Original Article

Ann Colorectal Res 2019;7(4):1-7.

Examining Hyper-Reactivity to Defecation Related Sensations in

Children with Functional Defecation Disorders

Isabelle Beaudry-Bellefeuille1*, Alison Lane1, Eduardo Ramos-Polo2, Shelly J Lane1

Occupational Therapy, University of Newcastle, Callaghan, Australia

1

MM, Pediatric Gastroenterologist, Private Practice, Oviedo, Spain

2

*Corresponding authors: Received: 08-10-2019

Isabelle Beaudry-Bellefeuille, Revised: 17-12-2019
Occupational Therapy, University of Newcastle, Callaghan, Australia. Tel: +34 985
295184; Email: [email protected] Accepted: 17-12-2019

Abstract

Background: Adequate sensory perception and reactivity to sensory stimuli associated with defecation is key
to successful stool toileting. Preliminary reports suggests that some of the difficulties that many children with
FDD experience with toileting could be related to sensory hyper-reactivity. Objective: This study investigated
the relationship between sensory hyper-reactivity and functional defecation disorders (FDD).
Methods: Parents of three to six-year-old children with and without FDD completed two questionnaires;
the Toileting Habit Profile Questionnaire-Revised (THPQ-R; tool that measures sensory hyper-reactivity to
defecation related sensations) and the Short Sensory Profile (SSP). On both questionnaires, low scores indicate
more concerns. Between group comparisons and the relationship between scores on the THPQ-R and on the
sensory hyper-reactivity items of the SSP were examined.
Results: The sensory hyper-reactivity mean score of the SSP was lower for children with FDD. The difference
was statistically significant (P<0.0005). There was a positive correlation between THPQ-R and SSP hyper-
reactivity scores (r274=0.485, P<0.0005). Further, higher levels of sensory hyperreactivity (low SSP score)
were associated with a higher frequency of the challenging defecation behaviors described in the THPQ-R
(low THPQ-R score).
Conclusion: Health practitioners do not usually consider sensory hyper-reactivity as a possible factor
contributing to the difficulties of the child with FDD. Our results indicate that routine screening for sensory
hyper-reactivity may be an important practice element when working with children with FDD. In addition, the
present study adds support to the validity of the THPQ-R in identifying behaviors potentially linked to sensory
hyper-reactivity

Keywords: Functional constipation, Functional defecation disorders, Children, Sensation disorders

Please cite this paper as:

Beaudry-Bellefeuille I, Lane A, Ramos-Polo E, Lane SJ. Examining Hyper-Reactivity to Defecation Related Sensations in Children with
Functional Defecation Disorders. Ann Colorectal Res. 2019;7(4):1-7. doi: .

Journal compilation © 2019 Annals of Colorectal Research, Shiraz University of Medical Sciences
 Beaudry-Bellefeuille I et al.

Introduction evaluate the construct validity of the THPQ-R in

relation to its intended usefulness in identifying

C hildhood functional defecation disorders (FDD)

are highly prevalent worldwide (1) and are
increasingly considered a public health problem (2).
challenging defecation behaviors related to issues
with sensory hyper-reactivity.

