Examining hyper-reactivity to defecation related sensations in children with functional defecation disorders

Document Type : Research/Original Article


1 Occupational Therapy, University of Newcastle, Callaghan, Australia

2 MM, Pediatric gastroenterologist, private practice, Oviedo, Spain


Background: Adequate sensory perception and reactivity to sensory stimuli associated with defecation is key to successful stool toileting. Preliminary reports suggests that some of the difficulties that many children with FDD experience with toileting could be related to sensory hyper-reactivity. Objective: This study investigated the relationship between sensory hyper-reactivity and functional defecation disorders (FDD). Methods: Parents of three to six-year-old children with and without FDD completed two questionnaires; the Toileting Habit Profile Questionnaire-Revised (THPQ-R; tool that measures sensory hyper-reactivity to defecation related sensations)
and the Short Sensory Profile (SSP). On both questionnaires, low scores indicate more concerns. Between group comparisons and the relationship between scores on the THPQ-R and on the sensory hyper-reactivity items of the SSP were examined. Results: The sensory hyper-reactivity mean score of the SSP was lower for children with FDD. The difference was statistically significant (p < .0005). There was a positive correlation between THPQ-R and SSP hyper-reactivity scores (r274 = .485, p < .0005). Further, higher levels of sensory hyperreactivity (low SSP score) were associated with a higher frequency of the challenging defecation behaviors described in the THPQ-R (low THPQ-R score). Conclusion: Health practitioners do not usually consider sensory hyper-reactivity as a possible factor contributing to the difficulties of the child with FDD. Our results indicate that routine screening for sensory hyper-reactivity may be an important practice element when working with children with FDD. In addition, the present study adds support to the validity of the THPQ-R in identifying behaviors potentially linked to sensory hyper-reactivity.


