Encopresis: Behavioral parameters associated with children who fail medical management

Encopresis: Behavioral Parameters Associated with Children Who Fail Medical Management

Lori J. Stark, PhD Anthony Spirito, PhD Anna V. Lewis, MD

Rhode Island Hospital~Brown University Program in Medicine Kathleen J. Hart, PhD

Xavier University

ABSTRACT: The present study examined behavioral parameters such as parent management of encopresis and parental coping styles (active, cognitive, and avoidance) as predictors of success with medical management of encopresis. The results suggest that parents use a variety of management strategies and treatment success cannot be pre- dicted using these variables. However, in line with previous research the presence of child behavior problems appeared to be a potential predictor variable.

KEYWORDS: Encopresis, Parent Management, Child Behavior Problems

Approx ima te ly 1.5% of e l e m e n t a r y school-aged chi ldren are esti- ma t ed to be encopret ic 1, 80% of whom are classified as the r e t en t ive type 2. This common type of encopresis is charac te r ized by constipa- t ion, impac t ion of stool, and subsequen t l eakage of fecal mate r ia l . T r e a t m e n t of encopresis has usua l ly t a k e n two forms: medical and psychological. T r e a t m e n t typica l ly involves a "clean-out" of the im- pacted feces, and dai ly oral mine ra l oil. O the r medica t ions such as psyll io supp lements m a y be prescribed, and pa ren t s and chi ldren m a y be g iven educa t iona l in fo rmat ion about encopresis, ins t ruc t ions to increase d ie t a ry f iber and/or decrease da i ry products, and recommenda- t ions to set up a dai ly toi le t s i t t ing p rog ram 3.

Received December 31, 1988 For revision February 15, 1989 Accepted April 11, 1989 Address for reprints: Lori J. Stark, Ph.D., Rhode Island Hospital/Brown University

Program in Medicine, Child and Family Psychiatry, 593 Eddy Street, Providence, RI 02903.

Child Psychiatry and Human Developm2nt, Vol. 20(3), Spring 1990 �9 1990 Human Sciences Press 1 6 9

170 Child Psychiatry and Human Development

Psychological treatment programs using a behavioral approach have also been reported in the literature. Such approaches have taught parents to reward appropriate toileting t,~,~,7,8,9, reward "clean pants ''mI,12, to use a punishment paradigm of cleaning clothing and cleaning themselves in a cold bath, 13,14 and to use combinations of these procedures '5'1~'~7. However, rarely have medical and psychological treatment approaches included or integrated components of each other's treatment '8'~9. Referrals for psychological intervention are typically made after a succession of medical failures 2~ Clinical impres- sions and research in other areas (e.g., abdominal pain) suggest that a psychological referral may be most effective if made during the medical work up. 2~ Psychological interventions, however, are often time and labor intensive, and not always necessary as medical intervention alone is successful with 60 to 80% of encropetic referrals 22~. This would suggest that research is needed to identify encopretic children who are at risk of failing medical management in order to pro- vide more comprehensive services.

Previous attempts to examine this question 2~ have focused on the child's presentation and history. Landman et al. 2~ found no differences between medical responders and failures in terms of the child's age, school functioning, socioeconomic status, infant feeding and bowel problems, toilet phobic behavior, somatic complaints, behavioral problems, or parental attribution of etiology at their initial presentation. Likewise, Levine and Bakow 2~ found few differences although treatment failures were more likely to have accidents in school, and, by parent report, have behavior problems at home and school.

Since most interventions for encopresis require substantial time and effort by parents, it was hypothesized that parental coping and/or management style may be different between children who succeed versus those who fail in medical treatment. Indeed, Gabel et al ~3 hypothesized that treatment outcome may be associated with parental reaction to and involvement with the child's encopresis. Thus, the present study was designed to evaluate parent behaviors related to encopresis and parental coping style in dealing with this problem. Further, the parents of encopretic children were compared on their coping style to parents of a control group of children referred to an outpatient psychiatry department for evaluation of behavioral problems. Finally, an assessment of demographic variables, and child characteristics of toileting history, soiling, self-esteem, and behavior problems were included to allow comparison to previous studies in the area ~o,22,23.

Lori J. Stark et al. 171

Method

Subjects

Encopretic subjects were children between the ages of 4 and 12 years (mean age 7.9 years) referred by their pediatrician to the Pediatric Encopresis Clinic for problems of soiling and constipation. All children had failed to respond, at least once, to medical treatment prescribed by their pediatrician. Fifty children, consisting of 40 males and 10 females, were referred over an 18 month data collection period. All children were diagnosed as retentive encopretics by the pediatric gastroenterologist at the initial clinic visit by means of an intake history and rectal exam. Success or failure was determined at the one- month follow-up in clinic via parent report of a significant decrease in the child's soiling (less than 1 episode per week), and rectal examination reveal- ing a disempacted bowel.

