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Education and Training in Developmental Disabilities, 2008, 43(3), 360–366 © <strong>Division</strong> on Developmental Disabilities Combined Curricular Intervention with Brief Hands Down to Decrease Hand Mouthing and <strong>the</strong> Use of Arm Splints for a Young Boy with Profound Disabilities Helen I. Cannella-Malone The Ohio State University Mark F. O’Reilly The University of Texas at Austin Jeff Sigafoos Victoria University of Wellington Jeffery M. Chan The University of Texas at Austin Abstract: Hand mouthing is highly prevalent in individuals with severe to profound developmental disabilities. Frequent hand mouthing may interfere with appropriate responding, have negative health impacts, and result in restrictive interventions, such as <strong>the</strong> application of arm splints, to prevent this challenging behavior. The continuous application of arm splints can have negative health outcomes and can interfere with daily activities. The purpose of this study was to replace arm splints with appropriate curricular activities in a 10-year-old boy with profound disabilities. An intervention package involving <strong>the</strong> provision of curricular activities and a brief hands down procedure was evaluated using a combined alternating treatments and reversal design across several hours of <strong>the</strong> school day to demonstrate <strong>the</strong> effectiveness of <strong>the</strong> intervention on <strong>the</strong> reduction of hand mouthing. The intervention was successfully implemented across several hours of <strong>the</strong> student’s school day within his natural school environments. Limitations, implications, and directions for future research are discussed. The prevalence of hand mouthing, a form of stereotypic behavior, has been estimated to occur in up to 16% of individuals with severe to profound disabilities (Rast & Jack, 1992). Hand mouthing can be detrimental to an individual’s health, adaptive behavior, and social functioning (Pelios, Morren, Tesch, & Axelrod, 1999; Wallace, Iwata, Zhou, & Goff, 1999), because it can lead to tissue damage, hematoma, salivary dermatitis, scarring, and skin breakage (Ball, Campbell, & Barkemeyer, 1980; Fisher, Piazza, Bowman, Hanley, & Adelinis, 1997; Luiselli, 1989). It can also interfere with participation in daily educational and living activities, because <strong>the</strong> individual’s Correspondence concerning this article should be addressed to Helen I. Cannella-Malone, The Ohio State University, PAES Building, Room A348, 305W17 th Avenue, Columbus, OH 43210. Email: malone.175@osu.edu 360 / Education and Training in Developmental Disabilities-September 2008 hands are consistently in his or her mouth (McClure, Moss, McPeters, & Kirkpatrick, 1986). Additionally, it is considered to be socially maladaptive because of <strong>the</strong> repulsive sights and smells it produces (Realon, Favell, & Cacace, 1995). A variety of interventions have been used to reduce <strong>the</strong> occurrence of hand mouthing in individuals with severe to profound disabilities, including overcorrection (Foxx & Azrin, 1973), contingent sensory reinforcement (Barmann, 1980; Case-Holden & Hupp, 1989), differential reinforcement of o<strong>the</strong>r behaviors (Favell, McGimsey, & Schell, 1982; Mc- Clure et al., 1986), differential reinforcement in combination with punishment (Lockwood & Williams, 1994; Mazaleski, Iwata, Rodgers, Vollmer, & Zarcone, 1994; Minness, 1980), environmental enrichment (Realon et al., 1995), and response restriction via mechanical restraint, such as arm splints (Ball et al., 1980; Luiselli & Waldstein, 1994).
