Research in Developmental Disabilities 32 (2011) 2114–2120

Contents lists available at ScienceDirect

Research in Developmental Disabilities

Review article

Identifying empirically supported treatments for pica in individuals with

intellectual disabilities
Louis P. Hagopian, Griffin W. Rooker *, Natalie U. Rolider
The Kennedy Krieger Institute, Johns Hopkins University School of Medicine, United States

A R T I C L E I N F O A B S T R A C T

Article history: The purpose of the current study was to critically examine the existing literature on the
Received 13 July 2011 treatment of pica displayed by individuals with intellectual disabilities. Criteria for
Received in revised form 26 July 2011 empirically supported treatments as described by Divisions 12 and 16 of APA, and adapted
Accepted 27 July 2011 for studies employing single-case designs were used to review this body of literature. A
Available online 8 September 2011 total of 34 treatment studies were identified, 25 of which were well designed and reported
at least an 80% reduction in pica (21 studies reported 90% or greater reduction in pica).
Keywords: Results indicated that behavioral treatments in general, and treatments involving the
Pica
combination of reinforcement and response reduction procedures in particular, can be
Intellectual disabilities
designated as well-established treatments for pica exhibited by individuals with
Treatment
intellectual disabilities.
ß 2011 Elsevier Ltd. All rights reserved.

Contents

1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . ................... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2114

2. Method . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ................... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2115
2.1. Article selection . . . . . . . . . . . . . . . . ................... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2115
2.2. Article review and coding . . . . . . . . ................... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2116
2.3. Interobserver agreement . . . . . . . . . ................... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2116
2.4. Criteria for determining empirically supported treatments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2116
3. Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ................... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2116
3.1. Participant characteristics . . . . . . . . ................... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2116
3.2. Study characteristics . . . . . . . . . . . . ................... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2116
3.3. Evaluation of empirical support . . . ................... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2117
4. Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . ................... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2118
References . . . . . . . . . . . . . . . . . . . . . . . . . . ................... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2119

1. Introduction

Individuals with intellectual and developmental disabilities (IDD) are more likely to engage in problem behavior
(National Institutes of Health [NIH], 1991) such as self-injurious behavior (SIB; e.g., hitting, biting, scratching oneself),
aggression (e.g., hitting, pinching, kicking, pulling hair of others), destructive behavior (e.g., breaking or throwing items), pica

* Corresponding author at: Neurobehavioral Unit, Kennedy Krieger Institute, John Hopkins University School of Medicine, 707 N. Broadway, Baltimore,
MD 21205, United States. Tel.: +1 443 923 2999.
E-mail address: Rooker@kennedykrieger.org (G.W. Rooker).

0891-4222/$ – see front matter ß 2011 Elsevier Ltd. All rights reserved.
doi:10.1016/j.ridd.2011.07.042
 L.P. Hagopian et al. / Research in Developmental Disabilities 32 (2011) 2114–2120 2115

