Constipation in children is one of the most common gastrointestinal malfunctions in childhood, starting in the neonatal period and continuing into adulthood in about 1/3 of children. In some of these children, treatment with conventional dietary fiber and laxatives is not effective, and the clinical course is chronic and persistent. The recent creation of neurogastroenterology and gastrointestinal dynamics, as well as the increased awareness of the biopsychosocial model of functional gastrointestinal disease, have not only further revealed the pathogenesis of functional constipation, but also opened up new horizons in clinical diagnosis and management. Based on these new concepts, psycho-behavioral and biofeedback treatments have been carried out in the clinic with remarkable efficacy. Psycho-behavioral treatment of functional constipation in children 1, the theoretical basis of psycho-behavioral treatment of functional constipation According to the modern biopsychosocial medical model, the pathophysiological mechanism of functional gastrointestinal disease involves abnormal gastrointestinal dynamics, gastrointestinal hypersensitivity, abnormal brain-gut axis interaction and psychosocial abnormalities. The brain-gut axis refers to the bidirectional pathway of the central nervous system and the enteric nervous system for the regulation of intestinal functions. External stimuli and internal information are connected to higher centers through neural connections, affecting gastrointestinal sensation, dynamics and endocrine; conversely, visceral activity also acts on central sensation, emotion and behavior, i.e., brain-gut and bowel-brain interactions. These modulations are accomplished through vasoactive intestinal peptides, 5-hydroxytryptamine, and other brain-gut peptides and modulators. Animal models show that psycho-behavioral effects on visceral sensation and/or dynamics at different levels in rat gastrointestinal smooth muscle, spinal cord dorsal horn, cerebral cortex and hippocampus. 2, psycho-behavioral factors and defecation function Psycho-behavioral and constipation are causally related to each other Various psycho-behavioral factors can affect gastrointestinal function. The incidence of constipation is higher in children with specific behavioral manifestations (female ding autism and obesity), the incidence of behavioral abnormalities in children with functional constipation is 3-4 times higher than in ordinary children, and the frequency of fecal incontinence is associated with delinquency and aggressive behavior. Mental states, such as short-term anxiety and stress, likewise affect defecation habits. Results of a national multicenter survey of risk factors for functional constipation in urban primary and secondary school students by Huiching Zhou et al. showed that functional constipation accounted for 25.92% of more than 50,000 study subjects, with nine factors such as insomnia, fatigue, and anxiety and irritability as the most likely risk factors. A study in Sri Lanka concluded that various stressful events such as separation from close friends, examination failure, intimidation, parental unemployment, frequent corporal punishment, and living in war-affected areas were associated with a high incidence of constipation. Artificial fecal control can lead to defecation dysfunctionFecal control behavior, often triggered instinctively by avoidance of painful defecation, is one of the main causes of poor defecation function in children. Studies have shown that 97% of children with constipation have fecal control behaviors, when the child remains in an upright position and forcefully contracts the buttocks and pelvic floor muscles until the stimulus to defecate disappears, causing rectal adaptation and making feces harder and more difficult to pass in the rectum, thus creating a vicious cycle that eventually leads to chronic rectal dilatation. Klauser et al. showed that the results of a 2-week observation by randomizing healthy volunteers to normal defecation or deliberately suppressing defecation showed that deliberate suppression of defecation resulted in Klauser et al. showed that deliberate suppression of defecation resulted in less frequent and less voluminous defecation, and prolonged transit time of feces through the whole colon and recto-sigmoid, suggesting that constipation can be “learned”. Inappropriate toilet behavior training causes constipation in children Domestic studies have shown that 42.1% of children with constipation are not trained to defecate or are not trained properly. A Turkish study reported that the main risk factors for constipation in children were consistent absence from school (OR=5.9) and problems with bowel control after 2 years of age (08=3.1). 3. Psycho-behavioral treatment strategies for functional constipation A minority of patients with functional constipation are co-morbid with psychological disorders and have persistent symptoms. Those with obvious psychological factors should have a complete psychological treatment plan developed by a psychiatrist, and appropriate medications, etc., should be selected as adjunctive treatment. Interventions for psycho-behavioral problems in most patients with milder symptoms and less obvious sources of psychological stress include education, bowel training, biofeedback therapy, etc. 4. Psycho-behavioral education for functional constipation Education should first establish a therapeutic doctor-patient relationship as a basis for correcting disease behavior, identify with the child’s and parents’ concerns about the disease and painful mental experiences, help reduce anxiety, increase confidence, cooperate with treatment, and Reinforcing healthy behaviors. The education includes an explanation of the pathophysiological mechanisms of constipation and the purpose, measures and necessity of long-term treatment. In addition to pharmacological and behavioral interventions and biofeedback treatment, the health education group was strengthened with the KAP (Knowledge-Attitude-Practice) model of health education, which included explaining the pathophysiological mechanisms of constipation, guiding various treatment measures, encouraging parents and children, and conducting health education every 2 weeks. The results showed that the health education group had significantly higher medication compliance and behavioral compliance than the general treatment group, and significantly lower symptom scores. 5. Defecation training for functional constipation The necessity of defecation training is necessary to maintain the laxative effect and establish normal defecation habits. The children in the intervention group were trained to sit for 10-15 min twice a day on the basis of regular application of laxatives. After 4 weeks, the fecal traits Bristo classification, frequency of defecation and accompanying symptom scores of the intervention group were significantly better than those of the control group, showing the effect of defecation habit training. Precautions for defecation training Before performing defecation training, firstly, we should remove fecal impaction and eliminate painful defecation, so that the child will not intentionally and/or subconsciously control the stool due to pain and affect the effect; secondly, instruction on methods and techniques should be given; finally, long-term persistence is necessary to restore normal sensation in the rectum in order to ensure the successful establishment of normal defecation habits. Methods and techniques instruction for infants and young children: parents should be instructed how to educate their children to establish healthy defecation habits, i.e., at the appropriate time and using appropriate methods, such as using a brightly colored, child-attractive appearance (small animal image) of the toilet seat, and training is more appropriate after dinner, which can make use of both the gastrocolonic reflex and the mental and emotional relaxation of parents, once a day, gradually forming habits, and rewards can be used to improve The effect can be improved by using rewards. Older children: guide the appropriate time (usually after dinner, to avoid mental tension due to time constraint), choose the appropriate toilet seat, adopt the appropriate defecation posture, relax the legs and feet, knees slightly above the hips, deep breath and hold the breath while pushing down, repeated training until normal toileting.