Feeding And Eating Disorder - Research Paper Example

Pica – a Review Abstract This paper considers pica, especially in relation to young people with developmental disorders, but also taking into account other groups with the condition . It concludes that certain interventions can reduce or eliminate the practice, but not in every case, and that therefore more research is required. Introduction Many, if not all, young children put non-food items, that is those items or substances with no nutritional value, into their mouths from time to time, and may chew or even swallow them. It is a way of exploring their environment, and so testing what is edible and what is not. They need to learn what is good food and what is not. Children are naturally curious about their environment, and might for instance chew the pages of a book, or pick up dirt and taste it. It is part of their self-conducted process of education, which begins long before they enter school or even nursery. Pica is the term used when the eating of particular non-food items continues for a month or more, and goes far beyond a simple exploratory bite. Pica is the persistent and compulsive craving to eat items others consider as non-food. It is considered to be a self-injurious condition ( Minshawl et al , 2014) with some children swallowing the substance quickly, whereas others held it in their mouths for prolonged periods ( Autism Speaks, undated). The term is derived from the Latin name for magpie, a bird with a fairly indiscriminate appetite. The term pica was first used to describe this abnormal eating pattern by Ambrose Paré (1509-1590), but was described far earlier, as by Aristotle in ancient Greece ( Young et al, 2008). There are many sub-groups of this condition, each named according to the preferred substance. These include coprophagia (faeces); geophagia (dirt, soil, clay); lithophagia (stones) and trichophagia (hair). Apart from actual observation of the individual eating these unusual substances, the condition may present because of its consequences such as toxic ingestion such as lead poisoning; parasitic infestation such as worms; perforation of the intestine; or damage to teeth ( Ellis and Pataki , 2015). Golden et al (2012) describe the condition as being a public health concern because it is potentially has negative health consequences, especially among the most vulnerable in society. Matson et al ( 2003) reported levels of pica in the general population to be at levels between 4 and 26%, but Beeker ( 2008, cited by Berends et al , 2014) could not give a definite percentage among those with developmental disabilities , so it is hard to judge the prevalence of pica. Many people who exhibit pica, apart from children under the age of three, are those who also have developmental debilities, such as those with autism. It can also occur after brain injury, among those with epilepsy and in some pregnant women. Among some groups pica is part of the local cultural behaviour. This topic will be considered in a literature review, especially with regard to child and adolescent psychopathology. Literature Review In 2004 McAdam et al considered pica in people with developmental disabilities , and ways to deal with this. The authors were aware that the eating of non-food items is common in those with developmental disabilities, and aware also of the dangers involved. They specifically mention damage to the gastro-intestinal tract, by blocking it, or even puncturing or tearing it. In some case the form pica takes is to eat dirt and this could result in infestation by parasites. The researchers felt that pica could interfere with a person’s quality of life, as well as their learning and ability to carry out tasks. They had considered twenty six separate studies which looked at behavioural interventions to overcome the problems. Methods used included the reinforcement of other behaviours and non-contingent attention. This means giving the person access to some kind of reinforcement, so that they are no longer so motivated to exhibit what is seen as negative behaviour . McAdam et al (2004) looked at both the effectiveness and the acceptability of the various interventions. The fact that they were able to examine twenty-four studies, shows both how widespread the problem is, and also the variety of methods in use. Young et al ( 2008) looked at the wide variety of materials involved, especially geophagic substances, such as clay and sand. These researchers felt that there was a dearth of understanding on the topic , and describe the reasons for this . Those mentioned include a lack of awareness of the condition, together with the fact that those who practice pica often hide what they are doing, perhaps because it is considered to be a mental illness. They also felt that research designs used were often those which failed to really answer questions as to causality. There was such variety in methods used to investigate pica, because of a wide spectrum of objectives among researchers. This, according to Young et al (2008) has resulted not only in irregular sampling, but also the incomplete analyses of the data obtained, which related to pica in its various forms. They considered the fact that it might be a person’s psychological response to a stressful situation, as a form of self-protection, as suggested by researchers such as Singhi et al in 1981. Young et al ( 2008) considered six types of procedures and methodologies. The most important point they make, in my opinion, is that it is necessary :- To avoid judgmental behaviour, comments, or questions, and to conduct interviews in a tolerant and compassionate way. They then follow this up with a list of questions to be asked, such as asking pica consumers why they prefer this food. Although they look carefully at what is eaten, why it is a preferred food, the amounts consumed and the chemical makeup of the pica substance, it is the way they deal with the topic with the individuals concerned which stands out in this text. Call et al (2015) agreed that behavioural interventions could decrease the levels of pica among autistic people, but added