Pica in individuals with developmental disabilities

Autism and Child Psychopathology Series
Series Editor: Johnny L. Matson

Peter Sturmey
Don E. Williams

Pica in
Individuals with
Developmental
Disabilities


Autism and Child Psychopathology Series
Series editor
Johnny L. Matson, Baton Rouge, LA, USA


More information about this series at />

Peter Sturmey Don E. Williams
•

Pica in Individuals
with Developmental
Disabilities

123


Peter Sturmey
Queens College

City University of New York
Flushing, NY
USA

Don E. Williams
Williams Behavioral Consulting
Greenville, TX
USA

ISSN 2192-922X
ISSN 2192-9238 (electronic)
Autism and Child Psychopathology Series
ISBN 978-3-319-30796-1
ISBN 978-3-319-30798-5 (eBook)
DOI 10.1007/978-3-319-30798-5
Library of Congress Control Number: 2016932858
© Springer International Publishing Switzerland 2016
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of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations,
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The use of general descriptive names, registered names, trademarks, service marks, etc. in this
publication does not imply, even in the absence of a specific statement, that such names are exempt from
the relevant protective laws and regulations and therefore free for general use.
The publisher, the authors and the editors are safe to assume that the advice and information in this
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Printed on acid-free paper

This Springer imprint is published by Springer Nature
The registered company is Springer International Publishing AG Switzerland


To individuals with pica and their families.
When we first observed people with pica, we
could find little research to guide us in
assessing and treating you. It took us a long
time to provide what you needed. Some died
prematurely perhaps, and we know you have
suffered. We apologize for our shortcomings.
This book represents our latest attempt to
improve your clinical treatment and your
movement to a safe, humane life. Chapter 8
recounts a program for people with pica
established over 25 years ago at one facility.
Although an article was published in 2009
describing the program for people with pica,
this article has been ignored by some, and
criticized by some, but we launched the program for you and your families and we think
you benefited. We did not plan the program
for research, but now we think parents and
staff have the right to know what we have
done. We are sure more criticism will come,
but that should not cause you to suffer. We


hope you and your parents will know the
difference between those who acted and those
who did not. After all,

it was B.F. Skinner who said
“caring is…a matter of action.”


Foreword

One of the most severely challenging aspects of raising an individual with autism is
discovering the limited number of people who know how to effectively help your
child. The professionals, including pediatricians and doctors, that a parent typically
turns to for support in a crisis are often ill-equipped to address the deficits of autism
and chart a clear path for the parent who is asking: “What do we do next?” Due to
an increased national focus on autism, however, there has been a corresponding
expansion of dedicated research toward treatment and etiology. There is now a
strong body of scientific research supporting improved outcomes through
evidence-based treatment utilizing applied behavior analysis (ABA). Nevertheless,
for individuals with autism who experience severe behavior problems, including
aggression and self-injury, parents may find themselves overwhelmed by the risk of
injury to themselves, siblings, or the child with problem behaviors. Ingesting items
of little or no-obvious nutritional value is among the most serious self-injurious
behaviors with consequences including infections, choking, intestinal blockage, and
possibly death. In the presence of low-incidence behaviors that pose a high risk to
the client or staff, parents frequently find the door to help closed with the prospect
of placement outside the home looming large.
The possibility of finding an effective treatment for autism and other developmental disabilities is more real today than ever—thanks to practitioners of behavior
analysis who continue to undertake the work of isolating and documenting techniques that are effective when applied consistently by trained educators and parents.
Much of the field’s work in the past 20 years has focused on documenting and
disseminating basic treatment information to ameliorate the key symptoms of
autism seen across a broad swath of the spectrum, including deficits in language,
social interaction, self-care, and academics. Major cities typically have at least a
half-dozen or more site-based treatment programs as well as practitioners consulting

with families and school districts to provide treatment that is increasingly subsidized by insurance or public funding. As a result, many families today have access
to professionals who are familiar with the basic methods of treating the most
common deficits. Nevertheless, the number of behavior analysts with a depth of

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Foreword

experience treating pica is small, and with the closure of institutional settings, the
responsibility for addressing severe problem behaviors today falls ever more
squarely on families.
This work by Sturmey and Williams is among those that represent the next step
in the behavior analytic treatment literature for autism: works that shed light on how
the field can better address problem behaviors, like pica, that lie at the extremes
of the spectrum. The authors gather what is known about past successes and failures
in the treatment of pica and provide direction for researchers and practitioners who
must start on the same page in order to collaborate to effectively treat behavior that
poses severe, often life-threatening danger to clients’ physical and emotional safety.
An effective treatment of all problem behaviors, including pica, requires consistency across environments with participation by family members and professionals. Because of the limited number of pica cases in most treatment locations,
it is essential that behavior analysts in geographically dispersed locales have a
common base of knowledge so that they may jointly move the treatment forward
and collaborate with families for consistency. The authors have laid the groundwork
for that collaboration. They begin with descriptive information on pica and follow
up with a comprehensive review of the existing literature on studies of pica in
autism, many of them single-subject design. They also review several
meta-analyses of the literature. This informs the assessment of the function of most
pica as automatic positive reinforcement as well as a hierarchy of the efficacy of

