Pica Disorder among African American Women: A Call for Action and Further Research

Abstract

Pica is simply defined as the consumption of none food products such as laundry starch, clay dirt, ice, soap, and chalk. The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) classifies Pica as the habitual consumption of nonfood and non-nutritive substances for at least one year. Pica disorder is usually unnoticed, under-reported, causes serious harm to clients especially African American women, and seldom discussed in social work scholarship. It is, therefore, important to begin to sensitize social workers to the harmful effects of Pica, especially because it is often unrecognized and misdiagnoses can cause harm. This article provides a panoramic overview of Pica, the signs and symptoms of the disorder specifically among African American women and also address some of the adverse effects, and highlights some of the evidence-based effective treatment strategies. Finally, an urgent clarion call to social workers to conduct more research on Pica disorders among African American women is articulated.

Full text

Pica Disorder among African American Women: A Call for Action
and Further Research
Mary S. Jackson
a
, A. Christson Adedoyin
b
, and Sarah N. Winnick
a
a
School of Social Work, College of Health and Human Performance, East Carolina University, West Greenville, North
Carolina, USA;
b
Department of Social Work, School of Public Health, Samford University, Birmingham, Alabama, USA
ABSTRACT
Pica is simply dened as the consumption of none food products such as
laundry starch, clay dirt, ice, soap, and chalk. The Diagnostic and Statistical
Manual of Mental Disorders (DSM-5) classies Pica as the habitual consump-
tion of nonfood and non-nutritive substances for at least one year. Pica
disorder is usually unnoticed, under-reported, causes serious harm to clients
especially African American women, and seldom discussed in social work
scholarship. It is, therefore, important to begin to sensitize social workers to
the harmful eects of Pica, especially because it is often unrecognized and
misdiagnoses can cause harm. This article provides a panoramic overview of
Pica, the signs and symptoms of the disorder specically among African
American women and also address some of the adverse eects, and high-
lights some of the evidence-based eective treatment strategies. Finally, an
urgent clarion call to social workers to conduct more research on Pica
disorders among African American women is articulated.
KEYWORDS
Pica disorder; African
American women; dirt-
eating; geophagy; pregnancy
Introduction
Pica is a condition caused by the craving and ingestion of items that are not considered editable (Leung
& Hon, 2019). This practice of eating non-editable substances and items is a developmental process
used by children during infancy to 24 months as a means of discovery (placing items in the mouth as
they crawl around in their environment) and exploring (McLeod, 2019). As children grow and
develop, they are socialized to either understand or believe that only “acceptable” items are considered
editable. However, if children continue to place non-edible items in their mouth it could lead to
a Freudian assessment (Fisher & Greenberg, 1996) of oral fixation which suggests an unmet oral need
(McLeod, 2019) or a Pica disorder if continued beyond the regular developmental stages.
Although Pica is has been identified as an anomaly among children who are mentally challenged
and some children from low socioeconomic background (Leung & Hon, 2019), it is a common
condition that can also persist among women (Rose, Porcerelli, & Neale, 2000). More specifically,
Pica is also a condition that exists among certain African American pregnant women even though it is
overlooked or underreported because of its commonality (Mishori & McHale, 2014). A common form
of Pica practiced by many African American women is geophagia or eating dirt. While some
researchers do not associate Pica with mental health issues, there are numerous unanswered questions
related to its definition, prevalence, and treatment. Whether the practice of eating clay dirt is
categorized as “normal” or abnormal may not be the major issue, but the major issues should be the
client’s physical, psychological, and emotional well-being. This implies a holistic approach to inter-
acting with clients to discover their behaviors with the inclusion of geophagia questions that can be
posed during the intake process. Because eating clay dirt is far too common (Leung & Hon, 2019;
CONTACT A. Christson Adedoyin aadedoyi@samford.edu Department of Social Work, School of Public Health, Samford
University, Birmingham, AL 35229
SOCIAL WORK IN PUBLIC HEALTH
2020, VOL. 35, NO. 5, 261–270
https://doi.org/10.1080/19371918.2020.1791778
© 2020 Taylor & Francis Group, LLC

