# The Handbook of High-Risk Challenging Behaviors in People with Intellectual and Developmental Disabilities

**Edited by James K. Luiselli, Ed.D., ABPP, BCBA-D**  
Baltimore·London·Sydney

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## Contents
- **About the Editor**  
- **About the Contributors**  
- **Foreword Peter Sturmey**  
- **Preface**

### I Self-Injurious Behavior
1. **Biological Perspectives on Self-Injury Among People with Intellectual and Neurodevelopmental Disabilities**  
   Frank J. Symons and Craig H. Kennedy  
   Page 3  
2. **Functional Behavioral Assessment and Functional Analysis of Self-Injury**  
   David E. Kuhn  
   Page 21  
3. **Function-Based Behavioral Intervention for Self-Injury**  
   Johannes Rojahn, Iser G. DeLeon, Griffin W. Rooker, Michelle A. Frank-Crawford, Abbey B. Carreau-Webster, and Yanerys Leon-Enriquez  
   Page 39

### II Aggressive Behavior
4. **Environmental Determinants of Aggressive Behavior**  
   Johnny L. Matson and Alison M. Kozlowski  
   Page 63  
5. **Biopsychosocial Features Influencing Aggression: A Multimodal Assessment and Therapy Approach**  
   William I. Gardner, Dorothy M. Griffiths, and Jeffery P. Hamelin  
   Page 83

### III Sexual Offending Behavior
6. **Risk Assessment for Sexual Offending**  
7. **Behavioral Assessment and Intervention for Sex Offenders with Intellectual and Developmental Disabilities**  
   Timothy R. Vollmer, Jorge R. Reyes, and Stephen F. Walker  
   Page 121  
8. **Problem-Solving Treatment for Sexual Offending**  
   Christine Maguth Nezu, Travis A. Cos, and Arthur M. Nezu  
   Page 145

### IV Health-Threatening Eating Disorders
9. **Behavioral Assessment and Treatment of Pica**  
   Louis P. Hagopian, Natalie U. Rolider, and Griffin W. Rooker  
   Page 161  
10. **Ruminative Vomiting**  
   Jonathan Tarbox, Amy L. Kenzer, and Michele R. Bishop  
   Page 177  
11. **Obesity and Weight Regulation**  
   Richard K. Fleming  
   Page 195

### V Criminal Behavior
12. **People with Intellectual and Developmental Disabilities in the Criminal Justice System**  
   Susan Carol Hayes  
   Page 211  
13. **The Death Penalty, the Courts, and Intellectual Disabilities**  
   J. Gregory Olley  
   Page 229

### VI Therapeutic (Physical) Restraint
14. **Therapeutic Implementation of Physical Restraint**  
   James K. Luiselli  
   Page 243  
15. **Regulatory Governance of Physical Restraint in Schools**  
   Joseph B. Ryan and Reece L. Peterson  
   Page 257  
16. **Emergency Physical Restraint: Considerations for Staff Training and Supervision**  
   David Lennox, Mark A. Geren, and David Rourke  
   Page 271

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### Behavioral Assessment and Treatment of Pica

Pica is defined diagnostically as 1) consumption of nonnutritive items for more than a month, 2) consumption of nonnutritive items inappropriate to developmental age, 3) eating that is not part of culturally sanctioned activity, and 4) behavior severe enough to require independent clinical attention when other clinical services are being provided for another mental disorder (American Psychological Association, 2000).

Several severe health risks are associated with pica (Decker, 1993), including lead poisoning, intestinal perforation, and death (Chisholm & Kaplan, 1968; Greenberg et al., 1958).

The research literature describes three populations of individuals that engage in pica, including typically developing individuals with a nutritional disorder and typically developing individuals who engage in ingesting inedible items (e.g., dirt).

The prevalence of pica in people with IDD has been reported to be between 5.7% and 25.8%. In the largest study, Danford & Huber (1982) found that pica occurred in 25.8% of a sample of 991 institutionalized individuals.

#### Behavioral Assessment of Pica
**Functional Behavioral Assessment (FBA)**
To assess the operant contingencies maintaining pica, a functional behavioral assessment (FBA) is recommended. A variety of FBA procedures have been described, categorized as indirect or direct.

- **Indirect Methods:** Interviews and questionnaires based on reports of others.  
- **Direct Methods:** Involves observation of behavior, categorized as correlational or experimental.

#### Treatment of Pica
Two broad classes of intervention have been shown to be successful: medical and behavioral interventions. Within the context of medical interventions, correcting identified nutritional deficits has shown promise.

Behavior analytic interventions have been shown to be extremely effective at reducing pica, with treatments often involving components such as:
- **Antecedent Interventions:** Noncontingent reinforcement.  
- **Consequent Interventions:** Reinforcement, response blocking, and punishment.

### Conclusion

Interventions developed in clinic settings must achieve generalization. Treatment of a child’s pica at school must also extend to the home if it occurs in that setting. The goal of treatment is to differentiate between edible and inedible items and ensure the individual responds appropriately to each category.