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The use of functional communication training to reduce pica.



Abstract

Pica is an eating disorder eat·ing disorder
n.
Any of several patterns of severely disturbed eating behavior, especially anorexia nervosa and bulimia, seen mainly in female teenagers and young women.
 characterized by the ingestion ingestion /in·ges·tion/ (-chun) the taking of food, drugs, etc., into the body by mouth.

in·ges·tion
n.
1. The act of taking food and drink into the body by the mouth.

2.
 of inappropriate items. The items may range from relatively harmless materials (e.g., food from the floor, grass) to other substances (e.g., glass) with risk for serious health problems or even death. Previous studies have shown that behavioral techniques behavioral technique Psychiatry Any coping strategy in which Pts are taught to monitor and evaluate their behavior and to modify their reactions to pain  are effective for decreasing pica, but few studies have assessed this in naturalistic nat·u·ral·is·tic  
adj.
1. Imitating or producing the effect or appearance of nature.

2. Of or in accordance with the doctrines of naturalism.
 settings. The current paper describes a study conducted in a classroom setting in which functional communication was taught to a 6-year-old boy with autism autism (ô`tĭzəm), developmental disability resulting from a neurological disorder that affects the normal functioning of the brain. It is characterized by the abnormal development of communication skills, social skills, and reasoning.  to replace pica. Differential reinforcement of functional communication behavior was used to teach the boy to request food rather than to engage in pica. This procedure decreased the boy's frequency of pica and of attempted pica.

Keywords: pica, autism; differential reinforcement; functional communication training; manding.

Introduction

Pica is an eating disorder often displayed by persons with developmental disabilities developmental disabilities (DD),
n.pl the pathologic conditions that have their origin in the embryology and growth and development of an individual. DDs usually appear clinically before 18 years of age.
 (Singh, 1983). It is typically defined as either the consumption of non-food items or the compulsive com·pul·sive
adj.
Caused or conditioned by compulsion or obsession.

n.
A person with behavior patterns governed by a compulsion.



compulsive

the state of being subject to compulsion.
 consumption of both food and non-food items (Albin, 1977; Paisey & Whitney, 1989). Many individuals with pica ingest in·gest  
tr.v. in·gest·ed, in·gest·ing, in·gests
1. To take into the body by the mouth for digestion or absorption. See Synonyms at eat.

2.
 items that are relatively harmless, such as food from the floor, grass, or bugs (Johnson et al., 1994; Fisher et al., 1994). However, some individuals with pica ingest items (e.g., glass) that can lead to serious digestive problems, health issues, and possibly death (Rojahn et al., 1987).

Several literature reviews describe interventions for persons who present with pica (e.g., McAdam, Sherman, Sheldon, & Napolitano, 2004). In one recent review McAdam et al. (2004) summarized the various behavioral interventions behavioral intervention Behavior modification, behavior 'mod', behavioral therapy, behaviorism Psychiatry The use of operant conditioning models, ie positive and negative reinforcement, to modify undesired behaviors–eg, anxiety.  that have been demonstrated to produce a clinically significant reduction in pica, including differential reinforcement, overcorrection o·ver·cor·rec·tion
n.
An adjustment that surpasses a set criterion, especially of a desired behavior.
, contingent aversive aversive /aver·sive/ (ah-ver´siv) characterized by or giving rise to avoidance; noxious.

a·ver·sive
adj.
 presentations, and discrimination training. However, this review also found that the majority of published studies used intervention packages that included a punishment component. Moreover, few of the studies were conducted in natural settings (e.g., public schools, community-based agencies for adults with developmental disabilities).

Three published studies have demonstrated that differential reinforcement as the primary independent variable was successful in decreasing the pica of 6 persons with developmental disabilities. In one of these studies, Goh, Iwata, & Kahng, (1999), used naturalistic observations Naturalistic observation is a method of observation, commonly used by psychologists, behavioral scientists and social scientists, that involves observing subjects in their natural habitats.  to assess the function of cigarette pica performed by three adult males and one female with developmental disabilities in a state residential facility. The function of pica for all participants was determined to be automatic reinforcement. That is, each participant's pica was maintained by non-socially mediated variables. Next, a series of preference assessments were conducted to identify the specific reinforcing aspect of the cigarette (e.g., the unsmoked filter) and to identify high preference items that could function as competing reinforcers. Initially, for three of the participants, the authors assessed the affect of satiation sa·ti·a·tion
n.
The state produced by having had a specific need, such as hunger or thirst, fulfilled.



sa
 by providing preferred edible items every 10 seconds, for 5 minutes, prior to the start of a session. Next, the participants were taught to hand a cigarette to their therapist and all attempts to engage in pica were blocked. For the fourth participant, a punishment procedure was used in addition to non-contingent reinforcement to reduce the participant's pica.

