging. During the physical restraint conditions. the women were placed in a mesh restraining bag for 30 min whenever they scavenged. The Overcorrection training was 30 min in duration. The upper portion of the figure shows the treatment course for Marte: the lower portion shows the treatment course for Susan.
Treatment
of coprophagy
and pica
159
The upper portion of Fig. 2 shows that Marie was scavenging between 5 and 6 times per day during 8 days of baseline recording. During the 5-day physical restraint condition, scavenging was reduced by 38 per cent to between 3 and 4 scavengings per day. The introduction of Overcorrection procedures reduced scavenging to zero within 2 days. Thereafter 6 scavenging episodes occurred during the remaining 31 days of the study. No instances of coprophagy occurred after Day 25. After Marie and Susan were taken out of restraints. the lacerations on their heads began to heal. They were able now to defend themselves against the attack of their fellow residents as well as maintain their balance. Casual observation and informal ward staff reports indicated that both women had become much more responsive to events and people. On several occasions, both women smiled at the senior author and Overcorrection trainers. Marie provided the greatest surprise by emitting several recognizable sounds. At the end of the third week of Overcorrection training, the biweekly stool specimens were showing no traces of whipworm ova for either woman.
STUDY
III
METHOD
Suhjrct Bobby was a well-built, mesomophic 33-yr-old profoundly retarded male who had been institutionalized for 13 yr. He had been normal until the age of 2 yr when he suffered extensive brain damage in an auto accident. Bobby scavenged almost exclusively for cigarette butts. He would pick cigarettes out of unflushed toilets, off of the floor or steal them from the employees’ ashtrays. Often, Bobby would watch the nursing station and when an ashtray was unattended he would dash in, lift the ashtray to his lips and quickly consume its contents. It was not uncommon for Bobby to ingest over 20 cigarette butts at one time. Although usually quite passive, Bobby would actively resist any attempts to take cigarette butts away from him. Several hours after eating the butts, he would regurgitate them leaving them in several piles scattered throughout the ward. No attempts had been made to eliminate Bobby’s scavenging. Standard ward practice was to attempt to keep all ashtrays locked within the nursing station, keep the ward toilets flushed and for employees to smoke only in the nursing station. Espn-inzentul
design
Two procedures were employed in the study: A 4-day baseline condition and an Overcorrection condition. The procedural sequence was Baseline, Overcorrection. two separate one day returns to Baseline, and Overcorrection. The baseline conditions were kept short deliberately due to the serious nature of Bobby’s scavenging. Recovdirlg
and reliability
Scavenging was defined as the gathering and eating of cigarette butts. During the baseline procedure a cigarette butt was placed in an ashtray every 15 min. The ashtray was placed in a location that could be seen easily from the nursing station. The ashtray was checked every 15 min to determine if Bobby had taken the butt. If Bobby was seen taking the butt. or if the butt was missing at the regularly scheduled check, a scavenging response was recorded and another butt placed in the ashtray. During the Overcorrection condition, the ashtray was checked every 1.5min. If Bobby scavenged the butt, he was given Overcorrection Training and another butt placed in the ashtray at the completion of the training. Each day throughout all conditions, a ward staff member was assigned the task of monitoring the ashtray. On randomly selected days within each condition, a second monitor was present. This additional observer had no knowledge of the intent of the study. Inter-observer reliability was calculated in the same manner as described in Study I. Interobserver agreement was 100 per cent for all conditions.
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R. M. Foxx and E. D. MARTIN
Procedure
A baseline record was taken for 4 days. Bobby had the opportunity to eat a cigarette butt every 15 min. The butts were available during an S-hr period each day. Whenever Bobby was found with a cigarette butt in his hand or mouth. he was admonished. guided to a toilet or trash can, encouraged to spit out the cigarette and required to wash his hands and mouth. Bobby was given the ward job of emptying and cleaning the seven ward ashtrays three times per day. He was accompanied on the job by an attendant and reinforced with edibles and praise each time he cleaned an ashtray. After the baseline recording, the Overcorrection program began. Every 15 min the specially assigned monitor checked the salted ashtray. If the ashtray was empty or if he had seen Bobby take the cigarette butt, Overcorrection training was given immediately for 30 min. The Overcorrection procedure consisted of Oral Hygiene Training for 10 min. Personal Hygiene training for 10 min, and 10 min of practice in emptying and wiping out ashtrays. The trainer provided graduated guidance whenever Bobby failed to follow an instruction during the training. After the Overcorrection training. Bobby was returned to the ward dayroom and a cigarette butt was placed in the ashtray. Overcorrection training was given also whenever Bobby entered the ward nursing station and attempted to grab an ashtray. Bobby’s ward job of emptying and cleaning ashtrays was continued throughout the Overcorrection phase of the study. RESULTS
Figure 3 shows that Bobby was scavenging for cigarette butts almost 100 per cent of the time during the first baseline period. Scavenging was reduced by 50 per cent on the first day of the Overcorrection condition and to a near zero level within 4 days. Scavenging increased substantially on Days 5 and 8 when baseline conditions were reinstituted. The immediate reinstatement of Overcorrection on Days 6 and 9 produced rapid decreases in scavenging to near zero levels. Scavenging remained at or near zero during the remaining 8 weeks of the study. There were no instances of Bobby entering the nursing station to raid ashtrays after the tenth day of Overcorrection training. One interesting by-product of the Overcorrection training was that Bobby spoke for the first time. None of the staff could ever recall having heard him speak before. Several times during the Overcorrection procedure Bobby told the trainer, “Stop that”. Despite his verbal protestations, he was extremely compliant throughout all phases of the Overcorrection training procedures.
