Children with autism display a variety of unique behaviors. Some behaviors charm us. One upstanding character I met last week proudly reported that he’d memorized all of the U.S. presidents plus special facts about each one. Then he proceeded to tell me 3 facts about 3 presidents. Other behaviors are not so charming and can be disruptive and dangerous. Two particularly daunting behaviors families affected by autism contend with are pica and elopement. Pica refers to the ingestion of non-food items. Elopement occurs when a child runs or wanders away from safe, supervised environments. Why do these behaviors occur and why are they so difficult to treat?
This is the first of a 2-part series for families tackling these difficult behaviors. Starting with pica, we’ll cover the following information about each of these difficult behaviors:
- Presentation and prevalence
- What makes them so challenging to treat
- Common, evidence-based treatments to consider
- Tips for parents to jump-start a treatment plan for these behaviors
Presentation and prevalence
Children exhibiting pica eat a variety of non-food items such as clay, mud, paperclips, hair, or paint. The behavior is common among those with autism and other developmental disabilities; however, the exact prevalence of pica in these populations is unknown and potentially, underreported (Beeker, 2008). A review by Matson and his colleagues (2013) reports prevalence in the general population to be 4 to 26%. Generally, from the child development literature, we also know it’s rare for typically developing children over the age of 2 to ingest non-food items.
What makes pica so challenging to treat?
Ingesting non-food items can have serious negative effects. At its worst, pica may result in the need for surgery, and in the most serious instance, death (Bell & Stein, 1992). Despite these implications, less research has focused on the treatment of pica than other common behaviors of concern in children with autism, such as self-injury and aggression (Matson et al., 2011).
What research we do have tells us that interventions employing Applied Behavior Analysis (ABA) are the most effective option available (Matson et al., 2013). In fact, researchers have effectively employed a wide variety of interventions using ABA; however, reliable intervention packages still need to be identified (Williams and McAdam, 2012).
So, you may be wondering, how is it that we’ve identified an effective intervention (ABA), yet continue to have no definitive treatment protocol for treating pica?
ABA is a process that professionals use to systematically address socially-significant problems. Principles of behavior guide interventions and data drives decision-making at an individual level. This means that there may be many ways to achieve the same outcome, and in the case of pica, this is true. The literature on effective interventions for pica show that different interventions (including environmental enrichment, positive reinforcement, overcorrection) and various combinations of these and other interventions have all resulted in positive changes in the lives of people with pica. That’s the good news.
The bad news is that because the literature shows many different ways to make an impact (instead of the same one proven over and over–which is the kind of backing we want to see for a treatment), it’s unclear which combinations make the most impact in the least amount of time and with the longest staying power.
As if that didn’t make treatment hard enough, there’s another significant obstacle to treatment. Over half of those individuals who exhibit pica do so for non-social reasons. That is, children are unlikely to engage in pica in order to get something or to avoid something (Matson & Bambur, 1999).
The most common function of this behavior seems to be to achieve sensory input (Hanley, Iwata, & McCord, 2003). In other words, maybe it just feels or tastes good to eat a non-food item. I think eating ice cream on a hot day feels good, because it’s cold and refreshing. Because that’s the case, it would be very hard for you to keep me from eating ice cream in August. Likewise, it’s tricky to combat pica in your child with autism if he or she gets sensory input from the experience.
Common, evidence-based treatments to consider
Now that we have a common understanding of what pica is and why it’s difficult to treat, let’s talk about what we’re going to do about it.
The first step to identifying an effective treatment for any behavior of concern is to identify the function of the behavior. That is, why the behavior is occurring. Although the research tells us that engagement in pica often functions to provide sensory input, we should never assume this is true for an individual. If we do, we may focus our energy on the wrong intervention strategy and see no reductions in the behavior. Instead, we want to gather information about the behavior and analyze what we find. We’ll discuss methods for colleting this information in the second part of this series when we address elopement. For now, let’s review a couple of effective treatment options from professional peer-reviewed journals:
- Environmental enrichment: This strategy involves changing your child’s environment in ways that may prevent the behavior. Examples of such changes include rearranging daily routines, adding or expanding time for play or recreational activities during times which pica is unlikely to occur, and adding preferred items (food or otherwise) to the child’s setting and leaving those items available for the child to interact with (Piazza et al., 1998).
- Reinforcement: Rewarding your child at regular intervals when s/he is not engaged in pica and/or offering rewards contingent upon other specific behaviors are two effective ways to use reinforcement to decrease the rate of pica. Possible alternative behaviors that can be rewarded are discarding small non-food items the child finds or engaging in other incompatible behaviors. For example, it’s difficult to engage in pica while your hands are busy playing with a toy, so, rewarding the child for playing with the toy would be rewarding an incompatible behavior (Petscher et al., 2009).
Tips for parents to jump-start a treatment plan for these behaviors
- Recruit a board certified behavior analyst (BCBA) for your treatment team: Due to the risks associated with pica and the difficulties related to treatment, it will be important to have a competent professional on your treatment team.
- While you bring together your treatment team, work on prevention strategies:
-Remove as many non-food items that your child is prone to eat from your home and other environments. Remember, this is only temporary.
