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Feeding and Eating Disorders of Infancy or Early Childhood: Pica

Andrea Barkoukis, M.A., Natalie Staats Reiss, Ph.D., and Mark Dombeck, Ph.D.

Disorders in the "Feeding and Eating Disorders of Infancy or Early Childhood" category include Pica, Rumination Disorder, and Feeding Disorder of Infancy or Early Childhood.

Pica

Pica is a disorder that occurs when children persistently eat one or more non-food substances over the course of at least one month. Pica may not sound like a dangerous problem, but when you consider that the non-food substances that are ingested are frequently toxic or otherwise harmful to the human body, the potential for illness and even death becomes clear. Pica may result in serious medical problems, such as intestinal blockage, poisoning, parasitic infection, and sometimes death. This disorder has been described as one of the most serious forms of self-injurious behavior (i.e., deliberate self-harm) because of the high risk of death from this type of behavior.

The typical non-food substances that children with pica ingest tend to vary with age. Younger children with Pica frequently eat paint, plaster, string, hair, or cloth. In contrast, older children with Pica tend to eat animal droppings, sand, insects, leaves, or pebbles. Adolescents affected by the disorder often consume clay or soil substances.

Theorized causes of Pica include iron-deficiency (anemia), zinc deficiency, mental retardation, developmental delays, and a family history of Pica. Other theories suggest that Pica is caused by oral fixations, a lack of appropriate stimulation, or a lack of parental attention. In other words, the reasons why Pica occurs are not definitively known at this time.

Pica is more common among children and adolescents with other developmental disabilities such as Autism and Mental Retardation. For example, the prevalence of Pica appears to increase with the severity of retardation. Approximately 15% of adults with severe Mental Retardation also have Pica. Information about the overall prevalence rates for Pica is limited, however.

Diagnosis of Pica

Because of the potential health hazards and risks associated with Pica (e.g, malnutrition, poisoning, death), children suspected of having Pica are generally thoroughly examined by a pediatrician or family physician. The assessing clinician will need to gather as much information about the child as possible, so parents will generally be asked to describe the child's medical, psychological, and developmental histories, as well as food-related behavior, environmental factors that seem to trigger the pica symptoms, and the consequences of food related behavior. A developmental assessment (such as the Bayley Scales, described below), and comprehensive evaluations of children's home environment, including parental caregiving practices, dietary factors (whether or not children have been eating properly and receiving the full complement of necessary nutrients), physical activity levels, etc., may also be conducted.

Bayley Scales of Infant Development

The Bayley Scales of Infant Development measure children's sensory and motor development. These scales assess children's sensation and perception, memory, learning, problem solving, abstract thinking, and motor movement (e.g., coordination of large muscles and fine muscles in the hands and fingers) abilities. Despite the test's name, it is appropriate for children aged 0 to 42 months, or roughly until age 3 ½.

Treatment of Pica

Pica can be difficult to treat. One of the first steps is to encourage children to eat a healthy, balanced diet. Replacing non-food items that children ingest with more suitable, nutritious food items is an important goal. Speaking with a dietitian who is familiar with Pica can be very helpful in coming up with appropriate and tempting menus. Dangerous substances that are possibly ingestible should be removed from the home (and other relevant environments) immediately so that they are not available as temptations.

Children with Pica enjoy not only the taste or texture of whatever substances they chose to eat, but also the oral stimulation involved. Therefore, a plan to decrease Pica should include alternative ways of obtaining stimulation (oral and otherwise) that are both positive and reinforcing (e.g., enjoying safe food items, and engaging in other highly desirable activities). To this end, therapists help parents and caregivers come up with developmentally-appropriate stimulation plans. Toddlers, for example, may be stimulated simply by playing a game searching for toys.

Parents should consider consulting with a behaviorally-trained mental health clinician, as a comprehensive behavioral plan based squarely on principles of learning theory (e.g., reinforcement, discrimination training, and punishment) may be necessary to manage and ultimately eliminate Pica. Reinforcement of healthy eating behaviors increases the likelihood that children will behave similarly in the future (e.g., they might earn tokens for each hour they behave appropriately and then turn tokens in for toys). Discrimination training is used to help children understand the differences between non-food and food items. Punishment (sometimes called aversive training) methods, such as placing children in 'time-out' when they engage in Pica behaviors, decreases the likelihood that children will engage in these behaviors in the future. For other examples of how learning principles may be used to influence behavior, please see our Psychological Self-Help Tools topic center.

Research is unclear with regard to which types of procedures are most successful (reinforcement vs. punishment) in helping children to discontinue eating non-food substances. Punishment may be a quick way of suppressing such dangerous and self-destructive behaviors, but the gains may come with unwanted long-term consequences and emotional side effects (e.g., the child may become overly anxious about eating) if the punishments are not carefully chosen and rigorously implemented. Behavioral clinicians will help design and modify a behavior modification plan based on the specific child and family being treated. Such a behavior modification plan should be implemented consistently within all of the child's environments (within other homes, at school, etc.).