(eating inedible objects), and tantrums (Condillac, 2007). Although all of these behaviors have the potential to cause harm to
oneself or others, pica is of particular concern because even one instance of the behavior may cause tremendous harm.
Published studies have reported on individuals who ingested lead paint, laundry starch, metal and feces, among other items
(Lacey, 1990). Several severe health risks are associated with pica (Decker, 1993), including lead-poisoning, intestinal
perforation and obstruction (sometimes necessitating surgical removal of the item), and death (Greenberg, Jacobziner,
McLaughlin, Fuerst, & Pellitteri, 1958).
The Diagnostic and Statistical Manual of the American Psychiatric Association (DSM-IV-TR) (2000) describes pica as:
(a) consumption of nonnutritive items for more than a month, (b) consumption of nonnutritive items inappropriate to
developmental age, (c) the eating is not part of culturally sanctioned activity, and (d) the behavior is severe enough to
require independent clinical attention when other clinical services are being provided for another mental disorder. The
prevalence of pica in persons with intellectual disabilities has been reported to be between 5.7 and 25.8% (Ashworth,
Hirdes, & Martin, 2009; Danford & Huber, 1982). In addition, research suggests that pica is relatively more prevalent
among lower functioning individuals (Ali, 2001), and is more common in individuals diagnosed with autism (Kinnell,
1985).
A variety of means have been used to identify variables that maintain pica. These include indirect (e.g., Matson &
Bamburg, 1999) and direct (e.g., Wasano, Borrero, & Kohn, 2009) functional behavioral assessment procedures. Additionally,
when assessing the environmental variables maintaining pica in a direct assessment, several studies have used of safe-to-
ingest or simulated pica items that can be consumed without harm to the individual (e.g., Finney, Russo, & Cataldo, 1982). In
contrast to other problem behavior such as aggression, self-injury, and property destruction, which are more often
maintained by social contingencies, the vast majority of studies describing functional analysis of pica report it to be
maintained by sensory or ‘‘automatic’’ reinforcement (Hagopian, Rolider, & Rooker, in press).
The most commonly reported treatments for pica can be characterized as behavioral treatments, in that they involve
procedures such as noncontingent reinforcement (NCR), response-effort manipulations, differential reinforcement, response
blocking/interruption and brief contingent holds. More recent studies describing the treatment of pica describe multi-
component interventions that involve reinforcement, antecedent stimuli, and response reduction procedures. For a more
detailed review of this literature, the reader is referred to McAdam, Sherman, Sheldon, and Napolitano (2004) (but see also,
Hagopian et al., in press; Myles, Simpson, & Hirsch, 1997).
Although several reviews describing the literature on the treatment of pica have been published, no study has critically
examined the literature in terms of the American Psychological Association’s (APA) criteria for empirically supported
treatments (EST) as described by Divisions 12 and 16 of APA (Kratochwill & Stoiber, 2002; Task Force, 1995). This approach
involves identifying treatment studies with good experimental designs that demonstrate effective outcomes. Based on the
number of rigorous studies documenting successful outcomes, treatment approaches can be designated as having a certain
level empirical support – with well-established being the highest. This standardized, objective approach has only recently
been used to evaluate treatments for individuals with intellectual disabilities. For example, Carr, Severtson, and Lepper
(2009) applied EST criteria to examine noncontingent reinforcement (NCR) as a treatment for problem behavior; Jennett and
Hagopian (2008) applied EST criteria for evaluating interventions for phobic avoidance; and Kurtz, Boelter, Jarmolowicz,
Chin, and Hagopian (in press) used EST criteria to evaluate functional communication training as a treatment for problem
behavior.
The purpose of the current study was to use EST criteria to determine the level of empirical support for the treatment of
pica. Additional criteria developed for studies employing single-case designs described by Jennett and Hagopian (2008) were
used because none of the studies describing the treatment of pica used group designs.

2. Method

2.1. Article selection

A literature search of PsychInfo, PubMed, and Web of Science was conducted for articles published between January
1980 and January 2011 to identify studies that reported on the treatment of pica. The primary search term was pica and the
secondary search terms were: assessment, behavior, disability, retardation,1 self-injury, self-injurious, and treatment. The
primary search term was combined with each of the secondary search terms. From this, the abstracts and articles returned
were reviewed to determine what treatment procedure was used and if sufficient details in the results and procedures were
present in the article. Studies were either included or excluded in this review based on the criteria described below.
Included articles were then reviewed and coded to determine whether treatment procedures met criteria as an empirically
supported treatment. Additionally, articles were reviewed and coded to determine if reinforcement-based, response-
reduction-based, and reinforcement and response reduction-based treatments met criteria as empirically supported
treatments.

1
The term ‘‘retardation’’ was included in the search because this term was commonly used during the search period (1980–2011). The authors recognize
that intellectual disability is the preferred term and therefore this term is used throughout the rest of the text.
2116 L.P. Hagopian et al. / Research in Developmental Disabilities 32 (2011) 2114–2120

2.2. Article review and coding

Results of the search identified 746 articles. However, only 34 of these studies presented sufficient information on
procedures and reported data on reduction of pica. Therefore, these 34 studies were included in the review. The criteria for
empirically supported treatments established by APA Divisions 12 and 16 were used to code all of the articles. All studies
identified were single-case design; therefore, adapted criteria were employed (see Jennett & Hagopian, 2008). Articles were
coded for: (1) participant characteristics, (2) study characteristics, (3) experimental design, (4) experimental control, and (5)
treatment efficacy.

2.3. Interobserver agreement

Two of the authors were trained on the coding definitions and procedures using eight of the identified articles. Following
this, one author independently coded the remaining articles (26) and the second author independently coded 38.5% of the
articles (10). Inter observer agreement was calculated using the exact agreement formula (number of agreements/(number
of agreements + number of disagreement))  100. An agreement was defined as both coders’ scoring the presence or absence
of experimental control (good experimental design and treatment superior to baseline with replications), demonstration of
treatment efficacy, detailed description of treatment procedures, and clear specification of participant characteristics. The
average reliability coefficient was 95.9% (range 90.9–100 across the 4 categories listed above).

