Unlocking Behaviors: Medication Effects
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 the proud recipients of the 2024 AADMD Excellence in IDD Journalism Award for this ongoing series.
Teresa is a 38-year-old female with a diagnosis of moderate intellectual disability (ID). She rarely uses words to communicate but does use words like “Oww” to indicate pain, “tired,” sleep,” and “eat,” as well. She has a history of high blood pressure and has taken daily medication for it for the last 3 years.
“Teresa was prescribed erythromycin, which is particularly known to cause nausea. Teresa’s “Oww” was at first related to her foot pain, but later was her attempt to indicate that she was nauseated. ”
She dropped a glass in the kitchen and sustained a cut to her left foot that required stitches to repair. A few days later, the wound appeared very red and began to drain a bit of pus. She was seen by her local nurse practitioner who started her on an antibiotic for the infection. It took a while, but the infection finally cleared up after a 2-week course of antibiotics. When the infection started, she would say “Oww,” which the staff interpreted as her indicating that her foot was in pain. After she started the antibiotic, her foot appeared to be improving, but she continued to say, “Oww.” She began to get agitated at times. She did not want to go into the kitchen anymore where the accident occurred. It was noted that she was seemingly more agitated around mealtimes. She later began throwing her plate on the floor and yelling, “Oww.” She did not eat much and lost a couple of pounds over the following week or so.
Medical Discussion
Teresa began to have behavior changes after the accident and the subsequent repair of her injury. These changes progressed when her foot became infected, and she was in pain. The changes may not seem abnormal, but what was unusual, however, was that even after the infection seemed to be improving, her aggression around mealtimes worsened.
What changed, you might ask? She was started on an antibiotic. Medications can have many different side effects, one of which is nausea. Teresa was prescribed erythromycin, which is particularly known to cause nausea. Teresa’s “Oww” was at first related to her foot pain, but later was her attempt to indicate that she was nauseated. When that was not recognized, she began to avoid the dining table, throw her food, and become aggressive around mealtimes.
Any time a new medication is started for any reason, or the dose of a routine medication is increased, all staff should be made aware of the medication change, and the person should be monitored for 2-3 weeks for any signs of behavioral changes.
Behavioral Discussion
When reading of Teresa’s injury, one of the primary concerns is not actually a behavioral issue. Under any circumstance, if a person is noted to have unintentional weight loss, this needs to be considered a medical concern. There are times when there can be behavioral components to unintended weight loss, but this occurrence should always prompt the inclusion of medical professionals in the interdisciplinary team discussion.
From a behavioral standpoint, it is worth considering if Teresa has generalized her use of the phrase “Oww” from a specific ailment (e.g., a laceration) to more general feelings of discomfort, such as feeling nauseous. It can be inherently difficult for a person with limited expressive verbal communication skills, such as Teresa, to make it known they are feeling bad when the symptoms are not visible to a caregiver. This can lead to generalizing communication skills that are effective under one condition to other conditions.
Lastly, it is important to recognize how people’s routines and personal baseline are impacted through the course of various medical treatments and/or changes in medications. As Teresa heals and begins to feel better, she will likely return to her preferred activities and preferences. If Teresa continues to avoid certain foods, routines, and activities, it can be an indication that she is still recovering, is experiencing side effects, or the treatment is not effective.
Outcome
When Teresa completed her course of antibiotics, she was noted to begin eating again and was no longer aggressive around mealtimes. It wasn’t until then that her support staff recognized the medication side effect was the likely cause of her agitated behavior. The team has now instituted a monitoring protocol to be used when anyone in support starts a new medication. Are you doing this in your program?
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.