Encopresis, soiling and constipation in children and adults with developmental disability

Resolving Barriers to Continence for Children with Disabilities: Steps Toward Evidence-Based Practice

Behavior-analytic toilet training (BATT) methods to support urine continence have been reviewed and replicated in numerous studies. Despite empirical validations of BATT, children with disabilities may not experience successful toilet training nor access the associated health and social benefits of urinary continence. It is possible these outcomes are partially due to practical barriers that arise throughout urine training. In practice, barriers may interfere with toilet training to the extent that training is postponed or discontinued, resulting in long-term incontinence and other related problems. Examples of barriers include problem behavior, excessive urine retention, recurrent accidents, and excessive or insufficient independent self-initiations to toilet. Researchers have sometimes described strategies to address these types of barriers. However, practitioners may not be aware of these strategies because they are secondary to the purpose of an investigation and may only apply to a subset of participants. The purpose of this review article is to synthesize the collection of barrier solutions described in published research on urine training for children with developmental disabilities. Results may assist practitioners in modifying BATT according to an evidence-based practice framework until their clients overcome barriers to achieve urine continence.

Association between early and current gastro-intestinal symptoms and co-morbidities in children and adolescents with Angelman syndrome

BACKGROUND

Angelman syndrome (AS) is a neurogenetic disorder that causes severe intellectual disability, expressive language deficits, motor impairment, ataxia, sleep problems, epileptic seizures and a happy disposition. People with AS frequently experience gastrointestinal (GI) symptoms.

METHOD

This study used data from the Global Angelman Syndrome Registry to explore the relationship between early and current GI symptoms and co-morbidity in children and adolescents with AS (n = 173). Two groups that experienced a high (n = 91) and a low (n = 82) frequency of GI symptoms were examined in relation to feeding and GI history in infancy, sleep and toileting problems, levels of language and communication and challenging behaviours. Predictors of GI symptoms were then investigated using a series of logistic regressions.

RESULTS

This analysis found that constipation and gastroesophageal reflux affected 84% and 64%, of the sample, respectively. The high frequency of GI symptoms were significantly associated with: 'refusal to nurse', 'vomiting', 'arching', 'difficulty gaining weight', gastroesophageal reflux, 'solid food transition', frequency of night-time urinary continence and sleep hyperhidrosis during infancy. GI symptoms were not significantly associated with sleep, toileting, language or challenging behaviours. Significant predictors of high frequency GI symptoms were gastroesophageal reflux and sleep hyperhidrosis.

CONCLUSIONS

Future research needs to investigate the association between AS and GI co-morbidity in adults with AS.

Age of Autism Spectrum Disorder Diagnosis and Comorbidity in Children and Adolescents with Autism Spectrum Disorder

AIM

Research is required to study the relationship between age of autism spectrum disorder (ASD) diagnosis and the presence of comorbidities.

METHOD

The Gastrointestinal Symptom Inventory, Autism Spectrum Disorder-Comorbid for Children, Behavior Problem Inventory-Short Form and Social Communication Questionnaire were completed by parents of 129 children and adolescents with a diagnosis of ASD.

RESULTS

Results revealed significant relationships between the age of ASD diagnosis, the presence of comorbidities and intellectual disability. Significant correlations were found between the age of ASD diagnosis and self-injurious and stereotyped behavior. Comorbid psychopathology significantly predicted the presence of GI symptoms. In addition, the relationship between comorbid psychopathology and challenging behavior in this study was reported as bi-directional as both comorbidities predicted one another in the sample.

CONCLUSION

Future research needs to consider the role of comorbidities in relation to ASD diagnosis.

A Pilot Randomized Clinical Trial of a Multidisciplinary Intervention for Encopresis in Children with Autism Spectrum Disorder

Children with autism spectrum disorder (ASD) are often delayed in achieving bowel continence, resulting in negative outcomes. In this pilot trial, 20 children with ASD and encopresis were randomly assigned to multidisciplinary intervention for encopresis (MIE; n = 10) or a waitlist control group (n = 10). The MIE group was treated for constipation and received a 10-day behavioral intervention that utilized suppositories to produce predictable bowel movements that were reinforced. Caregivers were trained to implement the intervention. Results support the feasibility of clinical trials of MIE, with high enrolment, competition, attendance, and caregiver acceptability. Preliminary outcomes were positive, with six of 10 in the MIE group achieving continence by the end of treatment compared to 0 in the control group (p = 0.005).Registered at clinicaltrials.gov (https://clinicaltrials.gov); ID: NCT02383732.

