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Pediatrics International (2015) 57, 143–148
doi: 10.1111/ped.12427
Original Article
Familial psychological factors are associated with encopresis Devrim Akdemir,1 S Ebru Çengel Kültür,1 ˙Inci Nur Saltık Temizel,2 Ays¸e Zeki4 and Gülser S¸enses Dinç3 Departments of 1Child and Adolescent Psychiatry and 2Pediatrics, Section of Gastroenterology, Hepatology and Nutrition, Hacettepe University Faculty of Medicine, 3Department of Child and Adolescent Psychiatry, Ankara Children’s Hematology Oncology Training and Research Hospital, Ankara, Turkey and 4Barıs¸ Psychiatry Hospital, Nicosia, Cyprus Abstract
Background: The aim of this study was to assess maternal psychiatric symptoms, family functioning and parenting styles in children with encopresis. Methods: Forty-one children with encopresis were compared to 29 children without any psychiatric disorder. Results: Higher maternal psychiatric symptoms were found in children with encopresis. The general family functioning and strictness/supervision in parenting were significant predictors of encopresis. Conclusions: Family functioning may be screened in children with encopresis, especially when standard interventions have had limited success. Identification and treatment of familial factors may enhance the treatment efficacy in encopresis.
Key words encopresis, family functioning, maternal psychiatric symptoms, parenting, treatment.
Encopresis is defined as both the voluntary and involuntary passage of feces in inappropriate places in a child aged ≥4 years, after medical causes have been ruled out, according to ICD-101 and DSM-IV-TR.2 It is a common childhood disorder and has been reported as approximately 3% in general outpatient clinics,3 and greater (4%) in developing countries.4 Numerous studies reported emotional, behavioral and social problems5–9 and comorbid psychiatric disorders10,11 in children with encopresis. Despite the fact that encopresis is a common disorder associated with psychosocial problems, there are few publications that address the psychiatric and familial factors that might affect the development, maintenance or treatment of encopresis in children. Factors such as separation from the family,4,12 difficult child temperament13,14 and inappropriate or incorrect toilet training15,16 have been reported to contribute to the development of toileting problems. Reports on parenting style in children with encopresis, however, especially surveys of children on the parenting styles of their parents, are scarce; this may be because encopresis is generally a disorder of earlier childhood. It may be useful to obtain reports of children about the parenting styles of their parents. Familial factors such as maternal depression and/or anxiety symptoms are associated with elimination disorders at school age.4 Given that depression and/or anxiety reduces capacity to cope with stress,17 elimination disorders may be accelerated or exacerbated. Ineffectual, disorganized and chaotic families might also have difficulty in handling encopresis symptoms.6,18 Little Correspondence: Devrim Akdemir, MD, Department of Child and Adolescent Psychiatry, Hacettepe University Faculty of Medicine, 06100, Ankara, Turkey. Email: [email protected] Received 20 March 2014; revised 26 May 2014; accepted 4 June 2014.
© 2014 Japan Pediatric Society
work on family environment or functioning, however, has been reported. The aim of this study was to extend the previous literature on the role of familial factors as components of encopresis. Thus, the present study assessed maternal psychiatric symptoms, mothers’ perception of family functioning, and perception of children regarding the parenting behaviors of their parents, in children with encopresis compared to children without any psychiatric disorder. We hypothesized that children with encopresis, when compared to children without any psychiatric disorder, would have (i) mothers with more maternal psychiatric symptoms; (ii) an impairment in family functioning; and (iii) less strictness/supervision in parental parenting behaviors.
Methods Participants
The study group consisted of 41 children with encopresis and their mothers. The inclusion criteria were admission to the child and adolescent psychiatry outpatient clinic with a complaint of fecal incontinence and diagnosis of encopresis; lack of medical causes of encopresis; and volunteering for participation. The presence of a pervasive developmental disorder, a neurological disorder or mental retardation, and refusal to participate in the study were the exclusion criteria. Constipation was not an exclusion criterion because it is often associated with encopresis. Children with encopresis were evaluated by the Gastroenterology Unit of the Department of Pediatrics at Hacettepe University. There were no identified medical causes of encopresis in any children after physical examination and appropriate laboratory tests. Patients with encopresis were included in the study in order of application, so they were consecutive patients. The study group consisted of 46 children fulfilling the criteria and aged between 6
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and 16 years old. One patient was excluded from the study due to suspected mental retardation on clinical evaluation. Three children with encopresis were excluded due to incomplete data, and one child was excluded due to unwillingness to participate in the study. Children in the study group received treatment for encopresis and comorbid psychiatric disorders according to the protocols of the Department of Child and Adolescent Psychiatry. The control group consisted of 29 children who were referred consecutively to other pediatric clinics of the same hospital with acute physical complaints and had no diagnosis or history of psychiatric complaint or disorder including encopresis. Voluntary parents and their children who had consented to participate and were matched with the encopresis group for age, gender and socioeconomic level were included. The exclusion criteria for the control group were presence of a chronic medical disorder including constipation or mental retardation in children. Thirtytwo children and their mothers were asked to participate in the control group. Two mothers refused to take part. One child with a diagnosis of major depressive disorder was excluded from the control group. Materials
All children and their mothers in the study and control groups were interviewed using the Schedule for Affective Disorders and Schizophrenia for School-Age Children, Present and Lifetime Version (K-SADS-PL), conducted by a child and adolescent psychiatrist, in order to diagnose encopresis and comorbid psychiatric disorders in the study group and to rule out any psychiatric disorder in the control group. Children in the study group were defined as having constipation currently if they fulfilled the Questionnaire on Pediatric Gastrointestinal Symptoms, Rome III version (QPGS-RIII) diagnostic criteria by having two or more of the six conditions (1 episode of fecal incontinence per week; retentive posturing or excessive volitional stool retention; history of painful or hard bowel movements; passage of large stools that clog the toilet; and detection of large fecal mass in the rectum by doctor) for at least 2 months.19 A reliability and validity study of this form for the Turkish population was conducted.20 If needed, abdominal plain radiography was used for the evaluation of constipation. Family socioeconomic level was measured using the Hollingshead–Redich Scale.21 Five levels of socioeconomic status (1, upper; 2, upper middle; 3, middle; 4, lower middle; 5, lower) are defined in this scale. Mothers were interviewed and were requested to complete a Symptom Check List-90-Revised (SCL-90-R) and McMaster Family Assessment Device (FAD) to assess maternal psychiatric symptoms and family functioning, respectively. A Parenting Style Scale (PSS) was filled out by children ≥8 years old. Data collection form
