Attention Magazine August 2018

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Chronic Constipation: The Other Add

Craig B.Liden, MD, and Terri West, PA-C

EDITOR’S NOTE: This article contains important information about constipation, an extremely common problem for children and adults with ADHD. We’ve learned a lot about how significant a problem it is and how to best manage it from these authors, and we feel you will too. Be forewarned that it does contain some adult humor, so if you feel you might be offended, please proceed with caution.

WORKING WITH more than 10,000 patients with ADD/ADHD over the past thirty-five years has taught us many things. One of the most important is that many adults with ADD/ADHD are FOS (full of sh*t)! Not so much figuratively (though this may be true in some cases) but literally! And many don’t even know it.

All kidding aside, chronic constipation (CC), characterized by difficulty passing bowel movements, abnormal consistency of BMs, or reduced frequency of BMs is a problem for many adults with ADHD. If unrecognized and untreated, it can have a significant impact on the individual’s quality of life and lead to other more serious medical problems. So let’s take a look at five key lessons we’ve learned about what we have come to call the other ADD– Attention Defecation Disorder.

LESSON #1

“Give a sh*t!”

Chronic constipation is a serious health problem.

The discomfort, cramping, and nausea associated with CC can have a significant impact on quality of life, including one’s sense of physical and emotional well-being, as well as social functioning. Seventy percent of individuals with CC say it has adversely affected their work or school performance, and 12 percent have absences because of it. CC can have a more significant impact on quality of life than other more “serious” conditions, including arthritis, diabetes, and chronic allergies. If not properly managed, CC can lead to other health problems, including anal fissures, hemorrhoids, rectal ulcers, impaction, obstruction, megacolon, encopresis (soiling accidents), rectal prolapse, irritable bowel syndrome, urinary retention or frequency, diverticulosis/ diverticulitis, and possibly even cancer of the colon.

LESSON #2

“Individuals with ADD find simple sh*t hard to do!”

The core characteristics of ADD/ADHD can lead to the development of chronic constipation.

As silly as it may sound, one of the life tasks that requires efficient attention and executive functioning is having regular BMs. The core characteristics of ADHD, including impulsivity, distractibility, short attention span, inefficient task management, and weak self-monitoring can predispose individuals with ADHD to develop CC:

• They don’t pay attention to body signals that alert them that they have to go.

• They ignore body signals because they are hyperfocused on other activities.

• They procrastinate acting on body signals because it’s going to be hard, take too much time, or be painful.

• They get distracted by other activities/things and forget that going to the bathroom was what they intended to do.

• They don’t pay attention to the task at hand; once sitting on the toilet, their mind wanders.

• They don’t sit on the toilet long enough to let their pelvic muscles relax so they can pass a BM.

• They impulsively get up and leave if there’s no action that happens quickly.

• They don’t pay attention long enough to do the whole job; they leave something behind so that the caliber of the BMs gets bigger and are harder to pass.

• They can have an urgent need to have a BM and experience soiling accidents (encopresis), because the caliber of the BMs gets bigger, the bowel wall gets stretched and, as a result, the signal that alerts them that they have to go (the bowel wall stretching) is weaker and often happen at the last minute.

● They do not maintain healthy eating, hydration, and exercise habits that promote regular bowel habits.

● They do not comply with structured routines and therapeutic measures to correct the problem and prevent recurrences.

The impact of these ADD/ADHD-based behaviors is frequently magnified by certain temperamental extremes that occur more frequently in individuals with ADD. They have difficulty self-regulating these extremes including: low sensory threshold, low frustration tolerance, short persistence, and a withdrawal nature that leads to avoidance.

LESSON #3

” If you have ADD, you may be full of sh*t!”

Chronic constipation is an extremely common problem in individuals with ADD/ADHD.

Fifteen to seventeen percent of all adults report symptoms of CC. It is the most common gastrointestinal complaint brought to doctors despite the fact that it frequently goes unrecognized or unaddressed until some type of more serious consequence pops up.

More than 20 percent of children with ADHD have CC. Compared to the general population, children with ADHD are three times more likely to have CC and six times more likely to have encopresis (soiling accidents). The study of CC has been largely ignored in adults with ADHD. There are no research studies of CC in adults with ADHD, but a chart review of our current active adult ADHD patients found that 23 percent of them either have a history of chronic constipation symptoms, meet the Rome IV criteria for chronic constipation, have x-ray evidence of a large fecal load, or have/are currently doing some form of treatment for CC. This is about a 50percent higher incidence of CC than in the general population.

We have a keen nose for CC (that is, a high index of suspicion) in our adult patients, and when we suspect that they have the problem, the first step is to have them complete our Chronic Constipation Screening Checklist (see figure). If you suspect that CC is a problem for you, complete the checklist. Two or more positive responses are strongly suggestive of a significant problem.

Interestingly, for many of our patients the initiation of medication treatment for ADD/ADHD is the first time they actually tune into their symptoms of CC. With improved attention comes increased self-awareness of the sometimes subtle signs of CC (nausea, diminished appetite, bloating, fullness, and vague abdominal discomfort). Oftentimes, these symptoms are interpreted as side effects of medication therapy or the consequence of too high of a dose of medication. On the contrary, after years of experience we now know that what’s really happening is the medication enhances the individual’s self-awareness, which leads to uncovering a CC problem that may have been present for years. As a result, we take aggressive steps to diagnose and treat CC in these patients, which then allows them to have successful experiences with medication treatment for their ADHD.

LESSON #4

” Take action when you feel like sh*t!”

Don’t ignore the signs of chronic constipation; if simple steps don’t work, see your doctor and get evaluated and treated.

