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PICA

2 paragraphs on the treatment options for PICA

Assessment and Treatment of Pica Within the Home
Setting in Australia

Tessa Taylor
Paediatric Feeding International, Sydney, New South Wales, Australia, a

University of Canterbury

Pica is one of the most serious, life-threatening topographies of self-injurious behavior
because a single instance can result in death. Despite this, there is a need for more research
on teaching adaptive skills to replace pica, particularly outside of intensive specialized
hospital admissions and with younger children. We present a case history of a 4-year-old
male with autism spectrum disorder, pica, food selectivity, and food stealing in which
assessment and treatment occurred in the family’s home. A functional analysis suggested
pica was maintained by automatic reinforcement. A competing stimulus assessment showed
pica was highest without competing stimuli, lowest with highly preferred edibles, and lower
with highly preferred tangibles. Response interruption and redirection with differential
reinforcement was effective with and without competing stimuli across contexts. The
participant learned to independently throw away, put away, and use appropriately some
materials and to refrain from touching other items he previously consumed inappropriatel

Pica decreased by 97%, independent discards increased by 100%, and 100% of admission
goals were met. His mother and therapist were trained to high procedural integrity on the
treatment procedures, and they continued testing for generalization and maintenance. His
mother reported high satisfaction with the program and outcomes and acceptability of the
treatment procedures. Gains were maintained for over 2 years.

Keywords: pica, pediatric feeding disorders, food selectivity, autism spectrum disorder,
avoidant/restrictive food intake disorder

Pica, the persistent eating of nonnutritive sub-
stances, is a serious and life-threatening self-injurious
behavior, as just one instance can result in death
(American Psychiatric Association, 2013; Williams
& McAdam, 2012). Examples of serious risks
include choking, intestinal obstruction and per-
foration, toxicity (e.g., lead paint), and the in-
gestion of parasites (Matson, Belva, Hattier, &
Matson, 2011; Stiegler, 2005). Physicians have
published case examples of x-rays and surgical

pictures depicting large hair balls, strings, and
disposable gloves spanning the colon, requiring
surgery and loss of tissue; glass or screws tear-
ing or getting stuck in the gastrointestinal sys-
tem; and batteries that have been swallowed
(Matson et al., 2011; Stiegler, 2005).

Functional analyses of pica most often identify
automatic reinforcement (Call, Simmons, Mevers,
& Alvarez, 2015; Hagopian, Rooker, & Rolider,
2011). That is, individuals who engage in pica

X Tessa Taylor, Paediatric Feeding International, Syd-
ney, New South Wales, Australia, and Department of Psy-
chology, Speech and Hearing, and School of Health Sci-
ences, University of Canterbury.

This case history was presented as an invited presenta-
tion at the Telethon Institute’s Autism Update Symposium:
Research Into Practice in Perth, Australia, in 2018. It was
also presented at the biannual conference of the Hellenic
Community for Behavior Analysis in Athens, Greece, in
2017, and at the annual meetings of the Association for
Behavior Analysis Australia in Sydney, Australia, in 2017.
The author reports no conflicts of interest. This case history

was performed in accordance with the ethical standards as
laid down in the 1964 Declaration of Helsinki and its later
amendments and the American Psychological Associa-
tion’s ethical standards in the treatment of humans. Thank
you to Hebert’s early intervention team including Susan
Petrie and Kayleigh Smith of Beanstalk Child Psychology.
Thank you to Nikolas Roglić for assistance with data
analysis and video scoring.

Correspondence concerning this article should be ad-
dressed to Tessa Taylor, Paediatric Feeding International,
Double Bay, Sydney, New South Wales 2028, Australia.
E-mail: DrTaylor@PaediatricFeedingIntl.c

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Behavioral Development
© 2020 American Psychological Association 2020, Vol. 25, No. 1,

–5

ISSN: 1942-0722 http://dx.doi.org/10.1037/bdb000009

often do so when left alone and with lower levels
of stimulation and engagement. Such functional
analyses of pica are typically conducted in inpa-
tient settings, in which a safe environment with
simulated pica items (rather than dangerous ma-
terials) can be arranged (Finney, Russo, &
Cataldo, 1982; Piazza et al., 1998; Piazza, Hanley,
& Fisher, 1996). Inpatient settings also allow the
individual to be observed while alone via a one-
way mirror or video.

Behavior-analytic treatments of pica, includ-
ing reinforcement and response-reduction pro-
cedures, are well-established and empirically
supported (i.e., the highest level and category of
evidence; Hagopian et al., 2011). These treat-
ments are often highly effective, producing
large effect sizes (Call et al., 2015). However,
treatment procedures for pica have changed
over the years. Historically, clinicians aimed to
suppress pica by limiting opportunities and us-
ing punishment when pica occurred (Hagopian
et al., 2011; Matson, Hattier, Belva, & Matson,
2013; McAdam, Sherman, Sheldon, & Napoli-
tano, 2004). Current treatment procedures entail
teaching appropriate eating in the right location
(e.g., food on plate rather than off floor), pro-
viding other options for reinforcement and stim-
ulation (e.g., food, toys), and teaching other
actions with pica items, such as throwing them
away (Hagopian et al., 2011).

As severe and dangerous as pica is, there is less
research on pica than on other topographies of
self-injurious and problem behavior (Matson et
al., 2011). More research is needed with longer
term follow-up (e.g., Busch, Saini, Zorzos, &
Duyile, 2018) and with younger children and ear-
lier intervention. More research is also needed on
teaching multiple alternative skills that are adap-
tive in a variety of contexts to replace pica and
increase independence (e.g., cleaning up, not han-
dling pica items, engaging with other items appro-
priately, eating healthier foods), rather than simply
limiting opportunities and using punishment.

Hagopian, González, Taylor Rivet, Triggs,
and Clark (2011) described a comprehensive
treatment of automatically reinforced pica for
two participants in an inpatient setting. Treat-
ment components included noncontingent ac-
cess to competing stimuli and response inter-
ruption and redirection with differential
reinforcement of alternative behavior. Partici-
pants had noncontingent and continuous access
to preferred items that were associated with low

levels of pica and high levels of engagement.
Pica attempts were blocked, and the experi-
menters taught participants to discard pica items
in the trash. The researchers then taught partic-
ipants to discriminate which items were and
were not appropriate to discard. They prompted
participants to use items appropriately, put
items away, comply with the next step of a
demand sequence, or engage in an incompatible
response (e.g., to put hands in pockets). The
researchers taught one participant to clean the
area when she changed locations to reduce pica
opportunities. The experimenters later general-
ized the treatment to other trash receptacles and
ensured the treatment effects maintained in
school and community settings. Schmidt et al.
(2017) also used response interruption and re-
direction (without competing stimuli) to treat
the automatically reinforced pica of three par-
ticipants in an inpatient setting. The researchers
taught participants to discard and vacuum pica
materials. The experimenters did not teach al-
ternative responses for items not appropriate to
discard or vacuum, nor did they provide com-
munity or follow-up data.

