Tuesday, February 26, 2019

Contrasting Pica Behavior for Individuals with ASD and IDD Against Presentation in the General Population Part III

Contrasting Pica Behavior for Individuals with ASD and IDD Against Presentation in the General Population Part III

By Janice Goldschmidt, MS, RD, LDN
(This is Part III of a 3 part series on the named topic. Part I was posted in the December 2018 E-Newsletter and can be found here. Part II was posted in the January 2019 E-Newsletter and can be found here. 
Complications of Pica
The most easily identified form of pica toxicity is lead poisoning, which was likely more common before removal from paint, ink, and toys. Individuals displaying pica are also susceptible to poisoning from other heavy metals. Other issues of interest to health care professionals in the treatment of pica for those with ASD and IDD include energy intake, obesity, gastrointestinal issues, or other complications.
One of the nutritionally related aspects of pica that is often overlooked in research is the fact that resolution of the disorder has been found in many studies to be mitigated by differential or increased access to food.   Food-related interventions have created defined rules for consumption,75 redirected to an alternate favored food,76 rewarded food for avoidance of pica,55 used favorite snacks to promote redirection,26,76  incorporated foods with comparable textures to preferred pica items,77 exchanged edible for inedible objects,48,78 coordinated restrictive approaches with food reinforcers,79 and provided training to discriminate between edible and inedible objects.49,74  Indeed, the striking number of pica studies that have incorporated food into treatment strategies suggests that, for at least a portion of those afflicted, energy needs were not being met.  Nutrition professionals are well positioned to contribute to this body of research by clarifying the relationship between pica display and energy intake.
The relationship of obesity and pica is demonstrated most clearly in Prader-Willi syndrome, which is highly comorbid with phenotypic overlap.80  Among other behaviors, individuals with this rare congenital disorder present hyperphagia and high rates of obesity.  Individuals with Prader-Willi are often willing to eat many items that would typically fall under the label of pica, including contaminated food, raw meat, or odorized non-food items, such as citrus-scented cleaning products.81
Gastrointestinal concerns are a common nutritionally related concern of pica, with constipation chronic across the ASD and IDD population. Ashworth found that pica was not associated with higher rates of gastrointestinal health problems among institutionalized individuals, with the exception of acid reflux.20 Other studies, however, have correlated the observation of pica with constipation, vomiting, nausea, fever and fecal impaction.25,82
Some pica behaviors contribute to significant health complications that can be fatal.77  Life-threatening outcomes involve choking, bowel obstruction and perforation, as well as intestinal bleeding or asphyxia.18  A ten-year follow-up of four individuals with DD who had successfully been treated for pica found that three of the four were deceased.  The researchers concluded that “…years of ingesting nonnutritive substances takes its toll and may lead to premature death.’’83
Other complications for those with ASD and IDD include dental complications, obstructions, surgery, aspiration risk and worm infestation.  Dental caries, or more significant damage including cracked teeth, loss of occlusion, or periodontal disease have also been documented alongside pica.22,28  Cigarette pica is a risk factor for oral cancer11 and ensuing halitosis, though not a significant health problem, may contribute to pre-existing social isolation.6
Obstructions and perforations caused by pica can also require surgery. An analysis of surgeries undertaken on pica patients between 1976-1991 found an 11% death rate and a complication rate of 30% demonstrating complex postoperative care 84. It has also been reported that 31% percent of pica-related hospitalizations were experienced by children with ASD 17.
One of the most common objects noted in published surgical interventions was vinyl gloves, which are found routinely in many contexts that individuals with ASD and IDD work and reside.85 Because of concerns about allergic reactions, most institutions have switched from latex to vinyl gloves for use by clinical staff.  Inside the digestive tract these gloves lose their pliability and stiffen to become bezoars with sharp edges or spikes.  Ingestion can lead to inflammation or a serious perforation or ulceration requiring surgery for removal.85 Consequently, many organizations and institutions carefully control access to gloves for those individuals with a history of pica 64.
Other complications relate to the presence of foreign bodies in the esophagus or from respiratory distress due to blockage 86. Worm infestation is most closely associated with coprophagaia and sometimes geophagia.38
Discussion
Pica is utilized in disability research to denote a wide range of behaviors — well beyond the formal diagnostic definition — including scavenging for food, mouthing objects, and consumption of ice.  The compelling factor is not what is consumed, but the compulsion for ingestion.  Consequently, it seems appropriate to expand the definition of the behavior when dealing with those with ASD and IDD.  However, this broad definition of pica likely also contributes to difficulty in comparing outcomes and finding consensus treatments.18,20,35,87
To truly understand how pica behavior is manifested in ASD and IDD populations, it needs to be understood as part of a context, rather than as an isolated behavior.  Instead of simply measuring the incidence of pica, researchers need to examine how subjects are coping overall.  Will extinction of pica simply manifest as a new and destructive behavior?
Though studied as an isolated behavior for those with ASD and IDD, pica is one of many conditions reflecting individualized sensory abnormalities through the prism of consumption.  Professionals working with this population need to understand and appreciate the range of disordered eating for those with autism before they can begin to determine appropriate treatment for specific display of pica.  If pica is to be situated and studied as part of the larger issue of disordered eating for those with autism, appropriate assessment tools will be vital.
Unless pica is sporadic in presentation, it likely warrants assessment for secondary symptoms amongst individuals with ASD and IDD.  Those seeking a generalized treatment plan would do well to build off of Williams and McAdams work for preventing pica in institutionalized settings, outlined above.29  Further, coordination of care is clearly a must given the severity of possible complications.
Screening for general malnutrition, as well as iron deficiency, is highly encouraged when assessing pica behavior, especially in reference to energy intake.  Likewise, enough interventions based on increased or differential food administration have been noted in this review to suggest that assessment of intake should be a priority.
Testing for lead poisoning should be considered dependent on the composition of intake, if known.88 Intestinal parasites are not uncommon with presentation of coprophagy, and evaluation for such should be should be considered in certain circumstances.
Conclusion
Though prevalence of pica behavior is difficult to assess in all populations, it is clearly represented at meaningful rates among those with ASD and IDD and poses a significant treatment challenge.   As more individuals with autism come of age, it is likely that nutrition professionals will have increased exposure to this population.  It is time for a more complete understanding of pica presentation for these populations, as well as an appreciation of the range of treatment options that hold the most potential.
About the author:
Janice Goldschmidt, MS, RD, LDN received her Master’s Degree from the University of Maryland-College Park in Nutrition and Food Science and is currently completing a Master’s in Public Health from the same institution.  She is actively involved as both a researcher and practitioner in the nutritional status of individuals with autism and has published and presented on this topic in numerous professional publications and conferences.  Other research interests include assessment and treatment of disordered eating on the Autism spectrum and development of cooking skills for this same population as a form of nutritional intervention.  In 2018, the American Association on Intellectual and Developmental Disabilities published her first book entitled Teaching Authentic Cooking Skills to Adults With IDD: Active Engagement.
Acknowledgements:
This analysis was originally undertaken as an independent study during my graduate studies at the University of Maryland – College Park.  Special thanks to Thomas Castonguay, PhD for guiding me during that research process and helping me find the appropriate focus for this paper.
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Tables

