Treatment of pica through multiple analyses of its reinforcing functions

Examining Procedural Variations of Delivering Competing Stimuli in the Treatment of Stereotypy

Competing stimulus assessments (CSA) are effective tools for identifying stimuli that compete with automatically reinforced behavior. However, Jennett et al. suggests there are cases for which non-contingent access to competing stimuli are insufficient at decreasing target responding and additional treatment components may be necessary. The purpose of the current study was to examine procedural variations (i.e., rotating competing items and prompted engagement) when presenting competing stimuli on increasing functional engagement and decreasing stereotypy. Following a functional analysis, a CSA was conducted to identify competing stimuli for four individuals with autism. Items identified were then used with two procedural variations. Levels of stereotypy, functional engagement, and item contact were measured. Results showed that for two participants both treatments were effective, while for the other two participants prompting functional engagement was more effective. Prompting functional engagement is likely a productive strategy for enhancing engagement with competing stimuli for automatically reinforced problem behavior as it may result in functional engagement becoming reinforcing in and of itself.

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 replication and extension of the augmented competing stimulus assessment

Augmenting competing stimulus assessments by embedding tactics to increase stimulus engagement and disrupt challenging behavior can improve outcomes of treatments for automatically maintained self-injurious behavior, even for treatment-resistant subtypes. This study replicated and extended research on augmented competing stimulus assessments by reporting outcomes for 16 consecutively encountered cases with automatically maintained self-injurious behavior (19 total applications); six participants had treatment-responsive Subtype 1 and 10 had treatment-resistant Subtypes 2 or 3. Fewer high-competition stimuli were identified for individuals with treatment-resistant subtypes. When response-promotion and disruption tactics were applied and withdrawn, outcomes improved for six of eight applications. At least one high-competition stimulus was still effective when maintenance probes were conducted for a subset of participants. Ultimately, at least one high-competition stimulus was identified for each participant. Although augmenting tactics may not be necessary for all individuals, these findings provide additional support for their efficacy with treatment-resistant self-injurious behavior.

A Competing Stimuli Intervention Package to Treat Automatically Reinforced Destructive Behavior

Behaviors maintained by automatic reinforcement are often more difficult to treat due to difficulty with identifying the relevant maintaining variable(s). One common intervention to treat automatically maintained behavior includes competing stimuli. Competing stimuli promote item engagement which may replace challenging behavior (i.e., response competition). Competing stimuli have shown to be a widely successful intervention across diverse topographies of challenging behavior; however, few studies have evaluated the use of competing stimuli on destructive behavior. The purpose of the current study was to treat automatically maintained destructive behavior with a competing stimuli intervention package for an adolescent with developmental disabilities. Results showed a decrease in destructive behavior when access to competing stimuli was a component of an intervention package in a clinic setting. Also, preliminary data are provided showing treatment effects when caregivers implemented the intervention. Due to the complexity of the final intervention package, recommendations for clinicians are provided which focus on improving feasibility, practicality, and sustainability of treatment components.

Nonhuman primate abnormal behavior: Etiology, assessment, and treatment

Across captive settings, nonhuman primates may develop an array of abnormal behaviors including stereotypic and self-injurious behavior. Abnormal behavior can indicate a state of poor welfare, since it is often associated with a suboptimal environment. However, this may not always be the case as some behaviors can develop independently of any psychological distress, be triggered in environments known to promote welfare, and be part of an animal's coping mechanism. Furthermore, not all animals develop abnormal behavior, which has led researchers to assess risk factors that differentiate individuals in the display of these behaviors. Intrinsic risk factors that have been identified include the animal's species and genetics, age, sex, temperament, and clinical condition, while environmental risk factors include variables such as the animal's rearing, housing condition, husbandry procedures, and research experiences. To identify specific triggers and at-risk animals, the expression of abnormal behavior in captive nonhuman primates should be routinely addressed in a consistent manner by appropriately trained staff. Which behaviors to assess, what assessment methods to use, which primates to monitor, and the aims of data collection should all be identified before proceeding to an intervention and/or treatment. This article provides guidance for this process, by presenting an overview of known triggers and risk factors that should be considered, steps to design a comprehensive evaluation plan, and strategies that might be used for prevention or treatment. It also outlines the tools and processes for assessing and evaluating behavior in an appendix. This process will lead to a better understanding of abnormal behavior in captive primate colonies and ultimately to improved welfare.

