REVIEW ARTICLE

Defecation-Specific Behavior in Children with Functional

Defecation Issues: A Systematic Review
Isabelle Beaudry-Bellefeuille, MSc; Debbie Booth, M App Sci; Shelly J Lane, PhD, OTR/L, FAOTA, PhD Perm J 2017;21:17-047
E-pub: 09/29/2017 https://doi.org/10.7812/TPP/17-047

ABSTRACT behaviors. However, both general and defecation-specific be-

Context: Atypical defecation habits are common and distress- havioral concerns are thought to play an important role in the
ing for children and families and can have a major impact on development and in the persistence of constipation.3 A deeper
quality of life. Often, no underlying factor can be identified, understanding of the behaviors reflective of actual toileting
and the defecation disorder is considered functional. Current and defecation problems could provide greater insight into the
interventions are not successful for up to 50% of children. We unique manifestations of functional defecation disorders and
suggest this high failure rate may be caused by lack of consistency thus a better foundation for treatment. Because approximately
in descriptors of behavioral indicators for functional defecation 25% to 50% of children do not fully recover from functional
problems. Most investigations and descriptors focus on general defecation disorders despite medical management and thera-
behavior. There are fewer reports concerning defecation-specific peutic strategies,3,4 reconsidering our understanding of these
behaviors. disorders is imperative.
Objective: To develop a thorough inventory of defecation- When referring to gastrointestinal disorders, the term func-
specific behaviors, providing a more informed foundation for tional is used to describe conditions that cannot be linked to a
assessment and intervention. single discrete underlying biological etiology and are the result
Design: A systematic review of six common databases was of the interaction between psychosocial factors and altered gut
performed following the Preferred Reporting Items for Systematic physiology via the brain-gut axis.5 The Rome Foundation diag-
Reviews and Meta-Analyses recommendations. Reference lists nostic criteria are considered a gold standard for identification
of retained articles were screened for additional studies. of functional gastrointestinal disorders.4,5 In the case of child-
Main Outcome Measures: Content analysis was used to clas- hood functional defecation disorders, the clinical manifestations
sify defecation-specific behaviors into 17 categories. typically result from an interaction of physiologic, social, and
Results: Our search yielded 2677 articles; 98 peer-reviewed behavioral processes.1,2 As such, once organic pathology has
publications were retained for full-text review, and 67 articles been ruled out, clinicians are often faced with myriad simulta-
were included in the final qualitative synthesis. Although there neous and interdependent behaviors that cannot be easily teased
is inconsistency in reported diagnostic criteria, stool withhold- apart, described, or classified. For example, the clinician must
ing and manifesting pain on defecation are the most commonly evaluate the impact of the caregiver’s behavior on the child’s
reported defecation-specific behaviors. In the studies that in- gastrointestinal tract processes (eg, punishment for involun-
cluded children with autism or attention-deficit/hyperactivity tary fecal incontinence, unrealistic expectations), the child’s
disorder, the defecation-specific behaviors were not unique to response to the caregiver (eg, stubbornness, toileting refusal),
the diagnostic group. the impact of gastrointestinal processes on the child’s behavior
Conclusion: Consistent use of established diagnostic criteria, (eg, painful defecation), and the impact of the child’s behavior
along with use of behaviors identified through this review, lay on the gastrointestinal processes (eg, voluntary stool withhold-
a foundation for more effective interventions. ing). Enhancing our understanding of these specific behavioral
elements could help optimize outcomes.
INTRODUCTION The behaviors of children with atypical toileting habits is a
Atypical defecation habits are a common and distressing con- longstanding subject of study and continues to be a central issue
dition for children and families and can have a major impact on of debate.6 Most reports focus on otherwise healthy children
quality of life.1,2 Given that they can be so impactful, appropriate and general behavior using measures such as the Child Behavior
and clear identification of problematic defecation behaviors is Checklist.7 Although most studies indicate a higher incidence
crucial. Research looking at behaviors associated with functional of general behavioral issues in these children,8-14 others fail to
defecation concerns has taken 2 approaches. The most frequent find this difference.15-17
has been to examine general behavioral concerns; considerably less Several reports exist concerning the elevated incidence of def-
common has been research concentrating on defecation-specific ecation issues in children with a diagnosis of autism spectrum

Isabelle Beaudry-Bellefeuille, MSc, is a PhD Candidate at the University of Newcastle School of Health Sciences in Callaghan,
New South Wales, Australia. E-mail: isabelle.beaudrybellefeuille@uon.edu.au. Debbie Booth, M App Sci, is a Senior
Librarian at the University of Newcastle in Callaghan, New South Wales, Australia. E-mail: debbie.booth@newcastle.edu.au.
Shelly J Lane, PhD, OTR/L, FAOTA, PhD, is a Professor of Occupational Therapy at the University of Newcastle School of
Health Sciences in Callaghan, New South Wales, Australia. E-mail: shelly.lane@newcastle.edu.au.

