Contrasting Pica Behavior for Individuals with ASD and IDD Against Presentation in the General Population Part II
By Janice Goldschmidt, MS, RD, LDN
Director of Nutrition Services
Community Support Services, Inc.
(This is Part II of a 3 part series. Part I was posted in the December 2018 E-Newsletter and can be found by clicking here). Part III will continue in the February 2019 E-Newsletter.)
Etiology of Pica:
The most commonly hypothesized trigger for pica amongst pregnant women is iron deficiency,30 though calcium insufficiency has also been proposed.5 Indeed, iron supplementation is often the default treatment option when pica behavior is identified within the general population (pregnant women and otherwise). While a handful of case studies have demonstrated cessation of pica following treatment for iron deficiency,15 two double-blind studies assessing the effect of iron supplementation on geophagy concluded that it was not effective.31,32 Still, a 2015 meta-analysis of studies related to pagophagy, amylophagy and geophagy found that pica behavior was correlated with 2.4 times increased odds for anemia as well as reduced hemoglobin concentration and hematocrit and deficient plasma zinc when compared to controls.33 However, the directionality of the relationship between pica and nutrient deficiencies remains unclear.33-35
When pica is hypothesized as a response to nutritional deficiencies for those with ASD and IDD, it is usually considered to be iron,33,36 calcium,25 zinc,33,36,37 or phosphorous,38 though nutritional supplementation and dietary adjustment have generally been ineffective as a treatment modality.39 Further, it is reported that the longer the behavior is manifested in this cohort the greater the likelihood of multiple causative factors.40
Aside from nutrition-related deficiencies, mental health, environmental causes and sensory abnormalities have also been proposed as mechanisms for onset of pica.41 Further, many individuals with ASD and IDD experience atypical sensory processing which is manifested in disordered eating, sleep pathologies, toe walking, stereotypy, challenging behaviors, self-injurious behavior (SIB), muscular hypotonia, and irregularities in tactile processing.42 Such sensory abnormalities likely play a significant, though incompletely understood, role in the presentation and/or onset of pica. Since these types of behaviors can serve as coping mechanisms for environmentally-induced anxiety,43 eradicating the pica behavior may not necessarily address the underlying problem and can even contribute to an increase in other destructive behaviors or result in aggression.44
One of the most compelling aspects of research on pica for those with ASD and IDD is the recent effort to correlate this behavior to reduced social and recreational opportunities.21 A study from Ontario, Canada of individuals with IDD found that pica was identified in 21.8% of the population and was associated with absence of strong or supportive family relationships. Among this subpopulation, a dearth of social contact was noted as well as low levels of participation in favorite activities. In other studies, presentation of pica has also been correlated to adults with IDD who lack day programs or work, that is low levels of stimulation.20,45 At present, environmental enrichment is the treatment modality for pica with the most potential for individuals with ASD and IDD.46-51
Assessment and Diagnosis of Pica
For the general public, assessment of pica is greatly dependent on self-report (or caregiver report) of cravings and/or consumption of inappropriate items. Formal diagnostic criteria are stipulated in the DSM-V as the “persistent” consumption of non-nutritive items for a minimum period of one month. Not included within this diagnosis are developmental behaviors (children’s explorative habits) or culturally sanctioned activities. Another exemption stipulates that with a co-occurring mental disorder (such as IDD or ASD) a formal diagnosis is only warranted if the behavior is “sufficiently severe”.1
Without self-report, assessment for pica can be very difficult. Pica related obstructions can be identified via scanning methods such as radiography or ultrasounds. Analysis of blood (or other biochemical markers) can also identify poisoning due to pica ingestion. The DSM-V reports more common comorbidity with anorexia nervosa and avoidant/restrictive food intake disorder (ARFID), so presence of these conditions should warrant further analysis.1
Individuals with ASD and IDD typically have moderate to severe communicative deficits and limited ability to report the status of their health. With self-report not typically useful, assessment tools typically fall into one of three categories: experimental functional assessment, descriptive methodologies or standardized tests.52 Functional analysis is considered the “gold standard” for evaluating behaviors on the spectrum53 as it attempts to understand the variables underlying behaviors under a variety of controlled conditions in order to uncover meaningful patterns. Thus, because functional analysis is focused on the cause of the pica behavior, it remains the preferred assessment choice. It should be noted, however, that this approach requires both resources and training and is often beyond the reach of many facilities.