In another study, Donnelly and Olczak (1990) used differential reinforcement of an alternative behavior (DRA DRA Delta Regional Authority
DRA Developmental Reading Assessment (educational test)
DRA Division of Ratepayer Advocates (California)
DRA Data Research Associates
DRA Directory and Resource Administrator
) to compete with the cigarette pica of two adult males. Both participants were differentially reinforced for chewing sugarless mint gum. The results demonstrated that gum chewing successfully competed with the participant's pica.

Smith (1987) used verbal prompting ("don't touch") and differential reinforcement of incompatible behavior (DRI See Digital Research. ) to reduce the pica of an adult male participating in community-based supportive employment. The DRI procedure involved differential reinforcement for touching and manipulating work materials. Results demonstrated that the DRI treatment package significantly reduced the participant's pica. These data are particularly interesting because they represent the first published demonstration that a differential reinforcement intervention package can be used successfully to reduce the pica of persons with developmental disabilities in natural (community-based) setting.

Finally, Kern Kern, river, 155 mi (249 km) long, rising in the S Sierra Nevada Mts., E Calif., and flowing south, then southwest to a reservoir in the extreme southern part of the San Joaquin valley. The river has Isabella Dam as its chief facility. , Daroshta, and Adelman (2006) demonstrated that differential reinforcement for the exchange of inedible items for edible items was successful in reducing the pica of two boys with developmental disabilities. One participant also was successful in maintaining the reduction in pica across a variety of settings, including the hospital, the classroom, and the cafeteria. The second participant required continued intervention to support generalization gen·er·al·i·za·tion
n.
1. The act or an instance of generalizing.

2. A principle, a statement, or an idea having general application.
 across settings.

Although several studies have demonstrated that intervention packages including differential reinforcement can be successful in reducing pica, only one study has examined the efficacy of differential reinforcement in educational settings. To date, no published study has examined the efficacy of differential reinforcement for the production of functionally equivalent communication behavior to replace pica in an educational setting. Thus, the purpose of the present study was to examine whether this type of functional communication training (FCT FCT Faculdade de Ciências e Tecnologia (Portuguese University)
FCT Fundamentals of Computation Theory
FCT Fundação para a Ciência e a Tecnologia (Portuguese Science and Technology Foundation) 
) could result in functionally equivalent behaviors to replace the pica of a 6-year-old boy with autism in his classroom.

Method

Participant

A 6-year-old boy with autism (Richard) served as the single participant in this study. Richard's diagnosis of autism had been established independently by a multi-disciplinary assessment team, including a developmental pediatrician pe·di·a·tri·cian or pe·di·at·rist
n.
A specialist in pediatrics.
 and a psychologist. Additionally, Richard presented with global delays in receptive and expressive language, cognitive skills cognitive skill Psychology Any of a number of acquired skills that reflect an individual's ability to think; CSs include verbal and spatial abilities, and have a significant hereditary component , and social skills. However, he could communicate his desires and needs through speech using 3- to 4-word utterances. Behaviorally, Richard displayed little awareness of dangerous situations, including the dangers of eating edible and non-edible items (e.g., rock salt) that he picked up from the floor. Since preschool, Richard had participated in classrooms that were structured according to according to
prep.
1. As stated or indicated by; on the authority of: according to historians.

2. In keeping with: according to instructions.

3.
 principles of applied behavior analysis Some of the information in this article may not be verified by . It should be checked for inaccuracies and modified to cite reliable sources.

Applied behavior analysis (ABA)
 (ABA Aba (ä`bä), city (1991 est. pop. 264,000), SE Nigeria. It is an important regional market, a road and rail hub, and a manufacturing center for cement, textiles, pharmaceuticals, processed palm oil, shoes, plastics, soap, and beer. ); and he had received early intensive behavioral intervention services prior to entering the preschool.

Setting

All observations were conducted in the participant's classroom over a three month period. The classroom included five other students whose educational status ranged from kindergarten through second grade. Throughout most of this study, Richard attended an ABA-based classroom with five other students, located in a district school. It offered a high level of support services support services Psychology Non-health care-related ancillary services–eg, transportation, financial aid, support groups, homemaker services, respite services, and other services  (e.g., 1:1 aide for each child, speech/language therapy, occupational therapy) as prescribed by each child's Individualized in·di·vid·u·al·ize  
tr.v. in·di·vid·u·al·ized, in·di·vid·u·al·iz·ing, in·di·vid·u·al·iz·es
1. To give individuality to.