The comparison group consisted of 39 children, 30 males and 9 females, between the ages of 4 and 14 years (mean age 8.6 years) referred to a Child Psychiatry outpatient clinic for evaluation and treatment of behavior problems during the same time period. None of the controls had problems with soiling.

Dependent Measures

Parent Assessment

History of Encopresis is a questionnaire to assess relevant historical data regarding the patient 's encopresis. The questions included for analysis in this study were: frequency of accidents; duration of problem; number of bowel movements in toilet; and primary versus secondary encopresis.

Child Management Questionnaire was devised specifically for the present study and assessed the variety and frequency with which parents used various strategies to manage soiling accidents. The strategies assessed included comforting, sympathy, a time-out procedure, enforcing self clean-up, shaming/embarrassing child, etc.. Parents rated their use of each strategy as either "Never", "Sometimes", or "Often". Management strategies consistent with social learning theory of behavior management (e.g., use of time-out, enforcing self- cleanup) were scored as 0. Strategies that increased attention contin- gent on soiling (e.g., sympathy, scolding) were scored as 2. The score on each item was summed to yield a total score. Higher scores repre- sent a greater use of non-behavioral management techniques.

Behavior Rating Form~Revised (BRF-R) 26 is an inferred self-esteem


instrument designed to be completed by parents about their children. The scale consists of 14 items which describe behaviors associated with high and low self-esteem. The parents rate their child's behavior on a five point scale ranging from "Never" to "Always". Scores range from 14 to 70 with higher scores indicating high levels of parent inferred self-esteem.

Other Problems were assessed via two questions asking the parent whether their child was experiencing any academic difficulties at school, or behavior problems at home. Affirmative responses were scored as 1, and negative responses were scored 0.

The Indices of Coping Responses 27 provides an indication of the method of coping adults utilize (active cognitive coping, active behavioral coping, and avoidance coping) in response to a specific stressful event (in this case, the child's soiling). The parents rate the frequency of their use of 32 different coping responses on a four-point scale ranging from "No", to "Fairly Often". High scores on the individual scales indicate higher use of the coping response. Parents of control children completed the scale in response to a specific behavior problem the parents found difficult to manage.

Child Assessment

Coopersmith Self-Esteem Inventory Short-Form (SEI) 2s is a 25-item derivative that correlates .86 with the 58-item original scale. The children were read each of the 25 statements and asked to respond whether the item was "like me" or "unlike me". Items conceptualized to indicate higher self-esteem are scored "l" and items conceptualized to indicate lower self-esteem are scored "0". The score is derived by multiplying the raw score by 4. A totally positive self-esteem score is 100 and a totally negative score is 0. Adequate internal consistency coefficients (mean = .72) have been reported. Validity of the scale can be inferred from the strong supporting data on the original scale.

Procedure

Encopresis Patients

Interview. Parents were mailed a History Questionnaire and Child Management Questionnaire prior to their initial visit. They were instructed to complete these questionnaires and bring them to their ap-

Lori J . S t a r k e t al. 173

pointment. Parents and children were initially seen by a staff psychologist or psychology intern and the multidisciplinary nature of the clinic was explained. The purpose of the interview with the psychologist was to review the questionnaires, to get a clear understanding of the history of the problem, and to assess the tactics the parents had tried to resolve the problem. Any missing information on the questionnaires was completed and any questions the parent had were an- swered. If parents had failed to complete any of the questionnaires they were completed at this time. In addition, the parents were asked to complete the Indices of Coping Responses Questionnaire and the Behavior Rating Form-Revised (BRF-R). In addition, the children were interviewed about their problem with soiling and their understanding of why they were attending clinic. Children over six years of age (N -- 27) were administered the Coopersmith Self-Esteem Inven- tory Short-Form (SEI) for Children.

Medical Treatment. Following the interview the children were seen by the pediatric gastroenterologist. Following physical examination and diagnosis, the physician typically prescribed an enema clean-out followed by oral doses of mineral oil. The enema-clean out was typically a series of three Pediatric Fleets enemas administered one ev- ery 24 hours over three days. For more severe impaction, additional enemas were prescribed. Following the clean-out regimen parents were instructed to give the child one to three tablespoons of mineral oil by mouth for nine weeks to soften newly forming stool, and to have the child sit on the toilet for 10 rain. following each meal. Par- ents were given the criteria by which to judge the amount of mineral oil necessary to produce appropriate stool consistency. Further, Lac- tulose (chronulac, a nonabsorbable sugar) was sometimes added to promote further softening, gas production, and to increase the sensa- tion to defecate. A high-fiber diet was also advocated with a decrease in dairy products and an increase in fluids.