GENERAL
RESULTS
Residents’ reaction to the overcorrectioll traiJzingprocedures
None of the 4 residents became combative or unmanageable during the study. Thus, one trainer was able to provide the Overcorrection training without the need for additional staff. Some passive resistance did occur. but was overcome quickly by the graduated physical guidance procedures. Side herleJitsofthe over-correction training
In addition to serving as inhibitory treatments for scavenging, the Oral Hygiene and Personal Hygiene training procedures were responsible for several improvements in the residents’ grooming behaviors and personal appearance. The Oral Hygiene taught the residents how to brush their teeth. The repeated teeth brushings during Overcorrection training greatly improved the condition and appearance of the residents’ teeth and gums; their teeth were whiter and cleaner and their gums a healthy pink color at the completion of the studies. The Personal Hygiene training program taught the residents how to wash their hands. Both of these newly learned self-help skills were incorporated into the residents’ daily routine during the Overcorrection portions of the studies and were continued thereafter. Reinforcement in the form of edibles and praise was provided whenever the tooth brushing or hand washing were not a part of the Overcorrection training.
Treatment
of coprophagy
161
and pica
Overcorrection
Bobby
z 0
07 I
4
I
7
17
IO
24
31
36
45
62
59
66
Days l-g. 3. The effect of Overcorrection training on the scavenging for cigarette butts of a profoundly retarded man. During the baseline no contingencies were in effect for scavenging. The arrows on Days 5 and 8 indicate a l-day return to baseline conditions. The slash marks on the abscissa indicate a l-week period.
DISCUSSION
The Overcorrection procedures were very effective in producing a near complete elimination of scavenging. Within 2 weeks after Overcorrection had been instituted, scavenging was at a near zero level. The procedures were immediate; in each case scavenging was reduced by about 90 per cent within 4 days. The procedures were effective for all 4 residents and in three different ward situations. The procedures were enduring; scavenging remained at or near zero throughout the course of treatment for all 4 residents. Both forms of scavenging were controlled-coprophagy and pica. The procedures were effective regardless of whether the type of material scavenged was fecal matter, trash, bits of paper and cloth, garbage or cigarette butts. During the Overcorrection conditions for coprophagy clinical lab reports showed that the 3 coprophagic scavengers had been rid of intestinal parasites. The Overcorrection procedures were easily implemented. No special knowledge of behavioral intervention techniques was required; ward staff as well as special trainers were able to conduct the procedures successfully. No increase in ward staffing was necessary since a single staff member was able to conduct the procedures. The Overcorrection procedures were found to be more effective than other inhibitory procedures. In Study II, the Overcorrection procedure was superior to a physical restraint procedure when both lasted 30 min. Whereas Overcorrection reduced scavenging to a near zero level, physical restraint was of only intermediate effectiveness reducing scavenging by about 40 per cent. The Overcorrection procedures were more preferable and acceptable to those who had been using the mesh restraining bags. These staff stated that the Overcorrection procedure offered a means of treating rather than merely preventing the scavenging. Also, the personal safety of the scavengers was improved since they were no longer physically prevented from defending themselves from the attacks of other residents. In each study, Overcorrection was vastly superior to the negative instructions. simple feedback and simple correction procedures that were employed during the baseline conditions. The aversive components of the Overcorrection procedure that contributed to its effectiveness have been described in detail elsewhere (Foxx and Azrin, 1972, 1973a). Briefly stated they are: (1) a contingent time-out period since the opportunity to engage in reinforcing activities is prevented by the requirement to engage in training. (2) the physical effort requirement ofcompleting the required overcorrective actions, (3) the annoyance of the graduated guidance procedure, and (4) removal of the reinforcement associated with the scavenging act since immediate correction of act is required. In the case of scavenging, the Oral Hygiene and Personal Hygiene training procedures altered the reinforcing gustatory and tactile sensations associated with the mouthing. ingestation and handling of nonnutritive material. In Study III, an additional component was added to the Overcorrection training program by using the Positive Practice for cigarette scavenging as both an educative aversive
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R. M. Foxx and E. D. MARTIN
event following a scavenging act and as a desirable activity to be reinforced at other times. Bobby. the cigarette eater, was given the job of cleaning the ward ashtrays 3 times per day. Praise and edible reinforcement were given for each cleaned ashtray. Whenever Bobby ate a cigarette butt. he was given Restitutional Overcorrection and then required to clean the ashtrays but for no social or edible reinforcement. The requirement to engage in the ashtray cleaning for no reinforcement. it was reasoned. should enhance the aversiveness of the Overcorrection period. Also. Bobby would learn the adaptive discrimination that scavenging for cigarettes produced Positive Practice Overcorrection while the same corrective behaviors at other times would be reinforced. The same adaptive discrimination training was programmed for all four residents regarding Oral Hygiene and Personal Hygiene training. The residents were reinforced during the day for brushing their teeth and washing their hands at appropriate times. During Overcorrection training. they were required to engage in teeth and hand cleaning for no reinforcement and for a longer duration of time. This discrimination was set up by the experimenters as a deliberate attempt to insure that the residents would not regard tooth brushing and hand washing solely as unpleasant events. As a result of these efforts. none of the residents emitted any emotional responses when confronted with a toothbrush or sink of soapy water. One of the most gratifying aspects of the study was freeing the 3 coprophagic residents of intestinal parasites. All 3 had been chronically infested with the parasites (whipworms) for several years. Only when the Overcorrection procedure suppressed the residents’ handling and ingestion of fecal matter was the life cycle of the parasites broken. There were additional benefits associated with the absence of parasites in the residents. The residents’ overall health began to improve as evidenced by increases in body weight and heartier appetites at mealtimes. Also, they began to be integrated into the general ward activities since there was no longer any fear that they might infect the staff or other residents. This integration provided the scavengers with an increased number of positive social interactions with other residents and staff and a greater exposure to potentially reinforcing appropriate activities. There were several indications that the Overcorrection program was educative. The residents had less difficulty washing their hands or brushing their teeth than other residents on the ward of similar behavioral limitations. On several occasions the former scavengers were seen flushing unflushed toilets and picking up debris from the floor and placing it in trash recepticles. The residents become more responsive to instructions in general. As noted earlier, no treatment is in general usage for treating scavenging by the institutionalized retarded. There has been an urgent need for such a treatment procedure. The Overcorrection procedure appears to answer that need. Overcorrection can be considered as a rapid, effective, easily implemented, enduring, and humane treatment for coprophagia and pica. Ark,lo~ledtlr,ll~rIts--Grateful acknovvledgement is due to B. Belcher. C. Bridges, J. Brown. J. Burnett, raker, J. Driver. L. Rendlemen and F. Simmerman for assisting m various phases of the studies. Claudia and Glenda Ridgway provided valuable technical assistance.
