A Pilot Randomized Clinical Trial of a Multidisciplinary Intervention for Encopresis in Children with Autism Spectrum Disorder
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| Title: | A Pilot Randomized Clinical Trial of a Multidisciplinary Intervention for Encopresis in Children with Autism Spectrum Disorder |
|---|---|
| Language: | English |
| Authors: | Lomas Mevers, Joanna (ORCID |
| Source: | Journal of Autism and Developmental Disorders. Mar 2020 50(3):757-765. |
| Availability: | Springer. Available from: Springer Nature. 233 Spring Street, New York, NY 10013. Tel: 800-777-4643; Tel: 212-460-1500; Fax: 212-348-4505; e-mail: customerservice@springernature.com; Web site: https://link.springer.com/ |
| Peer Reviewed: | Y |
| Page Count: | 9 |
| Publication Date: | 2020 |
| Document Type: | Journal Articles Reports - Research |
| Descriptors: | Autism, Pervasive Developmental Disorders, Behavior Modification, Intervention, Health Behavior, Caregiver Role, Training, Program Effectiveness, Toilet Training, Drug Therapy, Reinforcement, Children |
| DOI: | 10.1007/s10803-019-04305-5 |
| ISSN: | 0162-3257 |
| Abstract: | Children with autism spectrum disorder (ASD) are often delayed in achieving bowel continence, resulting in negative outcomes. In this pilot trial, 20 children with ASD and encopresis were randomly assigned to multidisciplinary intervention for encopresis (MIE; n = 10) or a waitlist control group (n = 10). The MIE group was treated for constipation and received a 10-day behavioral intervention that utilized suppositories to produce predictable bowel movements that were reinforced. Caregivers were trained to implement the intervention. Results support the feasibility of clinical trials of MIE, with high enrolment, competition, attendance, and caregiver acceptability. Preliminary outcomes were positive, with six of 10 in the MIE group achieving continence by the end of treatment compared to 0 in the control group (p = 0.005). |
| Abstractor: | As Provided |
| Entry Date: | 2020 |
| Accession Number: | EJ1243037 |
| Database: | ERIC |
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| FullText | Links: – Type: pdflink Url: https://content.ebscohost.com/cds/retrieve?content=AQICAHj0k_4E0hTGH8RJwT4gCJyBsGNe_WN95AvKlDbXJGqwxwGDuyzlWKXZv8gBON9TrBgqAAAA4zCB4AYJKoZIhvcNAQcGoIHSMIHPAgEAMIHJBgkqhkiG9w0BBwEwHgYJYIZIAWUDBAEuMBEEDL7TYezytljKwk2nywIBEICBm5GRXswNH6IwNevbHIta2RpsmspVMfI-OPufPAGVxq2iadLIgn8J0CAyDGHv02hnFv9ANogr3s1w_CqJZjAvsoHS46LrMLL-RHrpXHxYvOwwsItqD5eMQ4dF581T4zmbLUUVa0xZPEWwFOPtjRD4ATSFrRAJlT7ybVuhJofUp0RcXVgFp7flm5leslA2WmLYXCH9juDZaCPBcOW5 Text: Availability: 1 Value: <anid>AN0141662619;aut01mar.20;2020Feb12.03:27;v2.2.500</anid> <title id="AN0141662619-1">A Pilot Randomized Clinical Trial of a Multidisciplinary Intervention for Encopresis in Children with Autism Spectrum Disorder </title> <p>Children with autism spectrum disorder (ASD) are often delayed in achieving bowel continence, resulting in negative outcomes. In this pilot trial, 20 children with ASD and encopresis were randomly assigned to multidisciplinary intervention for encopresis (MIE; n = 10) or a waitlist control group (n = 10). The MIE group was treated for constipation and received a 10-day behavioral intervention that utilized suppositories to produce predictable bowel movements that were reinforced. Caregivers were trained to implement the intervention. Results support the feasibility of clinical trials of MIE, with high enrolment, competition, attendance, and caregiver acceptability. Preliminary outcomes were positive, with six of 10 in the MIE group achieving continence by the end of treatment compared to 0 in the control group (p = 0.005). Registered at clinicaltrials.gov (https://clinicaltrials.gov); ID: NCT02383732.</p> <p>Keywords: Encopresis; Multidisciplinary treatment; Pediatric gastroenterology</p> <hd id="AN0141662619-2">Introduction</hd> <p>Although there is a wide range of adaptive behaviors that are important to foster in children with autism spectrum disorder (ASD), toilet training is one that has a significant impact on the quality of life for both the child and their caregivers. Failure to acquire toileting independence may have negative health effects, restrict the child's school placement, or contribute to stigma from peers (Christophersen and Friman [<reflink idref="bib6" id="ref1">6</reflink>]; Dos Santos et al. [<reflink idref="bib8" id="ref2">8</reflink>]; Friman et al. [<reflink idref="bib12" id="ref3">12</reflink>]; Friman and Jones [<reflink idref="bib13" id="ref4">13</reflink>]). Furthermore, the opportunity to have many important life experiences alongside typically developing peers that are crucial for the social development of children with ASD, such as attending inclusive classrooms, childcare settings, or summer camps, are frequently off limits to those who are not fully toilet trained (Ritblatt et al. [<reflink idref="bib30" id="ref5">30</reflink>]). Negative consequences for caregivers include impaired parent–child relationships, expense of purchasing diapers, parental stress, and isolation from social supports (Christophersen and Friman [<reflink idref="bib6" id="ref6">6</reflink>]; Friman [<reflink idref="bib10" id="ref7">10</reflink>]; Friman and Jones [<reflink idref="bib13" id="ref8">13</reflink>]; Levine [<reflink idref="bib21" id="ref9">21</reflink>]; Macias et al. [<reflink idref="bib24" id="ref10">24</reflink>]).</p> <p>In the general pediatric population, children generally achieve continence between 2 and 4 years of age (Blum et al. [<reflink idref="bib4" id="ref11">4</reflink>]; Heron et al. [<reflink idref="bib15" id="ref12">15</reflink>]; Schum et al. [<reflink idref="bib35" id="ref13">35</reflink>]). By contrast, children with ASD are often delayed in acquisition of toileting skills, and some never achieve continence (von Gontard et al. [<reflink idref="bib38" id="ref14">38</reflink>]). For example, a recent review found that the median prevalence of daytime enuresis was 55% and encopresis was 12% for children with ASD over the age of four (Niemczyk et al. [<reflink idref="bib28" id="ref15">28</reflink>]). These estimates are considerably higher than the rates of enuresis and encopresis in 5 and 6 years old typically developing children (Friman [<reflink idref="bib11" id="ref16">11</reflink>]). Thus, it is not surprising that acquisition of toileting skills is reported as a high priority for treatment by caregivers of children with ASD (Rodger et al. [<reflink idref="bib31" id="ref17">31</reflink>]; Mruzek et al. [<reflink idref="bib27" id="ref18">27</reflink>]). Especially because once continence is achieved individuals stay continent over the long term (Huntley and Smith [<reflink idref="bib16" id="ref19">16</reflink>]; Lomas Mevers et al. [<reflink idref="bib22" id="ref20">22</reflink>]).