CHRONIC FUNCTIONAL CONSTIPATION AND ENCOPRESIS IN CHILDREN IN [623117]

CHRONIC FUNCTIONAL CONSTIPATION AND ENCOPRESIS IN CHILDREN IN
RELATIONSHIP WITH THE PSYCHOSOCIAL ENVIRONMENT -A PROSPECTIVE
COHORT STUDY

Authors:
Claudia Olaru MD PhD1,2, Smaranda Diaconescu MD PhD1,2, Laura Trandafir MD PhD1,2,
Nicoleta Gimiga MD PhD1,2, Radian A. Olaru MD3 , Gabriela Stefanescu MD PhD1,4,
Gabriela Ciubotariu MD1,2, Marin Burlea MD PhD1,2, Magdalena Iorga PhD1,2

1 ''Gr. T. Popa '' University of Medicine and Pharmacy, Iasi, Romania
2 ''Sf. Maria'' Emergency Hospital for Children, Iasi, Ro mania
3 ''Socola'' Emergency Hospital, Iasi, Romania
4 ''Sf. Spiridon'' Emergency Hospital, Iasi, Romania

*Corresponding author :
Smaranda Diaconescu MD PhD1
Address: no. 16, Universitatii Street
Telephone No. : +[anonimizat]
E-mail address: turti23 @yahoo .com

Abstract : Functional constipation is an issue both for the patient and his/her family ,
affecting the patient’s psycho -emotional balance, social relations, and their harmonious
integration in the school environment . We aimed to highlight the connection between chronic
constipation and encopre sis and the patient’s psychosocial and family -related situation .
Material and method: 57 patients with ages spanning from 6 to 15 were assessed within the
pediatric gastroenterology ward . Socio -demographic, medical and psychologic al data was
recorded . The collected data was processed using the SPSS 20 software . Results : The study
group consisted of 57 children diagnosed with encopresis, [43 boys (75.44 %) an d 14 girls
(24.56%) ], M=10.82 years. It was determined that most of the children came from urban
families with a poor socio -educational status. We identified a level of studies of 11.23 ±5.56
years in mothers, while fathers had an average number of 9.35 ±4.53 years of study. We also
found a complex relation ship between encopretic episodes and school performances
(F=7.968, p=0.001, 95%Cl). Children with encopresis were found to have more
anxiety/depression symptoms, greater social problems, more disruptive behavior, and poorer
school perfor mance . Concl usions : The study highlights the importance of the family
environment and socio -economic factors in manifestations of chronic constipation and
encopresis .
Key: child, encopresis, behavioral problems , family environment

Introduc tion
Functional constipation is characterized by infrequent stool evacuation, passing of hard stools
or painful defecation with no fundamental organic cause [1]. Up to 84% of the children with
chron ic constipation experience frequent episodes of fecal incontinence [2]. Chronic
constipation and secondary fecal incontinence are a source of concern for the child and his/her
family. The symptoms are often persistent and relapses are frequent [3-5]. Fecal incontinence
can also cause feelings of guilt and discomfort and is associated with social withdrawal
behaviors, anxiety and depression [6-8]. Encopresis is defined as a disorder characterized by
repeated stool evacuation in inappropriate places in childr en over the age of four. The
behavior can be either involuntary or intentional, it must be present for a minimum of three
months at a rate of at least once a month, and is not the direct effect of a subs tance or a
medical condition. [9] Biological and deve lopmental mechanisms can be responsible in the
etiology of encopresis, and so can psychosocial and environmental factors. Many of the
children presenting with encopresis have experienced a previous event that triggered the
disorder by making the bowel mo vement uncomfortable or scary. [10] Such an event can vary
from constipation associated with painful bowel movement or fear of using the toi let, to
repeated sexual abuse. The prevalence of encopresis was assessed in around 1 -3% of the
general pediatric popul ation. [ 11, 12] Reports show that this rate is higher ( 4%) in developing
countries. [13] No encopresis -related studies were carried out on the pediatric populati on in
Romania. [14, 15] The long -term results and factors influencing the prognosis are debatab le:
while some studies reported behavior disorders and the family environment as predictors of
poor outcomes in non -retentive encopresis, Montgomery [16 ] and V an Wering [17] described
retentive encopresis as being negatively correlated with the favorable e volution and risk
factors could not be determined. The aim of this study was to highlight the socio -demogra phic
characterist ics of the encopretic patients and those of their families , the occurrence of
behavioral issues, as well as to identify the depressi ve and anxious disorders occurring within
this group . For this purpose there was a focus on: identifying the social and family -related
environment conditions by determining the level of education and current profession of the
child’s next of kin , stud ying the changes in terms of somatization and behavior in patients
struggling with constipation and establish ing some correlations between the severity of
clinical aspects and the psycho -social impact on both the patient and his/her family ;