These studies were conducted in intensive,
specialized, inpatient hospital settings with
highly trained and experienced staff and super-
visors, custom built rooms, a full interdisciplin-
ary team, and 24-hr care. Pica treatment is la-
bor, time, and resource intensive (McAdam et
al., 2004) and has been largely limited to the

types of inpatient settings (i.e., a handful of
hospitals in the United States) to assess and treat
pica safely, especially for more severe and older
patients who also engage in other forms of
severe problem behavior (e.g., aggression,
property destruction; Williams & McAdam,
2012). Such treatments require constant and
consistent implementation to be safe and effec-
tive because just one instance can cause signif-
icant harm. Hospitalizations for the assessment
and treatment of pica can last over 6 months.

More treatment research is needed outside of
specialized settings in the United States. Be-
cause pica may be covert and automatically
reinforced, conducting assessment and treat-
ment evaluations without a specialized room
designed specifically for such evaluations can
be challenging to maintain the individual’s
safety while allowing for unobtrusive observa-
tion. In addition, locations outside the United
States may not have adequate or stable Internet

41PICA TREATMENT IN AUSTRALIAN HOME

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connections for covert alternatives to in situ
data collection (e.g., a video feed from which
data collectors measure instances of pica). Also,
the ingredients available in countries outside the
United States may vary significantly and thus
impact the recipes for creating simulated pica
items. Additionally, access to adequate, reli-
able, and trained behavior-analytic staff to assist
with conducting assessment and treatment eval-
uations can be limited outside the United States.

The present case history replicates and ex-
tends the study by Hagopian et al. (2011) in a
home setting overseas and in a condensed time
frame. We extended this research by evaluating
treatment with and without competing stimuli in
varied contexts, presenting data on compliance
with discards and other instructions across var-
ious contexts, adding additional contexts (e.g.,
outside) and skills (e.g., avoiding items such as
others’ food and dangerous or unhygienic
items), assessing caregiver satisfaction and so-
cial validity, and providing extended follow-up
data and qualitative information on applying
treatment over a longer period of time.

Method

Participant, Setting, and Materials

Hebert was a 4-year-old Caucasian male with
autism spectrum disorder, pica, food selectivity,
food stealing, and a history of iron deficiency
requiring supplementation. Iron supplementation
did not improve pica. Upon admission, Hebert’s
pica was significantly impacting his life and re-
stricting his location, daily activities, indepen-
dence, and adaptive functioning. He required con-
tinuous supervision and blocking of pica attempts.
He could not go outside without continuous su-
pervision because he ate leaves, sticks, and dirt.
He also ate plastic, paper, cloth, hair, tape, wood,
and paste. Pica limited Hebert’s access to aca-
demic, therapeutic, and leisure activities. Hebert
also mouthed and bit many household objects and
toys, and he once attempted to chew an extension
cord. Food stealing also significantly impacted his
daily life and social engagement. Access to cup-
boards and the outdoors had to be restricted. Oth-
ers could not eat around him, and they could not
have family dinners. These behaviors significantly
restricted him in community and social settings,
too. Hebert consumed no vegetables, and he ate
only three fruits. Hebert was ambulatory, did not

speak, and was enrolled in an early intensive be-
havioral intervention program. Hebert’s name was
changed to protect confidentiality.

A trained, doctoral-level behavior analyst
conducted sessions in the family’s home. Initial
sessions were conducted in a cleared-out bed-
room with observers positioned against a wall
and behind a barrier (i.e., a foldable picnic
table). Later sessions were conducted in the
dining room, living room, and backyard of the
family’s home. Materials included general ses-
sion materials (e.g., laptop computers for data
collection, a webcam, timers, child-sized table
and chairs, tangibles for the assessments, pre-
ferred edibles, competing items) and materials
specific to training various skills. Laminated
icons depicted pictures similar to those pro-
duced by Boardmaker.

To teach Hebert to discard items, we used
trash receptacles with laminated icons and large
trash items for training. Due to safety concerns
with ingestion of nonedible items, we identified
and used materials that were safe for ingestion
(i.e., simulated pica items that were as tasteless
as possible) but appeared similar to items that
Hebert had a history of ingesting. These items
included ground brown rice (sand); ground flax-
seed and brown rice (dirt); thin rice noodles,
tapioca flakes in noodle form, thick rice noo-
dles, and baked gelatin (plastic); uncooked
black bean spaghetti (sticks); rice paper (paper);
seaweed, lettuce strips, and grass blades (leaves,
grass); arrowroot starch, black beans, and fla-
vorless rice cakes (rocks); and nontoxic crayons
and homemade play dough (made from flour,
water, oil, and food coloring). We swept and
sanitized the floor for indoor sessions prior to
the placement of simulated pica items. The sim-
ulated pica items were scattered in the middle of
the room.

To teach other skills for items that were not
appropriate to discard, we used materials that
Hebert previously chewed, mouthed, and ate (or
attempted to) in the home. We taught Hebert to
“put away” items (e.g., hairbrush, nightlight)
into a large canvas box with laminated icon
depicting putting items away. We used leisure
and demand materials to teach Hebert to “use
appropriately” (e.g., draw with crayon). We
taught Hebert not to touch some materials,
which we called “don’t touch” materials. These
items included other’s food, dirt, electronics,
and household cleaners with a “don’t touch”

42 TAYLOR

laminated icon on them or on the table on which
the items were placed.

Response Measurement, Interobserver
Agreement, and Procedural Integrity

A trained observer recorded child and thera-
pist behavior live and via videos. Observers
used an Excel spreadsheet for data collection
during preference assessments and a program
called BDataPro (Bullock, Fisher, & Hagopian,
2017) running on laptop computers for other
sessions. We scored “pica success” as placing
an inedible item or simulated pica item past the
plane of the lips, “pica attempt” as a blocked
attempt to place an inedible item or simulated
pica item past the plane of the lips, “mouthing
attempt” as a blocked attempt to place an ined-
ible item larger than could fit into the mouth
past the plane of the lips (excluding teether),
and “independent discard” as placing an inedi-
ble item or simulated pica item in a rubbish
receptacle without a prompt. We scored “inde-
pendent compliance” as placing one of the ob-
jects in a “put away” receptacle and completing
a “use appropriately” redirection without a
prompt and “touch” as placing hands within 5.1
cm of a “don’t touch” item.