treatment protocols.
As parents of individuals with autism, we have identified ABA as the field
offering the greatest promise for treating our children with autism. We have also
spent inordinate amounts of time learning the concepts and language of ABA to
more effectively implement recommended procedures. Nevertheless, ours are like
most families that remain heavily reliant on public schools, therapists, and day
programs to carry out treatment protocols. We are acutely aware of the issues that
most programs face, including lack of training resources, high client-to-staff ratios,
and inadequate supervision by board-certified behavior analysts, all of which
combine to slow or eliminate our children’s progress—whether as students or
adults. In addition to recommendations for designing and conducting a treatment
program, the authors acknowledge and provide guidance on some of the practical
issues surrounding staffing, staff training, and creating pica-safe environments in a
section of the book that describes a 12-year-long pica program with 41 clients in an
institutional setting. The information is highly useful for professionals as well as
families evaluating and executing programs for a child or an adult with pica.
Over the past 20 years, much scientific research has emphasized the importance
of early intervention for ASD. As with all facets of behavioral treatment of autism,
early identification and intervention in the treatment of pica behaviors should
enhance long-term outcomes. Unfortunately, the existence of pica behaviors is not
always acknowledged or addressed before it becomes a life-threatening or an
endemic issue that isolates the child from environments that support integrated
learning experiences, according to the authors. Amidst a range of deficits, parents
and professionals are not attuned to pica as a problem until health suffers or a child


Foreword

ix

is hospitalized for swallowing a dangerous object. Laying a foundation for treating
pica behaviors and teaching safe adaptive behaviors early and in the context of
community and family settings is a significant need highlighted by this volume.
The more rapidly research is advanced and disseminated, the quicker targeted
treatment protocols will be widely available to families and service providers. We
believe, as do the authors of this book, that a solid foundation exists for researching
and disseminating the best treatment protocols for pica. This volume will be an
outstanding resource in moving those efforts forward.
Lisa Hill Sostack, MBA, Co-founder
Amy M. Wood, Pharm.D., President
Families for Effective Autism Treatment (FEAT)—Houston


Preface

Pica is a rare but serious and potentially life-threatening behavior disorder which is
quite difficult to treat in individuals with autism and intellectual disabilities (ID).
Until recently there was little evidence to guide treatment. Rather, individuals
received no treatment or tokenistic and ineffective treatment, or their problem
behavior was prevented as best as could be managed by restrictive practices such as
restraints, including fencing masks worn permanently, one-on-one staffing, and
locked in barren environments with no treatment in place. The results of such
treatments were miserable and restricted lives with no positive outcomes and
continued risks to clients.
Surprisingly, there are at least four previous books on pica. Cooper (1957)
presented a review of the cultural and medical literature on pica. Cooper also
reported an empirical study of pica in low-income families in Baltimore in the
1950s, whose children were at risk for lead poisoning and pica, which focused
mostly on environmental risk factors, such as lead paint, child nutrition, poverty,
and lack of child supervision at home. This volume mentioned autism and intellectual disabilities only in passing. Bicknell (1975) published a similar book but

which did focus on pica in children with autism and intellectual disabilities. Like
Cooper, she too presented a descriptive longitudinal survey of the characteristics of
15 children with autism and ID and pica. The survey searched for potential psychodynamic risk factors, but could only conclude that these risk factors were
heterogeneous. In some cases child development appeared typical and pica may
have been the cause of developmental delay due to ingestion of lead. One notable
feature of this volume is the mention in passing of the possibility of behavioral
treatment, but with little data available to discuss, there was little to say about it.
More recently, Young (2011) published a comprehensive review of pica mostly
from a cross-cultural and nutritional perspective, making little mention of pica in
individuals with autism or intellectual disabilities. This volume provided a fairly
comprehensive review of the history of pica, pica in literature, and epidemiological
studies in pregnant women, children, and certain cultural groups that engage in pica
as part of culture-specific practices. Young also attempted to integrate this mass of

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xii

Preface

cross-cultural data into an integrated theory of pica. Finally, Conner (2013)
published a brief self-help Kindle edition book on how to treat your own pica,
which provides everyday advice on how to treat your own pica, but now which is
not research based.
Both the authors of the present volume were involved in treatment of pica in
institutional settings and were faced with the challenge of delivering effective
treatment to groups of individuals almost all of whom were adults with severe and
profound intellectual disabilities scattered across multiple residential settings. One
of us (Don Williams) led a team that developed and evaluated a program for