Constipation management in people with intellectual disability: A systematic review

BACKGROUND

Constipation can lead to serious health issues and death. This systematic review summarizes international research pertaining to the management of constipation in people with intellectual disability.

METHOD

Studies published from 1990 to 2017 were identified using Medline, Cinahl, PsycINFO, Web of Science, email requests and cross-citations. Studies were reviewed narratively in relation to identified themes.

RESULTS

Eighteen studies were reviewed in relation to three themes: laxative receipt; interventions (dietary fibre, abdominal massage and macrogol); and staff issues (knowledge and training). Laxative polypharmacy was common. Studies report positive results for dietary fibre and abdominal massage although study quality was limited.

CONCLUSION

The main management response to constipation in people with intellectual disability is laxative use despite limited effectiveness. An improved evidence base is required to support the suggestion that an individualized, integrated bowel management programme may reduce constipation and associated health conditions in people with intellectual disability.

Toilet training in individuals with Angelman syndrome: a case series

OBJECTIVE

To assess if adapted versions of the response restriction toilet training protocol, based on the behavioral phenotype of Angelman syndrome (AS), were successful in fostering urinary continence in seven individuals with AS.

METHOD

Data were collected in AB-designs during baseline, training, generalization and follow-up. The response restriction protocol was adapted: individuals were trained in their natural environment, were prompted to void and along with improving continence, the interval between voids was prolonged and time-on-toilet decreased.

RESULTS

During generalization five individuals had less than two accidents and one to six correct voids per day; during baseline more accidents and/or less correct voids occurred. In two participants correct voids increased, but several accidents still occurred. Three participants maintained positive results after 3-18 months.

CONCLUSION

Despite their intellectual and behavioral challenges, urinary continence can be acquired in AS. Several indications of voiding dysfunctions were found; further research is indicated.

Gastrointestinal dysmotility in Rett syndrome

OBJECTIVES

Through evidence review and the consensus of an expert panel, we developed recommendations for the clinical management of gastroesophageal reflux disease, constipation, and abdominal bloating in Rett syndrome.

METHODS

Based on review of the literature and family concerns expressed on RettNet, initial draft recommendations were created. Wherein the literature was lacking, 25 open-ended questions were included. Input from an international, multidisciplinary panel of clinicians was sought using a 2-stage modified Delphi process to reach consensus agreement. Items related to the clinical assessment and management of gastroesophageal reflux disease, constipation, and abdominal bloating.

RESULTS

Consensus was achieved on 78 of 85 statements. A comprehensive approach to the assessment of gastroesophageal reflux and reflux disease, constipation, and abdominal bloating was recommended, taking into account impairment of communication skills in Rett syndrome. A stepwise approach to the management was identified with initial use of conservative strategies, escalating to pharmacological measures and surgery, if necessary.

CONCLUSIONS

Gastrointestinal dysmotility occurs commonly in Rett syndrome. These evidence- and consensus-based recommendations have the potential to improve care of dysmotility issues in a rare condition and stimulate research to improve the present limited evidence base.

An examination of specific daily living skills deficits in adults with profound intellectual disabilities

While some researchers have investigated daily living skills deficits in individuals with intellectual disability (ID) as a whole, research on specific daily living skills in a profound ID population is limited. Two hundred and four adults with profound ID residing in two large developmental centers in the southeast portion of the United States were studied. Data were collected on these individuals' daily living skills, utilizing the Vineland Adaptive Behavior Scales (VABS). Three dependent t-tests were conducted comparing the proportion of items endorsed by informants on each of the three subdomains of daily living skills on the VABS (personal, domestic, and community). A significantly larger proportion of Personal Subdomain items were endorsed compared to Domestic or Community Subdomain items. Additionally, participants exhibited a significantly larger proportion of Domestic Skills Subdomain items compared to Community Skills Subdomain items which is consistent with theoretical models suggesting that institutional living may curb broader community skill sets. No gender differences were found in daily living skills. Lastly, individuals between the ages 30 and 39 exhibited significantly more Personal Subdomain skills than individuals who were 60 or older, while participants between the ages 30 and 39 exhibited significantly more Domestic Subdomain skills than individuals between the ages 60 and 69.

