J Autism Dev Disord (2015) 45:21052114

DOI 10.1007/s10803-015-2375-z

ORIGINAL PAPER

Clinical Outcomes of Behavioral Treatments for Pica in Children

with Developmental Disabilities
Nathan A. Call Christina A. Simmons
Joanna E. Lomas Mevers Jessica P. Alvarez

Published online: 31 January 2015

Springer Science+Business Media New York 2015

Abstract Pica is a potentially deadly form of self-injurious behavior most frequently exhibited by individuals
with developmental and intellectual disabilities. Research
indicates that pica can be decreased with behavioral
interventions; however, the existing literature reflects
treatment effects for small samples (n = 14) and the
overall success of such treatments is not well-understood.
This study quantified the overall effect size by examining
treatment data from all patients seen for treatment of pica
at an intensive day-treatment clinical setting (n = 11),
irrespective of treatment success. Results demonstrate that
behavioral interventions are highly effective treatments for
pica, as determined by the large effect size for individual
participants (i.e., NAP scores C .70) and large overall
treatment effect size (Cohens d = 1.80).
Keywords Pica  Behavioral treatment  Behavior
analysis  Clinical outcomes

Introduction
Pica, the recurrent ingestion of inedible or nonnutritive
substances, is considered a potentially deadly form of selfinjurious behavior that is frequently exhibited by children

N. A. Call (&)  J. E. L. Mevers  J. P. Alvarez

Marcus Autism Center, 1920 Briarcliff Rd., Atlanta, GA 30329,
USA
e-mail: nathan.call@choa.org
N. A. Call  J. E. L. Mevers  J. P. Alvarez
Emory University School of Medicine, Atlanta, GA, USA
C. A. Simmons
University of Georgia, Athens, GA, USA

with developmental and intellectual disabilities. Items

consumed by children who engage in pica vary considerably, but often include paper, plastic, cloth, dirt, paint,
rocks, soap, and cigarette butts (Stiegler 2005). Some
children with developmental disabilities consume a wide
range of items, whereas others consistently ingest only
specific items (Stiegler 2005). Estimates of the prevalence
of pica in individuals with intellectual disabilities vary,
ranging from 5.7 to 25.8 % (Ashworth et al. 2009; Danford
and Huber 1982; Matson and Bamburg 1999); however, a
higher percentage is likely when accounting for less severe
forms of pica that do not receive clinical attention (Ali
2001). This dangerous behavior occurs across gender, age,
race, socioeconomic status, and geographic region (Stiegler
2005), although prevalence increases with the severity of
intellectual disability (Ali 2001).
Although children with developmental disabilities are at
an increased risk for many forms of problem behavior
(Emerson 2001), pica is particularly concerning because a
single occurrence can result in life threatening medical
consequences (Decker 1993; McLoughlin 1988). Serious,
and potentially fatal, medical complications as a result of
pica include intestinal obstruction and perforation, choking, infection, and poisoning (Rose et al. 2000; Williams
and McAdam 2012). Less dangerous, but still distressing,
medical issues include nutritional deficiency, oral and
dental health problems, irritable bowels, enlarged colon,
and constipation. Pica may also lead to social stigmatization, with subsequent social isolation potentially resulting
in more opportunity to seek out and ingest pica items when
supervision and alternative activities are unavailable. This
resulting lack of social contact may actually contribute to
the maintenance of pica over time (Stiegler 2005).
Several causes of pica are suggested in the literature,
including nutritional deficiencies (e.g., iron, zinc; Rose

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et al. 2000), environmental factors (e.g., stressful events,