Childhood FDD consist of functional constipation Methods

(FC) and functional non-retentive fecal incontinence
(FNRFI) (3). Stool toileting refusal (STR), often This investigation adopted a descriptive survey
associated with FDD, is not a diagnosis as such but methodology in which parents of three to six-year-
is described in the literature as fear or refusal of old children were invited to complete two different
defecation in the potty or toilet for a period lasting at online questionnaires; the THPQ-R and the Short
least one month, without concomitant fear or refusal Sensory Profile (SSP). The ethics committee of the
of micturition (4). Children with STR are at high University of Newcastle (#H-2017-0079) approved
risk of developing FDD, but may avoid developing the study.
FDD as long as their requests to be given a diaper
to defecate are respected4. FDDs are observed in Participants
children with and without diagnostic concerns but are Participants were caregivers of children with and
more prevalent in those with diagnoses such as autism without FDD or/and STR. Participants in the FDD/
spectrum disorder (ASD) (5) and attention deficit STR group were assigned to one of the following
disorder (ADHD) (6). Unfortunately, despite extensive categories according to the characteristics of their
characterization of the gastrointestinal and behavioral children: 1) children aged 3 to 6 years old with
features (3, 7, 8), our comprehension of the multiple FDD and/or STR and no additional diagnoses; or 2)
factors involved in the emergence and maintenance children aged 3 to 6 years old with FDD and/or STR
of childhood FDD continues to be incomplete, and and ASD and/or ADHD identified by parental report
success rates for treatment remain limited (2, 7, 9, 10). of diagnosis. The age range of 3–6 years was chosen
As such, further inquiries regarding clinical factors as it coincides with the time period when ongoing
associated with FDD are needed. toileting concerns generally become apparent
Normal defecation is a complex process that involves and when manifestations of pain upon defecation
multiple sensorimotor and psycho-behavioral factors or refusal of defecation appear (26, 27). Children
(11). Adequate sensory perception (i.e. the ability with a diagnosis of ASD or ADHD were included
to recognize and interpret sensory stimuli) and because of the reported higher prevalence of FDD in
reactivity (i.e., the modulation of neuronal activity children with these diagnoses (5, 6). The comparison
in reaction to sensory stimuli) to the sensory stimuli group was comprised of parents of children aged
associated with defecation is key to successful stool 3 to 6 years old without FDD and/or STR and no
toileting. For example, perceiving the need to void other diagnoses, or without FDD and/or STR and
the bowel and tolerance of the sensation of passing diagnosed with ASD and/or ADHD.
stool are necessary components of normal defecation Probe questions based on the Rome Foundation
(11). Although sensory perception is a longstanding diagnostic criteria for FDD were used to verify or
consideration in the study of children with FDD (12- rule out FDD (3). The diagnosis of interest was FC
14), and despite the fact that sensory hyper-reactivity for children younger than 4 years and FC and FNRFI
is increasingly considered in the study of other for children 4 years and older. A cover letter to the
types of functional gastrointestinal disorders (15- THPQ-R, which includes questions about initiation
17), specific links between sensory hyper-reactivity of toilet training and screens for STR, was part of
and FDD have not been thoroughly explored in the online survey (see appendix).
the literature (18). Our recent work and the work We excluded parents of children with organic causes
of others suggests that some of the difficulties that of defecation disorders. We also excluded from
many children with FDD experience with toileting both groups parents of children with neurological
could be related to issues in sensory hyper-reactivity conditions, intellectual disability, or psychiatric
(19-23). To further investigate this hypothesis, our disorders other than ASD and ADHD. Parents whose
research team has developed and validated a tool children were assigned to their school´s special needs
that measures sensory hyper-reactivity in relation program or had received early intervention services
to defecation-related sensations: the Toileting Habit were excluded. Only those participants whose
Profile Questionnaire-Revised (THPQ-R) (24). The children had initiated toilet training were included.
THPQ-R and its earlier version have been shown Parent support groups of all types were contacted
to adequately discriminate between children with and social media were also used to recruit participants.
and without FDD (19, 25); however, it´s efficacy in Public and private pediatric gastroenterology and
identifying bowel-related sensory hyper-reactivity occupational therapy clinics were also contacted for
concerns requires further investigation. This study recruitment of parents of children with FDD, STR,
aimed to: 1) investigate the relationship between ASD and/or ADHD. Recruitment efforts were aimed
sensory hyper-reactivity and FDD, and 2) further at various English and Spanish speaking countries.

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 Beaudry-Bellefeuille I et al.

