Passing your National Licensing Exam

Pica: Beyond Dirt and Paint Chips

• Linton Hutchinson, Ph.D., LMHC, NCC, Eric Twachtman

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Dive into the fascinating world of Pica with us as we unravel this often-misunderstood condition characterized by the persistent eating of non-food items. Named after the magpie bird known for its indiscriminate eating habits, Pica affects people across all age groups and presents unique challenges for clinicians and families alike.

We break down the multiple theoretical foundations attempting to explain this behavior – from nutritional deficiencies and sensory-seeking to stress responses and learned behaviors. You'll discover why people with anemia or sickle cell disease are more than twice as likely to develop Pica, and why an astonishing 30% of pregnant women worldwide experience these unusual cravings during pregnancy.

The diagnostic criteria reveal surprising insights - children under two can't be diagnosed with Pica because putting objects in their mouths is developmentally normal. We explore how clinicians must carefully distinguish between cultural practices and pathological behavior, sharing examples like Guatemalan clay tablets embossed with religious imagery consumed for perceived health benefits. From dirt and paint chips to ice and pencil erasers, the variety of non-food items consumed reveals patterns that help unlock effective treatments.

Whether you're a clinician preparing for licensing exams or simply curious about this compelling disorder, our evidence-based discussion of behavioral interventions offers practical approaches for addressing Pica. We examine differential reinforcement techniques, response interruption, and nutritional supplementation while emphasizing the importance of comprehensive assessment that considers psychological, medical, and cultural factors. Join us for this enlightening exploration that challenges assumptions and deepens understanding of human behavior at its most puzzling.

If you need to study for your national licensing exam, try the free samplers at: LicensureExams


This podcast is not associated with the NBCC, AMFTRB, ASW, ANCC, NASP, NAADAC, CCMC, NCPG, CRCC, or any state or governmental agency responsible for licensure.

Linton:

Hey there, eric, and hey to everyone out there. Today we're going to go through theory to therapy podcast, and we had a therapist that emailed us who had never worked with children before. She ran across a diagnosis that she wasn't familiar with, called PICA.

Eric:

Right and you pronounced it correctly, because sometimes people think it should be PICA. I don't know why, but it is pronounced PICA.

Linton:

You know, when I first heard it, the first thing I thought about was a typeface, as a matter of fact they come from the same derivation.

Eric:

Pica is the eating disorder, yeah, and it's characterized by persistent craving or actually eating non-food items, and in the DSM it has to be for more than a month. Is that only for kids, or everybody? Or everybody, as a matter of fact, except for under two, which we'll talk about in a little while. But pica comes from the latin word for magpie come on, I know magpie and the pie it means spotted. So pica for magpie is from the bird, because apparently magpies eat anything.

Linton:

Well, let's talk a little bit about the theoretical foundations. Okay, yes, there's several theories that attempt to explain pica behavior, and whenever you hear anyone say that there are several theories, basically what they're saying is that they don't know right exactly so when it? One of the theories they came up with was it was a nutritional theory. It's like, okay, people that have pica must have some kind of vitamin or some kind of deficiencies. Right, you dogs are like that. They're missing something in their diet.

Eric:

They'll go out and eat grass, eat grass or chew bark or whatever yeah.

Linton:

And they did find out that people that do have pica, there's like really two and a half times or odds that they are anemic or they have low zinc levels. So that was an idea of the reason people do pica is of nutritional lack.

Eric:

Well, and there's also the physiological theory, which is that they just need that texture, taste or smell like eating pencils, which I think you were right that they're reaching for it.

Linton:

Okay. I mean there's a little element of truth in all of them. There's a psychosocial theory that attributes pica to stress, and it's basically a way of an individual dealing with whatever anxiety or stress that they're having as a coping mechanism that alleviates their emotional distress.

Eric:

Well, and that sounds like the psychodynamic perspective, which is all about the underlying emotional content, that I have unmet emotional needs, so I'm eating paint chips.

Linton:

Okay, and then there's the behavioral perspective, that it's suggested that pica is a learned behavior. So if your mother used to eat dirt, chances are you may have picked that up from her or from your peer group. So, basically, if a child receives attention after they ate dirt or whatever that behavior may be, reinforced.