41 individuals with pica over a 9-year period that addressed both reducing pica
behavior and safely eliminating restraint and reducing medical risks, such as
surgeries for pica.
This volume brings together the research literature and our own clinical experience in treating pica. Since the publication of Bicknell’s volume on pica in
individuals with autism and intellectual disabilities, behavioral research has
increased apace. In the 1970s and 1980s research developed and evaluated effective
procedures using only positive punishment procedures. Influenced by the work of
Carr (1977) and Iwata et al. (1982/1994), the conceptual framework and related
behavioral technology of functional assessment and analysis was subsequently
extended to assess pica and develop function-based, ideographic behavioral treatments. In addition, a smaller quantity of research, including a small number of
experiments, supports the use of dietary interventions for some individuals with
predetermined nutritional deficiencies. There are a small number of uncontrolled
studies of various psychotropic medications and other interventions that researchers
have not yet evaluated with well-controlled studies. Thus, over the past 30 years a
group of evidence-based practices has been developed that may safely reduce and
perhaps eliminated pica in some individuals with autism and intellectual disabilities.
Over the past 15 years, institutional settings have reduced in number and size in
many (but not all) countries and there is a greater pressure to provide education and
adult services in integrated settings. Doubtless, many individuals with autism and
intellectual disabilities have benefited in many ways because of these changes. Yet,
geographically dispersed, multi-agency services face many significant challenges
and oversight is often very weak leading to unregulated and unsafe school and adult
community services that too often rely on restrictive and sometimes unsafe behavior
management practices (Sturmey 2015). This review of pica identifies two major
gaps in the research literature and indeed practice. First, we lack models of effective
and safe treatment of pica in contemporary school and adult service settings. This is
a serious gap in the literature and in services as the problem of pica remains a
serious and life-threatening one in community services. Second, little is known
about prevention of pica. It might not be too difficult in principle to identify
individuals at risk for pica, such as infants and children with severe and profound

intellectual disabilities and high rates of mouthing and other oral-stimulating
behavior present over unusually extended periods of time. It would be interesting to
know if generic early intervention for young children with severe and profound
intellectual disabilities and autism would be effective in preventing pica merely


Preface

xiii

through promoting better skills development and increasing the range of social
reinforcers available to young children or whether pica-specific interventions are
needed, for example, to increase alternate adaptive behavior, increase social reinforcers, reduce potential oral, and/or feeding behavior that might precede the
development of pica and reduce the reinforcement value of engaging in pica at an
early age.
This book comprises three parts. The first part, Foundational Issues, addresses
basic concepts such as definition and diagnosis, epidemiology, and theories of pica.
This section includes material on pica in a wide range of populations who engage in
pica, thereby providing an opportunity to examine the similarities and differences
between pica in pregnant women, pica as a cultural phenomenon, pica in individuals with psychiatric disorders, and individuals with developmental disabilities. The
second part, Treatment, focuses on treatment of pica using applied behavior analysis and individuals with ID/autism spectrum disorders (ASD). This section
addresses functional assessment and analysis of pica, behavioral interventions for
individuals, and a description of a group program that the second author was
involved in for many years. Consideration is also given to nonbehavioral treatments, such as nutritional interventions, psychotropic medication, cognitive
behavior therapy, and other treatments. The final part, Emerging Issues, consists of
one chapter that highlights the future directions for both research and services,
especially in the context of contemporary community services.
Peter Sturmey
Don E. Williams

Contents

Part I

Foundational Issues

1

Definition and Diagnosis . . . . . . . . . . . . . . . . . .
1.1 A Brief History of Pica. . . . . . . . . . . . . . .
1.1.1 Some Common Factors . . . . . . . . .
1.2 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . .
1.2.1 Pica Terms . . . . . . . . . . . . . . . . .
1.2.2 Differential Diagnosis . . . . . . . . . .
1.3 Culturally Normative Pica . . . . . . . . . . . . .
1.3.1 Culturally Normative Forms of Pica
1.3.2 Pica During Pregnancy . . . . . . . . .
1.4 Pica in Clinical Populations . . . . . . . . . . . .
1.4.1 Developmental Disabilities . . . . . .
1.4.2 Psychiatric Disorders . . . . . . . . . .
1.5 Pica in Non-humans . . . . . . . . . . . . . . . . .
1.6 Risks . . . . . . . . . . . . . . . . . . . . . . . . . . .
1.7 Summary . . . . . . . . . . . . . . . . . . . . . . . .

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3
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2

Epidemiology . . . . . . . . . . . . . . . . . . . . . .
2.1 General Populations . . . . . . . . . . . . .
2.1.1 Clinical Populations . . . . . . .

