Assessment, behavioral treatment, and prevention of pica: clinical guidelines and recommendations for practitioners

Off-Label Use of Naltrexone in Pica and Other Compulsive Behaviors: A Report of Two Cases

Pica is known to the medical community as an eating disorder in which individuals may ingest non-food items due to a nutritional deficiency and cause unintentional physical harm to themselves. This article discusses the cases of children with pica in addition to other comorbidities such as trichotillomania, depression, autism, and anxiety. Both patients were trialed on typical first-line treatments to address pica symptoms, including antidepressants, psychotherapy, and neurology consults, which were ineffective in treating pica symptoms. The introduction of naltrexone resulted in significant improvements, including decreased pica symptoms and improvements in depression, anxiety, and overall behaviors. These effects of naltrexone were further bolstered by the effects that occurred when both patients discontinued naltrexone for some time.

Relationship of self-reported pica and avoidant restrictive food intake disorder symptomology with dimensions of impulsivity, perceived stress among Pakistani University students

INTRODUCTION

Pica and avoidant/restrictive food intake disorder are two of the three new eating and feeding disorders introduced in the DSM-5, this inclusion has drawn attention to the immediate need for research into their prevalence, diagnostic assessment, underlying risk factors and optimal treatment. There are very few studies available that explored the predictors or causes of these eating disorders specifically in Pakistani context.

OBJECTIVES

The objectives of the current study include (a) to estimate the presence of pica and avoidant/restrictive food intake disorder symptomology among young adults in Pakistan, (b) to examine the relationship between dimensions of impulsivity, stress and presence of pica and avoidant/restrictive food intake disorder, (c) to explore the mediation role of stress.

METHODS

The sample consisted of 660 young adults with age range 18-25 years, recruited through convenient sampling. The respondents were provided with a questionnaire comprising of an informed consent, a demographic information sheet and self-report measures including PARDI-AR-Q to assess symptomology of pica and avoidant/restrictive food intake disorder, UPPS-P Impulsive Behaviour Scale to assess dimensions of impulsivity and Perceived Stress Scale to measure perceived stress.

RESULTS

The findings show that 28 participants (4.2%) reported Pica symptomology, of which eleven participants indicated that they currently consume more than one non-food item. 19 respondents (2.8%) reported avoidant/restrictive food intake disorder symptomology. 13 respondents reported varying degrees of all three symptom clusters namely sensory based food avoidance, lack of interest in food, and fear of negative consequences of eating. Additionally, each of the dimensions of impulsivity was found to be positively correlated to the presence of pica and avoidant/restrictive food intake disorder. Perceived stress was identified as a mediating factor between each of the dimensions of impulsivity and presence of pica and avoidant/restrictive food intake disorder.

CONCLUSION

Although current study focused on a particular age range, it has drawn attention to the necessity of screening and investigating other strata of Pakistani population for pica and avoidant/restrictive food intake disorder. The clinical utility of the present research resided in the identification of factors associated with pica and avoidant/restrictive food intake disorder, an information which can be used to tailor psychological interventions, modify existing ones, and inform the future research on evidence-based treatment.

Parent Use of a Safety Checklist to Prevent Their Child's Pica

Parents of three children with neurodevelopmental disorders and pica were taught to use a safety checklist to create pica-safe areas when transitioning to new locations. During baseline, no parent displayed pica-safe behavior, and their children attempted pica at moderate to high rates. After use of the checklist, parent pica-safe behavior increased, and instances of pica diminished to near zero. Results transferred to new contexts and additional substances associated with pica. Using the safety checklist appears to have aided parents in creating pica-safe environments to minimize pica.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40617-023-00798-w.

A rare case report of teen-onset pica in a female patient with a clinical high risk for psychosis

AIM

We aimed to further elucidate the under-researched, underdiagnosed and misunderstood comorbid pica in the context of psychosis.

METHOD

We report a case of teen-onset plastophagia in an antipsychotic-naïve girl at ultra-high risk (UHR) for psychosis.

RESULTS

HA is a 17-year-old unmarried girl who had a history of good premorbid functioning, no personal psychiatric history and an uncle with schizophrenia. She was referred to our psychiatry department with the complaint of having the habit of eating plastic for about 2 years. A thorough clinical history revealed that she developed, since more than a year, difficulty in school and interpersonal functioning. After clinical evaluation, a diagnosis of UHR with major depressive disorder, iron deficiency anaemia and pica was made.