Mishori & McHale, 2014) to ignore the possibility of posing geophagia questions when working with
clients.
Clay dirt is considered a multi-purpose ingredient (e.g. clean oil spills, facial mud masks, scent
absorber, and burial detail), but who would think that clay dirt is for eating? Who would eat clay dirt?
Why would someone eat dirt? Although the practice of eating dirt can be traced as far back as
Hippocrates in 400 BC, it is very popular in African countries (Rude, 2015). We posit that in our
estimation that some African Americans continue this behavior based on their African heritage that
emerged from the slaves brought into the American colonies in 1619. The practice of eating clay dirt
continues in the United States of America (USA) today especially in rural Southern part of America,
and it is passed on inter-generationally among African American females. This behavior of eating dirt
is well documented and formalized in the DSM-5 as a type of mental disorder. The category label is
Pica with specific criteria listed. According to the Diagnostic and Statistical Manual of Mental
Disorders (DSM-5), a diagnosis of Pica must consist of:
Persistent eating of nonnutritive, nonfood substance over a period of at least one month, the eating of
nonnutritive, nonfood substances is inappropriate to the developmental level of the individual, the eating
behavior is not part of a culturally supported or socially normative practice, and if the eating behavior occurs
in the context of another mental disorder, it is sufficiently severe to warrant additional clinical attention” (DSM-5,
2013, p. 329).
The detection of Pica can be difficult for many clinicians (Rose et al., 2000). Typically, the
detection of Pica is determined through an individual’s self-disclosure of Pica symptoms. However,
this is not the case for many intellectually or developmentally disabled individuals. The DSM-5
(2013) states “Pica is confirmed in people with intellectual disabilities by parents or staff observing
the ingestion itself, by the presence of foreign objects in the person’s feces, or through diagnostic
imaging such as X-ray or MRI” (p. 433). Since Pica is associated with possible iron or zinc
deficiencies, it is also possible to detect Pica through blood testing that reveals iron and zinc
deficiency levels (Chansky et al., 2017).
Although Pica is formally classified in the DSM-5, there is still limited information on the
prevalence of Pica in social work scholarship and practice. The reasons for this literature gap we
posit are two-fold. First, Pica is under-reported in mental and clinical practice or interventions with
African American women. Secondly, it is grossly under-studied in social work research. Hence, the
justification for the current paper.
Incontrovertibly, there is a need for knowledgeable health-care professionals to become more
proactive in providing information about Pica, the harm inherent in Pica practices, and interventions
for individuals and families (Ali, 2001). There is therefore a dire need for social workers to become
advocates for extending Pica knowledge, and a scholarship need for cohesive transdisciplinary
discussions and research (Stiegler, 2005).
Cultural Pica and geophagy
Bhatia and Kaur (2014) introduced a concept known as cultural Pica. It refers to eating of nonfood
items as a part of a culturally supported practice. Some researchers have traced the eating of dirt by
African American females to a custom or tradition brought into America by African Slaves specifically
from Nigeria (Hunter, 1993). When slaves were caught eating dirt, the slave masters would seal their
mouths to discontinue the practice, however, many of these slaves died due to malnutrition and as
a result the slave masters discontinued the binding of their mouths and slaves continued their practice
of eating dirt, which was passed on generationally. Contemporary African American females may be
hesitant to eat dirt because of the negative and stigmatized connotations associated with dirt eating as
a poor illiterate behavior of rural African Americans (Dirks & Duran, 2001; Fish, Brown, & Quandt,
2015). Nevertheless, more affluent African American females may substitute cornstarch or baking soda
for dirt (Hilmers, Hilmers, & Dave, 2012; Millstein, Yeh, Brancati, Batts-Turner, & Gary, 2009).
262 M. S. JACKSON ET AL.

