Dean Alexander, Ph.D., discusses pica, the ingestion of non-food substances, which has received insufficient attention as a common, sometimes lethal, form of self-injurious behavior. He discusses the prevalence of pica in autistic individuals and the long-term health implications associated with pica behavior. The speaker details numerous case studies and highlights the need for multidisciplinary collaborative treatment strategies based on functional behavior assessments. Alexander describes available treatment strategies and presents the SMART acronym for treatment recommendations. e.

Handouts are available for download (PDF) HERE
Take the knowledge quiz for this presentation HERE

This is a joint presentation by ARI and the World Autism Organisation.

In this webinar: 

2:12 – What is pica
5:22 – Study: Soda can and rubber ball
8:00 – Challenges with behavioral treatments
13:00 – Sensory stimulation and pica
14:20 – Pica prevalence and impact
16:08 – Study: GI symptoms and pica
17:30 – Study: Autism, GI symptoms, and pica
19:00 – Study: Pica prevalence in autistic adults
25:25 – Pica as a phenotypic subgroup
26:30 – Studies: polyvisol, vivinex, iron supplements, zinc and antioxidant therapy
29:46 – Metabolic profiles and phenotypic subgroups
31:57 – Why nutritional interventions
34:04 – Comprehensive vitamin-mineral interventions
36:10 – Dietary changes
38:21 – Study: Homeopathic treatment
44:28 – SMART interventions

Pica and behavioral treatments

Pica is the ingestion of inedible substances and is the most dangerous form of self-injurious behavior associated with autism (2:12). Items frequently ingested include generally harmless things like dirt, leaves, and grass, as well as dangerous and potentially lethal items like rubber gloves, clothing tags, and screws (3:30). Alexander details a case study involving a 50-year-old autistic man who ingested cigarette butts. The presenter explains how treatment strategies capitalized on the individual’s preferences by incorporating soda cans and a red rubber ball into his walk to work. Over six months, the client’s nicotine and cotinine levels decreased from those of a chain smoker to zero (5:22). Alexander highlights the simplicity of this case, noting the trial and error implicit in creating holistic treatment strategies (6:43). 

Establishing effective behavioral treatments for pica can be challenging due to costs, availability, environmental restrictions, and the generality of treatments across time (8:00). The presenter notes the importance of functional behavioral assessments, which help identify the factors that drive and maintain pica behavior, like attention-seeking, sensory issues, pain attenuation, or escape/avoidance (11:00). Sensory stimulation, he continues, is often a significant factor in maintaining pica behavior and can be challenging to address. Solutions to sensory drivers can include finding substitute foods with similar sensory properties (i.e., grape nuts in place of dirt) or engaging individuals with play during unstructured hours (13:00). The presenter notes that pain attenuation is often related to dental issues (14:01). 

Pica Prevalence and Impact

Around 23.2% of autistic children and up to 60% of autistic adults experience pica (14:20). The speaker outlines two studies on the intersection of autism, pica, and GI issues in children (16:08). Researchers found that autistic children and children with developmental disorders who also have pica have a higher prevalence of GI signs, symptoms, and diseases compared to those without pica (15:24). Prevalence of food cravings and specific GI conditions like irritable bowel syndrome (IBS) and gastroesophageal reflux (GERD) are also higher in autistic children with pica than those without (17:30). To assess the prevalence and co-occurring conditions in adults, researchers examined ten years of medical records compared to a comprehensive list of symptoms and diseases (19:00). Four groups were assessed: autism only, autism and pica, pica without autism, and a control group of developmentally disabled individuals without pica. Findings revealed that the prevalence rates across the ten most frequently occurring diseases were two to three times higher for individuals with pica, where the autism and pica group had the highest rate (22:33). Alexander emphasizes that pica takes a severe toll on the body over time which can lead to shorter life expectancy and higher mortality rates. He asserts that autistic individuals with pica may represent a phenotypic subgroup characterized by GI symptoms and requiring specialized treatments (25:25). 