Data Collection (24). Items 16 and 17 are recommended exclusively to

A web-based survey tool (Qualtrics®) (28) was gather clinical insight into possible links to sensory
used for data collection. We implemented several hypo-reactivity and/or poor perception (24). As
quality control strategies to identify and exclude such, only the sensory hyper-reactivity items (1
multiple entries and minimize erratic reporting: (1) to 15) are part of the final score, with lower scores
internet protocol address check; (2) access to the reflecting greater concerns in hyper-reactivity and
survey through e-mail invitation once interested defecation behavior. The THPQ-R has been shown to
participants contacted the researcher; (3) exclusion adequately discriminate between children with and
of respondents who were inconsistent on the probe without FC (25), with THPQ-R scores correlating
questions of the Rome Foundation3 diagnostic highly with the defecation specific scale of the
criteria or showed other evidence of indiscriminate Virginia Encopresis-Constipation Apperception
responding. Test (30).
Short Sensory Profile (SSP): The SSP is a
Measures condensed version (38 items) of the original Sensory
Toileting Habit Profile Questionnaire Revised Profile (SP; 125 items) (31). Both the SP and the
(THPQ-R): The THPQ-R (24) is a revised version SSP are caregiver questionnaires that measure
of the THPQ (29). This tool is a parent report responses to sensory events in daily life in children
questionnaire designed to distinguish typical aged between 3 and 10 years. The validity of these
defecation behaviors and reactions from those that tools is well established. The data provided by
are potential manifestations of sensory reactivity these questionnaires allows therapists to examine
issues associated with FDD and STR. The THPQ-R, how particular patterns in sensory reactivity may
available in English and Spanish, has 17 items scored be linked to difficulties with participating in daily
using a dichotomous scale (1=frequently or always; occupations (31). The SSP is scored on a five-point
2=never or rarely), 15 items designed to document Likert scale (‘Always’ to ‘Never’), with low scores
sensory hyper-reactivity, and 2 items designed to indicating greater concerns regarding sensory
document sensory hypo-reactivity and/or poor reactivity. The SSP (32), translated to Spanish
perception (Table 1). Examination of the construct (S-SSP) and distributed by the publisher (Pearson),
validity of the THPQ-R using Rasch and directed was revised for Spain (33) given that it was originally
content analysis supports the use of the items designed aimed at Spanish speakers living in the United States.
to identify sensory hyper-reactivity (items 1 to 15) This revised version was used in Spanish-speaking
(24). The reliability index (similar to Cronbach’s α) countries. The original English version of the SSP
for the hyper-reactivity items is documented as 0.89 was used for English-speaking countries. In order

Table 1: Items of the Toileting Habit Profile Questionnaire-Revised

THPQ-R items Sensory issue type
1. My child hides to poop. 1
2. My child asks for a diaper when he feels the need to poop. 1
3. My child prefers to poop in his clothing although the potty or toilet is nearby. 1
4. My child refuses to sit on the potty or the toilet to poop, but will accept to pee in the potty or toilet. 1
5. My child refuses or seems uncomfortable sitting on the toilet or potty for both peeing and pooping, 1
even at home.
6. My child withholds poop or resists the urge to poop. 1
7. My child follows an unusual ritual when pooping which involves actions or places not typically 1
associated with pooping or with the age of the child.
8. My child seems to feel pain when pooping, even if the poop is soft. 1
9. My child refuses to poop outside of the home. 1
10. My child shows exaggerated disgust at the smell of his poop. 1
11. My child refuses to wipe or be wiped after pooping. 1
12. My child shows fear or refusal related to certain features of the bathroom, such as fear of flushing 1
the toilet.
13. My child needs to pay attention to something else while pooping (a book, a game); this seems to help 1
him/her tolerate the sensation of pooping.
14. My child is sensitive to taste and/or food textures making it difficult to accept laxative medicine or 1
high fibre foods.
15. My child felt the urge to poop very early (younger than 12 months). My child would grunt in a certain 1
way and I would sit him/her on the potty to poop.
16. My child does not seem to feel the urge to poop. 2
17. My child does not realize he/she has soiled (poop) his/her clothes or is not upset by soiling. 2
Sensory issue type: 1=Sensory hyper-reactivity; 2=Sensory hypo-reactivity and/or issues with perception; items in Spanish are
available from the authors

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 Beaudry-Bellefeuille I et al.