C. CarHenson
REFERENCES AZRIN N. H. and Foxx R. M. (1974) Toiler Truiuirrg ill Lrss th (I .!III>,.Simon & Schuster. New York. BAERD. M.. WOLF M. M. and RISLEYT. R. (196X) Some current dimensions of applied behavior analysis. J. appl. Brhac. Ad. I. 91-97. Foxx R. M. and AZRIS N. H. (1972) Restitution: a method of elimmatmg aggresstveedisruptive behavior of Res. & 7hapy IO, I S-27. retarded and brain damaged patients. B&r. FOXXR. M. and AZRIN N. H. (197321) The elimination of autistic. self-stimulatory behavior by overcorrection. J. appl. Bdmc. AM/. 6, I- 14. Foxx R. M. and AZRIN N. H. (1973b) Toiler Trrriuiny f/w Rcrurded: A Rapid P,oyru~n./or Day ur7dNiyhttinlr Irdeprrde~tr Toi/ctiq/. Research Press, Champaign. III. Foxx R. M. and AZKIS N. H. (197%~) Dry Pants: A rapid method of toilet training children. Brhov. RPS. & Therap?’ 11,435--442. Foxx R. M. (1974) The use of overcorrection to eliminate the public disrobing (stripping) of retarded women. Brh~. Rcs. & T/wrap~~ (In preparation). KANYERL. (1962) Cltild Ps~~chirrfrJ~.Charles C. Thomas, Springfield. Ill. NET?ERF. H. (1962) The CIBA C’oll~ctim oJMedica/ Illustm7trom, Vol. 3. Diqesriw Sysrcm Part III, Lawcr Digmrior 7rucr. p. 175. CIBA, New York.
and E. D. Anna State Hospital. (Rxriued
MARTIN Anna. Illinois. U.S.A
19 Augusr 1974)
Summary-Scavenging behavior such as pica (ingesting non-nutritive substances) and coprophagy (ingesting fecal matter) represents a seritius health hazard in the care of the institutionalized retarded. The Overcorrection rationale was used to develop procedures for eliminating scavenging. The procedures were applied to 4 profoundly retarded adults who rumaged for and ate: paper. trash, garbage. cigarette butts. bits of cloth and feces. The 3 residents who habitually ate feces were chronically infested with intestinal parasites (Triclwris rrichra). The procedures emphasized correction of the scavenging act. as well as practice in alternative appropriate behavior in the situations in which scavenging normally occurred. The Overcorrection procedures reduced the scavenging of all 4 retardates to a near zero level within 1 week where it remained for the duration of the study. The results of biweekly stool specimens showed that all three coprophagic residents were free of parasites during the Overcorrection condition. The Overcorrection procedures were rapid. easily implemented. enduring and effective methods of reducing pica and coprophagic behavior.
Scavenging is a serious problem of the institutionalized retarded. Residents who rumage for and eat feces, trash, garbage and small objects are endangering their health. Pica, ingesting substances that have no nutritional value. can result in intestinal obstruction, frequent constipation, nutritional anemia and lead poisoning (Kanner. 1962). When the pica habit includes coprophagy, the ingestation of fecal matter. chronic infestation from intestinal parasites such as whipworms (7’1+cltu~istrichiur~) can result. Whipworms are commonly found in coprophagic retardates and can cause diarrhea or constipation, emaciation and anemia (Netter. 1962). Of all the maladaptive behavior of the institutionalized retarded, coprophagy is generally regarded by ward staff as the most disgusting. The coprophagic resident who digs in his rectum for feces to eat or eats the feces of others receives scant attention from ward staff. He smells bad. is generally quite messy and can be a source of infection and infestation. Frequently. the coprophagic resident is kept in isolation or his arm movements are restricted by restraints. At present, no method is in general usage for reducing or eliminating coprophagic or pica behavior. The recent success of Overcorrection procedures in reducing various types of maladaptive behavior suggests that scavenging behavior might be treated successfully by Overcorrection procedures. Overcorrection procedures have been used effectively to reduce or eliminate aggressive-disruptive behavior (Foxx and Azrin. 1972); self-stimulatory behavior (Foxx and Azrin. 1973a); stripping (Foxx, in press) and toileting accidents (Foxx and Azrin, 1973b, c). The general rationale of Overcorrection is: (1) to educate the person to accept responsibility for his misbehavior through Restitutional Overcorrection procedures that require him to restore the disturbed situation to a vastly improved state and (2) to require the offender to practice appropriate modes of responding through Positive Practice Overcorrection procedures that require him to behave appropriately in the situations in which he normally misbehaves (Foxx and Azrin, 1972). * Portions of the research were conducted at Anna State Hospital. t Author to whom reprint requests should be addressed. 153
Anna. 111
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R. M. Foxx and E. D. MARTW
An Overcorrection training program to treat scavenging would require the scavenger to accept personal responsibility for his actions. The scavenger would be required to expel1 ingested non-nutritive matter, expectorate foreign matter from his mouth and keep his mouth. hands and the ward free of debris. The ingestion of foreign substances is a possible source of self-infection. The Restitutional Overcorrection rationale dictates that this source of infection should be reversed by chemical, mechanical or tactile stimulation. Chemical stimulation could be accomplished by use of an emetic that would induce vomiting. Mechanical stimulation would require the use of a stomach pump. The primary disadvantage of both alternatives is that they could be used only once or twice per day, thereby rendering them unusable when the scavenging occurs at a high frequency as is often the case. However. tactile stimulation could be accomplished as frequently throughout the day as necessary. by use of an Oral 7 1973a). The Oral Hygiene procedure would Hygiene procedure (Foxx and Azrin, 197,. consist of cleansing the buccal area by requiring the scavenger to brush his teeth. tongue and gums with a toothbrush that had been soaked in an oral antiseptic. The scavenger would be instructed or coaxed to cough or spit out the foreign matter. If he refused or was unable to expel1 the object(s), the toothbrush could be used as a hygienic probe by inserting it into the mouth and moving it in a tickling manner to elicit coughing and spitting. Periodically, the scavenger would be required to expectorate the antiseptic. The handling of trash and feces also is a source