Resources for schools

• Survival
• To feel more normal
• To fit in with peers and friendship groups
• To avoid being thought less of, to be liked
• To avoid any negative attention or judgement

A short film made by Flo in Episode 1 of BBC2's 'Inside Our Autistic Minds'.

Written in the form of a letter to her mum, Flo explains the challenges of autistic masking or camouflaging.

• Observing and copying the behaviour of others (to try to fit in)
• Forcing themselves to make eye contact
• Consciously trying to vary facial expressions
• Matching body language to the person they are interacting with
• Preparing and memorising a 'script' to use in an expected conversation
• Working hard to hide the sensory sensitivities being experienced
• Avoiding stimming (self-stimulating behaviour)
• Avoiding talking about special interests
• Taking on the identity and the interests of someone they think a neurotypical person would like
• People pleasing - which might look like being overly helpful

People who 'mask' all day at school use a lot of energy to do so. This can lead to social, emotional or sensory exhaustion from managing the interactions and demands and any unpredictable changes that may occur. This may present as fight, flight, freeze or fawn.

This can make home behaviours challenging, as the child may have a meltdown or start an argument as they begin to release their pent-up anxiety and emotions and start to be themselves again in their home space. 

Quotes from young people working with SSS [NEEDS DEFINITION] practitioners

"Taking my mask off can be just as exhausting as keeping it on. Learning to lean into my autism and letting my mask slide has helped me to be me at college." Fiona, aged 16

"I have 'non-verbal episodes' where I just can't speak at all. I had one this morning, I was just too tired and overwhelmed and I couldn't talk." Alice, aged 14

• Understanding what masking is and explaining this to the child
• Sharing your understanding with everyone who is in contact with the child
• Supporting the child to unmask or to briefly slide their mask across during their day to give them respite from the emotional exhaustion that can result from masking
• Giving them the opportunity to go to a calm and demand-free environment with reduced language to help them regulate. At school, this might be the SEN provision while at home it is usually their bedroom
• At home, this environment is usually    

School strategies

• Supporting the child to understand their SEN presentation and what masking is
• Seat placement in class
• Sensory supports
• Altered school uniform
• Time out of class
• Movement breaks
• Environmental changes
• 1:1 sessions with trusted staff members
• Use their interests to motivate

Create sensory experiences to support a reduction in masking. In school this could be through sensory circuits, movement breaks or fidget items. Alter school uniform to support sensory needs.

Often after long periods of masking or an intense situation, overwhelm and shutdown can occur. The child may become non-verbal for a period of time. If their expressive language has stopped, their receptive processing won't work either. 

Do not overwhelm them further by asking questions. Accept where they are at that time and reduce expectations accordingly.

Focus on sensory needs. This could be through physically giving them:

• A weighted blanket
• Sensory basket
• Putting on music
• Providing a snack or drink

Once they have regulated, use the child's visual strengths, give them a note or draw a picture so they can visually process the information.

Pica is an eating disorder where someone eats non-food substances that have no nutritional value, such as paper, soap, paint, chalk, or ice.

For a diagnosis of pica, the behaviour must be present for at least one month, not part of a cultural practice, and developmentally inappropriate. Generally, it is not diagnosed in children under the age of two, as it is common for babies to mouth objects, which can lead to them accidentally eating substances that aren't meant to be eaten. Often, pica is not revealed until medical consequences occur, such as cracked teeth, stomach problems or infections.

Pica affects people of all genders and ages, though it is more likely to first appear among children. It can occur alongside other illnesses, including other eating disorders. In cases where it is this other illness that has caused the behaviour related to pica, a separate diagnosis of pica would be made only if it is serious enough to need clinical attention beyond that already being provided for the other illness.

People with pica don't usually avoid regular food, meaning they may still be getting all the nutrients they need. However, some non-food items that they consume can be very dangerous, especially if eaten in large quantities.

