Introducing the World’s Crappiest Behavior Analyst

In the movie Forrest Gump, Bubba Blue was Forrest’s best friend and the enterprising shrimp aficionado who helped create a multi-million-dollar shrimp boat business.  Remember how much Bubba knew about shrimp?  Well, you can call me “Bubba Blue the BCBA,” because I know just as many things about behavior!  Well, at least related to one specific topic area – poop!

Feces smearing.  Rectal digging.  Constipation.  Diarrhea.  Irritable Bowel Syndrome (IBS) with constipation.  IBS with diarrhea.  IBS with constipation and diarrhea.  Impaction.  Hemorrhoids.  Parasites.  Worms.  Ovum.  Bloody stool.  Defecating in the shower.  Defecating in the trash can.  Not defecating.  Suppositories.  Miralax.  Too much Miralax.  Why does a person need two stool softeners and a laxative twice a day anyway?

Maybe you should just call me the world’s crappiest behavior analyst – it would be apropos and not besmirch Bubba’s good name.  Let me be clear, this was not the moniker of my dreams, but sometimes destiny sneaks up on a person. 

I Know a Lot About Crap and the Problems It Can Cause

I have earned this title out of necessity because the number of behavioral problems originating from preventable and/or manageable gastrointestinal conditions is alarming.  Gastroesophageal Reflux Disease (GERD), constipation, and hemorrhoids are prime suspects.  

Dehydration and impaction cause a tremendous amount of worry.  Worms, parasites, and H. pylori are silent assassins.  My empirically-based assertions are supported from sources such as the Center for Disease Control, which in a 2016 report noted seven causes of death that are more prevalent in the Intellectual Disability and Related Disabilities (ID/RD) population (as compared to the general population).  

Third on the list? Intestinal obstruction and GERD (Landes et al., 2021).  GERD, as a cause of death!  Unbelievable!

It’s Hard to ‘Think Medical First’ When There’s Poop on the Wall 

As behavior analysts, frequently we are taught and trained to “think medical first”, but what exactly does this mean?  

How do you think medical when the presentation is “John has smeared feces all over the bathroom and himself for the third day in the row.  I still can’t get it out from under his fingernails” or, “It took us 3 hours to clean the walls of his bedroom after the explosion.” 

Or the clubhouse leader, “I walked in and ‘Oh, my heavens.  It was in their mouth.” All of these comments culminate in a routine battle cry, “Call Ley!  He’s not going to believe this (insert appropriate pun of your choice)!”

As an example, if a person with profound intellectual disabilities and limited verbal communication skills is experiencing discomfort from a gastrointestinal issue, such as constipation, they may try to resolve the problem themselves.  

Most people are able to identify the area of the body they are experiencing discomfort and recognize the cause of the problem. In our example, it is their anus and the inability to defecate.  

A logical solution, in their mind, is to attempt to manually dislodge or remove the feces from their rectum.  This action can lead to the person having feces on their hand(s) and their (logical) thought is, “I do not want this on my hands.  I need to get it off,” which results in them smearing and wiping the feces on the closest available surface. Generally, this is themselves, walls, sinks, cabinets, shower curtains, bath mats, and floors.  Inevitably, this situation is made worse by the inadvertent touching of every surface in the room.

There’s an Underlying Issue Within the Underlying Issue

Ley, thanks for your beautiful description, but how would you suggest resolving this issue?  Thanks for asking, Reader!  

It is not uncommon for behavioral presentations to be the result of undiagnosed/untreated medical conditions in conjunction with learned behaviors that actually have logic in their engagement (as we have just seen).  

A person engaging in feces smearing is highly likely to have some key behaviors occurring before this behavior.  The presenting behavior is not always the key behavior (although perhaps the most offensive) and I, as a behavior analyst, am tasked with looking at all of the behaviors that occur.  

Once we have noted all identifiable behaviors it can help with presenting the behaviors to medical professionals, such as nurses, primary care physicians, gastroenterologists, and all other multidisciplinary team members.

Over time, just as in behavioral presentations, patterns have developed in “gastrointestinal behavioral presentations”.  Below is a short list of the more common behaviors that can help multidisciplinary teams find the link between behavior presentations and medical conditions:

Rectal digging (usually precedes feces smearing) 

• Key suspect(s): constipation, impaction, other anal irritation

Rectal digging occurring at night 

• Key suspect(s): Worms, ova, parasites

Blood in the bathroom/toilet/clothing 

• Key suspect(s):  Hemorrhoids, rectal digging

·Refusal to eat, unplanned weight loss 

• Key suspect(s): GERD, H. pylori

Eating inedible items, such as flooring, drywall, paper (PICA)

• Key suspect(s): GERD, iron deficiency

Vomiting with refusal to eat, pain, & guarding abdomen

• Key suspect(s): Bowel obstruction, impaction

All of Ley’s work is original and no form of AI was used to write this blog. 

This piece originally appeared in HELEN as part of Ley’s co-authored series on “Unlocking Behaviors.”

Never disregard professional medical advice or delay seeking medical treatment because of something you have read in this article.