The social and recreational characteristics of adults with intellectual disability and pica living in institutions

Behavioral assessment and treatment of pica: a brief report

Pica is a life-threatening behavior that is relatively common among individuals with intellectual and developmental disabilities. Pica can be conceptualized as a response chain in which the pica item acts as a discriminative stimulus for the next response (i.e. picking up the pica item), which itself acts as a discriminative stimulus for the final response (i.e. consumption). Interventions that disrupt this response chain and alter the discriminative properties of the pica stimulus may be clinically indicated. Preliminary research supports response-interruption and redirection (RIRD) with differential reinforcement of alternative behavior (DRA) as an effective intervention for pica. We evaluated this procedure in an inpatient unit with a young boy with who engaged in pica. Our outcomes provide additional support for DRA with RIRD as an effective pica treatment.

Prevalence and recurrence of pica behaviors in early childhood within the ALSPAC birth cohort

OBJECTIVE

The present study examined prevalence and correlates of pica behaviors during childhood using data from the Avon Longitudinal Study of Parents and Children (ALSPAC) study.

METHOD

Data on 10,109 caregivers from the ALSPAC study who reported pica behavior at 36, 54, 65, 77, and 115 months on their child were included. Autism was obtained through clinical and education records, while DD was derived from the Denver Developmental Screening Test.

RESULTS

A total of 312 parents (3.08%) reported pica behaviors in their child. Of these, 19.55% reported pica at least at two waves (n = 61). Pica was most common at 36 months (N = 226; 2.29%) and decreased as children aged. A significant association was found between pica and autism at all five waves (p < .001). There was a significant relationship between pica and DD, with individuals with DD more likely to experience pica than those without DD at 36 (p = .01), and 54 (p < .001), 65 (p = .04), 77 (p < .001), and 115 months (p = .006). Exploratory analyses examined pica behaviors with broader eating difficulties and child body mass index.

DISCUSSION

This study enhances understanding of childhood pica behaviors, addressing a significant gap in knowledge. Pica occurrence in the general population is poorly understood due to few epidemiological studies. Findings from the present study indicate pica is an uncommon behavior in childhood; however, children with DD or autism may benefit from pica screening and diagnosis between ages 36 and 115 months. Children who exhibit undereating, overeating, and food fussiness may also engage in pica behaviors.

Prevalence and Recurrence of Pica Behaviors in Early Childhood: Findings from the ALSPAC Birth Cohort

Objective

Pica has been largely understudied in general population samples. Pica occurs most often in childhood and appears more prevalent in individuals with autism and developmental delays (DD). Pica occurrence in the general population is poorly understood due to few epidemiological studies.

Method

Data on 10,109 caregivers from the Avon Longitudinal Study of Parents and Children (ALSPAC) study who reported pica behavior at 36, 54, 66, 77, and 115 months on their child were included. Autism was obtained through clinical and education records, while DD was derived from the Denver Developmental Screening Test.

Results

A total of 312 parents reported pica behaviors in their child. Of these, 19.55% reported pica at least at two waves (n=61). Pica was most common at 36 months (N=226; 2.29%) and decreased as children aged. A significant association was found between pica and autism at all five waves (p < .001). There was a significant relationship between pica and DD, with individuals with DD more likely to experience pica than those without DD at 36 (p = .01), and 54 (p < .001), 65 (p=.04), 77 (p <.001), and 115 months (p=.006). Exploratory analyses examined pica behaviors with broader eating difficulties and child body mass index.

Discussion

Pica is an uncommon behavior in childhood; however, children with DD or autism may benefit from pica screening and diagnosis between ages 36-115 months. Children who exhibit undereating, overeating, and food fussiness may also engage in pica behaviors.

Impact of creative workshops in an institutionalized patient with moderate/severe cognitive impairment with behavioral disorders: A case report

The Hospital Care Unit for individuals with intellectual disabilities and behavioral disorders provides comprehensive care in a controlled and video-surveyed facility that minimizes access to potentially manipulative materials during aggression or pica episodes. The patient was admitted to the unit due to issues including ingestion of non-edible fluids, aggression toward staff and other patients, and self-injury. All patients participated in occupational activities led by an occupational therapist from Monday to Friday from 10 a.m. to 11:30 a.m. In addition, creative workshops such as cinema forums and cooking workshops were held on some afternoons. During the analyzed period from January to June 2022, the patient experienced three episodes of pica, 14 assaults toward staff, and eight toward peers. All of these incidents occurred after dinner and were triggered either by the inability to eat dessert or by refusal to brush teeth afterward. In our case study, the implementation of creative workshops such as cooking had a positive effect on decreasing instances of pica and aggression. These workshops slightly improved participation in other occupational therapy activities and stabilized the patient's behavior, increasing the likelihood of her being able to return to her habitual residence.

The assessment and management of pica in people with intellectual disability

Pica is a condition associated with a number of physical and mental health diagnoses. The potentially fatal consequences of pica and the links with significant physical health problems are not always recognised. Pica is like other forms of behaviour that can challenge: clinicians must seek the underlying cause and treat this first, before primarily pursuing a behavioural form of treatment. In this article, we discuss the associations, consequences, assessment and management options available for pica to guide professionals. Pica often presents in a way individual to the particular patient, so tailoring of assessment and treatment is important.

