Appendix B.2



Listed by Body System



1. Pain  

Pain can precipitate virtually any behavior, the two most obvious of which are 

self-injurious and  aggressive behaviors.  When an individual develops  a 

behavior in which he/she is hitting a particular body part, it is wise to examine 

that body part.  Previous trauma may be a precipitator of behaviors related to 

pain.  An individual could become aggressive when they are experiencing pain as

a result of their lack of understanding of what pain is and how to seek relief. 

a.  Behaviors such as  agitation, pacing and  running away can also  be

precipitated by pain.  Individuals with pain from any source may also

display a variety of sleep disturbances. 

b.  Also to be considered when evaluation such behaviors is the phenomenon of counter stimulation.  The dentist uses this when injecting lidocaine into the 

mouth.  The dentist will  shake your lip to provide counter stimulation. 

This provides additional stimulation for the nerves and the brain to process,

thus lessening the experience of pain at the injection site.  The individual 

with MR/DD  may be providing him or herself with some counter 

stimulation, potentially far from the site of the pain, in an effort to gain 

relief from the pain or discomfort. 

2.  Medication Effects,  Medication Side Effects and Medication Toxicity 

Medication effects, side effects, and toxic effects can precipitate many behaviors

with the most common being  aggression and  agitation or motor restlessness

(sometimes  called hyperactivity).   Self-injurious behaviors and  altered sleep

patterns can also be related to medication effects.  The direct care staff must be

informed when making any medication change for the individual, indicating to

the staff that observation is required and any changes in the behavior of the 

individual need to be reported. 

a.  Many of these behaviors will be due to a direct effect of the medications. 

The most obvious example of this would be over-sedation from the use of a 

medication to sedate an individual. 

b. Side  effects of medications precipitating behavior  problems  are a common

phenomenon.  Akasthisia is a  commonly recognized example and is 

generally expressed as agitation and/or motor restlessness.  Sedation from 

medication not used for sedation is another example. 

c. Toxic effects also may precipitate behaviors.  Most frequently, these effects

result in an altered sensorium and loss of coordination.  The individual may

appear “drunk” or “ill”. 

d.  Finally, remember that one  medication  may affect  another medication and 

may cause any of the above effects. 


1. Headaches 

The expression of headache pain may be through any behaviors, but should be 

considered when head-banging or hitting behaviors occur. 

a. Seizures.  The relationship between seizures and behavior is an 

exceeding important one.  Individuals with MR/DD do not, by definition, 

have a normal central nervous system.  Individuals with diagnosed 

temporal lobe seizures may have ictal, postictal and interictal aggressive


i.  Ictal (seizure) aggression may be manifest as  unpredictable

outbursts of rage or aggression.  Unilateral motor manifestations

of the seizure may precede the aggression, as  may autonomic


ii.  Postictal aggression may occur while the individual is disoriented 

and may be directed at  the caregivers that are  attempting to 

provide aid to the individual. 

iii.  During acts of  interictal aggression, the individual is alert and 

attentive.  All of the other signs of seizure activity are absent. 

Between seizures the individual may become angry at seemingly trivial events 

and may experience an urge to hit someone.  In addition, these temporal lobe 

seizures may precipitate a psychotic state in that the individual, leading to other 

behavior issues. 

Ictal aggression also occurs with non-convulsive frontal lobe seizures.  Common 

manifestations of these seizures include repetitive, bilateral arm motions that 

result in striking items in the environment, including persons.  A blank stare or 

“wild” facial expression, grimacing, teeth clenching, intense vocalizations, and 

occasionally biting or spitting may accompany these.  Autonomic signs are also 

seen.  These seizures often occur nocturnally, awakening the individual.  These 

episodes can follow anger or frustration or occur with provocation.  They may

last for a few minutes up to a half-hour.  Frequently, the individual seems to be 

physically stronger than usual during these involuntary outbursts. 


Behavior changes also occur with other seizure types.  Some individuals 

experience an aura that is represented by behavioral changes while others may

have post-ictal behavior changes related to the area of the brain that is affected by 

the seizure activity.  In all of these individuals, seizure control is the primary

treatment modality for these behaviors. 


1. Meningitis/Encephalitis

Central Nervous System (CNS) may produce behavioral changes through the 

intermediaries of pain or fever (delirium) or by directly altering the individual’s 

sensorium.  Infections may be accompanied by specific symptomatology. 

