Written by Evette D’Avy Reed, PT
In a study published by the World Journal of Clinical Pediatrics in 2021, it is stated that one of the most common gastrointestinal conditions noted in children with Autistic Spectrum Disorder (ASD) is chronic constipation. Constipation is defined by the CDC as a condition in which you may have fewer than three bowel movements a week; stools that are hard, dry or lumpy; stools that are difficult or painful to pass; or a feeling that not all stool has passed. It is often difficult for children with ASD to both have awareness and communicate sensations or discomfort they may be having, thus making it difficult for the child or the caregiver to be aware that the child is constipated.
Many individuals with ASD also present with varying levels of sensory processing disorder (SPD). This can contribute to being more, or in some cases less, sensitive to sensory input such as touch, taste, texture, sounds and lights amongst others. Interoception, one of our senses, is the ability to perceive the internal state of the body, such as feeling hungry or full, feeling hot or cold, feeling abdominal pain or a headache. Because it is common for people with ASD to have decreased interoception, their sense of awareness of feeling constipated can be affected making it more difficult to know there is trouble brewing. Sometimes, when someone has ASD and is having constipation, their negative behaviors may worsen due to the discomfort they are experiencing but they may have difficulty processing it and communicating it.
So, how do you know if your child is constipated? As mentioned by Dr. Steve Hodges a pediatric urologist and an expert in treating children with chronic constipation, here are some telltale signs:
- Extra-large poops (greater than ¾” inch diameter)
- Hard poops which can be like logs or pellets
- Poop accidents
- Bedwetting and/or daytime pee accidents
- Recurrent UTI’s (urinary tract infections)
- Frequent and/or urgent need to pee
- Infrequent pooping, 3 times per week or less, however even daily pooping doesn’t guarantee your child isn’t constipated
- Several small poops per day
- Abdominal pain
- Skid marks (called fecal smearing) or anal itching
- Super loose poops (especially if mixed with pellets, but liquid can seep around solid poop)
- Hiding to poop and standing to poop
What can a caregiver do if they realize their child has constipation? Because the cause is typically multifactorial, the treatment usually requires addressing several elements to have the best outcome.
- Talk to your child’s pediatrician. This is recommended to be the first step in this journey. In some cases, the pediatrician may order an X-ray called a KUB to determine if the patient is constipated. Sometimes, your child’s pediatrician may prescribe stool softeners. In more involved cases, they may recommend a bowel cleanout so the rectal walls have a chance to recover loss of rectal tone. They may refer to a pediatric gastroenterologist (Peds GI) or a pediatric urologist (Peds Urology). Other professionals who may be able to help with this condition are behavioral therapists, occupational therapists, and physical therapists (pediatric pelvic physical therapy).
- Encourage hydration. Water is believed to be the best drink for children. Where there are no definitive recommendations for the volume of water intake provided by the CDC, it is generally recommended to hydrate throughout the day with a goal of somewhere near the following amounts: (1 cup=8 oz)
- 4 to 8 years old – 5 cups
- 9 to 13 years old- 5 to 6 cups
- 14 to 18 years old – 6 to 8 cups
This recommendation does not consider any other medical conditions which may involve restriction of fluids, which is why starting with the pediatrician is key.
- Encourage a healthy diet. It can be challenging to have a child with ASD and/or SPD to accept some textures and foods, thereby further compounding the challenges of making changes to encourage a healthy diet and healthy poops. Sometimes disguising the healthier foods works. There is a cookbook I recommend in those cases, “Deceptively Delicious” by Jessical Seinfeld. In general, here are some recommended foods minimize and maximize for healthier stools.
- Minimize foods that make the stool harder (dairy such as milk, cheese and yogurt, bananas, apples, pasta/bread made with white flour, white rice, white potatoes, nuts and nut butters)
- Maximize foods that make the stool softer (fruits including raisins, prunes, pears, peaches; vegetables, LOW amounts of pasta/bread made with whole-grain flour, water, fruit juice—apple juice is okay).