Intervention Options

Alexander outlines research showing that autistic children have relatively less diversity in gut bacteria and generally have fewer healthy bacteria than unhealthy (30:55). These findings emphasize the importance of including nutritional interventions in treating pica. The speaker underscores that dietary interventions do not necessarily rely upon practitioner availability and so may be more accessible (27:36). He details promising research using iron supplements, liquid multivitamins (poly-vi-sol), specialized formulations (vivinex) (26:30), and zinc supplements and antioxidant therapy (28:42) to reduce pica behaviors like coprophagy (ingestion of feces) in autistic individuals. The presenter discusses a study that revealed significant differences in metabolic profiles between autistic children and their non-autistic peers (29:46). Targeted nutritional therapies, including folinic acid, betaine, and methyl B12, succeeded in correcting metabolic imbalances. Alexander asserts these findings suggest the presence of a metabolic phenotype and that aspects of autism are treatable. 

Maintaining a healthy gut is critical for the body’s ability to fight infection, digest food and produce vitamins (31:57). The presenter outlines other nutritional treatment approaches, including gluten-free, casein-free, and Mediterranean diets (37:17), as well as comprehensive vitamin-mineral interventions (34:04). Alexander details a case study where a seven-year-olds pica behaviors stopped just one week after implementing a gluten/casein free diet (36:10). The speaker summarizes the behavioral, dietary, and vitamin/mineral based interventions and highlights the need to try and assess each strategy. He outlines a homeopathic treatment study that showed remarkable improvements in a 15-year-old boy with severe autism. Supplemental behavioral interventions alongside homeopathic recommendations significantly improved the child’s functions, behavior, communication, and quality of life (38:21). 

S.M.A.R.T. Interventions

Alexander highlights the need for collaborative treatment strategies and introduces the SMART acronym for treatment recommendations (44:28): 

Safety: Safety precautions are critical. Potential dangers and treatment environments must be appropriately assessed based on individual needs.

Medical issues related to eating habits, food cravings, stomach pain, antibiotic use, and mouth sensitivities must be addressed. It is best to be assessed by a team of professionals including, but not limited to, a dentist, GI specialists, and nutritionist (45:33). 

Analysis/assessments of behavior function and consequences are best practices. Such assessments are critical for accurately identifying drivers and potential treatments for pica behavior (47:40). 

Reinforcement inventory or a “menu” of activities or objects that help minimize Pica behavior (e.g., soda cans and rubber balls). These can aid in implementing differential reinforcement strategies and finding alternatives. 

Treatment packages or a combination of various approaches to create a collaborative treatment strategy. Treatment packages include psychotherapy, pharmacological treatments, behavioral techniques, and nutritional support. Such holistic therapies are generally the most effective (49:44). 

Dean Alexander, Ph.D., discusses pica, the ingestion of non-food substances, which has received insufficient attention as a common, sometimes lethal, form of self-injurious behavior. Behavioral approaches to treatment, more often than not, fall short. Biological intervention, if supported, may hold out new promise.

Handouts are available for download (PDF) HERE

This is a joint presentation by ARI and the World Autism Organisation.

Part One: Challenges when your son or daughter is experiencing a difficult time

Paul Shattock provides a parent’s perspective on handling his son Jamie’s challenging behaviors and describes the experiences of other families who have navigated similar situations. This webinar was produced in partnership with the World Autism Organization.

In this webinar

0:00 – History of World Autism Organization|
1:25 – 5:00 – Jamie’s life from birth to age 8
4:40 – First signs of aggression
6:08 – Difficulties with hair cuts
8:40 – Sunderland parents and school
9:45 – Experiences with aggressive outbursts
12:15 – Age patterns for aggression and SIB
13:48 – Experience with pharmacological remedies
16:30 – Jamie’s life today 

Shattock details his son’s behaviors across his lifetime and describes the experiences of his family and community in creating supportive environments for Jamie and his peers. He recounts Jamie’s diagnosis, the disparity between autism science today compared to the 1970s, and their journey through various schools, medication, and community support. Shattock closes by noting that Jamie is now able to work and live away from his parents and that his aggressive behaviors dissipated over time. 