During assessment and initial treatment ses-
sions, opportunities for pica mostly involved
manipulation of simulated pica materials. Once
treatment was applied to more diverse settings
and over longer periods of time, there were
more varied opportunities for pica and mouth-
ing to occur due to the wider array of materials
naturally available. We scored duration (imme-
diate onset, 3-s offset) of item engagement as
touching, manipulating, and directing eye gaze
toward competing stimuli and consuming a bo-
lus of food larger than the size of a pea (includ-
ing self-feeding and chewing). We converted
frequency data to responses per minute (RPM)
by dividing frequency by session duration. We
calculated percentage of session with item en-
gagement by dividing duration of item engage-
ment by session duration.

We assessed interobserver agreement for
38% (range � 20%– 62%) of sessions across all
phases and conditions by having an independent
second observer collect data from videotaped
sessions. We separated sessions into 10-s inter-
vals and calculated proportional agreement be-
tween the two observers within each interval.

Interobserver agreement averaged 100%
(range � 98%–100%) for pica attempt, 95%
(range � 90%–100%) for pica success, 100%
for mouthing attempt, 100% for touch, 93%
(range � 81%–100%) for independent discard,
99% (range � 98%–100%) for independent
compliance, and 96% (range � 89%–100%) for
item engagement.

We assessed procedural integrity for 100%
of sessions. Observers scored incorrect pro-
cedural integrity using BDataPro when the
therapist failed to implement the target pro-
cedure within 3 s of when the procedure was
programmed to be implemented and when
therapists implemented procedures when they
were not programmed. The rate of incorrect
procedural integrity averaged 0.05 RPM
(range � 0 – 0.6 RPM). For all sessions scored
by a second observer (38%), that second ob-
server also assessed interobserver agreement
on procedural integrity, which averaged
100% (range � 98%–100%) across all proce-
dural-integrity measures. We calculated char-
acterizations of effect sizes using percentage
reduction (Hagopian, Fisher, Sullivan, Ac-
quisto, & LeBlanc, 1998; Hagopian & Greg-
ory, 2016) using the average of the last three
sessions of the final treatment.

Procedure

A trained doctoral-level behavior analyst
conducted sessions approximately 8 hr per day
for 9 consecutive days. The number of sessions
per day varied (n � 206 sessions; M � 2

sessions per day; range � 9 –39).

Sessions

lasted 5 min and occurred consecutively within
phases. We also took periodic short breaks as
needed between sessions (e.g., at the end of an
assessment or treatment phase, after three ses-
sions in each condition, after an hour). A second
person from Hebert’s early intervention team (a
bachelor-level program supervisor or a master-
level board-certified behavior analyst clinic di-
rector) was present and either collected data or
served as a session therapist during generaliza-
tion contexts. Hebert’s early intervention pro-
vider continued generalization, maintenance,
training, expansion, and simplification of the
treatment procedures for everyday life postdis-
charge.

43PICA TREATMENT IN AUSTRALIAN HOME

Functional Analysis

We conducted paired-stimulus tangible (16
items) and edible (13 items) preference assess-
ments (Fisher et al., 1992) to establish a hierar-
chy of preferred stimuli. Our functional analysis
was similar to that described by Piazza et al.
(1996) and Iwata, Dorsey, Slifer, Bauman, and
Richman (1982). The floor was baited with 16
simulated pica items. Sessions lasted until all
items were consumed or 5 min elapsed. All
sessions ended after 5 min. Conditions included
ignore, toy play (control), and social attention.
In the ignore condition, therapists were not in
the session room area, but were in the bedroom
in a mock observation area. We provided no
differential consequences for pica. In the toy-
play (control) condition, moderately preferred
toys were available noncontingently, and the
therapist in the session room delivered brief
social attention (e.g., “That’s a cool song you’re
playing”) every 30 s and provided no differen-
tial consequences for pica. In the social-
attention condition, moderate to low preference
toys were available noncontingently, the thera-
pist was in the session room but “busy” reading
and writing in a notebook, and the therapist
delivered brief attention (e.g., “That’s gross,”
“You’re not supposed to eat that,” “You’ll get
sick”) similar to what caregivers and therapists
reported to occur commonly following in-
stances of pica. Due to not having an observa-
tion room and concerns that Hebert would not
engage in pica with others in the room due to a
history of pica being interrupted, we started
with consecutive ignore sessions and did not
begin the social attention condition until after
evaluating automatic reinforcement.

Competing Stimulus Assessment

We conducted a competing stimulus assess-
ment (Piazza et al., 1998) to identify stimuli that
competed with Hebert’s pica. We evaluated five
nonedible stimuli and one condition with con-
tinuous delivery of a variety of highly preferred
edibles (i.e., one small piece of food placed on
a plate at a time and then immediately replen-
ished after being consumed). Simulated pica
items were on the floor, as in the functional
analysis. We presented each stimulus individu-
ally and on a child-sized table. We remained in
the mock observation room but ignored pica.

We also conducted a no-stimulus control con-
dition. Conditions occurred in a randomized
order, and we conducted three sessions per con-
dition (n � 21). Sessions lasted 3 min. We
identified and used within the treatment proce-
dures those competing stimuli associated with
low rates of pica and high percentages of item
engagement.

Treatment Evaluation

A small (approximately 30-cm tall) rubbish
receptacle with a visual icon and simulated pica
items were present across all sessions. The rub-
bish receptacle was placed on the border of the
scattered, simulated pica items.

Baseline ignore. Neither attention nor
competing items was available.

Competing stimuli. Hebert had continuous
and noncontingent access to nonedible compet-
ing stimuli. We told Hebert, “You can play with
your toys” and ignored pica.