Pica in Pediatric Sickle Cell Disease

Pica is the developmentally inappropriate consumption of non-nutritive items for at least one month. Pica can lead to many adverse outcomes, but the exact pathophysiology of pica is unknown or variable across populations. Several studies have evidenced that there is a high prevalence of pica among youth with sickle cell disease (SCD). However, the lack of knowledge regarding the correlates of pica contributes to overlooking the condition, inaccurate diagnoses, and a lack of evidence-based treatments once pica is identified. This review examines the literature to develop a biopsychosocial model of pica in SCD. Elucidating the potential relationships among the proposed biological, psychological, and social factors, and pica will inform our understanding of this phenomenon in pediatric SCD and may guide future research and clinical recommendations.

Mask Compliance Training for Individuals With Intellectual and Developmental Disabilities

Since the arrival of the novel coronavirus, recommendations for public masking have emerged to decrease infection rates. For a variety of reasons, tolerating wearing a mask is challenging for many individuals with intellectual and developmental disabilities (IDDs). Therefore, we evaluated behavioral strategies to promote compliance with wearing a mask with six hospitalized individuals diagnosed with IDDs. One participant was compliant with wearing the mask for extended durations during baseline while engaging in various activities (e.g., academics, leisure). For the other five individuals, engagement in activities alone was ineffective. Blocking mask removal, reinforcement for mask wearing, and noncontingent access to preferred activities or competing stimuli were then evaluated using a changing-criterion design in which the duration participants were required to tolerate the mask gradually increased. Increases in compliance with mask wearing were achieved with all participants; however, the terminal duration was attained for only four of the five individuals.

Assessment and treatment of tracheostomy tube manipulation: Effects of competing stimuli and protective equipment

Functional analyses (FA) are widely used in the assessment and treatment of problem behavior. However, with limited exceptions, the procedures are rarely applied to potentially dangerous behaviors involving medical equipment. The current study replicated and extended procedures previously used by Kurtz and Chin (2004) to assess and treat tracheostomy tube manipulation in a 5-year-old boy diagnosed with extensive medical and developmental conditions. FA results indicated that tracheostomy tube manipulation (i.e., touching, pulling, occluding) was automatically maintained. An augmented competing stimulus assessment was conducted to identify stimuli associated with low levels of tracheostomy tube manipulation and elevated levels of item engagement. A treatment package consisting of noncontingent access to competing stimuli with prompting and continuous application of protective equipment produced significant reductions in tracheostomy tube manipulation, as well as significant increases in toy engagement.

Competing stimulus assessments: A systematic review

The current review summarizes the literature on competing stimulus assessments (CSAs). CSAs are pretreatment assessments designed to systematically identify stimuli that reduce problem behavior (PB), ostensibly through reinforcer competition or substitution. We report on the participant characteristics, outcomes, and predictive validity of published CSAs that included (a) no-stimulus control trial(s), (b) test trials during which each stimulus was available singly and noncontingently, and (c) measurement of PB and stimulus engagement or contact. Results showed that CSAs have broad utility across a variety of topographies and functions of PB. In the majority of CSA applications for which extended analyses, or validations, were performed, stimuli shown to reduce PB during the CSA produced similar reductions during extended analysis. This was the case regardless of topography or function of PB, or whether the stimuli were assumed to be "matched" to the stimulation thought to be produced by PB. Implications for future research are discussed.

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.

Initial outcomes of an augmented competing stimulus assessment

Competing stimulus assessments (CSAs) are designed to identify stimuli that, when made freely available, reduce problem behavior. Although CSAs have demonstrated utility, identifying competing stimuli can be difficult for some individuals. The current study describes outcomes from an augmented CSA (A-CSA) for 6 consecutively encountered cases with treatment-resistant subtypes of automatically maintained problem behavior. When test stimuli were made freely available, only between 0 and 1 effective competing stimuli were identified for each case. Prompting and response blocking were temporarily employed in succession to promote engagement with stimuli and disrupt problem behavior. When those procedures were withdrawn and stimuli made freely available, the number of effective competing stimuli increased in all 6 cases. Findings suggest that procedures designed to promote engagement and disrupt problem behavior may allow the A-CSA to be a platform not only for identifying competing stimuli, but also for actively establishing competing stimuli.