</p> <p>Although there are well-established behavioral interventions for enuresis (Azrin and Foxx [<reflink idref="bib2" id="ref21">2</reflink>]; Leblanc et al. [<reflink idref="bib19" id="ref22">19</reflink>]), some of the treatment components that make these strategies effective cannot be readily extended to the treatment of incontinent bowel movements, or encopresis. For example, most treatments of enuresis include providing frequent access to preferred drinks (i.e., fluid loading), resulting in an increase in the number of urinations and an elevated probability of a continent void that can be positively reinforced. In contrast, most children have only one or two bowel movements per day (Sujatha et al. [<reflink idref="bib37" id="ref23">37</reflink>]), which significantly restricts the number of reinforcement opportunities. Furthermore, no equivalent to fluid loading exists for the treatment of encopresis. In addition, many children with ASD have primary encopresis, meaning that it is associated with constipation (Lancioni et al. [<reflink idref="bib18" id="ref24">18</reflink>]; Mruzek et al. [<reflink idref="bib27" id="ref25">27</reflink>]). Retention of feces can make stools larger and harder, causing defecation to be painful and creating a cycle of further withholding, worsening constipation and impeding successful treatment if unaddressed (Fishman et al. [<reflink idref="bib9" id="ref26">9</reflink>]). The fact that children with ASD experience constipation more often than typically developing peers (McElhanon et al. [<reflink idref="bib26" id="ref27">26</reflink>]) likely plays a role in the increased prevalence of encopresis in this population, and further highlights the need for treatments that specifically target children with ASD.</p> <p>Such challenges in the treatment of encopresis in children with ASD may explain the limited research in this area (Matson and LoVullo [<reflink idref="bib25" id="ref28">25</reflink>]). Although descriptions of best practices exist (Friman [<reflink idref="bib11" id="ref29">11</reflink>]; Friman et al. [<reflink idref="bib12" id="ref30">12</reflink>]), these have generally not been studied systematically, or studies were not conducted with children diagnosed with ASD. Furthermore, the few studies evaluating treatments for encopresis have generally been limited to case studies with poorly controlled experimental designs (Lancioni et al. [<reflink idref="bib18" id="ref31">18</reflink>]), and none have focused specifically on children with ASD. Finally, even those treatments in the literature that have produced successful outcomes have generally required implementation over long periods and required intensive sit schedules. For example, Axelrod et al. ([<reflink idref="bib1" id="ref32">1</reflink>]) reported successful treatment of encopresis for two individuals, but the intervention took between 9 and 10 weeks and had the participants complete at 2 min sit every 15 min throughout the entire day.</p> <p>Recently, Call et al. ([<reflink idref="bib5" id="ref33">5</reflink>]) reported successful treatment of encopresis in three children with ASD using a multidisciplinary approach. The treatment included medical screening and treatment of constipation by a pediatric gastroenterologist. The intervention used liquid glycerin suppositories to increase the predictability of bowel movements, which in turn increased the opportunity for reinforcement of continence. In this intensive treatment program, continence was observed in 6–15 days (<emph>M</emph> = 11.33) and the use of medication was faded over a span of between 2 and 13 days. The treatment program also included parent training to export the intervention to home. The purpose of the present study was to replicate and extend the findings from Call et al. in a pilot randomized feasibility trial. The study also offered the opportunity to evaluate the preliminary efficacy of this multidisciplinary intervention of encopresis in children with ASD using a clinical trial.</p> <hd id="AN0141662619-3">Method</hd> <p></p> <hd id="AN0141662619-4">Design</hd> <p>Twenty children with ASD and encopresis were randomly assigned to a 10-week structured Multidisciplinary Intervention for Encopresis (MIE) or waitlist in a 1:1 ratio. Random assignment was generated using permuted-blocks with allocation pattern concealed to investigators. Figure 1 outlines the study design and measurement points throughout the study.</p> <p>Graph: Fig. 1 Flow of participants and outcome measures through control and waist list groups for treatment for encopresis</p> <hd id="AN0141662619-5">Participants</hd> <p>Study participants were children (15 boys and 5 girls; mean age 7.6 years ± SD 3.46 years, range 5–16) seeking treatment in a specialized clinic for toilet training for children with ASD (participant demographics and clinical characteristics are found in Table 1). To be eligible participants had to have an ASD diagnosis from a community provider, a current history of encopresis, urine trained, not require the use of an interpreter for caregiver training, and clearance for suppository use by the study pediatric gastroenterologist. Children with a medical condition that would interfere with the sphincter control such as spina bifida or short gut syndrome were excluded. In addition children who had other neurological disorders that effect anal functioning, or children with prolonged or recurrent gastrointestinal infectious disease were excluded. Participants with previous intestinal surgeries or concurrent enuresis were also excluded. Caregivers were asked not to make changes to their daily medical or toileting routine during the 10-week clinical trial with the expectation of when the caregivers were trained to implement the intervention.