Eating Everything V Eating Nothing : Pica & ARFID

Thank you to Dr. Elizabeth Shea for the below. Dr. Shea is a Clinical Psychologist who support autistic individuals with their eating issues and those with ARFID through training, writing and consultancy.

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I first met Sally (name has been changed to preserve anonymity) when her parents brought her for an assessment of her ‘fussy’ eating. Sally had the classic combination of avoiding foods due to the look, texture, smell and taste; accepting only specific foods from certain brands and high levels of anxiety if asked to eat anything different. You won’t be surprised to hear I gave her a diagnosis of ARFID.

However, that didn’t fully explain the extent of Sally’s eating issues as she also displayed ‘pica’ or eating things that aren’t food. I remember at the time how baffling this was; how was it possible she only ate a tiny number of foods and yet ate many more things that weren’t foods?

Pica is the Latin name for ‘magpie’, a well-known bird that reputedly collects and eats almost anything. Pica as a medical term refers to the persistent eating of non-nutritive, or non-food items and it is now classed as a feeding or eating disorder [1]. This can be diagnosed when it occurs in children or adults who are over the age of two years and where the behaviour persists for at least a month.

Cases of pica are reported in different groups including pregnant women and in people with a learning or intellectual disability and/or autism. Pica is also reported across the world, and throughout history, with stories of people eating coal and earth documented as far back as Roman times. Common pica items include: soil, paper, cloth, plants, plastic, chalk, paint, hair and wood and individuals are often very motivated to obtain their chosen material.

We do not know yet what causes pica. Some possible reasons for pica behaviour include: a lack of awareness of what is, and what is not, a food; to gain attention or avoid a demand; to relieve anxiety or distress; for social attention; to obtain or escape something; a lack of adequate nutrition or for sensory feedback. Many researchers are now coming to the conclusion that the function of pica is almost always ‘automatic non-social reinforcement’[2].

Put simply, that the individual gains an internal ‘reward’ for consuming the item, perhaps because of the texture or taste, leading them to eat it again and again.

Sally’s pica became more severe as she got older. In particular, she would engage in pica more when she was anxious and at the same time would refuse even her usual foods. For Sally the key appeared to be in understanding her sensory processing which included both ‘hypersensitivity’ (being more sensitive) and ‘hyposensitivity’ (being less sensitive). As Sally became more anxious, so her sensory system became ‘dysregulated’, overloaded and out of kilter and she would engage in pica as a way of ‘rebalancing’ herself. So for Sally, pica was in part a self-soothing activity with her choosing to eat items that somehow suited her sensory needs at the time.

This may suggest pica is a conscious decision; it isn’t, in fact people seem almost unaware they are doing it and it can be very compulsive or hard to stop. This is partly why it can be such a potentially risky behaviour with even one episode being potentially life-threatening, although this is extremely rare.

The health risks of pica include: poisoning; oral and dental health problems; infections; intestinal obstruction and gut or bowel perforation. There is also a social risk particularly of exclusion from normal activities. For example, there was one whole winter in school where Sally couldn’t play outside because she kept eating the grit from the playground.

So what can we do to increase our understanding of a person’s pica, keep them safe and provide alternatives?

Good assessment and/or a diagnosis of pica can be very helpful, not least to prevent harm. It is also crucial to seek medical support if worried that an individual is eating anything potentially dangerous or if they appear unwell or there are changes in normal behaviours. It is important that everyone involved in the individual’s care is aware they have pica and ‘risk assessments’ can make it clear what steps are in place to protect them from harm. Other interventions include: providing safe alternatives to pica items, using other sensory strategies and tools, reducing anxiety and encouraging alternative and meaningful/enjoyable activities.

Sally now has a diagnosis of autism which has helped explain both her ARFID and her pica. Subsequent sensory strategies have both reduced her pica and increased the amount of foods she could accept. So for Sally there did appear to be some common ground shared by her pica and ARFID, namely her sensory processing differences. Whilst this may not necessarily be the case for other young people it is clear that much more research is needed in order to better understand both eating conditions and how they might overlap.

Pica top tips for parents/carers:

1. Look out for potentially dangerous pica items, e.g. sharp/poisonous objects.

2. Tell others, e.g. school, GP, other health professionals about pica and make sure it is included in health and educational records.

3. Get medical help if concerned about an individual’s health or wellbeing.

4. Offer safe alternatives, e.g. raw vegetables/chewy ‘buddies’ to chew/mouth.

5. Think ‘sensory’ – a sensory assessment and/or a ‘sensory diet’ may help

6. Think ‘anxiety’ – reduce stress wherever possible.Distraction and providing alternative and motivating activities can help reduce pica.

Further reading:

- Shea, E., Frankish, M. & Frankish, S. (2019). James Frankish and Pica: Learning the lessons from his life and death. Network Autism, March, 2019.

- Shea, E., Frankish, M. & Frankish, S. (2019). Understanding and Managing Pica. Network Autism, March, 2019.

- www.autism.org.uk/pica

With thanks to the family of Sally and dedicated to James Frankish (1994-2016).

[1] American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders. 5th Edition [2] Sturmey, P. & Williams, D. (2016). Pica in Individuals with Developmental Disabilities. Springer: Switzerland - Author: Dr. Elizabeth Shea, has worked as a clinician for 20 years both with children with autism and children with food refusal behaviours.