- Move around more. Mobility and movement are both helpful to encourage the GI system to move more quickly. The longer the poop is in the colon, the harder it becomes. Moving around helps to massage the GI system, advancing the stool. When we rotate our trunk, when we squat, when we bend and over and then stand back up, when we jump- these are all examples of activities which will massage the belly through movement and encourage GI motility.
- Start a bowel routine. Taking the time to sit and relax in the bathroom and giving your body a chance to poop is very important. Many of us have a “usual” time of day for pooping. If that’s the case, I always encourage working a bowel routine around your child’s natural rhythms. If possible, taking about 5-10 minutes to relax on the toilet after each meal is ideal, and it is also recommended to have your knees higher than your hips. This helps to relax one of the pelvic floor muscles. Many folks like the Squatty Potty to aid in ease of this position, and they also make two versions for kiddos.
- Relax when you’re on the potty. Relaxing is very important when on the potty. Our autonomic nervous system (ANS) is a large controller of our GI system. When we are not relaxed, our GI motility can be slowed. I encourage purchasing a plastic 5-minute hourglass timer to be used, allowing the sand to run through two times while sitting. If devices are allowed in the bathroom, YouTube has several great meditation videos for kids. One of my favorites is this Bubble Bounce Meditation: Bubble Bounce! Mindfulness for Children (Mindful Looking) (youtube.com)
- Do the I-Love-U massage. This massage is best performed after eating and before sitting on the toilet. While three times a day is what is recommended, it is challenging to achieve. And performing it once a day is still very helpful. Even if you miss the window between eating and sitting on the potty, doing it at any time of the day or night is far better than not doing it at all. I have attached our Pelvic Team’s handout for the massage which we teach in our sessions as well as review with the caregiver the best pressure to use. Some people with SPD are averse to touch, and in that case, the massage is likely to induce a stress response and decrease the GI motility via the ANS. For those children, skipping the massage is likely more beneficial. Click here for handout on how to complete this massage.
- Breathing with your diaphragm. This can be challenging for many of us, but if your child is amenable to trying this, work with them on breathing deeply, all the way into the abdomen. When we inhale, our abdominal organs should actually protrude slightly. When we breathe primarily with our diaphragm and less with our chest and neck muscles, the diaphragm serves as a massage for the organs and helps GI motility. In addition, it can settle the ANS by tricking the brain into believing your child is relaxed. This causes a multitude of changes in organ function, including improved GI motility.
- Positive reinforcement. No matter what changes your child agrees to do, providing positive feedback for each small step is important. All of these steps are beneficial and in the long run, will assist in reaching the goal of better poops.
- Learn more about ways to help with constipation. I love the website by Dr. Hodges, Bedwetting, Constipation, Pee Accidents, Poop Accidents | Dr. Steve Hodges | BedwettingandAccidents.com | US. There are numerous blog articles, free downloads and many books, including The M.O.P. Book 5th Edition recently being released. If finances prevent you from purchasing the books, you can reach out to the company on their website to request a coupon. Another great book is “The Poop Train: Helping Your Child Understand Their Digestive System” by Mora A Pluchino. There are many, many more books available, and often can be found at your local library.
- Request a referral to a specialist. If you have gone through these steps, and your pediatrician hasn’t made other referrals, you may want to request a referral to one or more of these specialists: a pediatric gastroenterologist, a pediatric urologist, a pediatric behavioral therapist, a pediatric occupational therapist, a pediatric pelvic physical or occupational therapist.
At UF Health SHANDS rehab services, we currently have two pelvic physical therapists who specialize in treating pediatric patients with bowel and bladder issues and two physical therapists who specialize in treating children under one year of age with colic and constipation issues. Your child’s pediatrician or other medical practitioner can send a referral to UF Health Rehab Center at Magnolia Parke for scheduling an evaluation and treatment plan.
Working with chronic constipation in many children can be a challenging and long road. Being persistent and consistent is key! The goal is having daily, complete bowel movements which are soft like soft serve ice cream, dark brown in color, and painless. And hopefully, you will see even more positive effects than simply better poop!