Unlocking Behaviors: Vision Changes
By Ley Linder, MA, M. Ed, BCBA and Craig Escudé, MD, FAAFP, FAADM
This article is part of a co-authored series on behavioral presentations in which a physician and a behavior analyst provide insight into real-life case studies to share their expertise on how behavioral issues can be addressed in an interdisciplinary fashion. Dr. Escudé and Ley are the proud recipients of the 2024 AADMD Excellence in IDD Journalism Award for this ongoing series.
Freddie is a 53-year-old man with a moderate intellectual disability who has been living in a group home for the last 22 years. He does not use words to communicate. He has always been known to be quiet and “to himself” but typically interacts well with others. He has been exhibiting aggression lately. He always enjoyed looking at magazines, especially those with pictures of animals, but recently, after flipping through them for just a minute or two, he would seemingly become agitated and throw them at the wall. Freddie often drew pictures of dogs and horses, which he loved. Lately, the quality of his drawings became more simplistic, and sometimes, it was hard to tell if he drew a horse, a dog, or something else.
Another favorite activity for Freddie is going to church. He still seemed to want to go, but when he arrived, he appeared almost fearful when approaching the building, which required going up about eight steps.
Medical Discussion
When someone does not use words to communicate, physiological changes often present as behavior changes. Many of us, as we reach the age of 40, begin to have difficulty with our eyes being able to focus on objects that are close to us. This could account for Freddie's frustration with being able to see pictures in magazines and the change in his drawings. As people age, cataracts can also develop, accounting for additional vision changes that may affect depth perception, fading of colors, sensitivity to light, and poor night vision. His hesitancy in going up steps at church could be related to his inability to see the steps enough to feel confident about navigating them.
“Many of us, as we reach the age of 40, begin to have difficulty with our eyes being able to focus on objects that are close to us. This could account for Freddie’s frustration with being able to see pictures in magazines and the change in his drawings. ”
Behavioral Discussion
In discussions regarding behavioral presentations, it is always noteworthy if a person has begun refusing highly preferred activities, changed their routine, or started showing differences in their daily life. Colloquially, people are creatures of habit and comfort, where breaking from their preferred habits and activities is a good indication that something has changed! For Freddie, these changes are related to preferred activities, both independent leisure activities at home and social events in the community, which indicate they are occurring across people and settings. When behaviors occur across settings, people, and time, it can increase the likelihood of a person experiencing a medical or health concern.
In Freddie’s case, the changes were noticed during preferred activities, as he was having difficulty drawing and coloring, but also navigating steps in the community. How could these two dynamics be connected? If behavior changes are related to global functioning, there are likely instances of changes in other areas of Freddie’s life, although potentially more subtle. For example, is Freddie having difficulty at mealtimes, in the bathroom, getting in/out of a vehicle, or at work? When behavioral changes are seen across settings, people, and time, a closer examination of the similarities and patterns of change can help specify potential areas of need.
Outcome
Freddie was evaluated by an ophthalmologist and fitted with glasses that improved his vision. His interest in drawing and magazines returned, and his aggression resolved. Interestingly, his hesitancy in entering the church did not improve. After further investigation, it was discovered that he experienced a negative situation where a group of teenagers teased him. A meeting was set up with the preacher, the teenagers, and Freddie, and the situation improved to the point where Freddie felt comfortable going into the church, and the teenagers became some of his best friends.
About the Authors
Ley Linder is a Board-Certified Behavior Analyst with an academic and professional background in gerontology and applied behavior analysis. Ley’s specialties include behavioral gerontology and the behavioral presentations of neurocognitive disorders, in addition to working with high-management behavioral needs for dually diagnosed persons with intellectual disabilities and mental illness. He works closely with national organizations such as the National Down Syndrome Society and the National Task Group on Intellectual Disabilities and Dementia Practices. He is the Founder/CEO of Crescent Behavioral Health Services based in Columbia, SC.
Dr. Craig Escudé is a board-certified Fellow of the American Academy of Family Physicians and the American Academy of Developmental Medicine and President of IntellectAbility. He has more than 20 years of clinical experience providing medical care for people with IDD and complex medical and mental health conditions. He is the author of “Clinical Pearls in IDD Healthcare” and developer of the “Curriculum in IDD Healthcare,” an eLearning course used to train clinicians on the fundamentals of healthcare for people with IDD.