You were right to have her see a doctor. In our experience,
incontinence in a person after years of independent toileting
is almost always indicative of a medical problem. Because her
doctor could not find a medical reason does not mean that there
isn’t one. Unfortunately, doctors familiar and comfortable
with providing care for persons with developmental disabilities
are relatively hard to find. It is not uncommon for many physicians
to attribute all behavior in persons with mental retardation
to attention seeking, if there is no obvious medical condition.
If these accidents don’t resolve soon we recommend seeking
another medical opinion.
Another line of inquiry important to pursue is the possibility
of physical, psychological, or sexual trauma. The sudden appearance
of toileting problems with no history may be suggestive of abuse.
Could this person have been victimized? We encourage you to
investigate this carefully.
Did the onset of these toileting accidents follow a time when
someone provided an inordinate amount of attention for a single
occurrence? Is there an increase in other behaviors that appear
“attention seeking?” If not, we would further doubt
this is happening solely for the attention it receives.
We recommend conducting a functional assessment of the behavior
in order to better understand the environmental variables that
may be influencing this woman’s toileting accidents. Your
psychologist will probably begin this process. If he or she
doesn’t, you may want to suggest it. It is possible the
behavior is related to a medical condition but not caused by
that condition, which would suggest a number of possible reasons
for it. For instance, she may feel bodily discomfort that is
relieved by spontaneous urination. She may have a physical or
emotional condition (i.e. anxiety or depression) that masks
or causes her to misread the bodily signals that cue the need
to urinate. Her toileting may have been dependent on specific
people or other features of the environment that have recently
changed. The toileting accidents may have been initially caused
by a physical problem and then come under the influence or control
of environmental events. Toileting “accidents” may
also provide an escape from odious tasks and anxiety producing
events. There are any number of possible explanations for the
behavior. A thorough functional assessment will point you in
the proper direction.
The functional assessment will answer questions you must ask
in order to support this person in a meaningful and effective
way.
• Where does the incontinence occur? Where does it never
occur?
• When does it occur? When does it never occur?
• Who is present when it occurs? Who is never present
when it occurs?
• Are there any recent dietary changes that could be affecting
her toileting?
• What is happening in the environment immediately before
the incontinence?
• What happens after the incontinence? What are the consequences?
Not just consequences mediated by the staff, but other consequences
that occur without the staff’s knowledge or control.
• Does the behavior occur despite your prompting her to
use the toilet at appropriate intervals? A
global review of this woman’s circumstances should also
be undertaken. Do the activities in her life provide meaning?
Is there opportunity for friendship and enjoyable activity?
Does she find her work rewarding? Does she have the opportunity
to exercise power and make choices? These are critical lines
of inquiry when deciding how best to support someone.
Let’s say you conduct a thorough investigation of the
behavior and, against all odds, the physician is correct and
the toileting accidents are maintained primarily by attention.
What does this suggest? First, remember that a reinforcer
like attention functions most powerfully when the person is
relatively deprived of it. That should prompt you to examine
your service setting closely. Why would this person have to
resort to such behavior in order to gain attention? Ensuring
adequate attention and relationship throughout her day will
not only encourage the behaviors you wish to see but will
reduce the power of attention to reinforce the behavior of
concern. |