lack of a stimulating environment, neglect; Edwards et al.
1994; Rose et al. 2000); and maintenance by physiological
consequences of the behavior (e.g., addictive effect of
nicotine consumption; Piazza et al. 1998). Due to individual differences in the etiology of pica, assessments of
maintaining factors have been proposed as an important
guide for treatment. Functional analyses are one such
assessment method that can be employed to identify any
environmental consequences affecting the pica of a particular individual (Hanley et al. 2003). Such assessments
are based upon the broader literature on treating other
problem behaviors exhibited by individuals with developmental disabilities (e.g., aggression, self-injury), which
shows that treatments based on a functional analysis are
more effective (Campbell 2003; Heyvaert et al. 2014).
Functional analyses evaluate the influence of environmental consequences that are likely to occur when an
individual engages in problem behavior (e.g., caregiver
attention, access to preferred items, escape from demands)
by examining the rate of problem behavior within test
conditions that deliver each type of consequence following
problem behavior (Iwata et al. 1982/1994). In cases of pica,
functional analysis methods have been modified to assess
whether such environmental consequences influence the
behavior by baiting session rooms with items that resemble
pica items but are safe to consume (e.g., certain starches,
seaweeds, dry beans; Piazza et al. 1996, 1998). Studies
employing this method indicate that pica is not always
under the control of consequences delivered by others.
Instead, findings from these studies suggest that pica is
most often maintained by the consequences automatically
produced by ingesting items (i.e., automatic reinforcement), which may be in the form of sensory stimulation
(e.g., texture, taste, and/or smell; Favell et al. 1982; Hanley
et al. 2003; Piazza et al. 1998) or reduction of some biological factors like amelioration of nutritional deficits or
nicotine addiction in those who consume cigarette butts.
Numerous studies have demonstrated that pica can be
significantly decreased with behavioral interventions conducted within well-controlled sessions (Hagopian et al.
2011; Matson et al. 2013; Williams and McAdam 2012).
McAdam et al. (2004) reviewed the treatment literature and
grouped pica interventions into nine categories: (a) noncontingent reinforcement, (b) differential reinforcement,
(c) discrimination training, (d) visual or facial screening,
(e) overcorrection, (f) negative practice, (g) timeout,
(h) physical restraint, and (i) contingent aversive presentation. One common feature of these behavioral treatment
components outlined by McAdam et al. is that they are
relatively intensive to implement. The pragmatic challenges of conducting effortful behavioral treatments may at
least partially explain why the majority of published

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accounts of the treatment of pica have been conducted in

institutional or clinical settings (Stiegler 2005).
Although McAdam et al. (2004) and others reviewed the
literature on behavioral treatments for pica, the overall
success of such treatments is not well-understood, owing
primarily to a lack of outcome studies. In an effort to
remediate this gap in the literature, Hagopian et al. (2011)
reviewed studies published between 1980 and 2011 and
identified 34 methodologically sound studies that included
data on the reduction of pica. Of these 34 studies, behavioral interventions resulted in an 80 % or greater reduction
of pica in 25 of 26 cases (96.2 %) and a 90 % or greater
reduction in 21 of 26 cases (80.7 %). Such positive findings
led the authors to conclude that behavioral interventions
are a well-established treatment for pica per standards for
empirically supported treatments, as indicated by the
American Psychological Association (Hagopian et al.
2011). However, due to the severity of the potential health
risks produced by pica, it is typically not acceptable for this
behavior to occur at any level in any context. Thus, the
goal of any treatment should be to reduce pica to a rate of
zero occurrences (Williams and McAdam 2012). Although
published research generally quantifies successful treatment of pica in terms of the reduction from baseline levels
(e.g., 7090 % reduction), very few studies report achieving complete elimination of pica.
Though helpful in summarizing the effectiveness of
behavioral treatments, the published literature on the
overall effectiveness of behavioral treatments for pica is
restricted to reviews of other published case studies. Such
reviews are themselves limited by the potential for publication bias, because those studies that report significant
treatment results have an increased likelihood of being
published. In contrast, case studies that fail to replicate such
treatment effects have a lower probability of publication
(Mahoney 1977; Sham and Smith 2014). Sham and Smith
(2014) systematically reviewed the behavioral treatment
literature and found that effect sizes in published singlecase design studies were higher than effect sizes of
unpublished dissertations, even when controlling for participant characteristics, interventionists, and methodological rigor. Thus, due to the possibility of such bias in the
literature on the treatment of pica, the overall success of
behavioral interventions for pica remains unclear. Furthermore, all currently published studies reflect treatment outcomes for very small sample sizes (i.e., 14 participants).
The purpose of this study was to clarify the effects of
behavioral interventions for pica by examining treatment
data from all of the patients seen for the treatment of pica
through an intensive day-treatment clinical setting
(n = 11), irrespective of treatment success. In addition,
this study quantified the overall effect size of pica treatment to indicate the rate of success of behavioral

J Autism Dev Disord (2015) 45:21052114

interventions. Given the potential severity of pica, this

study also quantified the success of reducing this behavior
to consistent rates of zero occurrences.