</p> <p>Baseline demographic and clinical characteristics</p> <p> <ephtml> &lt;table frame="hsides" rules="groups"&gt;&lt;thead&gt;&lt;tr&gt;&lt;th align="left" rowspan="2" /&gt;&lt;th align="left" colspan="2"&gt;&lt;p&gt;No. (%)&lt;/p&gt;&lt;/th&gt;&lt;/tr&gt;&lt;tr&gt;&lt;th align="left"&gt;&lt;p&gt;MIE group (n = 10)&lt;/p&gt;&lt;/th&gt;&lt;th align="left"&gt;&lt;p&gt;Waitlist group (n = 10)&lt;/p&gt;&lt;/th&gt;&lt;/tr&gt;&lt;/thead&gt;&lt;tbody&gt;&lt;tr&gt;&lt;td align="left" colspan="3"&gt;&lt;p&gt;Age, mean (SD, range) 7.2 (3.46, 5&amp;#8211;16) 7.9 (3.78, 5&amp;#8211;15)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left" /&gt;&lt;td align="left"&gt;&lt;p&gt;N (%)&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;N (%)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;Male&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;10 (100)&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;5 (50)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;Female&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;0 (0)&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;5 (50)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;Race&lt;/p&gt;&lt;/td&gt;&lt;td align="left" /&gt;&lt;td align="left" /&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; White&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;5 (50)&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;3 (30)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; Black&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;4 (40)&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;6 (60)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; Asian&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;1 (10)&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;1 (10)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;Ethnicity&lt;/p&gt;&lt;/td&gt;&lt;td align="left" /&gt;&lt;td align="left" /&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; Hispanic&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;8 (80)&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;9 (90)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; Non-Hispanic&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;2 (20)&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;0 (0)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; Unknown&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;0 (0)&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;1 (10)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;Vinland II adaptive scale&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;Mean (SD)&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;Mean (SD)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; Communication&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;55.7 (11.64)&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;48.11 (19.45)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; Daily living skills&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;57.9 (12.24)&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;46.11 (15.87)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; Socialization&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;57.89 (8.07)&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;53.38 (14.29)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; Adaptive behavior composite&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;56.4 (10.12)&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;52.38 (16.31)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;Childhood Autism Rating Scale II Severity group (%)&lt;/p&gt;&lt;/td&gt;&lt;td align="left" /&gt;&lt;td align="left" /&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; Mild to Moderate&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;5 (50)&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;4 (40)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; Severe&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;5 (50)&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;4 (40)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; Missing&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;0 (0)&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;2 (20)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;Social Communication Questionnaire&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;(n = 9)&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;(n = 8)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left" /&gt;&lt;td align="left"&gt;&lt;p&gt;25.56 (5.27)&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;26.75 (7.15)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;/tbody&gt;&lt;/table&gt; </ephtml> </p> <p>The diagnosis of ASD was supported by the Childhood Autism Rating Scale II (CARS II; Schopler et al. [<reflink idref="bib34" id="ref34">34</reflink>]) and the Social Communication Questionnaire (SCQ; Rutter et al. [<reflink idref="bib32" id="ref35">32</reflink>]). The CARS II is a 15-item measure that incorporates parent report and clinical observation of the child by an experienced clinician. The SCQ is a validated, 40-item caregiver report designed to screen for ASD. This tool focuses on communication skills and social functioning and was based on the Autism Diagnostic Interview-Revised (Lord et al. [<reflink idref="bib23" id="ref36">23</reflink>]).</p> <p>The pre-treatment assessment also included the Vineland Adaptive Behavior Scales-Second Edition, Survey Interview (Vineland II; Sparrow et al. [<reflink idref="bib36" id="ref37">36</reflink>]). The Vineland provides standard scores for age and gender on three domains: Communication, Socialization, and Daily Living Skills. The population norm is 100 plus or minus 15 points with higher scores reflecting better adaptive functioning.</p> <p>The consenting process included an overview of the treatment protocol, including a description of the suppositories, the method of their administration and training of staff who did so, as well as the fact that the first administration was overseen by a pediatric psychologist to evaluate the participant's response. Caregivers were also informed that participants who did not remain seated on the toilet were prompted to do so but never restrained on the toilet. Caregivers were also informed that they could observe the administration of suppositories.</p> <hd id="AN0141662619-6">Setting</hd> <p>The study took place in a specialized outpatient clinic that provides behavioral interventions for children with developmental disabilities and behavioral problems. The clinic is equipped with a private bathroom with a toilet, toilet paper dispenser, sink, soap dispenser, mirror, paper towel dispenser, and trash receptacle. When participants where in the bathroom the door remained closed to protect their privacy while completing the toileting routine. When not in the bathroom, participants remained in a nearby multipurpose room where they had access to toys and therapist attention.</p> <hd id="AN0141662619-7">Feasibility Measures</hd> <p>Feasibility focused on enrollment, attendance, attrition, treatment fidelity, and successful completion of study assessment and outcome measures.