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Response Interruption and Differential Reinforcement of Alternative

Behavior for the Treatment of Pica

Article in Behavioral Interventions · November 2011

DOI: 10.1002/bin.339

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Behavioral Interventions
Behav. Intervent. 26: 309–325 (2011)
Published online in Wiley Online Library
(wileyonlinelibrary.com) DOI: 10.1002/bin.339

RESPONSE INTERRUPTION AND DIFFERENTIAL

REINFORCEMENT OF ALTERNATIVE BEHAVIOR
FOR THE TREATMENT OF PICA

Louis P. Hagopian1,2, Melissa L. González1,2*, Tessa Taylor Rivet1,2,

Mandy Triggs1 and Seth B. Clark1
1
Department of Behavioral Psychology, Kennedy Krieger Institute, 707 North Broadway,
Baltimore, MD 21205, USA
2
Johns Hopkins University School of Medicine, 733 N. Broadway, Suite G49, Baltimore, MD
21205-2196, USA

Pica displayed by two individuals with autism was decreased by a treatment involving differential
reinforcement and response interruption that altered the chain of behavior involved in pica (i.e., picking
up items and placing them in the mouth). The treatment involved establishing prompts to ‘clean-up’
as a new discriminative stimulus (SD) for picking up items from the floor; and holding potential pica
items was established as an SD for discarding those items in a trash receptacle, putting them away, or
using them appropriately. After demonstrating the effectiveness of the treatment in an analog setting, the
treatment package was systematically generalized to community settings. Copyright © 2011 John Wiley &
Sons, Ltd.

Pica, the ingestion of non-nutritive substances, has been estimated to occur in

0.3–14.4% of persons with intellectual disabilities (ID) who reside in community
settings and in as many as 25.8% of persons with ID residing in institutions (Ali,
2001). This is a significant behavior problem that has potentially life-threatening
health risks including toxicity, parasitic infection, choking, and gastrointestinal
blockage/obstructions (Ali, 2001; Stiegler, 2005). The vast majority of studies report-
ing the results of functional analysis (FA) of pica indicate that it is most commonly
maintained by automatic reinforcement (McAdam, Sherman, Sheldon, & Napolitano,
2004; Piazza et al., 1998).
Interventions for pica typically involve multiple treatment components (for a review, see
Hagopian, Rolider, & Rooker, in press; McAdam, et al., 2004). Antecedent-based

*Correspondence to: Melissa González, Department of Behavioral Psychology, Kennedy Krieger Institute 707 N.
Broadway Baltimore, MD 21205. E-mail: GonzalezM@kennedykrieger.org
Seth B. Clark is now at the Marcus Autism Institute.

Copyright © 2011 John Wiley & Sons, Ltd.

310 L. P. Hagopian et al.

components include those that are designed to minimize opportunities for pica, alter
relevant establishing operations by providing alternative sources of reinforcement
(Favell, McGimsey, & Schell, 1982; Piazza et al., 1998), and bring ingestion of food
under appropriate stimulus control (Fisher et al., 1994). Other interventions aim to in-
crease the response effort required to engage in pica (Piazza, Roane, Keeney, Boney,
& Abt, 2002), or establish and increase responses that are incompatible with pica such
as giving potential pica items to care providers (Goh, Iwata, & Kahng, 1999), or dis-
carding potential pica items (Bogard, Piersel, & Gross, 1995). Consequent-based
treatment components include response interruption and redirection (Hagopian &
Adelinis, 2001; Piazza et al., 1996) and punishment (Fisher et al., 1994; Foxx &
Martin, 1975; Rojahn, McGonigle, Curcio, & Dixon, 1987).
Similar to Goh, Iwata, and Kahng (1999), the treatment package examined in
this study involved an interruption of responses leading to pica and differential
reinforcement of alternative responses. The extent to which the treatment package
remained effective under varying contexts, when applied to novel settings and across
caregivers was also evaluated.

