Behavioral Interventions to Reduce the Pica of Persons with Developmental Disabilities

The Neurology and Psychopathology of Pica

PURPOSE OF REVIEW

Pica is defined by the American Psychiatric Association's Diagnostic and Statistical Manual, 5th edition (DSM 5) as the ongoing ingestion of materials with no nutritive or food value. More specifically such ingestions must be unremitting for at least 1 month and occur at a developmentally inconsistent age for such behavior. This article reviews the association of pica with pregnancy, micronutrient deficiencies, psychiatric disorders, dementia, and developmental disorders with emphasis on autism spectrum disorders (ASD).

RECENT FINDINGS

Some variants of non-nutritive consumption are prevalent behavioral norms in non-western cultures, so not all picas should be considered pathological. However, the strong association of pica with iron deficiency anemia (IDA) lends credence to the hypothesis that dopamine transmission may be disrupted in this disorder. Picas associated with ASD are resistant to medications but can be treated with applied behavioral analysis therapy (ABA). Etiological hypotheses for pica are explored with a focus on neurobiological, neuroimaging, and psychiatric correlations. Pharmacological management and behavior modification strategies are also discussed. The possibility that pica is a form of addiction analogous to food cravings is introduced and suggested as an area for further research pursuits.

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.

Unusual presentation of pica in iron-deficiency anaemia associated with primary biliary cholangitis

A 50-year-old woman presented with worsening fatigue and shortness of breath. For 2 months, she has been having increased craving for unpeeled lemons and was seen in clinic about a month prior to presentation at the emergency room. At that time, she was asymptomatic except for endorsing craving for lemons. Physical exam findings at presentation noted obesity, sinus tachycardia, pallor, mild scleral jaundice and no other stigmata for chronic liver disease. Her labs suggested iron-deficiency anaemia (IDA), elevated liver enzymes and positive antimitochondrial antibody titre. Abdominal ultrasound and CT scan showed mild scarring. She was diagnosed with primary biliary cholangitis with portal hypertension complicated by oesophageal varices and IDA. Interventions included blood transfusion, oesophageal banding and treatment with ursodeoxycholic acid. Her craving for lemons, shortness of breath and fatigue resolved within 1 week. With ongoing outpatient follow-up and oesophageal variceal surveillance, she continues to do well.

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.

Decreasing Food Stealing of Child with Prader-Willi Syndrome Through Function-Based Differential Reinforcement

Challenging behaviors involving food are common for individuals with Prader-Willi syndrome (PWS) and often lead to obesity and other chronic health conditions. Efforts to decrease these behaviors, such as isolation during meals and strict monitoring of food consumption, can be stigmatizing. To decrease the food stealing of a 7 year-old girl with PWS, therapists conducted a latency-based functional analysis in a clinic setting before implementing a function-based intervention to facilitate her inclusion at the family dinner table. Intervention components entailed differential reinforcement procedures which incorporated a token board and schedule thinning. The intervention successfully generalized to the home setting and across food preferences and implementers.

A systematic review and evaluation of response redirection as a treatment for challenging behavior in individuals with developmental disabilities

Response redirection is widely used in clinical practice as a treatment for repetitive behavior or stereotypy in persons with developmental disabilities. However, to date the procedure has received comparatively little empirical evaluation. The current review sought to examine the literature describing the efficacy of response redirection alone, response interruption and redirection (RIRD), and multi-element treatment packages incorporating response redirection, as interventions for challenging behavior in individuals with developmental disabilities. Additionally, the status of response redirection, and RIRD, as evidence-based practice was evaluated in accordance with Reichow's (2011) recently developed criteria. Results indicated that interventions involving response redirection or RIRD typically led to large decreases in challenging behavior but did not result in behavioral suppression. On the basis of the current literature and in accordance with Reichow's criteria, interventions incorporating response redirection do not yet constitute evidence-based practice. The implications of these findings, for both research and practice, are discussed.

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.