While some non-food objects can pass through the body without harm, pica can potentially be life-threatening. Risks include vomiting, constipation, infections, blockages in the gut and intestines, choking and poisoning. Sometimes surgery is needed to remove objects from the gut or to repair damaged tissue.

Physical signs to look out for include:

• Stomach upset
• Stomach pain
• Blood in the poo (which may be a sign of an ulcer that developed from eating non-food items)
• Bowel problems (such as constipation or diarrhoea)
• Non-food items in the child s poo

Symptoms like these may be the result of toxic, poisonous, and bacterial content found in non-food items. Repeatedly eating non-food items over a period of time can lead to poisoning, an intestinal blockage or tearing (from eating hard objects, such as rocks), injuries to teeth, and infections (from organisms and parasites that get inside the body and cause disease). If you have concerns that your child has any of these symptoms in relation to pica, please seek medical advice from your GP.

Regular dental check-ups are also advised as chewing non-food items can cause damage to teeth and gums.

Nutritional deficiencies

Nutritional deficiencies happen when the body is not able to absorb the nutrients it receives from food. The cause of pica has been linked to some nutritional deficiencies, so it is important that these are explored by a healthcare professional.

Blood tests can identify nutritional deficiencies and supplements may then be prescribed. You can discuss blood tests with your GP, health visitor or paediatrician.

It is not possible to create a completely safe environment, but we can reduce the risk from pica by limiting access to higher-risk items.

Please consider this guidance for any environment where the child spends time, including family or friends homes as well as school or nursery.

Sharp objects

Reduce access to items with sharp edges or corners that could cause internal injury, including:

• Paperclips
• Pins
• Blades
• Screws and nails
• Glass
• Plastic items with sharp edges or corners

Try to keep areas clear of these items as much as possible. Put things in boxes that are harder to reach or locked away.

Swallowing non-food items can often be very impulsive and the child will take whatever is close by. If your child has swallowed a sharp item, please seek urgent medical advice from your local emergency department (A&E), providing details about what was swallowed and when this happened.

Blockages and obstructions

Eating non-food items can cause blockages or obstruction at any point in the bowel or gut. Blockages can also occur after swallowing small amounts of non-food items over time, e.g. wallpaper, string or leaves. If your child has constipation or leaking diarrhoea that they cannot control (soiled underwear), please seek medical advice from your GP.

Wires

Children with pica can sometimes chew on wires and cables, so restrict their access to wires and cables where possible and unplug anything that does not need to be on all the time. You may also want to use residual current circuit breakers so that power is cut immediately.

Household items

Many items that can be commonly found in homes can be very dangerous if swallowed, such as cleaning products, bleach or washing machine/dishwasher tablets. It is a good idea to keep substances like this locked away if you can.

Many common bathroom and self-care products can also be harmful if swallowed, such as shampoos, hair dyes and hand sanitiser. Keep these items out of reach or replace them with child-friendly, non-toxic versions wherever possible.

Household batteries can be very harmful if swallowed. These will mostly be found in remote controls, game console controllers and other toys. Secure the battery compartments as much as possible, either with tape or by gluing or screwing them shut. Placing battery-powered items out of reach or securing them in a locked cupboard is also recommended if you are worried your child may target them.

Garden plants

If you are worried about a risk of mouthing or eating plants, it could be worth considering an edible garden . This could be an area in your garden or indoors to plant edible herbs that can be easily purchased in a supermarket. You could also consider creating an edible area with salad items and vegetables with different textures, such as carrots or edible leaves.

Here are some useful links to help you create your own edible garden:

• Fruit and veg for kids to grow - BBC Good Food
• Sow, grow and glow - BBC Good Food
• Get the best from veg in pots - BBC Gardeners' World
• Growing edible flowers - BBC Gardeners' World
• Low-maintenance edible garden for lazy gardeners - BBC Food

Avoid using chipped bark outside - small, rounded pebbles are better, as they can pass through the bowels more easily, or consider quality decking or paving instead. You could consider sectioning off parts of the garden to create an area that can be made safer.

