If you’re a parent, you’ve probably seen your child put something in his/her mouth that isn’t food. During the mouthing stage before the age of two, it’s normal for curious babies to try and chew on just about everything. But when children try to actually eat non-food items past this stage of development, they may have an eating disorder known as pica (pronounced “pie-kuh”).
Pica is a dangerous, potentially life-threatening behavior for anyone. Depending on what objects are ingested, young children may face nutritional deficiencies, choking, poisoning, parasites, blood infections, intestinal blockages or perforations, etc. These problems can require hospital visits, surgery, and may even cause death.
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In this article, we’ll explore what exactly pica is, what may cause it, and how you can help your child with autism if it’s something he/she struggles with.
What is pica?
Simply put, pica is a compulsive appetite for items that are not food. The name for the disorder comes from the Latin word for magpies, birds known for collecting inedible objects.
Under the American Psychiatric Association’s diagnostic criteria, a person has pica when they a) eat non-food, non-nutritional substances for over a month, b) do so at a stage of development that isn’t appropriate, and c) do so outside of any culturally-accepted practice. The items vary from person to person—some may crave hair, paper, dirt, pebbles, thread, etc. Typically, individuals with pica will still eat normal food items as well.
Pica isn’t exclusive to autism spectrum disorder. It has also been seen in people with developmental disabilities, conditions such as schizophrenia or obsessive-compulsive disorder, and even in otherwise neurotypical pregnant women.
However, the prevalence of pica is higher in the ASD community than in others. According to a study published by the American Academy of Pediatrics, approximately 28.1% of children with autism and a co-occurring intellectual disability have pica, and 14% of children with autism but no intellectual disability do. Meanwhile, only 3.5% of children in the general population engage in pica.
The most obvious symptom of pica is, well, the behavior itself—eating inedible objects. There are other signs, too. If your child with autism has medical issues such as unexplained weight loss, abdominal pain, unhealthy nails and hairs, etc., then pica could be a possibility.
What causes pica in autistic children?
There are a number of potential causes for pica. The first thing you should do is contact a doctor to rule out any dietary deficiencies since some patients engage in pica because they crave iron or other minerals.
Other children with autism may just be unable to distinguish between edible and inedible items and require more practice. Some children with developmental disabilities may still be in the mouthing stage even above the age of two.
A dental issue could also be the culprit, causing the child with autism to chew on, and incidentally ingest, things in order to alleviate pain and pressure on his/her gums.
But perhaps the most common reason for ongoing pica in those with autism is sensory stimulation. For some kids, eating an object feels good in their mouth and fulfills a sensory craving.
Advice for managing pica in children
The path you take for treating your autistic child’s pica will, of course, depend on the cause.
If a nutritional deficiency is the problem, it may be enough to change your child’s diet and/or introduce vitamins or supplements. Likewise, dental care may be the solution if the patient suffers from an issue with his/her teeth.
Whatever the cause of your son or daughter’s pica, you should always make his/her health care providers aware of it. He/she will need to be monitored for pica-related problems such as blockages and lead poisoning.
Make sure that every member of your child’s team is aware of his/her pica, from teachers, to family members, to therapists, and any other care providers. They should know to watch out for the behavior and keep any of your child’s preferred items out of the way as much as possible.
Speaking of therapists, let’s talk about possible therapeutic treatment for eliminating or reducing pica.
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Managing pica through therapy
There hasn’t been as much clinical research into pica as other self-injurious behaviors sometimes displayed by people with autism, particularly pica in autistic children. Still, several studies have shown successful behavioral intervention for pica patients with autism, an intellectual disability, or other disorders.
Napolitano et al. (2000) used “differential reinforcement of functional communication” to lessen the pica of a six-year-old boy who has autism. Differential reinforcement is a concept used in Applied Behavior Analysis therapy. It means that specific behaviors are reinforced, while others are not—for example, if you’re trying to teach your child to consistently brush his/her teeth before bed, you might allow 10 minutes of free time as a reinforcer. If he/she doesn’t complete the target behaviors, you withhold that reinforcement.
In the Napolitano et al. case, the researchers wanted to encourage the six-year-old boy, Richard, to perform “functional communication” in place of pica. In other words, they wanted him to verbally request food instead of eating it off the floor.
They tested Richard by placing pretzels and rock candy on the floor near him. (Rock candy resembles rock salt, which he had been known to eat.) At first, he immediately reached for the items. The researchers taught him to wait and ask for the food after a timer went off, setting the timer for longer periods each session. Every time he asked for the food after the timer went off, without reaching for the food on the floor, he was reinforced with praise and a clean food item. Eventually, Richard was able to wait almost five minutes without grabbing the “bait” around him.
