Journal of Pediatric Psychology, Vol. 28, No. 6, 2003, pp. 375-382
© 2003 Society of Pediatric Psychology
Assessment of Behavioral Mechanisms Maintaining Encopresis: Virginia Encopresis-Constipation Apperception Test
University of Virginia Health System
All correspondence should be sent to Daniel J. Cox, Behavioral Medicine Center, P.O. Box 800223, University of Virginia Health System, Charlottesville, VA 22908.
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Abstract |
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Objective To develop and test a scale for parent and child, evaluating theoretical and clinical parameters relevant to children with encopresis. Encopretic children were hypothesized to have more bowel-specific, but not more generic, psychological problems, as compared with nonsymptomatic control children. In addition, mothers were also believed to be more discerning than children. Methods The Virginia Encopresis-Constipation Apperception Test (VECAT) consists of 9 pairs of bowel-specific and 9 parallel generic drawings. Respondents selected the picture in each pair that best described them/their child. It was administered to encopretic children (N = 87), nonsymptomatic siblings (N = 27), and nonsymptomatic nonsiblings (N = 35). The mothers of all the participants also completed the VECAT. Encopretic children were retested 6 and 12 months posttreatment with Enhanced Toilet Training. Results The VECAT demonstrated good test-retest reliability and internal consistency. Encopretic children and their mothers reported more bowel-specific, but not more generic, problems. Bowel-specific scores improved significantly posttreatment only for those patients who demonstrated significant symptom improvement. Mothers were significantly more discerning than children. Conclusion The VECAT is a reliable, valid, discriminating, and sensitive test. Bowel-specific problems appear to best differentiate children with and without encopresis.
Key words: encopresis; constipation; bowel habits; tests; diagnosis; assessment.
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Introduction |
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Encopresis is a relatively common but treatment-resistant condition (McGrath, Michael, & Murphy, 2000
). We have proposed a biopsychobehavioral model of encopresis
to better understand its development and maintenance as well as to guide
treatment (Cox, Sutphen, Ling, Quillian,
& Borowitz, 1996). The model has the following steps: (A)
Historically, encopretic children experience some physical (e.g., transition
from a liquid to a solid diet) or psychological (e.g., birth of a sibling)
constipating event. (B) This event results in a fecal impaction and a large,
hard stool. (C) Passage of this stool may be both difficult and painful, and
(D) subsequently the child may anticipate future defecation to be
painful/difficult. (E) Rectal distention cues (urges to defecate) may then be
experienced as unpleasant and/or the child may attempt to ignore these cues,
and (F) avoid using the toilet. (G) Chronic constipation may ensue, allowing
fecal matter above the impaction to leak around and out (overflow
incontinence). (H) Parents may respond by requesting their child use the
toilet more often, which the child may resist. (I) This resistance and
continued fecal soiling can set the stage for parent-child conflict over
toileting. (J) Persistent soiling can then lead the child to experience shame
and rejection and engage in deception such as hiding or lying about dirty
underwear. While this is an attempt to describe possible contributors to encopresis, not all elements of this model are expected to be relevant for every child with encopresis. From a theoretical perspective, it is important to test each step and determine whether in fact these behavioral issues are more prevalent among children with encopresis and their parents compared with nonsymptomatic children and their parents. If this is the case, determining whether these issues reflect learned behaviors specific to bowel movements or more general behavioral traits is important. For example, are children with encopresis more concerned about defecation pain or more apprehensive about pain in general? Are these children specifically noncompliant to toileting instructions or are they generally noncompliant children? Clarification of these issues would significantly contribute to the understanding of encopresis.