The Woodland Trust publishes a list of harmful plants. It is worth researching this further as this is not an complete list.

General

• Wallpaper in rooms is secure and not peeling.
• Threads and fabrics are secure and not unravelling.
• Indoor and outdoor plants are non-toxic varieties.
• Batteries in controllers, gadgets and toys are secured or put away.
• Access to wires and cables is restricted, electrical items are unplugged where possible, and residual current circuit breakers are in use.
• Office supplies are put away out of reach - paper clips, staples, paper, string.
• Sharp items are put away out of reach - blades, screws, glass (including plastics with sharp edges).
• Chemicals are put away out of reach - cleaning, decorating, building supplies (including washing tablets).
• Plastic bags, gloves, items are put away out of reach (items that can expand in/block the gut).

Areas to check

• Kitchen and dining areas
• Living, recreation and office areas 
• Bathroom and toilet areas
• Bedrooms
• Utility rooms, garage, hallways

Outdoors

• Clear fallen leaves as much as possible.
• Avoid chipped bark as ground cover.
• Unsafe areas are fenced off or made inaccessible.

The evidence so far shows that just preventing a child with pica from swallowing non-food items does not reduce their urges. In fact, it can make the cravings even stronger, and the child may find other ways to obtain items, such as hiding items, finding riskier items to swallow or demonstrating more challenging or aggressive behaviour when prevented from eating a non-food item.

It is important that your child is open and honest about what they are eating. They are more likely to do so if they know they will not get into trouble or be told off for swallowing items. Please encourage them to be open and reassure them that they are not bad or naughty, but their behaviour can make them ill, so we need to find other ways of not eating non-food items.

Helping your child communicate when they are having pica urges can be helpful as they can feel more in control of their own behaviour. It can also help you identify any patterns to when they get urges. Some children can feel embarrassed about reporting urges openly so an agreed non-verbal signal or code word can help if needed.

Positive reinforcement can also help, such as developing a reward system for when the child successfully resists eating a non-food item.

What are they eating?

It is important to have a good understanding of what is being eaten. This can help us identify what are the highest risk items, how often it is happening and notice if anything changes. It can also help us to understand if there are any common factors that can lead to swallowing non-food items.

We have created a pica recording form that you can download and use for this purpose. 

NHFT Pica Recording Form[docx] 234KB

It is important that other people involved in the care of your child, such as schools or nurseries, are aware of what they are swallowing. An up-to-date written record will make it easier to hand over what is being eaten and can support with any strategies that you have found helpful in reducing pica behaviours.

When are they eating?

It can be helpful to identify any patterns or common themes to your child s eating. Is it more likely to happen if they are bored or stressed? Is it more common at home or at school?

It can be very helpful to get them to talk about how they experience this, if possible. These questions may help you with these conversations. Some children can understand motivations and experiences but for others this is very difficult - so if they don t know the answer to these questions that is ok.

• When do they not get urges to eat items?
• What helps them put off the urges?
• What makes them more likely to eat items?
• How do they feel when they are not able to eat items?
• How do they feel before and after eating an item?
• How quickly does the urges come and do they try to delay it?

Providing edible alternatives

Preventing a child from eating non-food items does not usually reduce the pica urges and can in fact make the problem worse - so it can be helpful to create a Pica box or Swap box .

The pica box will contain edible items that share the sensory qualities of non-food items that they are chewing or eating.

The pica box should be easily accessible at home or at school or nursery as it is unlikely that the person will proactively request to use it. The person should be encouraged to use the pica box as much as possible and plenty of praise given when they do use it. It will need to be replenished and you will quickly gain an understanding of what food items are most sought after, so will be able stock it accordingly.

Pica box ideas

• Pistachios
• Peanuts, walnuts, etc.
• Crushed-up ginger biscuits
• Celery
• Twiglets
• Candy floss
• Popcorn
• Popcorn kernels
• Raw carrot
• Sour sweets
• Lemon / lime juice
• Marmite
• Rice cakes
• Chewy sweets / laces
• Sunflower seeds
• Hard sweets
• Savoury trail mix

Label your pica box with the thing that the food is replacing, or the sensory taste or texture.

