Unlocking Behaviors: Seasonal Allergies
By Ley Linder, MA, M. Ed, BCBA and Craig Escudé, MD, FAAFP, FAADM
This article is part of a co-authored series on behavioral presentations in which a physician and a behavior analyst provide insight into real-life case studies to share their expertise on how behavioral issues can be addressed in an interdisciplinary fashion. Dr. Escudé and Ley are recipients of the 2024 AADMD Excellence in IDD Journalism Award for this ongoing series.
Eugene is a 41-year-old man with no known chronic medical issues and does not take psychotropic medications. The only medical concern for Eugene is that he is allergic to bees and always carries an epinephrine auto-injector (Epi-pen) with him. Eugene lives with three other men and is independent with activities of daily living but needs support for more complex tasks like money management and cooking. Eugene can easily advocate for various needs, such as needing to see a doctor or requesting money for purchases. He is a proficient verbal communicator and has held competitive community employment. Currently, he works on the yard and maintenance crew for the agency where he lives. He is cutting grass at homes and businesses in his community most days.
In February 2025, Eugene and his housemates were diagnosed with the flu amidst an agency-wide “flu outbreak.” Eugene was out of work for a week and was quite sick. In March 2025, he woke up one morning complaining of a headache, was irritable, and lethargic. He asked a staff member for OTC medication for his headache, which he received, and he went to work on the yard crew. That afternoon, Eugene arrived home with a runny nose and sneezing. He immediately went to his room to lie down. Curiously, staff noticed that he didn’t turn on any music or his TV which, he typically does, and when they went to check on him, he was lying in his bed with the light off.
Staff members notified the nursing department, which immediately scheduled an appointment for flu and COVID-19 testing. Eugene was told he would have to isolate himself until the test results were obtained, which meant he could not go to work nor attend an upcoming social event. Eugene became upset and began yelling, screaming, and slamming doors.
“The key is to realize that many conditions can present with the same symptoms. When we list all the possible causes for a group of symptoms, we call this creating a ‘differential diagnosis.’ It includes listing all the possibilities that any particular group of symptoms might be signs of.”
Medical Discussion
Irritability, lethargy, headache, and a runny nose can be signs of several conditions, including COVID-19, influenza, the common cold, a foreign body in the nose, a sinus infection, and seasonal allergies. There are several ways clinicians can differentiate between these conditions. Lab testing can tell clinicians about COVID and the “flu.” A physical exam can tell us about a foreign body and help differentiate between a “cold” and allergies. The absence of fever also helps eliminate the infectious conditions from the others, though there could be some overlap. Understanding the context in which symptoms occur can be of help as well. Knowing Eugene works on a yard crew and has been outside during the allergy season increases the likelihood that seasonal allergies are the cause.
The key here is to realize that many conditions can present with the same symptoms. When we list all the possible causes for a group of symptoms, we call this creating a “differential diagnosis.” It includes listing all the possibilities that any particular group of symptoms might be signs of. Then, we can use testing and examinations to determine the actual cause of the symptoms. We must keep our “differential diagnosis” list as wide as possible to help ensure we don’t mistakenly diagnose someone with the wrong condition.
Behavioral Discussion
Behavior analysts are trained to “dissect” behaviors, understand their components, and determine their function or reason. One component of understanding behavior is setting events, which are defined as “factors that increase the likelihood of behavior hours or days before the occurrence of the behavior.” Examples of setting events include sleep patterns or a medical diagnosis, such as diabetes (think about how high or low blood sugar might impact behavior).
Setting events can sometimes “come and go” and not always contribute to behavior. For example, holiday seasons, anniversary dates, or birthdays can be setting events that do not always contribute to the occurrence of (challenging) behavior. For some people, these periods are not joyous and happy, but rather can elicit negative emotional responses related to family and friends, past trauma, or that they do not have anyone to celebrate with. Recognizing and accounting for the impacts of periodic, episodic, or “seasonal” setting events on behavior presentations is essential in understanding the cause of behavior, as well as the totality of the person.
Another example of periodic setting events is when a person has seasonal allergies. The likelihood that allergies will impact a person’s behavior is higher during certain times of the year, such as the spring season.
Outcome
On the afternoon Eugene was tested for the flu and COVID and was anxiously waiting for his test results, a staff member came to work for the second shift. As she was putting her purse away, she said, “I can NOT quit sneezing, and my head is killing me! My allergies are acting up terribly!” As she said this, everyone paused and, in unison, looked down the hall towards Eugene’s room, where he was lying on his bed with a faint murmur of a game show rerun coming through his door. Eugene had been working outside all week, cutting grass in a yellow pollen plume for the first time this year.
The recent “flu outbreak” had Eugene and the entire interdisciplinary team on high alert. Although reasonable, the extensive action taken by the support team to prevent another flu outbreak also led to behavioral issues for Eugene. Sometimes, our responses and interventions can be the antecedents to problem behavior when we do not consider all possible explanations.
About the Authors
Ley Linder 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 works closely with national organizations such as the National Down Syndrome Society and the National Task Group on Intellectual Disabilities and Dementia Practices, and is the Founder/CEO 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 more than 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.