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Assessment, behavioral treatment, and prevention of pica: Clinical guidelines and recommendations for practitioners
Research in Developmental Disabilities 33 (2012) 2050–2057
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Research in Developmental Disabilities
Assessment, behavioral treatment, and prevention of pica: Clinical guidelines and recommendations for practitioners Don E. Williams a,b,*, David McAdam c a
Richmond Behavioral Consulting, United States The Shape of Behavior, United States c University of Rochester Medical School, United States b
A R T I C L E I N F O
A B S T R A C T
Article history: Available online 28 June 2012
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. ß 2012 Elsevier Ltd. All rights reserved.
Keywords: Pica Clinical guidelines
1. Introduction Pica is the most dangerous form of self-injurious behavior exhibited by people with developmental disabilities because it is the only topography in which a single response can result in death as well as other life-threatening consequences including choking, intestinal obstruction, and surgery to remove inedible items (Foxx & Martin, 1975; McAdam, Sherman, Sheldon, & Napolitano, 2004; McLoughlin, 1988). In fact, there are increasing numbers of reports that pica has resulted in deaths of people with developmental disabilities. Foxx and Livesay (1984) conducted a follow-up of four individuals with developmental disabilities and pica who had been treated successfully several years earlier. The authors found that three of the four were deceased and concluded that ‘‘. . .years of ingesting nonnutritive substances takes its toll and may lead to premature death.’’ (p. 76). McLoughlin (1988) reported on three individuals with developmental disabilities whose death
* Corresponding author at: 5218 Virginia Drive, Richmond, TX 77406-8516, United States. E-mail address: [email protected] (D.E. Williams). 0891-4222/$ – see front matter ß 2012 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ridd.2012.04.001
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was attributed to long-term pica. McAlpine and Singh (1986, p. 177) commented: ‘‘In most institutions, pica is not seen as a major behavioural or medical problem. . .thus, often no systematic interventions for pica are instituted. . .and those who engage in pica are left to do so for several decades.’’ After 25 years, pica conditions as reported by McAlpine and Singh (1986) have not been eliminated in large public facilities. For example, Decker (1993) reported that during a 15-year period, 35 patients with pica were hospitalized on 56 occasions. Of these patients, 75% of those admitted with pica had surgery for the removal of foreign objects. The death rate was 11%. Second, a Department of Justice (DOJ) report of several deaths due to pica were cited by Van Dusen (1992). Finally, a recent DOJ report stated that pica was often underreported (Beeker, 2008), an indication that inadequate monitoring systems and lack of education about the dangers of pica were evident among personnel in large institutions. Thus it seems that those with developmental disabilities and pica do not suddenly ingest a dangerous object the first time by accident, but probably have a considerable history of pica that is either not recognized by staff as a dangerous behavior or not effectively dealt with – including some of the front-line personnel as well as some professionals and administrators hired to care for and treat individuals with such problems. Moreover, when – or if – they finally receive behavioral treatment that is successful, the behavioral treatment may not be carried out long enough to prevent harm. 1.1. Rationale for the study McAdam et al. (2004) and McAdam, Briedbord, Levine, and Williams (in press) conducted extensive descriptive and meta-analytic reviews of the published literature and concluded that applied behavior analysis has produced a high degree of success in reducing pica in individuals with developmental disabilities, but two major research limitations exist. First, most of the studies reporting reductions in pica did not address long-term maintenance or generalization strategies across settings, people, or stimulus conditions. Thus practitioners in typical institutional settings find there are few studies to pattern a comprehensive treatment strategy after. Second, there are a number of excellent studies that describe reductions in pica that represent significant decreases from baseline, yet pica responses still occur several times per day. While a large reduction in pica responses will substantially reduce the risk of adverse consequences, there is ongoing and substantial risk in 24-7 clinical (i.e., non-research) settings. This is a major challenge for practitioners in clinical settings, and for researchers to address in their future research. Matson, Belva, Hattier, and Matson (2011) reviewed the literature on pica and concluded that of all the types of aberrant behavior among people with developmental disabilities, pica was researched the least. 2. Methods The purpose of this paper is to formulate research-based clinical guidelines, and to identify recommended considerations for practitioners to assess, treat, and prevent pica. Based largely on two comprehensive literature reviews – McAdam et al. (in press) and McAdam et al. (2004) – as well as original sources, and with our many years of experience with children and adults with developmental disabilities and pica, we have formulated clinical guidelines and recommendations on the prevention, assessment, and treatment of pica exhibited by individuals with intellectual disabilities and Autism Spectrum Disorders. Researchers have demonstrated that a variety of behavioral intervention strategies have been used to reduce pica successfully. These interventions included strategies based on positive reinforcement (e.g., differential reinforcement of other or alternative behavior) and punishment (e.g., overcorrection, contingent aversive presentations such as water mist or a visual screen). Several important common characteristics of the published literature have been previously identified. These included: (a) treatment evaluations done within the framework of a single-case experimental design using relatively short experimental sessions (e.g., 10 min, 30 min), (b) limited examination of long-term maintenance (i.e., 6 month follow-up or longer, (c) lack of programming for generalization across settings, people, or stimulus conditions and (d) a need to conduct a component analysis of intervention packages (McAdam et al., 2004). The reader is referred to the comprehensive review papers published on pica for a complete description of the various intervention packages that have been used to reduce pica (Ali, 2001; McAdam et al., 2004, in press). 3. Recommendations for the prevention of pica Every clinic program and residential facility should screen for pica by conducting prevalence surveys, by direct observation, stool checks, review of medical history records, interviews with caregivers that deal with pica, and use of screening scales such as the Behavior Problem Inventory (Rojahn, Matson, Lott, Esbensen, & Smalls, 2001). The Identification of students with pica can then lead to strategies for secondary prevention, further assessment, and treatment. After initial screening for pica, a more thorough study should be done to determine the potential risks to each child, adolescent, or adult with pica. This approach should involve research of medical records, listing of objects ingested or found in stools, X-rays for stomach distention or intestinal blockages, and surgeries to remove foreign objects.