of self-infection since the scavenger’s hands come into frequent contact with his mouth. The Restitutional Overcorrection rationale would dictate that the scavenger be taught the opposite behavior of keeping his hands clean. After each scavenging episode, the scavenger should be required to wash his hands thoroughly and for an extended period. Finally, a Positive Practice Overcorrection procedure should be instituted whereby the scavenger is required to practice alternative correct responses in the situations in which he usually scavenges. This training would consist of teaching the scavenger to rid the ward of debris that had been scavenged formerly by emptying trash recepticles and ashtrays, flushing toilets, and mopping or cleaning up feces from the floor. The coprophagic resident who digs in his rectum for feces would be required to keep his anal region clean and free of fecal matter. A combination of the above procedures should be applied immediately following each scavenging episode. The present study sought to use Overcorrection procedures to treat the pica and coprophagic behavior of institutionalized retarded persons.
STUDY
I
METHOD
Dorris was a 30-yr-old profoundly retarded female who had been institutionalized for 20yr. Her gaunt and emaciated appearance made her seem much older than her years. Her retardation was diagnosed as resulting from encephalopathy. She habitually ate trash and feces and was considered to be the lowest functioning resident on the ward. She ate trash from the ward waste-baskets as well as any small objects she found on the floor. Her coprophagic behavior included digging in her rectum for fecal matter and eating the evacuated feces of herself and others. She was chronically infested with whipworms. Despite treatment by massive doses of antibiotics, she remained infested with the parasites since she invariably reinfected herself by eating the feces of other residents. There was no ward program in effect for treating her coprophagy or pica. Ward staff members studiously avoided any contact with Dorris other than providing her the very minimal custodial care.
A multiple baseline procedure was used (Baer, Wolf and Risley. 1968). The study contained three conditions: (1) Baseline recording of the frequency of coprophagic and pica
Treatment
of coprophagy
episodes; (2) Overcorrection for coprophagy Overcorrection for coprophagy and pica. Recording
and pica
155
and no treatment of pica episodes; and (3)
atld reliability
Scavenging was defined as the gathering and eating of any non-nutritive substance. e.g. trash or feces. A scavenging episode was defined as the presence of trash or feces around or in the mouth or on the hands. Dorris’s hands and mouth were inspected every 15 min throughout her waking hours and her scavenging recorded. Any scavenging episodes that were detected between inspections were recorded also. Each day two attendants were assigned to conduct the inspections; one on the morning shift, the other on the afternoon shift. On selected days within each condition a second observer was assigned on both shifts so that inter-observer reliability could be assessed. Reliability was calculated by dividing the number of daily observations in which the observers agreed by the total number of observations. times 100. The inter-observer agreement was never lower than 94 per cent. Stool specimens
Biweekly stool specimens were being collected when the study began. The specimens were analyzed at the hospital’s clinical lab for the presence of whipworm ova. Two specimens of Dorris’s stools continued to be sent to the lab each week throughout the study. Procedure
The Baseline condition lasted for 6 days. Whenever Dorris was found with trash or feces on her hands or around or in her mouth, she was admonished, encouraged to spit out the material. and required to wash her hands and mouth. This negative instruction and simple correction had been the standard ward procedure at the time the study began. The Overcorrection program for coprophagy began on the seventh day. Baseline conditions remained in effect for all instances of pica. After 2 weeks, an Overcorrection program for pica was instituted. All instances of coprophagy continued to receive Overcorrective consequences. Special trainers conducted the Overcorrection procedures for coprophagy and pica during the first week that each was instituted. The trainers were hospital attendants but were not assigned to the ward staff. During the first week, the special trainers instructed the entire ward staff in the proper conduct of the Overcorrection procedures. Once a staff member performed the procedure correctly, his name was added to a list of certified trainers that was conspicuously displayed on the ward (Foxx and Azrin. 1972, 1973b). Copr0phag.y
Whenever Dorris was discovered eating feces or with traces of feces on her mouth and/ or hands she was given the following Overcorrection training: (1) The trainer manually guided her to a toilet bowl and verbally encouraged her to spit the feces into the toilet. (2) She then was given Oral Hygiene training during which she was required to brush her mouth, teeth and gums gently with a soft toothbrush that had been soaked in an oral antiseptic (mouthwash). The mouth cleansing lasted for 10 min and was conducted at the toilet bowl. (3) Following Oral Hygiene training, Dorris was guided to the bathroom sink and given Personal Hygiene training during which she was required to wash her hands and scrub her fingernails in warm soapy water with a soft fingernail brush. The Personal Hygiene training lasted 10 min. (4) She was required to clean her anal area with a cloth that had been soaked in tepid soapy water and then to wash her hands briefly. (5) Dorris was guided to the area where she was discovered eating and handling the feces and required to mop up the area with a disinfectant. If she had obtained the feces from an unflushed toilet, she was required to flush all unflushed toilets on the ward. The entire procedure lasted 30 min. The trainer wore rubber gloves and a hospital gown to protect his/ her health and clothing. A Graduated Guidance technique (Foxx and Azrin, 1972; Azrin and Foxx, 1974) was used. whenever necessary, to motivate Dorris to engage in the Overcorrective behavior. This guidance consisted of the trainer manually guiding Dorris’ hands whenever she failed
