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Psychiatric Features of Children with Chronic Functional Constipation: Focusing on Individuals with Autism Spectrum Disorder

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Title: Psychiatric Features of Children with Chronic Functional Constipation: Focusing on Individuals with Autism Spectrum Disorder
Language: English
Authors: Fumiaki Akama, Katsunaka Mikami, Yasushi Orihashi, Syunya Takase, Kyuta Hanawa, Keita Nishikawa, Natsuru Watanabe, Keitaro Kimoto, Yuki Takahashi, Yuichi Onishi, Juan Salas, Kenji Yamamoto, Shigeru Ueno
Source: Journal of Autism and Developmental Disorders. 2025 55(2):585-591.
Availability: Springer. Available from: Springer Nature. One New York Plaza, Suite 4600, New York, NY 10004. Tel: 800-777-4643; Tel: 212-460-1500; Fax: 212-460-1700; e-mail: customerservice@springernature.com; Web site: https://link.springer.com/
Peer Reviewed: Y
Page Count: 7
Publication Date: 2025
Document Type: Journal Articles
Reports - Research
Descriptors: Children, Chronic Illness, Autism Spectrum Disorders, Incidence, Correlation, Symptoms (Individual Disorders), Individual Characteristics, Intervention, Foreign Countries
Geographic Terms: Japan
Assessment and Survey Identifiers: Aberrant Behavior Checklist
DOI: 10.1007/s10803-023-06228-8
ISSN: 0162-3257
1573-3432
Abstract: Purpose: The present study aimed to assess the psychiatric characteristics of children with chronic functional constipation using the Aberrant Behavior Checklist-Japanese version and the Pervasive Developmental Disorders/Autism Society Japan Rating Scale, and to examine the frequency of autism spectrum disorder in children with chronic functional constipation. We also investigated differences in treatment duration between children with and without autism spectrum disorder. Methods: Treatment outcomes were examined retrospectively for 55 participants (chronic functional constipation group: n = 30, mean age 3.4 years; control group: n = 25, mean age, 4.5 years). The association between chronic functional constipation and autism spectrum disorder was evaluated using multivariable logistic regression analysis. Results: The mean Aberrant Behavior Checklist score and frequency of individuals with autism spectrum disorder were significantly higher in the chronic functional constipation group. After adjusting for age and sex, chronic functional constipation was significantly associated with autism spectrum disorder. In the chronic functional constipation group, the frequency of onset was significantly higher in children with autism spectrum disorder under 1 year of age. When treated, the mean duration of constipation was significantly longer in children with autism spectrum disorder. Conclusion: Pediatricians, pediatric surgeons, and child psychiatrists should work closely to ensure appropriate treatment of chronic functional constipation in children with autism spectrum disorder.
Abstractor: As Provided
Entry Date: 2025
Accession Number: EJ1460667
Database: ERIC
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  Value: <anid>AN0182958592;aut01feb.25;2025Feb13.05:25;v2.2.500</anid> <title id="AN0182958592-1">Psychiatric Features of Children with Chronic Functional Constipation: Focusing on Individuals with Autism Spectrum Disorder </title> <p>Purpose: The present study aimed to assess the psychiatric characteristics of children with chronic functional constipation using the Aberrant Behavior Checklist-Japanese version and the Pervasive Developmental Disorders/Autism Society Japan Rating Scale, and to examine the frequency of autism spectrum disorder in children with chronic functional constipation. We also investigated differences in treatment duration between children with and without autism spectrum disorder. Methods: Treatment outcomes were examined retrospectively for 55 participants (chronic functional constipation group: n = 30, mean age 3.4 years; control group: n = 25, mean age, 4.5 years). The association between chronic functional constipation and autism spectrum disorder was evaluated using multivariable logistic regression analysis. Results: The mean Aberrant Behavior Checklist score and frequency of individuals with autism spectrum disorder were significantly higher in the chronic functional constipation group. After adjusting for age and sex, chronic functional constipation was significantly associated with autism spectrum disorder. In the chronic functional constipation group, the frequency of onset was significantly higher in children with autism spectrum disorder under 1 year of age. When treated, the mean duration of constipation was significantly longer in children with autism spectrum disorder. Conclusion: Pediatricians, pediatric surgeons, and child psychiatrists should work closely to ensure appropriate treatment of chronic functional constipation in children with autism spectrum disorder.