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Referral to a board certified behavior analyst or licensed psychologist with extensive experience in the treatment of pica should be done promptly. Pica, because of the life-threatening risk, should be under the direct services of an experienced professional, not someone just entering the field of developmental disabilities. Consider a pica-safe environment for use as a prevention method until behavioral treatment has proved effective in sessions and behavior analysts have done extensive generalization training across people, settings, and time. Pica-safe environs have been established in inpatient hospital settings (Fisher, Piazza, Bowman, Kurtz, & Lachman, 1994) and in classrooms, homes, and/or bedrooms that provide an environment where staff have special training in pica prevention, regular on-site monitoring occurs to ensure that no dangerous objects are available, and procedures guide staff behavior, such as the step-by-step procedure for safe disposal of rubber gloves (Williams, Kirkpatrick-Sanchez, Enzinna, Dunn, & Borden-Karasack, 2009). Establishment of special environs for reducing risks of harm is similar to hospital special wings for people whose conditions are medically unstable. Facilities using such an approach would not use restraint helmets, straight jackets, face-masks and other highly restrictive measures that are typically ineffective in preventing pica if dangerous objects are typically available. Ensure that all employees who work where people with pica live or attend school (e.g., housekeepers, temporary direct care or nursing staff) receive training initially and at regular intervals of time on pica, its risks, and prevention strategies (Williams et al., 2009). Investigate the availability of rubber gloves and ensure proper disposal to guarantee zero ingestion of rubber gloves. Rubber gloves account for many cases of surgery for removal of objects (Kamal, Thompson, & Paquette, 1999) and research demonstrates this can be controlled with environmental management of pica (Williams et al., 2009). Clients with life-threatening pica should not live or work in places with openly available dangerous objects unless treatment including generalization training and maintenance over time under a BCBA’s direct supervision has been done and a treatment team is in agreement with a plan to evaluate such an environment; however, due to the high-risk and lack of maintenance and generalization research, safety is a priority at all times. Inclusion will be a long-term priority. Hopefully, there will be no cases where a team unfamiliar with the risk involved with pica, or responding to administrative or external monitoring deficiencies will not send a person with pica to a workshop setting and within days discover that this person ingested a bolt and nut. 4. Assessment recommendations for practitioners 4.1. Diagnosis As noted in McAdam et al. (in press), the diagnosis of pica is based on the Diagnostic and Statistical Manual of Mental Disorders fourth revised edition (DSM-IVR; American Psychiatric Association, 2000) and the International Classification of Diseases ID (10th ed., World Health Organization, 1994): the ingestion of inedible items more than once over at least a 30-day period, not occurring as a cultural practice or developmental phenomena or as part of another mental disorder. The first author of this paper is familiar with several situations where a one-time incident of ingestion of inedible object raised the question: If only one incident occurs, is this pica? By definition, the answer is no; however, if the data collection system or reporting procedure for pica are absent or ill-conceived, there is reason to believe that other incidents could have occurred and not been reported. Moreover, not all incidents of pica are life-threatening. However, there are no data to guide clinicians on assessment of pica to determine if it is non-life-threatening, so clinicians and administrators must assume that pica is life-threatening. Failures to protect people with pica usually can be attributed to lack of understanding of the risks of pica. This article will hopefully dispel that deficit. The identification of potent arbitrary reinforcers may be critical to the successful treatment of pica given that some alternative behaviors will need to be increased. Preferences should be determined empirically (e.g., DeLeon & Iwata, 1996; Fisher et al., 1992). This will help provide choices and may be essential for treatment since most pica is maintained by automatic reinforcement and arbitrary reinforcers may be necessary. Pica must be assessed carefully, and should not be labeled as mouthing without extensive direct observation documenting that an individual does not ingest items. Items used for baiting should be considered with caution and with medical approval by physicians familiar with pica. Functional analyses should be considered only if qualified professionals as indicated above are available using the Iwata, Dorsey, Slifer, Bauman, and Richman (1982/1994) protocol that has been the standard for functional analysis; however, with pica there have been alterations in the Iwata protocol because of the need to use safe ‘‘baited’’ representations of the objects that individuals ingest (Fisher et al., 1994). Both food and safe non-food items have been used for baited sessions. Items we have used that physicians agreed were safe if consumed were non-food items such as small sections of leaves, string, paper, and small pieces of Play Doh. Some researchers have used food items that were rice, beans, pasta, and turnips (Piazza, Roane, Keeney, Boney, & Abt, 2002). In applied settings, an indirect assessment with the QABF (Matson & Vollmer, 1995) may be sufficient in most cases since a large majority of pica is maintained by automatic reinforcement (Hanley, Iwata, & McCord, 2003). Research indicates that the QABF predicts the function in about 75% of cases (Hall, 2005) – 3 of 4 cases. Research by Wasano, Borrero, and Kohn (2009) supports that of Hall. Some additional support for these findings was provided by Matson and Bamburg (1999) who
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used the Questions About Behavioral Function (QABF) and found that 67% of people with pica had non social functions. Practitioners are cautioned that that experimental functional analyses are not necessary in all cases, but they may be in some cases with pica. 5. Treatment recommendations for practitioners Develop a comprehensive treatment plan that includes brief sessions run by the behavior analyst and application of potentially successful interventions to prevent pica during all waking hours and during overnight if the client awakens often. Medical authorization should be obtained for use of baited treatment sessions and there should be periodic medical reviews. For life-threatening pica, the goal should be reduction to zero level. Procedures having the best chance of working should be considered as part of a treatment package. First, start with environmental enrichment and noncontingent reinforcement. An important study by Piazza et al. (1998) evaluated the effects of environmental enrichment (EE) with stimuli identified by a preference assessment and found that EE was substantially improved and pica was decreased in combination with noncontingent reinforcement (NCR). Consider differential reinforcement of an alternative response in combination with procedures listed below. According to Petscher, Rey, and Bailey (2009), differential reinforcement of alternative behavior (DRA) has been effective in the treatment of many individuals with a variety of destructive behaviors and intellectual disabilities. In the treatment of pica, however, no studies show that DRA alone produces reductions near zero rate and over a 24h period for 7 days a week. Smith (1987), for example, described the reduction of pica displayed by a 23-year-old male with autism and a profound intellectual disability following differential reinforcement of incompatible behaviors (DRI). The rate of pica at the end of treatment was 3.7 per day, still a high rate of pica in a clinical setting. Outcomes such as this suggest that an individual’s engagement with pica may still place them at risk despite a significant decrease in pica. Consider contingent visual screening for life-threatening pica. Fisher et al. (1994) used discrimination training along with less restrictive interventions (functional communication training, DRO, and reinforcement, frequent hand washing, response blocking, reinforcement of alternative behavior (throwing away items), alternate activities such as toy play, time out, to treat pica – all were ineffective. Due to the high risk involved, the authors did not perform functional analyses. Fisher et al. (1994) evaluated empirically derived consequences (EDC), i.e., both reinforcers and punishers to use in treatment. The nine punishers evaluated were: baskethold-timeout, ‘‘tidiness training,’’ chair time-out, water mist, facial screen, contingent demands, contingent exercise, brief restraint (hands down), and ‘‘quiet hands’’ (p. 450). In treating 3 individuals with life-threatening pica, Fisher et al. (1994) found that visual screens were the most effective punishers for all 3 individuals, although pica was not eliminated completely. Treatment was studied in a ‘‘baited’’ environment and was generalized to a fairly safe living environment. Follow-up of 9 months in the home and community settings showed that pica had been reduced by at least 90% from baseline. Environmental monitoring was also used to keep the pica environment safe outside of sessions. Johnson, Hunt, and Siebert (1994) decreased pica in two teenage males with profound intellectual disabilities and taught them to eat food from a specific placemat using differential reinforcement. Contingent on pica, the participants’ eyes were covered briefly (i.e., contingent visual screening procedure). The boys were instructed to eat food only if it was on their placemat. A multiple baseline across settings was used. One participant had averaged 35–39% in three environs before treatment and averaged 2.7% across three settings after treatment, a reduction of 97%. Brief physical restraint may be effective for some individuals in combination with overcorrection or contingent visual screening. In an early study, Bucher, Reykdal, and Albin (1976) reduced pica exhibited by a boy and a girl with profound intellectual disabilities using a contingent verbal reprimand (i.e., ‘‘No!’’), removal of non-edible material from the mouth, and holding both arms at the child’s sides for 30 s. Winton and Singh (1984) evaluated the duration of physical restraint (i.e., 10 s vs. 30 s for a participant, 3 s vs. 10 s for another participant), and gained a deceleration of pica exhibited by two young adolescent males with profound intellectual disabilities, across multiple areas of a residential facility. This study demonstrated that brief restraint was more effective than longer duration restraint, an important finding beyond the treatment of the clients. Singh and Bakker (1984) used brief-duration physical restraint to reduce pica and collateral behaviors (stereotypy, toy play) of two males, ages 20 and 21, with profound intellectual disabilities. 5.1. Overcorrection Overcorrection has been evaluated in a number of studies (e.g., Foxx & Martin, 1975; Matson, Stephens, & Smith, 1978; Mulick, Barbour, Schroeder, & Rojahn, 1980; Ricciardi, Luiselli, Terrill, & Reardon, 2003; Singh & Winton, 1984) and is one of the most effective interventions with pica. Foxx and Martin (1975) used overcorrection to reduce pica of four adult males with profound intellectual disabilities. This overcorrection procedure required the participants to spit-out a nonedible item, use a toothbrush soaked with mouthwash to clean his mouth, and complete positive practice acts (e.g., floormopping) contingent on pica. The pica was suppressed to near zero and effects were maintained for 84 days. Matson et al.