Methods
Record Review
A comprehensive review was conducted of the computerized data archive containing patient medical records at an
intensive day-treatment clinical setting that specializes in
the treatment of severe behavior, including pica, from
October 2001 to September 2013. All records containing
the search term pica were retrieved and evaluated for
potential inclusion. Selection criteria for inclusion in the
analysis were: (a) treatment targeted pica, (b) data for the
entirety of the pica treatment were available, and (c) baseline data on pica were collected.
Once the final sample was obtained, records were
reviewed to extract demographic (i.e., age at time of
admission, gender, diagnosis) and treatment information
(i.e., target pica items, treatments employed, number of
sessions to consistent rates of zero occurrences of pica).
When functional analyses of pica were conducted, data
were also reviewed to determine the function that was
identified by the functional analysis.
Participants
Patient records for 11 individuals with developmental
disabilities (8 males and 3 females) were included in this
analysis; see Fig. 1. Despite being a relatively small sample size by the standards of clinical trials research, this
sample represents 2.75 times the number of participants
included in any single previously published study. This
study is also the first to present data irrespective of treatment success to provide a clearer picture of the effectiveness of behavioral interventions for pica.
The average age of participants was 10.8 years (range
619 years). Ten of the eleven participants (90.90 %)
presented with an autism spectrum disorder. Nine of the
eleven participants (81.82 %) presented with intellectual
disability. Data on intellectual functioning were unavailable for the remaining two participants; however, available
data on adaptive behaviors and functional communication
suggest that these participants were functioning well within
the range of intellectual disability. Other comorbid diagnoses included attention-deficit/hyperactivity disorder for
two participants and speech delay and sickle cell anemia
for one participant. Primary caregivers for all participants
had previously given informed consent for the use of
clinical data for research purposes.

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Participants had histories of consuming a wide range of

objects (e.g., wood, paper, metal, glass, sticks, leaves, dirt,
paint chips, soda can tabs, soap, Christmas ornaments,
nails, coins, plastic wrap, batteries, feces; see Table 1).
Pica was the primary reason for admission for the majority
of participants (n = 10); the remaining participants
admission originally targeted aggression and disruptive
behavior and was extended to include treatment of pica
after those behaviors had been successfully treated.
Clinical Procedures
Whenever possible, clinical case managers conducted
observations in the natural environment (e.g., home,
school, community) where pica was reported to occur prior
to beginning sessions in the clinic to gather information
and ensure that treatments would be socially and ecologically valid. In all cases, the clinical team consulted with
caregivers in planning intervention goals and procedures,
considering the importance, acceptability, and feasibility of
intervention goals.
A functional analysis of pica was conducted with ten of
the 11 participants that followed the protocol employed by
Piazza et al. (1998). This protocol is frequently cited as a
model for assessing whether pica is influenced by environmental consequences. All functional analysis and
treatment sessions were conducted in session rooms and
other areas of the clinic (e.g., playroom, waiting area,
classroom). Each room was baited with materials that were
determined to be safe for consumption by medical staff and
that resembled items typically ingested by that participant.
For example, for Participant 4, dry seaweed shavings were
used to resemble dirt. Any items consumed during a session were replaced prior to the next session so that there
were always equal opportunities to engage in pica. All
sessions were conducted by bachelors and masters level
therapists with general training in applied behavior analysis
and specific training in all intervention procedures. Masters
or doctoral level board certified behavior analysts made all
treatment decisions under the supervision of a licensed
psychologist.
Data Collection
For each session, data were collected on occurrences of
pica using desktop or laptop computers running specialized
software that allowed individual keystrokes to record each
instance of pica, as well as other problem behaviors and
therapist behaviors. Data for each participant were graphed
for use by the clinical team as they evaluated various
treatment and baseline conditions using single case design
methodology. Ongoing data collection guided the subsequent addition and removal of intervention components.

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Fig. 1 Consort chart for

participant selection

Exclusion
Criterion A

Record
Review

Total clients treated for

severe behavior (n = 1,458)
Excluded (n = 1,439)
Did not engage in pica

Clients engaged in pica

(n = 29)
Excluded (n = 15)
Treatment did not target pica

Exclusion
Criterion B

Treatment targeted pica

(n = 14)
Excluded (n = 3)
Data were missing or incomplete

Exclusion
Criteria C

Data were available and

complete (n = 11)
Excluded (n = 0)
Baseline data were not collected

Baseline and treatment

data were collected
(n = 11)

Table 1 Participant characteristics

Participant

Age

Gender

Diagnosis

Pica Items

10

ASD; ID

Wood, paper and items found on the floor

10

ASD; ID

Wood, paper and items found on the floor

13

ASD; ADHD; ID

Wood, small metal objects, glass

ASD; ID

Paper, sticks, leaves, dirt, paint chips

19

ASD; ID

Any item (e.g., open safety pin, soda can tabs, glass, chlorine tablet, etc.)

ASD

Paint chips, soap, paper, and any food found on floors or counter

19

ASD; ID

Christmas ornaments, nails, soap, coins, dirt, plastic wrap, metal objects

8
9

6
3

F
F

ASD; ID
Speech delay; Sickle cell anemia; ID

Dirt, rocks, buttons, small toys

Any item (e.g., batteries, paper, pencil, toys, etc.)