to compare the results of this study with previous Rasch computations (Table 2). For interpretation of
results from a pilot study (19), the first edition of the SSP results, we used the published norms; typical
SSP was used. The newer version of the SSP, part scores on the hyper-reactivity items range from 77
of the Sensory Profile-2 family of assessments (34), to 95 (0.88 to 4.72 logits).
was not available at the time of the previous study.
Results
Analysis
Considering that the purpose of the study was to The recruitment period yielded 299 participants
develop a better understanding of the relationship whose children were aged between 3 and 6 years. After
between defecation behaviors and sensory hyper- verification of inclusion and exclusion criteria, 276
reactivity, our analysis was based on a subset of participants were retained for the analysis (Table 3).
relevant items from the THPQ-R and the SSP. The FDD/STR group (total n=136; ASD n=33,
In relation to the THPQ-R, the analysis included ADHD n=5) included children with FC (n=129),
the scores obtained on the first 15 items of the FNRFI (n=2) and STR (n=5). The comparison group
questionnaire as recommended by the authors (24). (total n=140, ASD n=6, ADHD n=2) consisted of
In the case of the SSP, analysis was done following children without FDD or STR.
the method described by Mazurek and colleagues
(35) and used in a previous study (19). A sensory Sensory Hyper-Reactivity in FDD/STR
hyper-reactivity score was calculated using the items An independent-samples t-test was run to
designed to detect sensory hyper-reactivity (items determine if there were differences in the sensory
1–14 and 34–38). hyper-reactivity scores between children with FDD/
The Student-t test was used to compare the scores STR and the comparison group. The sensory hyper-
of both groups (comparison group and FDD/STR reactivity mean score was lower for children with
group) on the THPQ-R and SSP. Differences were FDD/STR (0.91±0.09) than for children without
considered statistically significant at P<0.05. To FDD/STR (1.34±0.08). The difference (0.44 (95%
analyze the relationships between the SSP scores and CI, 0.67 to 0.21)) was observed to be statistically
the THPQ-R scores, a Pearson correlation coefficient significant: t(274)=-3.759; P<0.0005. The sensory
was calculated. In order to use parametric statistical hyper-reactivity mean score of the children without
tests, THPQ-R and SSP raw scores, based on ordinal FDD/STR (1.34±0.08) fell clearly within the typical
scaling, were transformed to linear measurements range (0.88 to 4.72). The mean score of children in
expressed in log odds probability units (logits) using the FDD/STR group (0.91±0.09), considering the

Table 2: THPQ-R and SSP Raw Scores Equivalence in Log Odds Probability Units
THPQ-R
Raw Logits S.E. Raw Logits S.E. Raw Logits S.E. Raw Logits S.E.
15 -4.41 1.87 19 -1.21 0.64 23 0.19 0.57 27 1.65 0.68
16 -3.08 1.08 20 -0.82 0.61 24 0.52 0.58 28 2.19 0.79
17 -2.23 0.81 21 -0.46 0.58 25 0.86 0.59 29 3.00 1.06
18 -1.66 0.70 22 -0.13 0.57 26 1.23 0.62 30 4.29 1.86
SSP
Raw Logits S.E. Raw Logits S.E. Raw Logits S.E. Raw Logits S.E.
19 -4.78 1.82 38 -0.82 0.23 57 0.01 0.20 76 0.83 0.23
20 -3.60 0.98 39 -0.77 0.23 58 0.05 0.20 77 0.88 0.23
21 -2.93 0.69 40 -0.72 0.22 59 0.09 0.20 78 0.94 0.24
22 -2.55 0.56 41 -0.67 0.22 60 0.13 0.20 79 1.00 0.24
23 -2.28 0.48 42 -0.62 0.22 61 0.17 0.20 80 1.06 0.25
24 -2.08 0.43 43 -0.57 0.22 62 0.21 0.20 81 1.12 0.26
25 -1.91 0.39 44 -0.53 0.21 63 0.25 0.20 82 1.19 0.27
26 -1.77 0.36 45 -0.48 0.21 64 0.29 0.20 83 1.26 0.28
27 -1.65 0.34 46 -0.44 0.21 65 0.33 0.20 84 1.34 0.29
28 -1.54 0.32 47 -0.40 0.21 66 0.37 0.20 85 1.43 0.30
29 -1.44 0.30 48 -0.35 0.21 67 0.42 0.21 86 1.52 0.31
30 -1.35 0.29 49 -0.31 0.20 68 0.46 0.21 87 1.63 0.33
31 -1.27 0.28 50 -0.27 0.20 69 0.50 0.21 88 1.75 0.36
32 -1.20 0.27 51 -0.23 0.20 70 0.54 0.21 89 1.88 0.39
33 -1.13 0.26 52 -0.19 0.20 71 0.59 0.21 90 2.05 0.42
34 -1.06 0.25 53 -0.15 0.20 72 0.64 0.22 91 2.25 0.48
35 -1.00 0.25 54 -0.11 0.20 73 0.68 0.22 92 2.51 0.55
36 -0.94 0.24 55 -0.07 0.20 74 0.73 0.22 93 2.89 0.68
37 -0.88 0.24 56 -0.03 0.20 75 0.78 0.22 94 3.54 0.98
95 4.72 1.81
Raw: Raw Score; Logits: Log odds probability units; S.E.: Standard Error