Geophagy
Individuals who eat dirt do not recognize Pica as an illness. Cultural Pica is a “normal” practice in
some African American communities. Many generations of African Americans, especially in rural
areas, have practiced eating clay dirt (Grigsby, Thyer, Waller, & Johnston, 1999). This behavior of dirt
eating has been termed geophagy (eating of soil and dirt), seems to continue among rural African
American females, and is especially associated with pregnant women (Jackson & Martin, 2000). Often,
the thinking is that it is common to eat Argo starch among African Americans. Argo laundry starch is
also often eaten, as it is considered a substitute for eating clay dirt. However, it is difficult to locate
studies focused on the prevalence of Argo starch consumption and therefore an understanding of
whether there has been an increase or decrease is not easily determined. But we do know from
personal sessions with clients that Argo starch is still a product consumed. The most common form of
cultural Pica is known as geophagy. Geophagy, also referred to as “earth eating”, is also characterized
by the consumption of earthly substances, such as clay, dirt, or chalk (Hunter, 1993).
According to Hunter (1993), Geophagy was a historically common practice in Europe, India, Asia,
the Americas, and Africa, and is it still commonly practiced in Africa. However, it should be noted that
some African American females in the northeastern states of the USA engage in the practice of
geophagy because families send clay dirt to family members who move to northern cities and miss the
clay dirt of the south. Therefore, the practice continues even though the family member relocates to
a northern state. In Hunter’s (1993) study that took place in Malawi, Zambia, Zimbabwe, Swaziland,
and the Republic of South Africa, it was found that geophagy was an extremely common practice
amongst pregnant females.
Hunter’s (1993) research suggested that the consumption of clay in these regions is considered
highly important in “providing mineral enrichment” (p. 89) for pregnant African women and the
practice is not considered harmful. Recent research, however, strongly suggests and presents data to
support the notion that this practice can in fact cause detrimental health effects due to high lead
content to both mothers and the fetus (Gundacker et al., 2017).
Cultural geophagy in Africa is “deeply rooted instinctual behavior passed forward by generations of
mothers and grandmothers and enshrined in traditional custom” (Hunter, 1993, p. 89). We hypothe-
size that the cultural practice of Pica seen among pregnant African American women could be related
to the generational aspect of this practice. Therefore, it is important for social workers to begin to
incorporate questions related to geophagy when compiling patients’ social history. Just as tobacco,
alcohol, and other drugs are included in the social and medical history, geophagy should also become
a common social history requirement of patients, especially of African American females due to the
possible negative effects that may be prevalent and treatable.
Geophagy among African American women
According to Corbett, Ryan, and Weinrich (2003), African American women are reported to have
more cultural Pica practices than other ethnicities in the USA. Data show that Pica is more prevalent
(38%) among African and African American females who are usually pregnant (Bhatia & Kaur, 2014).
Cultural Pica is a practice in numerous geographical areas among African American women and used
in some religious ceremonial rituals in some Africa countries. Pica can cause potassium abnormalities,
anemia, gastrointestinal conditions that could affect childbirth, dental problems, and become
a mediating factor causing emotional distress and depression (Chen, 2014; Gundacker et al., 2017;
Lallalanilla, 2006; Rude, 2015). This intergenerational practice of dirt eating is a learned behavior that
has little or no known nourishment effect but seems to provide social and psychological benefits. Social
benefits – provide an opportunity to socially bond with each other as they enjoy the Pica behavior on
the front porch or on the front steps of their home. Similar to a quilting event, the women come
together to discuss the latest occurrences in the world, in the community, family, and individually. The
brown bag of dirt is not passed around as each individual brings their bag to the social gathering
SOCIAL WORK IN PUBLIC HEALTH 263