Sociodemographic data, developmental and medical histories of the children and features of encopresis were collected using a data collection form created by the investigators. In this study, the timing of toilet training was defined as age at achievement of fecal continence for 30 consecutive days. © 2014 Japan Pediatric Society
K-SADS-PL
A reliability and validity study of K-SADS-PL for the Turkish population was conducted.22,23 The validity, interrater reliability and test–retest reliability of K-SADS-PL were found to be excellent for elimination disorders. SCL-90-R
The SCL-90-R is a 90-item self-rating inventory in which each item is rated on a 5 point Likert scale, ranging from “not at all (0)” to “extremely (4)”.24 It includes nine clinical subscales for somatization, obsessive compulsive, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideation, and psychoticism. The Global Severity Index (GSI) score is calculated by dividing the total score obtained from all items by 90. A GSI score >1.00 is considered to indicate symptoms on a psychopathology level. The validity and reliability of this scale in Turkey have been investigated.25 FAD
The FAD was developed based on the McMaster model of family functioning (MMFF) and measures structural, organizational and transactional properties of the family.26 According to the MMFF model, the family as a system plays a central role in the socialization, education, psychological and biological maintenance of family members, and it includes three kinds of tasks that families need to be fulfilled: (i) basic tasks related to the provision of support, love and understanding for all the family members; (ii) developmental tasks related to the stimulation of growth and maturation of family members, and the provision of support through all stages of individual and family lifecycle; and (iii) adaptation and response of the family to unexpected events such as illness, death and divorce.27 The MMFF model suggests that families unable to handle these task areas are most likely to develop clinically significant problems. The MMFF model has seven dimensions: problem-solving, communication, roles, affective responsiveness, affective involvement, behavior control and general functioning. FAD is a self-report questionnaire and includes 60 items on these dimensions, with six items for problem-solving, nine items for communication, 11 items for roles, six items for affective responsiveness, seven items for affective involvement, nine items for behavioral control, and 12 items for general functioning. All subscales have an average score ranging from 1 to 4. Scores >2.00 indicate problems in the related functioning of the family. A reliability and validity study of this scale was undertaken in Turkish families.28 PSS
In order to evaluate the perceptions of children regarding the parenting style of their parents in the study and control groups, the PSS29 was used. PSS is able to be completed by children ≥8 years old. A total of 33 children (80.5%) in the study group and 22 (75.9%) in the control group completed the PSS. The PSS includes 26 items grouped into three dimensions: acceptance/involvement, strictness/supervision, and psychological autonomy. A validity and reliability study of this scale in
Psychological factors in encopresis Turkey has been done.30 The test–retest reliability and internal consistency of dimensions were between 0.60 and 0.93 in elementary, high school and college student groups. The factor pattern of PSS for the elementary and high school students was very similar to the original scale’s factor pattern.
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subscale scores. A logistic regression model with a backward stepwise method was used to determine the predictors of encopresis. Results with P < 0.05 were accepted as statistically significant.
Results
Procedure
This study was carried out in the Department of Child and Adolescent Psychiatry at Hacettepe University Children’s Hospital. The study protocol was approved by the Institutional Review Board of Hacettepe University. Mothers of children who were admitted to the Hacettepe University Department of Child and Adolescent Psychiatry with a complaint of fecal incontinence were informed about the purpose and design of this investigation. Mothers of children in the study and control groups gave written informed consent for participating in the study. After the first evaluation in the Department of Child and Adolescent Psychiatry, children with encopresis were evaluated by the Gastroenterology Unit of the Department of Pediatrics. In their second visit to the child and adolescent psychiatry clinic, K-SADS-PL was carried out for the children and their mothers and other questionnaires were filled out by them. The children and mothers in the control group were also evaluated using the K-SADS-PL for psychiatric diagnosis and the QPGS-RIII diagnostic criteria for constipation. Statistical analysis
Shapiro–Wilk test was used to determine normality of the data. The significance of the differences in normally distributed continuous variables was analyzed using independent samples t-test when there were two groups. The Mann–Whitney U-test was used to compare the differences between two groups when the dependent variable was continuous but not normally distributed. Chi-squared test was used to examine significance of the differences in variable frequencies between groups. One-way multivariate analysis of variance (MANOVA) was applied to analyze the main effect of diagnosis on SCL-90-R, FAD and PSS
Sociodemographic results
The mean age of children in the encopresis group was 9.4 ± 2.1 years (range, 6–16 years) and that in the control group was 8.7 ± 1.5 years (range, 6–12 years). There were 29 boys (70.7%) and 12 girls (29.3%) in the encopresis group, and 16 boys (55.2%) and 13 girls (44.8%) in the control group. No significant differences in age, children’s gender or family socioeconomic level were seen between the two groups. The age and education level of parents in the two groups were not significantly different. The sociodemographic results in the encopresis and control groups are listed in Table 1. Clinical characteristics of children with encopresis
Of the 41 patients, 12 (29.3%) had primary and 29 (70.7%) had secondary encopresis. The mean age of onset for secondary encopresis was 6.6 ± 1.6 years (range, 5–10 years), and the mean interval between the onset of symptoms and diagnosis was 14.4 ± 14.2 months (range, 1–48 months). The time span between the onset of symptoms and admission to our clinic was 42 ± 27.8 months (range, 1–144 months) for all patients with primary or secondary encopresis, when the onset of symptoms in primary encopresis was assigned to the age of 4. Thirty-two (78%) of the children were living with nuclear families. Thirteen (44.8%) of the children with secondary encopresis had stressful life events before the onset of the disorder such as a separation from their mother, father or a loved one, starting a new school and having a new sibling. Constipation was found in 30 (73.2%) of children with encopresis. The timing of toilet training was significantly higher in children with encopresis (mean, 26.5 ± 7.4 months;
Table 1 Sociodemographic subject characteristics
Age (years), median (range) Age of mothers (years), mean ± SD Education level of mothers (years), median (range) Age of fathers (years) median (range) Schooling time of fathers (years), median (range) Gender, n (%) Male Female Socioeconomic status, n (%) Upper Upper middle Middle Lower middle Lower
Children with encopresis
Children without any psychiatric disorder
n = 41
n = 29
9 (6–16) 35.9 ± 5.8 8 (5–15) 40.5 (30–80) 10 (5–15)
Statistics†
z = −1.075NS‡ t = −0.168NS† z = −1.947NS‡ z = −0.195NS‡ z = −0.831NS‡
9 (6–12) 36.2 ± 4.0 11 (5–15) 40.0 (32–54) 11 (2–15)
29 12
70.7 29.3
16 13
55.2 44.8
χ2 = 1.791NS
7 3 11 11 9
17.1 7.3 26.8 26.8 22.0
6 5 7 5 6
20.7 17.3 24.1 17.2 20.7
χ2 = 2.327NS
t-test for independent samples; ‡Mann–Whitney U-test. NS, not significant, P > 0.05.