2. Dementia 

The early onset of Alzheimer’s and non-Alzheimer’s types of dementia 

particularly in the individual with Down’s syndrome (Trisomy 21) must be 

considered in the differential diagnosis of behavioral change.  The potential 

medical causes of dementia must be addressed, as many of these may be 



Cataracts and Glaucoma may produce behavior changes by altering the individual’s 

ability to see.  These behaviors are primary aggression and self-injury, although agitation 

is also fairly common.  In addition, acute angle closure glaucoma can be quite painful, 

manifesting with behaviors related to the intermediary of pain. 


Otitis media, wax impaction, sinus infection and dental caries or abscess may alter 

behaviors through the intermediary of pain. 


The authors have not seen any pulmonary issues present with behavioral manifestations 

with any degree of frequency. 


1.  Constipation/Fecal Impaction

These two common problems in the MR/DD population can precipitate a wide 

variety of behaviors ranging from rectal digging to aggression.  In addition, the 

usual behavioral changes to be expected from persons with normal cognition, 

such as decreased appetite, may not occur in this population. 

2.  Diarrhea

The individual may bring this problem to the attention of the staff by soiling, 

rectal digging or fecal smearing or flinging. 

3.  Inflammatory Bowel Disease (Crohn’s Ulcerative Colitis)

These medical issues will have other symptoms, but if behavioral manifestations 

are present, will most likely be related to pain or diarrhea. 

4.  Gastroesophageal Reflux/Hiatal Hernia

The behavioral manifestations of these problems will most likely be related to 

pain.  In addition, rumination may also be a related behavioral manifestation that 

can lead to significant illness and malnutrition, and in its extreme, death. 

5.  Ulcer Disease (H. pylori)

The primary behavioral manifestations will be those related to the intermediary

of pain. 

6. Intestinal Parasites/Pinworms 

Pinworm infestations are the most common and are frequently manifested by

rectal scratching or digging related to itching.  Other infestations are much less 

common but are also found in individuals who display PICA behaviors, and 

would manifest behaviorally through the intermediary of pain. 


1.  Dysmenorrhea and Urinary Tract Infection

Behaviorally manifested through the intermediary of pain.

2.  Premenstrual Syndrome and Premenstrual Dysphoric Disorder

The behavioral manifestations are myriad and include irritability, agitation, and 

aggression.  Occasionally self-injury will also be present.  The key to diagnosis is 

the timing of these behaviors, occurring in the one to two weeks prior to menses, 

on a regular basis. 

3.  Vaginitis and Vaginal Candidiasis

The primary behavioral manifestation of these issues will be related to 

unrelenting itching of the genital area.  In the less mobile and less verbal 

individuals, these manifestations may be simple irritability or agitation.  More 

mobile individuals may engage in scratching of the genitals, and verbal 

individuals may complain of itching. 


Most issues here relate to itching of the skin.  Behavioral manifestations include selfinjurious behaviors such as rubbing, scratching, gouging and picking at the skin.  Specific issues to look for are rashes such as contact dermatitis, eczema and psoriasis. 


The behavioral manifestations of fractures, bunions, degenerative joint disease and other 

podiatric issues are related to the intermediary of pain.  A particular issue to note is that 

nail care is a difficult issue in this population.  Problems related to ingrown toenails and 

toenails that are too long may also include refusal to walk or bear weight. 


The incidence of hypothyroidism is higher in this population than it is in the general 

public.  In addition, some medications will predispose individuals to hypothyroidism.  

Individuals with hyper and hypo-thyroidism may present with withdrawal and 

depression, lethargy, aggression, self-injury, agitation, sleep disturbance and changes in 

eating habits, just to list a few. 


Menopause can place great emotional strain on the individual.  The physiologic changes 

that occur in the peri-menopausal female can lead to significant behavioral changes.  

Virtually any behavior that is seen in a peri-menopausal female can be attributed to this 

dramatic change in endocrine status, ranging from agitation and motor restlessness to 

aggression and self-injury to withdrawal and depression.  Menopause may occur at a 

younger age in the MR/DD population, and therefore the diagnosis may be missed. 


Many individuals with mental retardation display pica behaviors.  Sometimes these 

behaviors result in anemia, but at other times they result from anemia.  All individuals 

who display pica behaviors should be screened for anemia when the behavior appears and 

at periodic intervals as long as the behavior exist. 

In summary, multiple medical issues may present with identical behavioral manifestations.  

The key to diagnosis is maintaining a high index of suspicion and performing a history, physical examination and special studies as indicated.  Medical illness should never be overlooked nor should its behavioral manifestations be treated with psychoactive agents or behavioral management without first addressing the appropriate diagnosis and treatment of the medical illness. 

Excerpt from Public Document; Full document found at