Pica assessments based on descriptive approaches typically use direct observation to create a baseline of the behavior, correlate with indirect assessment tools, or generate hypotheses about the function of the behavior.52 Many differing descriptive approaches have been used including, x-rays,54 component analysis (an entire object is provided to determine which part is desirable, i.e. cigarettes),55 or baiting (replacing pica items with an edible or non-harmful representation).48
Indirect assessment of pica is usually done through standardized assessments or surveys24,56 and can include interviews, questionnaires and Likert rating scales administered to support staff or caregivers. Examples include the Screening Test of fEeding Problems (STEP),57 the Motivation Assessment Scale, the Questions About Behavioral Functioning Scale (QABF),47 the Problem Behavior Questionnaire,58 the Student-Assisted Functional Assessment Interview,59 and the Functional Analysis Screening Tool.60 As they are less invasive, such approaches require minimal financial investment or training of personnel. Limitations center on the fact that the collected data is only as useful as the informant’s understanding of the individual being.
Treatment of Pica
Pica behavior outside of the ASD and IDD population is generally considered an eating disorder which typically remits over time. Though nutritional supplementation is available, neither behavioral treatment nor pharmacological options have been extensively examined for the general public.
In contrast, treatment options for pica amongst those with ASD and IDD have typically fallen into three broad categories: learning based approaches, pharmacological interventions or environmental controls. Learning based treatment modalities have included Applied Behavior Analysis (ABA), behavior therapy, social skills training, reinforcement models and token economies among others.
ABA, an operant conditioning process, is in wide use with the ASD and IDD population due to the fact that it focuses on discrete skills that can be measured.61 Use of ABA in the treatment of pica have been addressed in numerous reviews18,46,62-64 with methodologies utilizing differential reinforcement of alternative behavior (DRA),20,65 overcorrection,66 response interruption,67 differential reinforcement of other behavior (DRO),65,68 non-contingent reinforcement,48 replacement behavior training,64 and contingent time-out.69
Pharmacological treatment options for pica amongst those with ASD and IDD often focus on the use of selective serotonin re-uptake inhibitors (SSRIs), such as fluoxetine, based on anti-anxiety and anti-obsessive properties.19,62,70-72 Antipsychotic medications, utilized extensively in this population to treat aggressive and self-injurious behaviors, have also been utilized in treatment of pica but found to be ineffective.69 A case study of a female teen with ASD noted relief from pica with administration of aripiprazole, an atypical antipsychotic used across the spectrum for irritability.73
The most practical – and likely most common — approach to pica prevention for those with ASD and IDD is to simply sweep the environment for inappropriate items known to be particularly desirable as well as to plant objects that are acceptable for mouthing and/or consumption. This is commonly referred to as “pica proofing”20,41
and is considered the most pragmatic method as it requires minimal staff training. While such an approach can significantly reduce the incidence of pica, it is unknown if it will alter the underlying mechanism or help to resolve the problem.
Because individuals who display pica are also typically assigned additional staff to ensure their safety,20 allocation of resources for management of this condition is extensive.74
This analysis was originally undertaken as an independent study during my graduate studies at the University of Maryland – College Park. Special thanks to Thomas Castonguay, PhD for guiding me during that research process and helping me find the appropriate focus for this paper.
About the author:
Janice Goldschmidt, MS, RD, LDN received her Master’s Degree from the University of Maryland-College Park in Nutrition and Food Science and is currently completing a Master’s in Public Health from the same institution. She is actively involved as both a researcher and practitioner in the nutritional status of individuals with autism and has published and presented on this topic in numerous professional publications and conferences. Other research interests include assessment and treatment of disordered eating on the Autism spectrum and development of cooking skills for this same population as a form of nutritional intervention. In 2018, the American Association on Intellectual and Developmental Disabilities published her first book entitled Teaching Authentic Cooking Skills to Adults With IDD: Active Engagement.