†
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range, 12–48 months) compared to children without any psychiatric disorder (mean, 21.9 ± 5.4 months; range, 12–30 months, z = −2.328, P = 0.02). There was no history of encopresis in other family members or siblings. There was at least one comorbid psychiatric disorder in 34 children (82.9%) in the encopresis group. Twenty-five (73.5%) of the 34 children had more than one comorbid psychiatric disorder. The prevalence of these disorders was as follows: enuresis, 53.6% (n = 22); attention-deficit–hyperactivity disorder, 46.3% (n = 19); oppositional defiant disorder, 29.3% (n = 12); anxiety disorders, 14.6% (n = 6); tic disorders, 7.3% (n = 3); major depression, 4.9% (n = 2); and conduct disorder, 2.4% (n = 1). Maternal psychiatric symptoms, family functioning and parenting style results
The SCL-90-R and FAD subscale scores of mothers and PSS subscale scores of children in the study and control groups are summarized in Table 2. The GSI score of the SCL-90-R was significantly higher in mothers of children with encopresis compared to mothers of children without any psychiatric disorder (encopresis group, 1.0 ± 0.7; control group, 0.7 ± 0.4; t = −2.432, P = 0.018; 95% confidence interval: −0.59 to −0.06). The SCL-90-R and FAD subscale scores were not found to be significantly different in mothers of children with encopresis compared to mothers of children without any psychiatric disorder (Wilks’ lambda P = 0.26 for SCL-90-R and Wilks’ lambda P = 0.13 for FAD). Similarly, PSS subscale scores were not significantly different in the two groups (Wilks’ Lambda P = 0.07).
A logistic regression model with the backward stepwise method was used to identify predictors of encopresis. The GSI score of SCL-90-R and general functioning score of FAD were entered without other subscales due to their capacities to reflect the level of psychopathology and family functioning alone, respectively. The predictors entered in the model were GSI score of SCL-90-R; general functioning score of FAD; and the acceptance/involvement, strictness/supervision, and psychological autonomy scores of PSS. This logistic regression model explained 27.4% (Nagelkerke R2 = 0.274) of the variation in the encopresis. Statistically significant risk factors for encopresis were the general functioning score of FAD and the strictness/ supervision score of PSS. An increase of 1 unit in the general functioning score of FAD and strictness/supervision score of PSS produced a 3.2- and 0.8-fold increase in the odds of having encopresis, respectively (Table 3).
Discussion In the present study, maternal psychiatric symptoms, mothers’ perception of family functioning and, the perception of children regarding the parenting behaviors of their parents in the encopresis group were compared to those of the control group children. One of the findings was that higher maternal psychiatric symptoms were identified in children with encopresis compared to children without any psychiatric disorder. Although there were no significant differences in the measures of family functioning and parenting styles between the groups, overall the present findings support the idea that familial factors are associated with encopresis. A logistic regression model identified general family
Table 2 SCL-90-R, FAD and PSS subscale scores
SCL-90-R Somatization Obsessive compulsive Interpersonal sensitivity Depression Anxiety Hostility Phobic anxiety Paranoid ideation Psychoticism FAD Problem-solving Communication Roles Affective responsiveness Affective involvement Behavioral control General functioning PSS Acceptance/involvement Strictness/supervision Psychological autonomy
Children with encopresis (n = 41) (Mean ± SD)
Children without any psychiatric disorder (n = 29) (Mean ± SD)
F†
95%CI for mean difference‡
1.1 ± 0.8 1.3 ± 0.7 1.2 ± 0.8 1.2 ± 0.8 0.9 ± 0.8 1.1 ± 0.9 0.5 ± 0.6 1.0 ± 0.7 0.6 ± 0.6
0.9 ± 0.7 0.8 ± 0.5 0.8 ± 0.6 0.9 ± 0.7 0.6 ± 0.4 0.6 ± 0.6 0.2 ± 0.3 0.7 ± 0.5 0.3 ± 0.3
1.638 7.874 4.183 2.780 2.798 6.209 4.278 3.189 4.731
−0.14 to 0.64 0.13–0.75 0.01–0.74 −0.06 to 0.68 −0.05 to 0.60 0.09–0.84 0.01–0.51 −0.03 to 0.60 0.02–0.50
2.1 ± 0.7 1.9 ± 0.6 2.0 ± 0.5 1.9 ± 0.8 2.2 ± 0.6 2.0 ± 0.5 1.9 ± 0.6
1.9 ± 0.5 1.7 ± 0.4 1.8 ± 0.5 1.5 ± 0.5 1.8 ± 0.4 1.7 ± 0.3 1.5 ± 0.5
0.924 4.109 3.524 5.371 6.609 6.550 6.204
−0.16 to 0.46 0.004–0.50 −0.01 to 0.46 0.05–0.70 0.08–0.63 0.06–0.52 0.07–0.60
29.1 ± 4.6 27.7 ± 4.1 22.4 ± 5.0
30.9 ± 3.5 30.4 ± 2.6 22.3 ± 5.6
2.284 7.590 0.009
−4.05 to 0.57 −4.66 to −0.73 −2.77 to 3.04
† MANOVA. ‡Adjustment for multiple comparisons: Bonferroni. CI, confidence interval; FAD, McMaster Family Assessment Device; PSS, Parenting Style Scale; SCL-90-R, Symptom Check List-90-Revised.