Pica, Autism, and Other Disabilities

BACKGROUND AND OBJECTIVES

Pica, the repeated ingestion of nonfood items, can be life-threatening. Although case reports describe pica in children with autism spectrum disorder (ASD) or intellectual disability (ID), there has been little systematic study of pica prevalence. We assessed pica in children 30 to 68 months of age (median = 55.4 months) with and without ASD.

METHODS

Our sample from the Study to Explore Early Development, a multisite case-control study, included children with ASD (n = 1426), children with other developmental disabilities (DDs) (n = 1735), and general population-based controls (POPs) (n = 1578). We subdivided the ASD group according to whether children had ID and the DD group according to whether they had ID and/or some ASD characteristics. Standardized developmental assessments and/or questionnaires were used to define final study groups, subgroups, and pica. We examined pica prevalence in each group and compared ASD and DD groups and subgroups to the POP group using prevalence ratios adjusted for sociodemographic factors.

RESULTS

Compared with the prevalence of pica among POPs (3.5%), pica was higher in children with ASD (23.2%) and DD (8.4%), and in the following subgroups: ASD with ID (28.1%), ASD without ID (14.0%), DD with ID (9.7%), DD with ASD characteristics (12.0%), and DD with both ID and ASD characteristics (26.3%); however, pica prevalence was not elevated in children with DD with neither ID nor ASD characteristics (3.2%). Between-group differences remained after adjustment (adjusted prevalence ratio range 1.9-8.0, all P <.05).

CONCLUSIONS

Pica may be common in young children with ASD, ASD characteristics, and ID. These findings inform the specialized health care needs of these children.

The interRAI Suite of Mental Health Assessment Instruments: An Integrated System for the Continuum of Care

The lives of persons living with mental illness are affected by psychological, biological, social, economic, and environmental factors over the life course. It is therefore unlikely that simple preventive strategies, clinical treatments, therapeutic interventions, or policy options will succeed as singular solutions for the challenges of mental illness. Persons living with mental illness receive services and supports in multiple settings across the health care continuum that are often fragmented, uncoordinated, and inadequately responsive. Appropriate assessment is an important tool that health systems must deploy to respond to the strengths, preferences, and needs of persons with mental illness. However, standard approaches are often focused on measurement of psychiatric symptoms without taking a broader perspective to address issues like growth, development, and aging; physical health and disability; social relationships; economic resources; housing; substance use; involvement with criminal justice; stigma; and recovery. Using conglomerations of instruments to cover more domains is impractical, inconsistent, and incomplete while posing considerable assessment burden. interRAI mental health instruments were developed by a network of over 100 researchers, clinicians, and policy experts from over 35 nations. This includes assessment systems for adults in inpatient psychiatry, community mental health, emergency departments, mobile crisis teams, and long-term care settings, as well as a screening system for police officers. A similar set of instruments is available for child/youth mental health. The instruments form an integrated mental health information system because they share a common assessment language, conceptual basis, clinical emphasis, data collection approach, data elements, and care planning protocols. The key applications of these instruments include care planning, outcome measurement, quality improvement, and resource allocation. The composition of these instruments and psychometric properties are reviewed, and examples related to homeless are used to illustrate the various applications of these assessment systems.

Pica in persons with developmental disabilities: approaches to treatment

Pica is a very serious problem in which an individual ingests substances without nutrition value, such as paper and paint. As this behavior is often life-threatening resulting in surgery, pica has received attention from researchers for several decades. During that time, a number of interventions have been devised, such as behavioral methods (e.g., aversive stimuli, overcorrection, time-out, reinforcement) and biological interventions (e.g., pharmacotherapy, nutritional supplements). This paper is a broad review of the research on treatment studies for this problem, with a focus on persons with autism and/or intellectual disability (ID), which constitutes almost all of the published treatment papers. In addition, strengths and weaknesses of different pica treatments are discussed. Upon review, applied behavior analysis (ABA) was found to have the most robust empirical support to treat this behavior. Most clinicians are drifting away from aversive techniques and relying on more positive procedures to guide their treatment plans. The implications of current status and future directions for research are also addressed.

An examination of specific daily living skills deficits in adults with profound intellectual disabilities

While some researchers have investigated daily living skills deficits in individuals with intellectual disability (ID) as a whole, research on specific daily living skills in a profound ID population is limited. Two hundred and four adults with profound ID residing in two large developmental centers in the southeast portion of the United States were studied. Data were collected on these individuals' daily living skills, utilizing the Vineland Adaptive Behavior Scales (VABS). Three dependent t-tests were conducted comparing the proportion of items endorsed by informants on each of the three subdomains of daily living skills on the VABS (personal, domestic, and community). A significantly larger proportion of Personal Subdomain items were endorsed compared to Domestic or Community Subdomain items. Additionally, participants exhibited a significantly larger proportion of Domestic Skills Subdomain items compared to Community Skills Subdomain items which is consistent with theoretical models suggesting that institutional living may curb broader community skill sets. No gender differences were found in daily living skills. Lastly, individuals between the ages 30 and 39 exhibited significantly more Personal Subdomain skills than individuals who were 60 or older, while participants between the ages 30 and 39 exhibited significantly more Domestic Subdomain skills than individuals between the ages 60 and 69.