- American Psychiatric Association. Feeding and eating disorders : DSM-5 selections. Arlington, VA: American Psychiatric Association Publishing; 2016.
- Abrahams BS, Geschwind DH. Advances in autism genetics: on the threshold of a new neurobiology. Nat Rev Genet. 2008;9(5):341-355.
- Jackson WC, Martin JP. Amylophagia presenting as gestational diabetes. Arch Fam Med. 2000;9(7):649-652.
- Kutalek R, Wewalka G, Gundacker C, et al. Geophagy and potential health implications: geohelminths, microbes and heavy metals. Trans R Soc Trop Med Hyg. 2010;104(12):787-795.
- Erick M. Nutrition in Pregnancy and Lactation. In: Mahan LK, Escott-Stump S, Raymond JL, Krause MV, eds. Krause’s food & the nutrition care process. 13th ed. St. Louis, Mo.: Elsevier/Saunders; 2012. Chapter [16:34]0-374.
- Hartmann AS, Becker AE, Hampton C, Bryant-Waugh R. Pica and Rumination Disorder in DSM-5. Psychiatric Annals. 2012;42(11):426-430.
- MedlinePlus. Pica. Online Medical Encyclopedia 2002; http://www.nlm.nih.gov/medlineplus/ency/article/001538.htm. Accessed January 8, 2015.
- Foote E, and Dahl, N. More drug idiosyncrasies in end-stage renal disease. Seminars in Dialysis. 1998;11(3):167-174.
- Roberts-Harewood M, Davies SC. Pica in sickle cell disease: “She ate the headboard”. Arch Dis Child. 2001;85(6):510.
- Ivascu NS, Sarnaik S, McCrae J, Whitten-Shurney W, Thomas R, Bond S. Characterization of pica prevalence among patients with sickle cell disease. Arch Pediatr Adolesc Med. 2001;155(11):1243-1247.
- Ali Z. Pica in people with intellectual disability: a literature review of aetiology, epidemiology and complications. J Intellect Dev Disabil. 2001;26(3):205-215.
- Nag M. Beliefs and Practices About Food During Pregnancy – Implications for Maternal Nutrition. Economic and Political Weekly. 1994;29(37):2427-2438.
- Abrahams PW, Parsons JA. Geophagy in the tropics: A literature review. Geographical Journal. 1996;1[62:63]-72.
- Matalas A, and Grivetti, L. Non-Food Food During Famine: The Athens Famine Survivor Project. In: MacClancy J, Henry CJK, Macbeth HM, eds. Consuming the inedible : neglected dimensions of food choice. New York: Berghahn Books; 20[07:13]1-139.
- Rose EA, Porcerelli JH, Neale AV. Pica: common but commonly missed. J Am Board Fam Pract. 2000;13(5):353-358.
- Blinder B. An Update on Pica: Prevalence, Contributing Causes, and Treatment. Psychiatric Times. 2008;25(6):Online.
- Zhao Y, Encinosa W. An Update on Hospitalizations for Eating Disorders, 1999 to 2009: Statistical Brief #120. Healthcare Cost and Utilization Project (HCUP) Statistical Briefs. Rockville (MD)2006.
- McAdam DB, Sherman JA, Sheldon JB, Napolitano DA. Behavioral interventions to reduce the pica of persons with developmental disabilities. Behav Modif. 2004;28(1):45-72.
- Kinnell HG. PICA AS A FEATURE OF AUTISM. Br J Psychiatry. 1985;147(JUL):80-82.
- Ashworth M. – Pica among persons with intellectual disability: Prevalence, correlates, and interventions. University of Waterloo (Canada)2007.
- Ashworth M, Hirdes JP, Martin L. The social and recreational characteristics of adults with intellectual disability and pica living in institutions. Res Dev Disabil. 2009;30(3):512-520.
- LeBlanc L, Feeney, B., Bennett, C. Pica. In: Fisher JE, O’Donohue WT, eds. Practitioner’s guide to evidence based psychotherapy. New York, NY: Springer; 20[06:54]2-549.