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(1978) used an overcorrection procedure (i.e., oral hygiene, completion of various cleaning tasks) to reduce pica, then added a contingent-aversive procedure (i.e., oral administration of a diluted hot-sauce solution). The combined package resulted in reduction of pica and collateral behavior (i.e., hair-pulling) of an adult female with a profound intellectual disability. Mulick et al. (1980) compared overcorrection of either pica or precursor behaviors (i.e., the picking-up and handling of non-edible items) displayed by a 23-year old male and an adult female with profound intellectual disabilities. The greatest reduction of pica occurred when overcorrection was implemented earlier—contingent on picking up and handling nonedible items. One participant exhibited pica at 31 responses per minute in baseline and .03 per minute after treatment and 0 at follow-up. Ricciardi et al. (2003) used contingent practice involving oral expulsion and practice in the appropriate disposal of a non-edible to decelerate pica displayed by a 7-year-old male with autism. Follow-up data for overcorrection studies were collected at about 3 months post-treatment (Foxx & Martin, 1975; Matson et al., 1978) or daily over the course of four months while treatment was still in effect (Ricciardi et al., 2003). Unfortunately, overcorrection is seldom used to treat pica. The reasons for minimal use of overcorrection is that some state guidelines ban the procedures as well as aversive procedures. Also, overcorrection is physically demanding, difficult or complex at times, and requires the ongoing involvement of an expert behavioral consultant to oversee the program over the length of time conducted (Foxx & Livesay, 1984). Consider response blocking as a component of treatment to prevent ingestion of items. Hagopian and Adelinis (2001) demonstrated the potential clinical usefulness of response blocking in an assessmentbased intervention approach. Based on results of an analogue functional analysis suggesting a non-social ‘‘automatic’’ function of pica displayed by a 26-year-old male with moderate intellectual disability and bipolar disorder, the authors first attempted to reduce pica by blocking every attempt to engage in eating of nonedible items. Since response blocking as the sole component of treatment achieved limited pica reduction and increased aggression, it was then paired with redirection to eat popcorn instead of engaging in pica; popcorn was empirically identified as a highly preferred item via paired-choice preference assessment (Fisher et al., 1992) and its use as part of an augmentative redirection procedure was associated with reduced pica without the negative side-effect of aggression. McCord, Grosser, Iwata, and Powers (2005) compared effects of different response-blocking techniques on the pica of three adult males with profound intellectual disabilities. Results demonstrated that using a sweeping motion to move the participant’s hand away from his mouth, which terminated pica earlier in the response chain, was more effective than placing a hand between the participant’s hands and mouth. McCord et al. (2005) suggested that blocking by sweeping worked better since it reduced the likelihood of ingesting an item, thus preventing the unintentional, intermittent reinforcement of pica. Furthermore, LeBlanc, Piazza, and Krug (1997) evaluated the effects of response blocking with or without protective equipment (i.e., arm restraint, helmet) on the pica of a 4-year old female with a severe intellectual disability. Less therapist effort was associated with response blocking used in isolation because the participant attempted to remove any protective equipment she was required to wear. No data are available for maintenance of behavior change following interventions based on response blocking. Response blocking has also been evaluated as part of treatment packages including reinforcement-based interventions (Kern, Starosta, & Adelman, 2006; Piazza et al., 1998). Although response blocking works in brief sessions, it requires close staff proximity which may either be impractical to stay that close to a client during all waking hours or it could elicit aggression. As a sole treatment for severe pica, it has yet to be demonstrated as effective over the long-term because therapist proximity is difficult to maintain outside of brief sessions unless it leads to suppression of pica in a short period. Response blocking appears to function as a punisher and some consider it (or the proximity of the therapist as punishing). Nonetheless, it can be a component of a strategic plan Contingent aversive stimulation should be considered. Paisey and Whitney (1989) used a squirt of lemon juice along with differential reinforcement to decrease pica in a 16 year old adolescent with profound intellectual disabilities. In a more recent intervention, After attempting less restrictive interventions, Rapp, Dozier, and Carr (2001) used a contingent auditory stimulus (i.e., a loud tone) to quell pica in a 6-yearold girl with autism. Both studies represent others demonstrating efficacy when used with this population for the treatment of pica. 6. Discussion Baer, Wolf, and Risley (1968) stated that studies of socially significant behavior ‘‘. . .should display some generality.’’ (p. 92). Generality is the last of the major dimensions of applied behavior analysis, and the one receiving the least attention in behavioral research involving life-threatening pica. Pica is the most dangerous type of self-injurious behavior and it has been described essentially as the least researched of all types of aberrant behavior (Matson et al., 2011). The demonstration of generalized outcomes in applied research is important yet seldom seen in published studies that target severe problem behaviors such as pica. McAdam et al. (2004, in press) noted that most of the studies did not program for generalization. Table 1 displays pica treatment studies that did report follow-up to determine generalization and maintenance effects. Among these studies, Favell, McGimsey, and Schell (1982) reported 7 months of follow-up data; Fisher et al. (1994), included follow-up data at 1,3,6, and 9 months on 3 subjects; Rojahn, McGonigle, Curcio, and Dixon
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Table 1 Selective behavioral procedures in suppressing pica and conducting follow-up. Procedure Physical restraint Bogart et al. (1995) Negative practice Duker and Nielen (1993) Overcorrection Matson et al. (1978) Ricciardi et al. (2003) Aversive stimulation Singh and Winton (1984) Rojahn et al. (1987) Paisey and Whitney (1989) Matson et al. (1978) Fisher et al. (1994)
Follow-up results 54 months 7 months 3 months Daily over 4 months Generalization and maintenance two weeks/six months 90 days Six months 90 days 9 months
(1987) reported 90 consecutive days of follow-up on one subject; Paisey and Whitney (1989) reported 3 and 6 month follow-up data on one subject; Bogart, Piersel, and Gross (1995) with 57 months of continuous follow-up data with one subject; Williams et al. (2009) did a report on 41 individuals with intellectual disabilities and pica after 9 years showing progress (Table 1). This review and other research (McAdam et al., 2004, in press) show that while extensive research has been done to demonstrate that pica can be decreased by various behavioral treatment procedures, little research has been done to teach generalization strategies that promote durability. Most studies provide limited information about generalization and maintenance strategies and the evidence of maintenance and generalization; however, the data varied in quality and detail. The lack of long-term follow-up studies in pica represents a serious deficit in evidence-based research and raises questions regarding generality for practitioners and for researchers. How much research is needed on generalization and maintenance of pica before researchers can assure practitioners that there are sufficient data to show a pathway to safely predict that sufficient generalization and maintenance training means the risk of death is reduced enough to take the chance and recommend placement in a less restrictive setting?
