Original Article 35

DOI: 10.4274/tpa.582

Behavioral problems of encopretic children and their familial characteristics

Türkay Demir, Mesut Yavuz, Burak Doğangün, Nurullah Bolat*, Tayyib Kadak, Gül Karaçetin**, Levent Kayaalp
İstanbul University, Cerrahpaşa Medical Faculty, Department of Child and Adolescent Psychiatry, İstanbul, Turkey
* Child and Adolescent Psychiatry, Diyarbakır Children’s Hospital, Diyarbakır, Turkey
** Child and Adolescent Psychiatry, Çorum Public Hospital, Çorum, Turkey

Summary
Aim: The aim of this study was to assess behavioral problems in children with encopresis as well as anxiety levels of the mothers and marital
problems of the parents.
Material and Method: The case group included 31 boys with encopresis and their mothers; the control group included 26 boys who did not have
chronic disease and their mothers. Child Behavior Checklist (CBCL), Trait Anxiety Inventory (STAI-II) and Marital Conflict Questionnaire (MCQ)
were used. The mean scores of the scales of the two groups were compared by Mann-Whitney U test (ethics committe no: 17.12.2007/34516).
Results: CBCL total problem scores, externalization, aggressive behavior, delinquent behavior and attention problem scores were significantly
higher; CBCL competency total scores and school scores were significantly lower in the case group. In addition, MCQ scores were significantly
higher in the encopresis group. Maternal STAI-II scores did not differ significantly between the groups.
Conclusions: Attention and behavior problems may be the target of interventions for treatment of encopresis in children. Treatment of these
problems may increase treatment compliance and prevent conflicts that may occur within the family in relation to these problems. Addressing
severe marital problems which may be a source of distress and which may worsen the course of treatment may contribute to the treatment of
these children. (Turk Arch Ped 2012; 47: 35-9)
Key words: Anxiety, behavioral problems, children, encopresis, family

Introduction behavior disorder (3%) (7). Difficult personality traits in the child
has been reported to lead to conflict between the parents and
Encopresis is defined as fecal soiling in inappropriate places the child and problems in toilet training. It has been suggested
which is mostly involuntary and sometimes voluntary (1). It has that children who have not been able to complete their toilet
been reported that encopresis occurs in 2,8% of children of 4 training or who refuse to sit on the toilet have a more difficult
years of age, in 1,9% of children of 6 years of age and in 1,6% of personality (8) and difficult personality is an early indicator of
children of 10 years of age (2). It is observed 3-fold more bowel regulation problems and problems of internalization and
frequently in boys compared to girls (3). The term primary externalization (9).
encopresis is used for cases in which the problem is present from In addition to difficult mood, compelling life experiences and
the birth and accompanied by growth retardation and enuresis. conflict between the parents and the child have also been
The term secondary encopresis is used for cases in which reported to be associated with encopresis (4,8). Considering
encopresis usually starts after a compelling life experience (4). this information it has been assumed that behaviour disorders
It has been reported that anxiety, depression, attention and will be observed with a higher rate, the mothers will have a
behaviour problems are observed more frequently, school higher level of anxiety and marriage problems will be more
success is lower than the general population (5) and CBLC total frequent and severe in children with encopresis. In our study, it
problem scores are higher in children with encopresis (6). was aimed to examine psychological and behavioral problems,
Common comorbidities in encopresis include enuresis (55,2%), the levels of anxiety of the mothers and marriage problems of
oppositional defiant disorder (30,8%), childhood masturbation the parents with appropriate materials in children with
(6%), mental retardation (5%), anxiety disorders (3,5%) and encopresis in line with these assumptions.

Address for Correspondence: Türkay Demir MD, İstanbul University, Cerrahpaşa Medical Faculty, Department of Child and Adolescent Psychiatry, İstanbul, Turkey
Pohone: +90 212 414 30 00 / 22329 Fax: +90 212 414 31 45 E-mail: demirturkay@gmail.com Received: 04.30.2011 Accepted: 06.09.2011
Turkish Archives of Pediatrics, published by Galenos Publishing
36 Demir et al.
Encopresis Turk Arch Ped 2012; 47: 35-9