2.4. Criteria for determining empirically supported treatments

The levels of empirical support, as established by Division 12, are as follows: well-established, probably efficacious, and
experimental (Task Force, 1995). Treatments considered to be well-established have been demonstrated to be statistically
superior to another treatment, pill, or placebo, or equivalent to an already established treatment in two between-group
studies or nine single-case studies. These treatments must use a treatment manual or have clear descriptions of the
procedures, specific characteristics of the sample, and independent research groups must have replicated the effects.
Treatments considered to be probably efficacious have been demonstrated to the same statistical standard in two group
deigns compared to a wait list control group, or one group design that meets the well-established standard, or three single-
case design experiments that meet the well-established standard. Experimental treatments are those that meet neither the
well-established, nor the probably efficacious criteria.
These criteria are not ideal for single subject experimental designs (the type of design used in all pica studies reviewed);
therefore, this analysis adopted the modifications by Jennett and Hagopian (2008) to Divisions 12 and 16 criteria for judging
baseline quality, measurement system, and treatment quality. Baseline quality is determined by: (1) length of the baseline
(minimum three points), (2) stability of the data, (3) appropriate level of severity to require intervention, (4) data trend is
opposite to desired treatment effect, and (5) described with replicable precision. Measurement system is determined by: (1)
operational definitions of pica and (2) inter-observer agreement data. Treatment quality is determined by: (1) change in level
of behavior between baseline and treatment, (2) the change in trend of the data is in the desired direction, (3) length of the
treatment (minimum three points), (4) stability, and (5) minimal overlap between baseline and treatment. In addition, the
determination of treatment efficacy is more than an 80% reduction in pica relative to baseline rates. At least two-thirds of the
participants had to meet these criteria when there were multiple participants in a study.

3. Results

Studies were coded as meeting the criteria for experimental control (i.e., good experimental design), treatment efficacy
(at least an 80% reduction in pica), sufficient description (as to permit replication), and whether client characteristics were
specific. Twenty-six of 34 identified studies met these criteria and are presented in Table 1.

3.1. Participant characteristics

In the identified studies, 50 participants were described. The largest population of participants was adults (38%), followed
by children (36%), and then adolescents (20%). Additionally, almost a quarter of participants were diagnosed with autism
(22%), and the majority of participants were diagnosed with severe or profound intellectual disability (62%). Eighteen
percent had been diagnosed with lead poisoning. Pica was defined for each participant on a case-by-case basis, and generally
can be defined as the ingestion (or attempted ingestion) of (Table 2) inedible objects.

3.2. Study characteristics

Of the 26 studies, the average number of participants per study was 1.92 (range 1–4). Although the percentage of studies
conducted in each environment is not reported here because it is less relevant (i.e., pica occurs across environments), the
study setting was often hospitals, community centers, or day treatment facilities. All 26 studies described interventions that
could be characterized as behavioral interventions in that they involved manipulation of environmental antecedents and
 L.P. Hagopian et al. / Research in Developmental Disabilities 32 (2011) 2114–2120 2117

Table 1
Empirically supported treatment criteria and the status of studies employing single-case designs to evaluate behavior-analytic procedures as a treatment
for pica.

Demonstration of Determination of Treatment manual Client

experimental control efficacy characteristic

Good Treatment superior Attainment of 90% Description of Clearly

design to baseline reduction relative treatment equivalent specified
w/replications to baseline to treatment manual