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Defecation-Specific Behavior in Children with Functional Defecation Issues: A Systematic Review

disorder (ASD)18-20 or attention-deficit/hyperactivity disorder unclear whether these are specific to the diagnosis or consistent
(ADHD),21,22 but studies addressing the behaviors of chil- with behaviors seen in children without these additional diagno-
dren with these comorbidities are scarce. A few studies have ses. The aim of this review was to develop a thorough inventory
specifically looked at the general behavior of children with of reported defecation-specific behaviors and to document their
autism and toileting issues. For instance, Peeters et al23 report frequency, providing a more informed foundation for assessment
an association between mixed bowel symptoms and rigid- and intervention. Although there is a large body of literature
compulsive behaviors in children with ASD. Other studies addressing behavioral treatment approaches for children with
point to a relationship between maladaptive behaviors and defecation issues,30-33 a thorough summary of this literature is
gastrointestinal issues in this population.24,25 Studies dealing beyond the scope of this review.
with the behavioral characteristics of children with ADHD The objectives, inclusion criteria, and methods of analysis
and toileting issues were not found. for this review were specified in advance and documented in a
There are few reports concerning the defecation-specific be- protocol registered with the PROSPERO database (registration
haviors of children with constipation, fecal incontinence, and/ number CRD42016039436).
or stool toileting refusal. One older study compared children
with encopresis and asymptomatic siblings and nonsiblings.26 METHODS
Using an automated telephone survey system, caregivers report- Answers to the following questions were sought: In children
ed that children with encopresis voluntarily went to the toilet with functional defecation issues (constipation, fecal incontinence,
the same number of times each day as did controls. However, encopresis, stool toileting refusal), which defecation-specific behav-
caregivers also reported a significantly greater amount of pain iors have been identified, and to what extent? Considering the de-
associated with defecation among children with encopresis. scriptive nature of the inquiry, the PEO (population, exposure,
Cox et al27 provided some early guidance for distinguishing outcome) model for systematic review was used to formulate the
between defecation-specific behaviors and generic behavioral research question.34 The elements of the PEO question are as
concerns (eg, noncompliant to toileting instructions vs generally follows: 1) population: children age 0 to 18 years; 2) exposure:
noncompliant) in children with encopresis using the Virginia functional defecation issues (constipation, fecal incontinence,
Encopresis-Constipation Apperception Test. On the basis of this encopresis, stool toileting refusal); and 3) outcome or themes:
tool, both children with encopresis and their mothers reported defecation-specific behaviors.
more bowel-specific problems, but not more generic behavior
problems, compared with controls.27 Burket et al9 added the Search Strategy
dimension of stubbornness to the study of behavior in children The Preferred Reporting Items for Systematic Reviews and
with defecation issues, and differentiated between specific and Meta-Analyses (PRISMA) statement35,36 was used to guide the
generic toileting stubbornness. Together these studies suggest systematic review. An electronic database search of the Cumula-
that general behavior concerns and bowel-related behavior tive Index to Nursing & Allied Health Literature (CINAHL),
concerns can be differentiated and that bowel-related concerns Embase, PsycINFO, MEDLINE, The Cochrane Library, and
may be more useful in defining the problem.
Concomitantly with consideration of behavior and stub-
bornness, research has also focused on physical factors, such Table 1. MEDLINE search strategy, August 6, 2016
as pain, as contributing to functional defecation issues. Pain Number Search terms Results
on defecation as well as stool withholding to avoid pain have 1 Constipation 20,452
been identified as problematic in children with chronic func- 2 Fecal incontinence 9493
tional constipation and fecal incontinence; these behaviors also 3 Faecal incontinence 1578
differentiate children with and without functional defecation 4 Elimination disorder* 66
disorders. Dehghani et al28 identified painful defecation and 5 Dysfunctional elimination syndrome 46
stool withholding behavior in almost all of the 222 children 6 Encopresis 793
with constipation studied. Kammacher Guerreiro et al29 came 7 Toileting 687
to similar conclusions in a retrospective study of 270 children 8 Stool toileting refusal 15
with functional constipation, reporting that among the most 9 Soiling 1426
frequent complaints were pain during defecation and stool re-
10 Defecation 9591
tention. Borowitz and colleagues26 found that defecation-related
11 1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9 or 10 36,433
pain was also common in children with encopresis.
12 Behaviour 139,611
Despite these insights, no review and synthesis of the reported
13 Behavior 833,960
defecation-specific behaviors and other concerns associated with
functional defecation disorders could be found in the literature, 14 12 or 13 934,250
making it challenging to comprehensively characterize these 15 11 and 14 2516
children and to clearly delineate behaviors indicating a need for 16 Limit 15 to humans 1555
specific intervention. Importantly, although toileting concerns 17 Limit 16 to “all child (0 to 18 years)” 707
have been identified in children with ASD and ADHD, it is 18 Limit 17 to (English or French or Spanish) 655