This is not an exhaustive list. You will need to use trial and error and experimentation to get your pica box right. Please check that any alternatives are definitely edible. For example, some legumes such as chickpeas or lentils, can be harmful if eaten raw.

Pica behaviours have been associated with difficulties managing stress, anxiety and previous traumatic experiences. Promoting the use of alternative soothing strategies to help the person to manage stronger emotions and anxiety can be helpful.

Sensory stimulation

Encouraging use of physical sensory activities can be helpful if the driver for pica is seeking intense sensory sensation by chewing.

Active physical movement uses the vestibular and proprioceptive sensory systems of the child that can help them to regulate their emotions. Encourage the child to participate in regular muscle-resistant age-appropriate activities and games. Talking to them about how strong pica urges are during or after activities can help identify which activities reduce or increase pica urges. We can plan these activities into their daily routine at home, school or nursery to help reduce frequency of the urges.

Examples of muscle-resistant activities and games are:

• Carrying weighted objects like books, backpack, milk jugs, baskets with objects
• Resistant activities like pushing blocks, pulling a wagon, pressing a pillow or climbing
• Using weighted blankets, sitting in bungee chair or on a big pillow
• Strength-building activities for hands like playdough or (very robust) stress balls, fidgets
• Wheelbarrow walking or push-ups
• Using playground equipment like swings and slides

These activities promote body awareness in relation to the surrounding environment. Using movement in an intentional and playful way wakes up the body and brain and can help children with their attention, balance, coordination and regulating their emotions.

Vestibular - sense of balance and body position

• Rocking
• Swinging
• Cartwheels
• Yoga
• Dancing
• Jumping
• Skating / scooting
• Spinning
• Climbing
• Hanging upside down

Proprioceptive - sense of position and body awareness

• Massage
• Rolling
• Swimming
• Pillow fights
• Leap frog
• Animal walks
• Carrying shopping bags
• Weighted blankets
• Monkey bars
• Tug-of-war

Concentration activities

Some children with pica say that their urges are reduced if they are doing things that take concentration and attention. This is more often seen during down time or when they are not taking part in structured activity. Some of these activities can be physical and others can be done while sitting down. Finding a broad range that can be done at home or school / nursery may help reduce pica urges. Examples of activities include:

• Puzzles
• Phone or console games
• Board games
• School work
• Brain teasers
• Engrossing TV or films
• Colouring
• Arts and crafts
• Climbing
• Swimming
• Gymnastics

Discrimination training

Teaching your child the difference between food and non-food items and making them aware of the dangers some substances present to them is known as discrimination training. Pictures can be a helpful way to share this information to children. Encourage the child to pause and think about what they are putting in their mouth. This might help them to decide whether to eat it or throw it away.

Useful links

• National Autistic Society
• The Challenging Behaviour Foundation
• Pica information sheet - The Challenging Behaviour Foundation
• Using a pica box to reduce pica behaviour (video)

Who do I contact?

If you have any concerns that your child has swallowed a sharp object or anything that you believe could cause harm, please seek urgent medical advice from your local emergency department (A&E), providing details about what was swallowed and when this happened.

If you have concerns that your child has any of the below symptoms in relation to pica, please seek medical advice from your GP:

• Stomach upset
• Stomach pain
• Blood in the poo (which may be a sign of an ulcer from eating non-food items)
• Bowel problems (such as constipation or diarrhoea)
• Non-food items in the child s poo
• Injuries to teeth and gums
• Infections (which may be from organisms and parasites that get inside the body and cause disease)

If you have any other questions or concerns about your child and pica please contact your healthcare provider. For children under 5 years of age please contact your health visitor. Your GP or the 0-19 team can give you advice about other eating difficulties or disorders and about referrals to the Children and Young People Community Eating Disorder Service.