Fecal Smearing in Autism. Oh, Poop!

What is Fecal Smearing?

Imagine walking into your children’s room late at night to check on them sleeping, only to find them smearing poop all over themselves or their room! Some children who play with poop also do so in front of other people or while away from home at school or visiting family members. This kind of scenario is upsetting to parents for many reasons.

It raises concern about psychological status, health concerns like becoming ill or spreading illness, it creates an enormous mess for others to clean, and it can impact social relationships or the children’s ability to participate in normal daily activities with peers and family. It can also be embarrassing to parents if other people are involved or find out. Fecal smearing can be a highly distressing and socially isolating experience through which to parent when there is very little help.

While toilet training is a common challenge among parents of children with autism, few people discuss the smearing of feces or bowel problems. Parents may encounter various types of inappropriate or risky poop behaviors, including pica (eating the feces), anal poking, sexualized behavior with feces, and fecal smearing (playing with or spreading around of feces). This has been reported as one of the most common bowel related problem behaviors in autism, yet very little research exists around how often it happens, what causes it, and what to do. This article highlights some reported reasons for this problem and some practical strategies that parents can use to reduce fecal smearing at home.

Why Does Fecal Smearing Happen?

There are several reasons fecal smearing may happen for a child. Getting to the bottom of why it is happening is the first step to reducing or eliminating this behavior. An online search of parent reports, reveals three sets of variables that may contribute to fecal smearing behavior:

• Medical problems
• Sensory challenges
• Behavioral factors

Additionally, some research finds gender, presence of intellectual disability, gastrointestinal symptoms, and comorbid psychopathology to be significant predictors of toileting problems. Whether these findings relate specifically to fecal smearing, remains to be seen as research evolves in the coming years.

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Medical Problems

Some medical problems that may occur in autism or for a child in general, and that may contribute to the problem may include constipation or diarrhea, gastrointestinal issues, and abdominal or systemic pain.

Sensory Challenges

Challenges may include:

• Over-responsivity (SOR) such as tactile defensiveness (touch sensitivity) or oral defensiveness (smell sensitivity)
• Under-responsivity (SUR), i.e., the child needs more input in order to feel or smell certain things, and
• Poor interoception (difficulty being able to feel internal sensations like when it’s time to go to the bathroom).

If a child is hypersensitive to certain sensations that go along with having a bowel movement on the toilet (the sounds of a flushing toilet or ceiling fan, the feeling of toilet paper during wiping, or the lights in the bathroom), that child may avoid having a bowel movement in the toilet. The opposite of being hypersensitive is being under sensitive, and some children seek out extra touch or smell inputs in order to self-calm. They may like how the poop feels in their hands, or they may get more smell input than when they use the toilet. Approximately 86 percent of children with autism also have sensory differences, so they likely play a causative role in fecal smearing for many children with autism.

Behavioral Factors

Fecal smearing is considered a behavior, and all behavior has meaning. A child who is smearing is using that behavior to meet a need and/or to communicate. Very often, behaviors are also inadvertently or accidentally reinforced. A child may get a reaction from parents or a sibling. They may get more attention, or they may get the benefit of delaying or avoiding something they don’t want, such as bedtime or school. A child may use the behavior to seek attention due to anxiety, a desire for connection, or because they cannot communicate that something hurts. Behavior factors are but one primary set of variables that play a role in fecal smearing.

How Do You Stop Fecal Smearing?

Keep Track

Temple Grandin says, “We can’t manage what we don’t measure.” First keep a written log of when and where the smearing happens, and what was happening before, during, and after each incident. This information helps to identify patterns or certain triggers of the behavior or the need that it fills. This is one way to take the first step toward resolving the issue.

Talk to a Specialist

Communicate with the pediatrician and other specialists working with your child, including a nutritionist. They may be able to first identify or rule out one or more medical reasons for the behavior and they may help to develop solutions or offer information and resources. Sometimes the consistency of a child’s stool will determine if they can have a bowel movement, where or when it happens, and thus the potential for poop to even be available for play. Some parents have shared stories of struggle with fecal smearing for years only to find out that changing the consistency of the stool can help their child go at normal times of day in the toilet, instead of at night in their bed.

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Develop a Behavior Plan

Search for and work with a medical provider (Psychologist, Behavioral Therapist, or Occupational Therapist) to complete a Functional Behavior Assessment in order to accurately identify the variables contributing to the fecal behavior. Then use that data to develop an individualized plan for how to target those specific variables that are contributing to the maintenance of the behavior. Reinforce positive behaviors you want to see, such as going to bed without smearing or using the toilet for a bowel movement. Remain neutral when an incident occurs by having minimal interaction with your child and by showing no emotional reaction at the time. This keeps the reinforcement of the behavior to a minimum.

Use Social Stories and Visual Reminders

Read books, create social stories with pictures of your child using the toilet in desirable ways, and search for pictures that will reinforce and encourage your child to use the bathroom. The use of YouTube videos and favorite characters, toys, and even other family members can be motivating and when hung in obvious places around the house, it is a constant reminder of what is expected and “normal” in your home.

Address Challenges

Make the bedroom sensory-friendly. Items like a white noise machine, a light projector (for calming visual stimulation), and soft/tactile/squishy toys for input to the hands are all inputs that are more acceptable and tolerable and supportive of child development. Ensure opportunities for tactile messy play outside of sleep times and bathroom use. Examples are sensory bins, Play-doh, finger paint, water beads, and play with shaving cream, whipped cream, pudding, slime, or Cloud doh.

Adaptive Clothing

Use of special pajamas is one final way to minimize or eliminate smearing. How these pj’s fasten limits access to a child’s diaper or pull-up and they have no way to get to the poop through their clothing. This concept also comes in regular clothing which can be worn during the day and may help to normalize things for a child and their parents!

For parents who struggle with their child fecal smearing, it can be scary and overwhelming, frustrating, and confusing. There are few resources available and research has not yet shown a consistent one-size-fits-all approach that will help every child. Research has shown that if you find out and address the reasons that the behavior is happening in the first place it will help. Working with specialists such as a doctor, a psychologist, an occupational therapist or a behavior therapist can be a great support. Finally, there are practical tools such as adaptive clothing that might make bedtime or school a tidier experience for everyone involved. If your child struggles with this problem, please share with others so you can get support and don’t have to manage this poop problem alone!