This model has already been partially confirmed. Children with encopresis
were more likely to report painful and less frequent defecation, as reflected
in daily defecation diaries (Steps C and G;
Cox et al., 1996). On
manometric examination, children with encopresis demonstrated paradoxical
constriction when attempting to defecate a balloon (Step E;
Sutphen, Borowitz, Ling, Cox, &
Kovatchev, 1997). When children with encopresis were compared with
nonsymptomatic children, the encopretic children demonstrated toilet avoidance
(Step F, Borowitz, Cox, & Sutphen,
1999). Based on teacher reports, encopretic children were sought
out less by peers than those without fecal soiling (Step J;
Cox, Morris, Borowitz, & Sutphen,
2002).
From a clinical perspective, it is important to determine whether a particular child presenting with encopresis has a specific behavioral problem relevant to this model. For example, determining if a child's behavior is characterized primarily by concerns over pain or by struggles with parents over routine use of the bathroom is notable. Additionally, it would be important to establish whether a child has bowel-specific or more generic behavioral problems. Bowel-specific behaviors may be more easily modified than generic behavioral traits. Contrasting the parents' and the child's perspective on the same issues could identify possible denial, excessive concern, or some interfering style of parent-child interaction.
Currently, no published encopresis-specific test exists to address these
concerns. The use of generic pediatric tests has resulted in equivocal
differences between children with and without encopresis
(Loening-Baucke, 1993;
Ling, 1994). In fact, when we
compared the encopretic and nonencopretic children on traditional tests (Child
Behavioral Checklist [Achenbach, 1991a]; Teacher Report Form [Achenbach,
1991b]; Family Environment Scale [Moos
& Moos, 1986]; and Piers-Harris Children's Self-Concept
[Piers, 1984]), no clinically
significant group mean differences were found
(Cox et al., 2002). In lieu of
this, and given our highly specific biopsychobehavioral model, we developed a
test to specifically examine these issues. This is the first published data on
the Virginia Encopresis-Constipation Apperception Test (VECAT). The VECAT
consists of nine bowel-specific items that address particular steps in the
biopsychobehavioral model.
The hypotheses were as follows: Hypothesis 1: The VECAT would demonstrate internal consistency and test-retest reliability; Hypothesis 2: The VECAT would demonstrate more bowel-specific than generic psychological problems within a group of encopretic children (within-group differences); Hypothesis 3: The VECAT would demonstrate more bowel-specific problems among encopretic children compared with control children, but there would be no differences between these groups on general functioning (between-group differences); Hypothesis 4: The bowel-specific VECAT would be sensitive to positive treatment effects among encopretic children (responsive vs. nonresponsive encopretic children); and Hypothesis 5: Due to such factors as embarrassment, defensiveness, and denial, children's responses would be less discerning than mothers' responses (between-rater comparison).
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Methods |
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Scale Development
Since encopresis affects both male and female children of all ages and races with varying reading levels, a gender-, age-, and race-neutral test was needed that did not rely on reading skills. Consequently, a picture-based test was created with the assistance of a professional artist, employing race- and gender-neutral child figures. Nine pairs of bowel-specific and nine pairs of parallel generic pictures were developed. The bowel-specific pictures (exemplified on the left side of Figure 1) and their respective scripts were created to assess individual steps in our model. Bowel-specific item 1s (s = specific) addresses Step D of the model regarding anticipated defecation pain. Items 2s and 3s address Step E, involving ignoring or negatively interpreting rectal distention cues. Item 4s addresses Step F, toilet avoidance. Item 5s addresses Step G, resistance to parental toileting instructions. Item 6s addresses Step I, involving the issue of parent-child conflict. Finally, items 7s-9s address the concern in Step J, regarding shame, deception, and rejection.
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A parallel set of generic pictures were developed to assess problems similar to those in the bowel-specific items but with general content. For example, the first pair of bowel-specific pictures (1s) refers to anticipation of defecation pain versus relief upon expelling a stool, while the parallel generic pair of pictures, 1g (g = generic), refers to anticipation of pain from a medical procedure versus relief following the completion of the procedure. The second pair of bowel-specific pictures (2s) focus on negatively evaluating the internal sensation of rectal distention or urge to defecate, while its parallel generic pictures (2g) deal with interpreting the internal abdominal sensation of hunger.