- McCord BE, Grosser JW, Iwata BA, Powers LJ. An analysis of response-blocking parameters in the prevention of pica. J Appl Behav Anal. 2005;38(3):391-394.
- Matson JL, Bamburg JW. A descriptive study of pica behavior in persons with mental retardation. Journal of Developmental and Physical Disabilities. 1999;11(4):353-361.
- Danford DE, Huber AM. Pica among mentally retarded adults. Am J Ment Defic. 1982;87(2):141-146.
- Goh HL, Iwata BA, Kahng SW. Multicomponent assessment and treatment of cigarette pica. J Appl Behav Anal. 1999;32(3):297-316.
- McGuire BE, Daly P, Smyth F. Lifestyle and health behaviours of adults with an intellectual disability. J Intellect Disabil Res. 2007;[51:49]7-510.
- Delaney CB, Eddy KT, Hartmann AS, Becker AE, Murray HB, Thomas JJ. Pica and rumination behavior among individuals seeking treatment for eating disorders or obesity. Int J Eat Disord. 2014.
- Williams DE, McAdam D. Assessment, behavioral treatment, and prevention of pica: Clinical guidelines and recommendations for practitioners. Res Dev Disabil. 2012;33(6):2050-2057.
- Roy A, Fuentes-Afflick E, Fernald LCH, Young SL. Pica is prevalent and strongly associated with iron deficiency among Hispanic pregnant women living in the United States. Appetite. 2018;1[20:16]3-170.
- Gutelius MF, Millican FK, Layman EM, Cohen GJ, Dublin CC. Nutritional studies of children with pica. I Controlled study evaluating nutritional status. Pediatrics. 1962;[29:10]12-1023.
- Nchito M, Geissler PW, Mubila L, Friis H, Olsen A. Effects of iron and multimicronutrient supplementation on geophagy: a two-by-two factorial study among Zambian schoolchildren in Lusaka. Trans R Soc Trop Med Hyg. 2004;98(4):218-227.
- Miao D, Young SL, Golden CD. A meta-analysis of pica and micronutrient status. Am J Hum Biol. 2015;27(1):84-93.
- Byard RW. A review of the forensic implications of pica. J Forensic Sci. 2014;59(5):1413-1416.
- Ferguson TS, Tulloch-Reid MK, Younger NO, et al. Cardiovascular disease among diabetic in-patients at a tertiary hospital in Jamaica. Diab Vasc Dis Res. 2010;7(3):241-242.
- Danford DE, Smith JC, Jr., Huber AM. Pica and mineral status in the mentally retarded. Am J Clin Nutr. 1982;35(5):958-967.
- Lofts RH, Schroeder SR, Maier RH. Effects of serum zinc supplementation on pica behavior of persons with mental retardation. Am J Ment Retard. 1990;95(1):103-109.
- Parry-Jones B, Parry-Jones WL. Pica: symptom or eating disorder? A historical assessment. Br J Psychiatry. 1992;1[60:34]1-354.
- Furniss F, Biswas AB, Bezilla B, Jones A. Self-Injurious Behavior: Overview and Behavioral Interventions. In: Matson JL, Sturmey P, eds. International handbook of autism and pervasive developmental disorders. New York: Springer; 20[11:43]7-452.
- Matson JL, Belva B, Hattier MA, Matson ML. Pica in persons with developmental disabilities: Characteristics, diagnosis, and assessment. Res Autism Spectr Disord. 2011;5(4):1459-1464.
- Stiegler L. Understanding Pica Behavior: A Review for Clinical and Education Professionals. Focus Autism Other Dev Disabl. 2005;[20:27]-38.
- Leekam SR, Nieto C, Libby SJ, Wing L, Gould J. Describing the sensory abnormalities of children and adults with autism. J Autism Dev Disord. 2007;37(5):894-910.
- Wink LK, Erickson CA, McDougle CJ. Pharmacologic Treatment of Behavioral Symptoms Associated With Autism and Other Pervasive Developmental Disorders. Curr Treat Options Neurol. 2010;12(6):529-538.