laughing and snacking their dirt. Psychological benefits are based on folk beliefs that eating dirt can
“lift your spirits” and act as a self-soothing relief for emotional discomfort (Young, Khalfan, Farag,
Kavle, Ali, Hajji, Rasmussen, Pelto, Tieslsch, & Stoltzfus, 2010).
Grigsby et al. (1999) conducted a research study focused on geophagia and psychopathology in
central Georgia. The goal was to “gain a better understanding of features of kaolin (white clay dirt)
eating in central Georgia” (p. 191). They reported that dirt eating is “primary practice by black women
who were introduced to the behavior by their mothers, family members, friends, during their
pregnancy” (p. 190). They suggested that although eating dirt is a “culturally bound syndrome” it is
not associated with other psychopathological issues. Also included in their discussion is Garfinkle’s
(1995) findings that a significant proportion (14.4%) of pregnant women from rural areas in Georgia
practice Pica behavior.
Grigsby et al. (1999) concluded with the thinking that the commonality of geophagia in the general
population is not known but it is clearly a practice in Georgia in the Central Piedmont area. This study
utilized both quantitative and qualitative designs and a snowball sampling procedure in an effort to
obtain the participants' perceptions about their geophagia practices. During the semi-structured
interview participants were asked questions such as why do you eat dirt? Where do you obtain the
dirt? And asked to describe the taste. Although they identified a limitation of their study based on
small sample size (N = 21), this is a very relevant indicator of the need for more social workers to
become more aware of clients who may engage in Pica practices.
Although the DSM-5 (2013) criteria of Pica require that “the eating behavior is not part of
a culturally supported or socially normative practice” (p. 329) there is still reason for concern. The
eating of clay dirt for instance can cause serious medical complications. If medical histories are not
inclusive of Pica behaviors, it is likely that the medical physician and the social worker will not have
inclusive information to effectively treat the client.
In addition, the social worker may provide treatment that would not provide a successful inter-
ventional outcome for the client. Furthermore, physicians may not even consider the possibility of
geophagy as a major factor for the illness. Many African American females may eat dirt daily, as the
ritual is that, the dirt is dug from their favorite clay-dirt area, some will eat the dirt “raw” straight from
the earth, and others may bake it and add a little vinegar and salt. The dirt is maintained in a brown
bag or a jar and used for “snacking” purposes. Eating clay dirt is not simply a fetish in the many
southern states as many thousands of individuals engage in the practice (Chen, 2014). Not only
individuals from low socioeconomic status, but also middle- and upper-class African Americans as
well.
Due to the relevance of eating nonnutritive food items within the African American culture, it is
still essential to consider the adverse health effects that this practice can induce especially among
pregnant women. Chen (2014) suggests that pregnant women have the highest intense Pica cravings
due to a suppressed immune system that struggles to protect the fetus. The dirt can act as
a preventive measure if eaten in moderation by replacing damaged stomach lining and soothing
digestion (Rude, 2015), and as a binding protection against toxic alkaloids and tannic acids
(Lallalanilla, 2006). However, the binding properties of clay dirt may also serve as a danger to
pregnant women because the dirt may act as absorption and absolve bodily nutrients that are needed
during pregnancy. Pregnant women are the highest group of dirt ingestion related dirt-eating
practices (Chen, 2014). Even though some nutritionists suggest that eating clay dirt has some
nutritional values such as mineral supplements and absorbing plant toxins (Lallalanilla, 2006), it
is important for health-care professionals to monitor and advocate for best health-care practices
when interacting with clients.
Although the presumption in this article is that Pica is a disorder (because we are bound as clinical
practitioners to assess, diagnose, and provide treatment utilizing DSM-5 as the guide), this does not
imply that we advocate for the need to make decisions with the client based on the client’s best
interests and well-being. We strongly call for the need for social work practitioners and other health-
care personnel to provide more attention to Pica (e.g. clay dirt eating) because it is a common practice
264 M. S. JACKSON ET AL.