Table 1.  Most common forms of pica in general population
NameCharacterized by consumption of…
Amylophagiastarch
Coprophagyfeces
Pagophagyice
Geophagysoil, clay, or chalk
Hyalophagiaglass
Lithophagiapebbles or rocks
MucophagyMucus
Trichophagiahair or wool
UrophagiaUrine
Mxlophagiawood or paper
PlumbophagiaLead

Table 2.  Comparison of Pica in the General Population versus for those with ASD or IDD 
Pica in the General PopulationPica on the Autism Spectrum
Pregnant and Lactating Women
Children
Related to specific medical conditions
Culturally sanctioned behavior
Seen across the autism spectrum
Specific pica:  Prescribed nature of objects consumed, that is typically one class of pica (e.g., ice, clay)Generalized pica:  Widely varying nature of objects consumed, many times scavenging or opportunistic
Highest rates among children as a developmentally appropriate activityHighest rates among individuals who are institutionalized

Table 3.  Items reported as Consumed 
by Individuals with ASD or IDD
Item Consumed and Source
aftershave lotion 71
alkaline batteries 64,89
broken light bulbs 75
buttons 71,90
carpet 48,70
chalk 72,
cigarettes 24,55
cleaning products 23
cloth 91,92
clothes 48,77,90
coffee grounds 93
crayons 77
dead animals 77
dirt 23,34,90
feces 75,76,89,90
foam rubber 74,
foam padding 48
glass 75
grass 75,
hair 48,77,90
holiday decorations 94
insects 75
jewelry 64
keys 77,89
metal 92,95
mothballs 34
paint chips 23,76
paper 24,48,74,76,90
paper clips 78
pencils 76,
plastics 23,28,64,77,95
plastic tubing 64,77
rocks 75,77,89,96
rubber bands 64
sealed snack bags 64,
sewing needles 71
soap 89,93
spoiled food 93
string 91,93
styrofoam 23
tar 96
tea bags 71,
toilet bowl fresheners 34
toiletries 71
toilet water 93
trash 71
twigs 77,89
vinyl 85 or rubber gloves 89
vomit 93
wood chips 96


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