CONCLUSION

We draw attention to the possibility of an overlap between the pathogenesis of pica and psychosis, and we highlight the importance of early diagnosis and management of both pica and UHR since they can lead to serious medical and mental consequences.

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.

A Novel Type of Aspiration Presenting With Acute Respiratory Failure Caused by Upper Airway Obstruction Due to Diaper Pica

We herein report an extremely rare case of acute respiratory failure due to pica of the high-molecular-weight polymers in a diaper (HMWPD).

An 81-year-old woman was admitted to our hospital because of dyspnea. Several hours earlier, the facility staff saw her tearing the diaper and eating it. And several hours later, the staff found her complaining of dyspnea. Her chest computed tomography revealed airway foreign bodies. Immediately, flexible bronchoscopy was performed. The trachea and the bilateral bronchi were filled with the HMWPD. We tried to grasp the HMWPD with various common instruments, but the HMWPD could not be grasped. Finally, we performed direct bronchoscopic suction. All the HMWPD were removed successfully. The HMWPD have hygroscopic property resulting in volume expansion and the fatal consequence of upper airway obstruction.

Physicians working in an emergency department should be aware of this acute respiratory failure due to diaper pica and its effective treatment.

Foam Rubber Pica and Cautopyreiophagia in a Highly Educated Woman: A Clinical Case Study

Pica, the developmentally and culturally-inappropriate eating of non-nutritive and non-food substances, is most often documented in people with developmental disabilities and children, frequently in institutional and residential settings. To date, there are no randomized clinical trials on pica-specific treatments, and very little literature is available regarding the characteristics or treatment of pica in adults with no intellectual or social deficits, and co-morbid disorders. This case study addresses this gap, and involves a highly educated 30 year-old American woman with foam rubber pica and burned match consumption (cautopyreiophagia) behaviors, along with co-morbid depressive, anxiety, and obsessive-compulsive symptoms, who received treatment in a general intensive outpatient program for adults in a large urban community psychiatry setting. The case study describes how the Biosocial Theory and Transtheoretical Model of Health Behavior Change were used to conceptualize this woman’s symptoms and guide a treatment team of clinicians who did not specialize in pica. Providers in non-specialty clinic settings would benefit from reflecting on ways to adapt evidence-based techniques to the treatment of uncommon symptoms.

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.

Association between pica and gastrointestinal symptoms in preschoolers with and without autism spectrum disorder: Study to Explore Early Development

BACKGROUND

Pica, the repeated ingestion of nonfood items, can result in gastrointestinal (GI) outcomes. Children with autism spectrum disorder (ASD) and other developmental disabilities (DDs) are disproportionately affected by both pica and GI symptoms. Study of the inter-relationship between pica, GI symptoms, and ASD/DD is limited.

OBJECTIVE/HYPOTHESIS

We assessed associations between pica and GI symptoms in preschool-aged children with and without ASD and other (non-ASD) DDs in the Study to Explore Early Development.

METHODS

Our sample included children with ASD (n = 1244), other DDs (n = 1593), and population (POP) controls (n = 1487). Data to define final case-control status, pica, and GI symptoms were from standardized developmental assessments/questionnaires. Prevalence ratios, adjusted for sociodemographic factors (aPRs), and 95% confidence intervals were derived from modified Poisson regression.

RESULTS

Within each group (ASD, DD, POP) and for the total sample, pica was associated with vomiting (aPR for total sample 2.6 [1.7, 4.0]), diarrhea (1.8 [1.4, 2.2]), and loose stools (1.8 [1.4, 2.2]). In the DD group, pica was associated with constipation (1.4 [1.03, 1.9]) and pain on stooling (1.8 [1.2, 2.6]). In analyses of the subgroup without pica, increases in GI symptoms were still evident in the ASD and DD groups compared to POP group.

CONCLUSION

These findings highlight an important adverse effect of pica, GI symptoms, in children with and without ASD and DDs; nonetheless, pica does not fully explain the increased risk for GI symptoms among children with ASD and DDs. These findings inform the specialized healthcare needs of children with ASD and other DDs.