2.1.2 Summary . . . . . . . . . . . . . .
2.2 Developmental Disabilities . . . . . . . .
2.2.1 Institutional Settings . . . . . . .
2.2.2 Total Population Samples . . .
2.2.3 Risk Factors . . . . . . . . . . . .
2.2.4 Discussion. . . . . . . . . . . . . .
2.3 Other Clinical Populations. . . . . . . . .
2.3.1 Sickle Cell Anemia. . . . . . . .
2.3.2 Children with Lead Poisoning
2.4 Summary . . . . . . . . . . . . . . . . . . . .

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xv


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Contents

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29
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4

Behavioral Assessment and Treatment: An Overview . . .
4.1 General Features of Behavioral Approaches. . . . . . . .
4.2 Ethics of Treatment . . . . . . . . . . . . . . . . . . . . . . . .
4.3 Behavioral Assessment of Pica. . . . . . . . . . . . . . . . .
4.3.1 Measurement of Pica . . . . . . . . . . . . . . . . .
4.4 Behavioral Interventions Used with Pica . . . . . . . . . .
4.4.1 Treatment Goals for Behavioral Interventions.
4.4.2 Risk Assessment . . . . . . . . . . . . . . . . . . . .
4.4.3 Behavioral Interventions for Pica . . . . . . . . .
4.5 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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41
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5

Functional Assessment and Analysis and Function-Based
Interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5.1 Functional Assessment of Pica . . . . . . . . . . . . . . . . .
5.1.1 Observational Functional Assessments of Pica
5.1.2 Psychometric Measures of Function . . . . . . .
5.2 Functional Analysis of Pica . . . . . . . . . . . . . . . . . . .

5.2.1 Functional Analyses of Pica. . . . . . . . . . . . .
5.2.2 Response Effort . . . . . . . . . . . . . . . . . . . . .
5.2.3 Functional Analysis of Response-blocking
Parameters. . . . . . . . . . . . . . . . . . . . . . . . .
5.2.4 Stimulus Control . . . . . . . . . . . . . . . . . . . .
5.3 Function-based Treatment of Pica. . . . . . . . . . . . . . .
5.4 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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3

Etiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3.1 Learning Models . . . . . . . . . . . . . . . . . . . . . .
3.2 Neuroanatomical Models . . . . . . . . . . . . . . . . .
3.3 A Dopaminergic Model. . . . . . . . . . . . . . . . . .
3.4 Vitamin/Nutrient Deficiency Models . . . . . . . . .
3.5 Gastrointestinal Protection Hypothesis. . . . . . . .
3.6 Hunger Hypothesis . . . . . . . . . . . . . . . . . . . . .
3.7 Genetic Models . . . . . . . . . . . . . . . . . . . . . . .
3.8 Young’s Biocultural Approach . . . . . . . . . . . . .
3.9 Behavioral Equivalent of Depression Hypothesis

3.10 Psychoanalytic Theory . . . . . . . . . . . . . . . . . .
3.11 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . .

Part II

6

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Treatment

Behavioral Interventions: Non-function-based
6.1 Non-function-based Reinforcement-Based
6.2 Antecedent-based Procedures . . . . . . . . .
6.3 Positive Punishment . . . . . . . . . . . . . . .
6.3.1 Aversive Stimuli . . . . . . . . . . .
6.3.2 Restraint . . . . . . . . . . . . . . . . .

Treatments
Procedures .
.........
.........
.........

.........


Contents

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Prevention, Treatment, and Management of Pica. . . . . . . . . .
8.1 Prevention Using Crisis Intervention. . . . . . . . . . . . . . . .
8.1.1 One-to-One Staffing to Temporarily Prevent Pica .
8.1.2 Continuous Restraint. . . . . . . . . . . . . . . . . . . . .
8.1.3 Continuous Restraint Plus One-to-One Staffing. . .
8.1.4 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . .
8.2 The Program Methodology . . . . . . . . . . . . . . . . . . . . . .
8.2.1 Pica Survey and Participants . . . . . . . . . . . . . . .
8.2.2 Client Rights and Protections . . . . . . . . . . . . . . .
8.2.3 Behavior Plans. . . . . . . . . . . . . . . . . . . . . . . . .
8.2.4 Measurement of Pica . . . . . . . . . . . . . . . . . . . .
8.2.5 Pica Prevention by Environmental Systems

