Journal of Pediatric Psychology, Vol. 27, No. 7, 2002, pp. 585-591
© 2002 Society of Pediatric Psychology
Psychological Differences Between Children With and Without Chronic Encopresis
University of Virginia, Health Sciences Center
All correspondence should be sent to Daniel J. Cox, Box 800-223, University of Virginia Health Systems, Charlottesville, Virginia 22908. E-mail: djc4f{at}virginia.edu.
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Abstract |
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Objective: To validate a theoretical model of encopresis in terms of psychological factors that differentiates children with and without chronic encopresis and to identify scales that demonstrate these differences.
Methods: Eighty-six children with encopresis were compared to 62 nonsymptomatic children on five psychometric instruments. Differences in the mean scores and the percentages of children falling beyond preselected clinical thresholds were compared across the patient-control groups.
Results: Children with encopresis were found to have more
anxiety/depression symptoms, family environments with less expressiveness and
poorer organization, more attention difficulties, greater social problems,
more disruptive behavior, and poorer school performance (ps = .01
.001 on 15/20 subscales). There were no differences in self-esteem. On
those subscales where proportionately more encopretic children exceeded
clinical thresholds, approximately 20% more of the encopretic children
exceeded thresholds than control children.
Conclusions: As a group, children with encopresis differ from children without encopresis on a variety of psychological parameters. However, only a minority of children with encopresis demonstrated clinically significant elevations in these parameters. Identification and treatment of such clinical issues may enhance treatment efficacy.
Key words: encopresis; behavioral problems; family environment; children; biopsychosocial.
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Introduction |
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The role of psychological factors in the development and maintenance of encopresis is controversial. In two studies (Gabel, Hegedus, Wald, Chandra, & Chiponis, 1986
;
Loening-Baucke, Cruikshank, & Savage,
1987), children with encopresis were compared to the nonreferred
standardization sample of the Child Behavior Checklist (CBCL). In both
studies, children with encopresis had poorer social competency and more
behavioral problems than the standardization sample. Young, Brennen, Baker,
and Baker (1995) conducted the
first study to compare children with encopresis to a matched, nonclinical
group on the CBCL. Their results were similar: lower social competency and
greater behavioral problems in children with encopresis. However, the authors
of all three studies pointed out that the mean scores of the children with
encopresis did not fall in the clinical range. Friman, Mathews, Finney,
Christophersen, and Leibowitz
(1988), using the Eyberg Child
Behavior Inventory, did not find behavioral differences between children with
encopresis and a matched comparison sample drawn from the normative group.
Several studies have focused on more specific psychological factors in
children with encopresis. Levine, Mazonson, and Bakow
(1980) found that children
with encopresis who did not respond to treatment scored higher on
antisocial-aggressive behaviors before treatment. They also reported
differences between a nonsymptomatic comparison group and the children with
encopresis prior to treatment on affective-dependent behavior (i.e., those who
demonstrated signs of anxiety and depression). Johnston and Wright
(1993), using the subscale from
the CBCL designed to measure problems with attention or hyperactivity, found
that 23% of 167 children with encopresis scored in the 98th percentile. A
number of studies have demonstrated poorer social competency (e.g.,
Gabel et al., 1986) and greater
withdrawn behavior (e.g., Levine et al.,
1980) in children with encopresis. Stern, Lowitz, Prince,
Altshuler, and Stroh (1988)
reported that children with encopresis scored lower on two of the three
subscales of the Wide Range Achievement Test (WRAT): spelling and arithmetic.
Several authors have reported finding poorer self-esteem in children with
encopresis. For example, Landman, Rappaport, Fenton, and Levine
(1986) observed that children
with encopresis had lower feelings of self-worth than children with other
chronic physical problems. Owens-Stively
(1987), using the Piers-Harris
Self-Concept Scale, found that children with encopresis had lower self-esteem
than a group of nonsymptomatic children. Little empirical work has been
reported on the family environment of children with encopresis. Young et al.
