The Impact of PICA on Schools

Introduction to Pica and its Impact in School

The American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) defines pica as eating nonnutritive, nonfood substances over at least one month. The term is derived from “pica-pica,” the Latin word for the magpie bird, because of the bird’s indiscriminate gathering and eating of various objects for curiosity. For diagnosis, the behaviour must persist for at least one month, not be in keeping with the child’s developmental stage, and not be socially normative or culturally acceptable behaviour. In Schools PICA goes beyond the habit of eating glue sticks and can have a significant impact on education.

The Nature of Pica

Pica is a condition characterized by the consumption of substances with no nutritional value over an extended period. The ingested items vary widely, including earth (geophagy), raw starches (amylophagy), ice (pagophagia), charcoal, ash, paper, chalk, cloth, baby powder, coffee grounds, and eggshells. While it is commonly observed in children, it also affects intellectually impaired individuals and pregnant women. Cultural acceptance of non-nutritive substance consumption complicates diagnosis.

How Does PICA Impact Learning and Education?

1. Cognitive Challenges:
   • Lead Poisoning: Pica involves ingesting non-food items like paint chips or soil, leading to elevated blood lead levels. This can impair cognition, attention, and impulse control.
   • Individuals with pica may struggle with memory, concentration, and processing information.
2. Distraction and Disruption:
   • Pica behavior can distract students from learning activities. It disrupts the classroom environment and affects peers and teachers.
3. Health Risks and Absences:
   • Pica-related health issues (e.g., gastrointestinal problems, poisoning) may cause frequent absences from school.
   • Frequent absences hinder academic progress.
4. Safety Concerns:
   • Ingesting non-food items poses safety risks (choking, blockages).
   • Schools must implement safety protocols.
5. Social Isolation and Stigma:
   • Students with pica may face social isolation due to their unusual eating habits.
   • Awareness and empathy are essential.
6. Individualized Support:
   • Tailored strategies within the educational system are crucial.
   • Collaboration with healthcare professionals and families is essential.

Creating a Pica-Safe School Environment: Practical Strategies for Educators and Staff

Understanding pica is crucial, but knowing how to proactively manage it within the school setting is where the rubber meets the road. This section offers concrete, actionable strategies for educators and staff to create a pica-safe environment, minimizing risks and supporting students effectively.

Environmental Modifications

The first line of defence against pica is a thoughtfully adapted environment. Think about “pica-proofing” your classroom and common areas:

• Remove or Secure Hazardous Items: Conduct regular sweeps of your learning spaces to identify and either remove or securely store common non-food items that students might ingest. This includes small toys, art supplies like crayons and paint chips, loose paper, erasers, and even items from around the classroom like staples or paper clips. If an item can’t be removed, ensure it’s kept out of reach or locked away.
• Maintain Cleanliness: Implement regular and thorough cleaning protocols to minimize small debris that could be ingested. This means frequent vacuuming, sweeping, and wiping down surfaces.
• Offer Safe Sensory Alternatives: Many students with pica seek sensory input. Providing safe alternatives can help redirect this urge. Consider offering chewable jewelry, fidget toys, or creating a designated “chew station” with safe, durable materials like silicone or specific non-toxic chewables.
• Manage Outdoor Spaces: Pica doesn’t stop at the classroom door. Provide clear guidance on managing outdoor areas, actively discouraging the consumption of dirt, leaves, playground mulch, or other natural elements. Regular checks of outdoor play areas for potentially harmful debris are also advisable.

Curriculum and Instruction Adaptation

Modifying how you teach and what materials you use can significantly reduce opportunities for pica:

• Choose Safe Manipulatives: When planning lessons, opt for large, non-ingestible manipulatives for hands-on activities. If sensory bins are used, fill them with safe, edible items like dried pasta, beans, or even certain food-grade sensory materials, ensuring careful supervision.
• Structured Activities: For students prone to pica, highly structured activities with clear expectations can help keep them engaged and focused on appropriate materials.