Treatment (response interruption and
redirection). We conducted pretreatment
training initially with 15 large trash items on the
floor, then we mixed in simulated pica items
until independent discards increased and zero
physical prompting was needed. We taught He-
bert to pick up and discard items into a rubbish
receptacle to obtain reinforcement (i.e., verbal
descriptive praise and a preferred edible). If
Hebert did not pick up an item within 30 s, we
prompted him using a least-to-most prompting
procedure (i.e., verbal, gestural, and full physi-
cal prompts) to occasion compliance. We deliv-
ered an edible and descriptive praise following
each discard, unless physical guidance was re-
quired. If Hebert held a simulated pica item, we
blocked pica attempts by placing our hands
between Hebert’s hands and mouth. If he held
the simulated pica item longer than 2 s or at-
tempted pica, we blocked and redirected him to
discard the item in a rubbish receptacle. We
blocked attempts to discard competing stimuli
and attempts to engage with the rubbish bin
when not discarding, which did not occur.

Treatment with and without competing
stimuli. After demonstrating initial efficacy of
the treatment procedures, we then compared
treatment effects when noncontingent compet-
ing stimuli were and were not available within a
multielement design. We did this in preparation
for future contexts in which treatment would be

44 TAYLOR

implemented without the availability of com-
peting stimuli.

Generalization. We next took steps to gen-
eralize the treatment to better reflect the types of
situations and contexts Hebert experienced rou-
tinely and to account for the increased opportu-
nities for pica Hebert would encounter follow-
ing discharge. Up to this point, Hebert had
learned only to pick up and throw away bated
pica materials; therefore, prior to this phase, we
conducted sessions (not shown) to introduce
new contexts (e.g., a leisure and an academic
context) in which Hebert would interact with
materials that were not appropriate to throw
way. During these and all subsequent sessions,
we introduced pica materials that Hebert had a
history of mouthing or eating. We also discon-
tinued edible reinforcement for compliance
with prompts following pica and mouthing at-
tempts.

Following instances of attempted or actual
pica or mouthing, the therapist redirected He-
bert in one of three ways (hereafter referred to
as “use appropriately,” “put away,” and “don’t
touch”). For “use appropriately,” we conducted
treatment sessions in one of three contexts: de-
mand (sort shapes, place objects in egg crate,
insert popsicle sticks, put on lids), academic
(glue paper, hole punch paper, draw, paint,
mold play dough), and prompted leisure (place
toy CD in player, place toy fish in bowl, place
toy cookie in jar). Across these three contexts,
the therapist used a least-to-most promoting se-
quence to occasion compliance with the task at
hand. Attempted or actual pica or mouthing
resulted in the therapist implementing the next
prompt in the prompting sequence. For exam-
ple, if Hebert was in a demand context and
attempted to place demand materials in his
mouth, the therapist initiated the next step in the
prompting sequence until Hebert used the ma-
terials appropriately. For “put away,” we inter-
vened similarly by prompting Hebert to place
items that were appropriate for him to have
contact with at certain times (e.g., a hair brush,
shoes, a night light, a stuffed animal) in a re-
ceptacle with a visual “put away” icon on it. For
“do not touch,” we placed “don’t touch” lami-
nated visual icons on all items or surfaces that
Hebert should never touch (e.g., an extension
cord, dishwashing liquid, his mother’s purse, a
wooden spoon, his sister’s small plastic toys,
others’ mobile phones). Following attempts to

touch these materials, we prompted Hebert to
clasp his hands together as an incompatible
response. We also arranged differential rein-
forcement of other behavior (starting with a
30-s resetting interval) using a small piece of a
highly preferred edible for not touching these
materials. Across these three contexts, we con-
ducted 27 generalization sessions.

We then returned to the treatment evaluation
and combined all contexts and ways of redirect-
ing Hebert (i.e., use appropriately, put away, do
not touch) into each session. We removed dirt
and sand from simulated pica items, as we later
taught broom/dustpan skills inside, and dirt and
sand became do-not-touch materials when out-
doors. During this phase, starting with

Session

34, we removed descriptive praise for compli-
ance to simplify the treatment procedures.

Treatment plus clean-up. We next taught
Hebert to clean at the start of each session to
make the area safer by decreasing pica oppor-
tunities. We prompted Hebert to clean up which
included discarding all simulated pica items and
putting away all put-away items. Hebert did not
have access to competing stimuli during this
clean-up period. Once this was complete, He-
bert regained access to competing stimuli, and
the resetting differential reinforcement of other
behavior started. Following the clean-up period,
the therapist did not interact with him unless he
initiated interaction, but the therapist remained
within arm’s reach to block any pica attempts.
In this phase, we added a portable rubbish re-
ceptacle (clip on canvas pouch with rubbish
visual icon) and prompted him to empty it in the
rubbish bin (this bin remained in place) after
discarding all items. We also added a backpack
to carry competing stimuli for portability and
prompted him to unpack and pack it.

We conducted caregiver training with He-
bert’s mother using behavioral skills training.
We provided a written protocol and cheat sheet
for her to review, and she watched session vid-
eos of therapists modeling the treatment proce-
dures. We reviewed the written protocol and
cheat sheet with her and answered questions.
We conducted a role play with her and gave
feedback. We had her run sessions with us
present, and we gave feedback if needed. To
evaluate effectiveness in a more naturalistic set-
ting, we conducted sessions in different settings
including the dining room and lounge room. We
varied session therapists to ensure treatment

45PICA TREATMENT IN AUSTRALIAN HOME

remained effective across caregivers and loca-
tions.

After the treatment evaluation was complete,
we discontinued simulated pica items, as there
were sufficient pica opportunities in the gener-
alization contexts. To further generalize the
treatment, we conducted separate sessions (not
shown) for contexts hypothesized by caregiver
and Hebert’s treatment team report to be more
difficult (i.e., have a higher frequency of pica)
including when Hebert was outside in the back-
yard, while reading books, while eating with
others, and when playing with Play-Doh.
Across these contexts, we conducted 43 gener-
alization sessions.

Caregiver Satisfaction and
Social Acceptability

At the end of the intensive program, we gave
caregivers a written discharge questionnaire (on
a Likert-type scale ranging from 1 to 5) to
assess program satisfaction (23 items similar to
those listed in Table 1 in Hoch, Babbitt, Coe,
Krell, & Hackbert, 1994) and social acceptabil-
ity of treatment (16 items similar to the Inter-
vention Rating Profile used by Martens, Witt,
Elliott, & Darveaux, 1985).1 We computed a
score for each measure as an average (total
summed score divided by the number of items).

Results

A hierarchy was established for tangible and
edible stimuli. We used the top four edible
items: cheese and bacon balls, Tic Toc biscuits,
Twisties, and bread. Although books were
highly preferred, we did not use books as com-
peting stimuli due to the potential for pica with
the paper.

