Health and Problem Behavior Among People With Intellectual Disabilities (2024)

Abstract

Good health significantly improves a person's quality of life. However, people with intellectual disabilities disproportionately have more health problems than the general population. Further complicating the matter is that people with more severe disabilities often cannot verbalize health complications they are experiencing, which leads to health problems being undiagnosed and untreated. It is plausible these conditions can interact with reinforcement contingencies to maintain problem behavior because of the increased incidence of health problems among people with intellectual disabilities. This paper reviews common health problems influencing problem behavior and reinforcement processes. A clear implication of this review is the need for comprehensive functional assessments of problem behavior involving behavior analysts and health professionals.

Keywords: functional assessment, health problems, intellectual disabilities, problem behavior

Health problems are illnesses, injuries, impairments, or physical conditions negatively affecting a person's quality of life (World Health Organization, 2000). In general, health problems among people with intellectual disabilities (ID) are similar to those in the general population, although certain health conditions are more prevalent among the ID population (; ; ). Some of the more common health conditions among people with ID include motor deficits, epilepsy, allergies, otitis media, gastroesophageal reflux disease (GERD), dysmenorrhea, sleep disturbances, seizure disorders, mental illness, vision and hearing impairments, oral health problems, and constipation (; Kennedy et al., 2007; ; ). Further complicating the issue is that the more severe the disability, the less likely health problems are to be diagnosed and treated (; ). Undiagnosed and/or untreated health problems may reduce a person's life expectancy and contribute to the development of secondary health complications (; Piazza et al., 2003).

There is emerging evidence from the behavior-analytic literature that health problems may also contribute to increases in problem behavior among people with ID. For example, O'Reilly (1997) showed that the self-injury of a boy with ID occurred to reduce ambient noise when otitis media symptoms (inflammation in the middle ear) were present, but these behaviors did not occur when he was free of otitis media symptoms. Similarly, researchers have shown that food refusal in children with pediatric feeding disorders is often correlated with the presence of oral-motor deficits and/or GERD (; ). Treatment packages often include health and oral-motor interventions aimed at reducing the health problems and behavioral interventions aimed at increasing food intake (or reducing problem behaviors emerging around mealtime).

Symptoms of a health problem are initially treated with health interventions once they are identified. However, ignoring the reinforcement contingencies could result in problem behavior being socially reinforced in the absence of the health problem (; Piazza et al., 2003). For example, Carr and McDowell (1980) reported the case of a child with ID who began scratching himself in response to a skin allergy; the scratching was likely maintained by automatic reinforcement. After remission of the allergic reaction, scratching continued because the behavior acquired a social reinforcement function (i.e., positive reinforcement in the form of access to attention). In other words, although health problems can influence rates of problem behavior, problem behavior may persist in the absence of the original health problem.

It is becoming increasingly clear that, in some cases, comprehensive assessments and treatments are necessary to attenuate the influence of health problems on rates of problem behavior. However, behavior analysts are not trained to diagnose and treat health problems, and health professionals do not have the expertise in applied behavior analysis to identify response-reinforcer relations. Therefore, comprehensive assessments should be a collaborative effort between these professionals. The following sections describe how comprehensive functional assessments can identify interactions between common health problems and reinforcement contingencies influencing problem behavior in persons with ID.

How Can Functional Behavior Assessment Identify Health Problems?

Best practices in the assessment and treatment of problem behavior in a variety of clinical populations have changed with the development of functional behavior assessment (FBA) technologies (; Tasse, 2006). An FBA is a problem-solving strategy for identifying the contextual factors associated with problem behavior and consists of record reviews/interviews, descriptive assessments, and experimental analyses (). In other words, a behavior analyst identifies the stimulus controls, motivating operations, and response-reinforcer relations altering the rate, variability, topography, and/or intensity of problem behavior. Treatments are then derived from the FBA addressing antecedent events influencing and/or consequent events maintaining problem behavior.

