Pica
Pica refers to behaviorally and culturally
inappropriate eating of nonnutritional substances for at least 4 weeks. It is
most often as-sociated with poverty related nutritional deficiencies and mental
retardation.
Pica is a common, but frequently missed problem.
The onset of pica is usually during the toddler age between 12 and 24 months.
Because infants commonly mouth objects, it is difficult to make the diagnosis
in young infants. Estimates of the prevalence of pica among institutionalized
mentally retarded individuals range from 10 to 33%.
Children with pica are more susceptible to
malnutrition, anemia, diarrhea or constipation, and worm infestation. It has
been noted that pica is highest in a group of children hospitalized for
accidental poisoning and that more than 60% of mothers with children with pica
have pica themselves.
Organic,
psychodynamic, socioeconomic and cultural factors have been implicated in the
cause of this disorder. Some authors have suggested that inadequate dietary
intake of iron and calcium leading to abnormal cravings may induce pica. Other
authors have implicated psychosocial stress, maternal deprivation, parental
neglect and abuse, and disorganized and impoverished family situations in the
etiology of pica. In certain population groups, cultural acceptance of pica has
been considered an important factor in the etiology of this disorder as well.
Most
helpful clinically is a multifactorial etiology, whereby constitutional,
developmental, familial, socioeconomic and cultural factors interact with each
other. Children who en-gage in pica often experience frequent separations from
one or both parents followed by replacement of rapidly changing, in-adequate
caretakers who seemed to encourage oral gratification in response to the
child’s distress. These children show a high degree of other oral activities
(e.g., thumb-sucking or nail-biting) and may be seeking gratification caused by
the lack of parental availability and nurture.
Because
mouthing of objects is still common in toddlers between 1 and 2 years, the
diagnosis of pica should be made only if the behavior is persistent and
inappropriate for the child’s develop-mental level. The diagnosis of pica
should be explored in children with accidental poisoning, with lead
intoxication, or with worm infestation. Young children with signs of
malnutrition or iron de-ficiency should also be considered for the diagnosis of
pica.
The
assessment should include the history of the child’s development in general,
and feeding in particular. Special atten-tion should be given to other oral
activities that the child may use for self-soothing and relief of tension. In
addition, the home en-vironment and the parents’ relationship with each other
and with the child need to be explored to assess the parents’ availability to
nurture and supervise the child. Above all, mother and child should be observed
during a meal and during play to gain a better understanding of their
relationship and how the symptoms of pica can be understood in the context of
that relationship.
If the
diagnosis of pica is established, it is critical that the child undergo a
thorough physical examination to rule out any of the complications associated
with this disorder, such as nu-tritional deficiencies (especially iron
deficiency), lead poisoning, intestinal infections (toxoplasmosis or intestinal
parasites), or gastrointestinal bezoars.
In many
instances, the disorder is believed to be self-limited and to remit
spontaneously after a few months. However, there may be a developmental impact
of the disorder in some children. For example, younger children may be somewhat
retarded in the use of their speech and show conflicts about their dependency
needs and aggressive feelings. Adolescents may evidence some degree of depression,
borderline personality disorders, other forms of disturbed oral activities and the use of tobacco,
alcohol, or drugs. There may be a strong relationship between pica in childhood
and symptoms of bulimia nervosa in adolescence.
In treating pica, one must consider the various
factors that appear to contribute to the development of pica as well as its
complica-tions. It is important to treat the child medically while addressing
the psychosocial needs of the child’s family as well. The mothers need to be
made aware of the dangers of pica and should be en-listed in providing a
childproof environment. This might include removing lead from paint in old
substandard housing units or instituting anthelmintic therapy for family pets.
A psychoeduca-tional treatment approach that, in addition to teaching the
moth-ers the dangers of pica, would also provide social support to help them
become more available to their children is preferable.
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