Behavioral therapy for childhood constipation: A randomized controlled trial

OBJECTIVE. It has been suggested that the addition of behavioral interventions to laxative therapy improves continence in children with functional fecal incontinence associated with constipation. Our aim was to evaluate the clinical effectiveness of behavioral therapy with laxatives compared with conventional treatment in treating functional constipation in childhood. PATIENTS AND METHODS. In this randomized, controlled trial conducted in a tertiary hospital in the Netherlands, 134 children aged 4 to 18 years with functional constipation were randomly assigned to 22 weeks (12 visits) of either behavioral therapy or conventional treatment. Primary outcomes were defecation frequency, fecal incontinence frequency, and success rate. Success was defined as defecation frequency of 3 times per week and fecal incontinence frequency of 1 times per 2 weeks irrespective of laxative use. Secondary outcomes were stool-withholding behavior and behavior problems. Outcomes were evaluated at the end of treatment and at 6-months follow-up. All of the analyses were done by intention to treat. RESULTS.Defecation frequency was significantly higher for conventional treatment. Fecal incontinence frequency showed no difference between treatments. After 22 weeks, success rates did not differ between conventional treatment and behavioral therapy (respectively, 62.3% and 51.5%), nor did it differ at 6 months of follow-up (respectively, 57.3% and 42.3%). The proportion of children withholding stools was not different between interventions. At follow-up, the proportion of children with behavior problems was significantly smaller for behavioral therapy (11.7% vs 29.2%). CONCLUSION.Behavioral therapy with laxatives has no advantage over conventional treatment in treating childhood constipation. However, when behavior problems are present, behavioral therapy or referral to mental health services should be considered. C IN CHILDREN is a worldwide problem with a prevalence ranging from 0.7% to 29.6%.1 Up to 84% of functional constipated children suffer from fecal incontinence2 and more than one third exhibit behavior problems.3,4 It remains unclear whether behavior problems are primary or secondary to functional constipation. In the vast majority of patients no somatic cause can be found, and, therefore, these patients are considered to have a functional defecation disorder.5 Retentive posturing or stool-withholding behavior is probably the major cause for development and/or persistence of childhood constipation.6–11 Retained stools become progressively more difficult and painful to evacuate, leading to fear and avoidance of defecation.12,13 This vicious cycle can be described as learned behavior. www.pediatrics.org/cgi/doi/10.1542/ peds.2007-2402 doi:10.1542/peds.2007-2402 The funding source had no role in the study design, data collection, data analysis, data interpretation, writing of the report, or in the decision to submit the article for publication. All of the authors declare that they participated in the concept and design; analysis and interpretation of data; and drafting or revising the article. All the authors affirm that they have had full access to and uphold the integrity of the data presented. Also, all of the authors have seen and approved the final version. The corresponding author had final responsibility for the decision to submit for publication. This trial has been registered at www.clinicaltrials.gov (identifier ISRCTN25185569).