Addressing Pica in Autistic Children

Insight into pica (a compulsive appetite for items that are not food) from a clinical psychologist in the field of developmental disabilities.

An article by Claire Delano on the Autism Parenting Magazine blog provides an excellent overview of pica as a problem of great concern for parents of children with autism and other developmental disabilities. I would offer some additional perspective as a clinician for 35 years at a large developmental center.

My true successes with the behavioral treatment of pica as implemented by Psychiatric Technicians were exceedingly few, and perhaps numbered only one. Here, a Differential Reinforcement of Incompatible Behaviors (DRI) approach, not unlike the intervention cited by Ms. Delano, took advantage of a client’s inclination to hold a soft rubber ball in one hand and a can of soda in the other as he walked ¼ mile from residence to workshop. The soda was his upon arrival at and departure from his destination. Holding objects was incompatible with picking up cigarette butts to ingest. Nicotine and cotinine dropped from chain-smoker levels to zero over repeated laboratory tests.

Sometimes, but not often, we get lucky with behavioral approaches. Among the problems encountered are:

• The cost of staff training and staff availability
• Treatment aversion in some instances
• Environmental restrictions
• Issues of generalization and maintenance, i.e., the durable transfer of success in highly controlled settings to everyday settings [1]

Temptation is pretty much everywhere—but interventionists are not. It can feel like applying a Band-Aid to a deeper wound!

More optimistically, I turn to Ms. Delano’s mention of deficient vitamins and minerals, and to other “inside” approaches. (Deficiencies may occur even in the context of a balanced diet due to maldigestion and malabsorption [2].)

Iron is mentioned. I would point as well to low Zinc, particularly in tandem with high Copper levels. Researchers have shown that Zinc supplementation can lead to decreasing/ eliminating pica behavior [3].

Physicians can choose to obtain a panel of trace mineral values, including Zinc, Copper, Iron, Magnesium, and others. A multivitamin Polyvisol [4], and Standard Vivonex, a product containing all essential nutrients in a readily absorbable form [5], have been effective in reducing some pica behaviors.

In a 2020 publication with Stan Lunde, Ph.D., and Dale Berger, Ph.D. [6], and a presentation (2021) to a Moscow audience of parents and professionals, I shared the results of surveying four groups (64 clients) from our developmental center:

• clients with autism and pica
• autism only
• pica only
• a control group.

Those with autism and pica had significantly more gastrointestinal diseases than clients with autism across the 10 most commonly occurring diseases on a checklist:

• gastritis
• esophagitis
• colitis
• ulcer
• Helicobacter Pylori

Those with pica only had the second most. These clients respectively averaged 2.88 and 2.25 diseases per client. I would submit that pica is a red flag for gastrointestinal issues, and conversely, GI issues may be a red flag for pica.

Medical (and if indicated, gastroenterological) evaluation is warranted, as Ms. Delano suggests. Other interventions targeting the gut (microbiome) for children with autism [7] may hold promise for individuals with pica as well. My hope here is that the evaluative and treatment approaches that benefit one of these groups will also benefit the others.