(1995), however, suggested
this as an avenue of future study.
We have previously proposed a biopsychobehavioral model of encopresis
(Cox, Sutphen, Borowitz, Kovatchev, &
Ling, 1998), in which a constipating event leads to fecal
impaction and large, hard, painful bowel movements that are difficult to pass.
Children high in anxiety or depression may cope with painful defecation with
avoidance of bowel movements through inadequate straining or toilet avoidance.
Ineffectual families may be less capable of reversing this child avoidance
behavior. Inattentive/impulsive children would be less able to recognize and
respond to rectal distention cues or urges to defecate. These factors could
promote chronic constipation, followed by overflow incontinence. Subsequent
recurrent fecal incontinence can then lead to social problems, in which the
child may respond with disruptive or withdrawal behaviors. When these
behaviors and public soiling occur within the context of the school setting,
academic problems may result. All of this may culminate in poor
self-esteem.
To further test this biopsychobehavioral model
(Cox et al., 1998), and based
on the above literature, we hypothesized that children with encopresis, when
compared to children without encopresis, would have the following
difficulties: (1) more anxiety/depression symptoms, (2) less parental warmth
and organization, (3) more attention problems, (4) more social problems, (5)
more disruptive behaviors, (6) poorer school performance, and (7) lower
self-esteem.
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Method |
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Participants
All children in the encopretic group were participants in a study examining the additive benefits of laxative, toilet-training, and EAS biofeedback therapies in the treatment of pediatric encopresis (see Cox et al., 1998
). These
children (n = 86) were recruited through physicians in the University
of Virginia catchment area (radius of 150 miles) who had been notified about
the study via a direct mailing. Inclusion criteria were age 6 to 15 years old
and experience of encopresis for at least 1 year. Exclusion criteria were
documented mental retardation or any neuromuscular or gastrointestinal
dysfunction discernible through history taking or physical examination. Of the
105 patients who were referred to the study, six declined to participate
because of parental concerns regarding possible assignment to an
"experimental" treatment group, five did not want to continue
treatment, three did not want to delay treatment while baseline data was
gathered, and four dropped out during baseline evaluation. Two comparison groups were used, each consisting of children between the ages of 6 and 15 who did not meet the exclusion criteria and who had no history of chronic constipation or encopresis. The members of the first comparison group (n = 27) were siblings of the children with encopresis. All appropriately aged siblings were asked to participate. Twenty-eight of these met criteria and agreed to participate in all phases of pretreatment assessment. However, one sibling did not complete all psychometric instruments and was, therefore, not included. The second comparison group (n = 35) was recruited through advertisements in local publications for children without bowel disorders who were willing to participate in the evaluation. These two control groups were used to determine if there was something unique to "encopretic families." Descriptive data are shown in Table I for the three groups.
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Procedure
Each child came to clinic accompanied by his or her mother (or maternal
caretaker) for recruitment in this study. For children with encopresis, this
occurred prior to the initiation of treatment. Written institutional review
board—approved informed consent was obtained from the mother at that
time. The self-administered assessment instruments and background
questionnaire were then completed. The WRAT-R was administered to the child by
a research assistant during this visit. Teachers were mailed the Teacher
Report Form (TRF) to be completed.
Assessment Instruments
Twenty subscales from five instruments were used in this study to test the
seven hypotheses. The subscales are presented in Tables
II and
III. Clinical thresholds for
each instrument were selected based on the psychometric properties of the
instrument.
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The Child Behavior Checklist (CBCL;
Achenbach, 1991a) assesses
behavioral problems and competencies, and was completed by the maternal
caretaker. The TRF (Achenbach,
1991b) is similar to the CBCL but was completed by each child's
teacher. The TRF shares 89 items with the CBCL and the reliability estimates
are very similar. Scores are reported as T-scores (i.e., M of 50 and
SD of 10). A T-score of 67 on the syndrome subscales of these two
instruments was used as the clinical threshold, corresponding to the 95th
percentile. For the school performance subscales, a T-score of 33 or below was
used for similar reasons (Achenbach,
1991b).