10

ASD; ADHD

Dirt, rocks, small toys, paper

11

16

ASD, ID

Own fecal matter

ASD autism spectrum disorder, ID intellectual disability, ADHD attention-deficit/hyperactivity disorder

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Interobserver agreement data were collected by having a

second data collector simultaneously, but independently,
score the occurrence of pica during no fewer than 20 % of
sessions. Interobserver agreement always exceeded 80 %.
Treatment Evaluation
Treatments for all participants were evaluated using a
withdrawal design to demonstrate that any reductions in
pica that were observed were a result of the treatment.
Component analyses were frequently conducted when
treatments had multiple components to determine whether
all intervention components were necessary to achieve
meaningful outcomes.
Baseline
For each participant, baseline data were collected on the
rate of pica prior to the start of treatment. Session rooms
were baited with pica items and no therapist instructions
were provided. Once a stable level or countertherapeutic
trend in the rate of pica was observed, the first treatment
was introduced. If treatment successfully produced a stable
level in the rate of pica that was at or below the level
targeted in caregiver agreed upon treatment goals, baseline
was reinstated to demonstrate that those reductions were
due to the treatment. If the initial treatment did not achieve
adequate improvements in the rate of pica, then additional
treatment components were added.
Treatment
Functional analysis results suggesting that pica was maintained by automatic reinforcement for each of the participants informed the selection of individualized
interventions. An example of a participants clinical data
appears in Fig. 2. This example reflects how treatment
decisions were made for this participant based upon the
level, trend, and variability of the data collected on pica. In
the first baseline phase, pica occurred at a high rate, with an
increasing trend across the final three sessions of the phase
(i.e., sessions 35; M = 2.46 per min). Therefore, the
clinical team instituted an initial treatment that consisted of
response blocking (RB) and noncontingent reinforcement
(NCR; i.e., continuous access to preferred leisure items).
The rate of pica decreased significantly relative to baseline,
below a targeted 80 % reduction (i.e., sessions 610). After
reversing to the baseline condition to demonstrate that
reductions in pica were due to the treatment (i.e., sessions
1116), the original treatment package was reinstated,
producing similarly low rates of pica (i.e., sessions 1732).
The clinical team conducted a component analysis in
subsequent phases in an attempt to ascertain whether all

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components of the initial treatment package were necessary. While evaluating the treatment without the use of
NCR, no pica occurred across the first phase (i.e., sessions
3344). After reversing to baseline and observing a return
to high rates of pica (i.e., sessions 4549), the RB treatment
was reinstated in an attempt to replicate results. During this
treatment evaluation, the rate of pica became variable (i.e.,
sessions 50115). Similarly, while reinstating the original
treatment package, there was an increase in pica across
eight sessions (i.e., 159166) of this treatment phase (i.e.,
sessions 116171). Due to the variable rate of pica during
this treatment phase, the final phase consisted of the original treatment package with the addition of differential
reinforcement of an alternative behavior (DR; i.e., discarding pica items in a trash receptacle resulted in access to
a preferred edible item), which produced low rates of pica
(i.e., sessions 172216) that were comparable to the original treatment with the exception of two sessions (i.e.,
sessions 207 and 210).
Caregiver Training
Several steps were undertaken to ensure the social and
ecological validity of the treatment approach: Caregivers
were provided with the opportunity to observe all baseline
and treatments sessions conducted within the clinical setting. All treatment decisions were informed by consultation
with caregivers, considering the long-term goals and feasibility of intervention procedures. Treatment strategies
were also transferred to natural change agents. That is, once
an effective treatment had been identified with clinical staff,
caregivers (e.g., parents, teachers, respite care providers)
were trained on all intervention procedures. This training
initially took place within the clinical setting, beginning
with didactic training in the use of the treatment procedures,
followed by modeling, and role-playing. Caregivers were
then systematically introduced into sessions until they were
able to conduct all treatment components with C90 %
procedural fidelity. Following caregiver training in the
clinical setting, therapists assisted with transfer of pica
interventions to caregivers in the natural environment (e.g.,
home, school, community). These generalization sessions
consisted of therapists observing treatment implementation
by caregivers, providing feedback, and modifying treatments as necessary to fit the requirements of the natural
environment. Whenever possible, follow-up services were
provided within the natural environment for 6 months following discharge from the day-treatment clinic.
Analysis of Outcome Data
Following the methodology employed by Parker and
Vannest (2009), nonoverlap of all pairs (NAP) scores were