Bogart, Piersel, Yes Yes Yes No Yes

and Gross (1995)
Carter (2009) Yes Yes Yes No Yes
Donnelly and Olczak (1990) Yes Yes Yes Yes Yes
Duker and Nielen (1993) Yes Yes Yes No Yes
Falcomata et al. (2007) Yes Yes Yes Yes Yes
Favell, McGimsey, Yes Yes Yes Yes Yes
and Schell (1982)
Ferreri et al. (2006) No Yes Yes Yes Yes
Finney et al. (1982) Yes Yes Yes Yes Yes
Fisher et al. (1994) Yes Yes Yes Yes Yes
Goh, Iwata, and Kahng (1999) Yes Yes Yes Yes Yes
Hagopian and Adelinis (2001) Yes Yes Yes Yes Yes
Hirsch and Miles (1996) Yes Yes Yesa Yes Yes
Johnson, Hunt, Yes Yes Yes No Yes
and Siebert (1994)
Kalfus, Fisher-Gross, Marvullo, No Yes Yes No Yes
and Nau (1987)
Kern et al. (2006) Yes Yes Yes Yes Yes
Mace and Knight (1986) Yes Yes Yesa Yes Yes
Madden, Russo, Yes Yes Yes Yes Yes
and Cataldo (1980)
McCord et al. (2005) Yes Yes Yes Yes Yes
Mulick, Barbour, Schroeder, Yes Yes Yes Yes Yes
and Rojahn (1980)
Northup, Fisher, Kahng, Harrell, Yes Yes Yes Yes Yes
and Kurtz (1997)
Paisey and Whitney (1989) Yes Yes Yesb Yes Yes
Patel, Carr, Kim, Robles, and Yes Yes Yes Yes Yes
Eastridge (2000)
Piazza, Hanley, Yes Yes Yes Yes Yes
and Fisher (1996)
Piazza et al. (1998) Yes Yes Yes Yes Yes
Piazza, Hanley, Blakeley-Smith, Yes Yes Yesa Yes Yes
and Kinsman (2000)
Piazza et al. (2002) Yes Yes Yes Yes Yes
Rapp et al. (2001) Yes Yes Yesa Yes Yes
Ricciardi, Luiselli, Terrill, Yes Yes Yes Yes Yes
and Reardon (2003)
Rojahn, McGonigle, Curcio, Yes Yes Yes Yes Yes
and Dixon (1987)
Singh and Winton (1984) Yes Yes Yes No No
Smith (1987) No Yes Yes No Yes
Stanley and Glenn (1989) Yes Yes Yes Yes Yes
Winton and Singh (1983) Yes Yes Yes Yes Yes
Woods, Miltenberger, Yes Yes Yes Yes Yes
and Lumley (1996)
a
80–90% reduction.
b
78.1% reduction.

consequences, as well as behavioral skills training. A functional analysis of pica was conducted for 11 participants across 8
studies and indicated automatic reinforcement in all but one case.

3.3. Evaluation of empirical support

Table 3 shows the results of the analysis of treatment effectiveness. Behavioral treatments were effective at producing an
80% reduction or greater in 25 of 26 studies. It should be noted that the one study that did not meet this criteria reported a
78.1% reduction (Paisey & Whitney, 1989). A 90% reduction (or greater) was reported in 21 of 26 studies (80.7%). This number
of studies far exceeds the required 9, and therefore, behavioral treatment is a well-established treatment for pica in
individuals with intellectual and developmental disabilities. Studies were further subcategorized into those that involved
either reinforcement procedures alone, response reduction procedures alone (response blocking, effort manipulations,
2118 L.P. Hagopian et al. / Research in Developmental Disabilities 32 (2011) 2114–2120

Table 2
Participant characteristics (n = 50).

Category Number of participants

Age
Children (age 2.25–12) 18
Adolescents (age 13–18) 10
Adults (age > 18) 19
Unreported 3
Diagnosis
Autism spectrum disorder 11
Lead-poisoning 9
Other 3
None reported 27
Level of intellectual disability
None 1
Mild 0
Moderate 3
Severe 12
Profound 19
Unspecified 3
None reported 12

punishment), and combined reinforcement and response reduction procedures. Effective treatments involving both
reinforcement and response reduction-based procedures also meet criteria as well-established in their own right (12 studies
were identified). Treatments involving either reinforcement only or response reduction procedures only are a probably
efficacious treatment because fewer than 9 studies were identified for each (see Table 3).

4. Discussion

In light of the potential risks associated with pica, the use of well-established empirically supported treatments is
imperative. This review revealed that majority of published studies on the treatment of pica can be characterized as
behavioral interventions because they involve manipulation of environmental antecedents and consequences, as well as
behavioral skills training. Findings from the current analysis demonstrate that these behavioral approaches are highly
effective in reducing pica – as most studies identified reduced pica by more than 90% relative to baseline. Moreover, this
review and analysis demonstrates that there are more than a sufficient number of high-quality studies in the literature to
characterize behavioral treatment as well established empirically supported treatments. Treatments combining
reinforcement and response reduction procedures also exceed criteria to be designated as well established.
The treatment of pica has evolved considerably over the past several decades. Early studies generally relied more on
suppressing pica by limiting opportunities to engage in the behavior and by applying punishment. Contemporary behavioral
treatments aim to reduce pica by: (1) bringing eating under appropriate stimulus control (i.e., reinforcing and allowing
eating of appropriate food based on its location); (2) providing alternative and competing sources of stimulation (i.e.,
noncontingent or contingent access to food); and/or (3) establishing alternative responses (such as discarding items) once

Table 3
Study characteristics.