7. Criteria for successful treatment in practitioner settings An 70–90% reduction from a baseline sounds like successful treatment; however, in a practitioner setting it means that pica is still occurring 20–30% of the time or even higher during all waking hours. For example, if the baseline rate for pica was 30/h and it was reduced by 80%, then pica would still be occurring at a rate of 6/h in brief sessions. What would it be for the other 15 h/day? Our point is that reductions, even rather large reductions from baseline may leave some clients at risk, particularly if treatment is limited to a few sessions per day and there are no plans for clinical management outside of the brief sessions. Studies suppressing pica to near zero levels, even if during brief sessions only, may be necessary for successful treatment. Selection of interventions should be consistent with the literature. Findings from research conducted during brief, well-controlled studies are valuable for the advancement of knowledge and such studies can be used in the design of comprehensive treatment plans, which is what practitioners must do. An overlooked, yet important issue in behavior analysis is the large gap between what is published and what is practiced on a routine basis in facilities and programs around the country. Many of the articles in the published literature originate from university settings with highly trained students and faculty conducting these studies, often in fulfillment of a co-author’s thesis and dissertation. Based on our observations, practitioners in applied settings are not able to treat each individual with the same amount of attention as one would if a dissertation was the goal. Quite often, under the best of circumstances, a full-time practicing behavior analyst has a caseload of 20–25 individuals with intellectual disabilities and with the majority having behavior disorders. What can be done in academic settings is far different than what can be done in most practice settings. In practice settings, it is unlikely that behavior analysts will be present in most facilities in sufficient number and with excellent qualifications to treat pica. If there are several such behavior analysts present at a school or facility, they each will likely have at best 10–25 people on behavior support plans. Successful treatment in applied settings would include not just be reduced rates in sessions but also: (1) no foreign objects observed in stools, (2) no intestinal blockages due to foreign objects, (3) no medical complications caused by pica, (4) no continuous restraint to prevent pica, and (5) little or no pica attempts, and no ingestion of foreign objects. Therefore, the goal of treatment should be suppression to near zero rate, not just a significant reduction of pica.
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In closing, we want to make it clear that much of the research in applied behavior analysis conducted in brief sessions must be conducted that way to ensure experimental control. We have no criticism of such research and we recognize that it is essential. Author notes I wish to thank June W. Williams for reading an earlier draft and providing me with feedback that proved very helpful. References Ali, Z. (2001). Pica in people with intellectual disability: A literature review of aetiology, epidemiology, and complications. Journal of Intellectual and Developmental Disability, 26, 205–215. American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th Rev. ed.). Washington, DC: American Psychiatric Association. Baer, D. M., Wolf, M. M., & Risley, T. R. (1968). Some current dimensions of applied behavior analysis. Journal of Applied Behavior Analysis, 1, 91–97. Beeker, G. C. (2008). 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Treatment of scavenging behavior (coprophagy and pica) by overcorrection. Behaviour, Research and Therapy, 13, 153– 162. Hagopian, L. P., & Adelinis, J. D. (2001). Response blocking with and without redirection for the treatment of pica. Journal of Applied Behavior Analysis, 34, 527–530. Hall, S. S. (2005). Comparing descriptive, experimental, and informant-base assessments of problem behaviors. Research in Developmental Disabilities, 26, 1514–1526. 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. Iwata, B. A., Dorsey, M. F., Slifer, K. E., Bauman, K. E., & Richman, G. S. (1982/1994). Toward a functional analysis of self-injury. Journal of Applied Behavior Analysis, 26, 197–206. Johnson, C. R., Hunt, F. M., & Siebert, M. J. (1994). Discrimination training in the treatment of pica in a developmentally delayed child. Child and Family Behavior Therapy, 9, 49–63. Kamal, I., Thompson, J., & Paquette, D. (1999). The hazards of vinyl glove ingestion in the mentally retarded patient: New implications for surgical management. Canadian Journal of Surgery, 42, 201–204. Kern, L., Starosta, K., & Adelman, B. E. (2006). Reducing pica by teaching children to exchange inedible items for edibles. Behavior Modification, 30, 135– 158. LeBlanc, L. A., Piazza, C. C., & Krug, M. A. (1997). Comparing methods for maintaining the safety of a child with pica. Research in Developmental Disabilities, 18, 215–220. 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., Stephens, R. M., & Smith, C. (1978). Treatment of self-injurious behavior with overcorrection. Journal of Mental Deficiency Research, 22, 175–178. Matson, J. L., & Vollmer, T. (1995). The questions about behavioral function (QABF) user’s guide. Baton Rouge: Scientific Publications. McAdam, D. B., Briedbord, J., Levine, M., & Williams, D. E. Pica. In P. Sturmey & M. Hersen (Eds.), Handbook of evidence-based practice in clinical Psychology. New York: Wiley, in press. 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. McAlpine, C., & Singh, N. N. (1986). Pica in institutionalized mentally retarded persons. Journal of Mental Deficiency Research, 30, 171–178. McCord, B. E., Grosser, J. W., Iwata, B. A., & Powers, L. A. (2005). An analysis of response-blocking parameters in the prevention of pica. Journal of Applied Behavior Analysis, 38, 391–394. McLoughlin, J. (1988). Pica as a cause of death in three mentally handicapped men. British Journal of Psychiatry, 152, 842–845. Mulick, J. A., Barbour, R., Schroeder, S. R., & Rojahn, J. (1980). Overcorrection of pica in two profoundly retarded adults: Analysis of setting events, stimulus, and response generalization. Applied Research in Mental Retardation, 1, 241–252. Paisey, T. J., & Whitney, R. B. (1989). A long-term case study of analysis, response suppression, and treatment maintenance involving life-threatening pica. Behavioral Residential Treatment, 4, 191–211. 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. Piazza, C. C., Roane, H. S., Keeney, K. M., Boney, B. R., & Abt, K. A. (2002). Varying response effort in the treatment of pica maintained by automatic reinforcement. Journal of Applied Behavior Analysis, 35, 233–246. Rapp, J. T., Dozier, C. L., & Carr, J. E. (2001). Functional assessment and treatment of pica: A single-case experiment. Behavioral Interventions, 16, 111–125. Ricciardi, J. N., Luiselli, J. K., Terrill, S., & Reardon, K. (2003). Alternative response training with contingent practice as intervention for pica in a school setting. Behavioral Interventions, 18, 219–226.
