I receive a lot of questions every month about toileting difficulties. One question I am asked is what to do about fecal smearing. It’s an upsetting behavior because of the smell, mess, and unhygienic situation. Parents worry that fecal smearing will happen when their child is outside of their home – at school, daycare, or in a public place. It can cause isolation because the family will be reluctant and fearful to go places. Siblings don’t want to invite their friends over. It’s not a topic parents are able to discuss with friends and family. They may not have the confidence to speak with a professional about it because they worry about being criticized or judged.

I can remember my mother issuing an ultimatum over my son’s fecal smearing – extinguish the behavior or no more weekly Sunday dinners at her house. We never went for regular Sunday dinners again because it took me years to get this problem in control. I wish I had the understanding of fecal smearing that I do now back when it was a daily occurrence. I used to get so disheartened over the mess, smell, and clean up. I felt I had no one to talk to and felt really alone.

There is very little research that shows how common this problem is with autism and other related disorders. Because you can’t find much information about smearing, parents feel that other children don’t do this, they feel embarrassed, or they feel it is a part of the disability and nothing can be done about it.

What Is Fecal Smearing?

Smearing covers a variety of behaviors such as:

• Rolling feces in the hands, then hiding the pieces
• Taking feces of out of the toilet to play with or smear
• Choosing a spot in the house to play with feces
• Undressing in the school toilet, smearing feces on themselves, then getting dressed again and returning to class
• Using smearing as part of masturbation
• Smearing and shredding diapers at the same time
• Defecating in the bath, then smearing the surrounding area

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What Causes Smearing?

Smearing can be caused by a variety of things. Sometimes there is one than one cause, making it more difficult to resolve because the behavior is complex.

Some causes of smearing may include:

• Medical issues (constipation, GI issues)
• Psychiatric issues (OCD, exposure anxiety, mental health issues)
• Sensory factors (interoception problems – not knowing you have to go, enjoyment of smell and texture)
• Difficulties around teaching toilet training skills
• Dietary factors (limited diet may lead to constipation)
• Emotional factors (response to anxiety, the reward of a hot bath, sense of autonomy, understimulation/boredom, an expression of anger)
• Sexual factors (gratification, a sign of abuse)

Managing Smearing

Smearing can be both emotionally and physically draining for parents and caregivers. They need support from professionals to understand and develop toileting skills for the individual. This is the most important step in reducing or eliminating smearing, after ruling out medical or psychiatric causes.

Smearing can be reduced or minimized no matter how long it has been happening or how much it has occurred. Strategies will need to be individualized as every person has their own reason for smearing. Parents will need to work with everyone who is involved with their child (school team, caregivers, family members) to get everyone using the same approach. There should be no punishment involved as this will not reduce smearing episodes.

Use low-arousal responses which involve being as emotionally neutral as possible. This means having neither a positive or negative reaction to fecal smearing.

Some ways to do this are:

• Focus on your own breathing prior to clean up – calm, steady breaths
• Clean up quietly with few or no words
• Go somewhere alone to have an emotional reaction if there is the need to vent frustration, but make sure the individual is not present
• Clean the furniture, floor, walls etc. when the individual is not there so that they can’t see or hear your responses to the cleaning.
• When cleaning the individual, do so with as few words as possible or in silence. Keep your responses low-key and behave calmly so that your emotions don’t come through in your actions (like brisk scrubbing).

When Smearing Occurs

If you support an individual who smears, the first thing to do is seek advice from your family doctor. The cause of smearing has to be determined before any strategies can be put in place. We found out that our son was chronically constipated after having an abdominal ultrasound done. He had also experienced weight loss and vomiting with any increased food intake as a result of being constipated. Our son would dig in his anus and pick out bits of stool to relieve pressure and itching and that is why he smeared.

Constipation happens more often than we realize in people with ASD due to low fiber diets and limited fluid intake. You can keep a stool diary using the Bristol Stool Form Scale to record what bowel movements look like. This information is helpful for physicians to determine what is going on.

If underlying medical causes have been ruled out and the root cause is sensory (enjoys the smell, texture, feel of feces), you can try offering substitutions for the feces such as:

Touch – warm play dough, pudding, toothpaste, shower gel, clay, sand and water mixture

Visual – finger painting, shaving cream, clay, bread dough

Smell – Marmite, vinegar, essential oils, spices, scented lotions

Sound – the texture will tell you the sound the material will make when squeezed

Substitutions should be offered throughout the day and consistently used until they become routine. Have them accessible where the individual usually smears.

Toilet Training Skills

I have written numerous articles on toilet training and recommended books on the subject. Difficulties around acquiring toileting skills can be part of the reason a person fecal smears. Impairment in interoceptive awareness may be the reason someone doesn’t know they need to defecate.

I am a proponent of getting rid of diapers when toilet training. Using diapers can prevent a quick response to the urge “to go”, some may not even know you use a toilet to eliminate in, and remaining for any length of time in a soiled or wet diaper can cause the anal area to become sweaty or damp leading to anal itching, then picking and smearing.

You can learn everything you need to know about smearing by reading Kate E. Reynolds book, What to Do About Smearing. It is a highly accessible book that explains all aspects of smearing and provides answers to questions so many of us are afraid to ask. The important points for each chapter are summarized at the end and there is an extensive reference list provided for further study. I wish this book had been written years ago because it would have saved me much heartache. It is Kate’s book that I used for the basis of this post as well as my own firsthand experience.