METHOD

Participants and Setting

The participants described in the current study were admitted to an inpatient
behavioral unit for treatment of pica and other problem behavior. Lenney was
19-years-old and had diagnoses of autistic disorder, profound ID, fetal hydantoin
syndrome, and seizure disorder. He was referred for the assessment and treatment
of pica and self-injury. Lenney was ambulatory and communicated by taking a
caregiver by the hand and using a modified sign for ‘more’. He had a history of
engaging in pica with various objects such as small pieces of objects, string/clothing,
wood, paper, and household cleaners. His pica placed him at significant risk for
poisoning, obstruction, and choking. He required constant supervision from
caregivers, which consequently limited his participation in academic, vocational,
and community activities. Stephanie was 13-years-old and had diagnoses of autistic
disorder, attention deficit/hyperactivity disorder, and severe ID. She was referred
for the assessment and treatment of pica, rumination, and self-injury. She was ambu-
latory and used a few modified signs and gestures to communicate basic needs and
wants. She had a history of ingesting small objects found on the floor or counters, pa-
per from magazines and books, shampoo, fertilizer, and motor oil that required
medical attention including emergency room visits and the Heimlich maneuver on
several occasions.

Copyright © 2011 John Wiley & Sons, Ltd. Behav. Intervent. 26: 309–325 (2011)
DOI: 10.1002/bin
Treatment of pica 311

Assessment and initial treatment sessions were conducted in session rooms

(3 m  3 m) equipped with one-way mirrors located on the inpatient unit. Later
treatment sessions were conducted in the living area and bedrooms of an inpatient
unit and a classroom located off the inpatient unit. Bedrooms in which treatment
was conducted had beds, cabinets, countertops, and tables. The classroom accommodated
up to five children working individually with one-to-one aides. Treatment sessions
were also conducted in community settings.
Because of safety concerns regarding the ingestion of nonedible items, materials
that were safe for ingestion (hereafter, referred to as ‘simulated pica items’) but
appeared similar to items that the participants had a history of ingesting were identified
for each participant. Materials used as simulated pica items included a combination
of edibles (e.g., rice cakes, seaweed, dissolvable crackers) and nonedibles (e.g.,
PlayDohW, crayons). During the generalization of Stephanie’s treatment to the living
unit, additional household items that she had a history of attempting to ingest were
included to more fully simulate the home environment (hereafter, referred to as
‘inedible pica items’). These inedible pica items including a shampoo bottle, lotion
bottle, soap, and deodorant (containing the relevant substance) were placed on a table
during sessions. During all sessions in the hospital setting in which simulated pica
items were used, the floor and other surface areas were swept and sanitized prior to
item placement. Medical staff approved all simulated pica items and defined allowable
quantities that could be safely consumed for each participant.

Data Collection and Interobserver Agreement

Pica was defined as an occurrence or blocked attempt to place an inedible item
or any simulated pica item past the plane of the lips (hand mouthing, mouthing of
clothing, and mouthing of competing stimuli were excluded). During the assessments
and initial treatment sessions, opportunities for scoring pica mainly consisted of
simulated pica material and/or other material that was left on the floor or surface areas
of a treatment room, bedroom, or the main living unit. Once the treatment was
applied to more diverse settings and over longer periods, there were more varied
opportunities for pica to occur because of the wider array of materials naturally available.
An independent discard was scored each time that the participant independently
placed any inedible item or simulated pica item in a trash receptacle in the absence
of prompting. Data were collected on independent and prompted discards during
the initial 51 out of 176 treatment sessions for Lenney and 94 out of 190 sessions
for Stephanie.
During the competing stimulus assessment (CSA), item engagement was defined
as touching, manipulating, or directing eye-gaze toward the item (e.g., DVD player)
that was appropriate for the particular item. Each session was partitioned into 10-s

Copyright © 2011 John Wiley & Sons, Ltd. Behav. Intervent. 26: 309–325 (2011)
DOI: 10.1002/bin
312 L. P. Hagopian et al.

