The Brown University Child and Adolescent Behavior Letter

Eating Disorder
By Rowland P. Barrett, Ph.D.

CABL
nonfood substances in their mouths as a matter of exploration. Accidental ingestions are common in this age group and are not considered true pica. The cause of pica in children is unknown. A number of theories have been proposed to account for the behavior, including hypotheses that promote cultural, ethnic, and familial origins, as well as nutritional and dietary factors and neuropsychiatric conditions.

Pica: Toward understanding a complicated condition

Published in cooperation with Bradley Hospital

June 2008
Vol. 24, No. 6 ISSN 0898-2562 Online ISSN 1556-7575

Highlights
Dr. Rowland Barrett discusses the various theories surrounding pica, an eating disorder where children ingest non-nutritive substances. We also have Part II of the examination of early intervention for autism by Drs. Blane and Borden. Keep Your Eye On See page 2  Psychotropics common for children with autism  Partial syndromes of eating disorders in teens  Parental discipline and risky behavior in offspring Whats New in Research See pages 35  Prevalence and impact of chronic insomnia in adolescents  Public understanding of child MH: National Stigma Study-Children

Pica, a medical condition defined as the persistent ingestion of non-nutritive substances for at least one month without an accompanying aversion to food, is among the more perplexing forms of psychopathology in children. The condition is named for the magpie, one of many birds in the genus Pica that eats both food and nonfood items, indiscriminately. Children have been known to eat dirt, clay, wood, paper, coffee grounds, ashes, coins, crayons, and cigarette butts as well as more dangerous and potentially lethal objects, such as nails, glass, needles, household cleaners, medications, houseplants, gasoline, paint chips, and plaster. The exact prevalence of pica is unknown, but it is estimated to affect 10% to 32% of children ages 1-to-6-years old. Most infants and toddlers routinely place

Theories about pica

Ethnic and family customs have been considered as possibly playing a role in the development of pica behavior in children. Geophagia, the eating of soil, particularly clay, is a well-known folk medicine remedy thought to suppress morning sickness in pregnant women. It is a reasonSee Pica, page 5

Part II: Autism

The importance of early intervention for autism

By Karyn Blane, PsyD., and M. Christopher Borden, Ph.D.
In last months issue of CABL, the authors discussed what we currently know about autism in children and stressed the importance of early diagnosis and intervention. The following case presentation serves as an example of how early identification of a childs atypical relatedness, correct diagnosis, and intensive treatment based on principles of applied behavior analysis (ABA) can lead to a highly favorable prognosis. An additional intention for describing thoroughly this course of treatment was to demystify ABA. normal delivery. He was the first child for both parents, who were in their early 30s at the time of his birth. R. began smiling at 3 months of age and achieved motor milestones at expected times. Although his physical development progressed normally in most respects, his mother sensed that something was just not right in the first few months of his development. He failed to make eye contact when feeding, screamed excessively, and often appeared to have a glazed over look in his eyes. As R. approached the age of 8 months, his parents were increasingly concerned that he didnt babble or coo. In fact, R.
See Autism, page 6

Guest Commentary

A call for educating future caregivers by Barbara Tylenda, Ph.D. See page 8 Free Parent Handout

Helping a Child or Adolescent Deal with Death

Monthly reports on the problems of children and adolescents growing up

Case: R
R. was the 6 lb., 7 oz. product of an uncomplicated 38-week pregnancy and

Published online in Wiley InterScience (www.interscience.wiley.com) DOI: 10.1002/cbl.20068

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disorder, such as Prader-Willi syndrome, a disorder characterized by hyperphagia and an increased risk of ingesting nonfood substances. Finally, neurobiological theories involving diminished dopaminergic neurotransmission and elevated serotonin levels, as well as decreased and increased levels of endogenous opiates are thought to possibly play a role in the development and maintenance of pica.

ing laboratory studies to rule out dietary and/or mineral deficiencies, as well as the presence of toxic substances, such as lead, mercury, and copper. Liver function tests, electrolyte measurements, and studies to rule out eosinophilia, as well as diagnostic imaging to rule out the presence of indigestible objects and obstructive mass, should also be completed, as indicated.

in the mouth also may be effective in decreasing and eliminating the behavior. Combining learning based approaches and drug therapies also has been reported as achieving favorable results.