-Ensure all of your child’s care providers are aware of your child’s pica. Everyone should engage in an extra dose of vigilance until the effects of treatment are evident.
-Try not to over-react with more attention than necessary to your child if/when pica occurs. Safety should always come first, but it’s possible that your child’s pica functions to gain access to your attention so do your best to minimize your reaction.
- When a treatment team is assembled (this may include family members, your child’s medical providers and teachers, a BCBA, and other supportive people in your child’s life), discuss how you will tackle assessment:
-If the behavior will be observed for the purpose of information-gathering and analysis, consider how you will keep your child safe from ingesting harmful substances during observations.
-Consider x-rays and stool-checking as potential ways to identify what has been consumed and for reassurance that items have passed. Knowing what your child is eating will help inform the team to which items your child may be attracted.
- When the function of your child’s pica has been identified via a functional behavioral assessment, ensure a treatment plan is created with input from you and other team members. The more consistency with which the plan is implemented by all people in your child’s life, the greater success your child will have. Engaging team members from the start will help everyone be effective.
- Track how frequently pica occurs during treatment. This will allow you and your child’s team to see your child’s response to the treatment and make decisions on how to move forward.
Keep in mind that the function of pica can be different among individuals. For this reason, one method of treatment may not be effective for all. Systematically implementing a strategy while tracking the frequency of your child’s pica is the best way to identify if the treatment you’ve selected for your child is effective. You can lean on your treatment team and BCBA to ensure consistent implementation and for support with data tracking. Armed with these tools, you are well-equipped to begin tackling your child’s pica with an evidence-based approach.
The Pica Tool Kits for Parents and Professionals created by Autism Speaks Autism Treatment Network
Read Part 2 of this series to learn more about elopement and how to think about treatment for this behavior.
Bell, K. E., & Stein, D. M. (1992). Behavioral treatments for pica: A review of empirical studies. International Journal of Eating Disorders, 11, 377-389.
Hanley, G. P., Iwata, B. A., & McCord, B. E. (2003). Functional analysis of problem behavior: A review. Journal of Applied Behavior Analysis, 36, 147-185.
Matson, J. L. & Bamburg, J. W. (1999). A descriptive study of pica behavior in persons with mental retardation. Journal of Developmental and Physical Disabilities, 11, 353-361.
Matson, J. L., Belva, B., Hattier, M. A., & Matson, M. L. (2011). Pica in persons with developmental disabilities: Characteristics, diagnosis, and assessment. Research in Autism Spectrum Disorders, 5, 1459-1464.
Matson, J. L., Hattier, M. A., Belva, B., & Matson, M. L. (2013). Research in Developmental Disabilities, 34: 2564-2571.
Petscher, E. S., Rey, C., & Bailey, J. S. (2009). A review of empirical support for differential reinforcement of alternative behavior. Research in Developmental Disabilities, 30, 409-425.
Piazza, C. C., Fisher, W. W., Hanley, G. P. , LeBlanc, L. A., Wordsell, A., Lindauer, S., et al. (1998). Treatment of pica through multiple analyses of its reinforcing functions. Journal of Applied Behavior Analysis, 31, 165-189.
Williams, D. E. & McAdam, D. (2012). Assessment, behavioral treatment, and prevention of pica: Clinical guidelines and recommendations for practitioners. Research in Developmental Disabilities, 33, 2050-2057.
Pica is a symptom of mineral deficiency, not a behavioral issue. The cause must be treated, not the symptom.
I am amazed that anyone involved with autism would go for therapy to stop the symptom instead of treating the root cause which is nutritional.
The autistic child is giving you information about problem, fix the problem, not the child’s expression.
ABA is not a treatment for everything under the sun, nor should it be.
Thank you for your comment. While it’s true that pica is sometimes associated with a nutritional deficiency, in many cases of children with developmental or intellectual delays, it is a severe behavioral issue. A number o f interventions have been applied with this population including behavioral strategies and biological methods (e.g., pharmacology, supplements). Currently, applied behavior analysis is the intervention with the most empirical evidence for treating pica. For more information, please see a recent review published in the journal Research in Developmental Disabilities.
The citation follows:
Matson, J. L., Hattier, M. A., Belva, B., & Matson, M. L. (2013). Pica in persons with developmental disabilities: Approaches to treatment. Research in Developmental Disabilities, 34, 2564-2571.
Valori Berends, MS, BCBA and Eric Boelter, PhD, BCBA-D
If my child showed pica my first thought would be that she had a mineral deficiency. That should be everyone’s first thought and their second thought should be that the pica and autism behaviors could have a common underlying cause such as pernicious anemia or an endocrine disorder.
Thank you for reading. Visiting your child’s primary care provider to rule-out biological/medical factors prior to beginning any behavioral intervention is always recommended. That said, there is a body of research that shows behavioral treatment interventions can be effective at decreasing engagement in pica by persons with disabilities. Please see the article cited to the commenter above for more information (Matson, 2013).
-Valori Berends, MS, BCBA & Eric Boelter, PhD, BCBA-D
I believe you’ve misquoted a study. I believe pica has been found to occur in 4 -26 % of the institutionalized population. I do not believe it occurs in 1 of 4 people in the general population.