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4.0

NCR +
RB
BL

BL

NCR +
RB
RB

BL

RB

NCR + RB

DR+ NCR + RB

3.5

Responses Per Minute (Pica)

Fig. 2 Example participants

clinical data. BL Baseline, NCR
noncontingent reinforcement,
RB response blocking with and
without redirection, DR
differential reinforcement.
These data represent the
treatment evaluation for
Participant 2

J Autism Dev Disord (2015) 45:21052114

3.0
2.5
2.0
1.5
1.0
80 % reduction

0.5
0.0
0

25

50

75

100

125

150

175

200

Sessions

calculated from the clinical data collected for each participant. A NAP score is an index of behavior change based
upon the proportion of overlapping data points between
phases (i.e., baseline and treatment). As such, this measure
is widely considered to be an effective means of quantifying treatment effects from single-case designs (Kennedy
2004; Parker et al. 2011). A NAP score is considered to be
a strong indicator of treatment effect when summarizing
data from single subject analyses because every baseline
data point is compared to every treatment data point (Sharp
et al. 2010).
To generate NAP scores, an AB graph was created to
juxtapose the first baseline phase (A) and final treatment
phase (B) for each participant. As an example the A-B
graph for Participant 2 is presented in Fig. 3. Next, all
nonoverlapping pairs were tallied. Each overlapping pair
(i.e., higher rate of pica in the treatment datapoint than the
baseline datapoint) was counted as one overlap and each
pair of datapoints with equal rates of pica was counted as
one half of an overlap (i.e., .5). The number of total pairs
was calculated by multiplying the number of datapoints in
phase A (i.e., baseline) by the number of datapoints in
phase B (i.e., treatment). The NAP score was then determined by dividing the number of nonoverlapping pairs by
the number of total pairs:
NAP score nonoverlap=total pairs
A mean NAP score was calculated across participants.
This score was then converted to a Cohens d effect size,
which provides a standardized measure of the magnitude of
the relationship between the means of the first baseline and
final treatment. The equation used to convert the NAP
score to Cohens d (Parker and Vannest 2009) is:
p
Cohen0 s d 3:464  1  1  NAP=:5

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Percent reduction in pica was also calculated for each

participant by subtracting the mean of the final treatment
phase from the mean of the first baseline, dividing by the
mean of baseline, and multiplying by 100.
% Reduction lA lB =lA  x 100
An overall average percent reduction across participants
was also calculated.

Results
Pica interventions for the individuals in this analysis generally consisted of multiple treatment components falling
within the categories described by McAdam et al. (2004),
with three exceptions (see below). Although not all treatments in this analysis aligned perfectly with the McAdam
categories, they are described here in terms of these categories to maintain consistency with the published literature.
On average, 4.36 different treatment components were
evaluated per participant at some point during their treatment analysis (range 210). The average number of components in the final treatment was 2.45 (range 13). A list
of treatment components employed with each participant
appears in Table 2.
The most commonly used treatment component was
differential reinforcement; included in the final treatment
package for 10 participants (i.e., 90.90 %). These procedures included using reinforcement to establish alternative
responses with potential pica items (e.g., handing pica
items to a therapist or discarding pica items in a trash
receptacle) and reinforcing behaviors other than pica (e.g.,
engaging in leisure activities). Noncontingent reinforcement was part of the final treatment package for three

J Autism Dev Disord (2015) 45:21052114

Baseline

DR + NCR + RB

3.0

2.5

Responses Per Minute (Pica)

Fig. 3 Example participants

baseline-treatment graph. NCR
noncontingent reinforcement,
RB response blocking with and
without redirection, DR
differential reinforcement.
These data represent the
treatment evaluation for
Participant 2

2111

2.0

1.5

1.0

0.5

0.0
0

10

15

20

25

30

35

40

45

Sessions

Table 2 Treatments employed and outcomes by participant

Participant

Final treatment components

Other treatments employed

NAP Score

% reduction

# of sessions to 3 zero

DR ? NCR ? RB

1.00

100.00

24

DR ? NCR ? RB

1.00

99.73

NCR ? RB ? RC

DR

1.00

97.71

87

DR ? PF

NCR

1.00

100.00

DR ? RB

V/FS

1.00

98.25

15

DR ? RB

NCR; PF; V/FS; PR; RB

.70

78.38

33

DR

CAP (reprimand);