A descriptive scenario was written for each pair of pictures (see Figure 1). In the scenarios, male pronouns were used for male children and female pronouns were used for female children. Participants were first shown the pair of pictures and then read the scenario. They were then instructed to select the child in one of the two pictures that they/their child was most like. After selecting this picture, participants were asked if they/their child was a little or a lot like the picture. This forced-choice format rendered a 4-point ordinal scale for each pair of pictures, where a score of 1 was assigned to a selection a lot like the picture that did not reflect our model, and a score of 4 indicated a choice a lot like the picture that did reflect our model. For example, if the respondent said they/their child was a lot like the left picture in 1s, a score of 1 would be recorded. If the respondent said they/their child was a lot like the left picture in 2s, a score of 4 would be recorded. The total scores for the bowel-specific and the generic scale range from 9 to 36.
The VECAT was pilot-tested on 10 consecutive patients. Figures were revised to improve gender neutrality and to better convey information consistent with scenario content. Scenarios were revised to reduce confusion and differences in social desirability.
Participants
All children in the encopretic group were participants in a study examining
the additive benefits of laxative, toilet-training, and external anal
sphincter biofeedback therapies in the treatment of pediatric encopresis (see
Cox, Sutphen, Borowitz, Kovatchev, &
Ling, 1998; Borowitz, Cox,
Sutphen, & Kovatchev, 2002). These children (N = 87)
were recruited through physicians in the University of Virginia catchment area
(radius of 150 miles), who were notified about the study via a direct mailing.
To be included in the study, the children had to be between the ages of 6 and
15 years and to have been experiencing at least one encopretic accident a week
for at least one year. Exclusion criteria included documented mental
retardation or any neuromuscular or gastrointestinal dysfunction (e.g., cystic
fibrosis, Hirschsprung's disease, spina bifida) discernible through history
taking or physical examination. Participants were not excluded for such
disorders as attention deficit /hyperactivity disorder or obsessive-compulsive
disorder. All participants had previously failed various types of therapy for
encopresis. Of the 105 patients who were referred to the study, 6 declined to
participate because of parental concerns regarding possible assignment to an
"experimental" treatment group, 5 did not want to continue
treatment, 3 did not want to delay treatment while baseline data were
gathered, and 4 dropped out during baseline evaluation, leaving a total of
87.
Two comparison groups were used. These children did not meet the exclusion criteria and 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, and 28 of these children met criteria and agreed to participate in all phases of pretreatment assessment. However, one sibling did not complete all test instruments, and was therefore not included. The second comparison group (N = 35), recruited through advertisements in local publications, comprised children without bowel disorders who were willing to participate in the evaluation. Descriptive data are shown in Table 1 for the three groups.
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Procedures
Following the signing of an institutional review board-approved informed
consent form, all mothers and children were administered the VECAT separately
and privately, while completing a series of generic psychometric tests
(Cox et al., 2002). Children
with encopresis were administered the VECAT two weeks before beginning
treatment and again 6 and 12 months following the initiation of treatment.
Each pair of pictures was presented separately by an examiner, who read aloud
the scenario and recorded the participants' response. The bowel-specific and
generic stimuli were presented with the picture reflecting the theoretical
model appearing equally often on the right and left sides of the 11"
x 5.5" cards. The administration of the VECAT took approximately
10 minutes.
Data Analyses
In the results section, the mothers' data are presented first, followed by
the children's data. There were no differences between the two control groups
by either mothers or children on any of the generic or bowel-specific items.
Also, no gender differences were found. Therefore, data from the two control
groups and both genders were combined in all further comparisons of patient
and control children. The control group had older children (t = 2.71,
df = 147, p < .05) and a greater percentage of girls
(Z = 3.08, p < .05) than the encopretic group. All data
analyses were conducted while controlling for age, but not gender, both
because gender is a dichotomous variable and because direct comparison of
males with females yielded no significant differences. Nonparametric analyses
were used when analyzing individual items that had 4-point ordinal scales,
while parametric analyses were used when comparing total scores.