A systematic review of the effectiveness of behavioural treatments for pica in youths

Pica is the persistent consumption of non-nutritive, nonfood substances and is associated with adverse health complications. However, there is limited research on interventions for pica in youth. The objective of this study is to systematically review the empirical evidence for the effectiveness of behavioural interventions for pica in children and adolescents and to generate treatment recommendations. A systematic search yielded 823 articles extracted from five databases: CINALH, Family and Society Studies Worldwide, Medline, PsycINFO, and Web of Science. Two reviewers completed initial sorting based on article titles and abstracts. Five reviewers completed sorting based on full article review. Thirty articles were included and double coded for demographic information, co-morbid conditions, and intervention characteristics. These studies were case studies involving behavioural treatments for pica. Seventeen behavioural interventions were categorized into four treatment approaches: reinforcement-based, response interruption, "other" interventions, and punishment-based procedures. Interventions that resulted in near-zero rates of pica were deemed effective. Findings showed support for contingent reinforcement, discrimination training as part of a combination treatment, physical restraint, time out, and contingent aversive stimulus. No evidence supported the effectiveness of response interruption procedures, including response blocking and visual facial screen. Other coded procedures did not appear effective. We recommend that the least restrictive procedures are implemented first, including a combination treatment with contingent reinforcement and discrimination training. As needed, more restrictive procedures can be added to the treatment package. This review will facilitate future empirical work and assist clinicians with treatment options for pica in youth. High-quality trials are needed.

Pica Disorder among African American Women: A Call for Action and Further Research

Pica is simply defined as the consumption of none food products such as laundry starch, clay dirt, ice, soap, and chalk. The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) classifies Pica as the habitual consumption of nonfood and non-nutritive substances for at least one year. Pica disorder is usually unnoticed, under-reported, causes serious harm to clients especially African American women, and seldom discussed in social work scholarship. It is, therefore, important to begin to sensitize social workers to the harmful effects of Pica, especially because it is often unrecognized and misdiagnoses can cause harm. This article provides a panoramic overview of Pica, the signs and symptoms of the disorder specifically among African American women and also address some of the adverse effects, and highlights some of the evidence-based effective treatment strategies. Finally, an urgent clarion call to social workers to conduct more research on Pica disorders among African American women is articulated.

The Social and Material Life of Antimicrobial Clay: Exploring Antimicrobial Resistance, Medicines' Materiality, and Medicines Optimization

While sociologists have made significant theoretical contributions to the antimicrobial resistance (AMR) debate, little attention has been given to the antimicrobial products themselves. Here we advocate a significant new direction which centers on the social and material life of antimicrobials, specifically on what they are made from and how this affects their use. This focus is timely because, in the context of declining efficacy of biomedical antibiotics, diverse materials are increasingly taking center stage in research and drug discovery as potential agents for new antimicrobial treatments. Of particular significance are natural antimicrobials, such as plants, honey and clay, whose antimicrobial potential is well-documented and which are increasingly moving into mainstream antimicrobial research. Alongside this biomedical focus, we suggest that the social and material lives of these antimicrobial materials require attention to (i) highlight the ways they have been, and continue to be, used in diverse cultures globally, (ii) explore ways we might theorize these materials within wider AMR debates, and (iii) examine the impact of antimicrobials' materiality on their use by patients. This article takes the example of clay, whose antimicrobial properties are well-established and which has been used to treat wounds and gastrointestinal problems for millennia. We first locate clay as an exemplar of a wider shift toward natural products drug discovery in pharmaceutical science and antimicrobial research. We then offer a number of theoretical "ways in" for sociologists to begin making sense of clay as it comes under the western biomedical gaze. We map these conceptual lenses on to clay's physical and symbolic mobility from its use in the global south into western biomedical research and commercialization. We particularly concentrate on post-colonial theory as a means to understand clay's movement from global south to north; laboratory studies to examine its symbolic transformation to a black-boxed antimicrobial artifact; and valuation practices as a lens to capture its movement from the margins to the mainstream. We finish by reflecting on the importance of materiality in addressing optimal use of medicines and by advocating an interdisciplinary approach to AMR which positions sociology as a key contributor to AMR solutions.

Functional Analysis and Treatment of Pica on a Preschool Playground

Appropriate use of function-based assessments and interventions is crucial for improving educational outcomes and ensuring the well-being of children who engage in dangerous problem behaviors such as pica. A function-based assessment was conducted for a child engaging in pica in an inclusive childcare setting. Results suggest pica was maintained by access to adult attention. Function-based interventions were developed, assessed, and shared with the child's teaching team. Follow-up data suggest that his teachers continued to use the intervention and that levels of pica remained low.

