MEDICAL CONSIDERATIONS IN THE APPROACH TO PROBLEMATIC BEHAVIOR Listed by Body System
MEDICAL CONSIDERATIONS IN THE APPROACH
TO PROBLEMATIC BEHAVIOR
Listed by Body System
A. GENERAL CONSIDERATIONS
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.
B. NEUROLOGIC EFFECTS
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
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.
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.
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.
D. EARS, NOSE, AND THROAT
Otitis media, wax impaction, sinus infection and dental caries or abscess may alter
behaviors through the intermediary of pain.
E. PULMONARY or CARDIOVASCULAR
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.
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
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 http://www.nasddds.org/RestrictiveProcedures/GA%20GuidelinesSupportingAdultsChallengingBehaviors.pdf