</p> <hd id="AN0141662619-8">Treatment Fidelity</hd> <p>To ensure therapist fidelity to the treatment protocol, direct observation data were collected during 32% of sessions. At the end of these sessions, the second therapist experimenter who was also trained on the MIE protocol completed a treatment fidelity checklist on five components. Each component was scored as completed, not completed, or not applicable. The five components included (a) accurate implementation of the preference assessment; (b) 30 min independent sit; (c) suppository administration (as needed); (d) delivery of reinforcement (as needed); and (e) suppository dosage fading (as needed).</p> <hd id="AN0141662619-9">Treatment Acceptability</hd> <p>Caregivers completed a treatment acceptability measure based on the Treatment Acceptability Rating Form-Revised (TARF-R) (Reimers and Wacker [<reflink idref="bib29" id="ref38">29</reflink>]) at week 6. Each item on the modified TARF-R is rated on a 1–7 scale with higher scores reflecting greater acceptability. The measure includes: satisfaction with the treatment (18 items), satisfaction with the treatment program (7 items), and satisfaction with the treatment team (3 items).</p> <hd id="AN0141662619-10">Outcome Measures</hd> <p></p> <hd id="AN0141662619-11">Bowel Continence and Bowel Independence</hd> <p>A continent bowel movement was defined as any defecation that occurred while the participant was seated on the toilet. An incontinent bowel movement was defined as any defecation that occurred while the participant was not seated on the toilet. Throughout the study, caregivers in both groups collected data on the frequency of continent and incontinent bowel movements, suppository administration, and dose of the suppository when applicable. For MIE participants, a therapist collected the same data during treatment sessions.</p> <p>Based on parent report at Week 10, participants were classified as continent, incontinent, and/or independent. To be classified as continent a child had to have a continent bowel movement in at least 60% of days during the prior 7-day period (i.e., ≥ 5 out of 7), and no incontinent bowel movements more than 15% of days (i.e., 1 out of 7). Children who did not meet these criteria were classified as incontinent. Participants who met the definition of continence and did not require the use of suppositories during the same period were also classified as independent.</p> <hd id="AN0141662619-12">Clinical Global Impression-Improvement</hd> <p>The Clinical Global Impression for Improvement (CGI-I) is a 7-point scale designed to rate change from baseline. The CGI-I has been used in many randomized clinical trials in ASD (Bearss et al. [<reflink idref="bib3" id="ref39">3</reflink>]; King et al. [<reflink idref="bib17" id="ref40">17</reflink>]. The CGI-I ranges from a score of 1 (very much improved) through 4 (no change) to 7 (very much worse). By convention, ratings of 2 (much improved) or 1 (very much improved) are used to define positive response; all other scores define a non-response.</p> <hd id="AN0141662619-13">Parent Target Problem</hd> <p>At baseline, an independent evaluator (IE), who was blind to group assignment, interviewed the caregiver to identify a Parent Target Problem (PTP; Bearss et al. [<reflink idref="bib3" id="ref41">3</reflink>]). The PTP interview resulted in a brief narrative intended to capture a behavioral description of each problem. For example, the narrative described the frequency, duration, observable characteristics, and impact of the behavior on the family. Given the aim of the study, all caregivers nominated encopresis as a primary problem. Caregivers were encouraged to describe other problems behaviors as well. The PTP narrative was reviewed and updated at week 10 (Follow-up). At week 10, the IE used the PTP narrative and all available information to rate the CGI-I (Bearss et al. [<reflink idref="bib3" id="ref42">3</reflink>]; Scahill et al. [<reflink idref="bib33" id="ref43">33</reflink>]).</p> <hd id="AN0141662619-14">Multidisciplinary Intervention for Encopresis (MIE)</hd> <p>Prior to randomization participants in both groups completed an appointment with, a pediatric gastroenterologist to address constipation using tests and interventions if warranted (e.g., medication) per established guidelines prior to implementing the MIE (Furuta et al. [<reflink idref="bib14" id="ref44">14</reflink>]) and provided clearance for the use of suppositories. Participants in both groups received ongoing care from the pediatric gastroenterologist to address ongoing issues related to constipation.</p> <p>MIE consisted of 10 sessions lasting 1–4 h. At each appointment, therapists identified item(s) that could be used as reinforcers for continent bowel movements. Reinforcers were selected using a Multiple Stimulus without Replacement (MSWO) preference assessment (DeLeon and Iwata [<reflink idref="bib7" id="ref45">7</reflink>]). Items were selected with input from caregivers; therapists presented the participant with an array of three to five preferred items such as leisure items (e.g., toys, iPad), edible items (e.g., candy, chips), and/or preferred activities (e.g., going for a walk, playground). The item or activity identified as most preferred was used as the reinforcer for any continent bowel movements that occurred on that day.</p> <p>Each session consisted of a 32-min sequence of scheduled sitting on the toilet (i.e., sits). The sequence included 10 min on the toilet, followed by 1 min of standing, repeated with 10 min on, 1 min off sequence for three rounds. The instruction to stand up every 10 min was intended to ensure sufficient blood circulation to the legs. Participants either rested both feet on the floor or were provided a footrest to promote effective pushing for a bowel movement. If a participant had a continent urination the therapist delivered praise and the participant remained on the toilet. Participants who had a continent bowel movement were allowed to leave the bathroom, given enthusiastic praise, and access to the positive reinforcer identified by the preference assessment. A continent or incontinent bowel movement ended that day's appointment. All treatment sessions were conducted by trained research staff that had at least two-years of experience working with children with autism and had completed training on the MIE protocol. All research staff were overseen by a licensed psychologist who was also a Doctoral Level Board Certified Behavior Analyst (BCBA-D).