Functional Analysis and Competing
Stimulus Assessment

Pica was high in the initial ignore phase (M �
2.6). It decreased to low levels in the initial
control/toy-play phase, which had a therapist
present (M � 0.1). Pica increased again in the
ignore condition (M � 1.1) and remained high
and undifferentiated across conditions for the
remainder of the analysis, suggesting that the
behavior was maintained by automatic rein-
forcement. This interpretation of behavioral

function was consistent with caregiver and
treatment team reports. Figure 1 depicts these
results.

In the competing stimulus assessment, pica
was highest in the ignore condition (M � 3.4)
and lowest (M � 0.1) in the edible condition. In
the edible condition, he ate only one piece of
pink crayon which he likely mistook for a pink
cookie he had dropped. With the tangible stim-
uli, pica was lower than ignore, but pica re-
mained variable (M � 2.0, range 0.9 to 3.0), and
engagement was variable (M � 65%, range
17% to 98%). The teether was associated with
the highest rate of pica and the lowest levels of
engagement. Figure 2 depicts these results.

Treatment Evaluation

Pica was higher in baseline (M � 2.3) than
when competing stimuli were available (M �
1.5), and independent discards were zero in the
initial phase and replication. Independent dis-
cards increased with treatment (M � 4.3), and
pica decreased. Pica was lower in the replica-
tion (M � 0.1) when compared to the initial
treatment phase (no successes; M � 0.3 for
attempts). In the final treatment phase when we
expanded contexts, added clean-up, and did
training and generalization, independent dis-
cards (M � 3.6) and compliance (M � 1.6)
remained high, and pica (M � 0.1), mouthing
(M � 0.02), and touch attempts (M � 0.04)
remained low. Figure 3 depicts results of the
treatment evaluation.

In comparing treatment with and without
competing stimuli, pica was 0 without and low
(M � 0.1) with, and independent discards were
lower with competing stimuli available (M �
5.2 compared to 10.8) due to item engagement
(taking time to play with competing stimuli
rather than discard). This demonstrates that with
or without competing stimuli, response inter-
ruption/redirection and differential reinforce-
ment for discarding was effective; however,
previous data from the treatment evaluation
demonstrated that without response interrup-
tion/redirection and differential reinforcement,

1 Please see https://survey.zohopublic.com/zs/AeCsbn
for the satisfaction questionnaire and https://survey.
zohopublic.com/zs/WZCsQv for the acceptability question-
naire.

46 TAYLOR

pica was lower with competing stimuli avail-
able when compared to baseline.

For contexts conducted separately, for “de-
mand,” pica, mouthing, and touch attempts
were zero, and the reinforcement interval was
increased to 45 s. For “outside,” pica and
mouthing were zero and touch attempts were
low (M � 0.04), and the reinforcement interval
was increased to 1 min. For “do not touch” with
other’s food/eating with others, pica successes
and mouthing were zero, pica attempts were
low (M � 0.04), and touch attempts were low
(M � 0.2) and decreased to zero in the final
three sessions. For Academics, pica successes
were low (M � 0.1), as were pica attempts
(M � 0.2), and mouthing and touch attempts
were zero. With play dough, pica successes and
touch attempts were zero, mouthing was low
(M � 0.03), and pica attempts were higher than
in other contexts (M � 0.9).

For characterizations of effect sizes of the
treatment via percent reduction (Hagopian &
Gregory, 2016), there was a 100% increase in
independent discards and a 97% decrease in
pica, mouthing, and touch attempts. Hebert met

100% of his individualized goals (in summary,
identify preferences, identify function, identify
competing stimuli, teach alternative responses
to pica, formulate treatment package to reduce
pica by 90% or greater, train caregivers to pro-
cedural integrity of �1/min incorrect RPM, and
generalize the protocol).

Follow-Up

At a 3-month follow-up, the schedule of re-
inforcement for independent discards and redi-
rection compliance had been increased to vari-
able ratio 2. Independence remained high and
pica, mouthing, and touch attempts remained
low. Pica and mouthing attempts were zero,
touch attempts were low (M � 0.1), and inde-
pendent discards (M � 2.8) and independent
compliance (M � 3.0) were high. Follow-up
data are shown in Figure 3.

Caregiver Satisfaction and Social
Acceptability

Hebert’s mother reported high social treat-
ment acceptability (4.44 out of 5) and program

-1

0
1
2

0 5 10 15 20 25

etuni
Mrep

sesnopseR
Pi
ca

Sessions

Ignore

Toy Play /
Control

Social
A�en�on

Figure 1. Functional analysis.

47PICA TREATMENT IN AUSTRALIAN HOME

satisfaction (4.04 out of 5). At a 2-year,
3-month follow-up, Hebert’s mother reported
pica was much better than pretreatment (4/5) on
a 5-point Likert-type question from 1 (worse
than pretreatment) to 5 (resolved) on the satis-
faction survey (Hoch et al., 1994), and she
indicated that she would be highly likely to
recommend this treatment to other families.

Discussion

We replicated Hagopian et al. (2011) includ-
ing teaching multiple adaptive replacement
skills to increase independence. Pica decreased
by 97% and independence discards and appro-
priate alternative responses increased to 100%.
We extended this research in several ways. We
translated this process to a home setting over-
seas, condensing the treatment progression to
less than a 2-week admission (compared to over
6 months), and maintained experimental con-
trol, while reporting interobserver agreement
and procedural integrity data. Hebert learned to
throw away pica materials, put away items okay
for him to touch, use other materials appropri-
ately, and refrain from touching materials he
should never touch. Following treatment, he
was able go outside with less supervision and
eventually attend preschool. Gains maintained

over 2 years, and his mother reported high sat-
isfaction and acceptability.

Consistent with the literature, the functional
analysis clarified that Hebert’s pica was auto-
matically reinforced. Competing stimulus as-
sessment showed that pica was highest when
Hebert was alone, lowest with highly preferred
edibles (food), and lower with some highly pre-
ferred tangibles (toys). Response interruption/
redirection with differential reinforcement was
effective both with and without competing stim-
uli.

Hebert being able to more fully participate in
his early intervention program and eventually
go to preschool was a significant benefit. Prior
to treatment, there was a wide range of items
(e.g., paste, crayons, play dough) the early in-
tervention team could not use in his program
due to pica, and many other program materials
(e.g., plastic, paper, wood) had chew marks and
pieces missing due to pica. These are materials
typically accessible and used in a preschool
environment. Preschools in Australia also spend
a large amount of time outdoors, including
meals and outdoor playground time (with sand-
boxes). Prior to treatment, Hebert could not
participate in these activities.