Treatment Burst Data Points and Single Case Design Studies: A Bayesian N-of-1 Analysis for Estimating Treatment Effect Size

Single-case experimental designs (SCED) evaluate treatment effects for each participant, but it is difficult to aggregate and quantify treatment effects across SCED participants receiving the same type of treatment. We applied Bayesian analytic procedures to SCED data aggregated across participants that have previously only been applied to large-N and group design studies of treatment effect sizes. For the current study, we defined transient elevated treatment data points as (1) above the range of the last five baseline sessions during the first three sessions of treatment (i.e., extinction burst); (2) within or above the range of baseline after the first three treatment sessions (i.e., recurrence burst); or (3) thinning phase data points above the last three prethinning treatment data points (i.e., thinning burst). Results indicated that the treatment effect sizes remained large regardless of controlling for transient elevated treatment data points. Finally, we examined the effects of reinforcer schedule thinning on estimates of treatment effect size. Results indicated a moderate negative impact of schedule thinning on treatment effect size with a 16% decrease in effect size. Recommendations for research and practice are provided, and the utility of using Bayesian analysis in single-case experimental designs is discussed.

Increasing item engagement and decreasing automatically reinforced problem behavior within a modified competing stimulus assessment

A competing stimulus assessment (CSA) is commonly used to identify leisure items for use in treatments designed to decrease automatically reinforced problem behavior. However, this type of assessment may not yield useful information if participants do not readily engage with leisure items. The purpose of this study was to evaluate a modified CSA that included additional treatment components (i.e., prompting, prompting plus differential reinforcement of alternative behavior). The modified CSA identified the treatment components and leisure items that were most effective for increasing leisure-item engagement and decreasing problem behavior for each participant. Modified CSA outcomes maintained during an extended treatment analysis in a natural setting and when intervention components were faded.

A review of environmental enrichment as treatment for problem behavior maintained by automatic reinforcement

We reviewed studies that used environmental enrichment as treatment for problem behavior maintained by automatic reinforcement. A search of behavior analytic journals produced 71 publications with a total of 265 applications of environmental enrichment used alone or in conjunction with alternative behavior manipulations (e.g., prompting, reinforcement) and problem behavior manipulations (e.g., blocking, restraint). Environmental enrichment, as a sole intervention, was efficacious in 41% of the sample. Alternative behavior manipulations, problem behavior manipulations, and a combination of both improved the overall efficacy of environmental enrichment. We discuss factors that may influence the efficacy of environmental enrichment, current trends in research on this topic, and implications for both practitioners and researchers.

An evaluation of a punisher assessment for decreasing automatically reinforced problem behavior

We extended research on the identification and evaluation of potential punishers for decreasing automatically reinforced problem behavior in four individuals with autism spectrum disorder. A punisher selection interview was conducted with lead clinicians to identify socially acceptable punishers. During the treatment evaluation, treatment phases were introduced sequentially and included noncontingent reinforcement (NCR), NCR and differential reinforcement of alternative behavior (DRA), and NCR-and-DRA with punishment. During the NCR-and-DRA with punishment phase, four to five potential punishers were evaluated using a multielement design. Dependent measures included the target problem behavior, appropriate item engagement, and emotional responding. For all participants, NCR-and-DRA was not effective and punishment was necessary. However, the most effective punisher identified in the context of NCR-and-DRA differed across participants.

Eating disorders in children: is avoidant-restrictive food intake disorder a feeding disorder or an eating disorder and what are the implications for treatment?

