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Constipation is a common problem in children. Although most children respond to conventional treatment, symptoms persist in a minority. For children with refractory constipation, anorectal and colonic manometry testing can identify a rectal evacuation disorder or colonic motility disorder and guide subsequent management. Novel medications used in adults with constipation are beginning to be used in children, with promising results. Biofeedback therapy and anal sphincter botulinum toxin injection can be considered for children with a rectal evacuation disorder. Surgical management of constipation includes the use of antegrade continence enemas, sacral nerve stimulation, and colonic resection.

Constipation is a common problem in children. Although most children respond to conventional treatment, symptoms persist in a minority. For children with refractory constipation, anorectal and colonic manometry testing can identify a rectal evacuation disorder or colonic motility disorder and guide subsequent management. Novel medications used in adults with constipation are beginning to be used in children, with promising results. Biofeedback therapy and anal sphincter botulinum toxin injection can be considered for children with a rectal evacuation disorder. Surgical management of constipation includes the use of antegrade continence enemas, sacral nerve stimulation, and colonic resection.

Encopresis in Autism Spectrum Disorders: analysis of a clinical case. There is a profile of Autism Spectrum Disorder (ASD) in which the associated symptoms cover up the disorder. Within these symptoms there are proprioceptive sensory alterations, which complicate the identification of physical needs, among them, defecation. This study deals with encopresis that besides being a disorder in itself, can also be a symptom that accompanies other disorders, such as ASD. The aim is to show, by presenting a clinical case, that these associated symptoms might be undertaken in clinical care as a disorder in itself, when actually the principal disorder is an ASD, delaying the diagnosis of ASD and hindering the treatment of encopresis. The methods used to analyze the case consisted of a complete evaluation of the patient, a behavioral intervention on toilet training adapted to the characteristics of patients with ASD and its monitoring. The results show a gradual but progressive improvement in bowel habits, consistent with other studies that estimate an average training time of 2 years of toilet training in children with ASD. Despite having completed a behavioral intervention to improve the control of defecation, delayed diagnosis along with several features inherent to ASD, complicates and delays the acquirement of the habit of controlling defecation compared to other patients whose encopresis is not linked to ASD., Existe un perfil de Trastorno del Espectro del Autismo (TEA) en el cual los síntomas asociados enmascaran el trastorno. Dentro de estos síntomas se encuentran las alteraciones sensoriales de tipo propioceptivo que dificultan la identificación de necesidades corporales, entre ellas la defecación. El presente trabajo aborda la encopresis que además de ser un trastorno en sí mismo puede ser un síntoma que acompaña a otros trastornos, por ejemplo, TEA. El objetivo es dar a conocer a través de la presentación de un caso clínico como esta sintomatología asociada puede ser demanda de atención clínica como un trastorno en sí, cuando realmente el trastorno nuclear es un TEA, retrasando el diagnóstico de TEA y dificultando el tratamiento de la encopresis. La metodología utilizada para analizar el caso ha consistido en una evaluación exhaustiva del paciente, una intervención conductual sobre el control de esfínteres adaptada a las características del paciente con TEA y el seguimiento de ésta. Los resultados muestran una lenta pero progresiva mejoría en los hábitos de defecación, lo que concuerda con otros estudios que estiman una media de entrenamiento en control de esfínteres en niños con TEA de 2 años. A pesar de llevar a cabo una intervención conductual dirigida a mejorar el control de la defecación, el diagnóstico demorado junto a ciertas características inherentes a los TEA, dificulta y retrasa la adquisición del hábito de controlar la defecación en comparación con otros pacientes cuya encopresis no va ligada a un TEA.