The Family Environment Subscale (FES;
Moos & Moos, 1986)
measures "the social-environmental characteristics of all types of
families" (p. 1). The 2-, 3-, and 12-month test-retest reliabilities for
the FES subscales range from .52 to .91. For the FES, one standard deviation
beyond the mean of the standardization group was used as the clinical
threshold.
The Wide Range Achievement Test—Revised (WRAT-R;
Jastak & Wilkinson, 1984)
assesses skills required to learn reading, spelling, and arithmetic. It
produces one subscale for each of these areas. Scores are reported as standard
scores (i.e., M of 100 and SD of 15). The test-retest
reliability of the WRAT-R subscales ranges from .79 to .97. For the WRAT-R,
one standard deviation beyond the mean of the standardization group was used
as the clinical threshold.
The Piers-Harris Children's Self-Concept Subscale (PH;
Piers, 1984) assesses a
child's self-concept. It is completed by the child and produces a total score,
as well as six cluster scores. The test-retest reliability of the PH total
score is approximately .90. For the PH, one standard deviation beyond the mean
of the standardization groups was selected as the clinical threshold.
Data Analysis
Results of the assessment instruments were compared as follows. First, the
sibling group was compared to the nonsibling comparison group. The FES,
however, was contrasted between the encopretic group and the nonsibling
comparison group only, as it is a measure of the family, not of the child.
Following the comparison of group means, chi-square tests were performed to
determine whether a larger percentage of children with encopresis fell beyond
a clinically meaningful threshold when compared to children in the comparison
group. Each of the seven independent directional hypotheses was tested using
one to four subscales. Each subscale was analyzed using a Bonferroni corrected
alpha of .01 and two tailed probabilities.
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Results |
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The sibling and nonsibling comparison groups did not significantly differ on any of the 18 subscales on which they were compared. Thus, in all subsequent comparisons (except for the FES, as discussed above), the two comparison groups were collapsed into one.
Anxiety/Depression Symptoms. The group with encopresis was rated significantly higher than the comparison group on the CBCL Anxious/Depressed subscale (t[146] = 2.85, p = .005), but not on the comparable subscale from the TRF. Neither of these subscales yielded a greater percentage of children with encopresis over the threshold compared to children in the comparison group (see Table II).
Parental Warmth and Organization. In terms of family environment,
families of children with encopresis scored lower on expressiveness
(t[118] = -2.52, p = .01) and organization (t[95] =
-3.19, p = .002) than families of nonsymptomatic children (see
Table II). The subscale
measuring organization (
2 [1, N = 119] = 9.62,
p = .002) yielded a significantly greater percentage beyond the
selected threshold (i.e., less organized) for families of children with
encopresis (24%) than families with nonsymptomatic children (0%).
Attentional Difficulties. On the attention subscales of the CBCL
(t[145] = 4.35, p < .001) and TRF (t[112] =
5.07, p < .001), children with encopresis had significantly more
reported problems than the nonsymptomatic children. Both the CBCL Attention
Problem subscale (2 [1, N = 147] = 8.62, p =
.003), and the TRF Attention Problem subscale (2 [1,
N = 117] = 7.56, p = .006) showed a significantly higher
percentage of children with encopresis (20% and 26%, respectively) scoring
beyond the selected threshold than did children in the comparison group (3%
and 6%, respectively, see Table
II).
Social Problems. Children with encopresis were rated significantly
higher than the comparison group on the social problems subscales of the CBCL
(t[146] = 3.49, p < .001) and TRF (t[110] =
3.75, p < .001) as well as on the withdrawn behavior subscales of
the CBCL (t[124] = 4.75, p < .001) and TRF
(t[111] = 2.76, p = .007, see
Table III). Three of the
subscales yielded a significantly greater percentage of children with
encopresis than nonsymptomatic children over the selected threshold: the
teacher's report of social problems (24% vs. 4%, 2 [1,
N = 115] = 8.23, p = .004), the mother's report of withdrawn
behavior (15% vs. 2%, 2 [1, N = 148] = 7.67,
p = .006) and the teacher's report of withdrawn behavior (20% vs. 4%,
2 [1, N = 117] = 6.23, p = .01).