Avoidant-restrictive food intake disorder (ARFID) is a current diagnosis in the "Feeding and Eating Disorders" section of the Diagnostic and Statistical Manual of Mental Disorders (fifth edition) and captures a heterogeneous presentation of eating disturbances. In recent years, ARFID has been studied primarily within the context of eating disorders despite having historical roots as a feeding disorder. The following review examines ARFID's similarities with and differences from feeding disorders and eating disorders, focusing on research published within the last three years. Implications of this differentiation for treatment are discussed.

Further Analysis of the Predictive Effects of a Free-Operant Competing Stimulus Assessment on Stereotypy

We conducted five experiments to evaluate the predictive validity of a free-operant competing stimulus assessment (FOCSA). In Experiment 1, we showed that each participant’s repetitive behavior persisted without social consequences. In Experiment 2, we used the FOCSA to identify high-preference, low-stereotypy (HP-LS) items for 11 participants and high-preference, high-stereotypy (HP-HS) items for nine participants. To validate the results of the FOCSAs (Experiment 3), we used a three-component multiple schedule to evaluate the immediate and subsequent effects of an HP-LS stimulus, an HP-HS stimulus, or both (in separate test sequences) on each participant’s stereotypy. Results of Experiment 3 showed that the FOCSA correctly predicted the immediate effect of the HP-LS stimulus for 10 of 11 participants; however, the FOCSA predictions were less accurate for the HP-HS stimulus. Results of Experiment 4 showed that a differential reinforcement of other behavior procedure in which participants earned access to the HP-LS for omitting vocal stereotypy increased all five participants’ latency to engaging in stereotypy; however, clinically significant omission durations were only achieved for one participant. Experiment 5 showed that differential reinforcement of alternative behavior in which participants earned access to the HP-LS stimulus contingent upon correct responses during discrete-trial training reduced targeted and nontargeted stereotypy and increased correct academic responding for all four participants. The potential utility of the FOCSA is discussed.

The primatologist as a behavioral engineer

The field of primate behavior management has had only limited success in preventing and treating abnormal behaviors, such as stereotypy and self-injury, in captive non-human primates (NHP). In contrast, applied behavior analysts have had great success in treating similar topographies of behavior in human clinical settings. By adapting and adopting the behavioral principles and methodologies commonly used by applied behavior analysts, primatologists may be able to develop more effective ways to analyze, reduce, and prevent these aberrant behaviors in NHP. This article reviews studies that have used behavior analytic techniques to successfully address problem behaviors in NHP. Additionally, relevant literature from the field of applied behavior analysis is reviewed to illustrate how adopting a theoretical framework that emphasizes the determination of the underlying operant functions of behavior could lead to new behavioral technologies and advance the field of captive primate management. Am. J. Primatol. 79:e22500, 2017. © 2015 Wiley Periodicals, Inc.

Reducing Pica by Teaching Children to Exchange Inedible Items for Edibles

Assessment results indicated that pica exhibited by two boys with developmental disabilitieswas not associated with environmental contingencies. Consistent with previous research, an oral stimulation function was hypothesized. A related intervention that taught participants to exchange inedible items for edibles was developed. Findings showed that the intervention resulted in reductions in pica for both participants. When the interventionwas introduced across settings, reductions in pica were observed for one participant. However, additional training with alternative pica itemswas necessary to produce reductions in pica across settings with the second participant. Reductions in pica were maintained as the intervention was systematically thinned.

Using Food Aversion to Decrease Severe Pica by a Child With Autism

Food aversion was shown to be effective in the reduction of plastic pica by a 4-year-old boy with autism. The participantwas sufferingfrom digestive complicationsdue to the ingestionof plastic from a variety of toys. The intervention was initially conducted in the child's preschool classroom during instructional periods and was systematically generalized to the entire preschool classroom, and eventually to both classrooms within the preschool and across 25 teachers. The success of the intervention in decreasing pica was enhanced by its achievement in not reducing interactions with toys, considering appropriate play skills were a target goal.