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Defecation-Specific Behavior in Children with Functional Defecation Issues: A Systematic Review

Scopus was conducted to retrieve relevant articles for the lit- the search included all articles since the inception date of each
erature review. Key terms used for the advanced search were: database through August 2016. Articles were excluded if they
behavior, behaviour, constipation, fecal incontinence, faecal addressed organic defecation issues, focused on generic behav-
incontinence, elimination disorder*, dysfunctional elimination iors, included subjects older than age 18 years, were review
syndrome, encopresis, toileting, stool toileting refusal, soiling, and articles, or discussed the same study sample as another previous
defecation. The table of contents of all issues of the Journal of publication. Reference lists of included studies were reviewed
Pediatric Gastroenterology and Nutrition was also reviewed using for relevant publications. Table 1 illustrates an example of the
the same terms. The search strategy and the chosen keywords search strategy, and Figure 1 illustrates the PRISMA flow dia-
were developed and revised by the first (IBB) and second (DB) gram of searched results.
authors; DB is an experienced librarian. The first two authors identified search terms and strategy; the
first author performed the initial comprehensive literature search
Data Selection and filtered for duplicates. After duplicates were removed, IBB
Included articles met the following criteria: Addressed func- and the third author (SJL) screened each study title and abstract
tional (not organic) defecation issues; described defecation- for potential relevance. When disagreement was identified be-
specific (not generic) behavioral concerns; focused on children tween reviewers, the full text of the article was retrieved; disagree-
ages 0 to 18 years; were published in English, Spanish, or French ments were again considered and discussed until consensus was
with an English abstract (IBB is fluent in these languages); ap- reached. If disagreements had persisted, a third reviewer would
peared in a peer-reviewed journal; and were at any level of evi- have been consulted to determine final inclusion, but this was
dence. Given that the incidence of defecation issues is higher in not necessary. The reviewers kept a log of all reviewed abstracts
children with ASD18-20 and/or ADHD,21,22 studies that included with reasons for inclusion or exclusion of articles. The full text
children with these diagnoses were also included in the review, of articles included in the final selection was reviewed by the
but studies focused on children with other diagnoses were not. first author. A data extraction table was used to organize the
Given that no other review of this type has been identified, information extracted from each of the selected citations (see
Table 2, available online at: www.thepermanentejournal.org/
files/2017/17-047-Table2.pdf ).

Data Analysis
The descriptive nature of this inquiry supports using con-
ventional content analysis.37,38 This approach made it possible
to distill words into content-specific categories and enabled us
to identify and to categorize the behaviors. Engaging in con-
tent analysis enabled the investigators to immerse themselves
in the data and develop categories; here we used the process of
abstraction to develop mutually exclusive categories of defeca-
tion-specific behaviors. The PDF (portable document format)
files of the eligible studies were imported into qualitative data
analysis software (NVivo, version 11; QSR International Pty
Ltd, Doncaster, Victoria, Australia) to facilitate this analysis.
No preconceived categories were established. The categories
emerged from the data through repeated reading of the narrative
descriptions of behavior, with the link to toileting and defeca-
tion driving the creation of the final classifications.

RESULTS
Our search yielded 3991 citations. After eliminating du-
plicates, we screened titles, abstracts, and keywords of 2677
citations. We excluded 2579 citations that did not match our
research question; largely these citations focused on hygiene
behavior relative to toileting and stool disposal in developing
countries. DB was consulted on the possibility of narrowing
the search; however, this would have involved the risk of miss-
ing citations relevant to the research question and was there-
fore dismissed. Ninety-eight peer-reviewed publications were
retained for full-text review. After full-text review, 36 articles
Figure 1. PRISMA 2009 flow diagram for all sources searched (August 2016). were excluded as follows: Behaviors not defecation specific
JPGN = Journal of Pediatric Gastroenterology and Nutrition; PRISMA = Preferred Reporting (n  =  21), sample/study is described in another publication
Items for Systematic Reviews and Meta-Analyses.