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Rojahn, J., Matson, J. L., Lott, D., Esbensen, A. J., & Smalls, Y. (2001). The Behavior Problems Inventory; An instrument for the assessment of self-injury, stereotyped behavior, and aggression/destruction in individuals with developmental disabilities. Research in Developmental Disabilities, 31, 577–588. Rojahn, J., McGonigle, C., Curcio, C., & Dixon, M. J. (1987). Suppression of pica by water mist and aromatic ammonia. Behavior Modification, 11, 65–74. Singh, N. N., & Bakker, L. W. (1984). Suppression of pica by overcorrection and physical restraint: A comparative analysis. Journal of Autism and Developmental Disorders, 14, 40–45. Singh, N. N., & Winton, A. S. (1984). Effects of screening procedures on pica and collateral behaviors. Journal of Behavior Therapy and Experimental Psychiatry, 15, 59–65. Smith, M. D. (1987). Treatment of pica in an adult disabled by autism by differential reinforcement of incompatible behavior. Journal of Behavior Therapy and Experimental Psychiatry, 18, 285–288. Van Dusen, G. M. (1992). Health and Safety Risk at Agnews Development Center: A preliminary review of incidents involving resident access to hazardous materials. Protection & Advocacy, Inc. Wasano, L. C., Borrero, J. C., & Kohn, C. S. (2009). Brief report: A comparison of indirect vs. experimental strategies for the assessment of pica. Journal of Autism and Developmental Disorders, 39, 1582–1586. Williams, D. E., Kirkpatrick-Sanchez, S., Enzinna, C., Dunn, J., & Borden-Karasack, D. (2009). The clinical management and prevention of pica: A retrospective follow-up of 41 individuals with intellectual disabilities and pica. Journal of Applied Research in Intellectual Disabilities, 22, 210–215. Winton, A. S., & Singh, N. N. (1984). Suppression of pica using brief duration physical restraint. Journal of Mental Deficiency Research, 27, 93–103. World Health Organization. (1994). The international statistical classification of diseases and related health problems (10th ed.). Geneva: World Health Organization.
Contents lists available at SciVerse ScienceDirect
Research in Developmental Disabilities
Assessment, behavioral treatment, and prevention of pica: Clinical guidelines and recommendations for practitioners Don E. Williams a,b,*, David McAdam c a
Richmond Behavioral Consulting, United States The Shape of Behavior, United States c University of Rochester Medical School, United States b
A R T I C L E I N F O
A B S T R A C T
Article history: Available online 28 June 2012
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. ß 2012 Elsevier Ltd. All rights reserved.
Keywords: Pica Clinical guidelines
1. Introduction Pica is the most dangerous form of self-injurious behavior exhibited by people with developmental disabilities because it is the only topography in which a single response can result in death as well as other life-threatening consequences including choking, intestinal obstruction, and surgery to remove inedible items (Foxx & Martin, 1975; McAdam, Sherman, Sheldon, & Napolitano, 2004; McLoughlin, 1988). In fact, there are increasing numbers of reports that pica has resulted in deaths of people with developmental disabilities. Foxx and Livesay (1984) conducted a follow-up of four individuals with developmental disabilities and pica who had been treated successfully several years earlier. The authors found that three of the four were deceased and concluded that ‘‘. . .years of ingesting nonnutritive substances takes its toll and may lead to premature death.’’ (p. 76). McLoughlin (1988) reported on three individuals with developmental disabilities whose death
* Corresponding author at: 5218 Virginia Drive, Richmond, TX 77406-8516, United States. E-mail address: [email protected] (D.E. Williams). 0891-4222/$ – see front matter ß 2012 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ridd.2012.04.001
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was attributed to long-term pica. McAlpine and Singh (1986, p. 177) commented: ‘‘In most institutions, pica is not seen as a major behavioural or medical problem. . .thus, often no systematic interventions for pica are instituted. . .and those who engage in pica are left to do so for several decades.’’ After 25 years, pica conditions as reported by McAlpine and Singh (1986) have not been eliminated in large public facilities. For example, Decker (1993) reported that during a 15-year period, 35 patients with pica were hospitalized on 56 occasions. Of these patients, 75% of those admitted with pica had surgery for the removal of foreign objects. The death rate was 11%. Second, a Department of Justice (DOJ) report of several deaths due to pica were cited by Van Dusen (1992). Finally, a recent DOJ report stated that pica was often underreported (Beeker, 2008), an indication that inadequate monitoring systems and lack of education about the dangers of pica were evident among personnel in large institutions. Thus it seems that those with developmental disabilities and pica do not suddenly ingest a dangerous object the first time by accident, but probably have a considerable history of pica that is either not recognized by staff as a dangerous behavior or not effectively dealt with – including some of the front-line personnel as well as some professionals and administrators hired to care for and treat individuals with such problems. Moreover, when – or if – they finally receive behavioral treatment that is successful, the behavioral treatment may not be carried out long enough to prevent harm. 1.1. Rationale for the study McAdam et al. (2004) and McAdam, Briedbord, Levine, and Williams (in press) conducted extensive descriptive and meta-analytic reviews of the published literature and concluded that applied behavior analysis has produced a high degree of success in reducing pica in individuals with developmental disabilities, but two major research limitations exist. First, most of the studies reporting reductions in pica did not address long-term maintenance or generalization strategies across settings, people, or stimulus conditions. Thus practitioners in typical institutional settings find there are few studies to pattern a comprehensive treatment strategy after. Second, there are a number of excellent studies that describe reductions in pica that represent significant decreases from baseline, yet pica responses still occur several times per day. While a large reduction in pica responses will substantially reduce the risk of adverse consequences, there is ongoing and substantial risk in 24-7 clinical (i.e., non-research) settings. This is a major challenge for practitioners in clinical settings, and for researchers to address in their future research. Matson, Belva, Hattier, and Matson (2011) reviewed the literature on pica and concluded that of all the types of aberrant behavior among people with developmental disabilities, pica was researched the least. 