Q. I am a therapeutic foster parent and currently have a 17-year-old male client who lives in my home under 24/7 supervision. He is diagnosed with ADHD and OCD as well as schizophrenia. The only medication he is on is 36 mg of Concerta. His IQ is 72. He has had several episodes in the past year of playing with his feces in the shower and we suspect it is related to masturbation.

Why is he doing this? What would cause him to make these messes? Most of the time he seems quite normal and he does know right from wrong. The agency I am with told me to take him to the hospital for a psych evaluation the next time he does it and I am reluctant to put him through that as he may be placed in some type of institution and his goal is family reunification. I would appreciate any insight you can give.

A. This sounds like a very difficult situation for you, and I appreciate that you want to do the best thing for this client. Playing with, smearing, or even ingesting feces is occasionally reported in persons with mental retardation, schizophrenia, and certain types of brain damage.

The reasons may differ widely. For example, such activities may serve as self-soothing or self-stimulating behaviors for some patients with mental retardation, whereas some individuals with schizophrenia may be responding to delusional beliefs or auditory hallucinations. You certainly may be right that, in a 17-year-old male, this behavior may be related to sexual stimulation. In any case, I have a few suggestions.

First, there are some puzzling aspects about your client's diagnosis and treatment. If he truly suffers from schizophrenia, he is not taking the appropriate medication for it. Concerta is used to treat ADHD, and would not be helpful for schizophrenia--in theory, it could even make it worse. Second, you may need to get some expert advice on how to manage this behavior. For example, what are the consequences of this behavior for your client? Are there clear disincentives to his doing this? Are privileges, such as watching TV, withheld when he plays with his feces? Unless there are clear and consistent behavioral limits set, with clear and consistent consequences for this behavior, it is likely to continue.

If you can obtain a consultation with a behavioral psychologist, that might be a first step. He or she could help you set up an appropriate behavioral therapy program for this client. At the same time, his mental disorders (whatever they really are) must be appropriately treated. Thus, I would certainly advise an outpatient medication consultation with a psychiatrist who has expertise evaluating adolescents with schizophrenia and/or mental retardation. (Although technically, an IQ of 70 or less is required for an MR diagnosis, your client is pretty close to the line).

I think it very unlikely that an elective, outpatient appointment would lead directly to institutionalization of your client, absent some clear and present danger to you, the client, or others. (There is some risk of hepatitis-A being spread via oral/fecal contamination). If you need help getting appropriate support and consultation, I would recommend that you contact the National Alliance for the Mentally Ill (NAMI) at 800-950-NAMI. I hope you can work this out.

March 2003

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