The use of arm splints has been successful at eliminating hand mouthing by preventing <strong>the</strong> individual from being able to move his or her hands to <strong>the</strong> mouth. While effective as a preventative strategy, <strong>the</strong> use of arm splints has several potential disadvantages, including possible negative impacts on health, adaptive behavior, and social functioning of persons who wear <strong>the</strong>m (Fisher et al., 1997; Luiselli, 1989). Additionally, researchers have found that long-term wearing of arm splints can cause health problems such as bone demineralization, shortening of tendons, muscle atrophy, arrested motor development, contractures, and restricted circulation (Fisher et al.; Oliver, Murphy, Hall, Arron, & Leggett, 2003). These findings cast doubt on <strong>the</strong> ethical aspects of <strong>the</strong> long-term use of arm splints for reducing hand mouthing in individuals with severe to profound disabilities. Due to <strong>the</strong> ethical issues raised by <strong>the</strong> use of arm splints as a preventative intervention, it is important to examine o<strong>the</strong>r antecedent interventions that can be implemented to prevent <strong>the</strong> occurrence of hand mouthing. Several studies have investigated <strong>the</strong> use of various forms of environmental enrichment to prevent <strong>the</strong> occurrence of hand mouthing. For example, Vollmer, Marcus, and LeBlanc (1994) provided three individuals with severe disabilities who engaged in hand mouthing and hand biting access to an array of highly preferred stimuli and noted decreases in challenging behavior and increases in appropriate behavior across 10 min sessions. For one participant, explicit reinforcement of appropriate behaviors and a brief (5 s) time out was required. Realon et al. (1995) found reductions in hand mouthing when preferred toys were consistently made available to one participant with profound mental retardation across 5 min sessions. Although interventions have been successful at reducing challenging behavior, <strong>the</strong>y often only examine <strong>the</strong> effectiveness of an intervention over a short period of time (e.g., 10 min) and within only one environment. One purpose of <strong>the</strong> present study was to evaluate <strong>the</strong> effects of an intervention package for eliminating <strong>the</strong> use of arm splints in a boy with profound disabilities who had a long history of wearing arm splints to prevent hand mouthing. The intervention package included <strong>the</strong> provision of curricular activities and a brief hands down procedure. A second purpose of this study was to examine <strong>the</strong> effectiveness of <strong>the</strong> intervention across <strong>the</strong> student’s entire school day in his natural environments. Method Participant, Settings, and Materials Mat<strong>the</strong>w was a 10-year-old, Caucasian boy with profound mental retardation, cerebral palsy, and hydrocephalus. He did not speak or use any alternative form of symbolic communication. At <strong>the</strong> beginning of this study, Mat<strong>the</strong>w would respond to one-sentence requests, such as “Push <strong>the</strong> switch to tell me you’re here”. By <strong>the</strong> time <strong>the</strong> intervention was implemented, he had been taught by his classroom teacher to respond to one-sentence requests by pointing to <strong>the</strong> correct answer or his choice when presented with an array of items and/or photographs. He was non-ambulatory and spent <strong>the</strong> majority of his school day seated in a wheel chair or on a bean bag or mat on <strong>the</strong> floor. Mat<strong>the</strong>w was completely dependent on o<strong>the</strong>rs for all of his daily functioning (e.g., toileting, feeding, washing, etc.). He attended a functional life skills classroom at a school for individuals with severe to profound developmental disabilities. When he engaged in hand mouthing, his teachers would give him one verbal warning. After <strong>the</strong> warning, he would often stop hand mouthing for approximately 30 s while looking at <strong>the</strong> teacher, <strong>the</strong>n begin hand mouthing again if no fur<strong>the</strong>r direction or engagement was provided. If he continued to engage in hand mouthing, his teachers would put arm splints on both arms. Once <strong>the</strong> arm splints were placed on Mat<strong>the</strong>w, <strong>the</strong>y were generally not removed until <strong>the</strong> end of <strong>the</strong> school day when he left <strong>the</strong> school. All intervention sessions were conducted in Mat<strong>the</strong>w’s natural school environments, which included his classroom, <strong>the</strong> library, <strong>the</strong> gymnasium, and an outdoor playground. Materials for <strong>the</strong> curricular activities included picture books, non-interlocking puzzles, and various pieces of gym equipment, such as balls. Combined Curricular Intervention / 361
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Education and Training in Developme
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