A significant strength of this case history was
the early intervention team maintenance, gener-

0
1
2
3
4
0

100
Pica per M

inute
tne

megagnE
sulu

mitS
hti

w
slavretnIfo

egatnecreP

Figure 2. Competing stimulus assessment.

48 TAYLOR

alization, and follow-up as well as caregiver
dedication and involvement. The team contin-
ued monitoring by taking data, training Hebert’s
caregivers, conducting the program in various
contexts, thinning schedules of reinforcement,
and fading caregiver proximity in different con-

texts based on data. Hebert’s treatment was
labor intensive but critical. This intervention
would not likely be successful long term with-
out an adequate treatment team. The procedures
must be carried out with high procedural integ-
rity and by adequately trained, dedicated (1:1

-1
1
3
5

0 10 20 30 40 50 60 70

tnednepednI
etun i

MrepsesnopseR

Session

Baseline (BL) { – – RIRD – – } BL { – – – – – – – – – – – – – – – – – – ResponseInterrup�on/Redirec�on(RIRD) – – – – – – – – – – – – – – – – – – }
Ignore vs CS vs

Compe�ng + RIRD CS + RIRD Treatment Generalisa�on Treatment + Clean-up
S�muli (CS) (Reversal) with/out CS 3-mo Follow-up

Discard

Compliance

Discard
BL

Discard
CS

Discard
without CS

Co
nt

ex
ts

Re
m

ov
e

Di
rt

&
Sa

nd
Re
m
ov
e

Pr
ai

M
um

Di
ni

ng
Ro

Lo
un

ge
Ro

VR
2

–

0.5

0
0.5
1

1.5

2.5

3.5

4
0 10 20 30 40 50 60 70

aci P
etuni

Mr ep
sesnopseR

4
Session

A�empts

BL Ignore

CS
Without

Pica

Co
nt
ex
ts

Figure 3. (Top panel) Independent discards and compliance per minute and (bottom panel)
pica, mouthing, and touch attempts.

49PICA TREATMENT IN AUSTRALIAN HOME

without other responsibilities or divided atten-
tion) caregivers/therapists. The assessment and
treatment evaluations also have to be conducted
intensively with adequate resources and thera-
pists due to the significant risk and life-
threatening nature of pica, and the necessity of
eliminating and replacing automatically rein-
forced behavior.

Hebert’s highly preferred foods were un-
healthy foods. Additionally, the only competing
stimuli that were effective at reducing pica to
acceptable levels were these foods. Tangible
items, including a teether that could be mouthed
and chewed safely, did not reduce pica to clin-
ically significant levels. With other tangible
items that he manipulated with his hands, He-
bert could still engage in pica while playing
with these items.

Food stealing was also a significant problem
for Hebert. We expanded the Do not-Touch
context so that Hebert could eat with others
without food stealing. This was significant for
the household (e.g., family meals), in the com-
munity (e.g., food courts), and in preparation for
eating with other children at preschool. Follow-
ing the treatment of pica, we increased Hebert’s
food variety (to 13 vegetables, eight fruits, and
five proteins). This potentially opened up a wide
range of reinforcer options and the ability to
provide more low-calorie foods to consuming
instead of engaging in pica. Improved food va-
riety may also help decrease pica by correcting
and preventing nutritional deficiencies (e.g.,
iron, zinc). A limitation of the current case
history is that we did not evaluate the impact of
increased food variety on pica. Future studies
could evaluate this, as well as the effectiveness
using such foods later as competing stimuli for
pica.

There are several limitations of the current
case history worthy of discussion. We did not
conduct a component analysis to determine
which components were responsible for the
therapeutic effects. We also did not assess the
efficacy of blocking before conducting the treat-
ment procedures described. It is also important
to note that Hebert’s age and severity of intel-
lectual disability was lower than participants in
Hagopian et al. (2011) and Schmidt et al.
(2017). Hebert required substantially fewer
training sessions than participants in these prior
studies, and he learned the incompatible re-
sponse after a single model of the response.

Hebert also did not engage in other topogra-
phies of problem behavior (e.g., aggression,
self-injury), which could have extended the as-
sessment and treatment evaluation.

Much more research is needed on teaching
multiple adaptive skills to replace pica and in-
crease independence, and this is a needed rep-
lication and extension of the literature. We ex-
tended to a home setting overseas, added
additional contexts and skills (e.g., outside,
avoid items), and provided extended follow-up
data. Behavior-analytic treatments for pica are
well-established and empirically supported.
However, most families (and professionals) in-
ternationally may be unaware or unable to ac-
cess such treatments. This case history is a
significant step toward translating and condens-
ing specialized hospital admissions to the home
setting and increasing availability of effective
treatment for pica abroad. Future research
should continue to expand this treatment to be
more readily accessible to practitioners and
families.

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Received August 5, 2019
Revision received March 23, 2020

Accepted March 25, 2020 �

51PICA TREATMENT IN AUSTRALIAN HOME

226 McNaughten B, et al. Arch Dis Child Educ Pract Ed 2017;102:226–229. doi:10.1136/archdischild-2016-312121

AbstrAct
Pica is defined as the persistent ingestion of
non-nutritive substances for more than 1 month
at an age at which this behaviour is deemed
inappropriate. It occurs most commonly in
children, in patients with learning disabilities
and in pregnancy. The aetiology of pica is poorly
understood and is probably multifactorial.
Clinical assessment can be difficult. History
and examination should be tailored to address
potential complications of the substance being
ingested. Complications can be life threatening.
Pica often self-remits in younger children. In
those with learning disabilities, however, pica
may persist into adulthood. Management
strategies should involve a multidisciplinary
approach, and interventions are primarily
behavioural in nature. There is limited evidence
to support pharmacological interventions in the
management of children with pica.

IntroductIon
Pica is the persistent ingestion of non-nu-
tritive substances for more than 1 month
at an age at which this behaviour is
deemed inappropriate1 (see box 1). The
term originates in the Latin word for
magpie, a bird famed for collecting and
hoarding unusual objects.2

Pica can be classified according to the
particular substance ingested. Common
subtypes are listed in table 1. Ingestion of
non-food substances may also be associ-
ated with cultural practices. Geophagia,
including the ingestion of kaolin (white
clay), is seen in sections of the Afri-
can-American population in the USA and
is common practice in parts of Africa.3
Although often described as pica in the
literature, these practices may actually be
deemed to be socially normative practice
and therefore do not fit the diagnostic
criteria outlined in The Diagnostic and
Statistical Manual of Mental Disorders,
Fifth Edition (DSM-V).