Supervision Strategies

Vigilance and consistency are key to preventing pica incidents:

• Increased Proximity and Monitoring: Students at risk for pica may require increased vigilance and closer proximity from staff. This means actively supervising them during free play, group activities, and transition times.
• Consistent Staff Approach: Ensure all staff members who interact with the student – including teachers, teaching assistants, playground supervisors, and support staff – are aware of the student’s pica and implement consistent supervision strategies and responses. A unified front is critical for effectiveness.

Emergency Preparedness

Despite best efforts, ingestion of a harmful item can happen. Having clear protocols in place is vital:

• First Aid and Immediate Action: All staff should be aware of basic first aid procedures for choking or suspected ingestion of a harmful substance. Know who to contact immediately within the school (e.g., school nurse, administration).
• Contacting Parents/Guardians: Establish a clear protocol for promptly contacting parents or guardians in the event of an ingestion incident, providing all relevant details.
• Reporting and Documentation: Implement a system for reporting and documenting all pica-related incidents, including what was ingested, the amount, and any immediate actions taken. This information is crucial for ongoing management and collaboration with healthcare professionals.

Collaboration with Facilities/Maintenance

The school building itself plays a role in safety:

• Lead Paint Checks: In older school buildings, it’s essential to ensure regular lead paint checks are conducted, especially in areas accessible to students who might pick at surfaces.
• Proper Waste Disposal: Work with facilities staff to ensure proper and secure disposal of all waste, particularly hazardous materials, to prevent access by students.
• Building Material Awareness: Discuss any concerns about building materials with facilities, especially if students are targeting specific areas (e.g., crumbling plaster, loose tiles).

Aetiology (Causes) of Pica

The exact causes of pica remain unclear, although several factors have been implicated. Psychological stress, child neglect and abuse, maternal deprivation, and iron deficiency anaemia have been associated with pica. Additionally, some hypotheses suggest that pica may offer protection from harmful toxins during vulnerable stages of development, such as childhood and pregnancy.

Risk Factors and Epidemiology

Various factors contribute to the development of pica, including stress, cultural influences, learned behaviour, socioeconomic status, underlying mental health disorders, nutritional deficiencies, pregnancy, epilepsy, and familial psychopathology. Estimating the prevalence of pica is challenging due to variable definitions, under-reporting, and cultural influences. However, it appears more prevalent in pregnant women and young children, with a higher prevalence in certain regions.

Diagnosis and Evaluation

Diagnosing pica involves a comprehensive evaluation, including a detailed history and physical examination. Laboratory tests tailored to the suspected substances ingested, such as iron studies and lead levels, are essential. Imaging studies may be necessary in cases of abdominal symptoms. Evaluation should also consider differential diagnoses, including other eating disorders, psychiatric illnesses, and substance abuse.

• Health professionals who can diagnose pica include paediatricians, gastroenterologists, psychiatrists, and clinical psychologists.
• The Diagnostic Criteria for Pica from DSM-5 states that pica involves:
  • Persistent eating of non-nutritive substances for at least 1 month.
  • Inappropriate eating behaviour considering the individual’s developmental level.
  • Behaviour is not culturally supported or socially normative.
  • Severe enough to warrant independent clinical attention, especially if occurring alongside other mental disorders or medical conditions.

Treatment and Management of PICA

Treatment of pica requires a multidisciplinary approach involving physicians, psychiatrists, psychologists, behavioural therapists, social workers, and dietitians. Primary prevention strategies focus on identifying at-risk populations and reducing exposure to non-nutritive substances. Behavioural and aversive treatments may be effective, along with nutrient supplementation when deficiencies are identified. However, there are no specific medications for treating pica.