Eosinophilic meningitis caused by Angiostrongylus cantonensis in an adolescent with mental retardation and pica disorder

Eosinophilic meningitis or encephalitis is a rare disorder and is most commonly caused by Angiostrongylus cantonensis. Humans are accidentally infected when they ingest raw snails or vegetables contaminated with the parasite larvae. Because of the improvement in sanitary food handling practices, the occurrence of A. cantonensis eosinophilic meningitis has been decreasing in Taiwan in recent decades. The common symptoms and signs of eosinophilic meningitis are severe headache, neck stiffness, paresthesia, vomiting, nausea, and fever. Acute urinary retention is a rare presentation. We report a case of A. cantonensis eosinophilic meningitis in an intellectually disabled patient who presented with acute urinary retention without any other meningeal signs. The patient received supportive treatment with corticosteroid therapy and was discharged and received urinary rehabilitation at home.

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

Pica is a dangerous form of self-injurious behavior that occurs in people with developmental disabilities who are institutionalized. Studies also indicate that pica has led to the death of people with developmental disabilities. While a number of published studies have demonstrated that pica behavior can be decreased substantially with behavioral treatment, few of these studies incorporated strategies for generalization and maintenance outside of brief sessions. A second limitation of current research is that some studies reduced pica substantially, but pica responses still occurred at rates that are problematic in terms of prevention of adverse consequences, which leaves practitioners with the task of further decreasing pica to protect people exhibiting pica from harm. We make recommendations for assessment, treatment, and prevention of pica for practitioners. These recommendations are based on two extensive reviews of the literature and our extensive experience as practitioners in the treatment of pica. Our hope is that administrators, professionals and practitioners will consider our guidelines and recommendations as they attempt to protect people with pica and developmental disabilities from harm by developing standards for assessment, treatment and prevention for this difficult-to-treat population. Our hope is that children with pica will receive early intervention to prevent pica from developing into life-threatening behavior.

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.

Use of differential reinforcement to reduce behavior problems in adults with intellectual disabilities: a methodological review

The least-restrictive-alternative guideline for providing treatment emphasizes the use of non-aversive procedures to reduce maladaptive behaviors in individuals with intellectual disability (ID). Differential reinforcement (DR) is an excellent example of such a non-aversive, reinforcement based behavioral intervention. The purpose of this literature review was to summarize and provide a methodological analysis of studies, conducted between 1980 and 2009, using a DR contingency to reduce problem behaviors in adults with ID. A total of 31 studies were located that met the inclusion criteria. Of these, 15 reported DR to be an effective intervention when used independently. Of the remaining, 10 studies found DR to be useful as part of a treatment package, and six found a DR contingency used independently to be ineffective, and only observed treatment effects when an aversive component was added. Very few studies assessed the use of DR in older adults and in individuals with mild ID; these reflect areas of future research. A methodological analysis found that several studies did not report information on key methodological variables; for example, conducting a functional analysis and a stimulus preference assessment to guide choice of treatment and reinforcers, thinning very dense DR schedules, assessing collateral behaviors, generalization of behavior change across settings and implementers, and following up treatment outcomes over time. The overall positive findings about the effectiveness of DR are encouraging; however, more methodologically robust studies would serve to make such findings more conclusive and practically relevant for implementation in natural settings for adults with ID.

The diagnosis of eating disorders in adults with learning disabilities: Conceptualisation and implications for clinical practice

OBJECTIVE

The literature suggests that less attention has been afforded to eating disorders (EDs) in adults with learning disabilities (LDs) than in adults of normal intellect. This review aimed to examine the methods, prevalence and implications of an ED diagnosis in adults with LDs.

METHOD

Key texts, journals and online databases were searched for literature examining disordered eating in adults with LDs.

RESULTS

A review of the extant literature revealed that a range of dysfunctional eating behaviours have been classified as 'eating disorders' and highlighted a lack of clarity about the distinction between feeding and EDs. A small body of research suggests that some individuals with LDs show the emotional and cognitive characteristics of typical EDs.