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to respond to an instruction. As Dorris began a requested movement voluntarily. the guidance was reduced to just a touch and then faded ultimately to where the trainer just ‘shadowed’ Dorris’ hands with his. The shadowing allowed the trainer to reapply guidance immediately should it be necessary. Pica
When Dorris was found eating or handling trash the following Overcorrection training was given: (1) The trainer guided Dorris to a trash can where she was required to spit out or throw away the material. (2) Dorris was guided to the toilet and given 1Omin of Oral Hygiene training. (3) Dorris was required to wash her hands and clean her fingernails in warm soapy water with a soft fingernail brush for 10 min. (4) The trainer guided Dorris throughout the ward where she was required to sweep portions of the floor where trash was found, empty all trash cans, and pick up trash and debris from the floor. Graduated Guidance was used whenever necessary. RESULTS
Figure 1 shows that Dorris’was scavenging for feces about ten times per day and for trash about eight times per day during the 6-day baseline period. During the next 2 weeks when Overcorrection training was given only following each coprophagic episode. coprophagy was reduced to about one episode every other day: a reduction of over 95 per cent. During this same 2-week period, Dorris scavenged for trash about nine times per day. On the first day that Overcorrection was given following pica behavior (Day 15) it was reduced by over 90 per cent. Thereafter, pica episodes occurred about once every other day. Coprophagy continued to remain suppressed with episodes occurring about every other day. Both types of scavenging behavior were ultimately reduced by Day 49 to a near zero level where they remained throughout the study. During the Overcorrection conditions, Dorris displayed several dramatic behavior changes. She began to have a hearty appetite at mealtimes, and had gained over 301b at the end of the study. She appeared to become more aware of her surroundings near the completion of the study and on one occasion was found hiding in the ward time-out room digging in her rectum. Before. she had always sat in the main hallways in a seemingly oblivious state whenever she dug for and ate her feces. During the sixth week of Overccorection for coprophagy (Days 35-42) the clincial lab reported that Dorris’ stool specimens were negative; they did not contain any whipworm ova. Thereafter, all biweekly lab reports continued to report negative findings during the
Overcorrection Overcorrection coprophogy
for and
pica
-
Feces -Trash
Fig. I. The effect of Overcorrection Training on the scavenging for feces and trash of a profoundly retarded woman. The circular data points represent the treatment of coprophagy by Overcorrection. The triangular data points represent the treatment of pica by Overcorrection. During the baselme no contingencies were in effect for scavenging. During the Overcorrection training for coprophagy. no contingencies were in effect for pica. The slash marks on the abscissa Indicate a period of 1 week.
Treatment
of coprophagy
and pica
157
remaining 6 weeks of the study. The negative lab reports indicated that the near elimination of coprophagy by Overcorrection had interrupted the life cycle of the whipworms, since Dorris was no longer introducing ova-laden feces into her mouth. STUDY II
In Study I, Overcorrection procedures were employed in the successful treatment of coprophagy and pica. A major question that remained was the generality of the procedures. In Study II, two additional retarded residents who engaged in pica and coprophagy were treated by Overcorrection procedures as a further assessment of the utility of the procedures. METHOD
Subjects
Susan was a 31-yr-old profoundly retarded female with an assessed IQ of 16. She had been institutionalized for 25 yr. Susan was coprophagic, eating her own feces and any feces that she found in the ward toilets. She was chronically infested with whipworms. Susan also ate any bits of paper and cloth that she found lying on the floors. Marie resided on the same ward with Susan. Marie was 20-yr-old, profoundly retarded and had been institutionalized since the age of 11 yr. Her assigned IQ was 18. She was coprophagic, infested by whipworms, and would eat any small objects that she found on the floor. To control Susan and Marie’s scavenging, the ward treatment staff periodically kept them in continuous physical restraints. This restraint consisted of placing a mesh restraining bag over the body which was tied at the shoulders and between the legs thereby restricting any arm movements while still allowing the resident to walk. The restraint effectively eliminated scavenging but had several undesirable side effects: (1) Marie and Susan were very vulnerable to attacks by other residents. They often were pushed and fell down or lost their balance themselves and fell down. Both of them had numerous scars and open lacerations on their heads; (2) they could not be taught self-help skills such as toileting. feeding or dressing themselves; and (3) they presented even the most hardened institutional employee, and justifiably so, with the overwhelming impression that they were being subjected to inhumane treatment. Esperirnental
design
Study II contained three procedures: (1) a baseline condition, (2) a physical restraint condition in which a modified version of the existing ward procedure for scavenging followed each scavenging episode and (3) an Overcorrection procedure. The sequence of the conditions was: Susan: (1) Baseline, 3 days; (2) Physical Restraint. 5 days; and (3) Overcorrection. Marie: (1) Baseline, 3 days; (2) Baseline, 5 days: (3) Physical Restraint, 5 days; and (4) Overcorrection. The initial baseline period lasted 3 days. Susan then was placed in the physical restraint condition while Marie remained under baseline conditions. When Susan was switched to the Overcorrection condition. Marie was switched to the physical restraint condition. After 5 days, Marie was placed in the Overcorrection condition. The women were assigned to a specific treatment sequence on the basis of a coin flip. This design permitted a within-subjects comparison. as well as a between-subjects comparison. Recording
and reliahilitj
Scavenging was defined and recorded in the same manner as described in Study I. However. observations were made only between 8:00 a.m. and 4:OO p.m. each day. The observers were hospital attendants. Inter-observer reliability was obtained and calculated in the same manner described in Study I. The inter-observer agreement was above 97 per cent for Marie’s scavenging episodes and 100 per cent for Susan’s scavenging episodes. Procedure