intervals for laptop computer data collection. For the final portion of treatment
evaluation when sessions were conducted on the living unit or in the community, data
were collected via paper and pencil using 2-min intervals for Lenney, and 1-min
intervals for Stephanie.
To determine levels of interobserver agreement (IOA) separately for pica and
independent discard data collected with laptop computers, total agreement was
calculated by taking the sum of the occurrence (i.e., both observers recorded at least
one response) and nonoccurrence agreement (i.e., neither observer recorded that a
response occurred) divided by the total number of 10-s intervals in the session and
multiplied by 100. Similarly, pica and independent discard data collected with paper
and pencil were calculated by taking the sum of the occurrence and nonoccurrence
agreement divided by the total number of 2-min (for Lenney) or 1-min (for
Stephanie) intervals in the session and multiplied by 100. IOA for item engagement
was calculated by taking the sum of occurrence (i.e., both observers agreed
that at least 1 s of engagement occurred) and nonoccurrence agreement (i.e., neither
observer recorded that engagement occurred) divided by the total number of 10-s
intervals and multiplied by 100.
For Lenney, two independent observers collected frequency data via laptop
computers to determine levels of IOA for 80% of sessions of the FA (12 sessions),
38% of the CSA (29 sessions), and 38% of the treatment evaluation (152 sessions),
respectively. During the last 10 sessions of the treatment evaluation on the living
unit, data were collected via paper and pencil; 20% of these sessions had reliability
data. The average total agreement coefficient for pica was 97% for the FA, 98%
for the CSA, 99% for the treatment evaluation (with laptop computers), and 100%
for treatment sessions collected with paper and pencil. IOA data were collected for
47% of the 51 treatment sessions in which independent discard data were collected;
average total agreement was 99%. The average total agreement for percentage of
intervals of item engagement for the CSA was 94%.
Similarly, two independent observers collected frequency data during Stephanie’s
sessions via laptop computers to determine levels of IOA for 60% of FA sessions (15
sessions), 62% of the CSA (52 sessions), and 52% of the treatment evaluation (ses-
sions 1 through 150), respectively. During the last 40 sessions of the treatment
evaluation on the living unit and unit classroom, data were collected via paper
and pencil. Forty percent of these sessions had reliability data. The average
total agreement coefficient for pica was 83% for the FA, 95% for the CSA, 98%
for the treatment evaluation (with laptop computers), and 97% for treatment
sessions collected with paper and pencil. Similarly, IOA data were collected for
32% of the 94 treatment sessions in which independent discard data were collected;
average total agreement was 94%. The average total agreement for percentage
of intervals of item engagement (for the CSA) was 95%. IOA data were not

Copyright © 2011 John Wiley & Sons, Ltd. Behav. Intervent. 26: 309–325 (2011)
DOI: 10.1002/bin
Treatment of pica 313

obtained during community outings, extended treatment application (for Stephanie),

and follow-up.

Procedure
Functional Analysis
Multi-element functional analyses of pica (Piazza, Hanley, & Fisher, 1996)
were conducted for each participant. For Lenney, the floor was baited with a total
of 80 items (16 different types); sessions lasted until all items were consumed or
10 min had elapsed. Conditions included alone, ignore, and toy play (control) and
were similar to those described by Iwata, Dorsey, Slifer, Bauman, and Richman
(1994/1982). For Stephanie, 30 simulated pica items were placed on the floor and
sessions lasted until all items were consumed or 5 min had elapsed. Social attention,
alone, and toy play (control) conditions were based on the procedures described by
Iwata and colleagues; a tangible condition was also included in which each occurrence
of pica resulted in access to a preferred tangible for 30 s (Day, Rea, Schussler, Larsen,
& Johnson, 1988). Extended alone sessions that were 10 min in duration were then
conducted to determine if pica would occur in the absence of social consequences
(Vollmer, Marcus, Ringdahl, & Roane, 1995). A demand condition was not evaluated
for either participant based on parental report that pica typically did not occur during
demand situations.

Competing Stimulus Assessment

A CSA was conducted according to procedures described by Piazza et al. (1998)
for each participant. For Lenney, the CSA included five edible stimuli, seven
nonedible stimuli, and a noncontingent attention condition in which the therapist
delivered brief noncontingent attention every 10 s and following appropriate
initiations. For Stephanie, four trials of 12 nonfood stimuli were conducted. These
stimuli were identified as preferred based on caregiver interviews and prior paired-
choice preference assessments. Some of these items involved oral stimulation that
was potentially similar to the stimulation produced by pica (i.e., oral motor tool,
teething ring, bendable tube) as described by Piazza, Adelinis, Hanley, Goh,
and Delia (2000), whereas the other stimuli provided other forms of stimulation
(i.e., hand massager, books, DVD player). Prior to each session, simulated pica items
were placed on the precleaned floor. Each stimulus was presented individually and
placed on a chair (for Lenney) or on a table (for Stephanie) at the start of the session.
A therapist remained in the room during the sessions; however, all pica was ignored.
Observers recorded the frequency of pica and duration of engagement with the