</p> <p>If no continent bowel movement occurred during the first 32-min sequence, the participant received a 5 min break. Following the break, the therapist administered a full dose of a liquid glycerin suppository to promote a bowel movement. All therapists were trained by a Registered Nurse to administer the suppository. All suppositories were administered in a private bathroom. This dose of the suppository was consistent with the manufacturer's recommendation according to the age of study participants. After administration of the suppository, the sit sequence resumed as described above. If a bowel movement did not occur during the sit sequence, the participant received a 30-min break from the bathroom. If during this break the participant engaged in any behaviors known to the caregiver as a precursor to a bowel movement (e.g., squatting, facial expressions indicative of pushing, etc.), the therapist guided the participant to the bathroom to sit for 10 min. If the participant had an incontinent bowel movement during the break, they were escorted to the bathroom, cleaned, changed, and the appointment ended. If no bowel movement occurred during the 30-min break, the participant received a second dose of the glycerin suppository and completed a third sit sequence. After completion of the third sit sequence, the appointment ended even if a bowel movement did not occur.</p> <p>If a participant displayed obvious distress upon administration of the suppository (e.g., excessive crying, pushing away the hand of the person administering the suppository, uncharacteristic problem behavior), the session was terminated, and the child would have been be dismissed from the study, however this never occurred during the study.</p> <p>When a participant had a continent bowel movement for two consecutive days following the administration of the suppository, the dose of the glycerin suppository was decreased by 50%. Medication fading continued until continent bowel movements occurred independently during the first sit (i.e., without medication), until the participant was receiving a 1/8 dose, or until the 2 weeks of MIE were completed.</p> <p>On one of last 2 days of the 10-day clinic-based treatment, at least one caregiver was trained on all components of MIE. Caregivers were taught to implement the treatment program using a behavioral skills training model that included verbal instructions, modeling of the treatment and direct observation of the caregiver implementing the treatment. In addition caregivers were provided with written instructions for them to reference once they implemented the intervention in the home.</p> <hd id="AN0141662619-15">Data Analysis</hd> <p>Descriptive statistics were calculated for variables of interest including range, means and standard deviations and ranges for continuous variables and counts and percentages for categorical variables. For binary outcomes (i.e., continent or independent), between treatment group comparisons (MIE vs. waitlist control) were made using Chi square tests. Exact tests were used and mid-P adjusted p-values are reported. Because none of the participants in either group were continent or independent at baseline, it was not possible to calculate pre-post changes in those variables. Effect sizes [number needed to treat (NNT)] were also calculated across MIE and waitlist control groups. On the CGI-I, the rater of positive responses (i.e., "Much Improved/Very Much Improved") was compared by Chi square across treatment groups. Statistical analyses were conducted using SAS v. 9.4 (SAS Institute, Cary, NC) and statistical significance was assessed at 0.05 unless otherwise noted.</p> <hd id="AN0141662619-16">Results</hd> <p>A total of 41 potential participants were screened in order to meet our target enrollment of 20 participants. Of the 20 who did not enroll, 14 met exclusionary criteria and 6 were not interested or unable to participate in research. More specifically four participants did not met the age requirement for the study, four participants did not have an autism diagnosis, one participant did not me our definition for encopresis and therefore was determined not to need treatment, three participants required an interpreter, two participants were unable to travel to the clinic due to distance and lodging, three did not attend the characterization appointment and therefore were not randomized, one participant choose to wait for services through the clinic and two participants were categorized as ineligible but the specific reason was not listed.</p> <hd id="AN0141662619-17">Feasibility Outcomes</hd> <p>To evaluate feasibility of MIE, we set several benchmarks for recruitment, attrition, and attendance (Leon et al. [<reflink idref="bib20" id="ref46">20</reflink>]). In this 12-month study, we achieved our goal of 20 randomized participants. Of potentially eligible participants screened for the study, 76.9% enrolled, which was lower than the 85% expected enrollment (see Fig. 1). Nineteen of 20 randomized subjects completed the trial (95%), which exceeded our benchmark of 90%. The participant who did not complete the trial was in the MIE group and did not return for the endpoint assessment. Participants in the MIE group attended 95% of treatment sessions (range 80–100% across participants) exceeding out benchmark of 90%. On average, caregivers collected complete data on continence, incontinence and medication use in (92.1%; range 51.4–100%) across both groups. This was consistent with the pre-set benchmark of 70%. Caregivers rated the intervention as highly acceptable (<emph>M</emph> = 5.69, <emph>SD</emph> =.18). The mean for therapist fidelity was 99.38% (<emph>SD</emph> = 3.54%) (Table 2).