Unlocking Behaviors: Constipation

Risley “Ley” Linder, MA, M. Ed, BCBA, Craig Escude, 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.    

Meet our patient Ron

Ron is a 41-year-old man with a severe intellectual disability. He recently moved into a group home after living with his parents for most of his life. But because of their health issues, his aging parents can no longer provide the level of support he needs. Ron uses few words but can make most of his needs known through gestures  and limited sign language. He eats and goes to the bathroom on his own. He loves watching baseball on TV and goes to local minor league games when he can. He sometimes won’t eat when the game comes on because he’s so excited. Overall, he’s adjusting well to his new living arrangement, but seems to be missing his parents — especially when the games come on TV, as he used to watch them with his dad.  

Over a three-day period, Ron became less active. He sat most of the day, sometimes pulling his knees to his chest. He also ate less. The “big game” was in a few hours, but Ron wasn’t interested. This was unusual, and the staff brought it to the nurse’s attention.

Medical Discussion

“He’s just not acting right.” That’s one of the common complaints from supporters of a person with IDD during an office or emergency department visit. For many clinicians, this leaves the door open for a simple and easily treatable reason to something severe and potentially life-threatening. It’s helpful to know the more common causes of a change alertness or activity. And for people with IDD, one of the most commonly seen causes is constipation.

Constipation is one of the “Fatal Five,” the top preventable causes of illness and death in people with IDD.

Constipation causes a wide range of symptoms. There’s lethargy. Lack of interest in usual activities. Loss of appetite. Sitting or lying with the knees up to the chest or curled in a ball. Abdominal guarding. Restlessness. And aggression for no apparent reason. I often say, “think about constipation first,” as it’s a common cause of an acute change in behavior.

I’ve also  noted other changes, including a low-grade fever, vomiting, and increased seizure frequency for someone with a seizure disorder. I’ve had multiple patients experiencing acute increased seizure activity turn out to be constipated. Their seizure pattern went back to baseline after the impaction was resolved. Because of this, our standard practice was to check for an impaction when they had a seizure flurry. 

Why is constipation such an issue for people with IDD? There are several reasons. Many medications can anti-cholinergic effects, which dry things up and slow things down. Slower intestinal transit means increased water absorption, which firms up the stool. Movement of large muscle groups helps stimulate bowel activity, and for some, this may be limited. Inadequate fiber and fluid intake can negatively impact bowel regularity. And some with pica behavior may ingest non-food items that can cause bowel blockage. 

Behavioral Discussion

When we work with people with limited or idiosyncratic communication skills who exhibit acute changes in behavior (considered odd or not acting right), we always want to know if the behavior has occurred before. For Ron, has this change in positioning/posturing behavior happened before? If so, what was the outcome or resolution? Was there a clear cause and specific intervention that led to the end of the positioning behavior (and resolution of the underlying cause)? This is a classic example of “the best predictor of future behavior is past behavior.”  

We service providers frequently hear “think medical first,” but what exactly does this mean? One way of thinking medical first is observing if the acute behavior is focused on a specific area of the body. Ron bringing his knees to his chest compresses his abdomen, which gives us a clue that we should focus on that area. Is there also a logical reason for the behavior? Although Ron bringing his knees to his chest in a seated position is “odd,” it can relieve pressure by promoting gas relief and/or a bowel movement. Another way of thinking from a medical point of view is noting the connection between avoiding food and not having bowel movements. In this scenario, I often think, “Well, something is going on between when it goes in and when it comes out. 

Should we start following the path from the bottom or the top?!”  

For Ron, behavioral interventions to manage future constipation could include simple communication strategies and toileting logs. If Ron doesn’t have an effective way of communicating pain or discomfort, it would be beneficial to teach him a basic sign or gesture to help him communicate  if he does not feel well in any scenario. Regarding toileting logs, keeping simple documentation of bowel movements can help identify potential constipation issues early to prevent more severe gastrointestinal concerns, such as fecal impaction.  

Outcome

The nurse knew that Ron had bouts with constipation in the past and usually had similar behaviors when he did. After confirming a rectal fecal impaction, his physician recommended an enema and a short-term laxative. He also recommended a consultation with a dietician to slowly increase his diet’s fiber content and fluid intake. This is important as increasing fiber alone could make constipation worse. Within a few weeks, his fiber and fluid intake had increased to the recommended range, and his recurrent bouts of constipation resolved. Not surprisingly, his overall demeanor was more positive as well. 

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 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, 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.