  1. Koppen IJN, Vriesman MH, Saps M, et al. Prevalence of Functional Defecation Disorders in Children: A Systematic Review and Meta-Analysis. J Pediatr 2018;198:121-30.
  2. Rajindrajith S, Devanarayana N, Perera B, Benninga M. Childhood constipation as an emerging public health problem. World J Gastroenterol  2016;22(30): 6864-6875.
  3. The Rome Foundation. Rome IV Pediatric Functional Gastrointestinal Disorders-Disorders of Brain-Gut Interaction. Raleigh (NC): The Rome Foundation;2016.
  4. Niemczyk J, Equit M, El Khatib D, von Gontard A. Toilet refusal syndrome in preschool children: do different subtypes exist?. J Pediatr Gastroenterol Nutr 2014;58(3):303-6.
  5. McElhanon B, McCracken C, Karpen S, Sharp W. Gastrointestinal Symptoms in Autism Spectrum Disorder: A Meta-analysis. Pediatrics 2014;133(5):872-883.
  6. McKeown C, Hisle-Gorman E, Eide M, et al. Association of constipation and fecal incontinence with attention-deļ¬cit/hyperactivity disorder. Pediatrics 2013;132(5):1210-15
  7. Pijpers MA, Bongers ME, Benninga MA, Berger MY. Functional constipation in children: a systematic review on prognosis and predictive factors. J Pediatr Gastroenterol Nutr 2010; 50: 256-268.
  8. Tabbers M, Di Lorenzo C, Berger M, et al. Evaluation and Treatment of Functional Constipation in Infants and Children: evidence-based recommendations from ESPGHAN and NASPGHAN. J Pediatr Gastroenterol Nutr 2014;58(2):258-74.
  9. Bongers ME, van Wijk MP, Reitsma JB, Benninga MA. Longterm prognosis for childhood constipation: clinical outcomes in adulthood. Pediatrics 2010;126: e156-e162.
  10. Freeman K, Riley A, Duke D, Fu R. Systematic review and meta-analysis of behavioral interventions for fecal incontinence with constipation. J Pediatr Psychol 2014;39(8):887-902.
  11. Palit S, Lunniss PJ, Scott SM. The Physiology of Human Defecation. Dig Dis Sci 2012;57:1445–1464.
  12. Baum CF, John A, Srinivasan K, et al. Colon manometry proves that perception of the urge to defecate is present in children with functional constipation who deny sensation. J Pediatr Gastroenterol Nutr 2013;56(1): 19-22.
  13. Loening-Baucke V. Sensitivity of the sigmoid colon and rectum in children treated for chronic constipation. J Pediatr Gastroenterol Nutr 1984;3(3): 454-459.
  14. Wald, A. Biofeedback for neurogenic fecal incontinence: rectal sensation is a determinant of outcome. J Pediatr Gastroenterol Nutr 1983;2(2): 302-306.
  15. Castilloux J, Noble A, Faure C. Is visceral hypersensitivity correlated with symptom severity in children with functional gastrointestinal disorders?. J Pediatr Gastroenterol Nutr 2008;46(3): 272-278.
  16. Duarte MA, Goulart EMA, Penna FJ. Pressure pain threshold in children with recurrent abdominal pain. J Pediatr Gastroenterol Nutr 2000;31(3): 280-285.
  17. Iovino P, Tremolaterra F, Boccia G, et al. Irritable bowel syndrome in childhood: visceral hypersensitivity and psychosocial aspects. Neurogastroenterol Motil 2009;21(9): 940-e74.
  18. Beaudry-Bellefeuille I, Lane SJ, Lane A. Sensory integration concerns in children with functional defecation disorders: A scoping review. Am J Occup Ther:73(3)
  19. Beaudry-Bellefeuille I, Lane SJ. Examining sensory over-responsiveness in preschool children with retentive fecal incontinence.  Am J Occup Ther. 2017;71(5): 7105220020p1-7105220020p8.
  20. Beaudry Bellefeuille I, Ramos Polo E. Tratamiento combinado de la retención voluntaria de heces mediante fármacos y terapia ocupacional [Combined treatment of volontary stool retention with medication and occupational therapy]. Bol Pediatr 2011;51:169-176.
  21. Beaudry IB, Schaaf RC, Ramos EP. Brief Report—Occupational therapy based on Ayres Sensory Integration in the treatment of retentive fecal incontinence in a 3-year-old boy. Am J Occup Ther 2013;67(5), 601–606.
  22. Handley-More D, Richards K, Macauley R, & Tierra, A. Encopresis: Multi-fisciplinary management. Journal of Occupational Therapy, Schools, & Early Intervention 2009;2(2): 96–102.
  23. Pollock MR, Metz AE, Barabash T. Brief Report—Association between dysfunctional elimination syndrome and sensory processing disorder. Am J Occup Ther 2014;68(4), 472–477.
  24. Beaudry-Bellefeuille I, Bundy A, Lane A, et al. The Toileting Habit Profile Questionnaire; Examining Construct Validity using the Rasch Model. Br J Occup Ther. 2018:Advance online publication. doi: 10.1177/0308022618813266