the important rider that the samples covered in research in the existing literature tended to be very small, and also that the reasons why particular interventions were successful in preventing the negative behaviour were still poorly understood. They therefore chose to study all patients who presented with pica, whether or not interventions were successful. This meant that their sample numbers were higher than in other studies considered in this paper. The result of this research was that behavioural interventions were found to be an effective method of treatment , not only for individuals, but for the group as a whole. This fitted in with the findings of Hagopian et al in 2011, who considered a large number of treatment studies, and found 25 which they felt were well designed, and which also reported at least an 80% success rate in reducing pica, with the majority reporting success rates of 90% or more. The research team concluded that behavioural treatment interventions in general, and especially those which involved a combination of reinforcement, along with procedures designed to reduce responses, could be considered as being well-established interventions for pica when found in people with intellectual disabilities, despite the fact that these methods did not work in each and every case of pica. Autism Speaks (page 2 undated) lists a number of reasons why pica develops. These are stated as including as a belief that the substance is edible, as some of these children have a problem differentiating food from non-food items. It was felt though that the most common reason for pica is sensory feedback, also referred to as automatic reinforcement, that is to say the children derive some pleasure form the experience of eating these unusual substances. In some cases the desire to eat these non-foods is driven by having low levels of zinc or iron, which can be alleviated by giving supplements, an indication that every child displaying symptoms of pica, should have blood tests to eliminate these possibilities. Pica was not found commonly to be simply a way of getting attention , nor does it develop because the child cannot communicate what they want. The Autism Speaks document (undated) then goes on to explain ways in which parents can help the situation such as removing the items from sight; blocking, that is physically preventing the child from eating their chosen substance; skill building – ways to help the child to choose food items rather than non-food ones. Finally they should take steps to ensure that the medical results of pica are dealt with. Williams and McAdam (2012) saw pica as being a dangerous behaviour found among institutionalized people with developmental disabilities . They state that, despite a number of published studies which show how pica can be reduced by using behavioural interventions, they felt that very few of these papers showed ways in which these treatments could be generalised, and continued in the long term. Also it was felt by these authors that, although the reports were of considerable improvements made with regard to pica , these were not enough to eliminate the problem and its adverse effects. This means that further efforts are still required in order to prevent those affected from the consequences of their self-harming habits. For this reason Williams and McAdam (2012) came up with several recommendations for the prevention, assessment and then treatment of pica, based upon the idea that early intervention was the most appropriate method. O’Hara et al 2010 point out how people with intellectual disabilities often have not one but several unrecognised health needs which go untreated. This can be because of communication difficulties, or because they have multiple conditions and there is therefore a degree of diagnostic overshadowing, but this under diagnosis may, according to these writers, also be due to indifference or even active discrimination against those with developmental disorders. Whatever the reason, the result is that the inequality which already exists is increased by a lack of adequate diagnosis, and therefore treatment. In contrast to these reports concerned with those with developmental disabilities Golden et al ( 2012) considered the situation in Malaysia, where pica can be considered as being part of the culture, so presumably not considered by that society as either dangerous, or needing treatment, and where it is part of the diet of a range of people. Often particular clays are consumed and are considered to be valuable medicines or as food products. The aim of this research was to find the prevalence across the population and this was done by looking at 760 individuals, with the majority being children or adolescents. A range of thirteen different non-food substances were being consumed right across the population, with no peaks recorded during pregnancy. Unlike other research papers considered these researchers mentioned possible benefits such as a protection against harmful pathogens and toxins, as a means of quelling gastrointestinal problems such as nausea, or because the substances could contribute nutrients which might be beneficial. It can be seen that although pica has been observed in a variety of people, in certain groups, and among particular cultures, there has been a greater concentration upon eliminating it than in understanding the causes. Yes, it is associated in particular with developmental disabilities , but why did some observers see it as being only associated with those in institutions? Could it be that the inhabitants are less likely to obtain satisfaction in other ways? If it is that pica is more common within those in institutions is it because these are likely to be those with the most severe developmental disabilities, or because of the level and type of care offered? It is clear from other reports that it is also seen in children who do have developmental disorders , but who normally live with their families, and there is considerable advice for parents trying to deal with the situation. The advice offered to parents is extensive, such as helping their child to