This paper is a report of the treatment of Lara (4 years and 5 months old) who was experiencing secondary retentive encopresis, with an interval of over 72 hours between defecations. Methods: the evaluation was conducted through interviews with the parents and the nannies, observation at school, individual play sessions and family play sessions; the interventions focused on the use of animated films, play activities and toys to develop behavioral habits and toilet training. Results: after the intervention with the animated film, Lara defecated in the office and had daily defecations during the next 18 months of treatment; she had three serious accidents in this period. Discussion: most likely, after watching the characters’ toilet training and the stickers they got in the animated film, Lara was vicariously reinforced and learned the relationship between the behavior of the characters (toilet training) and the consequent reward (sticker). The game with the dolls used in the film is considered a type of play mediation., Este trabajo consiste en el relato del servicio, en ludoterapia de comportamiento, de Lara (4 años y 5 meses), que presentaba encoprese secundaria retentiva, que acarreaba un intervalo entre las defecaciones superior a 72 horas. Método: la evaluación consistió en entrevista con padres y niñeras, observación en la escuela, sesiones lúdicas y sesiones lúdicas familiares; las intervenciones enfatizaron el uso de film de animación, actividades lúdicas y juguetes para lograr la habituación de comportamiento y realizar el entrenamiento del aseo. Resultado: después de la intervención, utilizando film de animación, Lara defecó en el consultorio, mantuvo el comportamiento diario de defecación durante 18 meses de acompañamiento y presentó tres accidentes críticos en ese período. Discusión: el film de animación es sugerido como la principal intervención para el cambio de comportamiento de Lara. Probablemente, después de observar los personajes del film de animación realizando el entrenamiento de aseo y lograr adhesivos, Lara fue reforzada vicariamente y aprendió la relación entre el comportamiento de los personajes (entrenamiento del aseo) y la consecuencia lograda por ellos (adhesivo). La broma con las muñecas utilizadas en el film es concebida como un tipo de mediación lúdica., Este trabalho consiste no relato do atendimento, em ludoterapia comportamental, de Lara (4 anos e 5 meses), que apresentava encoprese secundária retentiva, o que acarretava um intervalo entre as defecações superior a 72 horas. Método: a avaliação consistiu em entrevista com pais e babás, observação na escola, sessões lúdicas e sessões lúdicas familiares; as intervenções enfatizaram o uso de filme de animação, atividades lúdicas e brinquedos para obter a habituação comportamental e realizar o treino do toalete. Resultado: após a intervenção, utilizando filme de animação, Lara defecou no consultório, manteve o comportamento diário de defecação durante 18 meses de acompanhamento e apresentou três acidentes críticos nesse período. Discussão: o filme de animação é sugerido como a principal intervenção para a mudança de comportamento de Lara. Provavelmente, após observar os personagens do filme de animação realizando o treino de toalete e obterem adesivos, Lara foi reforçada vicariamente e aprendeu a relação entre o comportamento dos personagens (treino do toalete) e a conseqüência obtida por eles (adesivo). A brincadeira com as bonecas utilizadas no filme é concebida como um tipo de mediação lúdica.

Missoula, MT

One hundred and seven children with faecal incontinence were evaluated and managed over a 3 year period by a multidisciplinary team. After initial clinical assessment, evaluation of defaecatory mechanisms (using a balloon model) and assessment of personal-social development and self-concept were undertaken. Management was based on initial bowel evacuation, short-term laxatives, and habit training involving systematic use of positive reinforcement; 69 children received biofeedback conditioning. Idiopathic megacolon with constipation and soiling was the most common finding (98 cases). Other diagnoses included previously undiagnosed neurogenic bowel (three cases), post-surgical anal anomalies (four cases), and psychogenic encopresis (two cases). Idiopathic megacolon was characterized by decreased rectal sensation, increased threshold for external sphincter relaxation and an inability to evacuate. Faecal incontinence was associated with an undesirably low social self-concept (70% of the 40 evaluated), but was not related to a delay in development (mean general developmental quotient = 105 ± 8, for the 35 tested). Family psychopathology warranting referral for family therapy was found in 14 children (13%). The management programme yielded a short-term (3 months) cure rate of 68% and a long-term (12 months) cure rate of 90%, with 10% having continued soiling which varied from occasional to several incidents/week. No significant improvement in self-concept was observed overall, although marked improvements were observed in some children. We conclude that disordered defaecatory dynamics are a major determinant of faecal incontinence in children. Undesirably low social self-concepts but normal developmental ability accompany this condition. Management is facilitated by a multidisciplinary approach, acknowledging the role of both behavioural and physiological components of the problem. This approach is effective in eradicating soiling in the majority of cases, comparing favou

EI artículo muestra la experiencia del autor, en el empleo de la técnica de la terapia familiar sistémica, como auxiliar terapéutico en el manejo de las consultas más frecuentes, atendidas en los servicios psiquiátricos oficiales. Tales quejas, en orden de frecuencia son: bajo rendimiento escolar, inquietud, enuresis, encopresis y trastornos psicofisiológicos. EI trabajo contiene la experiencia con las cuatro primeras, por cuanto el manejo de los trastornos psicofisiológicos, demanda una técnica particular que no es objeto de esta comunicación. No se reporta una cuantificación de resultados, pero se describen como buenos. EI enfoque del manejo global del caso está dentro de los postulados generales de la teoría general de los sistemas y los desarrollos posteriores del método biopsicosocial.