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Defecation-Specific Behavior in Children with Functional Defecation Issues: A Systematic Review

(n  =  5), concomitant diagnosis other than ASD or ADHD Toileting and Defecation Behaviors
(n = 6), subjects outside the age range (n = 1), defecation is- Narrative descriptions of reported defecation behaviors were
sues are not functional (n = 1), article is a review (n = 1), and classified by IBB into preliminary categories using common
article is not peer reviewed (n = 1). From the reference lists themes. Credibility and dependability of these themes were
of the resulting 62 articles, 5 additional articles were identi- established through discussion between IBB and SJL. This itera-
fied. A total of 67 articles published between 1953 and 2016, tive process allowed us to refine categories and create groupings
representing 18 countries worldwide, were included in the that would fully capture the subtle differences in the behaviors
final content analysis. described in the literature.37 For example, some children are
Because most of the citations belonged to observational described as always refusing to sit on the toilet, whereas others
studies, the Joanna Briggs Institute (JBI) evidence ranking manifest refusal of the toilet only for defecation, and some refuse
system was chosen.39 The JBI is a nonprofit research organi- to use the toilet only when outside their home; each of these
zation at the University of Adelaide in Australia whose ap- variations of toilet refusal was categorized separately. Another
proach to evidence-based health care considers the feasibility, example of this effort relates to resisting the urge to defecate.
appropriateness, meaningfulness, and effectiveness of health Stool withholding is often mentioned as a common behavior;
care practices. This system offers detailed subcategories for however, some authors additionally describe retentive posturing
observational studies, differentiating it from other systems, and movement as a means to avoid defecation. As such, stool
which are less specific for this type of research. For example, the withholding alone and retentive efforts accompanied by specific
JBI system categorizes observational analytic designs (Level 3) postures or movements have been categorized separately.
and observational descriptive studies (Level 4) into a total of Furthermore, to offer an accurate summary of the narrative
9 subcategories. According to the JBI system, 7 citations were description of children’s behavior, we chose to consider as part
Level 1 studies,40-46 3 were Level 2 studies,27,47,48 12 were clas- of the behavioral categories all types of responses and manifes-
sified at Level 3,15,24,49-58 35 belonged to Level 4,9,26,28,59-90 and tations of psychological or emotional distress, such as fear or
10 were expert opinions classified at Level 5.91-100 (Details of anxiety. This decision was based on the following definition of
subcategories can be found in Table 2, available online at: www. behavior: “anything that an organism does involving action and
thepermanentejournal.org/files/2017/17-047-Table2.pdf.) response to stimulation; the response of an individual, group,
Defecation behaviors were described as part of the charac- or species to its environment.”101
terization of the samples in multiple studies.a An additional A total of 17 behavioral categories were established, with
18 studies, specifically aimed at identifying clinical features of defecation-related manifestations of pain and stool withholding
children with functional defecation issues, described toileting- behavior being the most frequently reported defecation-specific
specific behaviors as part of the results section of the article.b behaviors in children with functional defecation disorders.
The remaining 12 articles included the description of toileting Different types of toilet refusal behaviors are also frequently
and defecation behaviors as expert clinical observations91-100 reported. Table 3 shows the number of articles that reference
or in the discussion section of the article.64,70 each of the 17 established behavioral categories.

Table 3. Defecation-specific behaviors identified in the literature

Number of articles referencing/
Behavior describing the behavior
Manifests pain or fear of pain on defecation or urge to defecate 40
Withholds stool/avoidance of defecation/resists the urge to defecate 39
Refuses to defecate in toilet (accepts to urinate in toilet)/stool toileting refusal 16
Refuses to sit on toilet/manifests fear or anxiety in relation to sitting on toilet (in all contexts, even at home) 16
Retentive posturing/moves in a particular way when urge to defecate 12
Asks for/waits for/prefers a diaper or pull-up to defecate 11
Refuses/is reluctant to use school toilet or to use a variety of toilets (accepts toilet at home) 9
Hides to defecate or on urge to defecate, refuses to defecate in presence of others 9
Straining/prolonged time needed to have a bowel movement 9
Denies incontinence/hides soiled underwear 6
Does not manifest sensation of urge to defecate/denies or ignores urge to defecate 6
Defecates in a specific place other than toilet after being toilet trained 5
Not upset by soiling/does not notice incontinence 4
Manifests fear/resistance of wiping after a bowel movement/soiling 3
Manifests fear of flushing toilet 2
Manifests aversion to smell of feces 1
Manifests fear of feces 1