To explore the perspectives of another parent, a pediatrician, and a behavior analyst on aggression and SIB, take a look at Aide Canada’s interview series on Understanding and Supporting Children with Self-Injurious Behaviour. 

Part Two: Teaching Children with Autism How to Communicate Their Wants and Needs 

Lauren Moskowitz, Ph.D., discusses teaching children with autism how to communicate their wants and needs. She reviews communication difficulties in the autistic population and highlights understanding challenging behaviors as communication functions. Moskowitz defines function-based behavior intervention plans and details functional communication training. She provides various examples and advises how to select and teach replacement skills and ensure they are used correctly. Moskowitz describes successful treatment plans and emphasizes the importance of learning to tolerate delays in reinforcements before closing with a Q&A session.

Handouts for Dr. Moskowitz’s talk are online HERE

In this webinar: 

1:00 – Communication in children with autism
3:55 – Communication impairment and challenging behaviors
5:25 – Challenging behaviors as functions of communication
9:40 – Functions of communication
11:18 – How to teach children with autism to communicate wants and needs
12:55 – Principle of functional equivalence
13:50 – How to identify the function
15:50 – ABC flowchart and examples
21:00 – Creating function-based behavior interventions
23:10 – Building replacement skills
24:10 – Functional communication training
25:36 – Replacement skills for gaining attention
27:54 – Replacement skills for escaping disliked activities
29:27 – Replacement skills for obtaining tangible item/activity
30:12 – Replacement skills for obtaining sensory stimulation
32:03 – What communication skills to teach?
32:40 – How will communication skills be taught?
34:17 – How to ensure communication skills will be used?
37:03 – When to teach communication skills?
38:30 – FCT Case Example – Eli
48:37 – Competing with challenging behaviors
50:23 – Learning to tolerate delays
53:12 – Notes from Dr. Stephen Edelson, Executive Director at ARI
56:20 – Q & A

Language and communication difficulties are core symptoms of autism, and around one-third of children with autism are nonverbal or minimally verbal. Moskowitz explains that verbal children often struggle with communication in moments of distress (1:00; 10:45). She emphasizes that communication impairments do not cause challenging behaviors (CB). However, the likelihood of an individual using CB can increase if they have difficulty communicating their wants or needs (3:55). Individuals engage in CB because those behaviors serve a specific function, and behaviors persist because they meet an immediate need (5:25). Throughout the presentation, Moskowitz emphasizes the difference between behaviors and their functions (8:35). She suggests viewing CB as functions of communication and focusing on why an individual exhibits CB instead of the behavior itself (9:40). 

Moskowitz describes functional communication training (FCT) as teaching appropriate functional communicative behaviors to replace CB (11:18). She outlines the principle of functional equivalence (12:55), functional behavior assessments (FBA) (13:50), and the ABC (antecedent, behavior, consequence) flowchart (15:50). She underscores looking for patterns of behavior via direct observations. The speaker presents three examples of observed behaviors and circumstances in the ABC format (16:46) and suggests video recording to help track patterns of behavior and caregiver reactions (19:19). Once antecedents and consequences (outcomes) are understood, treatment teams can create a function-based behavior intervention plan (BIP) that will (21:00):

1. Prevent CB by changing the circumstances that trigger behaviors
2. Teach appropriate replacement skills that allow individuals to get what they need
3. Respond to CB by changing consequences to no longer reinforce those behaviors

The presenter refers viewers to her previous webinars for information on prevention strategies and notes a variety of skills that can serve as alternative behaviors (23:10). Moskowitz stresses teaching skill sets that match the function and outcome of the CB specific to each individual (24:10). She provides examples of replacement skills that can be taught when the function of a behavior is to gain attention (25:36), to escape/avoid disliked or strenuous activities (27:54), to obtain a tangible item/activity (29:27), and to obtain sensory stimulation (30:12). Selected replacement skills should be something the individual is capable of learning and executing on their own. They must serve the same function and work as well or better than the CB (32:03). 