Management . . . . . . . . . . . . . . . . . . . . . . . . . .
8.2.6 Administrative Priority Requiring Leadership . . . .
8.2.7 Determining Risk . . . . . . . . . . . . . . . . . . . . . . .
8.2.8 Outcome Data . . . . . . . . . . . . . . . . . . . . . . . . .
8.3 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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6.4
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8

xvii

6.3.3 Response Blocking and Response Interruption .
6.3.4 Overcorrection . . . . . . . . . . . . . . . . . . . . . . .
6.3.5 Negative Practice . . . . . . . . . . . . . . . . . . . . .
6.3.6 Abbreviated Habit Reversal . . . . . . . . . . . . . .
6.3.7 Visual Screening . . . . . . . . . . . . . . . . . . . . .
6.3.8 Reprimands . . . . . . . . . . . . . . . . . . . . . . . . .
6.3.9 Idiosyncratic Aversive Stimuli . . . . . . . . . . . .
6.3.10 Comparative Studies . . . . . . . . . . . . . . . . . . .
6.3.11 Food Aversion . . . . . . . . . . . . . . . . . . . . . . .
6.3.12 Summary . . . . . . . . . . . . . . . . . . . . . . . . . .
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Behavioral Treatment: Treatment Programs
and Outcome Data . . . . . . . . . . . . . . . . . . . .
7.1 Case Series . . . . . . . . . . . . . . . . . . . . .
7.1.1 Williams et al. (2009) . . . . . . . .
7.1.2 Call et al. (2015) . . . . . . . . . . .

7.1.3 Commentary . . . . . . . . . . . . . .
7.2 Systematic Reviews and Meta-analyses . .
7.2.1 Bell and Stein (1992) . . . . . . . .
7.2.2 McAdam et al. (2004). . . . . . . .
7.2.3 Hagopian et al. (2011) . . . . . . .
7.2.4 McAdam et al. (2012). . . . . . . .
7.2.5 Comments . . . . . . . . . . . . . . . .
7.3 Summary of Evidence. . . . . . . . . . . . . .

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xviii

Contents

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10 Future Directions for Research and Services . . . . . . . . . . . .
10.1 Future Directions for Research . . . . . . . . . . . . . . . . . . .
10.1.1 Community-Based Research . . . . . . . . . . . . . .
10.1.2 Early Development and Pica . . . . . . . . . . . . . .
10.1.3 Applied Behavior Analysis . . . . . . . . . . . . . . .
10.1.4 Integrating Research Across Populations . . . . . .
10.1.5 Integrating Biomedical and Behavioral Research
10.1.6 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . .
10.2 Treatment Implications . . . . . . . . . . . . . . . . . . . . . . . .
10.2.1 Individual Cases. . . . . . . . . . . . . . . . . . . . . . .
10.3 Implications for Contemporary Services . . . . . . . . . . . .
10.3.1 Statewide and Regional Planning . . . . . . . . . . .
10.4 Advice for Families . . . . . . . . . . . . . . . . . . . . . . . . . .
10.5 Conclusions and Recommendations . . . . . . . . . . . . . . .

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9

Biomedical and Other Treatments .
9.1 Nutritional Interventions . . . . .
9.1.1 Controlled Studies . . .
9.1.2 Summary . . . . . . . . .
9.2 Psychotropic Medications . . . .
9.2.1 Summary . . . . . . . . .
9.3 Exposure Therapy . . . . . . . . .
9.4 Other Psychosocial Treatments.
9.5 Summary . . . . . . . . . . . . . . .

Part III

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Emerging Issues

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179


About the Authors

Peter Sturmey Ph.D. is a Professor of Psychology at Queens College and The
Graduate Center, City University of New York. He has published more than 200
papers, 50 chapters, and 20 authored and edited books on developmental disabilities, behavior analysis, clinical psychology, and evidence-based practice.
Don E. Williams Ph.D., BCBA-D is a consultant with over 30 years of practice
and research experience with severe behavior disorders, staff training and supervision, and developmental disabilities. He has published extensively on restraint
elimination, and the prevention and treatment of self-injurious behavior (pica
especially) and other severe behavior problems.

xix


Part I

Foundational Issues


Chapter 1

Definition and Diagnosis

1.1

A Brief History of Pica

As long as humanity has existed, people have eaten strange things of little or no
obvious nutritional value. Clarke (2001) presented evidence that Homo Habilis ate
dirt or clay some two million years ago. Many people are familiar with pregnant
women experiencing food cravings and eating odd substances to satisfy those
cravings. Many of us learn in history classes that at times of famine or war, people