Material and Method Results

31 boys with a diagnosis of encopresis made according to The mean age of the children with encopresis and the
DSM-IV-TR criteria who presented to the outpatient clinic of child children in the control group were 9,13±2,45 and 9,23±1,21
and adolescent psychiatry between 2008 and 2010 years, respectively and there was no significant difference
consecutively and their mothers were included as the study between the two groups (Student’s t testi, p=0,85). There was
group. The first complaint at presentation was encopresis in all no difference between the study and control group in terms of
these children. The diagnosis of encopresis was made by family integrity (Fisher Exact Test, p=0,24). 48,4% of the study
clinical interview and no structured interview was performed. group (n=15) had primary encopresis and 51,6% (n=16) had
The control group was composed of 26 boys who presented to secondary encopresis. Encopresis was observed as fecal
the outpatient clinic of the department of pediatrics and had no soiling in 80,6% (n=25) of the cases and as complete
chronic disease with similar characteristics as the study group in encopresis in 19,4% of the cases (n=6). In approximately one
terms of age and socioeconomical level. The diagnosis of the third of the children in the study group (32,3%), the comorbidity
children in the general pediatric outpatient clinic is upper of enuresis was found. In the control group, this rate was 7,7%
respiratory infection. Care was taken that no disease state which and the difference between the two groups was statistically
could prevent or affect the interview with the child was present. significant (x2=5,12, p=0,23). Enuresis was observed with a
If necessary, the interview was performed on another day. higher rate in cases of primary encopresis compared to cases
Before the study approval was obtained from Cerrahpaşa of secondary encopresis (40% and 25%, respectively), but the
Medical Faculty Ethics Committee (17.12.2007/34516). Families difference was not statistically significant (Fisher’s exact test,
who participated in the study signed the informed consent form. p=0.46). CBLC scores of the study and control groups are
To prevent mental retardation to affect the results WISC-R shown in Table 1.
(10,11) test was performed in children in whom mental There was no significant difference between the study and
retardation was suspected and children with a score below 70 control groups in terms of anxiety, depression, introversion and
were excluded from the study. Children with a digestive system somatization scores in the area of internalization disorders. On
disorder, with a diagnosis of nervous system disease and the other hand, total score, agressive behavior, delinquent
muscle disease and with a chronic disease were excluded from behavior and attention problems scores in the area of
the study considering that their physical disorders may affect the externalization problems were higher in the study group. CBLC
study results. During the study, three children were excluded sufficiency scale total scores and school scores in the
becuse of gender criterion, four children were excluded because sufficiency part were lower in the study group. There was no
of mental retardation, three children were excluded because of significant difference between the two groups in terms of
physical disorder and two children were exluded because their efficiency and sociability (Table 2).
parents did not wish to participate in the study. Marriage conflict scale prevalence scores and marriage
CBLC (Child Behavior Checklist/4-18): This checklist was conflict scale mean frequency scores were higher in the group
developed to determine the social ability areas and behavior with encopresis. There was no difference between the two
problems of children and adolescents in line with information groups in terms of STAI-II scores (Table 3).
obtained from the parents (12). Validity and reliability of the
Turkish version of this scale was established by Erol et al. (13). Discussion
State-Trait Anxiety Inventory (STAI-II): This is a self-
assessment scale including two seperate subscales of 20 items When elimination disorders are evaluated in terms of
(14). STAI-I measures state anxiety level and STAI-II measures comorbidities, high rate of enuresis is compatible with the
continual anxiety level. Validity and reliability study was done by literature (4,6,7). Although the comorbidity of enuresis was
Öner et al. (15). In our study, STAI-II scale was used. reported with a higher rate in patients with a diagnosis of
Marriage Conflict Scale: This scale which was developed primary encopresis compared to patients with secondary
by Hatipoğlu (16) is composed of 70 items on subjects encopresis in a study, no difference was found between the
including communication, relations with friends and relatives, two groups in our sample. This may be related to the difference
children, work, economy and sex for marriages which are in mean age and the sample size (4).
found to have a high possibility of conflict. Two different scores In previous studies, it was reported that children with
as score of prevalence and frequency are obtained. encopresis had significantly lower scores in subscales of
Statistical evaluation: The data obtained were evaluated by attention problems, delinquent behavior, social problems and
SPSS 13 (Statistical Package for Social Sciences) package anxiety/depression in CBLC compared to the contols (5). In
program. The frequency and mean values were calculated. accordance with this finding, oppositional defiant disorder
Mean scores of the groups obtained in the scales were (ODD), attention deficit-hyperactivity disorder(ADHD) and
compared by Mann-Whitney U test. A p value of <0.05 was behavior disorder (BD) are frequently associated with
considered to be significant in all analyses. encopresis (7). In line with the literature, scores of
Turk Arch Ped 2012; 47: 35-9
Demir et al.
Encopresis 37

Table 1. Statistical comparison of the CBLC¹ problem scores of children with encopresis and of the control group