Behavioral Interventions to Reduce the Pica of Persons with Developmental Disabilities

The consumption of nonfood items (i. e., pica) frequently occurs in persons with developmental disabilities. Pica may result in the puncture or blockage of the digestive tract, infestation by gastrointestinal parasites, and can interfere with an individual’s daily learning, occupational performance, and quality of life. Twenty-six published studies have examined the efficacy of behavioral-intervention packages (e. g., differential reinforcement of other behavior, noncontingent attention, or overcorrection) on the pica of persons with developmental disabilities. This article reviews those studies and discusses the effectiveness, generality, and acceptability of the various intervention packages used to reduce pica. Additionally, this article highlights the recent clinical advancements that have been made in the treatment of the pica of persons with developmental disabilities.

Multiple schedules in practical application: Research trends and implications for future investigation

Researchers began studying multiple schedules in basic laboratories, but recent advances have extended research on multiple schedules to a wide variety of socially significant applications, especially during the last decade. Applied researchers have used multiple schedules to (a) promote stimulus control over high-rate appropriate behaviors, (b) thin the schedule of reinforcement following functional communication training, and (c) obtain stimulus control over problem behaviors maintained by automatic reinforcement. In the current paper, we reviewed 31 studies with 147 applications identified through a search of the applied literature on multiple schedules. Using these studies, we (a) reviewed the empirical literature on multiple schedules, (b) recommended multiple-schedule procedures that serve as best practice guidelines for applied behavior analysts, (c) identified the generality and boundaries of current knowledge about the effectiveness of multiple schedules, and (d) critically analyzed the literature to provide directions for future multiple-schedule research.

Individual and combined effects of noncontingent reinforcement and response blocking on automatically reinforced problem behavior

Noncontingent reinforcement (NCR) and response blocking are 2 common interventions for problem behavior maintained by automatic reinforcement. We implemented NCR and blocking with 1 boy and found this combined intervention to be effective at decreasing high rates of automatically reinforced pica. With another child, we compared the effects of blocking alone to the combined intervention. With the third child, we compared NCR alone and blocking alone to the combined intervention. Results showed that the combined intervention was effective at reducing automatically reinforced problem behavior while moderate to high levels of item engagement maintained. When evaluated individually, neither NCR nor blocking was sufficient to reduce problem behavior to clinically significant levels.

An integrated model for guiding the selection of treatment components for problem behavior maintained by automatic reinforcement

We evaluated the usefulness of 2 assessments to guide treatment selection for individuals whose prior functional analysis indicated that automatic reinforcement maintained their problem behavior. In the 1st assessment, we compared levels of problem behavior during a noncontingent play condition and an alone or ignore condition. In the 2nd, we assessed participants' relative preferences for automatic reinforcement and social reinforcers in a concurrent-operants arrangement. We used the results of these 2 assessments to assign 5 participants to a treatment based on noncontingent access to social reinforcers or to a treatment based on differential access to social reinforcers. We conducted monthly probes with the participants over 10 to 12 months to evaluate the effects of the treatment procedures. All participants showed reductions in problem behavior over this period.

Assessment and treatment of pica and destruction of holiday decorations

Problem behavior exhibited by individuals with autism can be disruptive to family traditions, such as decorating for the holidays. We present data for a 6-year-old girl who engaged in automatically reinforced pica and destruction of holiday decorations. Treatment was evaluated within an ABCDCD reversal design. During baseline (Phases A and B), we observed elevated rates of problem behavior. We implemented differential reinforcement of alternative behavior in Phase C to teach a response to compete with problem behavior. Little change in toy play or problem behavior occurred. In Phase D, we added a facial screen to the differential reinforcement procedures, which resulted in increases in toy play and decreases in problem behavior. Findings are discussed in terms of how interventions for problem behavior can promote alternative behavior while they facilitate household activities and traditions.