Copyright © 2011 John Wiley & Sons, Ltd. Behav. Intervent. 26: 309–325 (2011)
DOI: 10.1002/bin
314 L. P. Hagopian et al.

available stimulus within 10-s intervals. A no-stimulus control condition comparison

was also conducted. The order in which stimuli were presented was randomized for
each trial. The rate of pica and percentage of intervals of item engagement were
averaged across trials. Stimuli that resulted in low rates of pica and high percentage
of intervals of engagement were identified and subsequently used in treatment.

Treatment Evaluation
The treatment evaluation was conducted using a reversal design (ABABCBC for
Lenney; ABCACDAD for Stephanie). Sessions were 10 min and were conducted in
a session room with simulated pica items on the floor (30 items for Lenney, 10 items
for Stephanie). Simulated pica items were not replenished following consumption in
Lenney’s sessions. If Stephanie consumed all simulated pica items, the therapist
would discretely replenish items on the floor.
Baseline. During baseline, neither attention nor toys were available. The therapist
did not interact with the participant; pica was ignored. For Lenney, a trash receptacle
was placed along the wall of the session room. For Stephanie, the therapist acted as
though he/she was busy.
Noncontingent competing stimuli. The participants were allowed continuous
noncontingent access to competing stimuli (NCS; i.e., microphone for Lenney; and
DVD, picture book, and hand massager for Stephanie). These materials were placed
on the floor or chair (for Lenney) or on a table (for Stephanie). Stephanie was told
‘you can play with your toys’, and the therapist pretended as though he/she was busy.
Both the participants’ pica was ignored.
Noncontingent competing stimuli with response interruption and redirection and
differential reinforcement of alternative behavior. Previous response blocking
analyses indicated that response blocking alone was not effective in significantly
reducing pica for both participants. Thus, response interruption and redirection
(RIRD) and differential reinforcement of alternative behavior (DRA) were introduced
and evaluated in combination with (NCS). Prior to evaluating these treatment compo-
nents, pretreatment training was conducted to establish a history of reinforcement for
the alternative response (i.e., picking up items and then discarding them). This pre-
treatment training initially involved large, safe, nonpica-like items that were placed
on a table in the session room. Each participant was taught to pick up and discard
items into a trash receptacle to obtain reinforcement in the form of verbal praise
and a preferred edible (i.e., M&MsW, OreoW cookies, Reeses PiecesW, chocolate
chip cookies, and SkittlesW for Lenney, and GoldfishW Crackers for Stephanie).
Once this alternative response was established, the materials were faded from large
items placed on a table, to large items placed on the floor and then to simulated pica

Copyright © 2011 John Wiley & Sons, Ltd. Behav. Intervent. 26: 309–325 (2011)
DOI: 10.1002/bin
Treatment of pica 315

items placed on the floor. If the participant did not pick up a simulated pica item for
30 s (gradually delayed to 45 and 60 s for Lenney), the participant was prompted to
do so using least to most 3-step guided compliance (i.e., verbal, gestural, and full
physical prompts). An edible and praise were delivered following discards (unless
full physical guidance was required to complete the trial). To eliminate potential au-
tomatic reinforcement for engaging in pica, all pica attempts were interrupted, and the
participant was redirected to the alternative response. The competing stimuli were
present; however, attempts to discard those items in the trash receptacle were
blocked. For Lenney, training sessions were 5 min in duration (the number of trials
averaged 10 per session) and continued for 45 sessions conducted across 5 days.
Training continued until there was an increasing trend in the number of independent
discards. For Stephanie, training sessions initially consisted of 10 trials but were
modified to 10-min sessions (the number of trials averaged 10 per session). Training
continued for 93 sessions conducted across 10 days for Stephanie until she met the
mastery criterion of independently discarding 90% of simulated pica items for two
consecutive 10-min sessions.
Once training was complete, the NCS + RIRD + DRA intervention was evaluated
within the treatment analysis. The participants were allowed noncontingent access
to competing stimuli. A trash receptacle was placed inside the session room. Each
independent and prompted discard (in the absence of physical guidance) resulted in
brief praise and a preferred edible (FR-1 schedule). Picking up items off the floor
was permitted, but attempts to put items into the mouth were blocked. Holding a
simulated pica item (longer than 2 s for Lenney and 5 s for Stephanie), or a pica
attempt (i.e., bringing an item to the lips) resulted in RIRD. That is, pica attempts
were interrupted, and the individual was redirected to discard the item in a trash
receptacle (using least to most prompting). Attempts to place competing stimuli in
the trash receptacle occurred occasionally in the initial phases of treatment, but these
were physically blocked and no verbal attention was provided. All other problem
behavior was ignored.

