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A Kid Beats the System

Updated: Feb 13, 2022

I saw one of my autistic patients last week. We’ll call him David. He’s 5, and he’s an awesome kid. But he has a problem. He’s constipated, and it’s all because of ABA.

Yes, you read that right. ABA causes constipation, at least in David’s case.

David attends special education pre-K in a school district that uses PBIS as part of their service support plan. During the COVID-19 pandemic, the schools in our area were virtual-only. In-person attendance was opened to special education students in February 2021. Because virtual pre-K was not going well, David’s mother allowed him to return to in-person instruction at that time. But, David’s mother had taken advantage of the time at home to start toilet training. And it was going really well. David was using the toilet for stooling about 90% of the time when he started in-person school.

And then, David just stopped pooping altogether. He quite literally refused to poop. This is a terrible idea, by the way. Because, if you withhold stool, the body reabsorbs more and more water from it, making it harder and harder. So when you finally go, it really hurts. For children, this becomes a cycle. It hurts to poop, so they don’t, so then it hurts more. And so on.

But what happened? He was doing so well at home! So his mother played detective. She quickly learned that David’s classroom worked on toileting with the children whose IEP included that skill. In order to incentivize toileting, there was a behavior chart, like the one below. We’re not totally clear on what toileting skills put a child in which category. What we know is that, at some point, David got a red sad face for toileting.

Here’s the thing about David. He’s autistic, but he’s also anxious. He loves to do well and takes failure very much to heart. That red sad face triggered his anxiety, and his only solution was to stop pooping at school. Because if he didn’t poop, he definitely wouldn’t get another sad face. He beat the system. But in the bargain, he gave himself a medical problem. He developed hard stool and taught himself that pooping is painful. Now, David will be on daily stool softeners until he stops associating stooling with pain. That could take months of treatment with a medication that would have been totally unnecessary, if not for this behavior modification program.

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