</p> <p>Unadjusted percent bowel movement, percent continent and percent independent</p> <p> <ephtml> &lt;table frame="hsides" rules="groups"&gt;&lt;thead&gt;&lt;tr&gt;&lt;th align="left" /&gt;&lt;th align="left"&gt;&lt;p&gt;Phase&lt;/p&gt;&lt;/th&gt;&lt;th align="left"&gt;&lt;p&gt;MIE&lt;/p&gt;&lt;/th&gt;&lt;th align="left"&gt;&lt;p&gt;Waitlist&lt;/p&gt;&lt;/th&gt;&lt;th align="left"&gt;&lt;p&gt;p-value&lt;sup&gt;a&lt;/sup&gt;&lt;/p&gt;&lt;/th&gt;&lt;th align="left"&gt;&lt;p&gt;NNT&lt;/p&gt;&lt;/th&gt;&lt;/tr&gt;&lt;/thead&gt;&lt;tbody&gt;&lt;tr&gt;&lt;td align="left" rowspan="3"&gt;&lt;p&gt;Continent&lt;sup&gt;b&lt;/sup&gt;&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;Baseline&lt;/p&gt;&lt;p&gt;(n = 10, 10)&lt;/p&gt;&lt;/td&gt;&lt;td char="(" align="char"&gt;&lt;p&gt;0 (0%)&lt;/p&gt;&lt;/td&gt;&lt;td char="(" align="char"&gt;&lt;p&gt;0 (0%)&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;1.00&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;&amp;#8211;&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;Week 6&lt;/p&gt;&lt;p&gt;(n = 10, 10)&lt;/p&gt;&lt;/td&gt;&lt;td char="(" align="char"&gt;&lt;p&gt;6 (60%)&lt;/p&gt;&lt;/td&gt;&lt;td char="(" align="char"&gt;&lt;p&gt;0 (0%)&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;0.005&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;1.7&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;Follow-Up&lt;/p&gt;&lt;p&gt;(n = 9, 10)&lt;/p&gt;&lt;/td&gt;&lt;td char="(" align="char"&gt;&lt;p&gt;5 (56%)&lt;/p&gt;&lt;/td&gt;&lt;td char="(" align="char"&gt;&lt;p&gt;1 (10%)&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;0.053&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;2.2&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left" rowspan="3"&gt;&lt;p&gt;Independence&lt;sup&gt;b&lt;/sup&gt;&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;Baseline&lt;/p&gt;&lt;p&gt;(n = 10, 10)&lt;/p&gt;&lt;/td&gt;&lt;td char="(" align="char"&gt;&lt;p&gt;0 (0%)&lt;/p&gt;&lt;/td&gt;&lt;td char="(" align="char"&gt;&lt;p&gt;0 (0%)&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;1.00&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;&amp;#8211;&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;Week 6&lt;/p&gt;&lt;p&gt;(n = 10, 10)&lt;/p&gt;&lt;/td&gt;&lt;td char="(" align="char"&gt;&lt;p&gt;0 (0%)&lt;/p&gt;&lt;/td&gt;&lt;td char="(" align="char"&gt;&lt;p&gt;0 (0%)&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;1.00&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;&amp;#8211;&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;Follow-Up&lt;/p&gt;&lt;p&gt;(n = 9, 10)&lt;/p&gt;&lt;/td&gt;&lt;td char="(" align="char"&gt;&lt;p&gt;4 (44%)&lt;/p&gt;&lt;/td&gt;&lt;td char="(" align="char"&gt;&lt;p&gt;1 (10%)&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;0.130&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;2.9&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;/tbody&gt;&lt;/table&gt; </ephtml> </p> <p> <emph>NNT</emph> number needed to treat <sups>a</sups>P-value based on a two-sided exact binomial test with a mid-p correction <sups>b</sups>60% of days during a 7 day period (i.e., ≥ 5 out of 7) with no incontinent/dependent bowel movements more than 15% of days (i.e., 1 out of 7)</p> <hd id="AN0141662619-18">Continence and Independence</hd> <p>A total of three participants were treated for constipation, two participants were randomized into the waitlist group and one participant was randomized into the MIE group. Figure 2 depicts the overall percent of participants engaging in continent and independent bowel movements at week 2 (Baseline), week 6 (Post Treatment), and week 10 (Follow-up). At week 2, participants from both the waitlist control and MIE groups were equivalent at 0% continent/independent bowel movements. At week 6, 60% (<emph>n</emph> = 6) of participants in the MIE group were continent and 0% were independent, compared to 0% in the control group for both continence and independence (<emph>p</emph> =.005; NNT = 2; i.e., the number of children treated with MIE to achieve continence compared to control). One participant in the MIE group did not complete the week 10 measures. Of the nine MIE participants with complete data, 56% (<emph>n</emph> = 5 out of 9) were continent and 44% (<emph>n</emph> = 4 of 9) participants met criteria for independence. In contrast, only one participant assigned to the control group (10%) met criteria for continence (<emph>p</emph> =.053; NNT = 3) and independence at week 10 (<emph>p</emph> =.130; NNT = 3).</p> <p>Graph: Fig. 2 Continent/Independent defined as 60% of days during a 7 day period (i.e., ≥ 5 out of 7) with no incontinent/dependent bowel movements more than 15% of days (i.e., 1 out of 7)</p> <hd id="AN0141662619-19">Clinical Global Impression-Improvement (CGI-I)</hd> <p>Table 3 presents the CGI-I rated by the panel of blinded independent evaluators at week 6 (immediate Post-treatment), and week 10 (Follow-up). At week 6, one participant (10%) in the MIE group was rated much improved/very much improved; nine were rated minimally improved/no change (90%); whereas, 10 of 10 participants in the control group were rated no change/minimally improved. At week 10, the CGI-I reflected continued gains for the MIE group with five of ten rated very much improved and much improved, compared to one participant in the control group (50% vs 10%, <emph>p</emph> = 0.076).</p> <p>Clinical global impression-improvement ratings by blinded panel at week 6 (immediate post-treatment) and week 10 follow-up</p> <p> <ephtml> &lt;table frame="hsides" rules="groups"&gt;&lt;thead&gt;&lt;tr&gt;&lt;th align="left" rowspan="2"&gt;&lt;p&gt;Study period&lt;/p&gt;&lt;/th&gt;&lt;th align="left" rowspan="2"&gt;&lt;p&gt;CGI-rating&lt;/p&gt;&lt;/th&gt;&lt;th align="left"&gt;&lt;p&gt;MIE&lt;/p&gt;&lt;/th&gt;&lt;th align="left"&gt;&lt;p&gt;Waitlist&lt;/p&gt;&lt;/th&gt;&lt;th align="left" rowspan="2"&gt;&lt;p&gt;p-value&lt;/p&gt;&lt;/th&gt;&lt;/tr&gt;&lt;tr&gt;&lt;th align="left"&gt;&lt;p&gt;&lt;italic&gt;n&lt;/italic&gt; = 10&lt;/p&gt;&lt;/th&gt;&lt;th align="left"&gt;&lt;p&gt;&lt;italic&gt;n&lt;/italic&gt; = 10&lt;/p&gt;&lt;/th&gt;&lt;/tr&gt;&lt;/thead&gt;&lt;tbody&gt;&lt;tr&gt;&lt;td align="left" rowspan="2"&gt;&lt;p&gt;Week 6&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;Much improved/very much improved&lt;/p&gt;&lt;/td&gt;&lt;td char="(" align="char"&gt;&lt;p&gt;1 (10%)&lt;/p&gt;&lt;/td&gt;&lt;td char="(" align="char"&gt;&lt;p&gt;1 (10%)&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char" rowspan="2"&gt;&lt;p&gt;1.00&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;Minimally improved/no change&lt;/p&gt;&lt;/td&gt;&lt;td char="(" align="char"&gt;&lt;p&gt;9 (90%)&lt;/p&gt;&lt;/td&gt;&lt;td char="(" align="char"&gt;&lt;p&gt;9 (90%)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left" rowspan="2"&gt;&lt;p&gt;Week 10&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;Much improved/very much improved&lt;/p&gt;&lt;/td&gt;&lt;td char="(" align="char"&gt;&lt;p&gt;5 (50%)&lt;/p&gt;&lt;/td&gt;&lt;td char="(" align="char"&gt;&lt;p&gt;1 (10%)&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char" rowspan="2"&gt;&lt;p&gt;0.076&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;Minimally improved/no change&lt;/p&gt;&lt;/td&gt;&lt;td char="(" align="char"&gt;&lt;p&gt;5 (50%)&lt;/p&gt;&lt;/td&gt;&lt;td char="(" align="char"&gt;&lt;p&gt;9 (90%)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;/tbody&gt;&lt;/table&gt; </ephtml> </p> <p>Participants that did not complete measure were classified as no change</p> <hd id="AN0141662619-20">Discussion</hd> <p>Findings from this study support the feasibility of MIE for encopresis in children with ASD. At screening, 25 children were considered eligible. Of these, five (20%) declined to enter. Nineteen of 20 randomized participants (95%) completed the 10-week study. The return rate for in-home data collection was 93% in both groups. For participants who received MIE, attendance to clinic appointments was 95%. Caregivers rated the intervention as acceptable as evidenced by the high acceptability scores captured by the modified TARF-R. The high rate of attendance, low attrition, and caregiver acceptability ratings indicate that caregivers did not find the intervention, including the use of suppositories, overly invasive. Therapists delivered MIE with 99.4% fidelity. Taken together, these data support the viability of conducting a larger scale clinical trial evaluating the effectiveness of MIE treatment.