eat wood, tree bark, dirt, sawdust, and other minimally nutritious substances and
incorporate them into existing food, such as bread, apparently to stave off hunger.
Such practices sometimes make the news when very poor people, such as those in
parts of contemporary Haiti, eat dirt cakes or bon bon terres, perhaps because of
lack of availability of alternate food sources, to avoid hunger, and to provide some
minimal nutrition from the content of the clay.
Less widely known are culture-specific religious practices. For example, for
some Catholic and other religious groups, eating sacred earth is said to be imbued
with healing, magical or quasi-magical properties. This occurs as part of the cult of
Our Lord of Esquipulas, Guatemala, where believers take sacred earth, rub it on
themselves, consume it in water, or take it back home. This practice has spread
from Guatemala as far north as Chimayo, New Mexico, where over 30,000 pilgrims
consume 25–30 tons of dirt a year, sometimes walking 90 miles from Albuquerque
to do so. The church in Chimayo might have been built on a location where Tewa
Indians used a sacred spring ascribed with healing powers, so perhaps such cultural
practices are specific examples of Christian colonists adapting indigenous practices
to Catholicism.
Similar culture-specific forms of pica occur when there are outbreaks of fads for
pica, such as consumption of large quantities of solid starch, ice, or clay among
certain groups within a society (Cooper 1957; Young 2011). Today, some individuals with pica for starch have now become YouTube starlets, pleading for help
while eating starch from boxes for all to see. Such examples of pica are interesting
© Springer International Publishing Switzerland 2016
P. Sturmey and D.E. Williams, Pica in Individuals with
Developmental Disabilities, Autism and Child Psychopathology Series,
DOI 10.1007/978-3-319-30798-5_1

3


4

1 Definition and Diagnosis

behavioral phenomena that require description and explanation. Two previous
volumes on pica (Cooper 1957; Young 2011) have described them fully.
Researchers have also reported individual cases of pica among individuals with
psychiatric diagnostic criteria such as dementia, obsessive–compulsive disorder,
and schizophrenia. These case studies are usually more dramatic and are often far
more serious and dangerous forms of pica than the preceding examples. (Formal
psychiatric diagnostic criteria for pica, such as those from DSM and ICD, usually
exclude these culturally appropriate forms of pica.)
This book, however, will focus on more serious forms of pica which are found
among individuals with developmental disabilities, such as autism spectrum disabilities (ASD) and intellectual disabilities (ID). Only, Bicknell’s book from the
mid-1970s has addressed pica in this population. This was published a long time
ago before most of the research on assessment and effective treatment of pica had
been conducted.

1.1.1

Some Common Factors

These clinical forms of pica share at least four features with other non-clinical forms
of pica. A first similarity is that sometimes the person with pica appears or reports to
be obsessed with eating certain substances, perhaps excluding other substances
from their diet. Thus, their preferences for the pica items are often highly specific
and highly motivated. Individuals who eat clay only eat certain kinds of clay and
would never eat dirt or other forms of non-preferred types of clay! Some people
who engage in pica with ice report only craving certain kinds of ice and will travel
miles to purchase the preferred kinds or even purchase expensive ice machines of
the preferred brand, even when other non-preferred types of ice are readily and

more conveniently available. People who eat solid starch have strong preferences
for specific brands of starch and for specific aspects of physical texture and taste.
They would never eat a non-preferred brand of starch or drink starch dissolved in
water! This strong preference for specific pica items is similar to the strong and
specific preferences that individuals with ASD and/or ID and some psychiatric
patients with pica have for specific items (Piazza et al. 1996). For example, an
individual with ASD, ID, and pica might search for certain kinds of string and reject
all other apparently similar items, but would never eat a cigarette, whereas others
only eat cigarettes and would never eat string. Some psychiatric patients with pica
seek out certain kinds of metallic items, but would never eat string or cigarettes.
A second similarity is that it seems that certain physical or sensory properties of
the pica items are highly important to the person. Young (2011) noted that many
commonly consumed pica items have a somewhat bland or neutral flavor or leave a
somewhat metallic or mildly acidic flavor in the mouth after consumption such as
might be experienced by those who eat cornstarch, baby powder, chalk, or certain
kinds of clay. The physical texture of the pica items also seems highly characteristic, sometimes grainy, as in certain kinds of clay, or with specific crunchy or other


1.1 A Brief History of Pica

5

mechanical properties. Young also emphasizes that many people engage in pica
secretively and away from other people, perhaps out of shame, again suggesting
that pica is more of a nonsocial/sensory activity, although the Internet now provides
ample social networks for almost all minority interests, including people who
engage in amylophagy (starch pica) (Young 2011). In a similar vein, functional
analyses of pica behavior in individuals with ID and/or ASD indicate almost uniformly that pica behavior is insensitive to social consequences. In contrast, other
maladaptive behaviors, such as self-injurious behavior (SIB), are maintained by a
variety of social and nonsocial consequences, whereas pica behavior is almost