Disruptive Behaviors. On the subscales measuring delinquent
behavior, the group of children with encopresis was rated higher than the
comparison group by mothers (t[144] = 4.62, p < .001) and
teachers (t[112] = 3.75, p < .001). Teachers reported
more aggressive behaviors (t[112] = 3.01, p = .003) for the
encopretic group. The aggressive behavior subscale of the TRF
(2[1, N = 115] = 7.85, p = .005) yielded a
significantly higher percentage of children with encopresis (19%) than
children in the comparison group (2%) beyond the selected clinical threshold
(see Table III).
School Performance. On the WRAT-R, children with encopresis scored
lower than the comparison group on reading (t[146] = -2.76,
p = .007) (see Table
III). Both reading and spelling yielded a greater percentage of
children with encopresis beyond the threshold compared to children in the
comparison group (reading: 30% vs. 13%, 2 [1, N =
148] = 6.11, p = .01, and spelling: 44% vs. 23%, 2
[1, N = 148] = 7.38, p = .007).
Children with encopresis were rated lower than nonsymptomatic children
(i.e., "not doing as well") on the TRF Child Academic Performance
subscale (t[115] = -3.26, p < .001), (see
Table III). The academic
performance subscale of the TRF (2 [1, N = 117] =
13.98, p < .001) yielded a greater percentage of children with
encopresis (36%) than nonsymptomatic children (6%) beyond the selected
threshold.
Self-Esteem. No significant difference was found between the encopretic and the comparison groups on the PH Self-Esteem Scale.
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Discussion |
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TopAbstractIntroductionMethodResultsDiscussionReferences |
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Six of the seven hypotheses in this study received support from at least one subscale. This study employed information from mothers, teachers, and children. Mothers, teachers, and children endorsed 78%, 86%, and 25% significant group mean differences, respectively. The only negative finding by teachers involved the internal symptoms of anxiety/depression. Both mothers and teachers agreed that encopretic children had more disruptive behaviors, attentional problems, social problems, and school problems. However, mothers and teachers disagreed on anxiety/depression symptoms (mothers reported their encopretic children to have more symptoms) and on aggression (teachers reported more aggression). These discrepancies may be explained by parents being more aware of their child's internal world, while teachers may be more sensitive to how the child relates to peers.
While encopretic children, as a group, revealed broad-ranging problems
relative to nonsymptomatic children, only half of the time did more encopretic
children have clinically significant elevations. Teachers reported more
encopretic children with clinically significant social, aggressive,
attentional, and academic problems; mothers only indicated more encopretic
children with attentional and withdrawal problems. As can be seen in the
tables, where there were significant differences, typically about 15% to 20%
more encopretic children than control children were problematic. While this
suggests that the majority of children suffering from encopresis do not have
accompanying psychopathology, approximately a quarter may have such problems.
This implies that approximately 75% of children with encopresis might benefit
from a symptom-focused behavioral intervention, while the remaining children
might require a broader intervention. This speculation is consistent with an
80% success rate associated with the symptom-focused Enhanced Toilet Training
(Cox et al., 1998). This is
indirectly supported by the observation that adding psychodynamic
psychotherapy routinely to behavioral interventions is generally not
beneficial (Taitz, Wales, Urwin, &
Molnar, 1986).
Regardless of whether the psychological issues or the encopresis occurs
first, it is important to consider disruptive behaviors, because they likely
affect the child's compliance with treatment
(Kuhn, Marcus, & Pitner,
1999). Refusal to comply with toilet sitting, medications, or
clean-out procedures undermines the fundamental principles of most treatment
protocols. Similarly, attention problems could interfere with symptom-focused
interventions. Johnston and Wright
(1993) suggest that there is
"a subset of children with attention deficits whose task impersistence,
poor prioritization, poor reinforceability, and deficient self-monitoring
predispose them first to stool retention and then to encopresis" (p.
