Behavioral therapy for treatment of childhood constipation: a randomized controlled trial.

It is suggested in literature that the addition of behavioral components to laxative therapy improves continence in children with functional fecal incontinence associated with constipation. In this study it is hypothesized that behavioral therapy in addition to conventional treatment is more effective than conventional treatment alone. 129 children aged 4-18 years with functional constipation were included and randomly assigned to either behavioral therapy or conventional treatment. Main outcomes measures were: defecation frequency/week, fecal incontinence frequency/week, success rate, relapse, stool-withholding behavior and general behavioral problems.

Behavioral therapy in addition to conventional treatment is more effective than conventional treatment alone.

N/A

Intervention period for both conventional treatment (CT) and behavioral therapy (BT) consisted of 12 visits to the outpatient clinic during 22 weeks.

Conventional Treatment:

CT was conducted by pediatric gastroenterologists of the gastrointestinal outpatient clinic and consisted of visits lasting approximately 20-30 minutes during which laxative treatment and the bowel diary were discussed. Patients and their parents received education. Furthermore, patients were instructed not to withhold stool when they felt urge to defecate. Motivation was enhanced by praise and small gifts from the pediatric gastroenterologists.

Protocolized Behavioral Therapy:

BT was developed by pediatric psychologists of the psychosocial department of our hospital and is based on clinical experience and behavioral theories. It includes two age-related modules: a module for children aged 4-8 years and a module for children aged >= 8 years. The learning process for child and parents consists of five steps: Know, Dare, Can, Will, and Do. This approach
was derived from a multidisciplinary behavioral treatment developed in a tertiary hospital in Nijmegen in the Netherlands, to treat children with defecation disorders (van Kuyk EM, Brugman-Boezeman AT, Wissink-Essink M, Severijnen RS, Festen C, Bleijenberg G. Defecation problems in children with Hirschsprung's disease: a biopsychosocial approach. Pediatr Surg Int. 2000;16:312-316). Basic assumption of this BT is that fearful and phobic reactions related to defecation and fecal incontinence can be reduced and that adequate defecation straining and toileting behavior can be (re)acquired by teaching parents behavioral procedures and by behavioral play therapy with the child. Pediatric psychologists in cooperation with co-therapists for children aged 4-8 years and without co-therapists for children >= 8 years, carried out BT. BT consisted of visits lasting approximately 45 minutes. For all involved psychologists a detailed manual for both age related modules was available to ensure a standard delivery of BT. Pediatric psychologist adjusted laxative dose and if necessary consulted a pediatric gastroenterologists.