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Many behavior analysts, psychologists, and other professionals working with individuals with autism spectrum disorders (ASD) or intellectual disabilities (ID) gain familiarity with externalizing behavior disorders such as aggression and tantrums, but not other low frequency, high-risk behavior. Aggression and tantrums are common and practitioners encounter them frequently. With some luck, they learn what evidence-based practices are for these problems and gain some effective clinical skills over time, but practitioners are often challenged by less frequent behavior disorders such as pica, hand mouthing, rumination, aerophagia, bruxism, and polydipsia.

What should our approach for low frequency, high-risk behavior be?

These behavior disorders are challenging because they are often maintained by automatic positive, positive reinforcement; are often seen in individuals with severe/profound cognitive disabilities and severe autism; sometimes involve management of restraint, and sometimes involve related medical conditions. Treatments are often problem-specific and do not overlap completely with typical treatments for aggression and self-injury and since these type of behavior do not occur on a regular basis (low-frequency) practitioners who do not work in specialized settings simply do not have ample opportunity to build up the professional skills necessary to become competent in treatment.

Consider pica as one such example. Pica occurs anywhere between 0-20% of individuals with ASD or ID and varies in severity from minor to lethal. Based on many functional assessments and analyses of pica, we know that almost always the function of pica is automatic positive reinforcement. Nevertheless, it can be difficult to pinpoint the exact reinforcers maintaining it. In the past treatment often involved positive punishment but today it often goes untreated because service providers do not recognize its danger and/or do not know what to do.

Fortunately, research on functional analysis has now developed positive alternatives, such as environmental enrichment, competing stimuli based on stimulus preference assessments, non-contingent reinforcement, discarding and exchanging pica items, and response-blocking. There are a few clinical case reports of extended treatment that practitioners can now use as models for application that address caregiver training and long-term maintenance, generalization, and restraint management.


Professor Peter Sturmey is an ABAC Resident Speaker and  Guest Blogger

Suggested Reading

Busch, L. et al., (2018).Treatment of life-threatening pica with 5-year follow-up. Advances in Neurodevelopmental Disorders. in press.

Ing A. D. et al. (2013). Functional analysis and treatment of copraphagia. Journal of Applied Behavior Analysis, 44, 151-155 

Mitter D. R. et al. (2014).Assessment and treatment of pica and destruction of holiday decorations Journal of Applied Behavior Analysis, 48, 912-917.
Slikum S. K. et al. (2017).Using differential reinforcement of a discard response to treat pica. Behavioral Interventions, 32, 234-241.

Sturmey, P. & Williams, D. E, (2014). Pica in individuals with developmental disabilities. New York: Spring.