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Table 3: Distribution of children by age

Age (years) 3 4 5 6 Total
FDD/STR 45 43 23 25 136
NO FDD/STR 46 40 30 24 140
Total 91 83 53 49 276
FDD: functional defecation disorder; STR: stool toileting refusal

standard error of measurement (0.82-1.00), could a clear difference between the groups. Consequently,
potentially be outside the typical range and within clinicians need to be sensitive to the possibility
the clinical range of sensory hyper-reactivity. of sensory hyper-reactivity when working with
FDD. Clearly identifying sensory hyper-reactivity
Relationship of THPQ-R and Sensory Hyper- related to FDD is of utmost importance to guide
Reactivity Scores the assessment and intervention process with this
The THPQ-R mean score was lower for children population.
with FDD/STR (1.83±1.59) than for children without Assessment of sensory reactivity using caregiver
FDD/STR (3.79±0.77). The difference (1.96; 95% questionnaires has become an accepted method of
CI: 2.26 to 1.66), was statistically significant: documenting issues in this area (34, 39); however,
t(193.879)=-12.967; P<0.0005. When all children tools available up to this point have not addressed
were considered together, there was a statistically defecation. The THPQ-R fills this gap. The THPQ-R
significant, moderate positive correlation between has been systematically developed and validated to
THPQ-R and sensory hyper-reactivity scores: measure a broad range of challenging defecation
r(274)=0.443; P<0.0005. This relationship was also behaviors potentially linked to sensory hyper-
found when children with FDD/STR were considered reactivity in children aged 3 to 6 years. The THPQ-R
separately (r(274)=0.485; P<0.0005). These results is a caregiver questionnaire, which in the case of
reveal that higher levels of sensory hyper-reactivity assessing the toileting behavior of young children, is
were associated with a higher frequency of the the most ecologically valid way to obtain information
challenging defecation behaviors described in the (48). Our previous work had provided preliminary
hyper-reactivity items of the THPQ-R. support for the hypothesis that the behaviors described
in the sensory hyper-reactivity section of an earlier
Discussion version of the THPQ were associated with sensory
hyper-reactivity in children with fecal incontinence
The relationship between sensory reactivity concerns with concomitant functional constipation who had
and FDD is a relatively recent area of study. On one not responded to conventional medical management
hand, the construct of sensory reactivity (hyper- (19). The present study adds support to the validity
reactivity and hypo-reactivity) is well established of the revised version of the THPQ and does so with
within the Ayres Sensory Integration® framework a bigger sample size of children with a variety of
(36-40), and issues in sensory reactivity are reported to defecation issues, thus increasing its relevance in
be highly prevalent in children with ASD and ADHD research and clinical practice.
(38, 41) as well as in children without developmental Health practitioners do not usually consider sensory
disorders42. Similarly, children with FDD have hyper-reactivity as a possible factor contributing to
been extensively characterized by the medical and the difficulties of the child with FDD; however, the
mental health fields (3, 8, 43). Furthermore, FDDs results presented here indicate that routine screening
are reported to be highly prevalent in the general for sensory hyper-reactivity may be an important
childhood population (1), and even more so among practice element. Tools such as the SSP may not
those with ASD or ADHD (5, 6). However, besides be sufficiently sensitive to identify sensory hyper-
the publication of a few case studies (21, 44, 45) and reactivity issues related to FDD. The use of a refined
program evaluations (20, 46), the interface between tool, with items specifically designed to detect hyper-
sensory reactivity issues and FDD has only been reactivity to defecation related sensations, is needed
formally considered recently (19, 23, 35, 47). to complement tools that address general aspects of
A comprehensive understanding of the factors sensory reactivity. There is emerging evidence that
contributing to the emergence and maintenance interventions designed to address the sensory hyper-
of FDD is becoming increasingly important as reactivity issues that appear to underlie the behaviors
the overall incidence rises2 and success rates for related to the onset and maintenance of FDD may
treatment of children with defecation concerns remain contribute to more successful treatment outcomes
limited (7, 9). This study adds to our understanding (20-22). Moreover, there is growing evidence
by identifying sensory hyper-reactivity in some supporting the use of occupational therapy to
children with FDD, and by showing that the two enhance participation and performance in activities
conditions are moderately correlated. Although the of daily living in children with sensory issues and
mean sensory hyper-reactivity score for children ASD (49, 50). Our current work supports the use of
with FDD was within a sub-clinical range, there was the THPQ-R in the identification of sensory hyper-