Eric:

You talk to little Jimmy now and he's like oh, I got talked to, normally I'm ignored, so now hand me the dirt, okay, okay. And finally, the cognitive theory that they just have a distorted thinking pattern. They have, you know, they think dirt's good and somehow they got into that cognitive deficit and they just need to be taught not to eat dirt, so you know it is in the dsm-5tr absolutely isn't there yes, and there are certain diagnostic criteria and probably the most significant is that the ingestion of non-nutritive substances for at least one month.

Eric:

Right, the month is the biggest one, so you just eat some paste today.

Linton:

And the second one is the behavior must be developmentally inappropriate. Right, those were two of the main takeaways that you need to remember when you're going to take your licensing exam.

Eric:

Well, and especially the developmentally inappropriate. Because what do babies do? Everything goes in their mouth, right? So babies don't have pica, they're eating the same thing. If you ate the same thing a baby did, then it's a problem. But you know, babies stick a paint chip in their mouth.

Linton:

A paint your house, but B it's not developmentally inappropriate well, I'm surprised you didn't do that at the house that you lived in when you were growing up. Who's who said I didn't? Because there was nothing but lead paint, as I remember right.

Eric:

Well, it's true, and I think some of my friends have suggested that that's why I'm not as smart as I might be. So you never know. And the other part of that developmentally appropriate, is also that it's not a cultural thing, that it can't have cultural significance. So that you lived out in the jungle and the doctor there said oh, you should eat this bark for your whatever problem. You have To westernize. That looks like pica, you're eating tree bark, whereas it was actually part of your culture. So you have to be culturally sensitive.

Linton:

As you're looking at the criteria, so, instead of eating the tree bark, what we do is we take it, we grind it up, put it in a pill and call it aspirin, right Well?

Eric:

yeah, exactly so. Right, you eat it as a pill, it's all fine, and it could be the same tree bark, but you put it in a gel cap and now it's medicine. It's true, yes, and so we did the non-nutritive four-month. You have to be developmentally appropriate in your thing, which meant nobody under two years old has pica, because you know, you just can't tell. And it has to be severe enough to warrant clinical attention.

Linton:

Okay, so it's called. You know it's basically eating the earth, so what's that called? Don't they have a term for that? That's right. Geophagia, geophagia, okay, geophagia. That'd be something to remember for the exam too, wouldn't it?

Eric:

yes, probably so, because that is, you know, a cultural thing in many places. As it turns out, if you have ever had an upset stomach and you've had kaopectate, it's a medicine you can get at your local drugstore, right Well, kao refers to kaolin, a kind of clay. So we ourselves are eating clay, only got to pay 10 bucks a bottle for it.

Linton:

Really? Yeah, well, there's certain mental health conditions. Children with autism exhibit nutritional challenges, including pica. Schizophrenia, pica sometimes yeah, it's sometimes presented as an impulsive consumption of non-food items, which are associated with delusions. Right?

Eric:

Obsessive compulsive disorder oh, I thought it was a turkey and I ate this dirt because I okay, that makes sense. Obsessive compulsive disorder oh, I thought it was a turkey and I ate this dirt because I okay that that makes sense.

Linton:

Obsessive compulsive disorder. Compulsive eating of non-food items to relieve stress is a form of pica and you can see that with OCD Individuals with some kind of intellectual disability. It occurs with mental health disorders associated with impaired functioning Post-traumatic stress. There's a strong correlation between pica and PTSD.

Eric:

Really, yeah, okay now. Now see, the schizophrenia made sense to me, but not so much the ptsd okay I guess we'll have to look into that.

Linton:

Other conditions, more medical conditions anemia pica is associated with anemia and deficiencies of iron, zinc and other nutrients okay, that goes back to what you said earlier.

Eric:

That makes sense about the body knowing what it needs.

Linton:

Another one if an individual in the case study, they say they have sickle cell, what's it called Sickle cell?

Eric:

disease, sickle cell disease, or it used to be sickle cell anemia, but now they just call it sickle cell disease.

Linton:

So it's really prevalent in individuals that have sickle cell disease. Like 34% of those people, many times will exhibit or demonstrate PICA behaviors.

Eric:

Right, because they have iron deficiency and they need the iron.

Linton:

Okay, that goes back to the nutritional theory. Yeah, absolutely.

Eric:

And the last one is pregnancy so we all know about them having cravings. That's certainly true uh-huh.

Linton:

So pica is common in pregnant women, with worldwide prevalence of about 30 percent during pregnancy.

Eric:

Wow, so not just ice cream?

Linton:

no, I, I knew someone. I knew a pregnant woman who did that all the time Really, and, yeah, I had to keep her from eating cat food. You have any idea who that was?

