According to the National Autism Center, pica is the “abnormal craving for non-food items such as paint, dirt or clay.” It can lead to poisoning, intestinal damage, dental problems and more. Children with developmental disabilities, like autism, are more likely to continue to explore orally or to not understand the dangers of ingesting non-food items. They may be seeking sensory input or may exhibit pica symptoms as a means of control over their environment.
What Can be Done to Prevent Pica in Autistic Children?
No single approach will work for every child. Multiple techniques may need to be tried with an autistic child eating non food items. Results may depend upon the cognitive and functional levels of the child. Successful methods include:
- positive reinforcement
- attention control
- sensory alternatives
- using a ‘pica box’
- discrimination training
- aversion and medical management
The positive reinforcement approach to stopping pica involves giving a child praise and positive attention when he or she is engaging in appropriate behaviors, such as eating food or handling a non food item correctly.
- positive reinforcement example: John, six years old, likes to eat sand. While playing in the sand box at school, he attempts to put the sand in his mouth. His teacher ignores the behavior. When John uses his shovel to fill a bucket with sand, the teacher praises him, tells him he is doing a great job playing with the sand, and gives him lots of attention.
The attention control approach to preventing an autistic child eating non food items involves giving little or no attention to the child when the behavior occurs. This theory is often successful if the child is using pica to get attention or to control his or her environment. When pica happens, eye contact is avoided, the facial expression of the adult is kept neutral, and any words spoken are monotone. If the child realizes they will not get attention for their behavior, they are more likely to stop it.
- attention control example: Bailey, four years old, is eating dirt in the back yard. Her father approaches her with a neutral face, does not look at her and leads her away from the dirt to another activity without speaking. He does this each time Bailey tries to eat dirt.
Modeling is the process of showing a child how to use an object appropriately, rather than eating it. Modeling can be deliberate or incidental. Incidental modeling can occur when an autistic child is surrounded by other children who are using the object correctly. When the child with autism sees other children playing appropriately, they are more likely to do so themselves. Giving autistic children opportunities to be amongst typically developing peers will help them learn via modeling. Deliberate modeling can be performed by parents, teachers, therapists and other caregivers. Correct use of the object is repeatedly demonstrated for the child.
- modeling example: Michael, ten years old, eats sticks of chalk he finds in his classroom. His occupational therapist brings a small chalkboard to class and sits next to Michael, writing numbers on the chalkboard and drawing pictures. She does not require Michael to use the chalkboard, but models appropriate use of the stick of chalk.
If an autistic child is eating non food items for the sensory input, providing alternative items to achieve sensory stimulation may help to reduce pica. It is important to find items of similar textures, tastes or smells for the greatest success with this method. Alternatives such as chewy theratubing (available from medical supply or special needs supply companies), chewing gum, foods with strong tastes, vibrating tethers etc. may be viable alternatives.
- sensory alternative example: Ben, twelve years old, eats clay. He is given a brown chewy tube instead, which mimics the color and texture of the clay. The tube is placed around Ben’s neck on a string, to give him constant access to it.
The Pica Box
A ‘pica box’ is a box of items that are safe for the child to mouth. When alert and calm, the child is shown the pica box and told that any of the objects inside the box can be placed in their mouth if they so wish. When the autistic child tries to eat a non food item, he or she is taken directly to the pica box and aided in choosing another item to mouth instead. In a 1996 article in the journal Focus on Autism and other Developmental Disabilities, Nancy Hirsch and Brenda Myles discuss the use of a pica box with a ten year old girl with autism. Their study showed a “decrease in pica attempts when the box was available to the student.”
- pica box example: Lucy, fifteen years old, eats cigarette butts. When she goes to put a cigarette butt in her mouth, she is immediately led to her pica box, which contains sugar-free gum, a rubber chew tube, and popcorn. She chooses the gum, and puts that in her mouth instead.
Over time, availability of the pica box can be gradually reduced as the child is weaned off non food items.
Some children with autism are unable to tell the difference between food and non food items. Games and activities can be set up to help the child learn what is food, and what is not. Children could sort different objects into groups, or help make a chart with pictures of edible and inedible items.
- discrimination training example: Toby, nine years old, likes to put small objects into his mouth. He works with his teacher on a sorting game. She helps him sort beads, buttons, stones and pins into one box, and grapes, raisins, crackers and popcorn into another box. She allows Toby to eat any of the items from the food box that he desires.
Aversion and Medical Management
In more serious cases of pica, children have been placed on medication to control anxiety and improve impulse control. Medications should be discussed with qualified physicians and psychiatrists.
The aversion approach to preventing pica involves mild punishment to give the autistic child negative consequences for eating non food items. When the child attempts to eat the object, an unpleasant correction is given. The negative consequence could be a particular noise, sensation or word. Having the child throw away the item can also be upsetting, but beneficial.
- aversion example: Kate, 8 years old, attempts to pick paint chips off the walls of her home to eat them. Each time she puts a paint chip in her mouth, her mother uses a recorded, high pitched beeping sound to alert Kate that her behavior is not acceptable.
In the past, helmets, masks, spraying water and physical restraints have been used to prevent pica. These practices are considered outdated and are highly controversial. As Johnny Watson, author of Clinical Assessment and Intervention for Autism Spectrum Disorders, points out, “such management strategies may prevent the problem from occurring in the short term, but do not constitute treatment.”
When to Seek Professional Help
If pica is suspected, the behavior should always be discussed with a medical professional as soon as possible. Children may be tested for nutritional deficiencies to rule out malnutrition as an underlying cause. If a child is ingesting or attempting to ingest poisonous, sharp or metal objects, seek help immediately to prevent serious injury or illness.
Treating pica will require collaboration between family members, therapists, school personnel and medical professionals.
Hirsch, Nancy and Myles, Brenda. “The Use of a Pica Box in Reducing Pica Behavior in a Student with Autism.” Focus on Autism and other Developmental Disabilities, 1996.
Matson, Johnny. Clinical Assessment and Intervention for Autism Spectrum Disorders. Elsevier. 2008.
National Autism Center. “Pica.” https://www.nationalautismcenter.org/learning/pica.php