Material and method
The prospective cohort study was carried out on a group of 57 patients and spanned on a
period of 20 weeks. The study included children aged 6 to 15 that were admitted to the
gastroenterology unit of a tertiary hospital from north -eastern Romania. The stu dy included
underage patients and their next of kin, who were informed in advance with regard to the
purposes of the study and signed an informed consen t form prior to the inclusion. The
inclusion criteria: patients with at least one encopret ic episode per week, spanning over at
least one year. The exclusion criteria: documented mental retardation or any neuromuscular or
gastrointestinal disorders associated with organic constipation, attention deficit/hyperactivity
or obsessive -compulsive disorders. Of all the 67 patients that were diagnosed with encopresis,
8 were excluded due to the parents’ refus al to participate in the study and 2 abandoned the
study during the assessment phase, with the final group including a total of 57 patients. The
medical history phase included gathering information regarding the parents’ level of
education and their level of professional certification. We also recorded school -related data:
education and training level, school results, absenteeism, abandonment. For the purpose of
assessing the clinical symptoms of encopresis, children and their parents were required to
record the frequency of such symptoms in a diary for a month. Laxative -based treatment was
stopped during this month. To determine the impact of encopretic disorders on the psycho –
emotional balance, all patients underwent psychological examination by a clinical
psychologist through observation, structured interview, the ASEBA scales [18 ], and
projective tests. ASEBA scales were use to describe the child's behavior. An assessment can
quickly and effectively assess diverse aspects of adaptive and maladaptive functioning
(schizoid or anxious, depressed, uncommunicative, obsessive -compulsive, somatic
complaints, social withdrawal, hyperactive, aggressive, delinquent, social withdrawal, sex
problems, etc). Interview and projectives tests were used to identify the personal believes and
the impact of the disease on daily life. Results were used also to build the individual therapy.

Results
A total of 57 underage patients participated in the study. The demographic c haracteristics and
medical data are described in (Table I ). Children were aged between 6 and 15, (median age
10.82 ± 2 .507). (Figure 1)

Figure 1 . Distribution of patients according to the age

Of all the subjects , 75.44% (N =43) were males and 24.56% (N =14) were females . The M : F
ratio is 3. 07:1. As far as the origin community is concerned, 59.65% came from urban areas
and 40.35% came from rural areas . (Table 1)

Table 1. Demographic characteristics , history and cl inical features of the patient series

Demographics
Age (Median) 10.82 (6-15)
Sex (M ) (N/%) 43/57 75.44%
Area of origin (urban ) (N/%) 34/57 59.65%
History
Family history of functional
constipation (N/%) 8/57 14.03%
Time lapsed from the onset of
symptoms (week ) to the first
medical consult (urban/rural) 7.8 / 11 .7 (1-17)/(5-19)
Duration of symptomatology
(years ) 4.21 (2-7)
Average duration of treatment
(months ) 14 (6-32)
Symptoms
Frequency of defecation/week 1.32 (1-3)
Encopretic episodes/ month 28.3 (18-41)
Urinary i ncontinen ce (N/%) 9/57 15.78%
Abdominal pain (N/%) 34/57 59.64%
Stool passing pain (N/%) 46/57 80.70%