Students With ASD in Mainstream Primary Education Settings: Teachers' Experiences in Western Australian Classrooms

The shift to inclusive education within Australia has resulted in increasing numbers of students with autism spectrum disorders (ASD) being placed in mainstream educational settings. This move has created new demands on teachers who are not necessarily trained to meet the challenge. Therefore, the present study aimed to develop an understanding of how 12 Western Australian primary school (K–7) teachers adapted to the challenge of having a student with ASD in their mainstream classroom. Using an interpretivist framework, data from semistructured interviews revealed that teachers perceived a need to first recognise and accept the challenges associated with having a student with ASD in their mainstream classroom before they could move to accessing avenues of support. The implications of this finding are discussed.

The relationship between race and challenging behaviours in infants and toddlers with autistic disorder and pervasive developmental disorder-not otherwise specified

OBJECTIVE

To examine the contributions of race and diagnostic category to endorsement rates of challenging behaviours in infants and toddlers with autism, PDD-NOS and atypical development without ASD, using the Baby and Infant Screen for Children with aUtIsm Traits, Part-3 (BISCUIT Part-3).

DESIGN

Multivariate analyses of variance (MANOVAs) on each sub-scale of the BISCUIT Part-3. Follow-up univariate analyses and post-hoc tests as needed.

METHODS

Scores on the BISCUIT Part-3 were compared for 453 Caucasian and 409 African-American infants and toddlers, grouped by race and diagnosis.

RESULTS

Significant differences between races were found on five out of 10 aggressive behaviours, while no significant differences were found on self-injurious or stereotypic behaviours. Significant differences between diagnostic groups were found on all behaviours.

CONCLUSION

Cultural factors should be taken into account when examining challenging behaviours in infants and toddlers with ASD.

Epidemiology of constipation in children and adults: a systematic review

We aimed to review the published literature regarding the epidemiology of constipation in the general paediatric and adult population and to assess its geographic, gender and age distribution, and associated factors. A search of the Medline database was performed. Study selection criteria included: (1) studies of population-based samples; (2) containing data on the prevalence of constipation without obvious organic aetiology; (3) in paediatric, adult or elderly population; (4) published in English and full manuscript form. Sixty-eight studies met our inclusion criteria. The prevalence of constipation in the worldwide general population ranged from 0.7% to 79% (median 16%). The epidemiology of constipation in children was investigated in 19 articles and prevalence rate was between 0.7% and 29.6% (median 12%). Female gender, increasing age, socioeconomic status and educational level seemed to affect constipation prevalence.

Assessment of toileting difficulties in adults with intellectual disabilities: an examination using the profile of toileting issues (POTI)

A lack of toileting skills is one of many impairments that individuals with intellectual and developmental disabilities experience. Unfortunately, little research has focused on problems in this area including assessment, function, and treatment. A newly developed checklist, the Profile of Toileting Issues (POTI), is being considered for use to screen for toileting issues in this population, and to identify potential functions to target in treatment. The purpose of the current study was to examine the reliability of the POTI. Internal consistency was sound (α = .83) and interrater reliability was significant. The implications of these findings are included.

An Examination of Psychotropic Medication Side Effects: does taking a greater number of psychotropic medications from different classes affect presentation of side effects in adults with ID?

This study examined whether the number of psychotropic medications an individual is taking across classes influences side effects among adults with Intellectual Disability (ID). Participants were 80 adults diagnosed with ID. Dependent variables were the composite score and domain scores of the Matson Evaluation of Drug Side-effects (MEDS), which is an instrument used to assess side effects. There were three levels of the independent variable: Group 1--those taking zero psychotropic medications, Group 2--those taking one psychotropic medication, and Group 3--those taking two psychotropic medications across different medication classes. There was a significant main effect regarding number of psychotropic medication classes prescribed. Further analysis revealed that four of the nine MEDS domains had significantly different mean scores for number of psychotropic medication classes. For the majority of MEDS domains, such as Central Nervous System-General, Parkinsonism/Dyskinesia, and Behavioral/Akathesia domains, participants in the no psychotropic medication group had significantly lower mean scores than those in the one and two psychotropic medication groups. Only two MEDS domains, Cardiovascular and Hematologic Effects as well as Skin, Allergies, and Temperature, were significantly different between participants taking one psychotropic medication as compared with two psychotropic medications from different classes. Implications of these findings and recommendations for future research are discussed.