Pica is most commonly seen in children
aged 2 or 3 years old. It may persist into

adolescence when it is usually associated
with learning difficulties.4 Studies suggest
pica can be present in between 5% and
25% of children with learning difficulties.
Pica is also common in pregnancy, occur-
ring in up to 28% of cases. It typically
occurs in younger women in their first
pregnancy.5 This article provides an over-
view of the possible causes and poten-
tial complications of pica. In addition, it
discusses important aspects of the clinical
assessment, investigation and manage-
ment of a child presenting with pica.

AetIology
The aetiology of pica is poorly understood
and is probably multifactorial. Proposed
mechanisms range from psychosocial to
biochemical.

An association between pica and micro-
nutrient deficiencies, including iron,
calcium and zinc has been well described.
A recent meta-analysis confirmed the
association between anaemia, low
plasma zinc levels and pica.6 Children
with pica may ingest substances rich in
the nutrients in which they are deficient.
However, there has been limited success
in preventing pica in cases where nutri-
tional deficiencies have been identified
and treated.

The higher incidence of pica noted
in children with learning and develop-
mental disabilities, including autistic spec-
trum disorder, was traditionally believed
to result from an inability to differen-
tiate between food and non-food items.
However, current thinking suggests that
this is more likely to be secondary to
learned behaviours.4 7

Pica in children has also been associated
with deprivation, parental neglect and
malnutrition.2 It may present in the pres-
ence of a coexisting psychiatric disorder,
and there is increasing evidence that it may
be associated with conditions leading to
malabsorption, poor nutritional status or
anaemia. Recent literature, for example,
has highlighted concerns regarding the

Best practice

Fifteen-minute consultation: the
child with pica

Ben McNaughten, thomas Bourke, andrew thompson

Royal Belfast Hospital for Sick
Children, Belfast, UK

Correspondence to
Dr Ben McNaughten, Royal
Belfast Hospital for Sick
Children, 180-184 Falls
Road, Belfast BT12 6BE, UK;
bmcnaughten095@ hotmail. com

Received 30 November 2016
Revised 15 February 2017
Accepted 28 February 2017
Published Online First
9 May 2017

To cite: McNaughten B,
Bourke T, Thompson A. Arch
Dis Child Educ Pract Ed
2017;102:226–229.

McNaughten B, et al. Arch Dis Child Educ Pract Ed 2017;102:226–229. doi:10.1136/archdischild-2016-312121 227

Best practice

Table 1 Common subtypes of pica according to the
substance ingested

Subtypes of pica Substance ingested

Acuphagia Sharp objects
Coniophagia Dust
Coprophagia Faeces
Emetophagia Vomit
Hyalophagia Glass
Lithophagia Stones
Pagophagia Ice
Plumbophagia Lead
Tricophagia Hair, wool or other fibres
Xylophagia Wood

increased incidence of pica among children with
sickle cell disease.8 9

clInIcAl presentAtIon
History taking
The clinical presentation of pica is highly variable and
depends on the particular substance being ingested
and the potential associated complications. History
taking should focus on the substance ingested. If there
is a risk of poisoning, the history should focus on the
consequences of that poisoning. Enquire about symp-
toms of anaemia, such as pallor, shortness of breath,
palpitations and lethargy. Ask about coexisting medical
conditions that may predispose to pica. Take a thor-
ough developmental and social history. Explore the
patient’s living environment, for example, the risk of
exposure to lead.

Challenges may arise in consultations with older
children, who might deny pica or show reluctance to
disclose information. This may limit the clinician’s
ability to make an accurate diagnosis and prediction
regarding potential complications.

clinical examination
Examination will often be normal in children with
pica. Clinical signs are usually secondary to compli-
cations of the substance that has been ingested. These
can be classified into four main groups (see figure 1):
1. Manifestations of toxic ingestion:

– Lead poisoning is the most common poisoning
associated with pica.

– Most patients are asymptomatic, and the signs can be
very subtle.10

2. Manifestations of infection or parasitic infestation:
– Toxocariasis and ascariasis are the most common

parasitic infections associated with pica.
– The clinical manifestations relate to the number of

larvae ingested and the organs to which the larvae
migrate.11

3. Gastrointestinal manifestations:
– Manifestations may be a result of mechanical bowel

problems, perforations and intestinal obstructions
caused by bezoar formation around indigestible
substances.

4. Dental manifestations:
– Manifestations may include severe abrasion and other

mechanical damage to tooth substance.12

InvestIgatIons
Pica is a clinical diagnosis based on the DSM-V diag-
nostic criteria. Investigations may be useful in screening
for potential causes and complications. The meta-anal-
ysis examining micronutrient status and pica noted a
strong association between pica and anaemia.6 Check a
full-blood picture and iron studies in all children.

Further investigations should be tailored according
to the substance ingested and the clinical findings. The
American Academy of Pediatrics recommends that routine
screening of blood lead concentrations be performed in
children who live in residential areas where at least 27%
of the houses were built before 1950.10 The prevalence
of lead piping in domestic water supplies in the UK has
decreased significantly in recent years. However, it is still
common in older houses, and knowledge of the local
environment is important.13 Check blood lead concen-
tration in children:

► with signs or symptoms of poisoning (figure 1)
► with a history of ingestion of lead based paints
► when environmental exposure is suspected.
There is little evidence to suggest an ideal set of

investigations in children presenting with faltering
growth.14 Consider checking at least urea and electro-
lytes, liver function tests, calcium, phosphate magne-
sium and trace elements in these children.

Imaging studies may be useful if there is a suspicion
that abrasive objects have been ingested or there are
clinical signs of gastrointestinal obstruction. Plain
film of the abdomen may show signs suggestive of
trichophagia. However, if there is a palpable mass or
signs of obstruction, a contrast study or CT are the
investigations of choice.15

MAnAgeMent
Although pica in young children and pregnancy
normally remits spontaneously, it is a potentially
deadly self-injurious behaviour. This is particularly true
when it persists into adolescence and adulthood. Social
stigmatisation may also occur. Pica is best managed
using a multidisciplinary team approach.16 The team

Box 1 DSM-V (The Diagnostic and Statistical
Manual of Mental Disorders, Fifth Edition) criteria
for the diagnosis of pica

► The eating of non-nutritive, non-food substances is
persistent over a period of at least 1 month.