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 Beaudry-Bellefeuille I et al.

reactivity-related FDD, which is an essential step in manifestations of FDD seem to be more prominent in
understanding some of the underlying issues that can younger children (26). Furthermore, the diagnostic
potentially be addressed in intervention. groups (ASD, ADHD) that were included in our
The main limitation to this study is the small age study represented a small proportion of our sample
range (3 to 6 years); older children and teenagers that was unevenly distributed among our FDD/STR
also experience FDD. Nevertheless, our focus was and comparison groups. We therefore could not
on younger children as ongoing toileting concerns analyze these cases separately. Thus, future studies
generally become apparent during this time and with wider age ranges and larger samples of children
symptoms such as painful defecation or defecation with ASD and ADHD are needed to further validate
refusal appear (26, 27). This age range was also the THPQ-R and better characterize children within
chosen given that the THPQ-R has been validated the diagnostics groups known to be at risk for FDD.
with this age group. Additionally, the THPQ-R is
based on observation of behavior, and behavioral Conflict of Interests: None declared.

References

1. Koppen IJN, Vriesman MH, Saps Systematic review and meta-analysis with retentive fecal incontinence.
M, et al. Prevalence of Functional of behavioral interventions for fecal Am J Occup Ther. 2017;71(5):
Defecation Disorders in Children: incontinence with constipation. J 7105220020p1-7105220020p8.
A Systematic Review and Meta- Pediatr Psychol 2014;39(8):887-902. 20. Beaudry Bellefeuille I, Ramos Polo
Analysis. J Pediatr 2018;198:121-30. 11. Palit S, Lunniss PJ, Scott SM. The E. Tratamiento combinado de la
2. Rajindrajith S, Devanarayana N, Physiology of Human Defecation. Dig retención voluntaria de heces mediante
Perera B, Benninga M. Childhood Dis Sci 2012;57:1445–1464. fármacos y terapia ocupacional
constipation as an emerging public 12. Baum CF, John A, Srinivasan K, [Combined treatment of volontary
health problem. World J Gastroenterol et al. Colon manometry proves that stool retention with medication and
2016;22(30): 6864-6875. perception of the urge to defecate is occupational therapy]. Bol Pediatr
3. The Rome Foundation. Rome IV present in children with functional 2011;51:169-176.
Pediatric Functional Gastrointestinal constipation who deny sensation. 21. Beaudry IB, Schaaf RC, Ramos EP.
Disorders-Disorders of Brain-Gut J Pediatr Gastroenterol Nutr Brief Report—Occupational therapy
Interaction. Raleigh (NC): The Rome 2013;56(1): 19-22. based on Ayres Sensory Integration
Foundation;2016. 13. Loening-Baucke V. Sensitivity of the in the treatment of retentive fecal
4. Niemczyk J, Equit M, El Khatib sigmoid colon and rectum in children incontinence in a 3-year-old boy. Am
D, von Gontard A. Toilet refusal treated for chronic constipation. J J Occup Ther 2013;67(5), 601–606.
syndrome in preschool children: do Pediatr Gastroenterol Nutr 1984;3(3): 22. Handley-More D, Richards K,