Moskowitz asserts that replacement strategies must be taught with prevention interventions and learned in situations that provoke the CB. It is best to practice new skills in contrived conditions before prompting them in naturally occurring situations (32:40). To ensure continued use of communication skills, the presenter explains that the new behaviors must be easier to perform than the CB and the consequence of the replacement skill should be more reinforcing than that of the CB. Replacement behaviors should also be responded to immediately and consistently, or an individual may revert to the CB (34:17). Moskowitz discusses when to teach replacement communication techniques and emphasizes that new skills can only be learned during teachable moments before escalation or after recovery (37:03). The presenter stresses that after the communication skill is well-established, individuals must learn to tolerate delay in responses/reinforcement so they can eventually use the technique independently (50:23). Moskowitz provides an in-depth case example of FCT broken down into seven steps: 

1. Assess the function of CB (38:34)
2. Select mode of communication (40:55))
3. Arrange the environment to create teaching opportunities (42:40)
4. Prompt communication (43:44)
5. Fade prompts (46:00)
6. Teach new forms of communication and expand settings where requests are made (47:33)
7. Modify the environment (48:25)

Before the question and answer session (56:20), Dr. Stephen Edelson, Executive Director at ARI, notes ARI’s free online screening tool (ATEC) as well as the development of an online program to help provide insight into various behaviors via a decision tree about causes and functions of CB (53:12). 

View Dr. Moskowitz’s past talks on:

• Assessing and Treating Challenging Behaviors
• Anxiety and ASD
• Self-injury and ASD

Also Featured: Resources

Read Dr. Edelson’s editorial HERE

Dr. Ferguson discusses current research indicating that GI issues coincide with behavior problems in autism. He explains how the autonomic nervous system drives stress response and details its relationship with GI functionality. The speaker describes five studies investigating different aspects of Gi issues, anxiety, stress, and problem behaviors in autism. Ferguson touches on pharmacological, vagal, and behavioral treatment strategies before the Q&A. 

Handouts are online HERE

In this webinar: 

2:25 – Prevalence of GI disorders in autism
5:10- Autonomic nervous system and autism
8:12 – Study: GI and stress relationship in autism
10:55 – Study: Psychophysiological associations
13:20 – Study: GI problems, difficult behavior, and internalizing symptoms in autism
16:30 – Results
18:30 – Do GI symptoms predict internalizing or externalizing symptoms?
20:20 – Results
21:44 – Discussion
22:45 – Study: Electrodermal activity and problem behaviors in autism
26:00 – Study premise and outline
27:10 – Analysis of electrodermal activity
29:45 – Relationship between stress response and problem behavior
31:15 – What happens when we treat the stress response?
36:20 – Study: Effects of propranolol on the relationship between GI issues and amygdalar reactivity
39:00 – fMRI results
43:00 – Future directions
46:40 – Take-home messages
47:40 – Acknowledgements and thanks
48:05 – Q & A

Introduction

Ferguson explains that up to 91% of autistic people experience GI difficulties, highlighting the importance of studying GI issues in relation to autism (2:40). Two of the most common GI issues in autism are constipation and irritable bowel syndrome (3:50). Ferguson asserts that altered autonomic nervous system response to stress in autism is linked to these conditions. The speaker outlines the autonomic nervous system (ANS), which controls smooth muscles like those used in breathing and digestion. The ANS is composed of the parasympathetic (PYM) (i.e., rest and digest) and the sympathetic (SYM) (i.e., fight, flight, freeze) branches. Ferguson explains that our bodies strive for a balance between these two systems (7:16). He emphasizes that intestine function is inhibited when the SYM is activated and posits that this could be why individuals with high-stress responses are often constipated (6:40). Ferguson presents numerous studies supporting the assertion that ANS imbalances are associated with GI and behavior difficulties in autism. 

Study 1: GI and stress relationship in autism

This study correlated stress response scores with GI issues in autistic children and adolescents. Baseline cortisol (stress hormone) levels were compared to levels after participants dipped their hands in cold water. They correlated this stress response to GI problems and found that Lower GI issues (e.g., abdominal pain and constipation) positively correlated with cortisol levels (8:12). The study also found a positive correlation between Upper GI issues and inflammation (10:00). Ferguson states that these results suggest that autistic individuals with lower GI issues will likely have high cortisol response to stressors (9:40). 