2. Methods The purpose of this paper is to formulate research-based clinical guidelines, and to identify recommended considerations for practitioners to assess, treat, and prevent pica. Based largely on two comprehensive literature reviews – McAdam et al. (in press) and McAdam et al. (2004) – as well as original sources, and with our many years of experience with children and adults with developmental disabilities and pica, we have formulated clinical guidelines and recommendations on the prevention, assessment, and treatment of pica exhibited by individuals with intellectual disabilities and Autism Spectrum Disorders. Researchers have demonstrated that a variety of behavioral intervention strategies have been used to reduce pica successfully. These interventions included strategies based on positive reinforcement (e.g., differential reinforcement of other or alternative behavior) and punishment (e.g., overcorrection, contingent aversive presentations such as water mist or a visual screen). Several important common characteristics of the published literature have been previously identified. These included: (a) treatment evaluations done within the framework of a single-case experimental design using relatively short experimental sessions (e.g., 10 min, 30 min), (b) limited examination of long-term maintenance (i.e., 6 month follow-up or longer, (c) lack of programming for generalization across settings, people, or stimulus conditions and (d) a need to conduct a component analysis of intervention packages (McAdam et al., 2004). The reader is referred to the comprehensive review papers published on pica for a complete description of the various intervention packages that have been used to reduce pica (Ali, 2001; McAdam et al., 2004, in press). 3. Recommendations for the prevention of pica Every clinic program and residential facility should screen for pica by conducting prevalence surveys, by direct observation, stool checks, review of medical history records, interviews with caregivers that deal with pica, and use of screening scales such as the Behavior Problem Inventory (Rojahn, Matson, Lott, Esbensen, & Smalls, 2001). The Identification of students with pica can then lead to strategies for secondary prevention, further assessment, and treatment. After initial screening for pica, a more thorough study should be done to determine the potential risks to each child, adolescent, or adult with pica. This approach should involve research of medical records, listing of objects ingested or found in stools, X-rays for stomach distention or intestinal blockages, and surgeries to remove foreign objects.
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Referral to a board certified behavior analyst or licensed psychologist with extensive experience in the treatment of pica should be done promptly. Pica, because of the life-threatening risk, should be under the direct services of an experienced professional, not someone just entering the field of developmental disabilities. Consider a pica-safe environment for use as a prevention method until behavioral treatment has proved effective in sessions and behavior analysts have done extensive generalization training across people, settings, and time. Pica-safe environs have been established in inpatient hospital settings (Fisher, Piazza, Bowman, Kurtz, & Lachman, 1994) and in classrooms, homes, and/or bedrooms that provide an environment where staff have special training in pica prevention, regular on-site monitoring occurs to ensure that no dangerous objects are available, and procedures guide staff behavior, such as the step-by-step procedure for safe disposal of rubber gloves (Williams, Kirkpatrick-Sanchez, Enzinna, Dunn, & Borden-Karasack, 2009). Establishment of special environs for reducing risks of harm is similar to hospital special wings for people whose conditions are medically unstable. Facilities using such an approach would not use restraint helmets, straight jackets, face-masks and other highly restrictive measures that are typically ineffective in preventing pica if dangerous objects are typically available. Ensure that all employees who work where people with pica live or attend school (e.g., housekeepers, temporary direct care or nursing staff) receive training initially and at regular intervals of time on pica, its risks, and prevention strategies (Williams et al., 2009). Investigate the availability of rubber gloves and ensure proper disposal to guarantee zero ingestion of rubber gloves. Rubber gloves account for many cases of surgery for removal of objects (Kamal, Thompson, & Paquette, 1999) and research demonstrates this can be controlled with environmental management of pica (Williams et al., 2009). Clients with life-threatening pica should not live or work in places with openly available dangerous objects unless treatment including generalization training and maintenance over time under a BCBA’s direct supervision has been done and a treatment team is in agreement with a plan to evaluate such an environment; however, due to the high-risk and lack of maintenance and generalization research, safety is a priority at all times. Inclusion will be a long-term priority. Hopefully, there will be no cases where a team unfamiliar with the risk involved with pica, or responding to administrative or external monitoring deficiencies will not send a person with pica to a workshop setting and within days discover that this person ingested a bolt and nut. 4. Assessment recommendations for practitioners 4.1. Diagnosis As noted in McAdam et al. (in press), the diagnosis of pica is based on the Diagnostic and Statistical Manual of Mental Disorders fourth revised edition (DSM-IVR; American Psychiatric Association, 2000) and the International Classification of Diseases ID (10th ed., World Health Organization, 1994): the ingestion of inedible items more than once over at least a 30-day period, not occurring as a cultural practice or developmental phenomena or as part of another mental disorder. The first author of this paper is familiar with several situations where a one-time incident of ingestion of inedible object raised the question: If only one incident occurs, is this pica? By definition, the answer is no; however, if the data collection system or reporting procedure for pica are absent or ill-conceived, there is reason to believe that other incidents could have occurred and not been reported. Moreover, not all incidents of pica are life-threatening. However, there are no data to guide clinicians on assessment of pica to determine if it is non-life-threatening, so clinicians and administrators must assume that pica is life-threatening. Failures to protect people with pica usually can be attributed to lack of understanding of the risks of pica. This article will hopefully dispel that deficit. The identification of potent arbitrary reinforcers may be critical to the successful treatment of pica given that some alternative behaviors will need to be increased. Preferences should be determined empirically (e.g., DeLeon & Iwata, 1996; Fisher et al., 1992). This will help provide choices and may be essential for treatment since most pica is maintained by automatic reinforcement and arbitrary reinforcers may be necessary. Pica must be assessed carefully, and should not be labeled as mouthing without extensive direct observation documenting that an individual does not ingest items. Items used for baiting should be considered with caution and with medical