Treatment Application in more Naturalistic Settings

In order to evaluate the effectiveness of these treatment components in a more
naturalistic setting, sessions were conducted in settings different than the initial
training setting including bedrooms, the unit classroom, and different areas of the
living unit. Therapists varied across sessions to ensure that the treatment remained
effective across caregivers and locations. The treatment was further individualized
for each participant, and sessions were further modified to better approximate the
participants’ home and school environments. In order to prepare for discharge, the
treatment was implemented in a variety of community settings outside the hospital.

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DOI: 10.1002/bin
316 L. P. Hagopian et al.

Lenney. Given the increased opportunities for pica with a wide range of
materials available, daily tasks and activities were expanded and modified to better
approximate his home and school settings. Additionally, the prompted alternative
responses were varied across settings in instances when the item was not suited for
discarding (e.g., furniture, toys, and shoes). For example, if he was in a demand
situation and attempted to place demand materials in his mouth, the next step in
the prompting sequence was initiated; or if he attempted to place a toy in his mouth
during leisure time, he was prompted to use it appropriately. If there were no
materials present and he attempted to place his shirt in his mouth, he was prompted
to put his hands in his pockets. The response of putting his hands in his pockets
was selected because it is incompatible with pica and could be used when the
other responses would not be appropriate or available. Eventually, treatment was
implemented continuously over 7-h periods (from 9 AM to 4 PM) across both leisure
and academic activities. During this period, simulated pica items were not used for
two reasons: there were sufficient opportunities to engage in pica with materials that
were naturally available in those settings; and other individuals on the inpatient
unit were present and could have accessed the simulated pica items. The DRA was
modified to a DRL (differential reinforcement of low rate behavior) such that Lenney
could only earn an edible for independent discards or compliance with the redirection
to discard if he had no more than one redirection within the last 10 min.
Community outings prior to discharge included Lenney’s school, a restaurant, and
a store. For each of these outings, a clip-on pouch was made available at all times to
ensure there was a receptacle available in which items could be discarded. Lenney’s
caregivers and school staff were trained to collect frequency data of pica and to
implement the treatment with 90% or greater accuracy.

Stephanie. An additional baseline was conducted on the living unit for Stephanie
to provide a basis for evaluating the treatment in this more naturalistic setting. During
this session, the therapist and simulated pica items were present. The therapist did not
interact with her, and pica was ignored. These sessions were the same as the previous
baseline sessions with the exception of the location, and the simulated pica items were
no longer replenished once they were consumed.
With the implementation of the NCS + RIRD + DRA treatment, a brief clean-up
period (during approximately the initial 2.5 min of a session) was introduced. During
clean-up, Stephanie was told that it was ‘time to clean-up’, and the therapist used the
least to most prompting sequence to prompt her to clean-up six of the 10 simulated
pica items from the floor. She received verbal praise and a preferred edible for
compliance following a verbal or gestural prompt. Following the clean-up period,
the therapist did not interact with her unless she initiated interaction but remained
close enough (i.e., within arm’s reach) to block any attempts to engage in pica.