► The eating of such substances is inappropriate to the
developmental level of the individual.

► The eating behaviour is not part of a culturally supported
or socially normative practice.

► If the behaviour occurs within the context of another
mental disorder or medical condition, it is sufficiently
severe to warrant independent clinical attention.1

McNaughten B, et al. Arch Dis Child Educ Pract Ed 2017;102:226–229. doi:10.1136/archdischild-2016-312121228

Best practice

Figure 1 Potential complications of pica and their clinical manifestations.

Figure 2 Behavioural interventions for pica.

may include physicians, social workers, dieticians,
psychologists and dentists. When devising a treatment
plan, consider the symptoms and complications that
the child is experiencing. Parents and patients should
receive education around sound nutritional practices
and be made aware of the potential severity of the
condition. Treat any nutritional deficiencies identified.

Additional treatment options can be divided into
two main groups: behavioural interventions and phar-
macological interventions. A variety of behavioural
interventions exist (see figure 2):

► positive reinforcement if pica is not attempted;
► discrimination training0 between edible and inedible

substances;
► visual screening, that is, eyes are covered for a short

period, if pica is attempted;
► aversive presentation if pica is attempted, for example, a

bitter taste, such as lemon juice;
► Physical interventions:

– Self-protection devices that prohibit placement of
objects in the mouth;

– Time-out if pica is attempted.
Although studies in the existing literature are limited

to small sample sizes, it is commonly believed that these
methods can be highly effective treatments for pica.16–18

Pharmacological interventions are rarely indicated in
pica. The use of selective serotonin reuptake inhibitors has

been reported in three adolescents with pica and learning
difficulties.19 A further case report describes resolution
of pica following the use of methylphenidate to treat
comorbid attention-deficit hyperactivity disorder.20

McNaughten B, et al. Arch Dis Child Educ Pract Ed 2017;102:226–229. doi:10.1136/archdischild-2016-312121 229

Best practice

Figure 3 Flow chart depicting literature search.

Key messages

► Pica is the persistent ingestion of non-nutritive
substances for more than 1 month at an age at which
this behaviour is deemed inappropriate.

► It occurs most commonly in children, in patients with
learning disabilities and in pregnancy.

► The aetiology is poorly understood.
► History and examination should be tailored to address
potential complications of the substance being ingested.

► Complications can be life threatening.
► Interventions should involve a multidisciplinary approach
and are primarily behavioural in nature.

Contributors BM wrote the first draft. TB and AT reviewed the content and
suggested amendments that BM incorporated. All authors approved the final
version.

Competing interests None declared.

Provenance and peer review Commissioned; externally peer reviewed.

RefeRences
1 American Psychiatric Association. Diagnostic and statistical

manual of mental disorders. 5th edn. Arlington, VA: American
Psychiatric Association, 2013.

2 Rose EA, Porcerelli JH, Neale AV. Pica: common but
commonly missed. J Am Board Fam Pract 2000;13:353–8.

3 Lar UA, Agene JI, Umar AI. Geophagic clay materials from
Nigeria: a potential source of heavy metals and human health
implications in mostly women and children who practice it.
Environ Geochem Health 2015:37:363–75.

4 Hagopian LP, Rooker GW, Rolider NU. Identifying empirically
supported treatments for pica in individuals with intellectual
disabilities. Res Dev Disabil 2011:32:2114–20.

5 Fawcett EJ, Fawcett JM, Mazmanian D. A meta-analysis of
the worldwide prevalence of pica during pregnancy and the
postpartum period. Int J Gynaecol Obstet 2016:133:277–83.

6 Miao D, Young SL, Golden CD. A meta-analysis of pica and
micronutrient status. Am J Hum Biol 2015:27:84–93.

7 Pica SP. Developmental disability. JABFM 2001;14:80–1.
8 Aloni MN, Lecerf P, Lê PQ, , et al. Is pica under-reported in

children with sickle cell disease? A pilot study in a Belgian
cohort. Hematology 2015:20:429–32.

9 O’Callaghan ET, Gold JI. Pica in children with sickle cell
disease: two case reports. J Pediatr Nurs 2012:27:e65–70.

10 Committee on Environmental Health. Screening for elevated
blood lead levels. Pediatrics 1998;101:1072–8.

11 American Academy of Pediatrics. Toxocariasis. In: Kimberlin
DW, Brady MT, Jackson MA, Long SS, eds. Red book®: 2015
Report of the Committee of Infectious Diseases. Washington,
DC: American Academy of Pediatrics, 2015:786–7.

12 Johnson CD, Shynett B, Dosch R, et al. An unusual case of
tooth loss, abrasion, and erosion associated with a culturally
accepted habit. Gen Dent 2007:55:445–8.

13 Watt GC, Britton A, Gilmour HG, et al. Public health
implications of new guidelines for lead in drinking water: a
case study in an area with historically high water lead levels.
Food Chem Toxicol 2000;38(1 Suppl):S73–9.

14 Shields B, Wacogne I, Wright CM. Weight faltering and failure
to thrive in infancy and early childhood. BMJ 2012;345:e5931.

15 Learning Radiology. http:// learningradiology. com/
archives2011/ COW% 20437- Bezoar/ bezoarcorrect. htm
(accessed Jan 2017).

16 Williams DE, McAdam D. Assessment, behavioral
treatment, and prevention of pica: clinical guidelines
and recommendations for practitioners. Res Dev Disabil
2012;33:2050–7.

17 Blinder BJ, Salama C. An update on Pica: prevalence,
contributing causes, and treatment. Psychiatric Times
2008;25:66–73.

18 Call NA, Simmons CA, Mevers JE, et al. Clinical outcomes of
behavioral treatments for pica in children with developmental
disabilities. J Autism Dev Disord 2015:45:2105–14.

19 Singh NN, Ellis CR, Crews WD, et al. Does diminished
dopaminergic neurotransmission increase pica? J Child Adolesc
Psychopharmacol 1994;4:93–9.

20 Hergüner S, Hergüner AS. Pica in a child with attention
deficit hyperactivity disorder and successful treatment with
methylphenidate. Prog Neuropsychopharmacol Biol Psychiatry
2010:34:1155–6.

Reproduced with permission of copyright owner.
Further reproduction prohibited without permission.

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