</p> <p>Keywords: Chronic Functional Constipation; Autism Spectrum Disorder; Abnormal Behavior; Infants; Children</p> <p>Constipation is one of the most prevalent gastrointestinal disorders in infants and children, with a substantial proportion of children suffering from functional constipation (Loening-Baucke, [<reflink idref="bib24" id="ref1">24</reflink>]). Chronic functional constipation (CFC) affects 0.7–29.6% of children and is often difficult to treat (Mugie et al., [<reflink idref="bib26" id="ref2">26</reflink>]; van den Berg et al., [<reflink idref="bib38" id="ref3">38</reflink>]) because these children often have dietary problems such as irregular eating habits, they are often reluctant to take medicine, or are afraid of treatment. In addition, CFC may lead kids to lose their urge to defecate, making it harder for them to develop regular toilet habits (Tunnessen, [<reflink idref="bib36" id="ref4">36</reflink>]). CFC is often associated with infrequent and/or painful defecation, fecal incontinence, and abdominal pain which causes significant distress to the child and family (Tabbers et al., [<reflink idref="bib35" id="ref5">35</reflink>]). A recent review identified growing evidence that CFC severely impairs health-related quality of life in patients and their families, as well as having a considerable influence on health-care costs. (Belsey et al., [<reflink idref="bib8" id="ref6">8</reflink>]). Although CFC may have several etiologies, in most children presenting with the condition, no underlying medical condition responsible for the symptoms can be found (Tabbers et al., [<reflink idref="bib35" id="ref7">35</reflink>]).</p> <p>Autism spectrum disorder (ASD) is a complex developmental condition that involves persistent challenges in social interaction, speech, nonverbal communication, and restricted/repetitive behaviors (DSM-5) (American Psychiatric Association, [<reflink idref="bib7" id="ref8">7</reflink>]). Medical comorbidities are common in patients with ASD including functional gastrointestinal disorders (fGIDs), which are reported in 30–70% of patients with ASD (Buie et al., [<reflink idref="bib10" id="ref9">10</reflink>]; Penzol et al., [<reflink idref="bib33" id="ref10">33</reflink>]; Valicenti-McDermott et al., [<reflink idref="bib37" id="ref11">37</reflink>]; Wang et al., [<reflink idref="bib39" id="ref12">39</reflink>]), the most common of which is constipation (Penzol et al., [<reflink idref="bib33" id="ref13">33</reflink>]; Wang et al., [<reflink idref="bib39" id="ref14">39</reflink>]). One retrospective study demonstrated that at least one fGID was present in 30.5% of 845 patients with ASD, with constipation being the most prevalent (47.4% of fGID patients) (Penzol et al., [<reflink idref="bib33" id="ref15">33</reflink>]). A review of 144 studies published from 1980 to 2017, including studies that assessed gastrointestinal (GI) symptoms or conditions, reported that the prevalence of constipation in patients with ASD was 4.3–45.5% (median, 22%) (Holingue et al., [<reflink idref="bib18" id="ref16">18</reflink>]). A meta-analysis of studies evaluating GI symptoms in children with ASD demonstrated that these children experienced significantly more general GI symptoms than their control counterparts (McElhanon et al., [<reflink idref="bib25" id="ref17">25</reflink>]). Children with ASD who have GI symptoms like constipation have a wide range of serious problems including irritability (Bresnahan et al., [<reflink idref="bib9" id="ref18">9</reflink>]), anxiety, and affective disorders (Fulceri et al., [<reflink idref="bib17" id="ref19">17</reflink>]; Valicenti-McDermott et al., [<reflink idref="bib37" id="ref20">37</reflink>]). Furthermore, a study using the Aberrant Behavior Checklist to compare behavioral problems in children with ASD, with and without GI symptoms, reported that children with ASD having GI symptoms had significantly more behavioral problems, especially social withdrawal and irritability (Chaidez et al., [<reflink idref="bib11" id="ref21">11</reflink>]).</p> <p>Although many reports have revealed that ASD tends to cause constipation, it remains unclear whether there is a higher incidence of ASD among children with CFC. To elucidate this relationship, attention must be paid to the psychiatric and developmental characteristics of children with CFC. However, few studies have been carried out on this particular subject. First, we hypothesized that children with CFC would have a higher frequency of psychiatric and developmental characteristics; therefore, the primary aim of the present study was to evaluate the psychiatric characteristics of children diagnosed with CFC and to examine the frequency of ASD in children with CFC. Next, we hypothesized that CFC in children with ASD would be more difficult to treat. Therefore, our subsequent investigation focused on differences in treatment duration between children with and without ASD.