Marie and Susan had been kept in the mesh restraining bags on an on-and-off basis for several years. Since they were in the bags at the beginning of the study, the bags were
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removed and they were allowed to adapt to their new freedom for 3 days. During the 3-day period. no contingencies were in effect for coprophagic or pica behaviors. Following the initial 3-day baseline period, baseline records of Marie’s scavenging were kept for an additional 5 days while Susan was assigned to the physical restraint condition. Whenever either woman was found scavenging or to have scavenged. she was admonished. required to wash her mouth and hands and encouraged to spit out any material in her mouth. Susan was then placed in a mesh restraining bag for 30 min. Marie received no further treatment. After 5 days, Susan was assigned to the Overcorrection condition and Marie assigned to the Physical Restraint condition. The Overcorrection program began immediately following both physical restraint conditions. Special trainers conducted the Overcorrection program throughout the study. These special trainers also served as observers. The Overcorrection procedures for pica and coprophagy were the same as described in Case I and were 30min in duration. Biweekly stool specimens were taken throughout the study. RESULTS
The lower portion of Fig. 2 shows that Susan was scavenging about 4 times per day during the 3 days of baseline recording. Scavenging was reduced by 35 per cent to between 2 and 3 episodes per day during the physical restraint condition. The Overcorrection procedures reduced scavenging to about 1 episode every other day within the first week. Scavenging was at zero level after 4 weeks of Overcorrection training (Day 35) with only two instances of scavenging occurring thereafter during the remaining 3 weeks of the study. Both instances involved the ingestion of trash.
Boseiine 71
f,
PhYS.l
~
Overcorrection
;y+/
Fig. 2. The effect of physical restraint and Overcorrection training on the scavenging for feces and trash of two profoundly retarded females. During the baseline conditions no contingencies were in effect for scavenging. During the physical restraint conditions. the women were placed in a mesh restraining bag for 30 min whenever they scavenged. The Overcorrection training was 30 min in duration. The upper portion of the figure shows the treatment course for Marte: the lower portion shows the treatment course for Susan.
Treatment
of coprophagy
and pica
159
The upper portion of Fig. 2 shows that Marie was scavenging between 5 and 6 times per day during 8 days of baseline recording. During the 5-day physical restraint condition, scavenging was reduced by 38 per cent to between 3 and 4 scavengings per day. The introduction of Overcorrection procedures reduced scavenging to zero within 2 days. Thereafter 6 scavenging episodes occurred during the remaining 31 days of the study. No instances of coprophagy occurred after Day 25. After Marie and Susan were taken out of restraints. the lacerations on their heads began to heal. They were able now to defend themselves against the attack of their fellow residents as well as maintain their balance. Casual observation and informal ward staff reports indicated that both women had become much more responsive to events and people. On several occasions, both women smiled at the senior author and Overcorrection trainers. Marie provided the greatest surprise by emitting several recognizable sounds. At the end of the third week of Overcorrection training, the biweekly stool specimens were showing no traces of whipworm ova for either woman.
STUDY
III
METHOD
Suhjrct Bobby was a well-built, mesomophic 33-yr-old profoundly retarded male who had been institutionalized for 13 yr. He had been normal until the age of 2 yr when he suffered extensive brain damage in an auto accident. Bobby scavenged almost exclusively for cigarette butts. He would pick cigarettes out of unflushed toilets, off of the floor or steal them from the employees’ ashtrays. Often, Bobby would watch the nursing station and when an ashtray was unattended he would dash in, lift the ashtray to his lips and quickly consume its contents. It was not uncommon for Bobby to ingest over 20 cigarette butts at one time. Although usually quite passive, Bobby would actively resist any attempts to take cigarette butts away from him. Several hours after eating the butts, he would regurgitate them leaving them in several piles scattered throughout the ward. No attempts had been made to eliminate Bobby’s scavenging. Standard ward practice was to attempt to keep all ashtrays locked within the nursing station, keep the ward toilets flushed and for employees to smoke only in the nursing station. Espn-inzentul
design
Two procedures were employed in the study: A 4-day baseline condition and an Overcorrection condition. The procedural sequence was Baseline, Overcorrection. two separate one day returns to Baseline, and Overcorrection. The baseline conditions were kept short deliberately due to the serious nature of Bobby’s scavenging. Recovdirlg
and reliability
Scavenging was defined as the gathering and eating of cigarette butts. During the baseline procedure a cigarette butt was placed in an ashtray every 15 min. The ashtray was placed in a location that could be seen easily from the nursing station. The ashtray was checked every 15 min to determine if Bobby had taken the butt. If Bobby was seen taking the butt. or if the butt was missing at the regularly scheduled check, a scavenging response was recorded and another butt placed in the ashtray. During the Overcorrection condition, the ashtray was checked every 1.5min. If Bobby scavenged the butt, he was given Overcorrection Training and another butt placed in the ashtray at the completion of the training. Each day throughout all conditions, a ward staff member was assigned the task of monitoring the ashtray. On randomly selected days within each condition, a second monitor was present. This additional observer had no knowledge of the intent of the study. Inter-observer reliability was calculated in the same manner as described in Study I. Interobserver agreement was 100 per cent for all conditions.