</p> <p>Six of 10 participants in the MIE achieved continence after 6 weeks of treatment compared to 0 of 10 in the control group (<emph>p</emph> = 0.005). Of the nine children in the MIE group who returned at week 10, five remained continent and four achieved bowel independence compared to 1 of 10 children meeting these gains in the control group. These findings suggest that in the absence of treatment, encopresis is unlikely to improve. The MIE results on these functional outcomes are encouraging. The CGI-I was rated by a panel of independent evaluators that was blind to the treatment group. The panel reviewed all available information including continence data, independence data and parent target problems. On the CGI-I, there was no difference between groups at Week 6. At Week 10 however, the rate of positive response was significantly greater in the MEI group compared to waitlist.</p> <p>To promote continence, this study used liquid glycerin suppositories to elicit predictable and timely bowel movements. Previous studies have used other medications such as laxatives to promote bowel movements (Lancioni et al. [<reflink idref="bib18" id="ref47">18</reflink>]). Although laxatives increase the probability of a bowel movement, there is a longer latency from administration to a bowel movement. This makes it difficult to predict the timing of the bowel movement and presents a practical problem of when to escort the child to sit on the toilet to promote the bowel movement. The predictable and timely result of suppositories increases the likelihood of delivering reinforcement for continence.</p> <p>Current approaches to the management of encopresis include either behavioral or medical interventions—rarely in combination. However, encopresis may have behavioral roots (e.g., aversion to using the toilet), a medical etiology (e.g., constipation), or some combination. Thus, a multidisciplinary approach may be warranted. The multidisciplinary approach in the current study incorporated medical consultation with a pediatric gastrologist and treatment of problems such as constipation prior to treatment. This approach set the stage for effective behavioral intervention, by ensuring that medical issues did not inhibit progress. For example, constipation can make bowel movements painful, which may cause the child to withhold to avoid having bowel movements. In such cases, administering a suppository may cause a painful bowel movement and promote further withholding. Resolving constipation before starting treatment with suppositories may decrease the likelihood of having an aversive experience during bowel training. Conversely, treating constipation medically without inclusion of behavioral elements to promote continent bowel movements may not foster the long-term goal of independent bowel movements. In addition, integrating behavioral methods and the use of suppositories appears to achieve positive results more rapidly (i.e., 2 weeks of treatment) than previous encopresis interventions that require up to 10 weeks of treatment (e.g., Axelrod et al. [<reflink idref="bib1" id="ref48">1</reflink>]). Despite the potential advantages of the multidisciplinary approach, behavioral and medical expertise may not both be available in some settings. If future studies support the multidisciplinary approach, additional research will be needed to evaluate the level and type of clinicians necessary to conduct this protocol.</p> <p>Although the findings from the current study are promising, only ten children per group participated. This small sample size requires replication in a large-scale randomized controlled study. Future studies should also include more comprehensive characterization to evaluate potential moderators of positive treatment response. Another limitation of the current study was the use of a waitlist control group. Comparing the effects of MIE to an active control group (e.g., such as an intervention that is consistent with typical practice for the treatment of encopresis) would provide a more rigorous test of efficacy.</p> <p>In conclusion, the findings of the current study suggest that the treatment is acceptable to caregivers of children with ASD and encopresis. The results also provide preliminary evidence that a multidisciplinary treatment that combines both behavior and medical interventions can be effective for the treatment of encopresis for children with ASD. MIE worked relativity quickly and treatment effects maintained and improved 1 month post treatment. Although these finding are promising, future studies should evaluate efficacy using more rigorous methods and evaluate longer term outcomes.</p> <hd id="AN0141662619-21">Funding</hd> <p>Funding was provided by Organization for Autism Research.</p> <hd id="AN0141662619-22">Author Contributions</hd> <p>All authors contributed to the study conception, design, data collection and/or study implementation. Material preparation, data collection and analysis were performed by JLM, NAC, KRG, MS, SJM, CM, SH, CM, LS, and BOM. JLM wrote the first draft of the manuscript and all authors contributed on previous versions of the manuscript. All authors read and approved the final manuscript with the expectation of SH who had left the organization prior to completion of the final manuscript.</p> <hd id="AN0141662619-23">Publisher's Note</hd> <p>Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.</p> <ref id="AN0141662619-24"> <title> References </title> <blist> <bibl id="bib1" idref="ref32" type="bt">1</bibl> <bibtext> Axelrod MI, Tornehl M, Fontanini-Axelrod A. Co-occurring autism and intellectual disability: A treatment for encopresis using a behavioral intervention plus laxative across settings. Clinical Practice in Pediatric Psychology. 