Lemon Juice Therapy

Contingent lemon juice for the treatment of behavior problems when combined with positive reinforcement for desirable behaviors can produce immediate, positive, and enduring change of clinical significance when applied judiciously by trained personnel or family members. It can be applied quickly in brief, convenient time intervals, resulting in little interference with the child's activities and ensuring close supervision of treatment. However, as with all aversive procedures, contingent lemon juice should only be used when positive reinforcement and less restrictive approaches such as differential reinforcement of other behavior (DRO), overcorrection, and time-out have been tried unsuccessfully. Approval from ethical boards and the family is needed before initiating treatment, and staff and child care workers should agree that the aversive procedure is less harmful than providing no treatment at all because of the dangerousness of the child's behavior problem either to the child or others.

Contingent lemon juice has proven to be successful for treating behavior problems in children, including rumination, repetitive, and self-injurious behaviors. Children who were formerly found to be unresponsive to positive reinforcement, DRO, overcorrection, and time-out have responded successfully to contingent lemon juice therapy. Although most often reported to be successful for children and adolescents with mild and profound mental retardation, lemon juice therapy has also been found to be effective for treating such problems as unremitting rumination in infants as young as 6 months of age. Chronic rumination is a life-threatening behavior that involves regurgitation of food without nausea or distress. The food is then ejected or reswallowed.

Lemon juice therapy involves squirting 5 to 10 cubic centimeters of unsweetened lemon juice into the child's mouth using a medical syringe or spray bottle immediately upon the onset of the undesirable behavior problem. It is important to specify behaviorally the target behavior to ensure that the lemon juice is applied consistently by staff and others. Applications of the juice should be paired with the verbal reprimand, “No,” so that verbal instructions will eventually obtain stimulus control over the response. The treatment sessions should be divided into observation blocks lasting a few minutes or seconds to obtain baseline and intervention data on treatment efficacy. For example, a 30-minute treatment session could be divided into 10-second observation blocks to collect baseline information on the number of times the target behavior occurs and then to document the number of incidents after treatment is initiated. Since not everyone finds lemon juice aversive, it is important to ensure the juice's punishing effect for each case before initiating treatment. Finally, treatment sessions should be scheduled when the target behavior such as rumination occurs to increase the opportunities to apply the contingency.

Research has revealed that contingent lemon juice can be more effective than DRO, time-out, DRO and overcorrection combined, mechanical restraints, overcorrection, water mist, and facial screening. The effects can be immediate, with a 50% reduction in the target behavior observed on the first day of treatment. Results are usually seen, on average, within 13 to 17 days, [Page 890]with near total suppression in 5 to 6 weeks. Success tends to be limited to the treatment setting, however, requiring that lemon juice be applied across settings, people, and situations to maximize the generalization of effects. It is important to ensure that lemon juice is applied consistently in these other settings and situations to maximize the opportunity for generalization. Treatment gains can be enduring, and there have been no reports of symptom substitution. Suppression of the target behavior is greater if DRO and positive reinforcement of desirable, incompatible behaviors are also applied. Relapses may occur after treatment is discontinued, but such reversals to pretreatment baseline levels can be addressed by reintroducing contingent lemon juice and verbal instructions for the child to refrain from engaging in the target behavior. In addition to effectively extinguishing behavior problems formerly found to be resistant to therapeutic approaches, there are anecdotal reports of collateral effects from therapy, including an increase in appropriate social behavior, smiling, and playing with others.

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