different subtypes exist?. J Pediatr 454-459. Macauley R, & Tierra, A. Encopresis:
Gastroenterol Nutr 2014;58(3):303-6. 14. Wald, A. Biofeedback for neurogenic Multi-fisciplinary management.
5. McElhanon B, McCracken C, fecal incontinence: rectal sensation is Journal of Occupational Therapy,
Karpen S, Sharp W. Gastrointestinal a determinant of outcome. J Pediatr Schools, & Early Intervention
Symptoms in Autism Spectrum Gastroenterol Nutr 1983;2(2): 2009;2(2): 96–102.
Disorder: A Meta-analysis. Pediatrics 302-306. 23. Pollock MR, Metz AE, Barabash T.
2014;133(5):872-883. 15. Castilloux J, Noble A, Faure C. Is Brief Report—Association between
6. McKeown C, Hisle-Gorman E, Eide visceral hypersensitivity correlated dysfunctional elimination syndrome
M, et al. Association of constipation with symptom severity in children and sensory processing disorder. Am
and fecal incontinence with attention- with functional gastrointestinal J Occup Ther 2014;68(4), 472–477.
deficit/hyperactivity disorder. disorders?. J Pediatr Gastroenterol 24. Beaudry-Bellefeuille I, Bundy A,
Pediatrics 2013;132(5):1210-15 Nutr 2008;46(3): 272-278. Lane A, et al. The Toileting Habit
7. Pijpers MA, Bongers ME, Benninga 16. Duarte MA, Goulart EMA, Penna FJ. Profile Questionnaire; Examining
MA, Berger MY. Functional Pressure pain threshold in children Construct Validity using the
constipation in children: a systematic with recurrent abdominal pain. J Rasch Model. Br J Occup Ther.
review on prognosis and predictive Pediatr Gastroenterol Nutr 2000;31(3): 2018:Advance online publication. doi:
factors. J Pediatr Gastroenterol Nutr 280-285. 10.1177/0308022618813266
2010; 50: 256-268. 17. Iovino P, Tremolaterra F, Boccia G, 25. Beaudry-Bellefeuille I, Lane SJ, Chiu
8. Tabbers M, Di Lorenzo C, Berger et al. Irritable bowel syndrome in S, et al. The Toileting Habit Profile
M, et al. Evaluation and Treatment childhood: visceral hypersensitivity Questionnaire-Revised; examining
of Functional Constipation in Infants and psychosocial aspects. discriminative and concurrent validity.
and Children: evidence-based Neurogastroenterol Motil 2009;21(9): Journal of Occupational Therapy,
recommendations from ESPGHAN 940-e74. Schools, & Early Intervention 2019;
and NASPGHAN. J Pediatr 18. Beaudry-Bellefeuille I, Lane SJ, Lane doi: 10.1080/19411243.2019.1590756
Gastroenterol Nutr 2014;58(2):258-74. A. Sensory integration concerns in 26. Borowitz SM, Cox DJ, Sutphen
9. Bongers ME, van Wijk MP, Reitsma children with functional defecation JL. Differences in toileting habits
JB, Benninga MA. Longterm disorders: A scoping review. Am J between children with chronic
prognosis for childhood constipation: Occup Ther:73(3) encopresis, asymptomatic siblings,
clinical outcomes in adulthood. 19. Beaudry-Bellefeuille I, Lane and asymptomatic nonsiblings. J Dev
Pediatrics 2010;126: e156-e162. SJ. Examining sensory over- Behav Pediatr 1999;20(3):145–149.
10. Freeman K, Riley A, Duke D, Fu R. responsiveness in preschool children 27. Wald ER, Di Lorenzo C, Cipriani

6  Ann Colorectal Res 2019;7(4)

 Beaudry-Bellefeuille I et al.

