Unlocking Behaviors: Abuse
Pictured: Hands holding anti-abuse sign
by Risley “Ley” Linder, MA, MED, BCBA and Craig Escudé, MD, FAAFP, FAADM
Maria seemingly disliked Jack, her new support staff, from the day he walked in the door. She would avoid him whenever she could. Once when he was assisting her to her room, she ran out of the front door of her home. As time went on, Maria, who didn’t use words to communicate, began to bite her arm when Jack was around. And later, as she learned Jack’s schedule, she began to curl up in a ball on the recliner or retreat to her room before he ever stepped foot in the door for his shift.
As other staff began noticing this pattern, they became concerned that Jack was doing something to Maria that she didn’t like. He was a nice enough guy, and no one else seemed to have a problem with him, but this pattern of behaviors couldn't be ignored. Jack denied any wrongdoing. But after a particularly violent outburst that was clearly sparked by Jack’s arrival for his shift, Jack was finally placed on administrative leave and was investigated for potential abuse.
Medical Discussion
Healthcare providers must report any suspected abuse to the appropriate authorities. “Suspected” is the keyword here. There doesn’t have to be clear evidence of abuse, just a strong enough suspicion. Clinicians can and should do a medical exam to look for any physical evidence of abuse and thoroughly document any positive or negative findings. However, the determination of whether or not abuse occurred is not one for the clinician to make. Legal authorities must be notified, and they will make the determination.
Behavioral Discussion
From my personal experience as a behavior analyst, a top-three cause of behavior issues is related to negative personal interactions. These social issues are frequently with peers, caregivers, and/or family, as these are the most likely to comprise social systems. Given the global shortage of health care workers, including Direct Support Professionals (DSPs), and the high turnover rate of this specific job role, there is an increased frequency of individuals with IDD interacting with novel people tasked with ensuring their care. A difficult task for caregivers, interdisciplinary teams, or any support provider is training and teaching new staff members the preferences and idiosyncrasies of the individuals they serve. Staff changes are often abrupt, unpredictable, and without choice from the individual — all of which increase the likelihood of behavior issues.
As behavior analysts, one of the ways that we can assist with addressing this area of concern is to ensure that our assessments and behavior programs focus on the individual and seek to introduce a person, not magnify behavioral issues. A person’s social history, lived experience, and personal perceptions of their environment are necessary to consider when seeking to understand how and why they interact with their social and physical environments. These components make up parts of the totality of a person, and behavior analysts can assist with compiling and sharing this information with interdisciplinary team members, especially DSPs. By incorporating this approach, behavior analysts can also (when appropriate) lead the increasingly necessary process of weaving trauma-informed care across all areas of support for the person.
Outcome
Maria’s physician evaluated her on two separate occasions, and she was not found to have any physical evidence of abuse. As the legal investigation continued, Maria’s family members were interviewed. Her mother, who had little to no current involvement in Maria’s life, related that when Maria was a young teenager, her now deceased stepfather had sexually abused Maria. She was too ashamed to admit it and never told anyone until now. During the investigation, pictures of Maria’s stepfather were found, and the resemblance to Jack was uncanny. Both Jack and Maria’s stepfather had dark wavy hair, a neatly trimmed dark beard, light brown eyes, and they were about the same height and build. Jack was also about the same age as her stepfather when the abuse occurred. It appeared that Maria was reliving her earlier traumatic experiences or anticipating they would begin again because of Jack’s similar appearance to her abusive stepfather.
“A key point to remember is that a person who appears to be an aggressor in a suspected abusive situation may not always be the aggressor. A resemblance to the actual aggressor could trigger an adverse reaction to the person.”
Jack was cleared of wrongdoing after passing a polygraph test and a thorough investigation. He was transferred to a different home to prevent the re-traumatization of Maria. All of Maria’s agitation and self-abusive behavior resolved promptly after Jack was transferred, and notes were made in Maria’s record about what was discovered to better inform staff in the future to avoid possible triggers from this unfortunate time in her past.
About the authors:
Ley is a Board-Certified Behavior Analyst with an academic and professional background in gerontology and applied behavior analysis. Ley’s specialties include behavioral gerontology and the behavioral presentations of neurocognitive disorders, in addition to working with high-management behavioral needs for dually diagnosed persons with intellectual disabilities and mental illness. He is an officer on the Board of Directors for the National Task Group on Intellectual Disabilities and Dementia Practices, works closely with national organizations such as the National Down Syndrome Society, and is the owner/operator of Crescent Behavioral Health Services based in Columbia, SC.
Dr. Craig Escudé is a board-certified Fellow of the American Academy of Family Physicians and the American Academy of Developmental Medicine and President of IntellectAbility. He has over 20 years of clinical experience providing medical care for people with IDD and complex medical and mental health conditions. He is the author of “Clinical Pearls in IDD Healthcare” and developer of the “Curriculum in IDD Healthcare,” an eLearning course used to train clinicians on the fundamentals of healthcare for people with IDD. He is also the host of the “IDD Health Matters” podcast.