2016; 4: 1-10. 10.1037/cpp0000131</bibtext> </blist> <blist> <bibl id="bib2" idref="ref21" type="bt">2</bibl> <bibtext> Azrin NH, Foxx RM. A rapid method of toilet training the institutionalized retarded. 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| Items | – Name: Title Label: Title Group: Ti Data: A Pilot Randomized Clinical Trial of a Multidisciplinary Intervention for Encopresis in Children with Autism Spectrum Disorder – Name: Language Label: Language Group: Lang Data: English – Name: Author Label: Authors Group: Au Data: <searchLink fieldCode="AR" term="%22Lomas+Mevers%2C+Joanna%22">Lomas Mevers, Joanna</searchLink> (ORCID <externalLink term="http://orcid.org/0000-0001-7774-1219">0000-0001-7774-1219</externalLink>)<br /><searchLink fieldCode="AR" term="%22Call%2C+Nathan+A%2E%22">Call, Nathan A.</searchLink><br /><searchLink fieldCode="AR" term="%22Gerencser%2C+Kristina+R%2E%22">Gerencser, Kristina R.</searchLink><br /><searchLink fieldCode="AR" term="%22Scheithauer%2C+Mindy%22">Scheithauer, Mindy</searchLink><br /><searchLink fieldCode="AR" term="%22Miller%2C+Sarah+J%2E%22">Miller, Sarah J.</searchLink><br /><searchLink fieldCode="AR" term="%22Muething%2C+Colin%22">Muething, Colin</searchLink><br /><searchLink fieldCode="AR" term="%22Hewett%2C+Shannon%22">Hewett, Shannon</searchLink><br /><searchLink fieldCode="AR" term="%22McCracken%2C+Courtney%22">McCracken, Courtney</searchLink><br /><searchLink fieldCode="AR" term="%22Scahill%2C+Lawrence%22">Scahill, Lawrence</searchLink><br /><searchLink fieldCode="AR" term="%22McElhanon%2C+Barbara+O%2E%22">McElhanon, Barbara O.</searchLink> – Name: TitleSource Label: Source Group: Src Data: <searchLink fieldCode="SO" term="%22Journal+of+Autism+and+Developmental+Disorders%22"><i>Journal of Autism and Developmental Disorders</i></searchLink>. Mar 2020 50(3):757-765. – Name: Avail Label: Availability Group: Avail Data: Springer. Available from: Springer Nature. 233 Spring Street, New York, NY 10013. Tel: 800-777-4643; Tel: 212-460-1500; Fax: 212-348-4505; e-mail: customerservice@springernature.com; Web site: https://link.springer.com/ – Name: PeerReviewed Label: Peer Reviewed Group: SrcInfo Data: Y – Name: Pages Label: Page Count Group: Src Data: 9 – Name: DatePubCY Label: Publication Date Group: Date Data: 2020 – Name: TypeDocument Label: Document Type Group: TypDoc Data: Journal Articles<br />Reports - Research – Name: Subject Label: Descriptors Group: Su Data: <searchLink fieldCode="DE" term="%22Autism%22">Autism</searchLink><br /><searchLink fieldCode="DE" term="%22Pervasive+Developmental+Disorders%22">Pervasive Developmental Disorders</searchLink><br /><searchLink fieldCode="DE" term="%22Behavior+Modification%22">Behavior Modification</searchLink><br /><searchLink fieldCode="DE" term="%22Intervention%22">Intervention</searchLink><br /><searchLink fieldCode="DE" term="%22Health+Behavior%22">Health Behavior</searchLink><br /><searchLink fieldCode="DE" term="%22Caregiver+Role%22">Caregiver Role</searchLink><br /><searchLink fieldCode="DE" term="%22Training%22">Training</searchLink><br /><searchLink fieldCode="DE" term="%22Program+Effectiveness%22">Program Effectiveness</searchLink><br /><searchLink fieldCode="DE" term="%22Toilet+Training%22">Toilet Training</searchLink><br /><searchLink fieldCode="DE" term="%22Drug+Therapy%22">Drug Therapy</searchLink><br /><searchLink fieldCode="DE" term="%22Reinforcement%22">Reinforcement</searchLink><br /><searchLink fieldCode="DE" term="%22Children%22">Children</searchLink> – Name: DOI Label: DOI Group: ID Data: 10.1007/s10803-019-04305-5 – Name: ISSN Label: ISSN Group: ISSN Data: 0162-3257 – Name: Abstract Label: Abstract Group: Ab Data: Children with autism spectrum disorder (ASD) are often delayed in achieving bowel continence, resulting in negative outcomes. In this pilot trial, 20 children with ASD and encopresis were randomly assigned to multidisciplinary intervention for encopresis (MIE; n = 10) or a waitlist control group (n = 10). The MIE group was treated for constipation and received a 10-day behavioral intervention that utilized suppositories to produce predictable bowel movements that were reinforced. Caregivers were trained to implement the intervention. Results support the feasibility of clinical trials of MIE, with high enrolment, competition, attendance, and caregiver acceptability. Preliminary outcomes were positive, with six of 10 in the MIE group achieving continence by the end of treatment compared to 0 in the control group (p = 0.005). – Name: AbstractInfo Label: Abstractor Group: Ab Data: As Provided – Name: DateEntry Label: Entry Date Group: Date Data: 2020 – Name: AN Label: Accession Number Group: ID Data: EJ1243037 |
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| RecordInfo | BibRecord: BibEntity: Identifiers: – Type: doi Value: 10.1007/s10803-019-04305-5 Languages: – Text: English PhysicalDescription: Pagination: PageCount: 9 StartPage: 757 Subjects: – SubjectFull: Autism Type: general – SubjectFull: Pervasive Developmental Disorders Type: general – SubjectFull: Behavior Modification Type: general – SubjectFull: Intervention Type: general – SubjectFull: Health Behavior Type: general – SubjectFull: Caregiver Role Type: general – SubjectFull: Training Type: general – SubjectFull: Program Effectiveness Type: general – SubjectFull: Toilet Training Type: general – SubjectFull: Drug Therapy Type: general – SubjectFull: Reinforcement Type: general – SubjectFull: Children Type: general Titles: – TitleFull: A Pilot Randomized Clinical Trial of a Multidisciplinary Intervention for Encopresis in Children with Autism Spectrum Disorder Type: main BibRelationships: HasContributorRelationships: – PersonEntity: Name: NameFull: Lomas Mevers, Joanna – PersonEntity: Name: NameFull: Call, Nathan A. – PersonEntity: Name: NameFull: Gerencser, Kristina R. – PersonEntity: Name: NameFull: Scheithauer, Mindy – PersonEntity: Name: NameFull: Miller, Sarah J. – PersonEntity: Name: NameFull: Muething, Colin – PersonEntity: Name: NameFull: Hewett, Shannon – PersonEntity: Name: NameFull: McCracken, Courtney – PersonEntity: Name: NameFull: Scahill, Lawrence – PersonEntity: Name: NameFull: McElhanon, Barbara O. IsPartOfRelationships: – BibEntity: Dates: – D: 01 M: 03 Type: published Y: 2020 Identifiers: – Type: issn-print Value: 0162-3257 Numbering: – Type: volume Value: 50 – Type: issue Value: 3 Titles: – TitleFull: Journal of Autism and Developmental Disorders Type: main |
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