Episodic variability in problem behavior may lead to the systematic monitoring of health symptoms such as excessive sneezing, bowel movements, or sleep patterns, which in turn may lead to the identification of a previously undiagnosed health problem. Symptoms related to a variety of health problems, whether acute or chronic, can produce unique patterns of problem behavior. Thus, FBAs are conducted at times when the health problem is present, and when it is absent (). During some FBAs, the problem behavior occurs only in the presence of the health problem. For example, Kennedy and Thompson (2000) tracked symptoms related to GERD (i.e., heartburn and regurgitation) in a man with ID while conducting an FBA. Results showed that the self-injury followed mealtimes producing GERD symptoms. When treated with antacids, this pattern of problem behavior following mealtimes was eliminated.

During other FBAs, problem behavior is present even when the person is healthy, but intensifies when the person is ill. For example, O'Reilly (1995) analyzed the aggression of a man with frequent night awakenings. O'Reilly tracked the sleep patterns of the individual while conducting functional analyses. On days when the man slept five or more hours, aggression was infrequent when demands were placed on him. When the man slept less than five hours, aggression occurred more frequently to escape demands placed on him.

There are at least three temporal patterns in which the onset of health problems can influence response rates during FBAs. Health problems can occur multiple times per day (e.g., heartburn after food ingestion) with a sudden onset or exacerbation of problem behavior being observed at each onset of the health problem (). The temporal onset of the health problem may be cyclical over shorter time periods (e.g., sleep disturbances), which may correspond to the onset or exacerbation of problem behavior in the presence of aversive environmental events (; O'Reilly, 1995). Finally, the effects of health problems can build up over longer time periods (e.g., constipation) with problem behavior becoming more and more likely as health symptoms worsen in the presence of aversive events (Christensen et al., 2009). These three temporal patterns of health problems can also be classified as acute symptomatology, in which sudden onset of the health problem is accompanied by relatively rapid remission of symptoms when treated, or chronic symptomatology, in which health problems are persistent over time and may progressively worsen if untreated.

How Does Health Affect Problem Behavior?

Health problems can alter behavior-consequence relations responsible for the development and maintenance of problem behavior in two distinct ways (; ; ). First, the health problem may alter the value of a particular reinforcer. For example, the discomfort associated with otitis media may increase the value of escape from loud noises or other environmental events that produce vibrations contacting the individual's eardrum. Similarly, environmental events typically effective as positive reinforcers could be rendered ineffective for evoking appetitive behaviors. Second, because of the value-altering effect the health problem has on a particular reinforcer, a response associated with the reinforcer becomes more or less likely to occur. For example, head hitting may increase because it has temporarily relieved pain associated with otitis media in the past. Similarly, on-task behavior, a response maintained by edibles, may decrease when GERD symptoms are present because the pain interferes with or abolishes the value of the positive reinforcer.

In most cases, health problems establish certain stimuli as noxious and increase rates of negatively reinforced behavior (although noxious stimuli can alter the value of positive reinforcement, as mentioned above). However, health problems alone do not determine whether or not problem behavior is maintained by environmental events. The following sections review health problems empirically demonstrated to interact with reinforcement contingencies to affect rates of problem behavior in people with ID.

Can Other Health Conditions Influence Reinforcement Contingencies?

There is emerging evidence of other health conditions that, under appropriate circ*mstances, may contribute to problem behavior. For example, mental illness can occur at any time during a person's lifespan and includes disorders of mood, thought, and/or behavior. The symptoms related to mental illness among people with ID in the United States is estimated at four to five times greater than that diagnosed in the general population (Borthwick-Duffy, 1994; ). However, analyzing mental health and problem behavior is a complex task, mainly due to the tautological tensions inherent in research on the etiological and environmental factors contributing to each. For example, problem behavior is often used as a criterion for psychosis. Thus, when problem behavior occurs, the conclusion is drawn that it must be an atypical symptom of psychosis. But classifying problem behavior as a diagnostic indicator for mental health problems runs the risk of obscuring complex interactions between impaired cognitive, adaptive, and communicative skills associated with the behavior and the controlling features of the environment on the problem behavior. In short, the presence of problem behavior cannot be causally linked to any particular psychiatric diagnosis (Tsiouris, 2003).

In most cases, health problems establish certain stimuli as noxious and increase rates of negatively reinforced behavior.