1. Assessment:
   • A thorough assessment of a person’s pica is essential. This process can be lengthy and complex.
   • Recommended assessment procedures include close clinician observation, physiological examinations in suspected cases of pica, and safe baiting.
2. Treatment Options:
   • Environmental Enrichment: Creating an environment that reduces access to non-food items.
   • Micronutrient Therapy: Addressing any underlying nutritional deficiencies.
   • Overcorrection: Implementing strategies to discourage pica behaviour.
   • Physical Restraint: In severe cases, physical restraint may be necessary to maintain the Child’s safety.
   • Psychological Interventions: Counseling or therapy to address psychological factors.
   • Behavioural Interventions: Strategies to reduce the consumption of non-food items.

Evidence-based strategies for managing PICA

1. Differential Reinforcement:
   • This approach involves reinforcing alternative behaviours while ignoring or providing minimal attention to pica behaviour.
   • For instance, if the person eats appropriately, offer praise or rewards. Conversely, avoid reinforcing pica behaviour.
2. Habit Reversal Training (HRT):
   • HRT aims to replace unwanted habits (such as pica) with more desirable ones.
   • The process involves:
     • Awareness Training: Helping the person become aware of when they engage in pica.
     • Competing Response Training: Teaching an alternative behaviour that is incompatible with pica (e.g., clenching fists instead of eating non-food items).
     • Social Support: Encouraging family members or caregivers to provide positive reinforcement and ensure responses are consistant.
3. Cognitive-Behavioral Therapy (CBT):
   • CBT can be effective in addressing the underlying thoughts and emotions associated with pica.
   • It helps the person recognise irrational beliefs related to pica and replace them with healthier thoughts.
4. Medication:
   • In some cases, medication may be considered. However, this should always be discussed with a healthcare professional.
   • Selective serotonin reuptake inhibitors (SSRIs) have been used to reduce obsessive-compulsive symptoms associated with pica.
5. Family Education and Support:
   • Educate family members and caregivers about pica and its management.
   • Encourage consistency in implementing strategies across different settings (home, school, etc.).
6. Peer Modeling:
   • If the person with pica is in a group setting (e.g., school), positive peer modelling can be beneficial.
   • Observing peers engage in appropriate eating behaviours can influence the individual.
7. Functional Communication Training (FCT):
   • Teach the person alternative ways to communicate their needs or desires.
   • If pica behaviour is related to seeking attention or sensory stimulation, FCT can help redirect those needs.

Complications and Prognosis

Pica can lead to various complications depending on the ingested substances, including bowel obstruction, bezoar formation, toxicity, and infections. While short-term pica is usually benign, long-term pica can result in serious health issues. The prognosis varies but is generally better in cases of short-term pica, with spontaneous resolution in pregnant women and children.

Q&A

Q1: What are the risk factors for developing pica?

A1: Risk factors include stress, cultural influences, learned behaviour, low socioeconomic status, underlying mental health disorders, nutritional deficiencies, pregnancy, epilepsy, and familial psychopathology.

Q2: What complications can arise from pica?

A2: Complications include bowel obstruction, bezoar formation, toxicity, infections, and fetal toxicity during pregnancy.

Q3: How is pica diagnosed and managed?

A3: Diagnosis involves a comprehensive evaluation, including history, physical examination, and laboratory tests. Management entails a multidisciplinary approach focusing on primary prevention, behavioural interventions, nutrient supplementation, and close follow-up.

References Used

Al Nasser Y, Muco E, Alsaad AJ. Pica. [Updated 2023 Jun 26]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK532242/

Hooda PS, Henry CJ, Seyoum TA, Armstrong LD, Fowler MB. The potential impact of soil ingestion on human mineral nutrition. Sci Total Environ. 2004 Oct 15;333(1-3):75-87. [PubMed]

Young SL, Wilson MJ, Miller D, Hillier S. Toward a comprehensive approach to the collection and analysis of pica substances, with emphasis on geophagic materials. PLoS One. 2008 Sep 05;3(9):e3147. [PMC free article]