Unlocking Behaviors: Feces Smearing
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.
Matt is a 36-year-old man with autism who lives with three other men of similar age and functioning level. He is a proficient verbal communicator both expressively and receptively. Matt enjoys social interactions with peers, staff, and family, and frequently participates in various activities in the community. Matt has several medical conditions that can impact his daily life and his psychobehavioral status. He is diagnosed with and has a history of the following: anemia, irritable bowel syndrome, abnormal weight loss, constipation, hemorrhage from the anus, hemorrhoids, and rectal ulcers. He also takes medications to treat anxiety and depression.
Sometimes, Matt says things repeatedly, and they appear to be statements he has heard and/or been told by others in the past. These statements can include things such as, “Matt is bad,” or “STOP doing that.’ Matt recently returned from a home visit and was heard moaning, grunting, and yelling phrases in the bathroom, such as “Matt STOP!” When Matt left the bathroom, staff noticed there was feces and blood on the floor around the toilet, on the counter, all the towels were soiled, and the toilet was clogged with toilet paper. In the past, staff have noted they believe Matt goes into the bathroom to masturbate and are concerned that he has injured himself by doing this.
Medical Discussion
Matt’s behaviors and verbalizations, particularly around bathroom use, may be influenced by a combination of medical, psychological, and environmental factors. His history of gastrointestinal issues—including irritable bowel syndrome, constipation, rectal ulcers, hemorrhoids, and anal bleeding—can cause significant discomfort, pain, and distress, especially during bowel movements. Chronic constipation can lead to straining, which may worsen hemorrhoids and contribute to rectal bleeding and ulceration. Poor hygiene, whether due to discomfort, fear, or lack of support, can further irritate the skin and lead to infections or inflammation. Additionally, parasitic infections, more common in individuals with compromised gastrointestinal health or hygiene challenges, can cause itching, pain, and gastrointestinal symptoms that may lead to compulsive scratching, excessive wiping, or even self-injurious behavior. These conditions may contribute to Matt’s use of excessive toilet paper, soiling of towels, and the presence of feces and blood in the bathroom. A comprehensive medical and behavioral evaluation is essential to address potential sources of pain, infection, and emotional distress, while promoting a trauma-informed and dignified approach to his care.
“Feces smearing garners a lot of attention quickly, especially if it is on another person! The key to understanding this behavior is a willingness to “work backwards” and think like the person engaging in it. ”
Behavioral discussion
Feces smearing garners a lot of attention quickly, especially if it is on another person! The key to understanding this behavior is a willingness to “work backwards” and think like the person engaging in it. Initial thoughts could be, “Where is the feces coming from? Are they digging in their rectum, defecating outside of the toilet, or reaching into the toilet? Do they wear an adult brief and are reaching into it?”
Generally, the answers will indicate that the person is experiencing some discomfort they are trying to relieve. Behaviorally, there are many important considerations that can help more clearly identify the characteristics of the behaviors. Are they itching? Are they possibly in pain? Are there certain times of day when they are engaging in the behavior? When was their last bowel movement? If they wear an adult brief, was it soiled? Do they have a rash or irritation? When did this behavior start? Do they have a history of the behavior? The primary role of a behavior analyst upon the initial presentation is to gather as much data as possible, while clearly identifying the characteristics beyond the presenting behavior to assist the interdisciplinary team. Future behavior and environmental approaches could include a toileting schedule, increased supervision, or expanding the use of effective communication to ask for assistance.
On some occasions, rectal digging and feces smearing may not be related to a medical diagnosis. These instances are likely idiosyncratic and require more in-depth behavior review. For example, a person may have learned routines in the bathroom where they defecate in the shower, or their feces have been removed from the toilet to be disposed of in other places.
Outcome
From the standpoint of thinking of behavioral presentations of medical diagnoses, a few common diagnoses related to feces smearing and rectal digging are constipation, hemorrhoids, and even parasites. Environmental issues can be related to poor hygiene after bowel movements, bowel accidents that lead to trying to clean up without assistance, and clogged toilets.
When putting yourself in the shoes of the person exhibiting feces smearing, their thought process could be the following: “I have this pain and discomfort in my rectum, I have tried to make it better, but now I have another problem. I have this offensive matter on my hands, I don’t like it, and I want it off.” They then wipe it on available surfaces (or themselves or others!).
For Matt, the feces and blood that were found in the bathroom were related to his chronic gastrointestinal concerns. Matt was experiencing constipation, which led to hemorrhoids. When he was in the bathroom, he was trying to remove feces from his rectum manually. This resulted in feces on his hands, which ended up on various surfaces as he wiped and tried to clean himself. Matt was seen by his primary care physician, who treated the hemorrhoids and ordered medication for constipation. The residential team also increased support and supervision while in the bathroom to ensure Matt’s health and safety and promote successful toileting.
Of special note from Ley’s experience, he has never seen rectal digging and feces smearing be related to sexual gratification. When compared to behaviors that serve a sexual function, rectal digging and feces smearing do not present the same.
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 e-learning course used to train clinicians on the fundamentals of healthcare for people with IDD.