Copyright © 2011 John Wiley & Sons, Ltd. Behav. Intervent. 26: 309–325 (2011)
DOI: 10.1002/bin
Treatment of pica 317

Given Stephanie’s history of consuming small items from the floor in her home,
highly preferred edibles (identified via a preference assessment; hereafter, referred
to as ‘HP simulated pica items’) were placed on the floor in lieu of simulated pica
items used in the previous sessions to provide an additional naturalistic challenge
to the intervention. These HP simulated pica items were faded into the treatment
across 24 sessions until all the simulated pica items on the floor were HP simulated
pica items (all subsequent sessions used HP simulated pica items). Next, household
items that were deemed unsafe if consumed including a shampoo bottle, a lotion bot-
tle, soap, and deodorant were placed on a table or counter prior to sessions. She was
prompted to ‘clean-up’ these inedible pica items by handing them to the therapist to
obtain praise and a preferred edible during the clean-up period. All attempts to touch
other items placed on tables that did not pose potential risk but were not appropriate
for mouthing (i.e., magazine, photo frame, telephone) were physically blocked but
not attended to verbally. To further examine and challenge the effects of this
intervention, the treatment was applied to a variety of naturalistic settings. The
environment was baited prior to Stephanie moving to a new location. With each
transition, she was prompted to clean-up the area before starting the scheduled
activity. These training opportunities during the clean-up period allowed for an
on-going assessment and training (if need be) of the alternative response in novel
settings. Eventually, treatment was implemented continuously over longer periods
of the day across both leisure and academic activities. The schedule of reinforcement
was faded to FR-2.
Community outings included the hotel where her mother stayed when visiting, a
supermarket, a mall, a mall food court, and a waterfront tourist area. For each of
these outings, a reusable shopping bag was made available at all times to ensure there
was a receptacle available in which items could be discarded. Stephanie’s primary
caregivers and school staff were trained to collect frequency data on pica and to
implement the treatment with 90% or greater accuracy.

RESULTS

In Lenney’s FA, rates of pica were higher in conditions with lower levels of
programmed stimulation (alone, M = 1.50 rpm; ignore, M = 1.35 rpm) and lower
in conditions with higher stimulation (toy play, M = 0.50 rpm; top panel, Figure 1).
Such a pattern of responding is generally viewed as indicating that the behavior is
maintained by automatic reinforcement (Hagopian et al., 1997). Results of the CSA
indicated that the edible stimuli and a microphone were associated with lower levels
of pica and higher levels of item engagement compared with other stimuli and the
control condition (top panel, Figure 2).

Copyright © 2011 John Wiley & Sons, Ltd. Behav. Intervent. 26: 309–325 (2011)
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318 L. P. Hagopian et al.

Figure 1. Pica per minute during the functional analysis.

For Stephanie, rates of pica were high across all conditions of the FA (alone,
M = 9.47 rpm; social attention, M = 11.59 rpm; toy play, M = 7.80 rpm; and tangible,
M = 6.67 rpm; bottom panel, Figure 1). Higher rates were observed in conditions with
lower levels of programmed stimulation (i.e., alone and social attention) and lower
rates in conditions with higher stimulation (i.e., toy play). This pattern of responding

Copyright © 2011 John Wiley & Sons, Ltd. Behav. Intervent. 26: 309–325 (2011)
DOI: 10.1002/bin
Treatment of pica 319

Figure 2. Percentage of 10-s intervals of stimulus engagement (dark bars) and pica per minute (light
bars) during the competing stimulus assessment.

Copyright © 2011 John Wiley & Sons, Ltd. Behav. Intervent. 26: 309–325 (2011)
DOI: 10.1002/bin
320 L. P. Hagopian et al.