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Results |
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Reliability
For mothers' responses, the Cronbach alpha for the bowel-specific and generic items was .68, (p < .001) and .43 (p < .01), respectively. Child responses yielded coefficient alphas of .70 (p < .001) for bowel-specific and .33 (p < .01) for generic items. This indicates greater internal consistency among bowel-specific than generic items, which was anticipated, since all of the bowel-specific items were related to various aspects of bowel habits, while the generic items represented unrelated topics.
All bowel-specific items were significantly correlated with the
bowel-specific total score for the mothers. The correlations were all 
.48
(p < .0001), except for the item regarding shame over accidents
(Item 8s, r = .12, p = .14). Similarly, all generic items
correlated significantly with the generic total score (r = .24 to
.58, p 
.01).
For children's responses, all bowel-specific items significantly correlated
with the bowel-specific total score. All correlations were .50
(p < .0001), except for shame over accidents (Item 8s, r
= .18, p = .047) and compliance with toileting (Item 5s, r =
.29, p = .003). Similarly, all generic items correlated significantly
with the generic total score (r = .20 to .54, p < .03).
Thus, individual items contributed to the respective total scores.
When the VECAT scores were correlated at 6 and 12 months posttreatment, there were no significant changes in mean bowel-specific scores for mothers (t = .38, df = 61, p = .71) or children (t = .72, df = 63, p = .48). Test-retest reliability over these six months, when there was no treatment, was significantly reliable both for mothers (r = .60, p < .001) and for children (r = .56, p < .001).
Validity
Total Scores
An analysis of covariance was conducted, with age as a covariate, using a 2
(Bowel-specific vs. Generic stimuli) x 2 (Patients vs. Controls) x
2 (Mother vs. Child responses) design. This yielded a significant
bowel-specific versus generic effect (F = 19.6, df = 1,
p < .001), patients versus controls effect (F = 54.5,
df = 1, p < .001), and mother versus child responder
effect (F = 41.8, df = 1, p < .01). This
indicates (1) bowel-specific items were more strongly endorsed than generic
items, (2) patients were more symptomatic than controls, and (3) mothers were
more discerning than children. The 2-way and 3-way interactions were also
highly significant, indicating that patients had more bowel-specific but not
more generic problems compared with controls (Hypothesis 3; F = 79.5,
df = 1, p < .001), that mothers endorsed more symptoms
than children when comparing patients versus controls (Hypothesis 4;
F = 21.2, df = 1, p < .001), and that mothers,
compared with children, endorsed more bowel-specific versus generic problems
among patient versus control children (Hypothesis 4; a 3-way interaction,
F = 42.3, df = 1, p < .001). As illustrated in
Figure 2, encopretic children
were reported to have greater difficulty with bowel-specific issues as
compared with generic issues by both mothers of encopretic children and
encopretic children themselves. Bowel-specific versus generic score means
(SD) for mothers were 23.7 (5.5) vs. 17.4 (3.8); and for children,
17.3 (5.1) vs. 15.7(3.5). As illustrated in
Figure 2, the controls' mean
scores for bowel-specific items were lower than those for generic
items, as reported both by mothers (14.7 [4.3] vs. 16.5 [4.4]) and by children
(14.7 [3.7] vs. 15.3 [3.8]), while the controls' bowel-specific mean ratings
were nearly identical to the patients' generic mean ratings.
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Mothers' responses were also evaluated in two additional ways to determine whether they were more discerning than children's responses (Hypothesis 4). First, difference scores (bowel-specific minus generic total scores) were calculated for each mother and child. The difference scores for mothers and the encopretic children were 6.3 versus 1.5 (t = 7.0, df = 87, p < .001). However, difference scores for mothers and the control children were -1.98 vs. -.68 (t = -2.13, df = 61, p = .036). This indicates that mothers of patients endorsed more bowel-specific problems than their encopretic children. Inversely, mothers of control children, compared with the control children, endorsed significantly fewer bowel-specific than generic problems. Second, using two discriminant analyses, the percentage of children correctly classified as patients and controls was calculated. Using the mothers' ratings of Items 1s, 3s, 4s, 5s, and 9s, 87% of the children were correctly classified, while 69% of the children were correctly classified using child ratings of Items 1s, 2s, 3s, 6s, 8s, and 9s.