</p> <hd id="AN0182958592-2">Methods</hd> <p></p> <hd id="AN0182958592-3">Participants</hd> <p>The present report consisted of two studies, a cross-sectional and a follow-up study. The cross-sectional study included children aged 2–15 years with CFC who visited the Department of Pediatric Surgery at our institution between July 2013 and March 2019. Patients with organic constipation due to Hirschsprung disease, aproctia, schistorrhachia, hypothyroidism, and drug-induced constipation (psychotropic medication, etc.) were excluded from the study. Patients aged 2–15 years without constipation who were examined at the Department of Pediatric Surgery at our institution were assigned to the control group. While we intended to obtain written consent from children aged ≥ 12 years, the maximum age of the participants was 10 years; therefore, written consent was obtained from guardians at the time of the cross-sectional study. The first cross-sectional study was approved by the Institutional Review Board for Clinical Research at Tokai University School of Medicine (ref, # 13R-106).</p> <p>In the present study, children in the CFC group were enrolled consecutively, and all were treated for constipation following the guidelines for CFC treatment (Tabbers et al., [<reflink idref="bib35" id="ref22">35</reflink>]) until remission. The outcomes of the treatment for and the duration of CFC through February 2021 were retrospectively examined. The duration of CFC was defined as the time from the onset of constipation to the end of treatment. The next follow-up study was also approved by the Institutional Review Board for Clinical Research at Tokai University School of Medicine (ref, # 20R-394).</p> <hd id="AN0182958592-4">Measures</hd> <p>Chronic functional and organic constipation were diagnosed by a pediatric surgeon based on the Rome III criteria (Hyman et al., [<reflink idref="bib19" id="ref23">19</reflink>]; Rasquin et al., [<reflink idref="bib34" id="ref24">34</reflink>]). ASD was diagnosed by a child psychiatrist using the Pervasive Developmental Disorders Autism Society Japan Rating Scale (PARS) (Ito et al., [<reflink idref="bib21" id="ref25">21</reflink>]) for both infantile and current ASD symptoms. The PARS is a semi-structured interview that assesses autistic symptoms and behaviors as defined in the Diagnostic and Statistical Manual (fourth edition), text revision (DSM-IV-TR) (American Psychiatric Association, [<reflink idref="bib6" id="ref26">6</reflink>]) based on information provided by caregivers. The PARS infantile rating includes four subscales: social communication, sensitivity/difficulty, stereotyped behavior, and restricted interest (Ito et al., [<reflink idref="bib21" id="ref27">21</reflink>]). ASD is suspected when the PARS score is ≥ 9 in preschoolers or ≥ 13 in primary school children (Ito et al., [<reflink idref="bib21" id="ref28">21</reflink>]). The evaluation of each item in the PARS, the validity of which has already been established, is based on a numerical rating ranging from 0 to 2, with higher scores indicating more severe autistic symptoms (Ito et al., [<reflink idref="bib21" id="ref29">21</reflink>]). A diagnosis of ASD was confirmed by child psychiatrists using the DSM-5 criteria (American Psychiatric Association, [<reflink idref="bib7" id="ref30">7</reflink>]).</p> <p>The Child Behavior Checklist (CBCL) and Aberrant Behavior Checklist-Japanese version (ABC-J) were used to evaluate the psychiatric characteristics of children with CFC based on the responses provided by their caregivers. The CBCL (Achenbach, [<reflink idref="bib1" id="ref31">1</reflink>], [<reflink idref="bib2" id="ref32">2</reflink>]; Achenbach et al., [<reflink idref="bib3" id="ref33">3</reflink>]) and ABC-J (Aman et al., [<reflink idref="bib4" id="ref34">4</reflink>], [<reflink idref="bib5" id="ref35">5</reflink>]) were both designed to provide standardized reports of recent emotional and behavioral problems. In the CBCL, problematic behaviors were scored in terms of eight characteristics (withdrawal, somatic complaints, anxiety/depression, social problems, thought problems, attention problems, delinquent behavior, and aggressive behavior) and three scales (internalizing, externalizing, and total problems) (Achenbach, [<reflink idref="bib1" id="ref36">1</reflink>], [<reflink idref="bib2" id="ref37">2</reflink>]; Achenbach et al., [<reflink idref="bib3" id="ref38">3</reflink>]). The score ranges from 0 to 100, with lower scores indicating higher functioning children, while a CBCL score ≥ 64 is classified as abnormal (Achenbach, [<reflink idref="bib1" id="ref39">1</reflink>], [<reflink idref="bib2" id="ref40">2</reflink>]; Achenbach et al., [<reflink idref="bib3" id="ref41">3</reflink>]). The ABC-J is a 58-item behavioral rating scale used to measure behavioral problems across five subscales (irritability and agitation, lethargy and social withdrawal, stereotypical behavior, hyperactivity and noncompliance, and inappropriate speech), in which higher scores indicate more severe behavioral problems (Aman et al., [<reflink idref="bib4" id="ref42">4</reflink>]). The Japanese version of the Aberrant Behavior Checklist-Community (ABC-Community) (Aman et al., [<reflink idref="bib5" id="ref43">5</reflink>]) had essentially the same factor structure of the original developed by Aman et al. ([<reflink idref="bib4" id="ref44">4</reflink>]). The factor validity and reliability of ABC-Community was assessed by rating 322 Japanese subjects with moderate to profound mental retardation (Ono, [<reflink idref="bib28" id="ref45">28</reflink>]). Furthermore, the ABC-J is a useful tool for evaluating problematic behaviors in individuals with ASD (Kaat et al., [<reflink idref="bib22" id="ref46">22</reflink>]), and the Japanese versions of the CBCL (Itani et al., [<reflink idref="bib20" id="ref47">20</reflink>]; Nakada et al., [<reflink idref="bib27" id="ref48">27</reflink>]) and ABC-J (Karabekiroglu & Aman, [<reflink idref="bib23" id="ref49">23</reflink>]; Ono, [<reflink idref="bib28" id="ref50">28</reflink>]) have good reliability and validity for infants and children.