is viewed as indicating that the behavior of interest is maintained by automatic

reinforcement (Hagopian et al., 1997). Levels of pica remained high (M = 8.46 rpm)
during extended alone sessions, which further supported a hypothesis that pica
was maintained by automatic reinforcement (Vollmer et al., 1995). Results of the
CSA indicated that the Barney DVD, family picture book, and a hand massager were
associated with relatively higher levels of engagement and lower levels of pica
compared with other stimuli and the control condition (bottom panel, Figure 2).
During the baseline phase of the treatment evaluation for Lenney, pica was a
variable ranging from 3.8 to 5.2 rpm (M = 4.63 rpm; top panel, Figure 3). With the
introduction of NCS, pica was somewhat reduced (M = 0.91 rpm) but increased when
session duration was increased from 5 to 10 min. When RIRD + DRA was added to
the treatment, rates of pica decreased (M = 0.01 rpm) 99.8% relative to baseline. This
treatment effect was replicated following a reversal to NCS (M = 1.00 rpm). Discards
were variable, independent discards averaged 0.16 rpm, whereas prompted discards
(including those following a verbal or gestural prompt) averaged 0.12 rpm. With treat-
ment applied on the living unit, pica remained low (M = 0.03 rpm). During the extended
application of treatment over a 7-h period (from 9 AM to 4 PM), pica remained low
(M = 0.02 rpm) during both leisure and work periods.
During the baseline phase of the treatment evaluation for Stephanie, pica was var-
iable ranging from 0 to 1.9 rpm (M = 0.94 rpm; bottom panel, Figure 3). With the
introduction of NCS, pica was somewhat reduced but remained variable (M = 0.55
rpm). When RIRD + DRA was added to NCS, rates of pica significantly decreased
(M = 0.05 rpm). This treatment effect was replicated (M = 0.14) following a reversal
to baseline. Pica remained low (M = 0.09 rpm) with treatment in place on the living
unit. Pica increased when treatment was briefly withdrawn (M = 2.60 rpm) and de-
creased again to near zero levels when re-introduced. Independent discards
(following the clean-up period) averaged 76%, whereas all discards (including those
following a verbal or gestural prompt) averaged 83% across sessions. Transient
increases in pica were observed as new simulated pica stimuli were introduced and
when the treatment was applied to the classroom. Rates of pica averaged 0.09 rpm
across both the living unit and classroom, which represent a 96% reduction from
the baseline conducted on the living unit. Pica remained low (M = 0.02 rpm) during
community outings; no occurrences of pica were observed during 11 out of 14
outings. As the focus of the community outings was the generalization of the
treatment and caregiver training, IOA data were not collected because of limited
staffing. However, data were collected by the same therapists who had demonstrated
reliable data collection during the previous treatment sessions. Following discharge,
Stephanie’s school staff reported that pica remained low (M = 0.04 rph) in the
classroom; no occurrences of pica were reported for 45 out of 49 school days (IOA
data were not collected for follow-up).

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Treatment of pica 321

Figure 3. Pica per minute across sessions during the treatment application in the session room and living
unit (triangles), unit classroom (closed triangles), and proportion of independent discards (circles).

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DOI: 10.1002/bin
322 L. P. Hagopian et al.

DISCUSSION

Pica is a serious problem that is often difficult to treat. Interventions for pica often
require multiple components in order to effectively decrease this behavior. In the
current study, treatment involved noncontingent access to competing stimuli,
response blocking and redirection of pica attempts, and differential reinforcement
for appropriately discarding items. These components were effective in reducing pica
in two individuals. Goh, Iwata, and Kahng (1999) and Bogard, Piersel, and Gross
(1995) taught individuals a similar alternative response to pica (i.e., reinforcement
for exchanging or disposing of pica material).
Pica has been described as a chain of responses (McCord et al., 2005), such that
each response in the chain serves as a conditioned reinforcer for the previous
response and a discriminative stimulus (SD) for the next response in the chain. That
is, once the item is picked up, it is ready to be consumed; and this in turn, occasions
placing the item in one’s mouth—which ultimately produces reinforcement. We have
limited the description of this behavioral chain to include only the picking up of items
and their placement in the mouth for ease of discussion; however, this should not be
viewed as suggesting that this chain is comprised of only two responses.
In the current study, treatment involved two types of alterations in the behavioral
chain. The first alteration left the first behavior in the chain (picking up the potential
pica item) unchanged and altered only the second behavior in the chain (putting the
item in the mouth). Through response blocking and differential reinforcement, the
participants learned to discard or put away the items rather than ingest them. The
intervention was arranged so that picking up items signaled the availability of
reinforcement for discarding items rather than ingesting them. In contrast to McCord
et al. (2005), the current study preserved the early link in the chain, and response
blocking (and redirection) was implemented later in the chain in order to estab-
lish an alternative response as the later link (discarding or putting away potential
pica items).
This study extends upon previous work by evaluating the effectiveness of a com-
prehensive treatment in naturalistic settings. After demonstrating the effectiveness of
the treatment in an analog setting, the treatment package was evaluated
and customized under more naturalistic settings and generalized to community
settings. The inclusion of a brief probe to baseline when applied on the living unit
(for Stephanie) provides a greater analysis of this treatment package and the extent
to which it is effective in naturalistic settings. Further, this study included data
collected when the treatment was applied in the community.
In order to prepare for treatment implementation in the community, generalization
was formally programmed in an attempt to facilitate the transfer of control to commu-
nity settings (Stokes & Baer, 1977). Following the application of the treatment to the

