Case Study III: A Closer Look
Based on this history, can you identify three to four problems/issues going on with Jack? Which would you address first?
Based on Jack’s history, constipation seems to be a significant problem that should be addressed first. Constipation is a common problem in children and should be addressed in a timely manner. In Jack’s case, constipation may be a result of multiple factors, including a diet low in fiber and toileting refusal. Additional concerns raised by the history include problems with sleep, picky eating, and toileting.
Is there a relationship between ASD and GI problems?
No clear relationship has been established between ASD and GI problems. Most of the research in this area has been from specialty clinics without an appropriate control sample and has relied on parental recall or medical records. Based on these reports, the prevalence of GI symptoms in children with ASD is between 17% and 86%. Other studies have shown no difference in rates of GI symptoms from the general population. The GI symptoms frequently reported are bloating, abdominal discomfort, diarrhea, and constipation.
- Results of a consensus panel were recently published in Pediatrics concluding that children with ASD should have the same thorough diagnostic workup for gastrointestinal symptoms as children without ASD. They identified GI disorders as a priority area for future research.
- There are many causes of constipation in children. It can occur when the diet is very limited, particularly when it is low in fiber. Children with ASD are often described as picky eaters (as in our case study) and therefore may not be eating enough fiber. Diet modification therapies, such as gluten-free/casein-free diets, may also limit the variety of foods a child eats.
- Another cause for constipation in children with ASD is resistance to toilet training. Their lack of social awareness, communication skills, and behavior problems (i.e., rigidity, sensory issues) pose unique challenges to toilet training.
Evaluating GI Symptoms
The evaluation of a child with ASD and GI symptoms should be the same as that of a child without ASD. In many cases, a physical exam is all that is needed if you do not suspect an underlying organic illness. Abdominal radiography may be warranted if you suspect severe constipation or your physical exam is difficult to perform because of noncompliance.
Treatment of constipation in children with ASD should include both medical management and behavioral intervention.
- Depending on the severity of the constipation, several medications can be used, including stool softeners, bowel stimulants, laxatives, and enemas.
- Manipulation of the diet should include increasing the fiber content and fluid intake.
- Behavioral management may address parental education regarding a child’s normal bowel habits and appropriate toilet training techniques.
- Follow-up should be arranged to assess improvement in GI symptoms and development of an ongoing plan to prevent recurrence.
When dealing with a child with ASD and GI complaints, remember they require the same kind of care as a child without ASD. Additional testing beyond what you would normally do is not recommended at this time. Also, families should be involved in the treatment plan as they know their child best and how they may react to certain treatments (e.g., enemas).
How might Jack’s problems with sleeping, feeding, and toileting be related?
- Constipation is a common problem in pediatrics and can occur in children with autism.
- Certain factors such as a limited diet or toileting difficulties, which are common in children with ASD, can predispose a child to having constipation.
- Constipation, which may be associated with discomfort, can disrupt normal sleep patterns.
- Sleep is a common problem for all children but especially for children with ASD.