HIDE AND SEEK

1
HIDE AND SEEK

• LOOKING FOR MEDICAL CONDITIONS THAT MAY
  MASQUERADE AS BEHAVIORAL PROBLEMS

2
BEHAVIOR PROBLEM?

• MM is a 24 year old man who has Sturge Weber
  Syndrome. He has a severe developmental
  disability, port wine stain, glaucoma, and
  seizure disorder. He is on a variety of ACMs,
  eye drops, vitamins and bowel aids. Recently he
  has been experiencing severe emotional outbursts
  with damage to property, injury to staff and
  severe self abuse. He complains of headaches
  sometimes. Seizures are relatively poorly
  controlled but this is not new. Recent
  anticonvulsant levels have been in the
  therapeutic range. What could be going on here?

3
BEHAVIOR THE FINAL COMMON PATHWAY

• COMMUNICATION
• BIOLOGIC
• PSYCHOLOGIC
• ENVIRONMENTAL

4
COMMUNICATION

• NONVERBAL
• LIMITED EXPRESSIVE LANGUAGE SKILLS
• LIMITED RECEPTIVE LANGUAGE SKILLS
• USUALLY HISTORY MUST BE OBTAINED FROM A THIRD
  PARTY - PARENT, GUARDIAN OR DIRECT CARE PROVIDER

5
WHY THINK BIOLOGIC?

• Behavior is independent of environment.
• There are associated vegetative symptom
  disturbances.
• Identified triggers are absent.
• Behavior may increase in severity over time as
  condition progresses.

6
BIOLOGIC ISSUES TO CONSIDER

• Specific medical conditions
• Medications
• Drug Allergies

7
SPECIFIC MEDICAL CONDITIONS COMMON DIAGNOSES

• GASTROINTESTINAL
• DENTAL PROBLEMS
• GERD
• CONSTIPATION
• ENDOCRINE PROBLEMS
• THYROID, DIABETES MELLITUS
• SEIZURE DISORDERS

8
SPECIFIC MEDICAL CONDITIONS COMMON DIAGNOSES

• PAIN
• SINUS, TEETH, EARACHES
• HEADACHE
• GLAUCOMA, OTHER EYE PAIN
• FRACTURES
• KIDNEY OR GALL STONES
• GERD

9
SPECIFIC MEDICAL CONDITIONS LESS COMMON
DIAGNOSES

• SLEEP APNEA
• VITAMIN DEFICIENCIES
• INCREASED ICP
• SPINAL CORD PROBLEMS
• HIDDEN ABSCESSES
• FOREIGN BODIES

10
SPECIFIC SYNDROMES

• Down Syndrome
• Fragile X Syndrome
• Congenital Rubella Syndrome
• Sturge Weber Syndrome
• Neural Tube Deficits
• Fetal Alcohol Syndrome

11
MEDICATIONS

• Side Effects
• Drug-Drug Interactions
• Idiosyncratic Reactions and Allergies

12
MEDICATIONS SIDE EFFECTS

• Neurologic paresthesias, seizures, psychiatric,
  movement disorders, headaches,delirium
• Gastrointestinal dry mouth, heartburn, pain,
  constipation, diarrhea, anorexia, bleeding
• Cardiac arrhythmias
• Genitourinary retention, incontinence
• Bone osteoporosis

13
MEDICATIONS DRUG-DRUG INTERACTIONS

• SSRIs
• Anticonvulsants
• Neuroleptics
• GI drugs acid blockers, proton pump inhibitors
• Antibiotics
• Birth Control Agents

14
MEDICATIONS IDIOSYNCRATIC AND ALLERGIC REACTIONS

• BENADRYL can cause hyperactivity
• PHENOBARBITOL can cause hyperactivity
• BENZODIAZEPINS can cause disinhibition
• NEURONTIN can cause disinhibition
• ALLERGIES TO DRUGS CAN CAUSE A MULTITUDE OF
  SYMPTONS FROM RASH TO ANAPHYLAXIS. LATEX GLOVES
  MAY CAUSE PERINEAL REACTION AND LEAD TO RECTAL
  DIGGING OR GENITAL MANIPULATION

15
EVALUATION PROCESS

• History and Physical Examination
• Further Diagnostic Workup
• Consider Therapeutic Trial
• Reevaluation
• Consider multidisciplinary consultation

16
AGING

• Life Expectancy
• Individuals with DD are not immune to common
  chronic medical conditions (cardiac,
  hypertension, endocrine)
• Menopause
• Dementia

17
BEHAVIOR PROBLEM?

• JG is a 34 year old man who has a severe
  developmental disability. He is nonverbal but
  ambulatory and has a seizure disorder. He takes
  multivitamins and depakote. Recently staff has
  noted an increase in maladaptive behaviors
  including increased aggression and self injury,
  disturbed appetite and sleep patterns. His
  seizures seem to be as well controlled as ever.
  He has lost about 12s but was a little obese to
  begin with and looks good. He seems tired but
  hasnt been sleeping well. What could be going
  on here?

18
BEHAVIOR PROBLEM?

• LL is a 30 year old man who has a severe
  developmental disability due to Congenital
  Rubella Syndrome. He is ambulatory but
  non-verbal, deaf, blind and about 30s
  overweight. Recently he has begun to grab food
  from his housemates and wet his pants at his day
  program. Staff are concerned about these
  behavior problems. What should you be concerned
  about?

19
COMING ATTRACTION

• THE FACTS OF LIFE.AND MORE Sexuality and
  Developmental Disabilities
• A free full day workshop presented by Leslie
  Walker-Hirsch, M.Ed
• Feb.2,2000 800am to 430pm
• Lovelace CME Building
• CEUs for nurses, social workers, and counselors