</p> <hd id="AN0182958592-5">Statistical Analyses</hd> <p>Continuous variables are presented as mean ± standard deviation and were compared using the Mann − Whitney <emph>U</emph> test. Categorical variables are presented as frequencies and percentages and were compared using Fisher's exact test for binary variables and the Mann − Whitney <emph>U</emph> test for ordered variables. The association between CFC and ASD was evaluated using multivariable logistic regression analysis.</p> <hd id="AN0182958592-6">Results</hd> <p>In the first cross-sectional study, the CFC group was selected from a consecutive sample of 34 patients of whom four patients refused to participate. Finally, the CFC group comprised 30 patients (18 boys, 12 girls; mean age, 3.4 years) and the control group had 25 participants (15 boys, 10 girls; mean age, 4.5 years). The age of the participants ranged from 2 to 10 years (Table 1).</p> <p>Table 1 Characteristics of the CFC and non-CFC groups</p> <p> <ephtml> <table frame="hsides" rules="groups"><thead><tr><th align="left" /><th align="left"><p>CFC</p></th><th align="left"><p>Non-CFC</p></th><th align="left"><p><italic>P</italic>-value</p></th></tr><tr><th align="left" /><th align="left"><p>n = 30</p></th><th align="left"><p>n = 25</p></th><th align="left" /></tr></thead><tbody><tr><td align="left"><p>Age, mean (SD)</p></td><td align="left"><p>3.4 (1.4)</p></td><td align="left"><p>4.5 (2.2)</p></td><td char="." align="char"><p>0.0709</p></td></tr><tr><td align="left"><p>Boys, number (%)</p></td><td align="left"><p>18 (60.0)</p></td><td align="left"><p>15 (60.0)</p></td><td char="." align="char"><p>1.0000</p></td></tr><tr><td align="left"><p>Individuals with ASD, number (%)</p></td><td align="left"><p>22 (73.3)</p></td><td align="left"><p>3 (12.0)</p></td><td char="." align="char"><p>< 0.0001</p></td></tr><tr><td align="left"><p>Mean total score of CBCL (SD)</p></td><td align="left"><p>28.6 (18.8)</p></td><td align="left"><p>18.7 (15.1)</p></td><td char="." align="char"><p>0.0506</p></td></tr><tr><td align="left"><p>Mean total score of ABC-J (SD)</p></td><td align="left"><p>13.4 (18.3)</p></td><td align="left"><p>4.0 (5.8)</p></td><td char="." align="char"><p>0.0298</p></td></tr></tbody></table> </ephtml> </p> <p>ABC-J, Aberrant Behavior Checklist-Japanese version; ASD, autism spectrum disorder; CBCL, Child Behavior Checklist; CFC, chronic functional constipation; SD, standard deviation</p> <p>The original study was designed for children aged 2–15 years old, but the actual participants were up to 10 years of age. In the CFC group, there were no other physical diseases that induced constipation and no history of psychiatric hospital visits. In the control group, 18 participants were diagnosed with inguinal hernias; two with testicular masses; and one each with persistent urachus, bleeding hemorrhoids, preauricular subcutaneous tumor, a subcutaneous tumor on the back, and umbilical hernia.</p> <p>The mean total ABC-J score was significantly higher in the CFC than in the control group, while the CBCL score was only marginally higher (<emph>P</emph> = 0.0506) (Table 1). Additionally, the frequency of ASD was significantly higher in the CFC than in the control group (Table 1). According to the PARS subitems, participants in the CFC group experienced more extreme faddiness than those in the control group (<emph>P</emph> = 0.0354). The ABC-J subscales (a) irritability and agitation and (b) lethargy and social withdrawal showed significantly higher scores in the CFC than the control group (Table 2), while hyperactivity and noncompliance showed marginally higher scores (Table 2). Since there was no significant difference in the total CBCL scores between the groups, subscale items were not examined. After adjusting for age and sex, CFC in children was significantly associated with ASD (<emph>P</emph> = 0.0001, using logistic regression).</p> <p>Table 2 Mean score of the subscales of ABC-J for individuals with and without CFC</p> <p> <ephtml> <table frame="hsides" rules="groups"><thead><tr><th align="left" /><th align="left"><p>CFC</p></th><th align="left"><p>Non-CFC</p></th><th align="left"><p><italic>P</italic>-value</p></th></tr><tr><th align="left" /><th align="left"><p>n = 22</p></th><th align="left"><p>n = 21</p></th><th align="left" /></tr></thead><tbody><tr><td align="left"><p>Mean subscale scores of ABC-J (SD)</p></td><td align="left" /><td align="left" /><td align="left" /></tr><tr><td align="left"><p>Irritability and agitation</p></td><td align="left"><p>4.8 (6.2)</p></td><td align="left"><p>1.4 (2.2)</p></td><td char="." align="char"><p>0.0213</p></td></tr><tr><td align="left"><p>Lethargy and social withdrawal</p></td><td