always maintained by automatic positive reinforcement, i.e., the reinforcing sensory
consequences of consuming the pica item.
A third similarity between pica in the general population and pica in individuals
with ID/ASD is that the pica items appear to be very powerfully positively reinforcing for a range of pica-related behavior. Thus, individuals with pica in the
general population may spend large amounts of time and money on pica-related
behavior. They may think “obsessively” about their favorite pica item, read about it,
and search for information from friends, family, and the Web. People who engage
in pagophagy (ice pica) spend much of their day thinking about ice, planning trips
to the store to buy ice, and spending money every day on ice. They eat ice even
though they injure themselves by wearing down their teeth. We sometimes describe
this by saying the person is “obsessed” with the pica item and that they are
apparently “compelled” to engage in pica. In a similar manner, a person with ASD
and/or ID is often described as “obsessed” with cigarettes, twigs, or eating threads
from clothes. They may be placed on one-to-one staffing, or restrained mechanically in an attempt to prevent pica-related injuries, such as choking or gastrointestinal damage. These strategies, which deprive the person of the opportunities to
engage in pica, only appear to increase the individual’s motivation to engage in
pica. The moment the one-to-one staff turns their back or the moment the person
can work their way out of mechanical restraint, the individual may bolt for the
nearest location where a pica item may be and consume it immediately. Thus, an
individual with ASD/ID and pica engages in the behavior despite some immediate
unpleasant consequences.
A final similarity is that both groups of people engage in pica for its short-term
benefits despite its long-term harms. Thus, some pregnant women eat dirt and
expose their fetuses to parasites, others eat starch and put on weight with long-term
health costs, and others knowingly damage their teeth when eating ice. Individuals
with ASD/ID engage in pica but struggle with staff to obtain the item and injure
themselves when attempting to obtain the item and its long-term harm.
Although similarities exist across pica in typically developing people and those
with ASD and/or ID, important differences do indeed exist. Some forms of
culture-specific practices, such as pica-related to religion, pregnancy, social contagion, such as groups interested in amylophagy, appears to be different to pica in
individuals with ASD and/or ID. That is, these forms of pica are probably highly

influenced by socially mediated learning processes, such as modeling and
rule-governed behavior. These people may imitate other people’s pica behavior; for


6

1 Definition and Diagnosis

example, they may observe family members and friends engaging in religious-related
pica or observe other pregnant women engaging in pica. They may receive direct
instruction from others to engage in pica, “go ahead try it, you might like it,” another
pregnant woman might say. They may also receive indirect forms of instruction.
For example, a religious person may here that “True Catholics believe in the power of
Our Lord of Esquipulas” or “Eat this dirt I brought you back from Chimayo. It is said
to be very powerful.” In such examples, the person never comes in direct contact
with contingencies—they never consume the dirt and feel better—but their previous
history of reinforcement for following instructions and rules related to religious
practices influences a more general class of religious rule-governed behavior. Clearly,
not only the topography and pica items are quite different between these populations,
but also the nature of pica is quite different. Thus, other people are important in the
acquisition and maintenance of these forms of pica in the general population, whereas
in other forms of pica in individuals with ASD/ID, this may be less true.

1.2

Diagnosis

Several formal sets of psychiatric diagnostic criteria have defined pica. The most
recent comes from the American Psychiatric Association (APA) (2013), which
defined pica with four criteria. First, there must be persistent eating of non-nutritive

substances for at least one month. Second, this behavior is inappropriate to the
person’s developmental level. Third, the behavior is not a culturally normative or
socially supported practice. Finally, if this behavior occurs at the same time as
another DSM diagnosis or other medical disorder, it must be sufficient to require
additional attention. Thus, the APA’s new definition makes no reference to specific
populations, such as individuals with ASD and/or ID, or ages, but does clarify that if
it coexists with other disorders, such as ID and/or ASD, and then it must warrant its
own attention. The ICD-10 diagnostic criteria for pica are broadly similar, and both
criteria are applicable to both adults and children.
There were relatively few changes in DSM criteria for pica when the APA revised
DSM-IV-TR to make DSM-5 (Hartmann et al. 2012). For example, the American
Psychiatric Association (2013) classified pica as a feeding and eating disorder,
alongside binge eating disorder, anorexia nervosa, and bulimia nervosa, whereas in
DSM-IV-TR it had been classified as a disorder usually first diagnosed in infancy,
childhood, or adolescence. Thus, the revisions to DSM-IV criteria appear relatively
minor in that they only clarified that pica could be diagnosed at any age.
The new DSM-5 criteria for pica require a reassessment of the diagnosis of pica
for several reasons. First, both children and adults can now be diagnosed with pica.
Formally, pica was only diagnosed as a disorder which usually onsets in childhood
and adolescence. Onset of pica can occur in adulthood, for example, both in some
individual with ASD and/or ID and in various other forms of pica; the new DSM-5
definition now permits such diagnoses with adult onset. Thus, there may be adults
who should now be diagnosed with pica.