.92

100.00

DR ? RB ? PR

NCR; RB

1.00

94.00

11

DR ? PR ? RB

DT

.84

92.93

10
11

DR ? PR
DR ? RB ? V/FS

NCR

.00
.92

99.42
97.60

35
11

Total: .94 96.18 21.27

Cohens d: 1.80
NCR noncontingent reinforcement, DR differential reinforcement, PF proximity fading, DT discrimination training, V/FS visual or facial
screening, PR physical restraint, CAP contingent aversive presentation, RB response blocking with and without redirection, RC response cost

participants (i.e., 27.27 %). This procedure involved

ensuring that the participants environment included items
hypothesized to compete with pica (e.g., toys, other
appropriate edible items); providing items which, when
participants interacted with them, were incompatible with
pica (e.g., chewing gum); and providing noncontingent
attention. Physical restraint (i.e., baskethold-timeout, hands
down) was implemented as part of the final treatment
package for three participants, whereas visual or facial
screening was included for one participant. RB with or
without redirection, response cost, and proximity fading

were the only treatment components evaluated that did not

fit within the categories described by McAdam et al.
(2004). RB was included in the final treatment with eight
participants (i.e., 54.50 %). When implementing this
treatment component, a therapist prevented pica by shadowing the participant and preventing any pica attempts.
When this component included redirection, a therapist
guided participants towards a preferred item or activity
following a blocked pica attempt. Response cost was
implemented with one participant. This treatment component included loss of access to a preferred leisure item

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contingent upon a pica attempt with the same item. Proximity fading was included in the final treatment package for
one participant. This component included gradually
increasing the distance between a therapist and the participant until they were no longer in the same room as the
participant.
Other treatment components evaluated prior to the final
treatment package included those from the aforementioned
categories as well as discrimination training (i.e., teaching
the participant to request preferred edible and leisure items
only when they were available) and mild reprimands.
Because this latter procedure consists of the delivery of a
stimulus, albeit a mild one, and resulted in a decrease in the
behavior upon which it was contingent, it meets the definition for a contingent aversive procedure described by
McAdam et al. (2004). Overcorrection, negative practice,
and timeout were not included in any participants treatment package.
The results of the analysis of treatment effectiveness can
be found in Table 2. The final treatment packages resulted
in a 90 % or greater reduction in 10 of 11 cases (90.90 %),
a 95 % or greater reduction in 8 of 11 cases (72.73 %), and
a 100 % reduction in 3 of 11 cases (27.27 %). For the
purpose of this analysis, 100 % reduction is defined as no
occurrences of pica for the duration of the final treatment
phase. However, of the remaining participants who did not
exhibit complete elimination of pica, only a single instance
occurred during the last treatment phase for three participants (Participants 3, 5, and 9). For two of these participants, the instance of pica occurred early in the final phase
(session 4 out of 31 for Participant 5; session 4 out of 12 for
Participant 9), after which no pica occurred for the
remainder of the sessions in the phase. Thus, these participants did not meet the more stringent definition of
complete elimination of pica because not all sessions in the
final phase contained no occurrences. However, given the
overall trend in the rate of pica during the final phase, it
seems reasonable to conclude that the elimination of pica
that was observed for the latter portion of the final phase
would have persisted. It should also be noted that for the
one participant (Participant 6) whose treatment did not
achieve a 90 % reduction in the final phase of treatment, a
97.30 % reduction was obtained using reductive procedures (i.e., physical restraint). This treatment component
was then removed in the final treatment condition for social
validity reasons (i.e., to ensure that parents could implement the treatment in the natural environment). The final
treatment, employing only the reinforcement-based components, resulted in a 78.38 % reduction of pica.
A NAP score of .70 or greater, which is regarded as a
large effect size (Parker and Vannest 2009), was obtained
for all participants. A NAP score of 1.00 was obtained for 7
of the 11 participants (63.64 %), indicating that no sessions

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in the final treatment phase exceeded the rate of pica in any

session during baseline.
Across participants, the resulting treatment outcome was
an overall reduction in pica of 96.18 % from baseline to
final treatment. The overall NAP score was .94, which
exceeds the standard established for a large effect. This
overall NAP score translates to a Cohens d = 1.80 (Parker
and Vannest 2009). The mean number of 10-min sessions
before achieving three consecutive sessions with no
instances of pica was 21.27 (range 387). The longest
treatment analysis had a total duration of 306 10-min
sessions.