Copyright © 2011 John Wiley & Sons, Ltd. Behav. Intervent. 26: 309–325 (2011)
DOI: 10.1002/bin
Treatment of pica 323

living unit for Lenney, a variety of alternative responses were programmed in order
to make the treatment applicable to a wider range of materials that may be encoun-
tered in a naturalistic setting. That is, other incompatible responses produced
reinforcement, including putting an item away in its proper place (if it should
not be discarded), using items appropriately, and putting his hands in his pockets.
For Stephanie, additional prompts were programmed for use when she entered a
new location. That is, a prompt to ‘clean-up’ was established as a new SD for the
alternative behavior to discard items in the trash receptacle. Some potential
advantages of programming this additional SD include decreased opportunities for
pica (as a function of clearing the area of potential pica items), as well as increased
opportunities for reinforcement of the newly established alternative response. In
addition, this component increased Stephanie’s role in keeping the environment
free of pica materials. The clean-up period in Stephanie’s treatment served as an
opportunity to train her to generalize the newly acquired skill of discarding items
found on the floor (Stokes & Baer, 1977). This appropriate alternative behavior
was prompted and reinforced in various settings throughout the day.
The current study replicates the findings of Goh, Iwata, and Kahng (1999) and
provides support that RIRD + DRA may be effective treatment components for
some individuals who engage in pica. Extending beyond other antecedent and
consequent-based pica treatments, the intervention (i) aimed to establish and maintain
an appropriate alternative behavior when encountering items that were previously
ingested (i.e., discarding or putting away items); (ii) more closely approximated,
the manner in which caregivers respond to typically developing young children
who pick up items that may be mouthed or consumed (i.e., they are blocked
from ingesting them and are redirected to discard them); (iii) was amenable to appli-
cation in various community settings; and (iv) was programmed in a manner that
allowed for frequent response opportunities to reinforce generalization of the newly
acquired skill.
The current study does not permit analysis of the mechanism (i.e., extinction
or punishment) underlying the effectiveness of RIRD. However, the response
patterns observed in the current study (i.e., immediate suppression of pica following
the implementation of the treatment) are similar to those that have been associated
with the effects of punishment rather than extinction (Lerman & Iwata, 1996; Smith,
Russo, & Le, 1999). It is also unclear what role competing stimuli had in the
treatment as RIRD was not evaluated in the absence of NCS with either partici-
pant. Thus, it is unclear if the treatment could be simplified to include only
RIRD and DRA.
Although significant reductions in the rate of pica were noted with this treatment
for both participants, this study has some methodological limitations. A receptacle
for discards was not present during the baseline phase for Stephanie (although it

Copyright © 2011 John Wiley & Sons, Ltd. Behav. Intervent. 26: 309–325 (2011)
DOI: 10.1002/bin
324 L. P. Hagopian et al.

was present for Lenney); thus, it is not clear if discards would have occurred if a
receptacle was present during the baseline phase prior to the training of the alternative
response. However, given that Stephanie required extensive training (i.e., 93 sessions)
in the alternative response prior to meeting the mastery criterion, it is unlikely that she
would have emitted the discard response without prior training. Another limitation is
that data were not collected on the alternative response throughout the entire analysis.
For Lenney, data on the alternative response (i.e., discards) were collected when the
room was baited; and for Stephanie, data on discards were collected for only 50%
of the treatment sessions. Another potential limitation is that the current study did
not control for or examine the effects of therapist proximity, which has been shown
to affect the success of response blocking (McCord et al., 2005). In the current study,
a caregiver was present at all times to monitor, block pica, redirect, and reinforce the
alternative response. It is unclear how practical the treatment implementation would
be for a caregiver when other competing demands are present, or how effective the
treatment would be if less supervision was provided. Although the inclusion of some
data from community settings is a strength of the current study, IOA data were not
collected during these phases (i.e., Stephanie’s community outings and follow-up).
Future research should be designed to examine how well treatments for pica can be
maintained over long periods in the community.

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Copyright © 2011 John Wiley & Sons, Ltd. Behav. Intervent. 26: 309–325 (2011)
DOI: 10.1002/bin

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