- Lerman DC, Kelley ME, Vorndran CM, Van Camp CM. Collateral effects of response blocking during the treatment of stereotypic behavior. J Appl Behav Anal. 2003;36(1):119-123.
- Ashworth M, Hirdes JP, Martin L. The social and recreational characteristics of adults with intellectual disability and pica living in institutions. Res Dev Disabil. 2009;30(3):512-520.
- Matson JL, Hattier MA, Belva B, Matson ML. Pica in persons with developmental disabilities: Approaches to treatment. Research in Developmental Disabilities. 2013;34(9):2564-2571.
- Applegate H, Matson JL, Cherry KE. An evaluation of functional variables affecting severe problem behaviors in adults with mental retardation by using the Questions about Behavioral Function Scale (QABF). Res Dev Disabil. 1999;20(3):229-237.
- Kern L, Starosta K, Adelman BE. Reducing pica by teaching children to exchange inedible items for edibles. Behav Modif. 2006;30(2):135-158.
- Madden NA, Russo DC, Cataldo MF. Environmental influences on mouthing in children with lead intoxication. J Pediatr Psychol. 1980;5(2):207-216.
- Burke L, & Smith, S. L. Treatment of pica: Considering least intrusive options when working and live in a community setting. Developmental Disabilities Bulletin. 1999;27: 30–46.
- Woo CC, Leon M. Environmental Enrichment as an Effective Treatment for Autism: A Randomized Controlled Trial. Behavioral Neuroscience. 2013;127(4):487-497.
- Lloyd BP, Kennedy CH. Assessment and Treatment of Challenging Behaviour for Individuals with Intellectual Disability: A Research Review. Journal of Applied Research in Intellectual Disabilities. 2014;27(3):187-199.
- Kodak T, Piazza CC. Assessment and behavioral treatment of feeding and sleeping disorders in children with autism spectrum disorders. Child Adolesc Psychiatr Clin N Am. 2008;17(4):887-905, x-xi.
- Burke L, & Smith, S. L. Treatment of pica: Considering least intrusive options when working and live in a community setting. Developmental Disabilities Bulletin. 1999;[27:30]–46.
- Piazza CC, Hanley GP, Fisher WW. Functional analysis and treatment of cigarette pica. J Appl Behav Anal. 1996;29(4):437-449; quiz 449-450.
- Hove O. Survey on dysfunctional eating behavior in adult persons with intellectual disability living in the community. Res Dev Disabil. 2007;28(1):1-8.
- Matson J, Kuhn D. Identifying feeding problems in mentally retarded persons: development and reliability of the screening tool of feeding problems (STEP). Res Dev Disabil. 2001;22(2):165-172.
- Lewis TJ, Scott, T.M., and Sugai, G. The Problem Behavior Questionnaire: A teacher-based instrument to develop functional hypotheses of problem behavior in general education settings. Diagnostique. 1994;[19:10]3-115.
- Kern L, Dunlap, G., Clarke, S., Childs, K. Student-Assisted Functional Assessment Interview. Assessment for Effective Intervention. 1994;19(2):29-39.
- Iwata BA, Deleon IG, Roscoe EM. Reliability and validity of the functional analysis screening tool. J Appl Behav Anal. 2013;46(1):271-284.
- Matson JL, Turygin NC, Beighley J, Rieske R, Tureck K, Matson ML. Applied behavior analysis in Autism Spectrum Disorders: Recent developments, strengths, and pitfalls. Res Autism Spectr Disord. 2012;6(1):144-150.
- Bell KE, Stein DM. BEHAVIORAL TREATMENTS FOR PICA – A REVIEW OF EMPIRICAL-STUDIES. Int J Eat Disord. 1992;11(4):377-389.
- Carter SL, Wheeler JJ, Mayton MR. Pica: A review of recent assessment and treatment procedures. Education and Training in Developmental Disabilities. 2004;39(4):346-358.