© 2014 Japan Pediatric Society
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Table 3 Predictors of encopresis
Step 1
Step 2
Step 3
Step 4
GSI score of SCL-90-R General functioning score of FAD Acceptance/involvement score of PSS Psychological autonomy score of PSS Strictness/supervision score of PSS Constant GSI score of SCL-90-R General functioning score of FAD Psychological autonomy score of PSS Strictness/supervision score of PSS Constant General functioning score of FAD Psychological autonomy score of PSS Strictness/supervision score of PSS Constant General functioning score of FAD Strictness/supervision score of PSS Constant
P
Exp (B)
0.233 0.824 0.289 0.029* 0.481 0.284 0.225 0.283 0.021* 0.290 0.037* 0.417 0.021* 0.249 0.048* 0.021* 0.083
2.276 2.611 1.024 1.079 0.764 29.517 2.304 2.428 1.072 0.773 56.480 3.678 1.052 0.772 87.722 3.192 0.769 397.325
95%CI for Exp (B) 0.488 0.539 0.832 0.937 0.601
10.614 12.637 1.259 1.243 0.972
0.500 0.580 0.944 0.621
10.618 10.167 1.217 0.962
1.080 0.931 0.619
12.532 1.189 0.962
1.010 0.615
10.086 0.961
*P < 0.05. CI, confidence interval; FAD, McMaster Family Assessment Device; GSI, Global Severity Index; PSS, Parenting Style Scale; SCL-90-R, Symptom Check List-90-Revised.
functioning and strictness/supervision-related parenting styles as statistically significant risk factors for encopresis. These results show that ineffectual families and psychiatrically distressed mothers may be less capable of managing a child’s soiling problems. Unfortunately, little empirical work has been done regarding the family environment of children with encopresis. In a small number of studies evaluating the family environment, children with encopresis were found to have inadequate family functioning and family environment with less expressiveness and poorer organization.6,31 In the present study, family functioning was identified as a risk factor, similar to previous studies. It was noted in the literature that disorganized or chaotic families may also require family support in addition to medical and behavioral management of encopresis.18 Successful treatment results were reported for an interactive parent–child family guidance intervention, which involves family members in a psychologically based treatment, after standard gastroenterologic intervention for encopresis and chronic constipation had been tried with limited success.32 But, given that the time span between onset of symptoms and admission to our clinic was nearly 4 years in the present study, maternal mental health, family functioning and, parenting might be influenced by the symptoms. Regardless of whether maternal psychiatric symptoms, insufficient strictness/supervision and poor family functioning are causes or consequences, they may be screened for, especially in cases of limited success of standard interventions, or in cases of referral to the psychiatry clinics for treatment of encopresis. The McMaster FAD (or the general functioning subscale alone) is accepted as a screening assessment to identify families having problems and it can also be used by clinicians to identify particular areas of difficulty within a family.26,33 The identification and treatment of such clinical issues may enhance the treatment efficacy of encopresis. In addition to maternal report, paternal or child report of family functioning may be collected in future studies.
In the present study, most of the children with encopresis (73.5%) had more than one comorbid internalizing or externalizing psychiatric disorder including enuresis (53.6%), attentiondeficit–hyperactivity disorder (46.3%), oppositional defiant disorder (29.3%), anxiety disorders (14.6%), tic disorders (7.3%), major depression (4.9%) and conduct disorder (2.4%). Most of the studies evaluated psychiatric problems in children with encopresis using questionnaires. Studies that assessed diagnosis using a structured, standardized psychiatric interview also reported high rates of comorbid disorders, similarly to the present study.31,34 The present study has some strengths and limitations. The evaluation of psychiatric diagnosis and assessment of maternal psychological factors and family functioning may constitute the strengths of the present study. Nevertheless, this study did not include fathers and was carried out in a psychiatry clinic in a tertiary pediatric setting, which may also limit the generalizability of the findings, especially due to the high rate of comorbid psychiatric disorders. The small sample size is another limitation of the present study. Analyzing many variables for such a small sample may decrease the statistical power of the results. Additionally, the backward stepwise regression analysis bears some limitations. This technique is not very heavily theorydriven and suggests a fairly weak approach to examining relations among constructs. Un a study area without a lot of previous work, however, this may be acceptable. Finally, as with all crosssectional studies, it is not possible to understand whether the psychological factors found in the present study are causes or consequences of soiling. Conclusions
Mothers of children with encopresis, who were referred to a psychiatry clinic primarily for the treatment of the encopresis, perceived themselves as psychiatrically distressed. Mother-rated inadequate family functioning and child-reported insufficiency in © 2014 Japan Pediatric Society
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strictness/supervision in parenting were also identified as risk factors for encopresis. Thus, close collaboration between the pediatrician and psychiatrist in order to evaluate each child and family for mothers’ psychiatric wellness and modification of familial organization has the potential to be an effective intervention in encopresis. Further research on the etiological and therapeutic importance of the family in the case of encopresis referred to a psychiatry clinic should be carried out.
Acknowledgments We thank Associate Professor Pınar Özdemir PhD from the Department of Biostatistics in Hacettepe University and Associate Professor Sait Uluç PhD from the Department of Psychology in Hacettepe University for reviewing the statistical analysis, Lori Russell Dag˘ MS from the Department of Computer Technology and Programming in Bilkent University for assistance with the manuscript, and Burcu Berberog˘lu MD from the Gastroenterology Unit of the Department of Pediatrics in Hacettepe University for her guidance of the patients in this unit.
