The link between somatic conditions and challenging behaviour
It seems clear that there is a link between somatic conditions and challenging behaviour. However, people often fail to see that challenging behaviour can be caused by somatic conditions for a number of different reasons.
The diagram below shows how this works.
Somatic condition [...]
Undisputed link
Somatic conditions can be a major cause of problem behaviours such as self-harming or aggressive behaviour in people with an intellectual disability. The literature review commissioned by the CCE also shows that somatic disorders can play a role in problem behaviour in children and adults with intellectual disabilities. It was found that urinary incontinence, severe pain related to spasticity, sleep disorders and visual impairments are related to a high probability of problem behaviour. The link with reflux disorders, certain forms of epilepsy, early dementia and discomfort during certain periods of the menstrual cycle was not fully proven but it is probable.
The connection was not investigated for other somatic disorders but it makes sense to assume it is present because many somatic disorders are accompanied by physical discomfort and pain. A physiological response to discomfort and pain is an increase in stress levels which is seen as a change in behaviour. Behaviour as an expression of stress can be effective (others see clearly what is bothering someone). But behaviour can also be ineffective. It will not be clear (in the short or long terms) where the problem lies. For example when someone is irritated, regurgitating or injuring himself or herself. This unexplained behaviour may be physically or psychologically harmful and/or disturbing for the people concerned or the people around them, and it may be an obstacle to involvement in social life. It is then considered to be problem behaviour.
The DSM V, the diagnostic and statistical manual of Mental Disorders, fifth edition, is a taxonomic and diagnostic tool published by the American Psychiatric Association.
A Dutch study of all adolescents with intellectual disabilities in the provinces of Groningen and Drenthe shows that the risk of behaviour problems is almost twice (1.99 times) as high in adolescents with one or more somatic disorders than in adolescents without any somatic disorders.
The link between somatic conditions and problem behaviour is undisputed.
Symptoms
Some symptoms can be seen by the person concerned but also by others. Severe shortage of breath or blood loss, for example. These are visible symptoms.
Examples of visible symptoms:
- Pain (this is sometimes – but more often not – seen by others and it is therefore also listed as a concealed symptom)
- Fever, sweating, fainting, swollen glands, fatigue
- Blood, pus, swelling, itching, skin abnormalities
- Soreness, irritability, restlessness, sleepiness*
- Discharge from eye, ear, vagina, anus
- Weight loss, weight gain, swallowing problems, vomiting, belching, bad breath, jaundice, diarrhoea, hard stools, swollen abdomen, incontinence
- Shortage of breath, coughing
- Limited movement, fractures, dislocated joints, loss of strength, loss of function, convulsion
(* These four symptoms are admittedly visible but they can be attributed to the intellectual disability and not to a somatic disorder. There is therefore diagnostic overshadowing.) Some of the visible symptoms listed here – such as swollen glands, fatigue, itching, shortage of breath and loss of strength – will only be seen on close observation.
Other symptoms are hidden and they will only be perceived by the person concerned and not by others, or hardly so (at best when the person in question is being closely observed). Palpitations and problems with vision are examples here. These are hidden symptoms.
Examples of hidden symptoms:
- Pain: including toothache, earache, sore throat, stomach-ache, abdominal pain, chest pain, headache, back pain, pain in the arm, leg, hand or foot, pain in the anus, menstrual pain
- Feeling generally ill (malaise), being cold, being warm
- Dizziness, lightheaded feeling, unsteadiness, fainting
- Fatigue, lethargy, nervousness, depression, anxiety, insomnia
- Tinnitus, impaired hearing, excessive earwax build-up, impaired vision, loss of field of vision, visual sensations such as flashing lights in migraine, changes in taste or smell
- Nausea, lack of appetite, heartburn, bloated feeling, constipation, difficulty urinating
- Heart palpitations, hot flushes
- Muscular spasm, muscle aches, muscle weakness, inability to walk long distances, stiff feeling, tingling
All concealed symptoms are highly likely to be missed by others. Possible observation depends on:
- the ability of the person concerned to express the complaint effectively,
- the severity of the symptom (the greater severity, the higher the probability of observation),
- the alertness of the observer
Expression of complaints [...]
Nevertheless, for several reasons, people often fail to see that problem behaviour can be explained by a somatic disorder.
Why are complaints not expressed?
Depending on the severity of the intellectual disability, the client cannot describe the symptoms effectively or adequately. There are several possible reasons for this:
- reduced awareness: signals from the body (for example pain or discomfort) may be identified differently by the person concerned.
- reduced insight: the insight into the condition is reduced due to limitations in the knowledge of the person concerned.
- problems with communication: factors such as cognitive development, socio-emotional development, a sensory problem, autism and anxiety can have an adverse effect on the communicative skills of the person concerned.
- atypical expression of problems with health: examples are withdrawal, aggression, self-harming associated with constipation rather than indicating that defecation is painful, a bloated sensation and abdominal cramps.
- a change in awareness and confusion as a result of a medical condition (as in delirium), as a result of which the people concerned can no longer adequately express their complaints.
Observation by others
- The symptoms and complaints are not recognised by others. See visible and hidden symptoms. The level of failure to recognise conditions depends on the nature of the symptoms, how others communicate with the person concerned, the nature of the behaviour, familiarity with the person concerned, and the experience and training of others.
- An atypical expression of problems with health: examples are withdrawal, aggression, self-harming associated with constipation rather than indicating that defecation is painful, a bloated sensation and abdominal cramps.
- Because the symptoms of a somatic disorder are observed but are attributed to the intellectual disability rather than to a medical condition (diagnostic overshadowing).
- The symptoms and complaints are not recognised by others. See visible and hidden symptoms. The level of failure to recognise conditions depends on the nature of the symptoms, how others communicate with the person concerned, the nature of the behaviour, familiarity with the person concerned, and the experience and training of others.
- An atypical expression of problems with health: examples are withdrawal, aggression, self-harming associated with constipation rather than indicating that defecation is painful, a bloated sensation and abdominal cramps.
- Because the symptoms of a somatic disorder are observed but are attributed to the intellectual disability rather than to a medical condition (diagnostic overshadowing).
Others respond
- The people who come into contact with the person concerned (the parents, carers, treatment team or general practitioner) are fully aware of the client's medical condition but they may not be aware of the possible relationship with problem behaviour and they will therefore 'treat' the problem behaviour.
- Because the symptoms of a somatic disorder are observed but are attributed to the intellectual disability rather than to a medical condition (diagnostic overshadowing).