Review articleIdentifying empirically supported treatments for pica in individuals with intellectual disabilities
Highlights
► 25 treatments reported an 80% reduction in pica exhibited by individuals with intellectual disabilities. ► Behavior analytic treatments are well-established for treating pica. ► Combined reinforcement and response reduction procedures are well-established treatments.
Introduction
Individuals with intellectual and developmental disabilities (IDD) are more likely to engage in problem behavior (National Institutes of Health [NIH], 1991) such as self-injurious behavior (SIB; e.g., hitting, biting, scratching oneself), aggression (e.g., hitting, pinching, kicking, pulling hair of others), destructive behavior (e.g., breaking or throwing items), pica (eating inedible objects), and tantrums (Condillac, 2007). Although all of these behaviors have the potential to cause harm to oneself or others, pica is of particular concern because even one instance of the behavior may cause tremendous harm. Published studies have reported on individuals who ingested lead paint, laundry starch, metal and feces, among other items (Lacey, 1990). Several severe health risks are associated with pica (Decker, 1993), including lead-poisoning, intestinal perforation and obstruction (sometimes necessitating surgical removal of the item), and death (Greenberg, Jacobziner, McLaughlin, Fuerst, & Pellitteri, 1958).
The Diagnostic and Statistical Manual of the American Psychiatric Association (DSM-IV-TR) (2000) describes pica as: (a) consumption of nonnutritive items for more than a month, (b) consumption of nonnutritive items inappropriate to developmental age, (c) the eating is not part of culturally sanctioned activity, and (d) the behavior is severe enough to require independent clinical attention when other clinical services are being provided for another mental disorder. The prevalence of pica in persons with intellectual disabilities has been reported to be between 5.7 and 25.8% (Ashworth et al., 2009, Danford and Huber, 1982). In addition, research suggests that pica is relatively more prevalent among lower functioning individuals (Ali, 2001), and is more common in individuals diagnosed with autism (Kinnell, 1985).
A variety of means have been used to identify variables that maintain pica. These include indirect (e.g., Matson & Bamburg, 1999) and direct (e.g., Wasano, Borrero, & Kohn, 2009) functional behavioral assessment procedures. Additionally, when assessing the environmental variables maintaining pica in a direct assessment, several studies have used of safe-to-ingest or simulated pica items that can be consumed without harm to the individual (e.g., Finney, Russo, & Cataldo, 1982). In contrast to other problem behavior such as aggression, self-injury, and property destruction, which are more often maintained by social contingencies, the vast majority of studies describing functional analysis of pica report it to be maintained by sensory or “automatic” reinforcement (Hagopian, Rolider, & Rooker, in press).
The most commonly reported treatments for pica can be characterized as behavioral treatments, in that they involve procedures such as noncontingent reinforcement (NCR), response-effort manipulations, differential reinforcement, response blocking/interruption and brief contingent holds. More recent studies describing the treatment of pica describe multi-component interventions that involve reinforcement, antecedent stimuli, and response reduction procedures. For a more detailed review of this literature, the reader is referred to McAdam, Sherman, Sheldon, and Napolitano (2004) (but see also, Hagopian et al., in press, Myles et al., 1997).
Although several reviews describing the literature on the treatment of pica have been published, no study has critically examined the literature in terms of the American Psychological Association's (APA) criteria for empirically supported treatments (EST) as described by Divisions 12 and 16 of APA (Kratochwill and Stoiber, 2002, Task Force, 1995). This approach involves identifying treatment studies with good experimental designs that demonstrate effective outcomes. Based on the number of rigorous studies documenting successful outcomes, treatment approaches can be designated as having a certain level empirical support – with well-established being the highest. This standardized, objective approach has only recently been used to evaluate treatments for individuals with intellectual disabilities. For example, Carr, Severtson, and Lepper (2009) applied EST criteria to examine noncontingent reinforcement (NCR) as a treatment for problem behavior; Jennett and Hagopian (2008) applied EST criteria for evaluating interventions for phobic avoidance; and Kurtz, Boelter, Jarmolowicz, Chin, and Hagopian (in press) used EST criteria to evaluate functional communication training as a treatment for problem behavior.
The purpose of the current study was to use EST criteria to determine the level of empirical support for the treatment of pica. Additional criteria developed for studies employing single-case designs described by Jennett and Hagopian (2008) were used because none of the studies describing the treatment of pica used group designs.
Section snippets
Article selection
A literature search of PsychInfo, PubMed, and Web of Science was conducted for articles published between January 1980 and January 2011 to identify studies that reported on the treatment of pica. The primary search term was pica and the secondary search terms were: assessment, behavior, disability, retardation,1
Results
Studies were coded as meeting the criteria for experimental control (i.e., good experimental design), treatment efficacy (at least an 80% reduction in pica), sufficient description (as to permit replication), and whether client characteristics were specific. Twenty-six of 34 identified studies met these criteria and are presented in Table 1.
Discussion
In light of the potential risks associated with pica, the use of well-established empirically supported treatments is imperative. This review revealed that majority of published studies on the treatment of pica can be characterized as behavioral interventions because they involve manipulation of environmental antecedents and consequences, as well as behavioral skills training. Findings from the current analysis demonstrate that these behavioral approaches are highly effective in reducing pica –
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