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Pediatrics International (2015) 57, 143–148
doi: 10.1111/ped.12427
Original Article
Familial psychological factors are associated with encopresis Devrim Akdemir,1 S Ebru Çengel Kültür,1 ˙Inci Nur Saltık Temizel,2 Ays¸e Zeki4 and Gülser S¸enses Dinç3 Departments of 1Child and Adolescent Psychiatry and 2Pediatrics, Section of Gastroenterology, Hepatology and Nutrition, Hacettepe University Faculty of Medicine, 3Department of Child and Adolescent Psychiatry, Ankara Children’s Hematology Oncology Training and Research Hospital, Ankara, Turkey and 4Barıs¸ Psychiatry Hospital, Nicosia, Cyprus Abstract
Background: The aim of this study was to assess maternal psychiatric symptoms, family functioning and parenting styles in children with encopresis. Methods: Forty-one children with encopresis were compared to 29 children without any psychiatric disorder. Results: Higher maternal psychiatric symptoms were found in children with encopresis. The general family functioning and strictness/supervision in parenting were significant predictors of encopresis. Conclusions: Family functioning may be screened in children with encopresis, especially when standard interventions have had limited success. Identification and treatment of familial factors may enhance the treatment efficacy in encopresis.
Key words encopresis, family functioning, maternal psychiatric symptoms, parenting, treatment.
Encopresis is defined as both the voluntary and involuntary passage of feces in inappropriate places in a child aged ≥4 years, after medical causes have been ruled out, according to ICD-101 and DSM-IV-TR.2 It is a common childhood disorder and has been reported as approximately 3% in general outpatient clinics,3 and greater (4%) in developing countries.4 Numerous studies reported emotional, behavioral and social problems5–9 and comorbid psychiatric disorders10,11 in children with encopresis. Despite the fact that encopresis is a common disorder associated with psychosocial problems, there are few publications that address the psychiatric and familial factors that might affect the development, maintenance or treatment of encopresis in children. Factors such as separation from the family,4,12 difficult child temperament13,14 and inappropriate or incorrect toilet training15,16 have been reported to contribute to the development of toileting problems. Reports on parenting style in children with encopresis, however, especially surveys of children on the parenting styles of their parents, are scarce; this may be because encopresis is generally a disorder of earlier childhood. It may be useful to obtain reports of children about the parenting styles of their parents. Familial factors such as maternal depression and/or anxiety symptoms are associated with elimination disorders at school age.4 Given that depression and/or anxiety reduces capacity to cope with stress,17 elimination disorders may be accelerated or exacerbated. Ineffectual, disorganized and chaotic families might also have difficulty in handling encopresis symptoms.6,18 Little Correspondence: Devrim Akdemir, MD, Department of Child and Adolescent Psychiatry, Hacettepe University Faculty of Medicine, 06100, Ankara, Turkey. Email: [email protected] Received 20 March 2014; revised 26 May 2014; accepted 4 June 2014.
© 2014 Japan Pediatric Society
work on family environment or functioning, however, has been reported. The aim of this study was to extend the previous literature on the role of familial factors as components of encopresis. Thus, the present study assessed maternal psychiatric symptoms, mothers’ perception of family functioning, and perception of children regarding the parenting behaviors of their parents, in children with encopresis compared to children without any psychiatric disorder. We hypothesized that children with encopresis, when compared to children without any psychiatric disorder, would have (i) mothers with more maternal psychiatric symptoms; (ii) an impairment in family functioning; and (iii) less strictness/supervision in parental parenting behaviors.
Methods Participants
The study group consisted of 41 children with encopresis and their mothers. The inclusion criteria were admission to the child and adolescent psychiatry outpatient clinic with a complaint of fecal incontinence and diagnosis of encopresis; lack of medical causes of encopresis; and volunteering for participation. The presence of a pervasive developmental disorder, a neurological disorder or mental retardation, and refusal to participate in the study were the exclusion criteria. Constipation was not an exclusion criterion because it is often associated with encopresis. Children with encopresis were evaluated by the Gastroenterology Unit of the Department of Pediatrics at Hacettepe University. There were no identified medical causes of encopresis in any children after physical examination and appropriate laboratory tests. Patients with encopresis were included in the study in order of application, so they were consecutive patients. The study group consisted of 46 children fulfilling the criteria and aged between 6
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and 16 years old. One patient was excluded from the study due to suspected mental retardation on clinical evaluation. Three children with encopresis were excluded due to incomplete data, and one child was excluded due to unwillingness to participate in the study. Children in the study group received treatment for encopresis and comorbid psychiatric disorders according to the protocols of the Department of Child and Adolescent Psychiatry. The control group consisted of 29 children who were referred consecutively to other pediatric clinics of the same hospital with acute physical complaints and had no diagnosis or history of psychiatric complaint or disorder including encopresis. Voluntary parents and their children who had consented to participate and were matched with the encopresis group for age, gender and socioeconomic level were included. The exclusion criteria for the control group were presence of a chronic medical disorder including constipation or mental retardation in children. Thirtytwo children and their mothers were asked to participate in the control group. Two mothers refused to take part. One child with a diagnosis of major depressive disorder was excluded from the control group. Materials
All children and their mothers in the study and control groups were interviewed using the Schedule for Affective Disorders and Schizophrenia for School-Age Children, Present and Lifetime Version (K-SADS-PL), conducted by a child and adolescent psychiatrist, in order to diagnose encopresis and comorbid psychiatric disorders in the study group and to rule out any psychiatric disorder in the control group. Children in the study group were defined as having constipation currently if they fulfilled the Questionnaire on Pediatric Gastrointestinal Symptoms, Rome III version (QPGS-RIII) diagnostic criteria by having two or more of the six conditions (1 episode of fecal incontinence per week; retentive posturing or excessive volitional stool retention; history of painful or hard bowel movements; passage of large stools that clog the toilet; and detection of large fecal mass in the rectum by doctor) for at least 2 months.19 A reliability and validity study of this form for the Turkish population was conducted.20 If needed, abdominal plain radiography was used for the evaluation of constipation. Family socioeconomic level was measured using the Hollingshead–Redich Scale.21 Five levels of socioeconomic status (1, upper; 2, upper middle; 3, middle; 4, lower middle; 5, lower) are defined in this scale. Mothers were interviewed and were requested to complete a Symptom Check List-90-Revised (SCL-90-R) and McMaster Family Assessment Device (FAD) to assess maternal psychiatric symptoms and family functioning, respectively. A Parenting Style Scale (PSS) was filled out by children ≥8 years old. Data collection form