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Clear classifications based on defecation diagnosis could not These findings move us beyond simply identifying a defe-
be made; a review of the retained publications shows that the cation-related behavior in broad, superficial terms, in a way
identified categories of defecation behaviors are seen across that parallels previous research,51,63 which guided clarification
studies and do not appear to be exclusive to any particular of fecal soiling. We now consider retentive and nonretentive
gastrointestinal diagnosis or defecation disorder. Thus, we fecal incontinence as very different conditions that require dif-
could not explore the relationship between specific defeca- ferent treatment approaches. Such may be the case with other
tion disorders and defecation-specific behaviors because 1) defecation-related behaviors, which once clarified and described
diversity of diagnostic criteria across studies makes it difficult in greater detail, could lead to better treatment.
to clearly classify articles according to specific defecation Further analysis of each of the identified defecation-specific
disorders and 2) several articles refer to samples that group behavioral categories in this review may be needed to broaden
together children with different defecation issues or with more our comprehension of the psychoemotional factors related to
than one diagnosis. the observable behaviors common to children with functional
defecation disorders. For instance, a behavior such as stool
Concomitant Diagnosis of Autism Spectrum Disorder toileting refusal is not unique to a specific defecation disorder
Among the articles retained from the systematic review, six and is often described as a disorder in itself15,52,73,99 or in asso-
articles include children with a diagnosis of autism.24,65,70,76,83,84 ciation with other concomitant diagnosesc or temperamental
The behaviors of these children are similar to those of children characteristics.9,80 The most frequently reported associations
with defecation issues without any concomitant diagnosis; mani- with this common childhood behavior are constipation and
festations of pain in relation to defecation, stool withholding painful defecation.d However, encopresis,44,45,51,83,92,98 sensory
behavior, and all variants of toilet refusal are common. Table 4 overresponsivity,59,76,84 anxiety,89,95,99 difficult temperament,9,80
shows the number of articles describing children with autism autism,65,76,83 and oppositional defiant disorder86 have also been
that reference the established behavioral categories. linked to stool toileting refusal. Differentiating subgroups in the
group with this common behavior may be necessary to provide
Concomitant Diagnosis of Attention-Deficit/Hyperactivity Disorder clearer direction for treatment.
Among the articles retained from the systematic review, four
included children with a diagnosis of ADHD.26,53,70,82 Once Diagnostic Criteria
again, manifestations of pain in relation to defecation and stool In addition to inviting researchers to deepen our understand-
withholding behavior are the most commonly reported defe- ing of common toileting behaviors in children with functional
cation-specific behaviors. Table 4 shows the number of articles defecation issues, this review also summons a reflection on
describing children with ADHD that reference the established
behavioral categories.
Table 4. Number of articles that document toileting and
DISCUSSION defecation-specific behaviors in children with defecation
To our knowledge, this is the first systematic review concern- disorders and a concomitant diagnosis of autism spectrum
ing defecation-specific behavior in children with functional disorder (ASD) or attention-deficit/hyperactivity disorder
defecation issues. Our search strategy included three languages (ADHD).
(English, French, Spanish), six databases from their inception Number of references
through 2016, the table of contents of the Journal of Pediatric Defecation-specific behaviors ASD ADHD
Gastroenterology and Nutrition, and the reference lists of all Pain 2 2
included articles. Content analysis was used to determine be- Withhold 3 2
havioral categories, which were determined to be both credible Refuse toilet 3 0
and dependable. Stool toileting refusal 1 0
The key findings of this study were: The identification of 17 Posture 0 0
unique categories of defecation-specific behaviors and delinea- Diaper 2 0
tion of the frequency of reporting for each. Our findings support
Hide 2 0
and extend previous work in this area.9,26,27 These categories can
Refuse school toilet 2 0
now provide researchers and clinicians with a foundation for a
Straining 0 0
clearer identification of, and differentiation between, functional
Deny fecal incontinence 0 0
defecation disorders. To date, there has been no consensus on
how to assess, classify, or address these behaviors. Given that Deny urge 0 1
current long-term success rates using conventional treatment Not feel fecal incontinence 0 0
regimens remain limited,3,4 there is an urgent need for consis- Place 2 0
tency in the description of defecation-specific concerns to en- Wiping 1 0
able optimal classification and lay the foundation for focused Flushing 1 0
interventions. We suggest that the descriptors identified in this Smell 0 0
review are a place to begin. Fear feces 0 0