approval by physicians familiar with pica. Functional analyses should be considered only if qualified professionals as indicated above are available using the Iwata, Dorsey, Slifer, Bauman, and Richman (1982/1994) protocol that has been the standard for functional analysis; however, with pica there have been alterations in the Iwata protocol because of the need to use safe ‘‘baited’’ representations of the objects that individuals ingest (Fisher et al., 1994). Both food and safe non-food items have been used for baited sessions. Items we have used that physicians agreed were safe if consumed were non-food items such as small sections of leaves, string, paper, and small pieces of Play Doh. Some researchers have used food items that were rice, beans, pasta, and turnips (Piazza, Roane, Keeney, Boney, & Abt, 2002). In applied settings, an indirect assessment with the QABF (Matson & Vollmer, 1995) may be sufficient in most cases since a large majority of pica is maintained by automatic reinforcement (Hanley, Iwata, & McCord, 2003). Research indicates that the QABF predicts the function in about 75% of cases (Hall, 2005) – 3 of 4 cases. Research by Wasano, Borrero, and Kohn (2009) supports that of Hall. Some additional support for these findings was provided by Matson and Bamburg (1999) who
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used the Questions About Behavioral Function (QABF) and found that 67% of people with pica had non social functions. Practitioners are cautioned that that experimental functional analyses are not necessary in all cases, but they may be in some cases with pica. 5. Treatment recommendations for practitioners Develop a comprehensive treatment plan that includes brief sessions run by the behavior analyst and application of potentially successful interventions to prevent pica during all waking hours and during overnight if the client awakens often. Medical authorization should be obtained for use of baited treatment sessions and there should be periodic medical reviews. For life-threatening pica, the goal should be reduction to zero level. Procedures having the best chance of working should be considered as part of a treatment package. First, start with environmental enrichment and noncontingent reinforcement. An important study by Piazza et al. (1998) evaluated the effects of environmental enrichment (EE) with stimuli identified by a preference assessment and found that EE was substantially improved and pica was decreased in combination with noncontingent reinforcement (NCR). Consider differential reinforcement of an alternative response in combination with procedures listed below. According to Petscher, Rey, and Bailey (2009), differential reinforcement of alternative behavior (DRA) has been effective in the treatment of many individuals with a variety of destructive behaviors and intellectual disabilities. In the treatment of pica, however, no studies show that DRA alone produces reductions near zero rate and over a 24h period for 7 days a week. Smith (1987), for example, described the reduction of pica displayed by a 23-year-old male with autism and a profound intellectual disability following differential reinforcement of incompatible behaviors (DRI). The rate of pica at the end of treatment was 3.7 per day, still a high rate of pica in a clinical setting. Outcomes such as this suggest that an individual’s engagement with pica may still place them at risk despite a significant decrease in pica. Consider contingent visual screening for life-threatening pica. Fisher et al. (1994) used discrimination training along with less restrictive interventions (functional communication training, DRO, and reinforcement, frequent hand washing, response blocking, reinforcement of alternative behavior (throwing away items), alternate activities such as toy play, time out, to treat pica – all were ineffective. Due to the high risk involved, the authors did not perform functional analyses. Fisher et al. (1994) evaluated empirically derived consequences (EDC), i.e., both reinforcers and punishers to use in treatment. The nine punishers evaluated were: baskethold-timeout, ‘‘tidiness training,’’ chair time-out, water mist, facial screen, contingent demands, contingent exercise, brief restraint (hands down), and ‘‘quiet hands’’ (p. 450). In treating 3 individuals with life-threatening pica, Fisher et al. (1994) found that visual screens were the most effective punishers for all 3 individuals, although pica was not eliminated completely. Treatment was studied in a ‘‘baited’’ environment and was generalized to a fairly safe living environment. Follow-up of 9 months in the home and community settings showed that pica had been reduced by at least 90% from baseline. Environmental monitoring was also used to keep the pica environment safe outside of sessions. Johnson, Hunt, and Siebert (1994) decreased pica in two teenage males with profound intellectual disabilities and taught them to eat food from a specific placemat using differential reinforcement. Contingent on pica, the participants’ eyes were covered briefly (i.e., contingent visual screening procedure). The boys were instructed to eat food only if it was on their placemat. A multiple baseline across settings was used. One participant had averaged 35–39% in three environs before treatment and averaged 2.7% across three settings after treatment, a reduction of 97%. Brief physical restraint may be effective for some individuals in combination with overcorrection or contingent visual screening. In an early study, Bucher, Reykdal, and Albin (1976) reduced pica exhibited by a boy and a girl with profound intellectual disabilities using a contingent verbal reprimand (i.e., ‘‘No!’’), removal of non-edible material from the mouth, and holding both arms at the child’s sides for 30 s. Winton and Singh (1984) evaluated the duration of physical restraint (i.e., 10 s vs. 30 s for a participant, 3 s vs. 10 s for another participant), and gained a deceleration of pica exhibited by two young adolescent males with profound intellectual disabilities, across multiple areas of a residential facility. This study demonstrated that brief restraint was more effective than longer duration restraint, an important finding beyond the treatment of the clients. Singh and Bakker (1984) used brief-duration physical restraint to reduce pica and collateral behaviors (stereotypy, toy play) of two males, ages 20 and 21, with profound intellectual disabilities. 5.1. Overcorrection Overcorrection has been evaluated in a number of studies (e.g., Foxx & Martin, 1975; Matson, Stephens, & Smith, 1978; Mulick, Barbour, Schroeder, & Rojahn, 1980; Ricciardi, Luiselli, Terrill, & Reardon, 2003; Singh & Winton, 1984) and is one of the most effective interventions with pica. Foxx and Martin (1975) used overcorrection to reduce pica of four adult males with profound intellectual disabilities. This overcorrection procedure required the participants to spit-out a nonedible item, use a toothbrush soaked with mouthwash to clean his mouth, and complete positive practice acts (e.g., floormopping) contingent on pica. The pica was suppressed to near zero and effects were maintained for 84 days. Matson et al.