Follow-up. At one month post-treatment the patients were again seen in the Encopresis Clinic and interviewed by a staff psychologist or psychology intern about the frequency of the problem during the intervening four weeks. Treatment successes (N-- 13) were readministered the BRF-R and children over age six years (N = 10) were readministered the SEI. Treatment failures (N = 27) were referred to Psychology for further treatment.


Control Subjects

The parents of the children referred to a Child Psychiatry Clinic was asked to complete the BRF-R, and the Indices of Coping Re- sponses during their intake interview with a staff member. Children over age six were given the SEI.

Results

Behavioral Predictors of Medical Outcome

The encopretic children were classified according to their status at the one-month follow-up. There were 13 medical responders, eight males, five females, with a mean age of 8.2 years. Twenty-seven children were classified as medical failures, 23 males, four females, with a mean age of 7.6 years. There were 10 t rea tment drop-outs, nine males, one female, with a mean age of 8.9 years. These groups were then compared on their demographic, history, parent management, and parent coping variables as measured at their initial visit to evaluate whether any of these measures had predictive value.

Demographic Variables. The three groups did not differ by age, F(2,47) -- .83 p > .10, or sex, X~(2, N = 50) = 3.85, p > .10. However, they did differ according to whether they had insurance or received welfare, X2(2, N = 49) = 7.38,p < .05. None of the t reatment successes received welfare, while 8 out of the 27 t rea tment failures received welfare.

History Variables. The three groups were compared on their soiling and toilet t raining histories. A Chi-square analysis revealed no differences between medical responders, failures and dropouts on the frequency of accidents pe r day (one vs. two or more), X2(2, N = 49) = 2.27, p > .10; whether the child was having any bowel movements on the toilet, X2(2, N = 48) = 2.57, p > .10; the duration of soiling (less than 6 months, 1 to 2 years, greater than 2 years), X2(4, N = 47) = 0.24, p > .10; or on whether the child had ever been bowel trained (primary or secondary encopresis), X2(2, N = 48) = 2.73, p > .10.

Parent Management and Coping. One-way ANOVAs computed on the Child Management Questionnaire again revealed no differences


between the groups, F(2, 42) = .03, p > .10, indicating that parents of responders as well as failures used a variety of management strategies tha t were not behavioral (e.g., shaming child). There were also no differences noted for the mothers on the Indices of Coping for any of the coping methods: Cognitive Coping, F(2,39) = .22, p > .10; Be- havioral Coping, F(2,39)= 1.61, p > .10; or Avoidance Coping, F(2,39) = .36, p > .10. Thus, t rea tment failures did not have mothers who coped differently or avoided the problem as compared to mothers of children who were t rea tment successes.

Child Self-Esteem. The parents did not report significant differences on the child's self-esteem as measured by the BRF-R, prior to treatment, F(2,43) = .23, p > .10. Nor were there differences in self-esteem between the three groups at the initial evaluation by child self- report on the SEI, F(2, 35) = .79, p > .10. However, children who were successfully treated for encopresis showed a significant in- creases in self-esteem pre- to post-treatment by child report. Scores on the SEI (N = 10) increased from a mean of 57.2 (S.D. = 16.3) to a mean of 67.2 (S.D. = 11.1), t(9) = 3.00, p < .02 (higher score better self-image). The parents also demonstrated an increase on the parent inferred measure of child self-esteem (BFR-R), but it was not statis- tically significant. For these children, (N = 13) their mean score of 44.2 pretreatment increased to to a mean of 51.4 post-treatment, t(12) = 2.12, p < .10 (higher score, better inferred self image).

Other Problems. Analyses were also conducted regarding parents report of behavior problems other than soiling. A Chi square analyses did not indicate significant differences in school problems among the three groups, X2(2, N = 32) = .55, p > .10. However, there were significant differences on behavior problems at home, X2(2, N = 32) = 6.62, p < .05. Only 25% of the parents of medical successes reported co-existing behavioral problems while 56% of the dropouts and 80% of the failures reported such problems at home.

Encopresis Patients Compared to Psychiatry Referrals

Demographic Variables. The three groups of encopretic children were combined (N = 50) and compared to the control group children (N = 39) on age and sex. A Chi square analyses did not reveal a significant sex difference between the two groups, X2(1, N = 89) = .01, p > .10. The mean age of the encopretic children was 7.9 years


(S.D. = 2.9) while the control group had a mean age of 8.6 years (S.D. = 2.5). A t-test did not reveal a significant difference in age between the two groups, t(87) = .35, p > .10.