Nonetheless, problem behavior may be temporally related to the course of a mental illness (). For example, McDougal (2000) used a functional analysis to examine aggression among institutionalized adolescents with mental illness. Antecedent events precipitating aggression included frustrating interactions, activity demands, and interventions by others perceived by the adolescent as an attack. These environmental events lead to increases in negatively reinforced aggression, but only when active symptoms of psychosis were present.

Problem behaviors could also occur in temporal cycles that are indicative of depressive versus manic symptomatology for bipolar disorder (). In the Sovner et al. (1993) study, adults with profound ID and rapid cycling bipolar disorder engaged in aggressive behavior when the individuals were experiencing manic symptoms, or self-injurious behavior when experiencing depressive symptoms. The use of antidepressant medication to treat chronic depression reduced self-injury and the use of restrictive behavioral programming (i.e., mechanical restraint). This study suggests that FBAs can assist in further understanding of behavioral manifestations of mental illness and in determining the effects of interventions on these behavioral manifestations.

Another possibility is that problem behavior may initially be symptomatic of mental health problems, but then be maintained by social reinforcement contingencies (Sigafoos et al., 2003). For example, someone with schizophrenia suffering from hallucinations may perceive that people are trying to attack them, resulting in physical aggression toward others in the environment. The aggression in this case may function to remove the other person, thereby increasing the probability this same behavior will be used to remove other noxious events in the future, regardless of the presence or absence of hallucinations.

However, it also seems possible that some mental illnesses may change the value of particular reinforcers. For example, a depressive phase of bipolar disorder may be associated with an unwillingness to participate in educational activities, establishing escape from the activities as negative reinforcement. Similarly, a manic episode of bipolar disorder may be associated with increased risk-taking behaviors, establishing certain events as more positively reinforcing than usual (e.g., promiscuity, excessive spending, drug taking). More research is needed to isolate symptoms of mental illness associated with problem behavior in people with ID. However, some studies have reported that treatment of conventional psychiatric symptoms improves associated problem behaviors (e.g., ; Sovner et al., 1993).

Some research suggests the seizures related to epilepsy co-occur with problem behavior (; ). Available data suggest that problem behavior may also be more common among people with sensory impairments, oral health problems (dental caries, gingivitis, and periodontal disease), asthma, medical side effects of polypharmacy, influenza, and other health issues (e.g., Jansen et al., 2004; Krahn et al., 2006). However, there currently exists no empirical evidence linking these health problems to problem behavior. It is important to recognize that the impact of such health problems on problem behavior can be assessed under conditions where antecedents and consequences are systematically manipulated as in an appropriate FBA.

Implications for Practice

The development of FBA techniques has allowed researchers to identify a range of variables influencing and maintaining problem behavior. Results from such an assessment can be used to build a behavioral intervention plan to teach the person with ID alternative appropriate behaviors, such as those used to escape from aversive situations. However, a clear implication for practice is that health problems may complicate FBA results, primarily leading to variable and difficult to interpret assessment outcomes. Because health-related conditions are often undiagnosed in people with ID, problem behavior is sometimes assigned a behavioral function unrelated to the health-related circ*mstances. Thus, a behavioral intervention may not be very effective at reducing problem behavior if health problems are not alleviated first. Conversely, the temporal presence of chronic health problems may allow behavior analysts to predict when problem behavior is more likely to increase, and anticipate this increase by taking steps to minimize antecedents and/or consequences related to problem behavior (e.g., decreasing task demands when an individual is sleep deprived or providing frequent breaks when requested).

It would be ill-conceived to assume health conditions affect rates of problem behavior without assessing all relevant variables occurring around the time problem behavior is most likely to occur (; ). However, coordinated effort between health professionals and behavior analysts should be able to isolate the relative impact of health problems and reinforcement contingencies on problem behavior. Once health causes are identified, they can be treated by health professionals before developing function-based interventions, or developed in conjunction with a function-based intervention that addresses the detrimental reinforcement contingency. Interventions with these individuals will usually be multifaceted: targeting the health conditions, teaching functional communication skills, and redesigning the environment to make demanding activities more tolerable or even pleasurable.

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