align="left"><p>2.5 (4.1)</p></td><td align="left"><p>0.7 (2.4)</p></td><td char="." align="char"><p>0.0057</p></td></tr><tr><td align="left"><p>Stereotypic behavior</p></td><td align="left"><p>0.2 (0.6)</p></td><td align="left"><p>0.0 (0.0)</p></td><td char="." align="char"><p>0.1722</p></td></tr><tr><td align="left"><p>Hyperactivity and noncompliance</p></td><td align="left"><p>5.1 (8.2)</p></td><td align="left"><p>1.7 (2.9)</p></td><td char="." align="char"><p>0.0610</p></td></tr><tr><td align="left"><p>Inappropriate speech</p></td><td align="left"><p>0.9 (1.8)</p></td><td align="left"><p>0.4 (0.8)</p></td><td char="." align="char"><p>0.2741</p></td></tr></tbody></table> </ephtml> </p> <p>ABC-J, Aberrant Behavior Checklist-Japanese version; ASD, autism spectrum disorder; CFC, chronic functional constipation; SD, standard deviation</p> <p>In the follow-up study, when evaluating for treatment outcomes of the 30 children with CFC, 24 children achieved remission, while the remaining six children continued to have constipation. All six children with persistent constipation had ASD, and the mean duration of CFC was significantly longer in children with ASD (Table 3). Additionally, the frequency of CFC onset at < 1 year of age was significantly higher in children with ASD than in those without (Table 3).</p> <p>Table 3 The frequency of CFC onset and duration for children with and without ASD</p> <p> <ephtml> <table frame="hsides" rules="groups"><thead><tr><th align="left" /><th align="left"><p>ASD</p></th><th align="left"><p>Non-ASD</p></th><th align="left"><p><italic>P</italic>-value</p></th></tr></thead><tbody><tr><td align="left"><p>The frequency of onset for CFC under 1 year of age (N)</p></td><td align="left"><p>11</p></td><td align="left"><p>1</p></td><td char="." align="char" rowspan="2"><p>0.0492</p></td></tr><tr><td align="left"><p>Over 1 year of age (N)</p></td><td align="left"><p>10</p></td><td align="left"><p>8</p></td></tr><tr><td align="left"><p>Duration of constipation (months), mean (SD)</p></td><td align="left"><p>69.8 (29.8)</p></td><td align="left"><p>44.9 (19.6)</p></td><td char="." align="char"><p>0.0298</p></td></tr></tbody></table> </ephtml> </p> <p>ASD, autism spectrum disorder; CFC, chronic functional constipation; N, number; SD, standard deviation</p> <hd id="AN0182958592-7">Discussion</hd> <p>To the best of our knowledge, the present study is the first that aimed to elucidate the psychiatric features of children with CFC. Children with CFC exhibited abnormal and problematic behaviors, such as irritability, agitation, lethargy, and social withdrawal. Compared to children without CFC, those with CFC had a higher incidence rate of ASD. In children with CFC who were diagnosed with ASD, the onset of constipation was earlier and more frequent within 1 year of birth, and the duration of CFC was longer than that in children without ASD.</p> <p>It is documented that children with ASD have a higher frequency of constipation (Bresnahan et al., [<reflink idref="bib9" id="ref51">9</reflink>]); however, in the present study, we elucidated that children with CFC, had a higher prevalence of ASD and that the duration of CFC was longer in children with ASD. The majority of cases of childhood constipation are due to CFC and the etiology is unknown, but when we evaluated children with CFC, we found that the most of them (73.3%) had ASD. This is a new finding and may lead to the elucidation of the cause of CFC. In the past, psychiatrists encountering children with ASD considered GI disorders, especially constipation, because GI symptoms affect the core symptoms of ASD (Buie et al., [<reflink idref="bib10" id="ref52">10</reflink>]). In contrast, the present study suggests that pediatricians and pediatric surgeons encountering children with CFC should consider the possibility of comorbid ASD. In other words, when treating a child with CFC with drug therapy, if the child also has ASD, pediatricians and pediatric surgeons should consider coordinating treatment plans with psychiatrists. Clinicians must establish a nursing care system for children with ASD to reduce the overall burden on their families and improve environmental factors. Psychosocial influences strongly affect CFC in children (Constipation Guideline Committee of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition, [<reflink idref="bib12" id="ref53">12</reflink>]; Felt et al., [<reflink idref="bib16" id="ref54">16</reflink>]; Pashankar, [<reflink idref="bib30" id="ref55">30</reflink>]); therefore, treating ASD can, in turn, help treat CFC. For children with refractory CFC, in particular, clinicians must be aware that the child may have ASD.