Study 2: Psychophysiological associations

The presenter explains that heart rate variability (HRV) measures the balance between the PYM and SYM. This study correlated HRV scores with Lower GI issues in autistic children and adolescents. Findings showed HRV response to stressors is much higher than average in autistic individuals who have anxiety. The same relationship exists between regressive autism and HRV (12:00). Ferguson therefore asserts that co-occurring anxiety disorders or regressions in autism alter the relationship between the PYM and the GI tract. This transformed relationship, he continues, is likely the cause of many GI issues in autism (13:05). 

Study 3: GI problems, problem behavior, and internalizing symptoms in autism

This study aimed to look at the relationship between GI problems, problem behaviors, and internalizing symptoms (e.g., anxiety) in autism. The speaker outlines study methods (14:11) and explains how they correlated scores across two age groups (15:43). Results showed that overall, younger children (ages 2 – 5) have more dietary problems than the older group (ages 6 – 18). However, for both groups, the following data was presented (16:30):

• 65% experienced constipation
• 50% experienced stomach aches or pain
• 29% experienced diarrhea
• 23% experienced nausea
• 93% were not taking GI medication
• 53% were taking medications for other reasons (ADHD, aggression)

The study also assessed whether or not GI symptoms predict internalizing or externalizing symptoms (i.e., anxiety or problem behaviors) (18:44). Researchers found that the younger children acted out more with aggression while the older group had more internalized symptoms. This relationship, he continues, is compounded when an individual is minimally or non-verbal (20:20). Ferguson therefore asserts that GI issues must be addressed in this population, especially in those with communication difficulties (21:44). 

Study 4: Electrodermal activity and problem behaviors in autism 

Electrodermal activity, or sweating, is an indicator of stress. This study aimed to see if sweating predicts problem behaviors (22:45). Participants wore sweat monitors, and researchers observed their behaviors in an educational setting (26:00). Results showed (27:10) that there is a rise in skin conductance lasting an average of about 10 minutes leading up to problem behaviors (29:45). This change in conductance is called the anticipatory rise, and it occurred before problem behaviors in 60% of observations (28:30). Ferguson posits that this anticipatory rise is likely the result of discomfort or pain and that it presents an opportunity for caretakers to intervene in the stress response. He outlines two clinical trials using propranolol to treat anxiety (31:15) and constipation (35:10).

Study 5: Effects of propranolol on the relationship between GI issues and amygdalar reactivity

The amygdala is a part of the central nervous system responsible for ANS activation. This study examined the effect of three medications on amygdalar response to emotional faces using fMRI technology (36:20). Participants took three 12-day sessions of different medications: placebo, nadolol, and propranolol. Propranolol is the only one known to penetrate the blood-brain barrier. At the end of each session, participants completed a face-matching task to activate the amygdala (39:00). Researchers correlated GI issues to fMRI results. They found that with the first two medications (placebo and nadolol), there was a statistically significant positive relationship between GI symptoms and amygdalar activity. Contrastingly, after 12 days of propranolol, there was no relationship between GI symptoms and amygdalar activity (40:14). Therefore, Ferguson posits that GI stress is related to the central nervous system. He notes the limitations of this study (42:10). 

What’s next?

The presenter describes Transcutaneous Vagus Nerve Stimulation (tVNS) and its potential in treating atypical PYM activation and GI issues in autism. tVNS is a small device that fits in the ear and stimulates the vagus nerve, which is part of the PYM (rest and digest) system. This stimulation helps the body calm down (43:00). Ferguson underscores the difference between blocking SYM activity (i.e., propranolol) and stimulating the PYM (tVNS). He summarizes the presentation and reiterates that GI issues in autism are often associated with an enhanced stress response. This is particularly true for Lower GI issues like constipation. GI symptoms, he continues, have also been associated with internalizing symptoms (i.e., anxiety) and problem behaviors. Stress response activation may often proceed problem behaviors in autism, and much more research is needed on new treatment strategies. Ferguson provides thanks and acknowledgments before the Q&A.