Unlocking Behaviors: A “Simple” Introduction
By Craig Escudé, MD with Ley Linder, MA, M.Ed, BCBA
Behaviors. We all have them. When we hear the term “behaviors” used in reference to people with intellectual and developmental disabilities, it is usually used to refer to some sort of adverse behavior that is disruptive or dangerous to the person, or a challenge for people who support that person in their life. Understanding what a particular behavior might mean can be the difference between someone getting the help they need and suffering needlessly in so-called silence, sometimes for years. When we understand that behavior is a form of communication, we learn that the person was never suffering in silence. We just didn’t understand what their behavior was communicating.
In this series of articles, you will be presented with a case related to some sort of behavioral issue, followed by a discussion from a medical perspective and from a behavioral analysis perspective. The idea is to help you think outside the box to avoid the infamous trap of “this is just what they’ve always done.” There is a high likelihood that most of us have fallen into this type of thinking, which is a form of diagnostic overshadowing, at some time or another during our careers. Diagnostic overshadowing is when a new behavior or symptom is attributed to the person’s intellectual or developmental disability rather than looking for a treatable underlying cause. It was the subject of the June 22, 2022, Sentinel Event Alert from The Joint Commission. It’s a document certainly worth reading.
Let’s start with one of the most memorable cases of my career.
History
John was a 32-year-old man with a severe intellectual disability who ambulated, could feed himself, needed assistance getting dressed, used the bathroom independently, and did not use words to communicate. There was a new physician who was on his first day at our residential program who was asked to take a look at John because of a new onset of a limp. Upon questioning staff, the limp started that morning when he got up from bed. There was no report of any injury in the preceding hours or days.
Exam
John’s shoes and pants were moved, and there was no evidence of any bruising, swelling, or apparent tenderness with passive or active movement of his hip, knee or ankle. Basically, he had a completely normal exam.
Tests
The new-to-the-job physician ordered an x-ray of the hip, knee, and ankle to look for any possible bone or joint issue that could be causing the limp.
Consultation
Being the “seasoned’ “brilliant” clinician that I was, (hope you are chuckling) I offered one more “examination” for the new doctor to consider. “Let’s take a look at his shoe.”
Inside of John’s shoe was a balled-up sock. I performed an emergency “sockectomy,” and John was miraculously cured of his limp.
Discussion
The moral of the story is “Think Simple First!” Many times, people who do not use words to communicate cannot express things that are quite simple to resolve: pants being too tight causing abdominal pain, resisting wearing an orthotic or CPAP mask because it is ill-fitting, and the like. Think about the simple causes of agitation, behavior changes, or clinical symptoms first and rule them out. Then we can move on to X-rays, CT scans, labs, and other tests and examinations. Plus, if you are the one to figure it out, it can make you look like a genius!
Hope you enjoyed this first “simple” case. The others won’t likely be quite so entertaining, but hopefully, they’ll help to broaden the differential diagnosis for particular behavioral issues and will increase clinical accuracy. My friend Ley Linder M.A, M. Ed., BCBA will be joining me in this series so you’ll get both a medical and behavioral perspective on future cases.
Until next time, “behavior” self!
About the Authors:
Dr. Craig Escudé is a board-certified Fellow of the American Academy of Family Physicians and the American Academy of Developmental Medicine and is the 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 serving as medical director of Hudspeth Regional Center in Mississippi for most of that time. While there, he founded DETECT, the Developmental Evaluation, Training, and Educational Consultative Team of Mississippi. 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.
Ley Linder, MA, M.Ed, BCBA 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.