distinguish non-foods from food items, but it should be remembered that they may be having to deal with other difficult behaviour at the same time, and so require considerable support. It can be difficult to get a diagnosis of autism confirmed, ( Ianelli 2013) as there is no one test , and some of the behaviours linked to it, are also normal for young children , such as being more interested in the way the wheels of a toy truck go round, rather than the whole toy. Pica is similar, in that almost every parent can report that their child has eaten cat food or chewed a piece of Lego or a page of a book. Definite exhibition of pica in a child aged three or over can lead to other investigations, and so to a diagnosis, which means the family can then access help, such as extra support at school, so in one sense it can be seen as positive. Many of the papers report on very small studies, often conducted over a quite limited time scale. Taken together these reports give a general picture of the situation, but are individually not necessarily of great value. They only tell us what happened with a very few young people under what could be an intense period of intervention, and does not always show what can be achieved in every case and over an extended period. Several of these papers report on the negative effects of eating non-foods, but in many cases, such as eating paper, the substance will just pass through the body, even if admittedly giving no nutrition. It would be interesting to know the proportion of those with pica who actually cause themselves harm, especially the more extreme forms such as perforating their bowels. This is rather different from planned self-harm methods such as slashing the arms, burning with matches or pulling out hair. These children are not deliberately doing something they know is wrong, but rather seem to be seeking a form of self-satisfaction, and this can be offered in many other ways. Conclusion Although pica is most often associated with having a developmental disorder such as autism, the texts considered also revealed that other groups may be affected such as some pregnant women, and even how, in some societies, it is not considered abnormal, but a definite part of the culture. So, what to most people might seem to be a dangerous practice is acceptable in certain groups. Most of the researchers considered pica to be potentially dangerous, and therefore something which required interventions, whether by parents or by medical personnel, in order to reduce or eliminate it. Several papers indicated that such help could be successful in many cases, but not all. More research is obviously needed. One problem with this is that it would be hard to produce empirical evidence. After all not all those affected by pica have developmental disorders, and even among those who have such a disorder there is a very wide spectrum of being affected. The fact that not everyone can be helped, or not helped enough in the views of others, is yet one more example of how little is actually known about conditions such as autism and the whole range of developmental disorders as well as why pica occurs among all kinds of people , despite years of research, and how those affected may or may not have brains which operate in somewhat different ways to the majority, or belong to cultures where pica is accepted or not. References Autism Speaks, undated, Pica, a guide for parents, Retrieved from https://www.autismspeaks.org/sites/default/files/docs/sciencedocs/atn/pica_parents_guide.pdf Berends, V., Persons, A., and Teweleit, A., 2014, Tackling Difficult Behaviors Part 1- Pica and Autism, http://theautismblog.seattlechildrens.org/tackling-difficult- behaviors-part-1-pica-and-autism/ Call, N., Simmons, C., Meyers, J. and Alvarez, J., 2015, Clinical Outcomes of Behavioral Treatments for Pica in Children with Developmental Disabilities. Journal of Autism and Developmental Disorders, Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/25636679 Ellis , C.and Pataki, C., Pica, MedScape, Retrieved from http://emedicine.medscape.com/article/914765-overview Golden, D. , Rasolofoniaina,B. Benjamin, R and Young, S., 2012, Pica and Amylophagy Are Common among Malagasy Men, Women and Children , Plos One Retrieved from http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0047129 Hagopian , L., Rooker G. and Rolider N., 2011, Identifying empirically supported treatments for pica in individuals with intellectual disabilities. Research in Developmental Disabilities, Science Direct, http://www.sciencedirect.com/science/article/pii/S089142221100299X Ianelli, V., 2013, How to get a diagnosis of autism, About Health http://pediatrics.about.com/od/autism/a/tests-autism.htm Matson, J. , Hattier, M., Belva, B., & Matson, M. (2013). Research in Developmental Disabilities, 34: 2564-2571. McAdam, D., Sherman J., Sheldon J. and Napolitano D., 2004, Behavioural interventions to reduce the pica of persons with developmental disabilities, Behaviour Modification, 28(1) pp45-72 Minshawl, N., Hurwitz S., Fodstad J., Biebl S., Morriss D. and McDougle C. 2014, The association between self-injurious behaviors and autism spectrum disorders. Psychological Research and Behavioral Management, Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/24748827 O’Hara, J., McCarthy, J. and Bouras, N., 2010, Intellectual Disability and Ill Health, Cambridge, Cambridge University Press. Singhi S., Singhi P., Adwani G.. Role of psychosocial stress in the cause of pica. Clinical Paediatrics, 1981;20:pp 783–785. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/7307412 Williams, D. and McAdam, D., 2012. Assessment, behavioral treatment, and prevention of pica: clinical guidelines and recommendations for practitioners. Research in Developmental Disabilities Nov-Dec;33(6):2050-7, Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/22750361 Young, S. , Wilson, J., Miller,D., Hillier, S. and Gagnier,J., 2008, Toward a Comprehensive Approach to the Collection and Analysis of Pica Substances, with Emphasis on Geophagic Materials, PLOS, Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2522275/ Read More