Sociodemographic data, developmental and medical histories of the children and features of encopresis were collected using a data collection form created by the investigators. In this study, the timing of toilet training was defined as age at achievement of fecal continence for 30 consecutive days. © 2014 Japan Pediatric Society
K-SADS-PL
A reliability and validity study of K-SADS-PL for the Turkish population was conducted.22,23 The validity, interrater reliability and test–retest reliability of K-SADS-PL were found to be excellent for elimination disorders. SCL-90-R
The SCL-90-R is a 90-item self-rating inventory in which each item is rated on a 5 point Likert scale, ranging from “not at all (0)” to “extremely (4)”.24 It includes nine clinical subscales for somatization, obsessive compulsive, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideation, and psychoticism. The Global Severity Index (GSI) score is calculated by dividing the total score obtained from all items by 90. A GSI score >1.00 is considered to indicate symptoms on a psychopathology level. The validity and reliability of this scale in Turkey have been investigated.25 FAD
The FAD was developed based on the McMaster model of family functioning (MMFF) and measures structural, organizational and transactional properties of the family.26 According to the MMFF model, the family as a system plays a central role in the socialization, education, psychological and biological maintenance of family members, and it includes three kinds of tasks that families need to be fulfilled: (i) basic tasks related to the provision of support, love and understanding for all the family members; (ii) developmental tasks related to the stimulation of growth and maturation of family members, and the provision of support through all stages of individual and family lifecycle; and (iii) adaptation and response of the family to unexpected events such as illness, death and divorce.27 The MMFF model suggests that families unable to handle these task areas are most likely to develop clinically significant problems. The MMFF model has seven dimensions: problem-solving, communication, roles, affective responsiveness, affective involvement, behavior control and general functioning. FAD is a self-report questionnaire and includes 60 items on these dimensions, with six items for problem-solving, nine items for communication, 11 items for roles, six items for affective responsiveness, seven items for affective involvement, nine items for behavioral control, and 12 items for general functioning. All subscales have an average score ranging from 1 to 4. Scores >2.00 indicate problems in the related functioning of the family. A reliability and validity study of this scale was undertaken in Turkish families.28 PSS
In order to evaluate the perceptions of children regarding the parenting style of their parents in the study and control groups, the PSS29 was used. PSS is able to be completed by children ≥8 years old. A total of 33 children (80.5%) in the study group and 22 (75.9%) in the control group completed the PSS. The PSS includes 26 items grouped into three dimensions: acceptance/involvement, strictness/supervision, and psychological autonomy. A validity and reliability study of this scale in
Psychological factors in encopresis Turkey has been done.30 The test–retest reliability and internal consistency of dimensions were between 0.60 and 0.93 in elementary, high school and college student groups. The factor pattern of PSS for the elementary and high school students was very similar to the original scale’s factor pattern.
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subscale scores. A logistic regression model with a backward stepwise method was used to determine the predictors of encopresis. Results with P < 0.05 were accepted as statistically significant.
Results
Procedure
This study was carried out in the Department of Child and Adolescent Psychiatry at Hacettepe University Children’s Hospital. The study protocol was approved by the Institutional Review Board of Hacettepe University. Mothers of children who were admitted to the Hacettepe University Department of Child and Adolescent Psychiatry with a complaint of fecal incontinence were informed about the purpose and design of this investigation. Mothers of children in the study and control groups gave written informed consent for participating in the study. After the first evaluation in the Department of Child and Adolescent Psychiatry, children with encopresis were evaluated by the Gastroenterology Unit of the Department of Pediatrics. In their second visit to the child and adolescent psychiatry clinic, K-SADS-PL was carried out for the children and their mothers and other questionnaires were filled out by them. The children and mothers in the control group were also evaluated using the K-SADS-PL for psychiatric diagnosis and the QPGS-RIII diagnostic criteria for constipation. Statistical analysis
Shapiro–Wilk test was used to determine normality of the data. The significance of the differences in normally distributed continuous variables was analyzed using independent samples t-test when there were two groups. The Mann–Whitney U-test was used to compare the differences between two groups when the dependent variable was continuous but not normally distributed. Chi-squared test was used to examine significance of the differences in variable frequencies between groups. One-way multivariate analysis of variance (MANOVA) was applied to analyze the main effect of diagnosis on SCL-90-R, FAD and PSS
Sociodemographic results
The mean age of children in the encopresis group was 9.4 ± 2.1 years (range, 6–16 years) and that in the control group was 8.7 ± 1.5 years (range, 6–12 years). There were 29 boys (70.7%) and 12 girls (29.3%) in the encopresis group, and 16 boys (55.2%) and 13 girls (44.8%) in the control group. No significant differences in age, children’s gender or family socioeconomic level were seen between the two groups. The age and education level of parents in the two groups were not significantly different. The sociodemographic results in the encopresis and control groups are listed in Table 1. Clinical characteristics of children with encopresis
Of the 41 patients, 12 (29.3%) had primary and 29 (70.7%) had secondary encopresis. The mean age of onset for secondary encopresis was 6.6 ± 1.6 years (range, 5–10 years), and the mean interval between the onset of symptoms and diagnosis was 14.4 ± 14.2 months (range, 1–48 months). The time span between the onset of symptoms and admission to our clinic was 42 ± 27.8 months (range, 1–144 months) for all patients with primary or secondary encopresis, when the onset of symptoms in primary encopresis was assigned to the age of 4. Thirty-two (78%) of the children were living with nuclear families. Thirteen (44.8%) of the children with secondary encopresis had stressful life events before the onset of the disorder such as a separation from their mother, father or a loved one, starting a new school and having a new sibling. Constipation was found in 30 (73.2%) of children with encopresis. The timing of toilet training was significantly higher in children with encopresis (mean, 26.5 ± 7.4 months;
Table 1 Sociodemographic subject characteristics
Age (years), median (range) Age of mothers (years), mean ± SD Education level of mothers (years), median (range) Age of fathers (years) median (range) Schooling time of fathers (years), median (range) Gender, n (%) Male Female Socioeconomic status, n (%) Upper Upper middle Middle Lower middle Lower
Children with encopresis
Children without any psychiatric disorder
n = 41
n = 29
9 (6–16) 35.9 ± 5.8 8 (5–15) 40.5 (30–80) 10 (5–15)
Statistics†
z = −1.075NS‡ t = −0.168NS† z = −1.947NS‡ z = −0.195NS‡ z = −0.831NS‡
9 (6–12) 36.2 ± 4.0 11 (5–15) 40.0 (32–54) 11 (2–15)
29 12
70.7 29.3
16 13
55.2 44.8
χ2 = 1.791NS
7 3 11 11 9
17.1 7.3 26.8 26.8 22.0
6 5 7 5 6
20.7 17.3 24.1 17.2 20.7
χ2 = 2.327NS
t-test for independent samples; ‡Mann–Whitney U-test. NS, not significant, P > 0.05.