Category Number of studies

Function of pica
Automatic 7
Attention 1
Effective treatment (>80% reduction)
Behavior analytic treatments 26
Reinforcement only 6
Response reduction only 8
Reinforcement + response reduction 12
Effective treatment (>90% reduction)
Behavior analytic treatments 21
Reinforcement only 5
Response reduction only 5
Reinforcement + response reduction 11
Design
Reversal 15
Multiple baseline 6
Multielement 5
Combination
 L.P. Hagopian et al. / Research in Developmental Disabilities 32 (2011) 2114–2120 2119

potential pica materials are contacted. While precautions should always be taken to limit access to non-food items that are
likely to be consumed (through supervision and maintaining a clean environment), taking this approach to its extreme–and
in the absence of appropriate behavioral treatment, can be restrictive, limit opportunities for a normalized routine and limit
access to a stimulating environment.
As evidenced in this study, there are a wide variety of behavior treatments for pica. Treatments that manipulated
antecedent events include NCR (e.g., Falcomata, Roane, & Pabico, 2007) and response effort (e.g., Piazza, Roane, Keeney,
Boney, & Abt, 2002). Treatments that manipulated consequent events include differential reinforcement (e.g., Kern, Starosta,
& Adelman, 2006), response block/interruption (e.g., McCord, Grosser, Iwata, & Powers, 2005), and punishment (e.g., Ferreri,
Tamm, & Wier, 2006). Additionally, antecedent and consequent events can be combined to create effective treatments (e.g.,
Rapp, Dozier, & Carr, 2001). Although there are a number of tools for treating pica demonstrated in the literature, this study
demonstrates particular procedures should be favored over others.

