I remember going to the 5th World Autism Organization congress and, after giving my lecture, being approached by one of the parents. He claimed that for the last few months, his daughter seemed irritable and prone to tantrums. She was now more inattentive and, alarmingly so, was experiencing a “regression”; losing some of her language and social skills. In addition, during the last few weeks she started waking up in the middle of the night and having difficulties falling back to sleep. Along the way in our conversation the parent mentioned that his daughter was suffering from constipation.
Considering all of the problems that his daughter was experiencing, the parent felt overwhelmed. Back at home, things were getting worse, day by day. His family physician attributed the multiple complaints to the patient’s primary diagnosis. Nothing much was recommended in terms of establishing a diagnosis or providing treatment. However, the father knew this was something different, requiring treatment.
Sleep problems tantrums, and irritability are common problems in autism. However, regression of acquired skills should always raise a red flag, especially so if noted after 3 years of age. In this particular case, the patient was in her forties. Just like her father, I thought something was definitely wrong and in need of urgent care.
For a significant number of autistic individuals, maladaptive or aberrant behaviors, irritability and hyperactivity may be the result of epilepsy. Although these changes have often been described in children, we should also be wary of such a possibility in the adult population. This is specially so for those patients with severe mental disability where the manifestations of seizures may remain unrecognized for many years, even decades. Our patient was severely intellectually disabled. A prolonged sleep EEG is usually recommended in such cases and should have been a priority in this patient. As part of the medical history it was noted that the patient had been receiving neuroleptics as treatment for irritability and aggressive behaviors. These drugs can lower the threshold for seizures. This is particularly the case in autism, a population with an imbalance of excitation/inhibition in the cerebral cortex that predisposed them to seizures. Following my suggestion an EEG was done the results of which were negative.
The fact that the patient was receiving neuroleptics would prove significant. Constipation is a common side effect of these medications. They impede gastrointestinal motility which in some cases may lead to gastrointestinal paralysis, obstruction, bowel ischemia and death. The mechanism is impactation by a stool bolus leading to increase pressure proximal to the obstruction. The increased pressure may lead to distention which in turn may lead to perforation. These complications, although quite painful, are not properly conveyed by the autistic individual.
Communication problems are common in autism. Not only do they find it difficult to convey the source of their discomfort, but the same may also be distorted. Due to deficits of interoception, the autistic individual may not feel a need to go to the toilet. The end result is compounded in those individual that lack exercise, live a sedentary life, are dehydrated, do not receive a normal amount of fiber in their diet or are receiving iron supplementation. Unfortunately, all of these complicating factors are common to autism.
In this particular case, the patient’s maladaptive behavior, regression of acquired skills, and sleep problems were all related to constipation. Thankfully, the problem was recognized and other possible side effects were avoided. In the end, appropriate treatment greatly increased the quality of life of the individual. Once recognized, treatment consisted in changing the prescribed medication and modifying lifestyle behaviors.
Exercise helps prevent constipation by reducing the time it takes for food to move through the large intestine. Exercise can be as simple as walking 10 to 20 minutes a couple of times per day. This may progressively build up to other types of aerobic exercise like running, swimming or dancing. Establishing routines for drinking water and going to the toilet (potty training) should be started early on. Dietary habits need to be changed. Fruits are high in fiber and help relieve constipation. Fiber adds bulk and absorb water that along with fatty acids help form a gel-like substance that softens the stool. Consider giving apricots, raisins, prunes, kiwi, peaches, pears, and bananas along with water and load up the plate with vegetables. Shy away from drinking coffee and other caffeinated drinks. Also, eat healthy, natural foods instead of processed items.