  25. Beaudry-Bellefeuille I, Lane SJ, Chiu S, et al. The Toileting Habit Profile Questionnaire-Revised; examining discriminative and concurrent validity. Journal of Occupational Therapy, Schools, & Early Intervention 2019; doi: 10.1080/19411243.2019.1590756
  26. Borowitz SM, Cox DJ, Sutphen JL. Differences in toileting habits between children with chronic encopresis, asymptomatic siblings, and asymptomatic nonsiblings. J Dev Behav Pediatr 1999;20(3):145–149.
  27. Wald ER, Di Lorenzo C, Cipriani L, et al. Bowel habits and toilet training in a diverse population of children. J Pediatr Gastroenterol Nutr 2009;48(3): 294-298.
  28. Qualtrics. Provo, UT: http://www.qualtrics.com. 2017
  29. Beaudry-Bellefeuille I, Lane SJ, Ramos-Polo E. The Toileting Habit Profile Questionnaire: Screening for sensory-based toileting difficulties in young children with constipation and retentive fecal incontinence. Journal of Occupational Therapy, Schools, & Early Intervention 2016;9(2): 163-175.
  30. Cox DJ, Ritterband LM, Quillian W, et al. Assessment of behavioral mechanisms maintaining encopresis: Virginia encopresis-constipation apperception test.J Pediatr Psychol 2003;28(6): 375-382.
  31. Dunn W. Sensory Profile. San Antonio TX: Pearson Education: 1999.
  32. McIntosh DN, Miller LJ, Shyu V, Dunn W (1999). Overview of the Short Sensory Profile. Dunn W, editor. In: The Sensory Profile: User’s manual. The Psychological Corporation. 1999; 59-73.
  33. Beaudry-Bellefeuille I, Lane SJ. Cultural adaptation for Spain of the Spanish version of the Short Sensory Profile using cognitive interviews. Austin J Autism & Relat Disabil 2015;1(1): 1004.
  34. Dunn, W. (2014). Sensory Profile 2. San Antonio, TX: Pearson Education: 2014.
  35. Mazurek MO, Vasa RA, Kalb LG, et al. Anxiety, sensory over-responsivity, and gastrointestinal problems in children with autism spectrum disorders. J Abnorm Child Psychol 2013;41(1): 165–176.
  36. Ayres AJ. Tactile functions. Their relation to hyperactive and perceptual motor behavior. Am J Occup Ther 1964;18(1): 6–11.
  37. Ayres AJ, Tickle LS. Hyper-responsivity to touch and vestibular stimuli as a predictor of positive response to sensory integration procedures by autistic children. Am J Occup Ther 1980;34(6): 375–381.
  38. Lane SJ, Reynolds S, Thacker L. Sensory over-responsivity and ADHD: Differentiating using electrodermal responses, cortisol, and anxiety. Front Integr Neurosci 2010;4: 8.
  39. Parham LD, Ecker C.  Sensory processing measure (SPM). Western Psychological Services: 2007.
  40. Su CT, Parham LD. Validity of sensory systems as distinct constructs. Am J Occup Ther 2014;68(5): 546–554. 
  41. Ben-Sasson A, Cermak SA, Orsmond GI, et al. Extreme sensory modulation behaviors in toddlers with autism spectrum disorders. Am J Occup Ther 2007;61(5): 584–592.
  42. Reynolds S, Shepherd J, Lane SJ. Sensory modulation disorders in a minority Head Start population: Preliminary prevalence and characterization. Journal of Occupational Therapy, Schools, & Early Intervention 2008;1(3-4), 186-198.
  43. American Psychiatric Association. Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Pub, 2013.
  44. Radford J, Anderson M. Encopresis in children on the autistic spectrum. Early Child Dev Care 2003;173(4): 375-382.
  45. Stadtler AC, Burke P. A group treatment approach to failure to toilet train: The case of Max. Clin Excell Nurse Pract 1998;2(2):83-7.
  46. Silva LM, Cignolini A, Warren R, et al. Improvement in sensory impairment and social interaction in young children with autism following treatment with an original Qigong massage methodology. Am J Chin Med 2007;35(3): 393-406.
  47. Little LM, Benton K, Manuel-Rubio M, et al, Contribution of Sensory Processing to Chronic Constipation in Preschool Children. J Pediatr 2019: article in press downloaded from https://www.jpeds.com/article/S0022-3476(19)30307-5/pdf
  48. Schmuckler MA. What is ecological validity? A dimensional analysis. Infancy 2001;2(4), 419-436.
  49. Pfeiffer BA, Koenig K, Kinnealey M, et al. Research Scholars Initiative—Effectiveness of sensory integration interventions in children with autism spectrum disorders: A pilot study. Am J Occup Ther 2011;65(1): 76–85.
  50. Schaaf RC, Benevides T, Mailloux Z, et al. An intervention for sensory difficulties in children with autism: A randomized trial. J Autism Dev Disord 2013;44(7): 1493-1506.