that can cause misdiagnosing and can lead to clients not receiving the most appropriate continuum of
care.
Prognosis
Fortunately, Pica is a feeding and eating disorder that can be cured. While it is essential to identify Pica
symptoms and seek Pica treatment as early as possible, Pica is underdiagnosed and typically ignored
until medical or dental complications arise (Federman, Kirsner, & Federman, 1997). The longer that
Pica is left untreated, the more detrimental the health effects can become even if cultural Pica behavior.
The prognosis of Pica will depend on a number of factors. To potentially detect Pica early, it is
beneficial for social workers and medical professionals to be aware of the signs and symptoms of Pica
and include questions regarding Pica during intake screening, especially for populations that most
commonly have a diagnosis of Pica, such as African American females, and pregnant females,
especially in rural southern regions of America. For example, the Pica behavior questions should be
included with the drug and alcohol questions based on acknowledgment (Do you eat items other than
food item), frequency, duration, and onset.
When describing the taste obtained from eating dirt, it varies from tasting like smooth chocolate to
creamy texture to sheer delight and may have some health benefits (Lallalanilla, 2006). Individuals who
eat clay dirt are particular about where they obtain their dirt. It is not any old dirt, but has to be from
a specific area or location.
In pregnant women, the mineral supplement is an increased demand and dirt is one of the world’s
first mineral supplement supplies (Lallalanilla, 2006). Mineral supplements such as iron, copper,
calcium and magnesium are essential for pregnant women and clay dirt contains these minerals.
These minerals build the immune system and can reduce nausea and vomiting during pregnancy.
Therefore, instead of taking Maalox or other antacids, some pregnant women will eat clay dirt which
has kaolin (kaolin is also a key ingredient in pharmaceutical antacids such as Maalox) (Grigsby et al.,
1999).
Women who have been eating dirt for a long period will find it difficult to stop the practice. There is
not a medical test to test for Pica disorder (Gill, 2019). The doctor can test nutrients in the body, which
may be related to Pica. Therefore, African American women will continue to practice Pica behavior
and medical and dental complications may occur without a clear understanding of how to provide
effective treatment. If social workers and other health-care professionals continue to overlook Pica as
an important intake screening mechanism, these women will continue to remain invisible and
untreated or misdiagnosed.
Pica treatment among African American women: a proposal
There is currently no test for Pica, which implies that obtaining a complete social and medical
history for the client is extremely important. Examining a pregnant woman’s medical history is
extremely important in the treatment process because it is the first step to determine if there are
physiological deficiencies of minerals such as iron or zinc. Psychological diagnosis and treatment
should therefore be a secondary consideration. This is because any psychological treatment will not
work, or may not be warranted if the problem is a physiological health condition, or deficiency.
Thus, the treatment process should consist of attention to both the physiological and mental health
issues of the client because to treat one and not the other may not yield successful outcomes for the
client. The treatment will depend on the identifying problem(s). Although the DSM-5 (2013) has
clearly delineated Pica as one of the mental disorders, there are no clear clinical guidelines for the
treatment of Pica (Williams & McAdam, 2012). However, utilizing social work interventions can
guide practice with the assessment process. The goal is to work with the client to determine their
needs. Included in the social history gathering process should be the standard questions regarding
use and ingestions.
SOCIAL WORK IN PUBLIC HEALTH 265

Young et al. (2010) suggest that clients may not respond to the questions truthfully regarding eating
dirt. It is therefore, incumbent on the social worker to establish a positive therapeutic alliance that will
produce an engaging environment where the client will feel comfortable to honestly provide informa-
tion that will assist with successful interventional outcomes. When clients feel that the social worker is
non-judgmental, honest, competent, and genuinely seeking to assist to resolve issues that the client
identifies, it is likely that the client will be forthcoming and honest. Treatment situations can also be
inclusive of observation of the client. In many instances, eating dirt is a habitual behavior for many
African American women. Therefore, if the goal is to reduce or at least eliminate the Pica behavior, the
practitioner may be able to also observe the client in their natural environment (or if in an inpatient
setting). A common procedure is behavioral treatments.
Cognitive Behavioral Therapy (CBT)
Cognitive Behavioral Therapy (CBT) may prove to be a useful treatment technique for African
American females who eat dirt. When exploring effective treatments for geophagy, it is essential to
identify treatment techniques that have proven successful with other eating disorders. According to
a study conducted by Signorini, Sheffield, Rhodes, and Fleming (2018) CBT was reported to be an
effective treatment intervention for individuals with various eating disorders. The implementation of
CBT with African American females who practice geophagy can assist with identifying alternative
coping strategies.
Generally, the CBT therapeutic approach empowers the client to undo what may have become
“automatic thinking” about eating dirt. Mechanisms that can be utilized to assist the client with
changing the cognitive processing would be mental rehearsing a situation with the client. For example,
if the client usually sits on the porch with friends eating dirt from their bags, review with the client how
this behavior can change.
Journaling is also a mechanism that can be explored with the client. Roleplay where the social
worker models the behavior and allow the client to assess and offer reduction or elimination strategies.
Homework assignments are also useful tools that are beneficial to clients with their task of changing
their thinking and behavior. It is important to provide follow-up sessions with clients. In this manner,
reinforcement of their ability to change their thinking and behavior is a means of empowerment for
the client and a method that can provide information to the practitioner.
African Americans who eat clay dirt usually describe it as “something that I have always done;
something that mother did.” There is no sense of wrongdoing, denial, or harmful effects considered
by the user. The Pica cravings are similar to those of a drug-addicted patient. Family members can
become enablers or can participate in the behavior. The CBT model is an appropriate model to use
with African American women experiencing Pica disorder. Stiegler (2005) has identified numerous
treatment interventions; however, these interventions are for pathological Pica such as nutritional
where nutrient supplements are provided to clients as a substitute for their Pica behavior.
Psychological interventions can also be used when Pica is causing emotional distress for the
individual. Pharmacological interventions where medications are utilized such as antidepressant
medications.
Williams and McAdam (2012) suggest that Pica treatment using behavioral interventions can
decrease the Pica behavior. Call, Simmons, Lomas Myers, and Alvarez (2015) suggest that there is
limited information in the literature on the success rate for all Pica treatment interventions. The
pathological Pica interventions discussed in the literature are focused on children with intellectual and
developmental disabilities and the behavioral Pica treatment interventions are extremely limited. Call
et al. (2015) suggest this limitation in the literature about “well-established treatment for Pica” is due
to publication bias (p. 2106) suggesting that because Pica behavioral interventions include small
sample sizes and the outcome may not produce the elimination of Pica and therefore not worthy of
publication. Therefore, it is even more imperative for social workers to identify and create innovative
methods of intervening with Pica clients.
266 M. S. JACKSON ET AL.