384). If this is correct, an essential component of successfully treating
children with attention problems would be to help them learn to become more
attentive to the internal cues associated with bowel movements, to resist the
impulse to get up and leave the toilet prematurely, and to carefully adhere to
regular medication taking and toilet sitting. Also, if the attention problems
reach a clinical level, it may be appropriate to address this more directly
(e.g., pharmacotherapy).
Young et al. (1995)
suggested using the FES to explore the role of various familial factors
"as they relate to both the maintenance and resolution of the encopretic
symptoms within the family system" (p. 231). Significant differences
were found on FES subscales of parental expressiveness and organization.
Families with encopretic children had less expressiveness and poorer
organization. Stark et al.
(1997) observed that
"disorganized or chaotic families also may require additional individual
support during group [treatment] in order to enhance compliance with weekly
assignments and monitoring" (p. 631). The findings presented here
suggest that at least these families could be identified sooner, possibly
during the assessment phase of treatment, and more attention and assistance
could be given to the execution of treatment recommendations.
This study supports previous research suggesting children with encopresis
have a number of social problems (e.g.,
Gabel et al., 1986;
Levine et al., 1980). This is
not surprising, given that fecal soiling may frequently be accompanied by
ridicule, rejection, and feelings of shame
(Nolan & Oberklaid, 1993).
At a minimum, in such cases, the treating clinician should discuss social
problems with the child and help the family try to resolve any such obstacles
to treatment.
Little previous research has focused on academics, perhaps because there is not an obvious link between academics and encopresis. The observed differences between children with and without encopresis could either be the consequence of preoccupation over uncontrollable fecal accidents and the resulting social tension, or the result of some developmental lag that could possibly play a role in the development or maintenance of encopresis. Further research is needed to establish if a developmental lag accounts for this difference.
Self-esteem was not found to differentiate children with and without
encopresis, either in terms of group means or in terms of percentage of
children with significant elevations. However, earlier studies (i.e.,
Landman et al., 1986;
Owens-Stively, 1987) have
reported self-esteem problems with encopretic children. This may be due to the
self-report measure used. Clinically, children seem to often deny to the
therapist that they experience peer taunting, though parents and teachers may
clearly be aware of such events. The insensitivity of self-reports among
encopretic children is supported by the observation that when parents and
children are asked to describe the child's toileting difficulties, children
are less forthcoming (Cox, Quillian,
Sutphen, Ling, & Borowitz, under review).
A weakness of this study is the lack of control for gender. Only 17% of the encopretic group was female, while 47% of the comparison group was female. Although an analysis of gender did not suggest that the findings in this study were due to gender, it cannot be definitively ruled out. Also, this study was not adequate to address developmental issues, which may play a role in the development or maintenance of encopresis. Future studies should include an agestratified sample, as well as at least one measure of developmental level. Finally, this sample incorporated only white and black children, so generalization to other minorities can only be done with reservation.
In summary, six of seven elements of the biopsychobehavioral model of encopresis were confirmed. In general, children with encopresis do not appear to have clinically significant psychological difficulties. However, these data suggest that a substantial minority of children with encopresis may have significant psychological problems. Such problems may interfere with the efficacy of a symptom-focused intervention. It would be prudent to screen for such issues before initiating a symptom-focused intervention and to address identified issues with a broader treatment program. Future research is necessary to confirm the importance of such an approach.
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Acknowledgments |
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This research was supported by NIH grant R01 HD 28160. We thank Dr. William Whitehead and Dr. Vera Loening-Baucke for consultative assistance.
Received January 14, 1999; revision received December 16, 1999; revision received December 4, 2000; revision received May 24, 2001; revision received October 11, 2001; revision received December 20, 2001; accepted January 10, 2001
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