George is a 49-year-old man with a moderate intellectual disability who communicates with short phrases, comprehends simple verbal communication, and is quite observant of his environment. 

When he moved to his new home approximately 12 months ago, he had a limited medical history, but diagnoses of iron deficiency, allergies, Gastroesophageal Reflux Disease (GERD), constipation, and an unspecified fluid restriction of 1500ml (50 ounces) per day were noted. He also arrived taking seven psychotropic medications, plus another for the side effects of these medications.

Periodically, staff members have reported that George exhibits changes in his behavior, such as staying in the bathroom for long periods, having difficulty walking, and “seeming out of it.”  

In the last month, George had two incidents where he became highly agitated and aggressive towards his housemates and walked away from his home to a convenience store. At the convenience store, he continued to be aggressive toward community members and employees, as well as “chugging gallons of milk,” which is his favorite drink. Law enforcement officers were called on both occasions where George was detained and issued no-trespassing orders. 

George has, once again, been referred to the psychiatrist to address his aggressive behaviors and follow up on the physician’s orders from his visits to the emergency room to address his current behavioral instability. George is seeing a new psychiatric team that declines to increase any medications, advocates for a long-term plan to decrease the number of psychotropic medications, and recommends a global review of his medical and behavioral needs.

The Formula Isn’t Always the Best Approach

We often hear the adage “think medical first” when we are assessing behavioral issues, particularly for people with comorbidities.  There are also the impacts of polypharmacy that are a noteworthy concern when looking at behavioral presentations.  

As a behavior analyst, we are often trained to think of behaviors in a singular, formulaic fashion that focuses on a linear understanding of behavior – setting event > antecedent > behavior > consequence.  However, this process does not always lead to a thorough understanding of complex medical issues.

One way to think medically is to look at the various components that comprise the totality of a person. In George’s case, this would be the behavioral changes (agitation, aggression, elopement, and staying in the bathroom for long periods), cognitive status changes (e.g., “he’s out of it”), physical changes (e.g., gait changes/stumbling), and his medical needs (e.g., diagnosis and medications).  

If only looking at behavioral changes, we, as behavior analysts, would not be accounting for the interconnected and fluid dynamics of all parts of a person that impact behavior.

At times, the goal of behavior analysts is not to solve the problem; rather, it is to understand it.  Our role can be to compile information, utilizing the input of other disciplines, to help the entire interdisciplinary team develop a better understanding of behavioral presentations.  We do this by looking beyond behavior and connecting the dots across the various components that make up a person.   

An IV, Not a Court Date

After the third instance of law enforcement being called, the interdisciplinary team “started over” and began examining all the possibilities that could explain the sudden change in cognitive status and rapid escalation of aggressive behaviors.  

The first question asked by the behavior analyst was, “Why would a person be restricted to only 1500ml of liquid per day?”  

Pulling this thread unwound a long history (not known prior to admission) of George being treated for hyponatremia.  The behavior analyst, with the help of the nursing staff, developed a “behavior symptom profile” of hyponatremia and trained staff to recognize the possible signs.  The next time George displayed the noted behaviors and characteristics, he was taken to the hospital to have his sodium levels checked.  You guessed it.  George needed an IV, not a court date. 

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.