If you have two or more positive responses on the chronic constipation screener you should begin some type of basic intervention. The initial step should include:

● Refinement of your daily routines to bring about a healthier lifestyle: drink six to eight glasses of water to improve your hydration, increase fiber in your diet (such as fruits, vegetables, legumes, nuts, grains and seeds), exercise for twenty to thirty minutes daily, and build in regular five-minute bathroom times twice a day.

● A short-term trial of at least one of the over-the-counter (OTC) CC remedies:

● osmotic laxatives (Miralax, Milk of Magnesia)

● stimulant laxatives (Ex-Lax, Correctal, Dulcolax, Senakot)

● stool softeners (Colace, Pericolace)

● suppositories (Glycerin – hyperosmotic)

● Compliance with a medication regimen for ADHD that provides all-day coverage (from shortly after wake time to just before bedtime) to help address the contribution of ADHD to the development of CC and to improve the attentional skills and executive functioning necessary to establish and maintain healthy bowel habits.

If, after a trial of at least two OTC options used regularly according to packaging directions for a month, there is no resolution of symptoms or if there is resolution but a reoccurrence of symptoms within three to six months after discontinuation of the OTC treatments, a physician should be consulted. An evaluation by a physician should include a thorough history and physical examination to identify other medical problems that can present with CC (such as colon or rectal obstruction, neurological problem affecting the bowel, problems with the muscles involved with defecation, or hormone imbalance). Additional testing may be required to rule out such problems.

If there are no other medical explanations for the CC, the next step is often obtaining an abdominal flat plate x-ray or an ultrasound in order to determine the burden of stool and the extent of the bowel involved. We actually use a scoring system to quantify the degree of problem exhibited on the x-ray. This can help determine the optimal oral or rectal disimpaction routine, which is absolutely essential in order to ultimately return to normal bowel habits. The most common routines currently used include:

● aggressive use of Miralax over several weeks

● magnesium citrate

● GoLytly or NuLytly

● high saline enemas

When liquid cathartics or enemas are used the return should be clear or brown colored liquid. If a full clean-out is not achieved the likelihood of recurrence is high. Often a follow-up x-ray is required to make sure the clean-out was successful. If it was not, the clean-out regimen needs to be repeated.

LESSON #5

” Keep on pushin!”

Maintaining healthy bowel habits is a lifelong proposition for individuals with ADD/ADHD.

Once the retained stool burden is cleaned out, establishing a maintenance bowel routine is absolutely critical. The highest likelihood of relapse of CC often begins during the maintenance period after the clean-out has been completed when the individual is asymptomatic.

Just because the symptoms of CC are gone, does not guarantee that bowel tone/function has returned to normal. From our clinical experience, it can take three months or longer to re-establish normal bowel tone and functioning after a clean-out. During this time, it is extremely critical to maintain a structured daily routine, including healthy hydration, eating and exercise habits, daily use of Miralax or mineral oil to facilitate having a daily BM, and, most importantly, twice daily five- to ten-minute bathroom times to promote slowing down and focusing and allowing the pelvic musculature to relax in order to have a BM. In our practice, we have patients complete a tracking chart of their daily bowel habits as a reminder and an accountability tool. We review these charts regularly with our CC patients.

We have also learned that establishing and maintaining an all-day ADHD medication regimen is necessary if the adult with ADD is going to comply with the bowel maintenance regimen and achieve long-term success.

The bottom-line is, “Keep your sh*t together!” throughout the day, every day, forever!

Craig B. Liden, MD, is an internationally recognized expert in the diagnosis and treatment of ADD/ADHD and the medical director of the Being Well Center in Pittsburg, Pennsylvania. A board-certified physician, he has served on the faculty at the University of Pittsburgh School of Medicine. Since the 1980s, he has been in private practice, evaluating and treating behavior and developmental issues across the lifespan. Dr. Liden has written and lectured extensively on ADD/ADHD.

Terri West, PA-C, is a NCCPA board-certified physician assistant and the associate medical director of the Being Well Center. She has over twenty years of experience in working with patients across the lifespan in a variety of settings, including pediatrics, family practice, gynecology, surgery, and a breast cancer specialty practice, where she gained a keen insight into women’s health issues.

Adult Chronic Constipation Screener

(Rome IV Criteria Expanded)

1 Do you spontaneously have a normal (soft sausage or snake shaped) bowel movement (BM) fewer than three times in one week? (Stool type 3 or 4, refer to Bristol Stool Chart)

2 Do you have large stools, perhaps even clogging the toilet?

3 Do you pass rabbit droppings/rocklike stools (Bristol type 1) along with intermittent episodes of diarrhea?

4 Do you have a poor appetite and feel bloated, full or nauseated after eating just a few bites of food?

5 Are you having soiling/accidents in your pants?

6 Do you have to strain passing stools?

7 Do you have BMs that are painful or difficult to pass?

8 Do you have rectal/anal pain with BMs?

9 Do you have bleeding with BMs?

10 Do you avoid having a BMs until you are at home or wait to have a BM for other reasons?

11 Do you have daytime wetting accidents or the need to urinate frequently?

12 Do you pass a lot of gas or have very foul smelling gas?

13 Do you have the sensation that you have not fully evacuated your bowel after having a BM?

14 Do you have to do manual maneuvers to facilitate having a BM?

25 Do you have the sensation of ano-rectal obstruction/ blockage when trying to have a BM?

16 Have you had previous episodes of constipation or any of the symptoms of constipation?

Total # of YES responses:_/16

(Two or more “yes” meets criteria for chronic constipation)

Source: The Being Well Center