Napolitano et al. cited three other studies that utilized differential reinforcement to treat pica. Donnelly & Olczak (1990) used differential reinforcement of an alternate behavior (DRA), which means reinforcing a behavior that can replace the problem behavior. In this case, two intellectually disabled men were rewarded for chewing gum instead of engaging in pica.
Smith (1987) used differential reinforcement of an incompatible behavior (DRI), which means reinforcing behaviors that can’t be completed at the same time as the problem behavior. Here, the participant was a young man with autism who engaged in pica at his place of employment. He was reinforced with praise and favorite drinks and snacks for the incompatible behavior of using his work tools.
Lastly, Goh et al. (1999) used DRA to teach four adults with developmental disabilities to exchange their preferred pica item—cigarettes—for actual food. The therapist verbally instructed the participants to hand him/her the cigarette, repeating the instruction and modeling the behavior if there was no response. If the participant didn’t respond again, the therapist verbally and physically prompted him/her. If he/she attempted to eat the cigarette, the therapist took it away and prompted him/her again. The participants only received a food item if they handed over the cigarette without physical prompting. DRA showed promise in reducing pica for three of the four patients with developmental disabilities. For the fourth, the only real solution seemed to be close supervision.
All children with autism spectrum disorder are different, so each will respond best to a different method. Experienced professionals can help you access the best treatments, services, support, and resources to help your child.
Managing pica at home
Aside from your therapy program, there are things you can do to protect your child’s health until his/her pica is under control.
First, find out what your autistic child’s preferred objects are, if any. There may be a particular object, or a class of similar objects, that fulfills a sensory experience. As you observe your child, determine what those are and how to keep them out of his/her way.
You probably can’t supervise him/her at every moment, so child-proof cabinets, drawers, or boxes might be a good idea. Clean the floor and surfaces regularly to avoid having small items sitting out and about.
Try to find activities that keep your son or daughter with ASD distracted from pica. Behaviors that involve the use of hands could engage his/her sensory needs and keep him/her from picking up things to eat.
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Substitutes for pica, like healthy snacks, gum, or sensory chew toys, can also keep your child with autism stimulated in a safe way.
Finally, be sure to prioritize your own emotional support. Pica is a dangerous disorder, so it’s difficult for families to go through. Make room for your feelings and don’t be afraid to access mental health resources for yourself and the rest of your family.
Pica is a serious concern for all parents because of the potential for medical complications. The prevalence of pica in children with autism and other disorders makes it particularly difficult for ASD families. But introducing behavioral intervention as early as possible can be an effective treatment for this condition.
As an autism parent, you’re never alone in any of your struggles—and pica is no exception.
Fields, V. L., Soke, G. N., Reynolds, A., Tian, L. H., Wiggins, L., Maenner, M., DiGuiseppi, C., Kral, T. V.E., Hightshoe, K., & Schieve, L. A. (2021). Pica, Autism, and Other Disabilities. Pediatrics, 147(2). https://pediatrics.aappublications.org/content/147/2/e20200462
Goh, H.-L., Iwata, B. A., & Kahng, S. (1999). MULTICOMPONENT ASSESSMENT AND TREATMENT OF CIGARETTE PICA. Journal of Applied Behavior Analysis, 32(3). https://onlinelibrary.wiley.com/doi/pdf/10.1901/jaba.1999.32-297?casa_token=rbKtH1qeC8oAAAAA:GSeHyTJD3ihas06TZvRoIleRQFepx_VwwOtiwWez_HPcQ4ZHN-2OL4-PkWjfIse1wf7Lz0ISZaUDFDKL
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(4). https://www.sciencedirect.com/science/article/abs/pii/S1750946711000390?casa_token=TUsKbXvdQl4AAAAA:TQZOQvD-RFsqOaBXJmyLfvgkiGJ9p-0PFie2kHg_IKOeQ6_Flzko8XGg0SecQkr30-RRSe0E6f0
Napolitano, D. A., Blakkman, L. A., Kohl, L. B., Vallese, H. M., & McAdam, D. B. (2007). The use of Functional Communication Training to Reduce Pica. The Journal of Speech and Language Pathology – Applied Behavior Analysis, 2(1). https://psycnet.apa.org/fulltext/2014-51871-003.html
Theravive. (n.d.). Pica DSM-5 307.52 (F98.3) (F50.8). Theravive. https://www.theravive.com/therapedia/pica-dsm–5-307.52-(f98.3)-(f50.8)