Identifying empirically supported treatments for pica in individuals with intellectual disabilities

The purpose of the current study was to critically examine the existing literature on the treatment of pica displayed by individuals with intellectual disabilities. Criteria for empirically supported treatments as described by Divisions 12 and 16 of APA, and adapted for studies employing single-case designs were used to review this body of literature. A total of 34 treatment studies were identified, 25 of which were well designed and reported at least an 80% reduction in pica (21 studies reported 90% or greater reduction in pica). Results indicated that behavioral treatments in general, and treatments involving the combination of reinforcement and response reduction procedures in particular, can be designated as well-established treatments for pica exhibited by individuals with intellectual disabilities.

The relationship between psychopathology symptom clusters and the presence of comorbid psychopathology in individuals with severe to profound intellectual disability

In the typically developing population, comorbid psychopathology refers to the co-occurrence of two different psychopathologies other than cognitive impairments. With respect to individuals with intellectual disability, comorbidity is often described as cognitive deficits and one additional psychopathology manifesting together. However, just as within the typically developing population, individuals with intellectual disability may also present with symptoms of two or more additional disorders. The presentation of these symptom clusters may similarly correlate. Therefore, the current study used the Diagnostic Assessment for the Severely Handicapped-II in order to examine relationships between psychopathological symptom clusters in adults with severe to profound intellectual disability. Additionally, we assessed comorbid presentation of disorders other than cognitive impairments in these same adults. Several symptom clusters were identified as being related with moderate to strong positive correlations. Furthermore, elevations on the Impulse subscale were noted to be the most prevalent in the current sample, with comorbid elevations most commonly occurring along the Mood, Mania, and Anxiety subscales. The significance of these findings is discussed.

Incidence and trends in psychopathology symptoms over time in adults with severe to profound intellectual disability

Individuals with intellectual disability (ID) have a high risk for developing comorbid psychopathology. While researchers have shown that symptoms of psychopathology remain relatively stable in children with ID over time, little research has been conducted to demonstrate symptom stability for adults with ID. Incidence of psychopathology symptoms was examined in 124 adults with severe to profound ID. Then, trends in symptoms of psychopathology over time were studied in 74 of those individuals who had data collected quarterly over the span of one year. Data from the Diagnostic Assessment for the Severely Handicapped-Second Edition (DASH-II) were evaluated for each of the 13 subscales, as well as the total DASH-II score. For all of the scales except PDD/Autism, symptoms did not fluctuate significantly over the one year period. The PDD/Autism scale revealed a significant change in symptoms from Time 1 to Time 3. The implications of these results are discussed.

Assessment of toileting difficulties in adults with intellectual disabilities: an examination using the profile of toileting issues (POTI)

A lack of toileting skills is one of many impairments that individuals with intellectual and developmental disabilities experience. Unfortunately, little research has focused on problems in this area including assessment, function, and treatment. A newly developed checklist, the Profile of Toileting Issues (POTI), is being considered for use to screen for toileting issues in this population, and to identify potential functions to target in treatment. The purpose of the current study was to examine the reliability of the POTI. Internal consistency was sound (α = .83) and interrater reliability was significant. The implications of these findings are included.

Social skills: differences among adults with intellectual disabilities, co-morbid autism spectrum disorders and epilepsy

Assessing social skills is one of the most complex and challenging areas to study because behavioral repertoires vary depending on an individual's culture and context. However, researchers have conclusively demonstrated that individuals with intellectual disabilities (ID) have impaired social skills as well as those with co-morbid autism spectrum disorders (ASD) and epilepsy. However, it is unknown how these groups differ. Assessment of social skills was made with the Matson Evaluation of Social Skills for Individuals with Severe Retardation. One hundred participants with ID were matched and compared across four equal groups comprising 25 participants with ID, 25 participants with epilepsy, 25 participants with ASD, and 25 participants with combined ASD and epilepsy. When controlling for age, gender, race, level of ID, and hearing and visual impairments, significant differences were found among the four groups on the MESSIER, Wilks's Λ=.58, F(18, 257)=3.05, p<.01. The multivariate η(2) based on Wilks's Λ was .17. Significant differences were found on the Positive Verbal subscale, F(3, 96)=3.70, p<.01, η(2)=.10, Positive Non-verbal subscale, F(3, 96)=8.95, p<.01, η(2)=.22, General Positive subscale, F(3, 96)=7.30, p<.01, η(2)=.19, Negative Non-verbal subscale, F(3, 96)=5.30, p<.01, η(2)=.14, and General Negative subscale, F(3, 96)=3.16, p<.05, η(2)=.09. Based on these results, individuals with ID expressing combined co-morbid ASD and epilepsy had significantly more impaired social skills than the ID only or groups containing only a single co-morbid factor with ID (ASD or epilepsy only). Implications of these findings are discussed.