Functional analysis and treatment of problem behavior exhibited by children with fragile X syndrome

The efficacy of function-based interventions for the treatment of severe problem behavior exhibited by individuals with intellectual and developmental disabilities (IDD) is well established. However, few studies have reported on behavioral interventions in fragile X syndrome (FXS) specifically. The present study is a consecutive case-series analysis that reports on functional analysis and treatment of problem behavior of nine children with FXS. Assessment findings were consistent with previous research indicating that among individuals with FXS, problem behavior is more commonly maintained by escape from demands and access to tangible items, relative to the broader population of individuals with IDD. Functional analysis-based behavioral interventions resulted in a mean reduction in problem behavior of 95.2% across the nine participants. Additionally, generalization of treatment effects from controlled clinical settings to home, school, and community was demonstrated. The current findings suggest that function-based behavioral interventions shown to be effective with the broader population of individuals with IDD are also effective for individuals with FXS. Our results in combination with those of previous studies describing functional analysis outcomes provide additional evidence for a unique functional behavioral phenotype for severe problem behavior in individuals with FXS. Implications of study findings for early intervention and prevention of problem behavior in children with FXS are discussed.

Delineating subtypes of self-injurious behavior maintained by automatic reinforcement

Self-injurious behavior (SIB) is maintained by automatic reinforcement in roughly 25% of cases. Automatically reinforced SIB typically has been considered a single functional category, and is less understood than socially reinforced SIB. Subtyping automatically reinforced SIB into functional categories has the potential to guide the development of more targeted interventions and increase our understanding of its biological underpinnings. The current study involved an analysis of 39 individuals with automatically reinforced SIB and a comparison group of 13 individuals with socially reinforced SIB. Automatically reinforced SIB was categorized into 3 subtypes based on patterns of responding in the functional analysis and the presence of self-restraint. These response features were selected as the basis for subtyping on the premise that they could reflect functional properties of SIB unique to each subtype. Analysis of treatment data revealed important differences across subtypes and provides preliminary support to warrant additional research on this proposed subtyping model.

Using Conditional Percentages During Free-Operant Stimulus Preference Assessments to Predict the Effects of Preferred Items on Stereotypy: Preliminary Findings

To date, researchers have not identified an efficient methodology for selecting items that will compete with automatically reinforced behavior. In the present study, we identified high preference, high stereotypy (HP-HS), high preference, low stereotypy (HP-LS), low preference, high stereotypy (LP-HS), and low preference, low stereotypy (LP-LS) items based on response allocation to items and engagement in stereotypy during one to three, 30-min free-operant competing stimulus assessments (CSAs). The results showed that access to HP-LS items decreased stereotypy for all four participants; however, the results for other items were only predictive for one participant. Reanalysis of the CSA results revealed that the HP-LS item was typically identified by (a) the combined results of the first 10 min of the three 30-min assessments or (b) the results of one 30-min assessment. The clinical implications for the use of this method, as well as future directions for research, are briefly discussed.

Clarifying inconclusive functional analysis results: Assessment and treatment of automatically reinforced aggression

We conducted a series of studies in which multiple strategies were used to clarify the inconclusive results of one boy's functional analysis of aggression. Specifically, we (a) evaluated individual response topographies to determine the composition of aggregated response rates, (b) conducted a separate functional analysis of aggression after high rates of disruption masked the consequences that maintained aggression during the initial functional analysis, (c) modified the experimental design used during the functional analysis of aggression to improve discrimination and decrease interaction effects between conditions, and (d) evaluated a treatment matched to the reinforcer hypothesized to maintain aggression. An effective yet practical intervention for aggression was developed based on the results of these analyses and from data collected during the matched-treatment evaluation.

Pica patient, status post gastric bypass, improves with change in medication regimen

The causes and origins of pica remain unknown and are the source of speculation and heated debate. Bariatric surgery patients are increasingly being observed in eating disorders treatment programs. Often associated with pregnancy, iron deficiency anemia, early development and mental retardation, pica has only recently been noted in post bariatric surgery patients, all of whom presented with pagophagia (eating of ice). Although there is literature detailing the presence of bezoars in gastric bypass patients, the association of pica, bezoars and abnormal eating behavior after bariatric surgery is still not understood completely. We present the case of a patient diagnosed with pica who underwent bariatric surgery due to a specific bezoar causing obstruction, followed by a treatment plan aimed at curbing the impulses. The patient was diagnosed to have a cardboard and paper bezoar causing gastric obstruction, which was removed endoscopically. After incomplete improvement of pica symptoms with treatment including ziprasidone, lorazepam and behavioral therapy, Saphris (asenapine) was introduced resulting in significant and complete resolution.