L, et al. Bowel habits and toilet and gastrointestinal problems in Diagnostic and statistical manual
training in a diverse population of children with autism spectrum of mental disorders (DSM-5®).
children. J Pediatr Gastroenterol disorders. J Abnorm Child Psychol American Psychiatric Pub, 2013.
Nutr 2009;48(3): 294-298. 2013;41(1): 165–176. 44. Radford J, Anderson M. Encopresis
28. Qualtrics. Provo, UT: http://www. 36. Ayres AJ. Tactile functions. Their in children on the autistic spectrum.
qualtrics.com. 2017 relation to hyperactive and perceptual Early Child Dev Care 2003;173(4):
29. Beaudry-Bellefeuille I, Lane SJ, motor behavior. Am J Occup Ther 375-382.
Ramos-Polo E. The Toileting Habit 1964;18(1): 6–11. 45. Stadtler AC, Burke P. A group
Profile Questionnaire: Screening for 37. Ayres AJ, Tickle LS. Hyper- treatment approach to failure to toilet
sensory-based toileting difficulties in responsivity to touch and vestibular train: The case of Max. Clin Excell
young children with constipation and stimuli as a predictor of positive Nurse Pract 1998;2(2):83-7.
retentive fecal incontinence. Journal response to sensory integration 46. Silva LM, Cignolini A, Warren
of Occupational Therapy, Schools, & procedures by autistic children. Am R, et al. Improvement in sensory
Early Intervention 2016;9(2): 163-175. J Occup Ther 1980;34(6): 375–381. impairment and social interaction in
30. Cox DJ, Ritterband LM, Quillian 38. Lane SJ, Reynolds S, Thacker L. young children with autism following
W, et al. Assessment of behavioral Sensory over-responsivity and ADHD: treatment with an original Qigong
mechanisms maintaining encopresis: Differentiating using electrodermal massage methodology. Am J Chin
Virginia encopresis-constipation responses, cortisol, and anxiety. Front Med 2007;35(3): 393-406.
apperception test. J Pediatr Psychol Integr Neurosci 2010;4: 8. 47. Little LM, Benton K, Manuel-Rubio
2003;28(6): 375-382. 39. Parham LD, Ecker C. Sensory M, et al, Contribution of Sensory
31. Dunn W. Sensory Profile. San Antonio processing measure (SPM). Western Processing to Chronic Constipation
TX: Pearson Education: 1999. Psychological Services: 2007. in Preschool Children. J Pediatr
32. McIntosh DN, Miller LJ, Shyu V, 40. Su CT, Parham LD. Validity of sensory 2019: article in press downloaded
Dunn W (1999). Overview of the Short systems as distinct constructs. Am J from https://www.jpeds.com/article/
Sensory Profile. Dunn W, editor. In: Occup Ther 2014;68(5): 546–554. S0022-3476(19)30307-5/pdf
The Sensory Profile: User’s manual. 41. Ben-Sasson A, Cermak SA, Orsmond 48. Schmuckler MA. What is ecological
The Psychological Corporation. 1999; GI, et al. Extreme sensory modulation validity? A dimensional analysis.
59-73. behaviors in toddlers with autism Infancy 2001;2(4), 419-436.
33. Beaudry-Bellefeuille I, Lane SJ. spectrum disorders. Am J Occup Ther 49. Pfeiffer BA, Koenig K, Kinnealey M,
Cultural adaptation for Spain of the 2007;61(5): 584–592. et al. Research Scholars Initiative—
Spanish version of the Short Sensory 42. Reynolds S, Shepherd J, Lane SJ. Effectiveness of sensory integration
Profile using cognitive interviews. Sensory modulation disorders in a interventions in children with autism
Austin J Autism & Relat Disabil minority Head Start population: spectrum disorders: A pilot study. Am
2015;1(1): 1004. Preliminar y prevalence and J Occup Ther 2011;65(1): 76–85.
34. Dunn, W. (2014). Sensory Profile 2. characterization. Journal of 50. Schaaf RC, Benevides T, Mailloux
San Antonio, TX: Pearson Education: Occupational Therapy, Schools, Z, et al. An intervention for sensory
2014. & Early Intervention 2008;1(3-4), difficulties in children with autism:
35. Mazurek MO, Vasa RA, Kalb LG, et 186-198. A randomized trial. J Autism Dev
al. Anxiety, sensory over-responsivity, 43. American Psychiatric Association. Disord 2013;44(7): 1493-1506.

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