ÇDDÖ¹ subscales Children with encopresis (n =31) Controls (n=26) Z value p value
Internalization problems 63.26±10.18 59.69±9.77 -1.24 0.214
Anxiety /depression 65.03±10.10 61.27±8.91 -1.58 0.113
Social introversion 59.45±10.07 58.69±8.65 -0.12 0.909
Physical complaint 57.55±7.81 56.15±6.27 -0.66 0.507
Externalization problems 62.74±8.62 51.27±8.87 -4.44 <0.001
Agressive behavior 63.23±9.75 54.31±8.00 -3.80 <0.001
Delinquent behavior 59.55±9.03 53.00±5.51 -2.95 0.003
Social problems 59.74±8.96 56.15±8.20 -1.82 0.068
Thought problems 63.55±8.57 60.88±7.99 -0.86 0.391
Attention problems 65.35±9.79 56.12±7.81 -3.97 <0.001
Sexual problems 58.27±10.24 53.18±6.40 -1.82 0.069
Total problems 65.23±9.30 56.03±10.19 -3.39 0.001

¹Child Behavior Checklist

Table 2. Statistical comparison of CBLC¹ sufficiency scores of the children with encopresis and the control group

CBLC¹- SSC The group with encopresis (n=31) Control group (n=26) Z value p value
Total 39.11±9.32 45.85±7.41 -2.79 0.005
Efficiency 39.65±9.19 43.88±8.08 -1.79 0.073
Sociability 41.77±9.20 45.81±6.82 -1.56 0.119
School 39.46±7.44 49.50±4.25 -4.55 <0.001
¹Child Behavior Checklist – Sufficiency Subscales

Table 3. Comparison of continual anxiety scores of the mothers and frequency and prevalence scores of marriage
conflict of the parents of the children with encopresis and the control group

The group with encopresis (n=27) Control group (n=26) Z value p value
MCS1-P 12.89±9.91 4.96±5.83 -3.03 0.002
Marriage conflict scale 2- F 1.75±0.66 1.28±0.97 -2.38 0.017
Encopretic group (n=31) Control group (n=26) Z value p value
DSKE²-S 48.00±6.66 47.88±5.85 -0.11 0.910

¹Marriage conflict scale Prevelance, 2 Marriage conflict scale -Frequency 3 State-Trait Anxiety Inventory- Continual score

externalization, attention, agressive behavior and delinquent externalization problems should be treated independent of the
behavior were found to be higher in children with encopresis order of psychological problems and encopresis, because
compared to the contols in our study. However, no difference externalization problems affected the child’s compliance to
was found between the two groups in terms of subcales of treatment. This was also emphasized in two case presentations
social problems and anxiety/depression in our study in contrast which reported metylfenidate use was beneficial in treatment of
to previous studies. encopresis (18,19).
It has been suggested that sitting on the toilet and hygiene It is thought that encopresis may be associated with conflict
procedures are among the main principles of encopresis between the parents and child and low educational and social
treatment and treatment of attention problems will provide function level which is observed frequently in ADHD and
compliance to hygiene and exercises for sitting on the toilet by metylfenidate treatment may provide improvement in encopresis
rendering the children more sensitive to internal stimuli secondary to improvement in ADHD symptoms (18). Joinson et
including bowel movements (5). Kuhn et al (17) reported that al.(2) reported that children with retardation in areas of
38 Demir et al.
Encopresis Turk Arch Ped 2012; 47: 35-9

communication and social ability experienced defacation included in the study to eliminate the effect of gender variable on
problems more frequently. In our sample, social function the study, since encopresis is observed more frequently in boys.
sufficiency scores of the children with encopresis were similar to This prevented obtaining information about the features of
the control group. On the other hand, significantly lower total encopresis and family structure in girls. Another limitation of the
sufficiency scores in children with encopresis compared to the study was the relatively low number of subjects. Since children
control group support the results of the study performed by with mental retardation and girls were excluded from the study, the
Joinson et al.(2). Treatments focused on attention and behavior number of subjects remained low. As a result of the research
problems may decrease encopresis symptoms in these children attention and behavior problems were found with a higher rate in
and may lead to improvement in the area of sufficiency. boys with encopresis which was compatible with the literature. In
Bemporad and Hallowel (10) defined the mothers of contrast to what was expected, the anxiety levels of the mothers
encopretic children as neurotic. Taichert (21) reported that of children with encopresis were found to be similar to the
encopresis might increase distress and anger of the mother and controls. On the other hand, it was found that marriage problems
child, disturb the functionality of the family and this might lead to were more frequent and more widespread in the families of
the continium of conflict between family members. It was reported children with encopresis. Based on these results it can be
that the risk of defacation problems is high in the future in children suggested that addressing attention and behavior problems of
whose mothers experience anxiety and depression during the children with encopresis and integrative approach to the family are
period of the child’s toilet education (2). It was stated that a part of significant in terms of providing compliance to treatment and
children with encopresis might not have taken, might have refused regression of symptoms.
or forgotten the treatment reccomended at the first presentation
and the attitude of the families on this subject should be examined Conflict of interest: None declared.
(22). In some studies, it was reported that encopresis might be
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