MILWAUKEE — Intensive behavioral therapy with laxatives is no better than conventional therapy in the treatment of childhood constipation, data from a randomized controlled trial show.
Little is known about the effectiveness of behavioral therapy in the treatment of constipation, although it is thought that learned behavior plays a role in the development of constipation, Dr. Marc Benninga reported at an international symposium sponsored by the International Foundation for Functional Gastrointestinal Disorders.
Children may consciously or unconsciously contract their pelvic and gluteal muscles when they feel the urge to defecate. Physiologically, the rectum becomes increasingly distended, which disrupts rectal compliance and the urge to defecate.
Behaviorally, the child experiences repeated difficulty with defecation and pain due to large or hard stools, reinforcing the stool-withholding behavior. The combination creates a vicious cycle of learned behavior that, in theory, could be unlearned through intensive behavioral therapy, Dr. Benninga explained.
Dr. Benninga and associates tested the theory in 129 youths aged 4–18 years who visited a gastrointestinal outpatient clinic for functional constipation. For the study, functional constipation was defined as the presence of at least two of the following criteria: defecation less than three times per week, fecal incontinence two or more times per week, and the presence of large amounts of stool or a palpable fecal mass.
Participants were randomized to 12 months of either conventional therapy—consisting of education, oral laxatives, toilet training, and dietary advice, or a five-element, age-based behavioral intervention program that was developed over a decade (Patient Educ. Couns. 2007 March 17 [Epub doi:10.1016/j.pec.2007.02.002]). Twelve sessions were held over the 12 months.
Children aged 4–8 received the following: education along with their parents that was designed to reinforce a nonaccusatory attitude regarding defecation; anxiety reduction through play therapy; laxatives and skill learning, including appropriate defecation straining; reinforcement using stickers; and establishment of a toileting routine.
The protocol for children older than 8 years did not include anxiety reduction, but instead focused on taking responsibility for their own bowel habits and keeping a bowel diary, said Dr. Benninga, of the department of pediatric gastroenterology and nutrition, Emma Children's Hospital/Academic Medical Center, University of Amsterdam.
Most participants were male, with an average age of 6.5 years in the conventional therapy (CT) group, compared with 7 years in the behavioral therapy (BT) group.
Data analysis was based on 58 patients in the BT group (9 treatment dropouts) and 56 in the CT group (2 treatment dropouts and 4 lost to follow-up).
Among the study's three primary outcomes, only defecation frequency per week showed a significant difference in favor of BT, but that difference was not sustained after 6 months of follow-up, said Dr. Benninga, who characterized the results as “not very convincing.”
Defecation frequency increased from 2.2/wk at baseline to 7.5/wk post treatment to 6.3/wk at follow-up in the BT group, compared with 2.2/wk, 5.5/wk, and 5.7/wk in the CT group, Dr. Benninga reported at the meeting, which was cosponsored by the University of Wisconsin.
Fecal incontinence frequency decreased significantly in both groups from 15 times per week to roughly 3 times per week at follow-up.
Treatment success was slightly higher at follow-up in the BT group (63%), compared with the CT group (54%), but again the difference was not significant. Success was defined as defecation frequency more than twice a week and fecal incontinence less than once every 2 weeks.
“The only striking finding of this study,” Dr. Benninga said, was that significantly fewer children treated by a psychologist had abnormal scores on the Child Behavior Checklist at follow-up, compared with those treated conventionally (38% vs. 82%).
Based on the findings of this investigation, Dr. Benninga recommended screening for behavioral problems in constipated children and referring those with problems to a pediatric psychologist or behavioral therapist.