Eric:

Ez, I have no idea. You know a cat food eating. Does she eat cat food now? No, she doesn't, but she was your sister Really, and she ate cat food? Yeah, I had to keep her away from that she snuck in the little friskies and you had to keep it away from her. I did, I did. Wow, if I'd known I'd have snuck her some cans myself. I didn't know you were, you know, keeping it from her.

Eric:

The common substances dirt, clay, sand stones, hair feces, vinyl gloves. I can't imagine vinyl gloves, plastic pencil erasers, which I chewed on my pencil eraser in class. So there you go ice paper, paint chip and cat food. I guess when you look at children over two that have pica, that gives insights into the normal and abnormal development pattern. So they actually study pica as a way of looking at normal as opposed to abnormal development patterns. And of course they look at pica to see if they can't stop lead poisoning, because it is true that lead, the metal lead, is sweet, is it? Yeah, that's why the Romans liked to drink wine out of lead cups, because it actually made the wine sweeter and they didn't know they were poisoning themselves back then.

Linton:

Yeah, well, let's say that you have a client that does have pica. All right, so let's look at some behavioral interventions. Differential reinforcement how many of you out there know what that is?

Eric:

Yes, I didn't see anyone raise their hand.

Linton:

Okay, Let me give you an example. If a child tried to eat your carpet, you're in session. They're trying to eat your carpet. So instead of doing that, you would provide them with some kind of chewy toy yeah, the same kind that you gave to your dogs and before they started to chew your rug up, you would give them the chewy toy. And then you would praise them and say, oh, that's great job that you're chewing on the chewing toy instead of the carpet. So if they attempt to do it again to eat the carpet or your desk, you block their access and redirect them to the toy, while minimizing any attention that you might have for that inappropriate behavior.

Eric:

You can't give them the attention right.

Linton:

Yeah, otherwise it just reinforces them eating your carpet, sure.

Eric:

Right yeah, which is always a problem with that. They do an inappropriate thing, you give them attention for it and it tends to be a reinforcer. Right yeah, exactly.

Linton:

Another one would be differential reinforcement of alternative behaviors, and they call that DRA. I don't know why they don't call it DRAB drab.

Linton:

Yeah, maybe that's why they don't so that's providing reinforcement for desired responses that are alternatives to pica itself. For example, you've got a six-year-old in your office. They enter your office and they try to eat some kind of non-edible object let's say paperclips or your diploma off your wall. You have to go through a whole procedure to deal with that. You identify the function, determine that the pica behavior is maintained by sensory stimulation. You choose some kind of alternative behavior to teach the child to place non-edible items in a trash can. So you have a pica can. So whenever they go you set up the environment with this pika can. So when they engage in pika, right, you prompt them to take it and put it in the container. So then you immediately reinforce them and praising them for, instead of eating, you know your diploma, you took it off the wall and you put it in the pica and so Huh, and that works Well, I guess it does. They wouldn't be using it.

Eric:

You know, I suppose that's true, yeah, true.

Linton:

So, and then there's differential reinforcement of incompatible behaviors. In other words, you give them something to do at the same time they're trying to do pica, so you have them fold their hands and then they really can't eat whatever the paper clips and everything, because they can't pick them up. So that's another technique. And then you, you know, give them stars, or Okie doke.

Eric:

Well, I also read about one called non-contingent reinforcement, NCR, which is one of the most commonly used, as it turns out. Oh yeah, and that means that you're reinforcing other behaviors other than the pica, so that they're doing something positive. You reinforce those and basically ignore the pica.

Linton:

Okay yeah, okay yeah, yeah. So like I'm doing right now is called response interruption. There you go. So this technique blocks the attempts to consume non-food items and redirects the individual to more appropriate activities.

Eric:

Yes, okay, that makes perfect sense. And then I guess the next step up or down from that, I'm not sure which I guess it depends on whether you're on the receiving end but mild aversive therapy, where you pair non-food items with mildly unpleasant consequences while rewarding healthy eating behaviors. So you have an unpleasant consequence when they eat your diploma and you have some grapes and then you give them positive feedback for eating the grapes Great.

Linton:

So of course, psychoeducation, but with small children that's a little more difficult.

Eric:

And then finally nutritional supplementation.