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(1978) used an overcorrection procedure (i.e., oral hygiene, completion of various cleaning tasks) to reduce pica, then added a contingent-aversive procedure (i.e., oral administration of a diluted hot-sauce solution). The combined package resulted in reduction of pica and collateral behavior (i.e., hair-pulling) of an adult female with a profound intellectual disability. Mulick et al. (1980) compared overcorrection of either pica or precursor behaviors (i.e., the picking-up and handling of non-edible items) displayed by a 23-year old male and an adult female with profound intellectual disabilities. The greatest reduction of pica occurred when overcorrection was implemented earlier—contingent on picking up and handling nonedible items. One participant exhibited pica at 31 responses per minute in baseline and .03 per minute after treatment and 0 at follow-up. Ricciardi et al. (2003) used contingent practice involving oral expulsion and practice in the appropriate disposal of a non-edible to decelerate pica displayed by a 7-year-old male with autism. Follow-up data for overcorrection studies were collected at about 3 months post-treatment (Foxx & Martin, 1975; Matson et al., 1978) or daily over the course of four months while treatment was still in effect (Ricciardi et al., 2003). Unfortunately, overcorrection is seldom used to treat pica. The reasons for minimal use of overcorrection is that some state guidelines ban the procedures as well as aversive procedures. Also, overcorrection is physically demanding, difficult or complex at times, and requires the ongoing involvement of an expert behavioral consultant to oversee the program over the length of time conducted (Foxx & Livesay, 1984). Consider response blocking as a component of treatment to prevent ingestion of items. Hagopian and Adelinis (2001) demonstrated the potential clinical usefulness of response blocking in an assessmentbased intervention approach. Based on results of an analogue functional analysis suggesting a non-social ‘‘automatic’’ function of pica displayed by a 26-year-old male with moderate intellectual disability and bipolar disorder, the authors first attempted to reduce pica by blocking every attempt to engage in eating of nonedible items. Since response blocking as the sole component of treatment achieved limited pica reduction and increased aggression, it was then paired with redirection to eat popcorn instead of engaging in pica; popcorn was empirically identified as a highly preferred item via paired-choice preference assessment (Fisher et al., 1992) and its use as part of an augmentative redirection procedure was associated with reduced pica without the negative side-effect of aggression. McCord, Grosser, Iwata, and Powers (2005) compared effects of different response-blocking techniques on the pica of three adult males with profound intellectual disabilities. Results demonstrated that using a sweeping motion to move the participant’s hand away from his mouth, which terminated pica earlier in the response chain, was more effective than placing a hand between the participant’s hands and mouth. McCord et al. (2005) suggested that blocking by sweeping worked better since it reduced the likelihood of ingesting an item, thus preventing the unintentional, intermittent reinforcement of pica. Furthermore, LeBlanc, Piazza, and Krug (1997) evaluated the effects of response blocking with or without protective equipment (i.e., arm restraint, helmet) on the pica of a 4-year old female with a severe intellectual disability. Less therapist effort was associated with response blocking used in isolation because the participant attempted to remove any protective equipment she was required to wear. No data are available for maintenance of behavior change following interventions based on response blocking. Response blocking has also been evaluated as part of treatment packages including reinforcement-based interventions (Kern, Starosta, & Adelman, 2006; Piazza et al., 1998). Although response blocking works in brief sessions, it requires close staff proximity which may either be impractical to stay that close to a client during all waking hours or it could elicit aggression. As a sole treatment for severe pica, it has yet to be demonstrated as effective over the long-term because therapist proximity is difficult to maintain outside of brief sessions unless it leads to suppression of pica in a short period. Response blocking appears to function as a punisher and some consider it (or the proximity of the therapist as punishing). Nonetheless, it can be a component of a strategic plan Contingent aversive stimulation should be considered. Paisey and Whitney (1989) used a squirt of lemon juice along with differential reinforcement to decrease pica in a 16 year old adolescent with profound intellectual disabilities. In a more recent intervention, After attempting less restrictive interventions, Rapp, Dozier, and Carr (2001) used a contingent auditory stimulus (i.e., a loud tone) to quell pica in a 6-yearold girl with autism. Both studies represent others demonstrating efficacy when used with this population for the treatment of pica. 6. Discussion Baer, Wolf, and Risley (1968) stated that studies of socially significant behavior ‘‘. . .should display some generality.’’ (p. 92). Generality is the last of the major dimensions of applied behavior analysis, and the one receiving the least attention in behavioral research involving life-threatening pica. Pica is the most dangerous type of self-injurious behavior and it has been described essentially as the least researched of all types of aberrant behavior (Matson et al., 2011). The demonstration of generalized outcomes in applied research is important yet seldom seen in published studies that target severe problem behaviors such as pica. McAdam et al. (2004, in press) noted that most of the studies did not program for generalization. Table 1 displays pica treatment studies that did report follow-up to determine generalization and maintenance effects. Among these studies, Favell, McGimsey, and Schell (1982) reported 7 months of follow-up data; Fisher et al. (1994), included follow-up data at 1,3,6, and 9 months on 3 subjects; Rojahn, McGonigle, Curcio, and Dixon
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Table 1 Selective behavioral procedures in suppressing pica and conducting follow-up. Procedure Physical restraint Bogart et al. (1995) Negative practice Duker and Nielen (1993) Overcorrection Matson et al. (1978) Ricciardi et al. (2003) Aversive stimulation Singh and Winton (1984) Rojahn et al. (1987) Paisey and Whitney (1989) Matson et al. (1978) Fisher et al. (1994)
Follow-up results 54 months 7 months 3 months Daily over 4 months Generalization and maintenance two weeks/six months 90 days Six months 90 days 9 months
(1987) reported 90 consecutive days of follow-up on one subject; Paisey and Whitney (1989) reported 3 and 6 month follow-up data on one subject; Bogart, Piersel, and Gross (1995) with 57 months of continuous follow-up data with one subject; Williams et al. (2009) did a report on 41 individuals with intellectual disabilities and pica after 9 years showing progress (Table 1). This review and other research (McAdam et al., 2004, in press) show that while extensive research has been done to demonstrate that pica can be decreased by various behavioral treatment procedures, little research has been done to teach generalization strategies that promote durability. Most studies provide limited information about generalization and maintenance strategies and the evidence of maintenance and generalization; however, the data varied in quality and detail. The lack of long-term follow-up studies in pica represents a serious deficit in evidence-based research and raises questions regarding generality for practitioners and for researchers. How much research is needed on generalization and maintenance of pica before researchers can assure practitioners that there are sufficient data to show a pathway to safely predict that sufficient generalization and maintenance training means the risk of death is reduced enough to take the chance and recommend placement in a less restrictive setting?
7. Criteria for successful treatment in practitioner settings An 70–90% reduction from a baseline sounds like successful treatment; however, in a practitioner setting it means that pica is still occurring 20–30% of the time or even higher during all waking hours. For example, if the baseline rate for pica was 30/h and it was reduced by 80%, then pica would still be occurring at a rate of 6/h in brief sessions. What would it be for the other 15 h/day? Our point is that reductions, even rather large reductions from baseline may leave some clients at risk, particularly if treatment is limited to a few sessions per day and there are no plans for clinical management outside of the brief sessions. Studies suppressing pica to near zero levels, even if during brief sessions only, may be necessary for successful treatment. Selection of interventions should be consistent with the literature. Findings from research conducted during brief, well-controlled studies are valuable for the advancement of knowledge and such studies can be used in the design of comprehensive treatment plans, which is what practitioners must do. An overlooked, yet important issue in behavior analysis is the large gap between what is published and what is practiced on a routine basis in facilities and programs around the country. Many of the articles in the published literature originate from university settings with highly trained students and faculty conducting these studies, often in fulfillment of a co-author’s thesis and dissertation. Based on our observations, practitioners in applied settings are not able to treat each individual with the same amount of attention as one would if a dissertation was the goal. Quite often, under the best of circumstances, a full-time practicing behavior analyst has a caseload of 20–25 individuals with intellectual disabilities and with the majority having behavior disorders. What can be done in academic settings is far different than what can be done in most practice settings. In practice settings, it is unlikely that behavior analysts will be present in most facilities in sufficient number and with excellent qualifications to treat pica. If there are several such behavior analysts present at a school or facility, they each will likely have at best 10–25 people on behavior support plans. Successful treatment in applied settings would include not just be reduced rates in sessions but also: (1) no foreign objects observed in stools, (2) no intestinal blockages due to foreign objects, (3) no medical complications caused by pica, (4) no continuous restraint to prevent pica, and (5) little or no pica attempts, and no ingestion of foreign objects. Therefore, the goal of treatment should be suppression to near zero rate, not just a significant reduction of pica.
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