Parent Coping. The parents of the encopretic children were then compared to the parents of the control group on their predominant coping style, as measured by the Indices of Coping. No significant differences were found between the parents of the encopretic children and the parents of the control group on cognitive coping, F(1,64) = 1.17, p > .10; or behavioral coping, F(1,63) = .54, p > .10. However, a significant difference was found on parental avoidance coping, F(1,63 = 10.73, p < .01. The parents of encopretic children used avoidance coping less frequently (mean 10.0; SD = 3.5), than the parents of the controls (mean 13.1; S.D. = 3.7).

Child Self-Esteem. There was no difference in the parents ' est imate of the children's self-esteem as measured by the BRF-R, F(1,80) = .63, p > .10. There were significant difference on the child's self-report on the SEI, F(1,62) = 5.44, p < .05. The encopretic children ob- tained a mean score of 61.9 (S.D. = 14.8) while the control group had a lower self-esteem, mean score of 53.3 (S.D. = 13.9).

D i s c u s s i o n

The present s tudy evaluated parental management of encopresis and parental coping at the initial presentation in order to assess the relationship between parental behavior and response to medical t reatment. In this regard no differences were noted between parents of children who responded to medical t reatment versus those whose children failed. In addition, no differences were found between either of these groups and those who dropped out of t rea tment prior to the one-month follow-up.

From the present data it appears that encopresis is a distressing problem and that, overall, parents at tempt a variety of strategies to alleviate it. However, prior to t rea tment in our clinic, it does not appear tha t parents use any one strategy consistently even though they have previously received a prescribed medical t rea tment from their pediatrician. For example, most parents report being both sympa- thetic to the child following a soiling incident and scolding the child at another incident of soiling. Thus, parents of children who succeed do not appear to be any more consistent or to use more appropriate


behavioral strategies such as a self-cleaning routine in their management of encopresis than parents of children who fail. Further, the parents did not differ in their overall coping style. Parents of treatment failures did not report using avoidance coping strategies any more frequently than parents of treatment successes.

In regard to other measures the results are similar to previous research in the area 2~ Few differences were found on the demographic, and toilet history variables between treatment successes and failures. However, consistent with Levine and Bakow 2~ it was found that children who failed treatment were more likely to be perceived by their parents as having other behavior problems at home. While it appears difficult to predict who will fail and who will succeed in treatment, one potential variable may be whether the child is perceived as a behavior problem and this may be related to the parents overall management style. Although the present study did not assess specific behavior problems of the child, the parents of children who failed medical treatment and were referred for more intensive treatment described themselves as unable to comply with the treatment recommendations. They reported that their children would not cooperate with some aspect of treatment (enemas, mineral oil, or diet). The parents inability to get their child to cooperate with treatment may af- fect outcome by interfering with compliance to the prescribed treatment. Indeed, in their study, Levine and Bakow 2~ reported that treatment failures were significantly less compliant than treatment successes.

A second difference between the children who succeeded with medical treatment and those who failed or dropped out was their payment for services status: Insurance, or welfare. While two-thirds of the failures had insurance, none of the treatment successes were families receiving welfare. These results indicate that families receiving fi- nancial assistance may have other life stressors which interfere with their ability to follow medical recommendations without supportive services.

Inclusion of a behavior problem control group allowed comparison of children with encopresis with another "problem" group. Parents of children with encopresis reported using avoidance strategies less frequently in coping with soiling incidents when compared to parents of children with behavior problems in dealing with their child's presenting problem. Further, encopretic children reported having a higher self-esteem than children with behavior problems. Thus, children with encopresis and their parents appear to cope better and feel bet-


ter about themselves than children with other problems. This finding is similar to those reported by Gabel et a124 who found that the individual scores for children with encopresis did not reach the clinical range on the Child Behavior Checklist (CBC), and that most of the problems reported concerned bowel movements.

Summary

There was no significant difference between children who succeed or fail medical management of encopresis on measures of parental management or coping with their child's soiling incidents. The most promising predictor of medical outcome appears to be the parents' report of their child having behavior problems at home. It was hypothesized that children with behavior problems may be less compliant with the encopresis t reatment regimen. A further comparison of children with encopresis to children referred for outpatient psychological t reatment revealed that children with encopresis had significantly higher self-esteem and their parents appeared to cope better with their presenting problem. The results suggest that behavior problems may be an important predictor of t reatment failure for children with encopresis.

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Encopresis: Behavioral parameters associated with children who fail medical management