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DOI 10.1007/s10803-015-2375-z
ORIGINAL PAPER
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
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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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Exclusion
Criterion A
Record
Review
Exclusion
Criterion B
Exclusion
Criteria C
Age
Gender
Diagnosis
Pica Items
10
ASD; ID
10
ASD; ID
13
ASD; ADHD; ID
ASD; ID
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
10
ASD; ADHD
11
16
ASD, ID
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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
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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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
DR + NCR + RB
3.0
2.5
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2.0
1.5
1.0
0.5
0.0
0
10
15
20
25
30
35
40
45
Sessions
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
.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
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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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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.
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
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