Role of priority effects in the early-life assembly of the gut microbiota

Understanding how microbial communities develop is essential for predicting and directing their future states. Ecological theory suggests that community development is often influenced by priority effects, in which the order and timing of species arrival determine how species affect one another. Priority effects can have long-lasting consequences, particularly if species arrival history varies during the early stage of community development, but their importance to the human gut microbiota and host health remains largely unknown. Here, we explore how priority effects might influence microbial communities in the gastrointestinal tract during early childhood and how the strength of priority effects can be estimated from the composition of the microbial species pool. We also discuss factors that alter microbial transmission, such as delivery mode, diet and parenting behaviours such as breastfeeding, which can influence the likelihood of priority effects. An improved knowledge of priority effects has the potential to inform microorganism-based therapies, such as prebiotics and probiotics, which are aimed at guiding the microbiota towards a healthy state.

Fifteen-minute consultation: the child with pica

Pica is defined as the persistent ingestion of non-nutritive substances for more than 1 month at an age at which this behaviour is deemed inappropriate. It occurs most commonly in children, in patients with learning disabilities and in pregnancy. The aetiology of pica is poorly understood and is probably multifactorial. Clinical assessment can be difficult. History and examination should be tailored to address potential complications of the substance being ingested. Complications can be life threatening. Pica often self-remits in younger children. In those with learning disabilities, however, pica may persist into adulthood. Management strategies should involve a multidisciplinary approach, and interventions are primarily behavioural in nature. There is limited evidence to support pharmacological interventions in the management of children with pica.

Pediatric feeding and eating disorders: current state of diagnosis and treatment

The Diagnostic and Statistical Manual of Mental Disorders now recognizes six primary feeding and eating disorders including pica, rumination disorder, avoidant/restrictive food intake disorder, anorexia nervosa, bulimia nervosa and binge-eating disorder. Guided by research from the past 3 years, the current review outlines diagnostic criteria for each disorder, their clinical correlates and treatment options. Recent modifications to diagnostic criteria will likely help to improve treatment outcomes and prognosis. Nevertheless, several concerns remain regarding the validity of current diagnostic criteria for youth, including the clinical relevance of the size and frequency of binge eating episodes. Additionally, the lack of randomized controlled trials has led to an overreliance on data from quasi-experimental studies, case series and single case studies that impede development of strong clinical recommendations for treating feeding and eating disorders. Recommendations for future research include identifying empirically supported treatments and prevention programs focused on early markers of pediatric feeding and eating concerns.

Pagophagia - a common but rarely reported form of pica

Pagophagia is a particular form of pica characterized by ingestion of ice, freezer frost or iced drinks often associated with iron or calcium deficiency. It occurs due to a complex interplay in between behavioural components. Only few cases of pagophagia have been reported from India.We report a case, a married lady, who presented with pagophagia and responded to fluoxetine.

RETRACTED: A comparison of tantrum behavior profiles in children with ASD, ADHD and comorbid ASD and ADHD

This article has been retracted: please see Elsevier Policy on Article Withdrawal (http://www.elsevier.com/locate/withdrawalpolicy). This article has been retracted at the request of the Editor in Chief, after review by an independent panel of experts, due to evidence of a compromised peer review process and the failure of one author to disclose significant conflicts of interest. An independent peer-review process is a cornerstone of scientific integrity that allows for research to be scrutinized before publication to ensure that conclusions are anchored in sound methodology and objective interpretation of the results. Equally important is that the readership of research is fully informed about any potential competing interests that may have influenced the research process. This article is being retracted because it did not include a declaration of a conflict of interest of one author in relation to diagnostic tools which the paper endorses. The same author was also the Editor in Chief of the journal at the time of publication and evidence indicates that the paper was accepted without any independent peer review by external reviewers. The article is therefore retracted in accordance with the ethical guidelines of Elsevier: https://www.elsevier.com/about/policies/publishing-ethics and the Committee on Publication Ethics (COPE) https://publicationethics.org/files/retraction-guidelines.pdf.

Cardiopulmonary complications in a patient with bezoar

We report a case of a 17-year-old institutionalised male with a medical history of fragile X syndrome, bilateral congenital glaucoma, cataracts and pica disorder. He was transferred to our paediatric intensive care unit owing to respiratory failure and hypotension. On transoesophageal echocardiogram, he presented left atrium compression. A CT of the thorax and mediastinum revealed an unknown heterogeneous material in the lumen of the stomach and oesophagus, with a lung parenchyma suggestive of alveolar foreign material. Endoscopic evaluation showed diaper fragments inside the oesophagus and stomach. Fragmentation and suction of diaper material was made. Medical treatment was performed with inotropic support, conventional mechanical ventilation and antibiotics.