Like so many other characteristics commonly found in association with autism, bowel problems are rarely mentioned. There is very little in the research literature other than a few case studies. Yet, over the years, I have come across many more instances of bowel problems in children with Autism Spectrum Disorders (ASD) than would be found among non-disabled children, or children with other disorders. Not only has this been apparent in my clinical work, which you would expect, since I provide toilet training advice and programs for parents, but also in my senior positions as a clinical psychologist and administrator in both specialist autism and general developmental disability services in two Australian states.
Problems of bowel control often exist alongside full self-control of bladder, although some children with ASD also have difficulty learning bladder control as well. As in so many other aspects of ASD, bowel problems differ markedly from one autistic child to another. However, there are two abnormalities in bowel control which are most common in children with ASD.
One seems to be a problem in the digestive process itself. Stools may be very loose some or all of the time, or they may be formed, but of a consistency that provides no pressure against the bowel wall. It is very difficult for any individual either to pick up the sensations just prior to a bowel motion or to control stools of this consistency. This is because the sensations prior to a bowel motion normally come from pressure on the bowel wall, resulting when there is enough firm bulk to exert this pressure. Firm stools with bulk are also necessary to prevent them from slipping out through the bowel opening as a result of reflex contractions in the gut. A child with this kind of digestive problem cannot physically prevent soiling or get to the toilet in time to catch bowel motions. The solution requires adjusting the digestive system, something which few practitioners of any kind are either aware of or offer as a service. The few practitioners whom I have been told do tackle the digestive problems are either medical practitioners interested in holistic medicine or naturopaths. There may also be others who can help.
I am not qualified to deal directly with the digestive system. However, when it has not been possible or advisable to adjust the child’s digestion, I have found that psyllium husks in powder form will often provide enough bulk to enable bowel motions to be controlled. Psyllium is a food consisting of fibre which swells up as it absorbs moisture. One to three teaspoons-full will be enough to provide adequate bulk for most children. The amount can be adjusted according to the consistency of the stools. Powdered psyllium husks in tasteless form are available as a powder or in orange or vanilla flavour at most health food shops or at pharmacies.
The greatest difficulty can be persuading the child to accept the powder. Parents have used many different strategies; sprinkled on cereal or stired into yoghurt, in milkshakes (it does eventually go to jelly in liquid), in stews, on sandwiches, in several foods throughout the day, or with reward for eating the powder in any medium. Often, psyllium husks alone have resulted in full self control of bowel motions, consistent toilet use and no more soiled pants.
The second problem commonly found in children with ASD is real anger and distress at passing stools. I have interpreted this as part of their fear of any event which they cannot either understand or control. Children with this problem often hide when passing stools and some will hold back a bowel motion for days or weeks despite experiencing extreme discomfort or pain. Then, of course chronic constipation and additional pain from tears in the bowel opening may add to the problem. Many children also insist on only passing stools while wearing a nappy. Some will even
ask for a nappy to be put on and will then go into another room, have a bowel motion, then ask for the nappy to be removed.
The same kind of help to overcome any aversion to change in children with ASD is useful here. However, specific intensive teaching strategies may be necessary to bring the child to understand what should be done and how to do it. You will find a number of suggested programs and procedures in my book, Toilet Training for Children with Austism or Intellectual Disabilities, available on my web site, www.learn2do.net.