I used to be one of those people who hated talking about poo. It was gross, and if people mentioned it I would protest and change the subject. So I understand that this post may elicit some queasiness, disengagement or outright dislike. But it is such a crucial subject for those who support children, young people or adults, particularly those with health issues or learning disabilities. So bear with this post, start the conversation at home and in your workplace, share it with your friends and colleagues and don’t let defecating/pooing/dropping the kids off at the pool (insert your favourite analogy here) to be ignored any longer.
What is constipation?
Let’s start off with defining constipation, as like most things, we can all have a different understanding of what it actually means. Constipation refers to both the difficulty in passing a stool, and the infrequency of defecation. It is commonly referred to as “unsatisfactory defecation” due to the lack of complete evacuation of the bowels, the hardness of a stool, and pain associated with straining or bloatedness. Essentially, constipation results in a really unpleasant feeling in the lower stomach region, before, during and after attempts to defecate.
Why does it matter?
Constipation matters for a lot of reasons, partly due to some of the complex health implications if left untreated including rectal prolapse, haemorrhoids, bleeding, twisted bowels, nausea, vomiting, and in extreme cases, death. Perhaps you think death from toileting issues only happens in countries with poor plumbing and access to health care: unfortunately severe and chronic constipation has caused deaths in “Western” countries too: this is an issue regardless of where you live.
It’s difficult to get an highly accurate estimation of the prevalence of constipation, however studies from the US and Canada indicate rates in the general population may be as high as 27%. In individuals with learning difficulties, this number increases further.
Constipation also matters for another reason besides physical health issues: it also impacts behaviour and self regulation.
Why do we need to explore constipation when supporting an individual’s regulation?
I’m sure you can all relate with the discomfort associated with constipation. It’s not a pleasant experience, and one most people are keen to avoid or bring an abrupt end to! When we are in pain or discomfort, we are more irritable and have a decreased ability to think and respond rationally to triggers. Feeling bloated can also make us feel run down, unmotivated and distracted, because our focus is being drawn internally. Perhaps there is an increased frequency of visiting the toilet: it’s hard to remain focused when your attention is constantly interrupted!
It isn’t always easy to identify that the cause of these feelings are due to constipation. Some individuals may have more difficulty recieving and interpreting internal cues. This can mean external monitoring (frequency, duration and quality of defecation) is needed as the internal feeling is less clear. Individuals may need support to express what is happening internally or access assistance even when the cause of the pain has been identified. If this is a challenge (due to age, communication differences or lack of external support), other behaviours may be displayed in an attempt to communicate the need to alleviate the pain.
But it isn’t just the discomfort that impacts our regulation when it comes to constipation. Constipation can be caused by primary (e.g. diet, slow transit through colon) or secondary (e.g. medication, neurological, psychiatric) causes. These causes can all impact on regulation in various ways themselves, with constipation being just one symptom of them.
For example, one common cause of constipation in individuals with autism is due to their diet. As well as constipation, they may experience periods of low energy, high changes in blood glucose levels, or difficulties concentrating if their diet is one consisted of high GI foods. An individual who is taking anti-psychotic medication (associated with constipation) may also be feeling extremely lethargic, and may find it hard to regulate their arousal to the needed levels for what they want or need to do.
Considering the prevalence and impact of constipation, it’s surprising that there isn’t a lot more information about the relationship between constipation and regulation, both in the literature or pages/blog online. Which leads me to a bit of a “soapbox moment”. If you know me or have read any of my blog, you will know regulation is an area that I’m particularly passionate about. The impact regulation has on occupational engagement and participation (especially in the paediatric sector I work in) is huge. It is a “hot topic” and one that may professions are exploring and valuing (which is great!).
However, there is an intense focus on the interventions that “support self regulation development” and their effectiveness, rather than on the individual and their needs. Many occupational therapists in particular tend to primarily focus on one or two areas that are “impacting regulation”; quite frequently sensory processing in recent years. Now I totally agree that an individual’s sensory processing needs to be addressed HOWEVER it can not be the sole focus from onset. We must see all individuals as just that: individual. We shouldn’t prescribe an intervention from broad diagnosis alone. This is true for all involved: parents, educators, doctors, allied health. Looking at just one component of a person results in missing the full picture, and will make progress slower and more frustrating for all involved (including the individual that you are trying to support). So if you think I’m strange for being a bit “poo obsessed”, that’s why!
To wrap up, I want to acknowledge that talking about poo isn’t the most pleasant or glamorous topic, and that it’s not surprising it’s an area that most people don’t really want to “deal” with. But, I hope that I’ve managed to provide a perspective that outlines the reasons why acknowledging it is crucial to supporting individuals, regardless of their age/stage/diagnosis/behaviours. An individual is not just one part, and to support them to “take off”, a broad and holistic view is needed.