Future directions
Epidemiological research is crucial for a better understanding of pica. Studies are needed to establish the true prevalence of the disorder, including developing a risk profile of the children most likely to be afflicted. (It is not sufficient to assume that only children with autism spectrum disorder and intellectual deficit are at risk.) Clinical studies could include the controversial role of nutritional and mineral deficiencies, specifically in terms of the role played by iron and zinc. Anecdotal reports of the effectiveness of stimulant drugs must be subjected to double-blind, placebo-controlled studies. Similarly, because of the repetitive (obsessive) nature of pica, well-controlled studies of SSRIs also are indicated. Finally, a standardized prevention protocol needs to be developed that alerts parents to the prospect of pica in children, while also informing them of what measures they should take to combat it, including the identification of available resources and community support. Taken together, studies such as these can eventually lead to the collaboration of pediatrics and child psychiatry on the development of a best practice standard for both the medical evaluation and treatment of the child with pica.
Rowland P . Barrett, Ph.D. is Associate Professor of Psychiatry at the Warren Alpert Medical School of Brown University.

Treatment
Prevention is of the utmost importance when developing a treatment plan for children with pica. Child and parent education regarding the dangers associated with placing objects in the mouth is a crucial first step. Instructions to parents to provide close supervision of the child, along with a referral to an agency that can provide support (such as a poison control center) and identify additional community resources that will allow parents to improve the safety of the home environment also are important. In the absence of effective prevention, there are many serious health risks associated with pica and medical treatment is invariably required. It may be as simple as developing a nutritional program that includes dietary supplements for mineral deficiencies (iron, zinc) or a complicated medical procedure such as chelation therapy for children with clinical lead poisoning. Psychological interventions and medication trials also may be warranted. In children with anxiety disorder, including obsessive-compulsive disorder (OCD), pica may be favorably addressed by treatment with a selective serotonin reuptake inhibitor (SSRI). In other children, there are anecdotal reports of a favorable response to treatment with stimulant medication. Behavior modification procedures designed to prevent pica (response blocking) and extinguish the behavior through a learning model, as well as differential reinforcement procedures that reward the omission of placing nonfood substances

Diagnosis and assessment

Toddlers who complain of abdominal pain and all children diagnosed with autism spectrum disorder and intellectual deficit, without exception, should be evaluated for the presence of pica. Although it is important to distinguish between accidental ingestions and true pica, it is more important to focus on the health risks, including parasitic infection, brain damage and the life-threatening effects of poisons contained in petrochemical products and certain houseplants, and obstructions occurring secondary to swallowing indigestible objects. Except in cases that involve children with autism spectrum disorder and intellectual deficit, most cases of pica are easily diagnosed on the basis of the childs self-report or parent interview. However, in some cases, children may not disclose pica out of fear that they will be punished for the behavior or, simply, because they are embarrassed by their actions. Similarly, parents may contend that they are unaware of pica because they are embarrassed, or to safeguard cultural and familial secrets and to protect themselves against the perceived threat of child neglect and endangerment. The evaluation of children with true or suspected pica should begin with an interview that includes parents and, with parental permission, siblings of the child being assessed. (Brothers and sisters may provide details of a siblings habits that are unknown to parents.) A comprehensive physical examination also is vital, includ-

Reference
Barrett RP: Atypical behavior: Self-injury, selfmutilation, and pica. In Wolraich ML, Drotar DD, Dworkin PH, Perrin EC (Eds.): Developmentalbehavioral pediatrics: Evidence and practice. Philadelphia: Mosby Elsevier, 2008 (pp.871885).

Autism
From page 1

was quiet generally and didnt attempt to communicate through pointing or gestures.

By the time he was 1 year old, his parents noted that R. engaged in repetitive twitching or tic-like movements and questioned whether he was having seizures. He was seen by a neurologist and his EEG was normal at that time. Rs parents remained persistent in their

questioning regarding his development, sensing his atypical relatedness, communication, and behavior. They noted an increasingly frequent behavior pattern in which R. circled the dining room table while gazing peripherally at the walls, door frames, and other angles.

The Brown University Child and Adolescent Behavior Letter June 2008

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He was evaluated at the Child Development Center (Rhode Island Hospital) at the age of 20 months and was diagnosed with Autistic Disorder. Shortly thereafter, he began to receive early intervention services, including weekly speech/language and occupational therapies in the home and participation in a therapeutic playgroup twice per week. Further, Rs parents sought information regarding local agencies and providers of treatment based on principles of Applied Behavior Analysis (ABA) as had been recommended in the diagnostic evaluation. table and tokens were awarded for Rs correct responses to therapist instructions. In this format, R. learned that he could earn unstructured free time or access to a preferred activity in exchange for a predetermined number of tokens. The specific skills emphasized in the first 6 months of Rs treatment included only physical movements or those behavioral responses that could be readily prompted. This emphasis allowed precise communication of expectations and provided errorless opportunities for R. to learn the format of discrete trial teaching: therapist gives instruction, R. responds in the learned/expected way and therapist rewards R. with praise and/ or something tangible that he likes. over, he learned to respond consistently to adult-directed play activities and to interact appropriately (functionally) with a variety of toys.