To develop a treatment plan from a mental health perspective for an individual who engages in
geophagy Pica behavior, it is first essential to identify the etiology of Pica and additional underlying
factors. If an individual is experiencing Pica symptoms but is practicing geophagia, or any form of Pica
culturally, a mental health professional cannot diagnose this individual with Pica based on engaging in
a strong therapeutic alliance with the client. It is still necessary, however, that the social worker offers
psychoeducation regarding the possible adverse health effects of Pica related practices, especially if this
individual is pregnant. A team approach is beneficial where the medical doctor, nurse, and nutritionist
can also work with the client.
A team approach is especially useful for individuals who have a Pica diagnosis and do not practice
Pica culturally, however, there are many interventions that can be utilized. It is essential for the social
worker to obtain assistance, with the client’s permission, from a medical professional and nutritionist,
as it is likely that this individual may be experiencing cravings for non-food items due to a vitamin or
mineral deficiency. It is then necessary for the mental health professional to determine whether the
Pica symptoms are experienced in the context of an intellectual or developmental disability. For
neurotypical individuals, therapy methods such as individual and/or group counseling, diary, and
daily log can be extremely beneficial to reduce cravings.
As it is unlikely that intellectually or developmentally disabled individuals will respond well to
interventions that can be utilized with neurotypical individuals, there are alternative-suggested pre-
vention methods. According to Fletcher, Barnhill, and Copper (2017) citing the DM-ID 2, it is most
important to consider psychosocial factors when addressing Pica with intellectually or developmen-
tally disabled individuals. The DM-ID 2 suggests behavioral interventions such as punishment and
reward systems for mildly intellectually or developmentally disabled individuals. For moderately,
severely intellectually, or developmentally disabled individuals, however, the DM-ID 2 states that Pica
symptoms will most likely solely be reduced with increased supervision and an environment that
limits opportunity for the eating of non-food items.
Implications for practice
There is still a lack of clarity regarding the definition, the effects, and the prevalence of Pica use. The
literature is sparse regarding assessing, diagnosing, and treatment which is partly due to the limited
research conducted generated by the notion that either geophagy does not exist or due to the
population seemingly most affected there is no need to consider the serious consequences if continued
unnoticed. Some social workers may feel that eating clay dirt should not be considered a serious issue
if it is a common practice that is not considered abnormal by many cultures and continue to be
practiced in many southern states in America (Mishori & McHale (2014)).
However, some adverse health effects can occur based on frequency and quality of use. For
example, some studies have suggested that there is a negative relationship between Pica use and
iron deficiencies and anemia. Bernardi, Ghant, Andrade, Recht, and Marsh (2016) suggest that iron
deficiency and iron deficiency anemia among women are generally 4% to 12% respectfully during
menstrual cycle and even higher among African American women. They also reported that African
American women, during premenopausal period, reported heavy menstrual bleeding, iron deficiency,
and anemic conditions as well. Geophagia can exacerbate this condition due to lack of iron in
geophagy (Borgna-Pignatti & Zanella, 2016).
Given the high frequency of iron deficiency in pregnant women in America (Auerbach, Abernathy,
Juul, Short, & Derman, 2019), it is important to iron deficiency testing in the first trimester of
pregnancy. However, this may present another issue for African American pregnant women living
in rural areas lacking transportation and medical insurance for testing. Yet, another underlying issue is
whether the social worker feels diversely competent to ask geophagy questions that will assist the
medical practitioner with the quality of care for the client. Therefore, it is significant that social
workers join the medical professionals who appear to be advocated for more attention to clients who
SOCIAL WORK IN PUBLIC HEALTH 267