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diagnostic criteria. The Rome Foundation’s diagnostic crite- tally does not represent an in-depth analysis of results; however,
ria are the most frequently cited in this review,e but others given that the goal of this review was to develop an inventory
such as the American Psychiatric Association’s Diagnostic and of defecation-specific behaviors, this method provides a valid
Statistical Manual of Mental Disorders (DSM) criteria for en- means by which to report our results.
copresis47,63,76,91,99 or the North American Society for Pediatric
Gastroenterology, Hepatology and Nutrition description of CONCLUSION
constipation50 are also cited. However, it is noteworthy that most Our review delineated 17 unique behaviors that have been
articles in this review (n = 52) do not reference any standardized identified as characterizing functional defecation concerns. We
diagnostic criteria. In many cases, researchers develop their own also identified a lack of consensus, fueled partly by the differ-
questionnaires and/or criteria using definitions found in the lit- ences in diagnostic criteria but also in relation to assessment and
erature. This variability in diagnostic criteria makes it difficult classification of defecation-specific behaviors. Furthermore, this
to comprehensively appraise the research. Future studies should review found that defecation-specific behaviors overlap across
aim to use internationally accepted diagnostic criteria, such as functional defecation disorders and, on the basis of the limited
Rome IV, for diagnosis, and develop surveys or questionnaires evidence available, that the defecation behaviors of children
that tap into the 17 defecation-specific behaviors identified in with autism or ADHD are not unique to their diagnostic group.
this study to clarify the link between specific behaviors and Moving forward, we suggest that we look at defecation-specific
functional defecation disorders. behaviors, rather than more general behaviors, in defining issues
It is also necessary to consider a deeper understanding of specifically related to defecation concerns. This work provides
toileting behavior in relation to diagnosis. For example, the some guidelines for characterization that go beyond that of cur-
DSM-V criteria for encopresis, the second most frequently rent diagnostic guidelines or existing assessment tools in looking
cited diagnostic criterion in this review, includes the repeated at the context of behaviors. v
passage of feces into inappropriate places, either voluntarily or a
References 40-50,52-54,56,57,59-61,63,66,68,72,73,75,78,79-85,89-90.
involuntarily. Considering this definition more closely, if a child b
References 9,15,24,26,27,28,51,55,58,62,65,67,69,71,74,77,78,86.
voluntarily chooses to defecate in an unorthodox place, can we c
References 44,45,50,51,57,65,76,83,98.
consider this child to have the same diagnosis as the child who
d
References 15,51,52,56,71,89,92,95,99.
e
References 28,62,70,77,78,82,85,86,94.
involuntarily defecates in his clothing? If a child feels the urge
to defecate, momentarily withholds stool, voluntarily goes to a Disclosure Statement
specific place, although it may not be a socially acceptable one, The author(s) have no conflicts of interest to disclose.
and then proceeds to defecate, does s/he not possess all the
elements of continence? The only problem is where the child Acknowledgment
chooses to defecate. The questions might be why is the child Kathleen Louden, ELS, of Louden Health Communications provided editorial
not able to accept the socially acceptable place, what are the assistance.
features of this chosen place that the child is seeking, and what
Author Contributions
features of the socially acceptable place is he avoiding? On the
Isabelle Beaudry-Bellefeuille conducted the systematic review and wrote the
other hand, the child who involuntarily defecates in his clothing manuscript.
shows none of the elements of continence. Considering volun- Debbie Booth assisted Isabelle Beaudry-Bellefeuille in the literature search.
tary and involuntary defecation together, simply because it is Shelly J Lane reviewed all included abstracts and reviewed and edited each
not in the toilet, does not make sense as we strive to ameliorate draft of the manuscript.
our understanding of functional defecation disorders.
How to Cite this Article
Beaudry-Bellefeuille I, Booth D, Lane SJ. Defecation-specific behavior in
Limitations children with functional defecation issues: A systematic review. Perm J
Although we saw including all levels of evidence as essential 2017;21:17-047. DOI: https://doi.org/10.7812/TPP/17-047.
to answering the question posed in this review, the inclusion
of weaker study designs may be seen as a limitation. However,
given the intent of this investigation to produce a broad inven- References
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