DISCUSSION

The lack of consensus about conceptualisation, assessment, diagnosis and treatment of EDs in individuals with LDs needs to be addressed in order to aid awareness and enhance clinical approaches for this population.

Behaviour guidance in dental treatment of patients with autism spectrum disorder

BACKGROUND

Autism spectrum disorder (ASD) is a neurodevelopmental disorder categorized into autism, pervasive developmental disorder - not otherwise specified (PDD-NOS) and Asperger syndrome.

AIMS

To identify factors associated with the behaviour of patients with ASD in a dental setting, use of general anaesthesia (GA), and protective stabilization.

DESIGN

The dental charts of 395 patients with ASD patients and 386 unaffected patients were reviewed. The following data were analysed: ASD diagnosis, age, gender, residence, seizure disorder, additional diagnosis (mental retardation, cerebral palsy, self-injurious behaviour or pica), medications, caries prevalence and severity, dental treatment history, behaviour, and behaviour guidance technique(s) used.

RESULTS

Within both groups, younger patients were more uncooperative. ASD patients with autism were more uncooperative than patients with PDD-NOS; patients with an additional diagnosis were also more uncooperative. ASD patients with higher caries severity, who were uncooperative or female, were more likely to require GA. Use of protective stabilization was associated with lower caries severity, presence of seizure disorder, uncooperative behaviour, male gender, or residency in a group home/institution.

CONCLUSIONS

Autism spectrum disorder patients with autism, younger age and an additional diagnosis were more uncooperative. Factors associated with the use of GA and protective stabilization in patients with ASD were also identified.

The Girl Who Ate Her House—Pica as an Obsessive-Compulsive Disorder

This report concerns the interesting clinical phenomenology of a 17-year-old Ethiopian female student with a long-standing history of ingesting nonnutritive materials. She was initially non-selective, but later began more exclusively consuming mud obtained from a wall in front of her house. She suffered from a feeding and eating disorder known as pica. Currently, there is no clearly established etiology for pica. This patient's particular psychopathology—recurrent, unwanted, intrusive images and thoughts of the mud wall and of eating the mud; feelings of distress and anxiousness that were not relieved unless she consumed mud; and significant effects on her daily life from her uncontrollable need to return home to eat mud from her wall—suggests an ego-dystonic, obsessive thought-distress-consumption-relief pattern that is consistent with obsessive-compulsive disorder. This case may contribute to the etiological understanding that some forms of pica may be part of the obsessive-compulsive spectrum disorders.

Evidence-based practices in intellectual disability and behaviour disorders

PURPOSE OF REVIEW

To critically review the most recently published studies on the treatment of challenging behaviours/behaviour disorders for individuals with intellectual disability.

RECENT FINDINGS

Literature published in the review period was from three traditions: applied behaviour analysis, psychopharmacology, and service evaluation. Applied behaviour analysis treatments have a large evidence base, and recent research has focused on refining issues such as dealing with low rate behaviours, improving generalization, the effects of choice-making, and setting event variables that may affect treatment outcomes. Recent interest in risperidone as a treatment for behaviour disorder has dominated the literature on pharmacological interventions. Several empirical studies support the use of risperidone in children, although a recent review is more sceptical of the quality of the evidence to date. A small number of service evaluation studies suggest in particular that applied behaviour analysis technologies can be scaled up to benefit large numbers of patients.

SUMMARY

Applied behaviour analysis methods for the assessment and treatment of behaviour disorders continue to be the focus of research, and continue to result in positive outcomes. Recent data show the value of using applied behaviour analysis technologies as a service model for people with behaviour disorders. Pharmacological treatments, especially risperidone, also have a developing evidence base despite a lack of understanding of their mechanisms of action. A number of questions about behaviour disorders remain unanswered, especially whether early intervention may be effective and their putative relationship with psychiatric conditions.