References

Ali, Z. (2001). Pica in people with intellectual disability: A literature review of aetiology, epidemiology and complications. Journal of Intellectual & Developmental
Disability, 26, 205–215.
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text revision). Washington, DC: Author.
Ashworth, M., Hirdes, J. P., & Martin, L. (2009). The social and recreational characteristics of adults with intellectual disability and pica living in institutions.
Research in Developmental Disabilities, 30, 512–520.
Bogart, L. C., Piersel, W. C., & Gross, E. J. (1995). The long-term treatment of life-threatening pica: A case study of a woman with profound mental retardation living
in an applied setting. Journal of Developmental and Physical Disabilities, 7, 39–50.
Carr, J. E., Severtson, J. M., & Lepper, T. L. (2009). Noncontingent reinforcement is an empirically supported treatment for problem behavior exhibited by
individuals with developmental disabilities. Research in Developmental Disabilities, 30, 44–57.
Carter, S. L. (2009). Treatment of pica using a pica exchange program with increasing response effort. Education and Training in Developmental Disabilities, 44,
143–147.
Condillac, R. A. (2007). Behavioral intervention and intellectual disabilities. In I. Brown & M. Percy (Eds.), A comprehensive guide to intellectual and developmental
disabilities (pp. 363–372). Baltimore, MD: Brooks.
Danford, D. E., & Huber, A. M. (1982). Pica among mentally retarded adults. American Journal of Mental Deficits, 87, 141–146.
Decker, C. J. (1993). Pica in the mentally handicapped: A 15-year surgical perspective. Canadian Journal of Surgery, 36, 551–554.
Donnelly, D. R., & Olczak, P. V. (1990). The effect of differential reinforcement of incompatible behaviors (DRI) on pica for cigarettes in persons with intellectual
disabilities. Behavior Modification, 14, 81–96.
Duker, P. C., & Nielen, M. (1993). The use of negative practice for the control of pica behavior. Journal of Behavior Therapy and Experimental Psychiatry, 24, 249–253.
Falcomata, T. S., Roane, H. S., & Pabico, R. R. (2007). Unintentional stimulus control during the treatment of pica displayed by a young man with autism. Research in
Autism Spectrum Disorders, 1, 350–359.
Favell, J. E., McGimsey, J. F., & Schell, R. M. (1982). Treatment of self-injury by providing alternate sensory activities. Analysis and Intervention in Developmental
Disabilities, 2, 83–104.
Ferreri, S. J., Tamm, L., & Wier, K. G. (2006). Using food aversion to decrease severe pica by a child with autism. Behavior Modification, 30, 456–471.
Finney, J. W., Russo, D. C., & Cataldo, M. F. (1982). Reduction of pica in young children with lead poisoning. Journal of Pediatric Psychology, 7, 197–207.
Fisher, W. W., Piazza, C. C., Bowman, L. G., Kurtz, P. F., Sherer, M. R., & Lachman, S. R. (1994). A preliminary evaluation of empirically derived consequences for the
treatment of pica. Journal of Applied Behavior Analysis, 27, 447–457.
Goh, H., Iwata, B. A., & Kahng, S. (1999). Multicomponent assessment and treatment of cigarette pica. Journal of Applied Behavior Analysis, 32, 297–316.
Greenberg, M., Jacobziner, H., McLaughlin, M. C., Fuerst, H. T., & Pellitteri, O. (1958). A study of pica in relation to lead poisoning. Pediatrics, 22, 756–760.
Hagopian, L. P., & Adelinis, J. D. (2001). Response blocking with and without redirection for the treatment of pica. Journal of Applied Behavior Analysis, 34, 527–530.
Hagopian, L. P., Rolider, N. U., & Rooker, G. W. Behavioral assessment and treatment of pica. In J. K. Luiselli (Ed.), The handbook of high-risk challenging behaviors:
Assessment and intervention. Brookes, in press.
Hirsch, N., & Miles, B. S. (1996). The use of a pica box in reducing pica behavior in a student with autism. Focus on Autism and Other Developmental Disabilities, 11,
222–225.
Jennett, H. K., & Hagopian, L. P. (2008). Identifying empirically supported treatments for phobic avoidance in individuals with intellectual disabilities. Behavior
Therapy, 39(2), 151–161.
Johnson, C. R., Hunt, F. M., & Siebert, M. J. (1994). Discrimination training in the treatment of pica and food scavenging. Behavior Modification, 18, 214–229.
Kalfus, G. R., Fisher-Gross, S., Marvullo, M. A., & Nau, P. A. (1987). Outpatient treatment of pica in a developmentally delayed child. Child and Family Behavior
Therapy, 9, 49–62.
Kern, L., Starosta, K., & Adelman, B. E. (2006). Reducing pica by teaching children to exchange inedible items for edibles. Behavior Modification, 30, 135–158.
Kinnell, H. G. (1985). Pica as a feature of autism. British Journal of Psychiatry, 147, 80–82.
Kratochwill, T. R., & Stoiber, K. C. (2002). Evidence-based interventions in school psychology: Conceptual foundations of the Procedural and Coding Manual of
Division 16 and the Society for the Study of School Psychology Task Force. School Psychology Quarterly, 17, 341–389.
Kurtz, P. F., Boelter, E. W., Jarmolowicz, D. P., Chin, M. D., & Hagopian, L. P. An analysis of functional communication training as an empirically supported treatment
for problem behavior displayed by individuals with intellectual disabilities. Research in Developmental Disabilities, in press.
Lacey, E. P. (1990). Broadening the perspective of pica: Literature review. Public Health Reports, 105, 29–35.
Mace, F. C., & Knight, D. (1986). Functional analysis and treatment of severe pica. Journal of Applied Behavior Analysis, 19, 411–416.
Madden, N. A., Russo, D. C., & Cataldo, M. F. (1980). Behavioral treatment of pica in children with lead poisoning. Child Behavior Therapy, 2, 68–81.
Matson, J. L., & Bamburg, J. W. (1999). A descriptive study of pica behavior in persons with mental retardation. Journal of Developmental and Physical Disabilities, 11,
353–361.
McAdam, D. B., Sherman, J. A., Sheldon, J. B., & Napolitano, D. A. (2004). Behavioral interventions to reduce the pica of persons with developmental disabilities.
Behavior Modification, 28, 45–72.
McCord, B. E., Grosser, J. W., Iwata, B. A., & Powers, L. A. (2005). An analysis of response-blocking parameters in the prevention of pica. Journal of Applied Behavior
Analysis, 38, 391–394.
Mulick, J. A., Barbour, R., Schroeder, S. R., & Rojahn, J. (1980). Overcorrection of pica in two profoundly retarded adults: Analysis of setting effects, stimulus, and
response generalization. Applied Research in Mental Retardation, 1, 241–252.
Myles, B. S., Simpson, R. L., & Hirsch, N. C. (1997). A review of literature on interventions to reduce pica in individuals with developmental disabilities. Autism, 1,
77–95.
National Institutes of Health. (1991). Treatment of destructive behaviors in persons with developmental disabilities. Washington, DC: NIH Consensus Development
Conference, US Department of Health & Human Services.
Northup, J., Fisher, W., Kahng, S. W., Harrell, R., & Kurtz, P. (1997). An assessment of the necessary strength of behavioral treatments for severe problem behavior.
Journal of Developmental and Physical Disabilities, 9, 1–16.
2120 L.P. Hagopian et al. / Research in Developmental Disabilities 32 (2011) 2114–2120