Linton:

Okay, now here's another thing in terms of cultural practice. Oh, like the geophagia. Yeah, yeah, exactly so like, for example, people in Guatemala will go ahead and make holy tablets out of clay and they emboss them with religious images and then they consume them and they think that that gives them additional health benefits.

Eric:

Really. So you've got the little clay tablet which might have whatever mineral.

Linton:

Yeah, it might have zinc.

Eric:

And then you put St Joseph on there. And now you're not just eating a mineral tablet, you're eating St Joseph too. I wonder what St Joseph thinks about that.

Linton:

That will help you combining religious and health benefits. Huh, interesting. How's that different from ingesting calcium that I know is extracted from minerals?

Eric:

Oh well, not only extracted from minerals. My cousin inherited a marble quarry. Lucky him, I know I did feel that he was lucky for having done that, although good on him. But he sold his marble not to make headstones or countertops, but they ground it up to make calcium supplements. So you go to the store and buy a calcium supplement. It might be just marble dust.

Eric:

Yeah, a piece of marble that didn't look good, Right yeah, so they ground it up into a powder, stuck it in a capsule, and there you go. So yeah, and I think the fact is that if a big supplement company went down to Guatemala and was selling St Joseph clay tablets, then all of a sudden it's good for us.

Linton:

Okay, eric. What are some criticisms and limitations here?

Eric:

Well, you know, as maybe you've picked up on some of my skepticism about it, I did. Yeah, the fact is that some of the definitions are inconsistent. So you go to Guatemala and you see them eating the clay tablets and some people say, oh, that's pica, that's clay. And yet you dig further down and you realize that there, the clay tablets and some people say, oh, that's pica, that's clay. And yet you dig further down and you realize that there's a you know a purpose behind it. So there's an inconsistency in the definitions and in the cultural considerations. So unless you've really burrowed down into those issues, you know you risk labeling somebody inappropriately, and the fact is that there haven't been many controlled studies about it.

Linton:

Well, it's time for a knowledge check. All right, I'm ready. All right, this is maybe the kind of question that you might find on a licensing exam. Which of the following is not typically considered an evidence-based treatment for pica? A cognitive behavioral therapy, B applied behavioral analysis, C exposure and response prevention or D psychodynamic theory?

Eric:

Hmm, Okay, so we've talked about all of those behavioral-based ones having actual data behind them, which we know behavioral therapy is all about. The data is all about collecting all of those data points in order to find out. So I'm going to guess that it's psychodynamic theory. D.

Linton:

Right. All the other ones have shown effectiveness in treating pica, but there's limited evidence supporting the use of psychodynamic therapy for pica and supporting the use of psychodynamic therapy for PICA. So, Az, through this whole thing, why didn't you focus on assessment instruments that would be used for assessing PICA? It seems like that might be something that would be on a licensing exam.

Eric:

Well, here we go the PICA screening questionnaire, the direct observation PICA assessment protocol, the child eating behavior inventory, the sensory profile. You see where we're going with this. Okay, okay, I get it. Yeah, you can go on and on. I mean they're just gobs of them, but they all say PICA or something about eating.

Linton:

Okay, yeah, okay. So let's do a summary and key takeaways for PICA. Yes, yeah, okay. So let's do a summary and key takeaways for pica. Yes, first, pica involves persistently eating non-food items for at least one month, and this behavior must be developmentally inappropriate right over two years old.

Eric:

Second, pica can occur across different age groups and populations and, as you pointed out so efficiently, co-occurs with other mental health or developmental conditions.

Linton:

The third evidence-based treatments for PICA include cognitive behavioral therapy, applied behavioral analysis and nutritional counseling.

Eric:

And PICA assessment should include psychological measures and a medical evaluation to check for complications and if there are any nutritional deficiencies.

Linton:

And finally, remember that treating PICA often requires a multifaceted approach, addressing behavioral, cognitive and, of course, environmental factors. Yes, and with that we'll wrap up today's episode on pica. We hope the information helps you on your exam preparation and any future clinical work that you're doing.

Eric:

Absolutely. Thanks for tuning in and remember, just because you're 18 month old, is running around eating crickets and popping in the mouth like there's no tomorrow, and popping in their mouth like there's no tomorrow it's not pica, because they're not over two and you know crickets are nummy. So don't fret too much about your toddlers. They'll grow out of it and, let's face it, you'll have bigger problems when they grow up to be teenagers or beyond. So until then, just remember it's in there, in there, all right. Thanks for listening.

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Dr. Linton Hutchinson, LMHC

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Eric

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Stacy

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