practice geophagy because as Grigsby et al. (1999) has reported that medical complications can be Pica
related.
Pica is a complex disorder because it is classified in the DSM-5 with other mental disorders; yet, it is
a cultural behavior that is habitually practiced by many African American females. It can cause
medical complications that could possibly end in death. Pregnant females appear to be the most
venerable as they engage in Pica behavior (geophagy) at a high rate (Rose et al., 2000). The focus on
Pica in the literature is disappointing due to the limited articles written about Pica behavior among
African American women. Much of the literature that does exist focuses on children with develop-
mental disabilities (Stiegler, 2005). Social workers should begin to advocate more for the inclusion of
Pica related questions in the intake and screening process by health-care providers. Medical doctors
and dentists will also experience more effective treatment outcomes if they inquire about Pica behavior
during their initial examination process.
It is significant to note that there is an urgent need for social work practitioners to discuss Pica at
conferences, in practice settings, and in the classroom as well. Schizophrenia, depression, and
substance disorders are major areas of mental health discussions regarding policy and practice
among social workers. Many social worker practitioners may have experienced a feeling of discomfort
during substance use disorder and mental health training sessions when the field of social work
escalated in these directions. Nevertheless, most social workers know and understand the significance
of inquiring about substances used during their sessions with clients because substance use disorders
have become a common area of focus in social work practice. The need now is to expand the level of
competency to consider focus on an invisible entity (Pica) that is in need of more research. The
inclusion of Pica during intake screening or social history may assist many clients and their families
with a better understanding of the client’s behavior. Early intervention is a key factor in effective
prevention and deters the need for what may be long-term interventions (Goh, Iwata, & Kahng, 1999).
Even if Pica's behavior is a cultural bound behavior, the social worker should not simply ignore it but
should explore further with the client possible complications that the behavior may be causing and
develop strategies with the client that may assist with resolving issues that are caused by the Pica
behavior.
Pica is underexplored territory for social work practitioners and researchers. Therefore, in an effort
to establish intake and screening procedures to include Pica behavior questions, social workers must
begin to advocate more at local, state, and national conferences through their presentations and
publications for more research on etiology, effects, and intervention methods (Stiegler, 2005). In this
manner, the stimulation and motivation to focus on Pica will lead to more creative methods of
addressing Pica behavior among African American women.
Conclusion
The etiology and prevalence of Pica are unclear (APA, 2013), and there is no single agreed on
explanation for the cause (Rose et al., 2000). However, research suggests that Pica is most often seen
amongst African American females, pregnant females, low socioeconomic females, and intellectually
or developmentally disabled individuals. Research also indicates that it is a very common practice
among African American rural cultures (Mishori & McHale 2014) with disagreement among research-
ers about whether it is an abnormal behavior (Grigsby et al., 1999; Mishori & McHale, 2014). Although
many affluent African Americans are giving up the dirt eating because of technological advances where
they may be influenced by social media, however, there are still many African Americans in rural areas
that do not have access to social media.
Treatment interventions for Pica are complex, controversial, and not clearly understood. Even
though cultural Pica (clay dirt eating) is considered less harmful in moderation (Grigsby et al., 1999), it
can become life threatening. Diverse treatment interventions are used however; there are few indica-
tions that complete elimination of the Pica behavior is accomplished. Results of behavioral interven-
tions have proven to be very effective for at least reducing Pica to the near-zero level (Call et al., 2015).
268 M. S. JACKSON ET AL.

Therefore, treatment interventions utilizing behavioral approaches should become a focus, when
appropriate, to move to a point of not only reducing but to eliminate the Pica behavior. Although
other disciplines (e.g. medical, special education, psychology, and nursing) have conferences, numer-
ous journal articles, and suggested interventions about Pica, the same cannot be said about social
work. Consequently, there is an urgent need for social workers to become more proactive with
discussions, classroom instructions, conference presentations, and research in the area of Pica,
especially geophagia behaviors practiced by African American women in America.
Disclosure statement
No potential conflict of interest was reported by the authors.
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270 M. S. JACKSON ET AL.

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