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R. M. Foxx and E. D. MARTIN
Procedure
A baseline record was taken for 4 days. Bobby had the opportunity to eat a cigarette butt every 15 min. The butts were available during an S-hr period each day. Whenever Bobby was found with a cigarette butt in his hand or mouth. he was admonished. guided to a toilet or trash can, encouraged to spit out the cigarette and required to wash his hands and mouth. Bobby was given the ward job of emptying and cleaning the seven ward ashtrays three times per day. He was accompanied on the job by an attendant and reinforced with edibles and praise each time he cleaned an ashtray. After the baseline recording, the Overcorrection program began. Every 15 min the specially assigned monitor checked the salted ashtray. If the ashtray was empty or if he had seen Bobby take the cigarette butt, Overcorrection training was given immediately for 30 min. The Overcorrection procedure consisted of Oral Hygiene Training for 10 min. Personal Hygiene training for 10 min, and 10 min of practice in emptying and wiping out ashtrays. The trainer provided graduated guidance whenever Bobby failed to follow an instruction during the training. After the Overcorrection training. Bobby was returned to the ward dayroom and a cigarette butt was placed in the ashtray. Overcorrection training was given also whenever Bobby entered the ward nursing station and attempted to grab an ashtray. Bobby’s ward job of emptying and cleaning ashtrays was continued throughout the Overcorrection phase of the study. RESULTS
Figure 3 shows that Bobby was scavenging for cigarette butts almost 100 per cent of the time during the first baseline period. Scavenging was reduced by 50 per cent on the first day of the Overcorrection condition and to a near zero level within 4 days. Scavenging increased substantially on Days 5 and 8 when baseline conditions were reinstituted. The immediate reinstatement of Overcorrection on Days 6 and 9 produced rapid decreases in scavenging to near zero levels. Scavenging remained at or near zero during the remaining 8 weeks of the study. There were no instances of Bobby entering the nursing station to raid ashtrays after the tenth day of Overcorrection training. One interesting by-product of the Overcorrection training was that Bobby spoke for the first time. None of the staff could ever recall having heard him speak before. Several times during the Overcorrection procedure Bobby told the trainer, “Stop that”. Despite his verbal protestations, he was extremely compliant throughout all phases of the Overcorrection training procedures.
GENERAL
RESULTS
Residents’ reaction to the overcorrectioll traiJzingprocedures
None of the 4 residents became combative or unmanageable during the study. Thus, one trainer was able to provide the Overcorrection training without the need for additional staff. Some passive resistance did occur. but was overcome quickly by the graduated physical guidance procedures. Side herleJitsofthe over-correction training
In addition to serving as inhibitory treatments for scavenging, the Oral Hygiene and Personal Hygiene training procedures were responsible for several improvements in the residents’ grooming behaviors and personal appearance. The Oral Hygiene taught the residents how to brush their teeth. The repeated teeth brushings during Overcorrection training greatly improved the condition and appearance of the residents’ teeth and gums; their teeth were whiter and cleaner and their gums a healthy pink color at the completion of the studies. The Personal Hygiene training program taught the residents how to wash their hands. Both of these newly learned self-help skills were incorporated into the residents’ daily routine during the Overcorrection portions of the studies and were continued thereafter. Reinforcement in the form of edibles and praise was provided whenever the tooth brushing or hand washing were not a part of the Overcorrection training.
Treatment
of coprophagy
161
and pica
Overcorrection
Bobby
z 0
07 I
4
I
7
17
IO
24
31
36
45
62
59
66
Days l-g. 3. The effect of Overcorrection training on the scavenging for cigarette butts of a profoundly retarded man. During the baseline no contingencies were in effect for scavenging. The arrows on Days 5 and 8 indicate a l-day return to baseline conditions. The slash marks on the abscissa indicate a l-week period.