Home-based treatment
Over the next year of home-based treatment, the fundamental skills of imitation (nonverbal and verbal) and discrimination were applied systematically (in the discrete-trial followed by incidental teaching/generalization training format described above) to an increasingly complex range of skills. Further, self-help skills involving a sequence of actions (e.g., toileting, dressing) were broken down into their component parts and taught step-by-step using a reward-based technique called behavioral chaining. Once R. began to use words (e.g., more) to make requests, the expectation that he apply this skill as needed was increased gradually and with heavy emphasis on reward. Thus, R. showed a gradually increasing tendency to engage in more typical behaviors and to communicate, interact, and play in the way he had been taught with a corresponding decrease in the atypical behaviors that had characterized his autism. In short, R. learned how to learn and, at the time of writing this article, is on course for placement in a Kindergarten class with typically developing age peers and minimal or no special education services. Importantly, several factors conspired to make Rs most positive treatment response possible. First, his condition was identified early and intensive services were started soon after diagnosis. Second, there was extensive collaboration between professionals (EI, speech/language, occupational therapy, ABA providers) and parents, who shared goals and acted as a treatment team. Finally, there were dedicated adults who exhaustively attended to and amplified Rs successes, however small, and found ways to motivate and reward his progress each step of the way.
M. Christopher Borden, Ph.D., and Karyn K. Blane, PsyD., are Co-Directors of the Intensive Behavioral Treatment Program, Bradley Hospital and Clinical Assistant Professors, Alpert Medical School of Brown University.

Intensive Behavioral Treatment

Following a brief wait-list period, R. was enrolled in the home-based Intensive Behavioral Treatment (IBT) Program at Bradley Hospital and began direct (ABA) services, budgeted for 30 hours weekly, at the age of 25 months. The IBT program focused initially on expanding the ongoing early intervention services, which were determined to be appropriate for Rs age and developmental needs, but insufficient in intensity. Home-based therapists sought to engage R. with an object or activity of interest and then, after removing the item, made its availability to R. contingent on some attempt to communicate. Approximations of the desired communicative response were accepted and the expectation was increased gradually (and prompted as necessary) with each successive opportunity. This incidental teaching approach included therapist reward/reinforcement of eye-contact, shared/joint attention, and behavioral responding, which enhanced Rs learning readiness in preparation for more formal discrete-trial instruction. Concurrent with teaching and rewarding new behaviors, therapists either ignored or casually redirected any atypical behaviors/ movements that would interfere with Rs attention to teaching materials and opportunities for new learning. As Rs attention, compliance with adult requests, and the overall range of his typical behaviors increased, the occurrence of repetitive movements and other forms of self-stimulation decreased in frequency (particularly during structured teaching sessions). Increasingly, with time and Rs demonstrated readiness, portions of treatment sessions were conducted at a small

Early treatment goals

Thus, early treatment goals included imitation of gross motor movements, responding to single-step commands (e.g., come here; stand up; clap hands), identification of body parts (e.g., touch nose; point to foot), matching objects or pictures to sample (put with same given an array of choices), and recognition of objects by their correct label (e.g., point to car; find the cup). In addition, R. learned that he could make requests for specific items or activities via picture exchange. Work on this skill had begun during Rs contact with a speech/language therapist through early intervention and entailed getting an adults attention, making eye-contact, and presenting a picture of the desired item (having learned to expect that the request would be rewarded with access to the pictured item). Once skills were learned, through repetition and reinforcement in the contrived discrete trial format, a most important process of generalizing those skills to (functional) use in natural situations was undertaken. Accordingly, therapists, parents, and other caregivers were encouraged both to take advantage of natural opportunities for R. to practice what hed been taught and to create practice scenarios outside of the original learning context. R. showed steady progress in his development of receptive language skills, joint attention, and cued imitation of motor behaviors as well as some single words and sounds through the first 9 months of home-based treatment. More-

The Brown University Child and Adolescent Behavior Letter June 2008