</p> <p>Functional defecation disorders in ASD are associated with sensory irritability, intestinal motility, and muscle coordination problems (Peeters et al., [<reflink idref="bib32" id="ref56">32</reflink>]). Moreover, ASD is thought to result in slow stool transit and involves autonomic nervous system (ANS) problems (Pang & Croaker, [<reflink idref="bib29" id="ref57">29</reflink>]). Therefore, ASD is considered a cause of CFC based on the effects of ANS problems. Second, transitioning from bottles or breastfeeding to baby food and inappropriate toilet training may lead to constipation (Faure et al., [<reflink idref="bib15" id="ref58">15</reflink>]; Hyman et al., [<reflink idref="bib19" id="ref59">19</reflink>]). Children with ASD may also have problems changing toilet habits, (Whiteley, [<reflink idref="bib40" id="ref60">40</reflink>]) leading to constipation (D'Cruz et al., [<reflink idref="bib13" id="ref61">13</reflink>]). Third, dietary effects, such as an unbalanced diet (Eswaran et al., [<reflink idref="bib14" id="ref62">14</reflink>]) and genetic factors (Peeters et al., [<reflink idref="bib31" id="ref63">31</reflink>]), are thought to cause CFC in children. If the intake of fruits and vegetables containing dietary fiber is unbalanced, the intestinal transit time of stool is prolonged, resulting in constipation (Eswaran et al., [<reflink idref="bib14" id="ref64">14</reflink>]). The results of a large prospective cohort study comprising 114,516 Norwegian children indicated that children with ASD had a significantly increased odds of having constipation (adjusted odds ratio, 3.4; 95% confidence interval, 2.1–5.5) in the 6–36-month age range compared with developmentally typical children (Bresnahan et al., [<reflink idref="bib9" id="ref65">9</reflink>]). The results of the aforementioned study also indicated that constipation could be related to an unbalanced diet, genetic factors, immunity, metabolism, and serotonin signaling. Children with ASD tend to have constipation because they consume many unbalanced and processed foods instead of fruits and vegetables that provide dietary fiber (Eswaran et al., [<reflink idref="bib14" id="ref66">14</reflink>]; McElhanon et al., [<reflink idref="bib25" id="ref67">25</reflink>]). In the present study, we observed similar results in that children in the CFC group who were more frequently diagnosed with ASD had a more unbalanced diet.</p> <p>Based on the present study's findings, we believe that the pathophysiology of childhood CFC is strongly related to that of constipation in children with ASD. In the present study, the average total ABC-J score was significantly higher in the CFC than in the control group, indicating that the CFC group was more likely to exhibit behavioral problems. These results can be attributed to the high frequency of ASD in the CFC group. Constipation in children with ASD has been reported to be related to behavioral problems and anxiety symptoms (Chaidez et al., [<reflink idref="bib11" id="ref68">11</reflink>]; Fulceri et al., [<reflink idref="bib17" id="ref69">17</reflink>]); therefore, GI symptoms may contribute to problematic behavior in children with ASD (Wang et al., [<reflink idref="bib39" id="ref70">39</reflink>]). Essentially, unless the negative chain reaction due to the brain–gut interaction is disrupted, neither the problematic behavior nor the constipation will improve. If clinicians simultaneously treat constipation and problematic behaviors in children with ASD, brain–gut interactions may positively affect both. The clinicians treating children with CFC are primarily pediatricians and pediatric surgeons; therefore, the possibility of ASD as a comorbidity must always be considered when encountering CFC in children. Furthermore, when children with constipation have ASD, the treatment plan should account for both constipation and psychosocial issues, as approaching these issues simultaneously will positively impact both.</p> <p>The present study had some limitations. First, this was a cross-sectional study; therefore, the co-treatment of children with CFC or ASD was not evaluated. Second, this was a single-hospital observational study; therefore, similar studies should be conducted in multiple hospitals. Third, we only evaluated whether or not children with CFC were diagnosed with ASD. Other disorders, such as depression and anxiety, must be evaluated in future studies. Fourth, PARS is based on DSM-IV criteria; therefore, we had no other option but to use PARS (DSM-IV) even though ASD is diagnosed using DSM-5 in Japan.</p> <hd id="AN0182958592-8">Conclusion</hd> <p>In this study population, children with CFC had a high frequency of ASD and that children with ASD had a longer duration of CFC and experienced CFC earlier in life. If clinicians encounter children with CFC and behavioral problems, they should consider the possibility of ASD as a comorbidity. When children with CFC develop ASD, pediatricians, pediatric surgeons, and child psychiatrists should work closely together to treat both CF and ASD effectively and immediately.</p> <hd id="AN0182958592-9">Author Contributions</hd> <p>All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by Fumiaki Akama, Katsunaka Mikami, Yasushi Orihashi and Juan Salas. The first draft of the manuscript was written by Fumiaki Akama and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.</p> <hd id="AN0182958592-10">Funding</hd> <p>This study has no funding support to declare.</p> <hd id="AN0182958592-11">Data Availability</hd> <p>The datasets generated and analyzed during the current study are not publicly available due to obligation to secrecy towards the participants.