2. To consider or treat individually; particularize.

3.
 Education Plan (IEP IEP

In currencies, this is the abbreviation for the Irish Punt.

Notes:
The currency market, also known as the Foreign Exchange market, is the largest financial market in the world, with a daily average volume of over US $1 trillion.
). During the summer, Richard's classroom was located in a self-contained school for children with disabilities staffed by some of the same paraprofessionals as during the regular school year under the direction of a different teacher.

The sessions were conducted by the authors, who also provided services to the participant in the classroom (i.e., behavioral consultant, speech therapist speech therapist Speech pathologist, speech/language therapist A health professional trained to evaluate and treat voice, speech, language, or swallowing disorders–eg, hearing impairment, that affect communication. See Speech pathology. , associate teacher, and classroom teacher). Sessions were conducted in the context of different classroom activities, and the participant's 1:1 paraprofessional paraprofessional

1. a person who is specially trained in a particular field or occupation to assist a veterinarian.

2. allied animal health professional.

3. pertaining to a paraprofessional.
 continued to provide support for Richard as appropriate for these activities. Initially the sessions were conducted during structured activities (e.g., discrete-trial teaching). Later, they were conducted at other times throughout Richard's school day (see below).

Preliminary Procedures

Functional assessment: Prior to the intervention, naturalistic observations of the antecedents and consequences of the behavior were conducted by the classroom behavioral consultant. Data collected did not indicate a specific pattern to the behavior (e.g., no social consequence was consistently associated with the participant's pica), and the function was therefore determined to be non-socially mediated (i.e., maintained by automatic reinforcement).

Preference assessment: A preference assessment was conducted in order to identify preferred food item(s) which could be used to "bait" the environment during the study. Bating bate 1  
tr.v. bat·ed, bat·ing, bates
1. To lessen the force or intensity of; moderate: "To his dying day he bated his breath a little when he told the story" 
 involved placing preferred food items on the floor as a temptation for Richard to engage in pica. Results indicated that pretzels could be used for this purpose. Additionally, Richard had been observed to eat rock salt from the floor during the winter. For this reason, rock candy rock candy
n.
A hard confection that is made by cooling a concentrated sugar syrup into large clear crystals around a piece of string or a stick.

Noun 1.
 (which looked like rock salt) was also used at points later in this study.

Dependent Variable

Data were collected on the latency and frequency of pica and pica attempts. The specific dependent measure was the length of time between the placement of a preferred edible item on the floor near Richard and Richard's reaching for the item. A "+" was scored, for each trial, if the participant did not reach for the items on the floor for the required latency and then verbally requested the item. A "-" was scored if the participant either reached for the item before the required latency or did not request the item. Data were collected on the latency and frequency of pica and pica attempts. The specific dependent measure was the length of time between the placement of a preferred edible item on the floor near Richard and Richard's reaching for the item. A "+" was scored, for each trial, if the participant did not reach for the items on the floor for the required latency and then verbally requested the item. A "-" was scored if the participant either reached for the item before the required latency or did not request the item. The reliability of scoring was assessed by calculating the inter-observer agreement during 70% of the sessions and involving 76% of the trials. The total number of agreements was divided by the total number of agreements plus disagreements. Results indicated 98% inter-observer agreement.

Experimental Design

A single-subject changing criterion design was used to demonstrate experimental control.

Baseline: Three baseline trials were conducted during one session to measure the dependent variable before any treatment was introduced. Each trial began with the placement of preferred food (pretzels) on the floor near Richard and it ended when Richard reached for the item. Results indicated that Richard reached for the pretzels immediately after they were placed (0-second latency) on all baseline trials (i.e., 3 times).

Independent Variables: After baseline, Richard was taught to ask for pretzels. Because functional communication (requesting attention) had been taught to Richard previously as a replacement for self-injury, he was familiar with the process. As before, a verbal prompt was used to teach Richard to request the pretzel; and only one trial was necessary for him to understand the contingencies. After that he began requesting pretzels independently.

