How should I manage a 15-year-old autistic girl with intellectual disability who repeatedly inserts her hands into her pants, has a prior negative urinalysis, and is currently on fluconazole (Diflucan)?

Management of Repetitive Hand-to-Genital Behavior in an Autistic Adolescent with Intellectual Disability

This behavior requires a structured behavioral intervention approach first, with discontinuation of the unnecessary fluconazole, followed by systematic assessment for underlying medical causes and psychiatric comorbidities before considering any pharmacological intervention. 1

Immediate Actions

Discontinue Inappropriate Medications

• Stop the fluconazole (Diflucan) immediately, as there is no evidence of fungal infection (negative UA) and antifungal therapy has no role in managing behavioral symptoms in autism or intellectual disability. 1
• Discontinue the AZO (phenazopyridine) as well, since the urinalysis was negative and there is no indication for urinary analgesic therapy. 1

Rule Out Medical Causes First

Before attributing this to behavioral or psychiatric issues, systematically evaluate for physical discomfort that she cannot verbally communicate:

• Assess for genital/urinary sources of irritation: vulvovaginitis, urinary tract infection (repeat UA if symptoms suggest infection), constipation causing pelvic pressure, menstrual issues, or dermatologic conditions causing itching. 1, 2
• Evaluate for other pain sources: dental problems, ear infections, gastroesophageal reflux, or occult injuries that may manifest as self-soothing behaviors in nonverbal individuals. 1, 2
• Review all current medications for side effects that could contribute to behavioral dysregulation or physical discomfort. 2

First-Line Behavioral Interventions

Functional Behavioral Assessment

• Conduct a functional analysis to determine what reinforces this behavior: Is it sensory stimulation, attention-seeking, escape from demands, or communication of an unmet need? 1
• The American Academy of Child and Adolescent Psychiatry explicitly recommends function-based behavioral interventions tailored to the specific reinforcement maintaining the behavior. 1

Applied Behavior Analysis (ABA) Techniques

• Implement ABA strategies that have demonstrated efficacy for problem behaviors in individuals with intellectual disabilities. 1
• Teach alternative appropriate behaviors that meet the same functional need—for example, if the behavior serves a sensory function, provide alternative sensory outlets such as fidget toys, textured objects, or occupational therapy devices. 1
• Use visual schedules and social stories appropriate to her developmental level to teach privacy concepts, appropriate versus inappropriate touching, and social boundaries. 1

Structured Socio-Sexual Education

• Provide developmentally appropriate sex education covering privacy, appropriate places for self-touching (if sensory-driven), consent concepts, and social boundaries. 1
• This should be individualized to her cognitive and adaptive functioning level, not her chronological age. 1

Caregiver Training

• Train all caregivers and school staff on consistent behavioral strategies, recognizing triggers, and providing appropriate redirection without inadvertently reinforcing the behavior through attention. 1
• Ensure communication systems are optimized across all settings, as limited communication ability can frustrate individuals and exacerbate behavioral symptoms. 2

Assessment for Psychiatric Comorbidities

Screen for Common Co-occurring Disorders

Psychiatric disorders occur at least three times more often in children with intellectual disability than in typically developing children. 3

• ADHD: Particularly high rates in this population; inattentive symptoms do not typically decrease in adolescence as they do in typically developing teens. 3
• Anxiety disorders: Very common and may manifest as repetitive behaviors or self-soothing actions rather than typical worry symptoms. 3
• Mood disorders: Depression can present atypically in adolescents with intellectual disability, particularly those with higher functioning. 3
• Trauma history: Individuals with intellectual disabilities have significantly elevated risk for victimization; behavioral symptoms may represent trauma responses. 1

Avoid Diagnostic Overshadowing

• Do not attribute all behavioral symptoms to the intellectual disability itself—this delays appropriate psychiatric treatment. 2
• Recognize that psychiatric illness may present atypically through behavioral changes rather than verbal complaints. 2

Pharmacological Intervention (Only if Behavioral Approaches Fail)

Criteria for Medication Consideration

Medication should only be considered when: 1

• Behavioral interventions have been implemented consistently and failed to provide significant improvement
• There is risk of harm to self or others
• The behavior risks loss of access to essential services (school, residential placement)

First-Line Pharmacological Option

• Sertraline 25-50mg daily, starting at the lower end and titrating slowly, as individuals with intellectual disabilities may have heightened sensitivity to medication side effects. 1
• Alternative SSRIs (fluoxetine) can be considered if sertraline is not tolerated, following the same "start low, go slow" principle. 1

Critical Caveat

Psychotropic medications should never be used as a substitute for appropriate behavioral services—this violates evidence-based practice guidelines and exposes patients to unnecessary medication risks. 1

Specialized Referral Indications

• Refer to a psychiatrist specializing in intellectual disabilities if symptoms remain treatment-refractory despite behavioral interventions and appropriate medication trials. 1
• Engage developmental-behavioral pediatricians who can provide comprehensive assessment of medical, developmental, and behavioral factors. 1
• Coordinate multidisciplinary teams including psychology, social work, occupational therapy, and case management to address complex biopsychosocial factors. 1

Common Pitfalls to Avoid

• Do not prescribe medication without first attempting behavioral interventions—this is the most common error and violates evidence-based guidelines. 1
• Do not use chronological age (15 years) as the reference point for expected behavior; compare to her developmental age and baseline functioning. 1
• Do not overlook caregiver stress and burnout, which can trigger or exacerbate behavioral symptoms in individuals with intellectual disability. 1
• Do not assume the behavior is purely sexual in nature—it may represent sensory-seeking, communication of discomfort, anxiety management, or other functions. 1