Massachusetts Department of Developmental Services Risk Management Protocols

Subject: 		Pica

What is it? 

PICA is defined as a pattern of ingesting (swallowing) non-food items, bath soap, cigarette ends, rocks, coins, leaf, dirt, string, ball, bolt or protective gloves. Individuals who exhibit pica may seek out a wide variety of items to ingest. The behavior is very individualized. Some persons seek out specific items to ingest while others may ingest any small item in their environment. Pica is a very dangerous condition and denying, ignoring, or minimizing it may put a person at great risk. Once diagnosed with pica this is a condition that may be managed but never completely eliminated and therefore should be considered a life long risk for an individual.

The cause of pica is usually unknown and could be associated with a profound developmental disability or may be due to dementia or loss of opportunity to eat by mouth, or some other reason. Other suggested causes are nutritional deficiencies (iron or zinc rare in USA), mental illness (e.g. OCD, psychosis or mania), behavioral reasons (want more food; mischievous), and brain damage (e.g., related to aging or head injury). Very rare known causes are parasites (worms) and an addiction to nicotine (cigarette ends).

What risk does it present?

PICA is a dangerous condition and denying, ignoring, or minimizing it, may put the person at higher risk for injury or death.  Pica can result in poisoning, parasitic infection, and/or perforation or blockage of the GI tract.  The severity of pica varies by individual, due to the frequency of the behavior, what is ingested and how hard the person’s pica is to manage and treat. If a person with pica becomes ill, pica should always be ruled out as a possible cause of the illness. It is important to involve health professionals when assessing risk or health status of an individual with pica.  Here is a list of negative health outcomes associated with pica:

•	Dental and Mouth Injuries- ingestion of toxic cleaning supplies, hard to chew materials such as rocks, metal, or plastic items such as buttons

•	Choking/Aspiration-ingestion of  non-food items large enough to block the airway  

     Primary symptoms – chest pain, difficulty breathing, wheezing on inspiration

•	Bowel blockage – Small items such as bark, small stones, nails, screws, string, scraps of paper, candy wrappings, paper clips when swallowed, may clump or stick together and eventually block the bowel. Symptoms of bowel obstruction:

Primary Symptoms: a) vomiting b) change in bowel movement pattern such as diarrhea around the blockage, c) a person completely stops having bowel movements and d) refusal of food or fluids or a significant decrease from normal appetite.

Secondary Symptoms (not present initially and represent an emergency):  a) low grade fever, b) abdominal distention (protruding of abdomen) c) stomach cramps, d) pain when the abdomen is pressed and e) a lack of bowel sounds.

•	Ulceration and perforation - Any object that stays in contact with one spot in the bowel or stomach can cause ulceration and eventually perforation. Coins are particularly dangerous. Any sharp object, such as a safety pin, paperclip or screw can puncture the esophagus, stomach or intestines.

•	Poisoning is life threatening- ingesting the following can be immediately life threatening: furniture polish, cleaning solvents (bleach/ammonia/soaps), antifreeze, small batteries, dirt from areas frequented by animals and chemicals such as gas or oil  in driveways

How is it managed?

It is the expectation of the Department of Developmental Services that pica is managed within all the individual’s environments. The best strategy for pica is prevention.

A behavior plan specific to the individual support requirements needs to be developed after a careful behavioral assessment. Some interventions may include free access to food all or most of the day, praise for picking up and disposing trash, redirection for picking up and not quickly putting non-food items in trash. Other protocols should:

•	Indicate why the individual is at risk (list favored items of pursuit and times/locations where pursuit is most likely, if known).
•	Ensure close supervision of the individual for small indigestible items in environments that are not monitored such as parks, playgrounds, churches or other community settings
•	Provide caregiver training in all locations where the person spends time and evaluate all caregivers, for their understanding of the individual’s risk of pica.
•	Consider the need for routine surveillance (pica sweeps) of the environment  frequented by the individual to find and remove items
•	Avoid clothing with buttons/bows that can easily be pulled off and gifts with small pieces that can be chewed or broken off and swallowed.
•	Staff should be advised to keep their own personal belongings secure: money, keys, and medication etc. at all times when supporting an individual with pica.

Environmental Screen (SWEEPS) for non-food items

Areas in which an individual with pica spends time may need to be checked for ingestible items and made a “pica-free” environment.  This can include access to routine office supplies such as paper clips, elastics bands, string, tacks, as well as,  medical items such as gloves, Band Aids, pins and medication. Disposable underwear and diapers should be stored immediately after use/removal.  For some individuals, an underclothing body suit may be effective to inhibit access to disposable diapers.

For individuals with pica it is critical to remove any small parts (such as caps on soaps or creams) or large parts of objects easily broken from a work or recreational area. Buttons or ribbons on clothing; decorative ornaments on hats or purses need to be securely fastened and not able to be easily removed and ingested. It is also important to periodically check seats, bedding, and padding for rips and tears.  

Transportation Screen (SWEEPS) for non-food items

Any van/car/staff vehicle should be checked for non-edibles (coins, keys, toys, cigarette ends) each time a person enters.  The driver should check for pica behavior when an individual is exiting and entering a vehicle. When an individual with pica goes on outings to public parks, malls, or recreational areas, most areas cannot be made “pica” free. Supervision must be even more vigilant.  Familiar staff may recognize in what environments an individual is most prone to engage in pica and respond accordingly.

Responding To a Witnessed or Suspected Incident of Pica

It is imperative that there is immediate communication with a licensed health professional associated with the care of any individual who has pica and is seen ingesting a non-food item.
The risk of injury from pica behavior is so severe that only a health professional should assess potential risk and advise staff on follow up instructions. DDS providers can designate which licensed health care professional to be contacted:(i.e. primary care provider, agency nursing, urgent care,  walk-in clinic or local  ER) 

If a person is seen or suspected of ingesting toxic material such as medication, cleaning fluids, or gasoline immediately call 911 for transport to the Emergency Room. Staff should document the kind and type of ingested substance and transport the container to the ER with the individual.

Where and to whom does this apply?

Information regarding the individual’s status relative to pica is to be handled in the same manner as any medical information, according to HIPAA regulations. 

Where can I find additional help?

NOTE - Many doctors and nurses, including those in emergency rooms, have little or no experience treating people with developmental disabilities and pica and information about the disorder may be helpful to their future recognition and diagnosis of it.  DDS Area Office clinicians or Service Coordinators may be able to provide information and education to these professionals.