</p> <hd id="AN0182958592-12">Declarations</hd> <p></p> <hd id="AN0182958592-13">Declarations of Conflicting Interests</hd> <p>Fumiaki Akama has received a Grant-in-Aid for Scientific Research (C) (Number 21K11372) and financial support from Otsuka Pharmaceutical and Shionogi & Co. and honoraria from Eisai Co, Pfizer, Shionogi & Co., and Sumitomo Pharma. Katsunaka Mikami has received a Grant-in-Aid for Scientific Research (C) (Number 22K07624) and financial support from Otsuka Pharmaceutical Co., Ltd., and Shionogi & Co., Ltd.; honoraria from Otsuka Pharmaceutical Co., Ltd., Shionogi & Co., Ltd., Sumitomo Pharma Co., Ltd., and Takeda Pharmaceutical Co., Ltd.; travel expenses for the spouse from Pfizer; and a consulting fee from Otsuka Pharmaceutical Co., Ltd., Shionogi & Co., Ltd., and Viatris. Yasushi Orihashi received consulting fees from the Association of Medical Education and Ethics, Kitasato Clinical Research Center, and Daiichi Sankyo Co. Natsuru Watanabe received Grant-in-Aid for Early-Career Scientists (Number 19K17072). Keitaro Kimoto reports grants and personal fees from Otsuka Pharmaceutical Co., Ltd., and Shionogi & Co., Ltd, honoraria from Sumitomo Dainippon Pharma Co., Ltd., Takeda Pharma Co., Ltd, and Viatris. Yuki Takahashi reports grants and personal fees from Shionogi & Co. Yuichi Onishi has received honoraria from Takeda Pharma Co., Ltd. Kenji Yamamoto reports grants and personal fees from Eisai Co., Ltd., grants and personal fees from Otsuka Pharmaceutical Co., Ltd., personal fees from Meiji Seika Pharma Co., Ltd., personal fees from Sumitomo Dainippon Pharma Co., Ltd., personal fees from Pfizer Japan Inc., personal fees from Mitsubishi Tanabe Pharma Corporation, personal fees from Shionogi & Co., Ltd, personal fees from Eli Lilly and Company, personal fees from EA Pharma Co., Ltd., personal fees from Merck Sharp & Dohme, personal fees from Viatris Inc., personal fees from Astellas Pharma Co., Ltd., personal fees from Shionogi & Co., Ltd., personal fees from Takeda Pharma Co., Ltd., grants from Grants-in-Aid for Scientific Research (C), outside the submitted work. Syunya Takase, Kyuta Hanawa, Keita Nishikawa, Juan Salas, and Shigeru Ueno had no conflict of interest.</p> <hd id="AN0182958592-14">Ethical Approval</hd> <p>This research consisted of two clinical studies. The first cross-sectional study was approved by the Institutional Review Board for Clinical Research at Tokai University School of Medicine (ref, #13R-106). The next follow-up study was also approved by the Institutional Review Board for Clinical Research at Tokai University School of Medicine (ref, # 20R-394).</p> <hd id="AN0182958592-15">Consent to Participate</hd> <p>While we planned to obtain written consent from children ≥ 12 years, the maximum age of the participants was 10 years; therefore, written consent was obtained from guardians.</p> <hd id="AN0182958592-16">Consent to Publish</hd> <p>Not Applicable.</p> <hd id="AN0182958592-17">Publisher's Note</hd> <p>Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.</p> <ref id="AN0182958592-18"> <title> References </title> <blist> <bibl id="bib1" idref="ref31" type="bt">1</bibl> <bibtext> Achenbach, T. M. (1991). Manual for the child behavior checklist/4–18 and 1991 profile. Department of Psychiatry, University of Vermont.</bibtext> </blist> <blist> <bibl id="bib2" idref="ref32" type="bt">2</bibl> <bibtext> Achenbach, T. 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  Label: Title
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  Data: Psychiatric Features of Children with Chronic Functional Constipation: Focusing on Individuals with Autism Spectrum Disorder
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  Data: English
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  Data: <searchLink fieldCode="AR" term="%22Fumiaki+Akama%22">Fumiaki Akama</searchLink><br /><searchLink fieldCode="AR" term="%22Katsunaka+Mikami%22">Katsunaka Mikami</searchLink><br /><searchLink fieldCode="AR" term="%22Yasushi+Orihashi%22">Yasushi Orihashi</searchLink><br /><searchLink fieldCode="AR" term="%22Syunya+Takase%22">Syunya Takase</searchLink><br /><searchLink fieldCode="AR" term="%22Kyuta+Hanawa%22">Kyuta Hanawa</searchLink><br /><searchLink fieldCode="AR" term="%22Keita+Nishikawa%22">Keita Nishikawa</searchLink><br /><searchLink fieldCode="AR" term="%22Natsuru+Watanabe%22">Natsuru Watanabe</searchLink><br /><searchLink fieldCode="AR" term="%22Keitaro+Kimoto%22">Keitaro Kimoto</searchLink><br /><searchLink fieldCode="AR" term="%22Yuki+Takahashi%22">Yuki Takahashi</searchLink><br /><searchLink fieldCode="AR" term="%22Yuichi+Onishi%22">Yuichi Onishi</searchLink><br /><searchLink fieldCode="AR" term="%22Juan+Salas%22">Juan Salas</searchLink><br /><searchLink fieldCode="AR" term="%22Kenji+Yamamoto%22">Kenji Yamamoto</searchLink><br /><searchLink fieldCode="AR" term="%22Shigeru+Ueno%22">Shigeru Ueno</searchLink>
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  Data: <searchLink fieldCode="SO" term="%22Journal+of+Autism+and+Developmental+Disorders%22"><i>Journal of Autism and Developmental Disorders</i></searchLink>. 2025 55(2):585-591.
