Communicating Constipation: Differential Diagnosis of Agitation in Autism at a Pediatric Hospital

Constipation is a common concern for youth with autism spectrum disorder (ASD). Many children with ASD also experience episodes of behavioral dysregulation; however, few studies have explored the relationship between constipation and dysregulation among youth with ASD, particularly for those with limited verbal communication ability. We present the case of a 14-year-old boy with ASD with accompanying language impairment, moderate intellectual disability, and longstanding gastrointestinal symptoms, including constipation and encopresis, who had an extended (120+ day) hospitalization in a quaternary care pediatric hospital while awaiting an inpatient psychiatric placement. Throughout his hospitalization, this patient presented with frequent and seemingly spontaneous episodes of behavioral dysregulation, characterized by self-injurious behavior, fecal smearing, and aggression toward others. The hospital's inpatient board-certified behavior analyst tracked potential antecedents to these behaviors through the completion of a functional behavior assessment. This assessment demonstrated a relationship between frequency of stooling and occurrence of dysregulated episodes and prompted an increased focus on treatment of constipation. With aggressive treatment of his constipation, the frequency of his behavioral dysregulation decreased. This case highlights the value of conducting formal behavioral assessment within a hospital setting to determine the function of dysregulated behaviors, particularly for patients with communication deficits. This case also highlights the importance of conceptualizing dysregulated behaviors as potentially secondary to a medical concern that needs to be addressed before considering psychiatric hospitalization.