Discussion
Results of this analysis demonstrate that behavioral interventions can be highly effective at reducing pica to rates of
near zero occurrences, as determined by the large overall
effect size. Effect size is typically quantified as small,
medium, and large Cohens d values (i.e., 0.20, 0.50, 0.80
respectively; Cohen 1988). In this study, the overall effect
size of 1.80 well exceeds the threshold for a large effect.
By examining the reduction in pica produced by behavioral
interventions for all patients referred for the treatment of
pica in a clinical setting, this study provides data to support
the efficacy of such treatments for pica absent the potential
for publication bias that existed in previously published
studies.
Williams and McAdam (2012) note that, due to the
potentially life-threatening consequences of a single
instance of pica, the goal of treatment should be to eliminate this behavior. Consistent with the published literature,
our results indicate that a 100 % reduction was only evidenced in about 25 % of participants; however, a 95 %
reduction was achieved for nearly 75 % of participants and
a 90 % reduction for 90 % of participants. Although these
data represent a substantial reduction, pica still occurred at
least occasionally for some participants. However, the rate
of pica observed during clinical sessions represents a
worst case scenario, in that sessions took place within a
room that had been baited with many pica items. In contrast, in the natural environment caregivers implemented
prevention and monitoring strategies that included watching for and eliminating such items to minimize opportunities for pica. Also, caregivers were trained in all
intervention procedures and 6 months of follow-up services were provided whenever possible. As such, further
reduction in pica could be expected. Despite this, future
research evaluating behavioral treatments to achieve
complete elimination of pica is warranted as well as
evaluation of the rate of pica during generalization and
follow-up sessions in the natural environment.

J Autism Dev Disord (2015) 45:21052114

Pica was found to be maintained by automatic reinforcement for all 10 of the participants with whom a
functional analysis was conducted. When a behavior is
maintained by automatic reinforcement, it presents a particular set of treatment challenges (Vollmer 1994) because
it is presumably maintained by variables outside of the
therapists control (e.g., sensory stimulation) that are likely
to be unpreventable given an occurrence of pica. Thus, the
inability to implement extinction-based procedures may
account for the difficulty in achieving complete elimination
of pica for the participants in this study.
All participants in this analysis received treatment in an
intensive day-treatment clinical setting. The types of
behavioral treatments implemented in this study can be labor
intensive and expensive. Cost can also be measured by the
time required to produce change. On average, 21.27 10 min
sessions were required to achieve three consecutive sessions
with no instances of pica, with up to 87 for one participant.
Despite the investment of resources in these interventions,
given the potentially life-threatening nature of pica, such
costs must be weighed against those of no treatment, which
include a host of expenses such as caregiver time spent
supervising the individual or medical care such as surgical
procedures to remove ingested items. Furthermore, the
interventions and setting described here are not unlike those
portrayed in the majority of smaller-n studies that present
outcomes of treatments for pica in the literature (McAdam
et al. 2004). Thus, although the purpose of this study was to
ascertain the potential for such interventions to produce a
reduction in pica, it would seem that the need to measure and
improve the cost/benefit ratio and efficiency of such treatments is an important subject for future research.
Future studies should also focus on taking additional
steps to include caregivers and natural environments in
treatment. It is important to note that these participants
were treated over a period of 12 years, and so some cases
reflect the prevailing approach in applied behavior analysis
at the time of treatment, which did not always emphasize
social and ecological validity to the degree it is now
stressed in the literature. Although the clinical model
employed here included caregiver training and generalization, the overall trend in such behavioral interventions is
towards further involving caregivers in establishing
meaningful treatment goals, selection of acceptable treatment components, and generalization to natural environments. The measurement of the social validity of
treatments and long-term outcomes are now a regular
feature of the treatment program described in this study,
but were not consistently collected for all participants in
this study. Thus, future studies examining long-term outcomes of behavioral treatments for pica are necessary
Despite these limitations, the findings of this study show
that very large effect sizes are not only possible, but may

2113

actually be typical for behavioral interventions for pica.

Again, these data represent all of the eligible participants
seen for the treatment of pica during a twelve-year span,
regardless of treatment success. As such, this study eliminates the potential for publication bias that could be considered a serious limitation of all previous studies on
behavioral treatments for pica. Although larger clinical
trials and additional future research may be needed to
evaluate the probability of such large effect sizes, the stability of treatment gains over time, or whether these outcomes are worthwhile given the costs, demonstrations of
efficacy such as this may help to provide a rationale for
those future studies.