1.2 Diagnosis

7

Young (2010) discussed various forms of eating unusual items. She noted that

although DSM diagnostic criteria were more operationalized than previous definitions, they failed to capture what for her is one of the key features of pica, namely
intense craving for the pica item. She argued that when people eat earth and clay at
times of famine, they do so out of necessity and because of lack of availability of
alternate foods, but without craving for the substance. Similarly, some culturally
appropriate forms of pica, such as religious-based pica, are due to local social customs and practices, rather than intense cravings for specific pica items. She argued
that both of these forms of unusual eating are not true pica because the forceful
craving for the item, akin to a drug addiction, is absent. Therefore, she proposed that
pica is “the craving and purposeful consumption of substances that the consumer
does not define as food for >1 month” (p. 405). This refinement is interesting because
it not only captures something about pica in the general population that is missing
from DSM and other definitions, but also captures something of the quasi-obsessional
aspects of pica in individuals with ASD/ID.
Potential problems with the reliability and validity of different diagnostic criteria
for pica come from data published by Cooper et al. (2007). Although this study was
an epidemiological study rather than a formal study of the reliability of the diagnosis
of pica, some of their findings hint at this problem. In a large-scale study conducted in
Glasgow of 1023 individuals with ID aged over 16 years, they reported that the
prevalence of pica ranged from 0.0 to 2.0 % depending upon the diagnosis and
methods used. While these differences are small with respect to the absolute differences in magnitude, the relative differences are large. Given the difficulties in
establishing reliability of low-frequency diagnoses, these data suggest that this matter
should receive more attention in formal reliability and validity studies.

1.2.1

Pica Terms

Cooper (1957) listed a number of historical terms that have been used to refer to
pica. These include citta, malacia, mal d’estomache, erdessen, Cachexia Africana,
allotriophagia, and geophagy, and others have used terms such as parorexia
(Ruddock 1924). There are several terms that combine a prefix to indicate the type

of pica item consumed with the suffix -phagy. Thus, McAdam et al. (2012) divided
the physical classes of materials associated with pica into six classes. These were
(1) biologic secretions including copraphagia (feces), vomit (emetophagia), blood
(hematophagia), mucous (mucophagia), and urine (urophagia); (2) biologic solids
including dermatophagia (skin), fingernails (onychophagia), bone (osteophagia),
and hair (trichophagia); (3) chemicals including cuprophagia (copper), pharmacophagia (pharmaceuticals), and lead chips (plumbophagia); (4) food stuffs
including geomelophagia (potatoes), gooberphagia (peanuts), lectophagia (lettuce),
and oophagia (eggs); (5) organic materials including amylophagia (laundry starch),
bibliophagia (book pages), coniophagia (dust), foliophagia (acorns, grass, pine
cones, leaves), geophagia (dust, sand, clay), and pagophagia (ice, freezer frost); and


8

1 Definition and Diagnosis

(6) physically damaging materials including acuphagia (sharp items), cautopyreiophagia (matches), hyalophagia (glass), lignophagia (bark, twigs), tobaccophagia
(cigarette butts), and xylophagia (wood). Others have unnecessarily gilded the
dictionary with the terms sapophagia (soap; Saddichha et al. 2012) and, perhaps
facetiously, jumperphagia (Jumpers!; Nash et al. 2003).
The meaning and functional value of such distinctions—such as those between
eating leaves rather than twigs—are unclear and may represent little more than
pseudoacademic neologia nervosa or perhaps even logophagia! A more important
functional distinction might be between those forms of pica where some aspect of
texture and/or taste might be the important automatic reinforcer maintaining pica
behavior and those forms of pica where a substance, such as caffeine or nicotine,
might be the important consequence, as this distinction has important implications
for indicated and contraindicated behavioral treatments.

1.2.2

Differential Diagnosis

An accurate and swift diagnosis of pica is essential in order to avoid delay in
treatment. As some forms of pica are highly dangerous and indeed lethal, failure to
make accurate diagnoses and provide evidence-based treatment is unethical (see
Box 1.1). Failure to make an accurate diagnosis also places people who are
underdiagnosed at a higher risk of harm because they will receive no treatment plan
for pica, thereby unnecessarily exposing them to preventable risks, which is
incompatible with professionals’ ethical obligation of beneficence to their clients.
Thus, failure to diagnose pica or deliberate misdiagnosis (i.e., a false negative)
would be a serious oversight.
Box 1.1 Ethics and Accurate Diagnosis of Pica
“We do not have any cases of Pica here” stated the medical director and
nursing staff at a residential school and center for individuals with ASD
and/or ID. If the matter had been left there, nothing would have happened;
indeed, a review of the medical and nursing records would not have revealed
any diagnoses of pica.
A review of injury and incident data, restraint records, informal interviews
with staff of individuals who had been restrained extensively, however,
quickly revealed a number of individuals who had been restrained for months
or longer to prevent them engaging in pica. None had treatment plans to
address pica, even though some had choking incidents and other medical
complications from pica incidents.
When the interviewer confronted medical and nursing staff with these facts
they merely looked away. Later some explained quietly that if the diagnosis
of pica was “not on the books,” treatment was unnecessary.