News and Knowledge

Toilet training one’s child is a nearly universal challenge for parents, but it is a particularly distressing ordeal for parents of children with autism spectrum disorder (ASD). While most typically developing children stop having daytime toileting accidents between the ages of 2 and 4, most individuals with ASD are either delayed in their acquisition of toileting skills or never achieve continence.

Clearly, not being toilet trained effects both individuals with ASD and their parents/caregivers. It impacts the hygiene, self-confidence, physical comfort, and independence of the individual with ASD and can cause social stigma. For parents, it can cause significant stress and take up a lot of time in the daily routine. Without effective treatment, the problem may persist into adulthood.

Nathan Call, Ph.D., proposed a program to treat encopresis, or bowel incontinence, which he will pilot in his OAR-funded study, An Interdisciplinary Approach to the Treatment of Encopresis in Children with Autism Spectrum Disorder. Dr. Call is a pediatric psychologist and director of the behavior treatment clinics at the Marcus Autism Center at Emory University, Atlanta, Ga., and will work with colleagues in behavioral psychology and gastroenterology.

Study Design

The pilot program relies on over-the-counter medications and behavioral strategies to reinforce continence. Dr. Call has recruited 20 individuals with ASD and encopresis to participate in a trial program and a control group. The treatment program will consist of 10 appointments of up to four hours each, over a 14-day period.

The program involves having participants sit on the toilet for periods of time interspersed with breaks if there is no bowel movement. At certain points, participants who have not had a bowel movement will be given a glycerin suppository and then a bisacodyl suppository.

If participants do not have bowel movements for two consecutive treatment days, their parents/caregivers will be asked to provide senna, an oral laxative, each evening until directed to slowly taper off of it. The goal is to increase the opportunity for continent bowel movements and reinforcement during study appointments. As participants maintain continent bowel movements, use of laxatives will be reduced unless continent bowel movements cease and they are needed again.

Reinforcement plays a key role in the study. If a participant has a continent bowel movement, he will be provided with enthusiastic praise along with positive reinforcement and allowed to get off the toilet. A continent bowel movement will end that day’s appointment.

Caregivers will be trained on all components of the program still in use on the last day of the study so they can be used in the participant’s home.

Evaluation

Each participant’s primary caregiver will be asked to collect data on the frequency of bowel movements and whether they are continent for two weeks prior to and throughout the treatment (the control group caregivers will collect the same data). These data, in combination with records of bowel movements during treatment sessions, will be used to determine how effective the program is in increasing continent bowel movements. Caregivers will also collect data for four weeks after treatment so Dr. Call and his team can see if participants maintain the same percentage of continent bowel movements at four weeks post-intervention.

Applying the Findings

Dr. Call hopes that his study will provide an evidence-based treatment for encopresis and establish best practice guidelines for clinicians to treat encopresis in individuals with ASD. He plans to develop a structured treatment manual based upon the study’s findings for use by parents and clinicians.