Sensitivity to Treatment Effects
The VECAT was readministered to encopretic children and their mothers 12
months following treatment. Regardless of treatment condition, patients were
dichotomized as those who demonstrated a significant reduction (p
< .001) in daily fecal accidents from baseline to 12 month follow-up.
Hypothesis 5 stated that those children who demonstrated significant symptom
improvement (responders, N = 40) would have greater improvement on
the bowel-specific subscale, compared with nonresponsive children (N
= 34). Analyses of variance with a 2 (Pretreatment vs. Follow-up) x 2
(Responders vs. Nonresponders) design revealed that while both mothers
(F = 42.12, df = 1, p < .001) and children
(F = 13.422, df = 1, p < .001) demonstrated a
significant pretreatment versus follow-up improvement, only mothers
demonstrated a significant interaction, where responders had significantly
more improvement (F = 8.56, df = 1, p < .01).
Maternal bowel-specific mean scores for responders decreased from 24.0 to 17.5
from pretreatment to follow-up, while pretreatment to follow-up scores for
nonresponders decreased from 23.4 to 20.9. This suggests that mothers of
children whose encopresis improved also reported improvement in bowel-specific
behaviors.
These data support the five hypotheses: 1) VECAT is reliable; 2) children with encopresis have more behavioral problems specific to bowel habits than parallel generic problems; 3) children with encopresis differ from nonsymptomatic children on bowel-specific but not on generic problems; 4) the VECAT bowel-specific subscale was sensitive to successful treatment intervention; and 5) mothers of encopretic children identified more bowel-specific problems among their encopretic children than did the children themselves. The remaining data analyses evaluate individual items, including whether these items support the proposed model.
Item Analysis
The means/SDs for the nine bowel-specific and nine generic stimuli
appear in Table II, with mother
and child responses relative to patient and control children. Means > 2 on
bowel-specific items reflect our model. The following analyses compared the
4-point rating data for individual items with the nonparametric Wilcoxon test.
Contrasts indicated that mothers' ratings of encopretic children and control
children did not differ on any of the generic items
(Table II, columns E vs. F).
Similarly, encopretic children and control children rated the generic items
equally (columns G vs. H). However, as illustrated in
Table II columns A vs. B,
mothers reported that encopretic children differed from control children on
seven bowel-specific items: greater defecation pain (Item 1s; Z =
6.83, p < .0001), distress over rectal distention cues (Item 2s;
Z = 7.85, p < .0001), avoidance of a bowel movement (Item
3s; Z = 8.88, p < .0001), nonresponsiveness to rectal
cues (Item 4s; Z = 8.52, p < .0001), noncompliance with
maternal requests to use the toilet (Items 5s; Z = 5.02, p
< .0001), more aversive parenting around toileting (Item 6s; Z =
3.12, p < .002), and more deception around dirty underwear (Item
7s; Z = 3.37, p < .001). Columns C vs. D show that
encopretic children, compared with control children, endorsed more problems
with only three bowel-specific items: more defecation pain (Item 1s;
Z = 5.39, p < .0001), greater distress with rectal
distention cues (Item 2s; Z = 3.43, p < .001), and more
nonresponsiveness to rectal cues (Item 4s; Z = 2.32, p =
.02).