†
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range, 12–48 months) compared to children without any psychiatric disorder (mean, 21.9 ± 5.4 months; range, 12–30 months, z = −2.328, P = 0.02). There was no history of encopresis in other family members or siblings. There was at least one comorbid psychiatric disorder in 34 children (82.9%) in the encopresis group. Twenty-five (73.5%) of the 34 children had more than one comorbid psychiatric disorder. The prevalence of these disorders was as follows: enuresis, 53.6% (n = 22); attention-deficit–hyperactivity disorder, 46.3% (n = 19); oppositional defiant disorder, 29.3% (n = 12); anxiety disorders, 14.6% (n = 6); tic disorders, 7.3% (n = 3); major depression, 4.9% (n = 2); and conduct disorder, 2.4% (n = 1). Maternal psychiatric symptoms, family functioning and parenting style results
The SCL-90-R and FAD subscale scores of mothers and PSS subscale scores of children in the study and control groups are summarized in Table 2. The GSI score of the SCL-90-R was significantly higher in mothers of children with encopresis compared to mothers of children without any psychiatric disorder (encopresis group, 1.0 ± 0.7; control group, 0.7 ± 0.4; t = −2.432, P = 0.018; 95% confidence interval: −0.59 to −0.06). The SCL-90-R and FAD subscale scores were not found to be significantly different in mothers of children with encopresis compared to mothers of children without any psychiatric disorder (Wilks’ lambda P = 0.26 for SCL-90-R and Wilks’ lambda P = 0.13 for FAD). Similarly, PSS subscale scores were not significantly different in the two groups (Wilks’ Lambda P = 0.07).
A logistic regression model with the backward stepwise method was used to identify predictors of encopresis. The GSI score of SCL-90-R and general functioning score of FAD were entered without other subscales due to their capacities to reflect the level of psychopathology and family functioning alone, respectively. The predictors entered in the model were GSI score of SCL-90-R; general functioning score of FAD; and the acceptance/involvement, strictness/supervision, and psychological autonomy scores of PSS. This logistic regression model explained 27.4% (Nagelkerke R2 = 0.274) of the variation in the encopresis. Statistically significant risk factors for encopresis were the general functioning score of FAD and the strictness/ supervision score of PSS. An increase of 1 unit in the general functioning score of FAD and strictness/supervision score of PSS produced a 3.2- and 0.8-fold increase in the odds of having encopresis, respectively (Table 3).
Discussion In the present study, maternal psychiatric symptoms, mothers’ perception of family functioning and, the perception of children regarding the parenting behaviors of their parents in the encopresis group were compared to those of the control group children. One of the findings was that higher maternal psychiatric symptoms were identified in children with encopresis compared to children without any psychiatric disorder. Although there were no significant differences in the measures of family functioning and parenting styles between the groups, overall the present findings support the idea that familial factors are associated with encopresis. A logistic regression model identified general family
Table 2 SCL-90-R, FAD and PSS subscale scores
SCL-90-R Somatization Obsessive compulsive Interpersonal sensitivity Depression Anxiety Hostility Phobic anxiety Paranoid ideation Psychoticism FAD Problem-solving Communication Roles Affective responsiveness Affective involvement Behavioral control General functioning PSS Acceptance/involvement Strictness/supervision Psychological autonomy
Children with encopresis (n = 41) (Mean ± SD)
Children without any psychiatric disorder (n = 29) (Mean ± SD)
F†
95%CI for mean difference‡
1.1 ± 0.8 1.3 ± 0.7 1.2 ± 0.8 1.2 ± 0.8 0.9 ± 0.8 1.1 ± 0.9 0.5 ± 0.6 1.0 ± 0.7 0.6 ± 0.6
0.9 ± 0.7 0.8 ± 0.5 0.8 ± 0.6 0.9 ± 0.7 0.6 ± 0.4 0.6 ± 0.6 0.2 ± 0.3 0.7 ± 0.5 0.3 ± 0.3
1.638 7.874 4.183 2.780 2.798 6.209 4.278 3.189 4.731
−0.14 to 0.64 0.13–0.75 0.01–0.74 −0.06 to 0.68 −0.05 to 0.60 0.09–0.84 0.01–0.51 −0.03 to 0.60 0.02–0.50
2.1 ± 0.7 1.9 ± 0.6 2.0 ± 0.5 1.9 ± 0.8 2.2 ± 0.6 2.0 ± 0.5 1.9 ± 0.6
1.9 ± 0.5 1.7 ± 0.4 1.8 ± 0.5 1.5 ± 0.5 1.8 ± 0.4 1.7 ± 0.3 1.5 ± 0.5
0.924 4.109 3.524 5.371 6.609 6.550 6.204
−0.16 to 0.46 0.004–0.50 −0.01 to 0.46 0.05–0.70 0.08–0.63 0.06–0.52 0.07–0.60
29.1 ± 4.6 27.7 ± 4.1 22.4 ± 5.0
30.9 ± 3.5 30.4 ± 2.6 22.3 ± 5.6
2.284 7.590 0.009
−4.05 to 0.57 −4.66 to −0.73 −2.77 to 3.04
† MANOVA. ‡Adjustment for multiple comparisons: Bonferroni. CI, confidence interval; FAD, McMaster Family Assessment Device; PSS, Parenting Style Scale; SCL-90-R, Symptom Check List-90-Revised.
