Saturday, September 28, 2013

Evidence update: Pediatric fecal incontinence and best practices for intervention


Almost seven years ago I wrote a blog entry on pediatric fecal incontinence which is archived here.  In that review I briefly discussed psychological and physiological and regulatory factors that might contribute to the problem.  The evidence at that time indicated that dietary, activity, and cognitive behavioral interventions were most likely to be successful in helping families.

I also discussed a common occupational therapy mythology that sensory processing factors such as preference for deep pressure stimulation might contribute to fecal retention.  There has never been any evidence to indicate that this is a relevant factor.

In the current issue of the American Journal of Occupational Therapy there is an article by Bellefeuille, Schaaf, and Polo (2013) that describes OT intervention for a child with retentive fecal incontinence.  The authors hypothesize that a 3 year old child's difficulty with passing stool is related to overresponsivity to sensory stimulation.  By report, toilet training started at 2.8 years of age when he had to attend a preschool.  The parents were concerned after 4 months of unsuccessful training and according to the article they felt 'pressured' because he needed to be toilet trained for preschool participation.

An assessment included the Sensory Profile which indicated overresponsivity to sensory stimulation.  Occupational therapy intervention began at 3.7 years using an Ayres Sensory Integration Approach.  The authors report that the Ayres Sensory Integration was a useful framework that contributed to the child's improvement.

I have several questions about this article because I believe it represents a rather serious departure from conventional evidence and knowledge on the topic.

To begin with, fecal incontinence is not generally diagnosed in three year old children. At a minimum this diagnosis is not applied until the age of four, at which time a child may be reasonably expected to have completed toilet training and have the ability to exercise bowel control (Mayo Clinic, 2011; American Academy of Pediatrics, 2013). Additionally, at least 20% of developmentally normal children 18 to 30 months of age may refuse stool toilet training at some point (Taubman, 1997). Therefore the core premise of the article that the child had any actual diagnosable condition as would be identified under conventional medical standards is dubious.

A second concern is that the 'objective' data collected as reported in the article is a parent questionnaire about sensory processing difficulties.  Parent reports may be important to help obtain narrative understanding of a clinical problem but they do not represent any direct measure of a child's actual capability in an objective sense.  Additionally, Dickie, Baranek, et.al., (2009) indicated quite clearly that parents don't automatically frame children's activities in sensory terms. Specifically, they state

 "that sensory aspects of experiences are often not noted unless they are unusual (as in having a child who is hyperresponsive to certain sensory situations), or attention has been drawn to them (e.g., through education about characteristics of autism, or by an occupational therapist reframing a child’s behavior in sensory terms)."

Certainly, and as indicated above, childhood fecal retention is hardly an unusual phenomenon and it  does not automatically link to sensory overresponsivity.  It seems reasonable to wonder if the interpretation of the problem was reinforced by the frame of reference of the occupational therapist.

Of additional note is that there was no report of direct assessment of the child that would support the hypothesis that the child had any sensory processing difficulty.  Additionally, no other developmental atypicalities were reported.  If a child had a sensory overresponsivity, wouldn't we expect to see other developmental consequences of the problem?

I am concerned about the concept of providing skilled occupational therapy intervention to three year olds simply on the basis of slow toilet training.   There is no questions that fecal incontinence and struggles to develop toileting skills are a significant point of stress for families, particularly in relation to enrollment in institutionalized day care.  However, individual child readiness has to be assessed across a multitude of factors including child developmental factors, contextual demands, and cultural norms (Brazelton, Christophersen, Frauman, et al (1999).  There is simply no evidence that a sensory overresponsivity construct is an important factor to consider for this problem, particularly in otherwise typically developing children.

It seems irresponsible to suggest that application of a treatment program to an otherwise typically developing child is responsible for progress that one would expect under any circumstance within that developmental period.

Families should always consult with their pediatricians about these concerns to rule out medical difficulties.  The recommendations I made from seven years ago still stand.  Occupational therapists might help families with these difficulties through basic education about healthy activity and nutrition, providing support and information about normal development, and implementing simple cognitive behavioral plans that can be applied across care contexts. This intervention can be provided in time-limited consultation models.


References:

American Academy of Pediatrics (2013, July 9). Soiling (Encopresis). Retrieved at http://www.healthychildren.org/English/health-issues/conditions/emotional-problems/pages/Soiling-Encopresis.aspx

Bellefeuille, IB; Schaaf, RC; and Polo, ER. (2013). Occupational therapy based on Ayres Sensory Integration in the treatment of retentive fecal incontinence in a 3-year-old boy.  American Journal of Occupational Therapy, 67(5), 601-606.

Brazelton, T.B., Christophersen, E.R., Frauman, A.C., et al (1999).  Instruction, timeliness and medical influences affecting toilet training. Pediatrics, 103, 1353-1358.

Dickie, V. A., Baranek, G. T. Schultz, B. Watson, L.R., and McComish, C.S. (2009). Parent reports of sensory experiences of preschool children with and without autism: A qualitative study. American Journal of Occupational Therapy, 63, 172-181.

Mayo Clinic (2011, Jan 4). Encopresis.  Retrieved at http://www.mayoclinic.com/health/encopresis/DS00885

Taubman, B. (1997). Toilet training and toileting refusal for stool only: A prospective study. Pediatrics, 99, 54–58.

2 comments:

Anonymous said...

This is a perfect example of why a classroom teacher I just started working with refers to the practice of O.T. as voodoo. I have my work cut out for me.

Erik Mastrianni said...

Very well written! I feel this "theory" could be applied to many cases I am involved in. Also, I feel a parent questionairee about sensory processing is skewed, as parents clearly have to report issues in order to receive services.