DISCUSSION
The Overcorrection procedures were very effective in producing a near complete elimination of scavenging. Within 2 weeks after Overcorrection had been instituted, scavenging was at a near zero level. The procedures were immediate; in each case scavenging was reduced by about 90 per cent within 4 days. The procedures were effective for all 4 residents and in three different ward situations. The procedures were enduring; scavenging remained at or near zero throughout the course of treatment for all 4 residents. Both forms of scavenging were controlled-coprophagy and pica. The procedures were effective regardless of whether the type of material scavenged was fecal matter, trash, bits of paper and cloth, garbage or cigarette butts. During the Overcorrection conditions for coprophagy clinical lab reports showed that the 3 coprophagic scavengers had been rid of intestinal parasites. The Overcorrection procedures were easily implemented. No special knowledge of behavioral intervention techniques was required; ward staff as well as special trainers were able to conduct the procedures successfully. No increase in ward staffing was necessary since a single staff member was able to conduct the procedures. The Overcorrection procedures were found to be more effective than other inhibitory procedures. In Study II, the Overcorrection procedure was superior to a physical restraint procedure when both lasted 30 min. Whereas Overcorrection reduced scavenging to a near zero level, physical restraint was of only intermediate effectiveness reducing scavenging by about 40 per cent. The Overcorrection procedures were more preferable and acceptable to those who had been using the mesh restraining bags. These staff stated that the Overcorrection procedure offered a means of treating rather than merely preventing the scavenging. Also, the personal safety of the scavengers was improved since they were no longer physically prevented from defending themselves from the attacks of other residents. In each study, Overcorrection was vastly superior to the negative instructions. simple feedback and simple correction procedures that were employed during the baseline conditions. The aversive components of the Overcorrection procedure that contributed to its effectiveness have been described in detail elsewhere (Foxx and Azrin, 1972, 1973a). Briefly stated they are: (1) a contingent time-out period since the opportunity to engage in reinforcing activities is prevented by the requirement to engage in training. (2) the physical effort requirement ofcompleting the required overcorrective actions, (3) the annoyance of the graduated guidance procedure, and (4) removal of the reinforcement associated with the scavenging act since immediate correction of act is required. In the case of scavenging, the Oral Hygiene and Personal Hygiene training procedures altered the reinforcing gustatory and tactile sensations associated with the mouthing. ingestation and handling of nonnutritive material. In Study III, an additional component was added to the Overcorrection training program by using the Positive Practice for cigarette scavenging as both an educative aversive
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R. M. Foxx and E. D. MARTIN
event following a scavenging act and as a desirable activity to be reinforced at other times. Bobby. the cigarette eater, was given the job of cleaning the ward ashtrays 3 times per day. Praise and edible reinforcement were given for each cleaned ashtray. Whenever Bobby ate a cigarette butt. he was given Restitutional Overcorrection and then required to clean the ashtrays but for no social or edible reinforcement. The requirement to engage in the ashtray cleaning for no reinforcement. it was reasoned. should enhance the aversiveness of the Overcorrection period. Also. Bobby would learn the adaptive discrimination that scavenging for cigarettes produced Positive Practice Overcorrection while the same corrective behaviors at other times would be reinforced. The same adaptive discrimination training was programmed for all four residents regarding Oral Hygiene and Personal Hygiene training. The residents were reinforced during the day for brushing their teeth and washing their hands at appropriate times. During Overcorrection training. they were required to engage in teeth and hand cleaning for no reinforcement and for a longer duration of time. This discrimination was set up by the experimenters as a deliberate attempt to insure that the residents would not regard tooth brushing and hand washing solely as unpleasant events. As a result of these efforts. none of the residents emitted any emotional responses when confronted with a toothbrush or sink of soapy water. One of the most gratifying aspects of the study was freeing the 3 coprophagic residents of intestinal parasites. All 3 had been chronically infested with the parasites (whipworms) for several years. Only when the Overcorrection procedure suppressed the residents’ handling and ingestion of fecal matter was the life cycle of the parasites broken. There were additional benefits associated with the absence of parasites in the residents. The residents’ overall health began to improve as evidenced by increases in body weight and heartier appetites at mealtimes. Also, they began to be integrated into the general ward activities since there was no longer any fear that they might infect the staff or other residents. This integration provided the scavengers with an increased number of positive social interactions with other residents and staff and a greater exposure to potentially reinforcing appropriate activities. There were several indications that the Overcorrection program was educative. The residents had less difficulty washing their hands or brushing their teeth than other residents on the ward of similar behavioral limitations. On several occasions the former scavengers were seen flushing unflushed toilets and picking up debris from the floor and placing it in trash recepticles. The residents become more responsive to instructions in general. As noted earlier, no treatment is in general usage for treating scavenging by the institutionalized retarded. There has been an urgent need for such a treatment procedure. The Overcorrection procedure appears to answer that need. Overcorrection can be considered as a rapid, effective, easily implemented, enduring, and humane treatment for coprophagia and pica. Ark,lo~ledtlr,ll~rIts--Grateful acknovvledgement is due to B. Belcher. C. Bridges, J. Brown. J. Burnett, raker, J. Driver. L. Rendlemen and F. Simmerman for assisting m various phases of the studies. Claudia and Glenda Ridgway provided valuable technical assistance.
C. CarHenson
REFERENCES AZRIN N. H. and Foxx R. M. (1974) Toiler Truiuirrg ill Lrss th (I .!III>,.Simon & Schuster. New York. BAERD. M.. WOLF M. M. and RISLEYT. R. (196X) Some current dimensions of applied behavior analysis. J. appl. Brhac. Ad. I. 91-97. Foxx R. M. and AZRIS N. H. (1972) Restitution: a method of elimmatmg aggresstveedisruptive behavior of Res. & 7hapy IO, I S-27. retarded and brain damaged patients. B&r. FOXXR. M. and AZRIN N. H. (197321) The elimination of autistic. self-stimulatory behavior by overcorrection. J. appl. Bdmc. AM/. 6, I- 14. Foxx R. M. and AZRIN N. H. (1973b) Toiler Trrriuiny f/w Rcrurded: A Rapid P,oyru~n./or Day ur7dNiyhttinlr Irdeprrde~tr Toi/ctiq/. Research Press, Champaign. III. Foxx R. M. and AZKIS N. H. (197%~) Dry Pants: A rapid method of toilet training children. Brhov. RPS. & Therap?’ 11,435--442. Foxx R. M. (1974) The use of overcorrection to eliminate the public disrobing (stripping) of retarded women. Brh~. Rcs. & T/wrap~~ (In preparation). KANYERL. (1962) Cltild Ps~~chirrfrJ~.Charles C. Thomas, Springfield. Ill. NET?ERF. H. (1962) The CIBA C’oll~ctim oJMedica/ Illustm7trom, Vol. 3. Diqesriw Sysrcm Part III, Lawcr Digmrior 7rucr. p. 175. CIBA, New York.