Next, Richard was told that a timer would be set and that if he wanted a food item when the timer beeped, he could ask for it. Initially, the timer was set for 1 second, and food items (initially pretzels) were placed on the floor as they were in the baseline condition; and Richard was told "don't touch". If Richard attempted to reach the food items, he was blocked and a "-" was scored for the trial. When the timer began to beep, and if Richard didn't request a pretzel (or other food item) independently, he was verbally prompted to do so. If he verbalized a request, he was reinforced with social praise and given a "clean" food item from a container. A "+" for each trial was only scored if Richard both and verbally requested the item and did not reach for the food item prior to the timer beeping Beeping is a cellphone communications tactic where a cash-strapped cellphone caller gets the person he/she is "beeping" to call him/her back. [1] Method . The length of time during which Richard was required to wait without touching or attempting to reach for a food item on the floor was systematically increased across trials.

Typically no more than 10 trials were conducted in one treatment session or per day. Initially, 1 session of approximately 10 trials was conducted per day for the trials with the terminal criteria of 1 to 59 seconds. On Figure I, below, this included trials 1 through 132. When the wait criteria increased to 60 seconds or more per trial, the number of trials conducted per session varied between 1 and 6 per day, depending on time constraints In law, time constraints are placed on certain actions and filings in the interest of speedy justice, and additionally to prevent the evasion of the ends of justice by waiting until a matter is moot.  dictated by the participant's schedule. On Figure I, this included trials 133 through 157.

The distance between the therapist and Richard also varied across sessions. This was done both to replicate the various instructional situations which Richard experienced in his classroom and to ensure that the proximity of the therapist was not influencing his behavior. When the first intervention sessions were conducted, the therapist was seated directly across from Richard. When the latency of the trials was increased to 60 seconds, the therapist began to vary her distance from Richard systematically in order to promote stimulus generalization Noun 1. stimulus generalization - (psychology) transfer of a response learned to one stimulus to a similar stimulus
stimulus generalisation, generalisation, generalization
. During these trials, the therapist placed pretzels on the floor near Richard's feet and then stepped back.

Once the latency criteria increased to 120 seconds, the therapist started to conduct the sessions during different parts of Richard's school day. For example, sessions were conducted when Richard participated in large-group instruction conducted by his classroom teacher and during transitions between classroom activities. These were natural contexts in which Richard had displayed pica prior to the initiation of this study.

Finally, in order to evaluate the external validity External validity is a form of experimental validity.[1] An experiment is said to possess external validity if the experiment’s results hold across different experimental settings, procedures and participants.  of the intervention, sessions were conducted for 30 consecutive minutes across 2 days. The specific times were chosen to correspond with a variety of natural activity contexts during which Richard had been observed to display pica prior to the intervention (e.g., reading lessons, transitioning across the room). During these sessions, Richard's entire classroom was "baited" with a variety of items including crushed rock candy.

[FIGURE 1 OMITTED]

Results

The results of this study are summarized in Figure 1, above. Richard participated in 157 trials over a 3-month period. The data show that differential reinforcement of functional communication was effective in reducing the frequency with which he engaged in pica (see Figure 1). Richard only reached for the food on the floor on 4 (3%) of the 157 trials. These occurred once at each of four criterion levels (i.e., 1-second, 4-second, 60-second, and 240-second trials, respectively). More importantly, Richard succeeded on 153 (97%) of the 157 trials in reaching the latency criteria and verbally requesting the food item rather than attempting to engage in pica.

Discussion

While the results of studies with small numbers of participants must be interpreted with caution, the current results do suggest that functional communication training could be a promising procedure for helping children with autism to use functionally equivalent communication responses as a replacement for pica when their history of pica has involved food items from the floor. Additionally, since anecdotal data suggested that Richard successfully generalized his communication skills across settings (e.g., to the general education class and to transitions between activities), it is possible that other individuals with similar histories of engaging in pica also may also be successful in generalizing these skills.

As indicated above, however, one must be cautious about the generality gen·er·al·i·ty  
n. pl. gen·er·al·i·ties
1. The state or quality of being general.

2. An observation or principle having general application; a generalization.

3.
 of these results. There is great variability in skill sets among children with the diagnosis of autism, and there is variability in the environments in which they function. The participant in this study was enrolled in a highly-structured school program, with educational staff trained in ABA, and he had a previous history of using functional communication successfully as a replacement for problem behavior. Further, only specifically identified food items were used as stimuli. Therefore, it is unclear whether the current intervention package would be effective for a person with different entry-level skill sets, with a history of pica involving a variety of non-edible items, or in a classroom with less adult support. Additionally, although anecdotal reports from Richard's staff indicated that the intervention package was successful in settings other than his classroom (e.g., at home, in the community), his performance was not assessed formally in these other settings. Replication and extension of these procedures should be done to assess formally whether these results can be generalized to other participants and other environments.