Paisey, T. J. H., & Whitney, R. B. (1989). A long-term case study of analysis, response suppression, and treatment maintenance involving life threatening pica.
Behavioral Residential Treatment, 4, 191–211.
Patel, M. R., Carr, J. E., Kim, C., Robles, A., & Eastridge, D. (2000). Functional analysis of aberrant behavior maintained by automatic reinforcement: Assessments of
specific sensory reinforcers. Research in Developmental Disabilities, 21, 393–407.
Piazza, C. C., Fisher, W. W., Hanley, G. P., LeBlanc, L. A., Worsdell, A. S., Lindauer, S. E., & Keeney, K. M. (1998). Treatment of pica through multiple analyses of its
reinforcing functions. Journal of Applied Behavior Analysis, 31, 165–189.
Piazza, C. C., Hanley, G. P., Blakeley-Smith, A. B., & Kinsman, A. M. (2000). Effects of search skills training on the pica of a blind boy. Journal of Developmental and
Physical Disabilities, 12, 35–41.
Piazza, C. C., Hanley, G. P., & Fisher, W. W. (1996). Functional analysis and treatment of cigarette pica. Journal of Applied Behavior Analysis, 29, 437–450.
Piazza, C. C., Roane, H. S., Keeney, K. M., Boney, B. R., & Abt, K. A. (2002). Varying response effort in the treatment of pica maintained by automatic reinforcement.
Journal of Applied Behavior Analysis, 35, 233–246.
Rapp, J. T., Dozier, C. L., & Carr, J. E. (2001). Functional assessment and treatment of pica: A single-case experiment. Behavioral Interventions, 16, 111–125.
Ricciardi, J. N., Luiselli, J. K., Terrill, S., & Reardon, K. (2003). Alternative response training with contingent practice as intervention for pica in a school setting.
Behavioral Interventions, 18, 219–226.
Rojahn, J., McGonigle, J. J., Curcio, C., & Dixon, M. J. (1987). Suppression of pica by water mist and aromatic ammonia. Behavior Modification, 11, 65–74.
Singh, N. N., & Winton, A. S. W. (1984). Effects of a screening procedure on pica and collateral behaviors. Journal of Behavior Therapy and Experimental Psychiatry, 15,
59–65.
Smith, M. D. (1987). Treatment of pica in an adult disabled by autism by differential reinforcement of incompatible behavior. Journal of Behavior Therapy and
Experimental Psychiatry, 18, 285–288.
Stanley, A. E., & Glenn, K. (1989). An integrated treatment approach to pica: A case report. Journal of the Multihandicapped Person, 2, 155–165.
Task Force on Promotion and Dissemination of Psychological Procedures. (1995). Training in and dissemination of empirically-validated psychological
treatments. The Clinical Psychologist, 48, 3–23.
Wasano, L. C., Borrero, J. C., & Kohn, C. S. (2009). Brief report: A comparison of indirect versus experimental strategies for the assessment of pica. Journal of Autism
and Developmental Disorders, 39, 1582–1586.
Winton, A. S. W., & Singh, N. N. (1983). Suppression of pica using brief duration physical restraint. Journal of Mental Deficits Research, 27, 93–103.
Woods, D. W., Miltenberger, R. G., & Lumley, V. A. (1996). A simplified habit reversal treatment for pica related chewing. Journal of Behavior Therapy and
Experimental Psychiatry, 27, 257–262.