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, 205215.
Ashworth, M., Hirdes, J. P., & Martin, L. (2009). The social and
recreational characteristics of adults with intellectual disability
and pica living in institutions. Research in Developmental
Disabilities, 30, 512520.
Campbell, J. M. (2003). Efficacy of behavioral interventions for
reducing problem behavior in persons with autism: A quantitative synthesis of single subject research. Research in Developmental Disabilities, 24, 120138.
Cohen, J. (1988). Statistical power analysis for the behavioral
sciences (2nd ed.). Hillsdale, NJ: Lawrence Erlbaum Associates.
Danford, D. E., & Huber, A. M. (1982). Pica among mentally retarded
adults. American Journal of Mental Deficiency, 87, 141146.
Decker, C. J. (1993). Pica in the mentally handicapped: A 15-year
surgical perspective. Canadian Journal of Surgery, 36, 551554.
Edwards, C. H., Johnson, A. A., Knight, E. M., Oyemade, U. J., Cole,
O. J., Westney, O. E., & Westney, L. S. (1994). Pica in an urban
environment. The Journal of Nutrition, 124, 954962.
Emerson, E. (2001). Challenging behaviour: Analysis and intervention in people with severe intellectual disabilities. Cambridge:
Cambridge University Press.
Favell, J. E., McGimsey, J. F., & Schell, R. M. (1982). Treatment of
self-injury by providing alternate sensory activities. Analysis and
Intervention in Developmental Disabilities, 2, 83104.
Hagopian, L. P., Rooker, G. W., & Rolider, N. U. (2011). Identifying
empirically supported treatments for pica in individuals with
intellectual disabilities. Research in Developmental Disabilities,
32, 21142120.
Hanley, G. P., Iwata, B. A., & McCord, B. E. (2003). Functional
analysis of problem behavior: A review. Journal of Applied
Behavior Analysis, 36, 147185.
Heyvaert, M., Saenen, L., Campbell, J. M., Maes, B., & Onghena, P.
(2014). Efficacy of behavioral interventions for reducing problem behavior in persons with autism: An updated quantitative
synthesis of single-subject research. Research in Developmental
Disabilities, 35, 24632476.
Iwata, B. A., Dorsey, M. F., Slifer, K. J., Bauman, K. E., & Richman,
G. S. (1994). Toward a functional analysis of self-injury. Journal
of Applied Behavior Analysis, 27, 197209 (Reprinted from
Analysis and Intervention in Developmental Disabilities, 2,
320, 1982).

123

2114
Kennedy, C. H. (2004). Single case designs for educational research.
Boston, MA: Pearson.
Mahoney, M. J. (1977). Publication prejudices: An experimental
study of confirmatory bias in the peer review system. Cognitive
Therapy and Research, 1, 161175.
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, 353361.
Matson, J. L., Hattier, M. A., Belva, B., & Matson, M. L. (2013). Pica
in persons with developmental disabilities: Approaches to
treatment. Research in Developmental Disabilities, 34,
25642571.
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,
4572.
McLoughlin, I. J. (1988). Pica as a cause of death in three mentally
handicapped men. British Journal of Psychiatry, 152, 842845.
Parker, R. I., & Vannest, K. (2009). An improved effect size for
single-case research: Nonoverlap of all pairs. Behavior Therapy,
40, 357367.
Parker, R. I., Vannest, K. J., & Davis, J. L. (2011). Effect size in
single-case research: A review of nine nonoverlap techniques.
Behavior Modification, 35, 303322.
Piazza, C. C., Fisher, W. W., Hanley, G. P., LeBlanc, L. A., Worsdell,
A. S., Lindauer, S. E., & Keeney, K. M. (1998). Treatment of

123

J Autism Dev Disord (2015) 45:21052114

pica through multiple analyses of its reinforcing functions.
Journal of Applied Behavior Analysis, 31, 165189.
Piazza, C. C., Hanley, G. P., & Fisher, W. W. (1996). Functional
analysis and treatment of cigarette pica. Journal of Applied
Behavior Analysis, 29, 437450.
Rose, E. A., Porcerelli, J. H., & Neale, A. V. (2000). Pica: Common
but commonly missed. Journal of the American Board of Family
Practice, 13, 353358.
Sham, E., & Smith, T. (2014). Publication bias in studies of an
applied behavior analytic intervention: An initial analysis.
Journal of Applied Behavior Analysis, 47, 116.
Sharp, W. G., Jaquess, D. L., Morton, J. F., & Herzinger, C. V.
(2010). Pediatric feeding disorders: A quantitative synthesis of
treatment outcomes. Clinical Child and Family Psychology
Review, 13, 348365.
Stiegler, L. N. (2005). Understanding pica behavior: A review for
clinical and education professionals. Focus on Autism and other
Developmental Disabilities, 20, 2738.
Vollmer, T. R. (1994). The concept of automatic reinforcement:
Implications for behavioral research in developmental disabilities. Research in Developmental Disabilities, 15, 187207.
Williams, D. E., & McAdam, D. (2012). Assessment, behavioral
treatment, and prevention of pica: Clinical guidelines and
recommendations for practitioners. Research in Developmental
Disabilities, 33, 20502057.

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