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  Data: Springer. Available from: Springer Nature. One New York Plaza, Suite 4600, New York, NY 10004. Tel: 800-777-4643; Tel: 212-460-1500; Fax: 212-460-1700; e-mail: customerservice@springernature.com; Web site: https://link.springer.com/
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  Data: 7
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  Data: 2025
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  Data: Journal Articles<br />Reports - Research
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  Data: <searchLink fieldCode="DE" term="%22Children%22">Children</searchLink><br /><searchLink fieldCode="DE" term="%22Chronic+Illness%22">Chronic Illness</searchLink><br /><searchLink fieldCode="DE" term="%22Autism+Spectrum+Disorders%22">Autism Spectrum Disorders</searchLink><br /><searchLink fieldCode="DE" term="%22Incidence%22">Incidence</searchLink><br /><searchLink fieldCode="DE" term="%22Correlation%22">Correlation</searchLink><br /><searchLink fieldCode="DE" term="%22Symptoms+%28Individual+Disorders%29%22">Symptoms (Individual Disorders)</searchLink><br /><searchLink fieldCode="DE" term="%22Individual+Characteristics%22">Individual Characteristics</searchLink><br /><searchLink fieldCode="DE" term="%22Intervention%22">Intervention</searchLink><br /><searchLink fieldCode="DE" term="%22Foreign+Countries%22">Foreign Countries</searchLink>
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  Label: Geographic Terms
  Group: Su
  Data: <searchLink fieldCode="DE" term="%22Japan%22">Japan</searchLink>
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  Label: Assessment and Survey Identifiers
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  Data: <searchLink fieldCode="SU" term="%22Aberrant+Behavior+Checklist%22">Aberrant Behavior Checklist</searchLink>
– Name: DOI
  Label: DOI
  Group: ID
  Data: 10.1007/s10803-023-06228-8
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  Label: ISSN
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  Data: 0162-3257<br />1573-3432
– Name: Abstract
  Label: Abstract
  Group: Ab
  Data: Purpose: The present study aimed to assess the psychiatric characteristics of children with chronic functional constipation using the Aberrant Behavior Checklist-Japanese version and the Pervasive Developmental Disorders/Autism Society Japan Rating Scale, and to examine the frequency of autism spectrum disorder in children with chronic functional constipation. We also investigated differences in treatment duration between children with and without autism spectrum disorder. Methods: Treatment outcomes were examined retrospectively for 55 participants (chronic functional constipation group: n = 30, mean age 3.4 years; control group: n = 25, mean age, 4.5 years). The association between chronic functional constipation and autism spectrum disorder was evaluated using multivariable logistic regression analysis. Results: The mean Aberrant Behavior Checklist score and frequency of individuals with autism spectrum disorder were significantly higher in the chronic functional constipation group. After adjusting for age and sex, chronic functional constipation was significantly associated with autism spectrum disorder. In the chronic functional constipation group, the frequency of onset was significantly higher in children with autism spectrum disorder under 1 year of age. When treated, the mean duration of constipation was significantly longer in children with autism spectrum disorder. Conclusion: Pediatricians, pediatric surgeons, and child psychiatrists should work closely to ensure appropriate treatment of chronic functional constipation in children with autism spectrum disorder.
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  Data: 2025
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  Data: EJ1460667
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        Value: 10.1007/s10803-023-06228-8
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      – Text: English
    PhysicalDescription:
      Pagination:
        PageCount: 7
        StartPage: 585
    Subjects:
      – SubjectFull: Children
        Type: general
      – SubjectFull: Chronic Illness
        Type: general
      – SubjectFull: Autism Spectrum Disorders
        Type: general
      – SubjectFull: Incidence
        Type: general
      – SubjectFull: Correlation
        Type: general
      – SubjectFull: Symptoms (Individual Disorders)
        Type: general
      – SubjectFull: Individual Characteristics
        Type: general
      – SubjectFull: Intervention
        Type: general
      – SubjectFull: Foreign Countries
        Type: general
      – SubjectFull: Japan
        Type: general
      – SubjectFull: Aberrant Behavior Checklist
        Type: general
    Titles:
      – TitleFull: Psychiatric Features of Children with Chronic Functional Constipation: Focusing on Individuals with Autism Spectrum Disorder
        Type: main
  BibRelationships:
    HasContributorRelationships:
      – PersonEntity:
          Name:
            NameFull: Fumiaki Akama
      – PersonEntity:
          Name:
            NameFull: Katsunaka Mikami
      – PersonEntity:
          Name:
            NameFull: Yasushi Orihashi
      – PersonEntity:
          Name:
            NameFull: Syunya Takase
      – PersonEntity:
          Name:
            NameFull: Kyuta Hanawa
      – PersonEntity:
          Name:
            NameFull: Keita Nishikawa
      – PersonEntity:
          Name:
            NameFull: Natsuru Watanabe
      – PersonEntity:
          Name:
            NameFull: Keitaro Kimoto
      – PersonEntity:
          Name:
            NameFull: Yuki Takahashi
      – PersonEntity:
          Name:
            NameFull: Yuichi Onishi
      – PersonEntity:
          Name:
            NameFull: Juan Salas
      – PersonEntity:
          Name:
            NameFull: Kenji Yamamoto
      – PersonEntity:
          Name:
            NameFull: Shigeru Ueno
    IsPartOfRelationships:
      – BibEntity:
          Dates:
            – D: 01
              M: 02
              Type: published
              Y: 2025
          Identifiers:
            – Type: issn-print
              Value: 0162-3257
            – Type: issn-electronic
              Value: 1573-3432
          Numbering:
            – Type: volume
              Value: 55
            – Type: issue
              Value: 2
          Titles:
            – TitleFull: Journal of Autism and Developmental Disorders
              Type: main
ResultId 1