Pica - The Basics for Caregivers

Introduction

Pica is one of the most common eating disorders among individuals with autistic spectrum disorder and intellectual disabilities. Practically the illness is characterized by a pattern (more than once in 1 month) of ingesting (eating vss mouthing) inedible materials (rocks, rubber gloves, hair, etc.). Risks of pica are discussed below but may include infection, respiratory obstruction, or gastrointestinal obstruction.

Common non-edible items include:

• Hair

• Rubber gloves

• Bottle caps

• Kleenex/Toilet tissue

• Cardboard

• Rubber bands

• Paper

• Paper clips

• Paint chips

• Dirt

• Cigarette butts

• Rocks

• Soap

• Hand sanitizer

• Laundry detergent

• Clothing

Epidemiology

Pica behaviors can be seen in all cultures; however prevalence is greatly increased in cultures that accept the practices and in individuals with intellectual disabilities. Prior to the age of 18 months, pica is considered developmentally appropriate. While there is some support for cultural practices or nutritional deficiencies leading to increased rates of pica, in individuals with intellectual disabilities, literature suggests stronger relation to behavioral, developmental, and other cues driving behavior.

• Behavioral

  • Positive Reinforcement: Swallowing or chewing feels good and provides sensory stimulation.

  • Negative Reinforcement: Swallowing relieves some bad feeling.

• Developmental

  • Cannot discriminate between food/non-food due to intellectual disability or developmental level.

• Other

  • Hunger and desire for more food

  • Imitation/mirroring of observed behavior

  • Boredom

  • Attention seeking

Prevention

A safe living environment requires constant vigilance on the part of caregivers and visitors. Clear “House Rules” and regular sweeps aim to prevent access to pica hazards. Individuals with a history of pica should be clearly identified and their “favorite” non-edible items should be identified. Additionally, visitors and caregivers should be educated on the disease and trained in prevention and treatment.

Specific preventative actions include:

• Routinely monitor areas utilized by the individual with pica tendencies.

• Restrict access to garbage and compost (including cigarette butts, food waste, paper products).

• Store all medical and cleaning supplies out of reach or in locked cabinets (latex gloves, medication cups, thermometers, Band-Aids, bottles/aerosol with removal caps).

• Pay special attention to pleasantly scented items (wet-wipes, hand sanitizer, lotions).

• Secure devices with small batteries (remotes, toys, clocks).

• Remove easily ingestible items such as pens, erasers, paper clips, etc.

• Ensure decorative items on clothing and toys are well-secured (buttons, snaps, patches, strings).

• Evaluate materials that may be worn or easily disassembled (worn clothing, bedding, toys).

• Limit observance of behaviors by others (chewing on hair, pens, etc.)

Intervention

Appropriate and timely medical evaluation is important when it is discovered or suspected that an individual has ingested a non-food substance. Referral for medical evaluation may be based on observation of ingestion, discovery of a missing item, self-report by the individual, or physical symptoms. Ingestion of non-food items can cause airway obstruction, dental injury, poisoning, infectious disease, gastrointestinal obstruction, and other internal injuries. In some instances, hospitalization and invasive surgery may be required.

Physical symptoms may include:

• Coughing or gagging

• Respiratory distress (wheezing, pain, difficulty breathing)

• Nausea or vomiting

• Diarrhea or constipation

• Abdominal pain

• Behavior changes (irritability, routine change, restlessness, new repetitive behavior)

Treatment

Prevention is the most effective treatment for pica in individuals with developmental or intellectual disabilities. Treatment focuses on distracting and providing alternative stimulation that satisfies the individuals’ sensory needs. Further treatment options should be discussed with the individuals’ health care providers.

Examples of effective treatments:

• Unlimited access to nutritive substances (limit one hour before meals)

• Foods of diverse texture, density, and strong flavor

• Alternative sensory stimulation - tactile, temperature, visual, sound, taste

• Oral sensory stimulation - safely chew objects

• Structured activities and increased engagement to prevent boredom

Additional resources on mental health in people with Down syndrome can be found here.

References

Ali, Z. (2001). Pica in people with intellectual disability: A literature review of aetiology, epidemiology and complications. Journal of Intellectual & Developmental Disability, 26, 205–215.

Carter, S. L., Wheeler, J. J., & Mayton, M. R. (2004). Pica: A review of recent assessment and treatment procedures. Education and Training in Developmental Disabilities, 39, 346–358.

Green, G. (1990). Least restrictive use of reductive procedures: guidelines and competences. In A. C. Repp & N. N. Singh (Eds.). Perspectives on The Use of Non-Aversive and Aversive Interventions for Persons with Developmental Disabilities. Sycamore, IL: Sycamore Company.

McAdam, D. B., Sherman, J. A., Sheldon, J. B., & Napolitano, D. A. (2004). Behavioral interventions to reduce the pica of persons with developmental disabilities. Behavior Modification, 28, 45–72.

McAdam, D.B., Breidbord, J. B., Levine, M., & Williams, D. E. Pica. In P. Sturmey & M. Hersen (Eds). Handbook of Evidence-based Practice in Clinical Psychology. John Wiley & Sons, Hoboken: NJ.