- Williams DE, Kirkpatrick-Sanchez S, Enzinna C, Dunn J, Borden-Karasack D. The Clinical Management and Prevention of Pica: A Retrospective Follow-Up of 41 Individuals with Intellectual Disabilities and Pica. Journal of Applied Research in Intellectual Disabilities. 2009;22(2):210-215.
- Chowdhury M, Benson BA. Use of differential reinforcement to reduce behavior problems in adults with intellectual disabilities: A methodological review. Res Dev Disabil. 2011;32(2):383-394.
- Foxx RM, Martin ED. Treatment of scavenging behavior (coprophagy and pica) by overcorrection. Behav Res Ther. 1975;13(2-3):153-162.
- Hagopian LP, Gonzalez ML, Rivet TT, Triggs M, Clark SB. RESPONSE INTERRUPTION AND DIFFERENTIAL REINFORCEMENT OF ALTERNATIVE BEHAVIOR FOR THE TREATMENT OF PICA. Behavioral Interventions. 2011;26(4):309-325.
- Finney JW, Russo DC, Cataldo MF. Reduction of pica in young children with lead poisoning. J Pediatr Psychol. 1982;7(2):197-207.
- Matson JL, Sipes M, Fodstad JC, Fitzgerald ME. Issues in the Management of Challenging Behaviours of Adults with Autism Spectrum Disorder. Cns Drugs. 2011;25(7):597-606.
- Herguner S, Ozyildirim I, Tanidir C. Is Pica an eating disorder or an obsessive-compulsive spectrum disorder? Prog Neuropsychopharmacol Biol Psychiatry. 2008;32(8):2010-2011.
- Jawed SH, Krishnan VHR, Prasher VP, Corbett JA. WORSENING OF PICA AS A SYMPTOM OF DEPRESSIVE-ILLNESS IN A PERSON WITH SEVERE MENTAL HANDICAP. Br J Psychiatry. 1993;1[62:83]5-837.
- Bhatia MS, Gupta R. Pica responding to SSRI: an OCD spectrum disorder? World J Biol Psychiatry. 2009;10(4 Pt 3):936-938.
- Herguner A, Herguner S. Pica in an Adolescent with Autism Spectrum Disorder Responsive to Aripiprazole. J Child Adolesc Psychopharmacol. 2016;26(1):80-81.
- Bogart LC, Piersel WC, Gross EJ. THE LONG-TERM TREATMENT OF LIFE-THREATENING PICA – A CASE-STUDY OF A WOMAN WITH PROFOUND MENTAL-RETARDATION LIVING IN AN APPLIED SETTING. Journal of Developmental and Physical Disabilities. 1995;7(1):39-50.
Table 1. Most common forms of pica in general population
|Name||Characterized by consumption of…|
|Geophagy||soil, clay, or chalk|
|Lithophagia||pebbles or rocks|
|Trichophagia||hair or wool|
|Mxlophagia||wood or paper|
Table 2. Comparison of Pica in the General Population versus for those with ASD or IDD
|Pica in the General Population||Pica on the Autism Spectrum|
|Pregnant and Lactating Women
Related to specific medical conditions
Culturally sanctioned behavior
|Seen across the autism spectrum|
|Specific pica: Prescribed nature of objects consumed, that is typically one class of pica (e.g., ice, clay)||Generalized pica: Widely varying nature of objects consumed, many times scavenging or opportunistic|
|Highest rates among children as a developmentally appropriate activity||Highest rates among individuals who are institutionalized|
Table 3. Items reported as Consumed
by Individuals with ASD or IDD
|Item Consumed and Source|
|aftershave lotion 71|
|alkaline batteries 64,89|
|broken light bulbs 75|
|cleaning products 23|
|coffee grounds 93|
|dead animals 77|
|foam rubber 74,|
|foam padding 48|
|holiday decorations 94|
|paint chips 23,76|
|paper clips 78|
|plastic tubing 64,77|
|rubber bands 64|
|sealed snack bags 64,|
|sewing needles 71|
|spoiled food 93|
|tea bags 71,|
|toilet bowl fresheners 34|
|toilet water 93|
|vinyl 85 or rubber gloves 89|
|wood chips 96|