What is the appropriate evaluation and management for a 15‑year‑old adolescent presenting with pica manifested by chewing cardboard?

Evaluation and Management of Pica (Cardboard Chewing) in a 15-Year-Old

Screen for iron deficiency anemia immediately with a complete blood count, ferritin, and C-reactive protein, as iron deficiency is strongly associated with pica and correcting it may reduce the behavior. 1

Initial Laboratory Assessment

• Obtain CBC with differential, ferritin, and C-reactive protein to identify iron deficiency, which is a common reversible cause of pica 1
• Check comprehensive metabolic panel and thyroid function tests (TSH, free T4) to exclude systemic metabolic or endocrine disorders that may contribute to the behavior 1, 2
• Consider folate and B12 levels as nutritional deficiencies beyond iron have been associated with pica 3

The evidence strongly supports that iron deficiency anemia is one of the most consistent biological correlates of pica, though the relationship is complex—some studies show improvement with iron replacement while others do not 4, 5. The hypothesis is that iron deficiency disrupts dopamine transmission, potentially driving the compulsive behavior 5.

Psychiatric and Developmental Evaluation

• Assess for autism spectrum disorder (ASD), intellectual disability, and obsessive-compulsive features, as pica is strongly associated with these conditions 1, 4, 5
• Screen for depression and anxiety disorders, as pica can manifest as a compulsive behavior related to stress and mood disturbance 6
• Evaluate for other psychiatric comorbidities including psychotic disorders, as 87% of patients with pica have associated psychiatric conditions 4

Pica in adolescents with developmental disorders is particularly resistant to medication but responds to applied behavioral analysis (ABA) therapy 5, 7. The behavior often represents an inability to discriminate between edible and non-edible substances, particularly in those with profound cognitive impairment 4.

Risk Assessment for Complications

• Obtain plain radiographs of the abdomen (AP and lateral) if there is any abdominal pain, change in bowel habits, or concern for intestinal obstruction 8
• Maintain high suspicion for gastrointestinal complications, as surgical complications are common and can be life-threatening despite treatment 4
• Assess for respiratory symptoms including chronic cough or recurrent pneumonia, as aspiration is a significant risk, particularly in patients who also exhibit gluttony or rapid eating 4

The literature emphasizes that pica carries approximately 1% risk of perforation with sharp objects, though cardboard itself is less dangerous than metal or glass 8. However, bezoar formation and intestinal obstruction remain significant risks 4.

Treatment Approach

Refer to behavioral health for applied behavioral analysis (ABA) therapy, which has the most robust empirical support for treating pica in adolescents. 5, 7

• Initiate iron supplementation if deficiency is confirmed, with follow-up testing in 1-3 months, though behavioral improvement may be limited 1, 4
• Provide nutritional counseling focusing on calcium and iron-enriched foods 1
• Consider cognitive behavioral therapy (CBT) to address pica as a learned behavior that may respond to behavioral modification 4, 6
• Avoid relying solely on pharmacotherapy, as neuroleptics produce only transient improvement and are best reserved for patients with comorbid psychotic features 4

The shift in clinical practice has moved away from aversive techniques toward positive behavioral interventions, with ABA showing the strongest evidence base 7. Pica may represent a form of addiction analogous to food cravings, suggesting that approaches used for obsessive-compulsive disorder (including SSRIs) warrant consideration 4, 5.

Common Pitfalls

• Do not dismiss pica as benign simply because cardboard is relatively soft—serious gastrointestinal complications including obstruction and perforation can still occur 4
• Do not assume iron replacement alone will resolve the behavior—while iron deficiency should be corrected, the behavioral component requires specific intervention 4
• Do not overlook the possibility of ASD or intellectual disability in an adolescent, as these are the most common underlying conditions and require specialized behavioral intervention 1, 5, 7
• Recognize that pica in sickle cell disease is common and unrelated to iron status—do not give iron supplementation without biochemical proof of deficiency in these patients 1