Acknowledgment acknowledgment, in law, formal declaration or admission by a person who executed an instrument (e.g., a will or a deed) that the instrument is his. The acknowledgment is made before a court, a notary public, or any other authorized person.  

The authors would like to thank Kim Lazzar, Lindsey McIlvene, Richard, and his family for their support in conducting this study.

References

Donnelly, D. R., & Olczak, P. V. (1990). The effect of differential reinforcement of incompatible behaviors (DRI) on pica for cigarettes in person with intellectual disability. Behavior Modification behavior modification
n.
1. The use of basic learning techniques, such as conditioning, biofeedback, reinforcement, or aversion therapy, to teach simple skills or alter undesirable behavior.

2. See behavior therapy.
, 14, 81-96.

Fisher, W. W., Piazza, C., Bowman, L. G., Kurtz, P. F., Sherer, M. R., & Lachman, S. R. (1994). A preliminary evaluation of empirically derived consequences for the treatment of pica. Journal of Applied Behavior Analysis The Journal of Applied Behavior Analysis (JABA) was established in 1968 as a The Journal of Applied Behavior Analysis is a peer-reviewed, psychology journal, that publishes research about applications of the experimental analysis of behavior to problems of social importance. , 26, 23-36.

Goh, H., Iwata, B. A., & Kahng, S. W. (1999). Multicomponent assessment and treatment of cigarette pica. Journal of Applied Behavior Analysis, 32, 297-316.

Johnson, C., Hunt, F., & Siebert, M. J. (1994). Discrimination training in the treatment of pica and food scavenging scavenging

of anesthetic. See anesthetic scavenging.
. Behavior Modification, 18, 214-229.

Kern, L., Starosta, K., & Adelman, B. E. (2006). Reducing pica by teaching children to exchange inedible items for edibles. Behavior Modification, 30, 135-158.

McAdam, D. B., Sherman, J. A., Sheldon, J. B., & Napolitano, D. A. (2004). Behavioral interventions to reduce the pica of persons with developmental disabilities. Behavior Modification, 28, 45-72.

Rojahn, J., McGonigle, J., Curcio, C., & Dixon, M. (1987). Suppression of pica by water mist and aromatic ammonia: A comparative analysis. Behavior Modification, 11, 65-74.

Singh, N. N. (1983). Behavioral treatment of pica in mentally retarded Noun 1. mentally retarded - people collectively who are mentally retarded; "he started a school for the retarded"
developmentally challenged, retarded
 persons. Psychiatric Aspects of Mental Retardation mental retardation, below average level of intellectual functioning, usually defined by an IQ of below 70 to 75, combined with limitations in the skills necessary for daily living.  Newsletter, 2, 33-36.

Smith, M. D. (1987). Treatment of pica in an adult disabled by autism by differential reinforcement of incompatible behavior. Journal of Behavior Therapy behavior therapy or behavior modification, in psychology, treatment of human behavioral disorders through the reinforcement of acceptable behavior and suppression of undesirable behavior.  and Experimental Psychiatry, 18, 285-288.

Author Contact Information:

Deborah A. Napolitano

University of Rochester The University of Rochester (UR) is a private, coeducational and nonsectarian research university located in Rochester, New York. The university is one of 62 elected members of the Association of American Universities.  School of Medicine

Box 671

601 Elmwood Dr.

Rochester, NY 14642

Phone: 585-273-3315

e-mail: Deborah_Napolitano@urmc.rochester.edu

Lisa A. Blakkman

Monroe #1 BOCES BOCES Board Of Cooperative Educational Services  

41 O'Connor Rd.

Fairport, NY 14450

(585) 377-4660

Lori B. Kohl

Monroe #1 BOCES

41 O'Connor Rd.

Fairport, NY 14450

(585) 377-4660

Heather M. Vallese

Monroe #1 BOCES

41 O'Connor Rd.

Fairport, NY 14450

(585) 377-4660

David B. McAdam

University of Rochester School of Medicine

Box 671

601 Elmwood Dr.

Rochester, NY 14642

Phone: 585-273-2759

e-mail: David_Mcadam@urmc.rochester.edu
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Author:Napolitano, Deborah A.; Blakkman, Lisa A.; Kohl, Lori B.; Vallese, Heather M.; McAdam, David B.
Publication:The Journal of Speech-Language Pathology and Applied Behavior Analysis
Geographic Code:1U2NY
Date:Dec 22, 2006
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