© 2014 Japan Pediatric Society
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Table 3 Predictors of encopresis
Step 1
Step 2
Step 3
Step 4
GSI score of SCL-90-R General functioning score of FAD Acceptance/involvement score of PSS Psychological autonomy score of PSS Strictness/supervision score of PSS Constant GSI score of SCL-90-R General functioning score of FAD Psychological autonomy score of PSS Strictness/supervision score of PSS Constant General functioning score of FAD Psychological autonomy score of PSS Strictness/supervision score of PSS Constant General functioning score of FAD Strictness/supervision score of PSS Constant
P
Exp (B)
0.233 0.824 0.289 0.029* 0.481 0.284 0.225 0.283 0.021* 0.290 0.037* 0.417 0.021* 0.249 0.048* 0.021* 0.083
2.276 2.611 1.024 1.079 0.764 29.517 2.304 2.428 1.072 0.773 56.480 3.678 1.052 0.772 87.722 3.192 0.769 397.325
95%CI for Exp (B) 0.488 0.539 0.832 0.937 0.601
10.614 12.637 1.259 1.243 0.972
0.500 0.580 0.944 0.621
10.618 10.167 1.217 0.962
1.080 0.931 0.619
12.532 1.189 0.962
1.010 0.615
10.086 0.961
*P < 0.05. CI, confidence interval; FAD, McMaster Family Assessment Device; GSI, Global Severity Index; PSS, Parenting Style Scale; SCL-90-R, Symptom Check List-90-Revised.
functioning and strictness/supervision-related parenting styles as statistically significant risk factors for encopresis. These results show that ineffectual families and psychiatrically distressed mothers may be less capable of managing a child’s soiling problems. Unfortunately, little empirical work has been done regarding the family environment of children with encopresis. In a small number of studies evaluating the family environment, children with encopresis were found to have inadequate family functioning and family environment with less expressiveness and poorer organization.6,31 In the present study, family functioning was identified as a risk factor, similar to previous studies. It was noted in the literature that disorganized or chaotic families may also require family support in addition to medical and behavioral management of encopresis.18 Successful treatment results were reported for an interactive parent–child family guidance intervention, which involves family members in a psychologically based treatment, after standard gastroenterologic intervention for encopresis and chronic constipation had been tried with limited success.32 But, given that the time span between onset of symptoms and admission to our clinic was nearly 4 years in the present study, maternal mental health, family functioning and, parenting might be influenced by the symptoms. Regardless of whether maternal psychiatric symptoms, insufficient strictness/supervision and poor family functioning are causes or consequences, they may be screened for, especially in cases of limited success of standard interventions, or in cases of referral to the psychiatry clinics for treatment of encopresis. The McMaster FAD (or the general functioning subscale alone) is accepted as a screening assessment to identify families having problems and it can also be used by clinicians to identify particular areas of difficulty within a family.26,33 The identification and treatment of such clinical issues may enhance the treatment efficacy of encopresis. In addition to maternal report, paternal or child report of family functioning may be collected in future studies.
In the present study, most of the children with encopresis (73.5%) had more than one comorbid internalizing or externalizing psychiatric disorder including enuresis (53.6%), attentiondeficit–hyperactivity disorder (46.3%), oppositional defiant disorder (29.3%), anxiety disorders (14.6%), tic disorders (7.3%), major depression (4.9%) and conduct disorder (2.4%). Most of the studies evaluated psychiatric problems in children with encopresis using questionnaires. Studies that assessed diagnosis using a structured, standardized psychiatric interview also reported high rates of comorbid disorders, similarly to the present study.31,34 The present study has some strengths and limitations. The evaluation of psychiatric diagnosis and assessment of maternal psychological factors and family functioning may constitute the strengths of the present study. Nevertheless, this study did not include fathers and was carried out in a psychiatry clinic in a tertiary pediatric setting, which may also limit the generalizability of the findings, especially due to the high rate of comorbid psychiatric disorders. The small sample size is another limitation of the present study. Analyzing many variables for such a small sample may decrease the statistical power of the results. Additionally, the backward stepwise regression analysis bears some limitations. This technique is not very heavily theorydriven and suggests a fairly weak approach to examining relations among constructs. Un a study area without a lot of previous work, however, this may be acceptable. Finally, as with all crosssectional studies, it is not possible to understand whether the psychological factors found in the present study are causes or consequences of soiling. Conclusions
Mothers of children with encopresis, who were referred to a psychiatry clinic primarily for the treatment of the encopresis, perceived themselves as psychiatrically distressed. Mother-rated inadequate family functioning and child-reported insufficiency in © 2014 Japan Pediatric Society
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strictness/supervision in parenting were also identified as risk factors for encopresis. Thus, close collaboration between the pediatrician and psychiatrist in order to evaluate each child and family for mothers’ psychiatric wellness and modification of familial organization has the potential to be an effective intervention in encopresis. Further research on the etiological and therapeutic importance of the family in the case of encopresis referred to a psychiatry clinic should be carried out.
Acknowledgments We thank Associate Professor Pınar Özdemir PhD from the Department of Biostatistics in Hacettepe University and Associate Professor Sait Uluç PhD from the Department of Psychology in Hacettepe University for reviewing the statistical analysis, Lori Russell Dag˘ MS from the Department of Computer Technology and Programming in Bilkent University for assistance with the manuscript, and Burcu Berberog˘lu MD from the Gastroenterology Unit of the Department of Pediatrics in Hacettepe University for her guidance of the patients in this unit.
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