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Discussion |
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Compared with control children and their mothers, both children with encopresis and their mothers reported significantly more problems with the process of defecation. Specifically, they reported that defecation hurt, rectal distention urges to defecate were distressing, and they avoided responding to urges to defecate. Additionally, mothers, but not children, reported less compliance by the child with instructions to use the toilet, more aversive parenting around toileting, and more deception concerning fecal accidents. In contrast, neither children nor mothers reported any differences on parallel generic issues, except that encopretic children reported slightly more peer teasing with general embarrassing situations ("falling in a mud puddle"). Neither mother nor child data support shame or peer rejection as a common element of encopresis. The finding that shame is not a significant problem is consistent with the observation that these encopretic and control children did not differ in terms of their responses on the Piers-Harris Children's Self-Concept scale. However, inconsistent with these findings was the observation that teachers reported these encopretic children to be more socially isolated (Cox et al., 2002
). Consequently, our model may need to be modified by
minimizing issues of shame.
In general, the findings indicate that treatment of encopresis should focus
on bowel habits, that is, use of laxatives to keep stools soft and painless,
teaching children how to relax their external anal sphincter and to
appropriately strain to effectively expel a stool, and helping children to
interpret rectal distention positively and know how to respond to these
internal cues promptly. The findings also suggest that parents need assistance
in positively managing their children's toileting behaviors. These are the
basic elements of Enhanced Toilet Training, found to be twice as effective as
intensive medical management with enemas and laxatives
(Cox et al., 1998;
Borowitz et al., 2002).
However, these results do not indicate that treatment of such children should
routinely address more general behavioral issues, which is consistent with the
literature (Cox, 2002;
Taitz, Wales, Urwin, & Molnar,
1986). Consistent with McGrath's recent review of treatment
procedures (McGrath et al.,
2000), the VECAT may be useful in identifying different subgroups
of patients that might differentially respond to different treatment
procedures.
While these findings indicate that treatment of encopretic children should be symptom focused, the items' large standard deviations (relative to the means) and clinical experience indicate that any one of the items in the VECAT may represent clinically significant issues for any particular child. For example, aversive parenting and its subsequent child/parent power struggles, child deception of fecal accidents, and attempts to avoid dealing with the problem, or the shame and rejection associated with public soiling and subsequent dissociation from the problem, may be central issues for a specific patient.
The VECAT, administered to both parent and child, may be an expedient way of accessing such issues. Given the mean ratings and standard deviations of both control mothers and children, a rating of 3 or 4 (mean plus one SD, 86th percentile) would be considered clinically significant on all bowel-specific items, except for shame (8s) and peer rejection (9s), which would require a 4. Not only could the VECAT identify significant bowel-specific issues, but it could also identify when these issues reflect more general problems. If there are 3's and 4's on both the specific and generic issues, then the clinician should consider a more generic assessment and intervention. For example, if the child gives a rating of 3 to both bowel-specific and generic aversive parenting, then a clinical focus on positive parenting should be more general in its focus. Discrepancies between parent and child ratings may reflect either denial or exaggeration. The clinician would need to help clarify such discrepancies.
The current data indicate that bowel-specific items on the VECAT were internally consistent, reliable, discriminating, and sensitive and have both theoretical and clinical implications. All items, except shame, contributed to the total scores of the bowel-specific and generic subscales. There was little internal consistency among generic items, which verifies the specificity of the model. Also, the generic items did not differentiate symptomatic from nonsymptomatic children. While intriguing and potentially useful, the VECAT should be used in other facilities to demonstrate its external validity. It also needs to be tested with older and younger samples. It is anticipated that constipated children, without fecal soiling, should have similar responses to Items 1s-6s, but not have problems around deception, shame, and peer rejection. Because mothers were more discerning than children, a self-administered, text-based version of this instrument might be easier to administer to parents and be equally informative. A computerized version of the VECAT is currently being developed and will be able to be delivered over the Internet (www.ucanpooptoo.com).
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Acknowledgments |
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This research report was supported by NIH grant RO1 HD 28160. The authors would like to thank Dr. Robert Pianta for suggestions on scoring the VECAT.
Received September 25, 2000; revision received April 2, 2002; revision received December 1, 2002; accepted December 28, 2002
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