68.42% (39/57) of children received treatment with oral laxatives 6 months before the
enrolment. Recta l enemas were used at the begin ning of the trea tment as disimpac tion
therapy, 19.29% (11 /57) of children were treated with oral laxatives and underwent dietary
changes ( fiber rich diet and toilet training), and 12. 28% (7/57) underwent dietary changes.
Only 7.01 (4/57) of the children went to a psychologis t. All of them were from urban area s.
12.28% (7/57) declared th at they did not follow the recommended treatment. 85.71% ( 6/7)
were from rural areas . The frequency of encopretic episodes ranged between 18
episodes/month and 41 episodes/month, with an average of 28.3± 6.67.
As far as the social and family environment is concerned :14.03% ( 8/57) of the children were
living in single parent families , 19.29% ( 11/57) of the children had one parent working
abroad, and 7.01% ( 4/57) had both parents working abroad and lived with their grandparents.
The study considered variables related to the parents’ level of education, profession, and their
addressability to medical services (the time from the onset of the symptom s to first medical
consult). In terms of education al level , we noted that 50% of the parents (N=57) had finished
middle school (8 grades ), 15.78% (N =18) completed professional studies, while 34.22%
(N=39) of the participants had completed secondary or high er education (high school and
university diplomas ). Another variable we tracked was the number of years of study averaged
by the parents . Thus we identified a level of studies of 11. 23 ±5.56 years in mothers, while
fathers had an average number of 9. 35 ±4.53 years of study. The analysis of current
occupation and professional status showed that the parents included in the study work ed in
various fields: 48 workers, 23 intellectuals, 28 unemployed persons and 15 people w ho retired
for medical reasons. The ANO VA test interpretation revealed that the number of encopretic
episodes per month was influenced by the level of education of the patients’ female next of

kin. (F= 2.684, p=0.008, 95%Cl). (Tab le 2)

Table 2 . Encopresis frequ ency and relation with the level of education of the patients’ female
next of kin

ANOVA Frequency of enco presis / month
Sum of Squares df Mean Square F Sig.
Between Groups 1055.652 12 87.971 2.684 .008
Within Groups 1442.278 44 32.779
Total 2497.930 56

Education -related data was collected during interviews with the next of kin and conversations
with the patient . We quantified the level of education and number of missed school days
within the studied group . Of the 57 children included in the group, 9 (15.78%) had abando ned
school and 5 (8.77%) failed one year of study . (Figure 2)

Figur e 2. Distribution of patients according to school performance and number of
encopretic episodes per month

21 of the children had around 0-10 missed classes, 31 children had around 11-40 missed
classes , and 5 of them had a large number of missed classes, namely around 41 and 100.per
semest er The Anova test interpretation revealed that the number of encopretic episodes per
month influences the number of missed classes. (F= 7.968, p=0.001, 95%Cl). (Table 3),
(Figure 3)

Tabl e 3. Frequency of encopretic episodes and relationship with the school absenteeism

ANOVA Frequency of encopre sis / month
Sum of Squares df Mean Square F Sig.
Between Groups 569.178 2 284.589 7.968 .001
Within Groups 1928.751 54 35.718
Total 2497.930 56

Figur e 3. The average value of encopretic episodes’ frequencies compared to the number of
missed classes

Psychological data were collected in order to shape a psychological profile for children wit h
encopretic and constipation problems. The psychological evaluation identified (in various
associations) psychomotor agitation (N = 9; 15 .79%), anxiety (N = 22; 38 .59%), affective
deprivation (N = 30; 52 .63%), social adjustment difficulties (N = 13; 22 .81%), introversion
(N = 12; 21.05%), low frustration tolerance (N = 11; 19,29%), depressive syndrome (N = 8;
14.03%), speech disorders (N = 5; 8 .76%) , and emotional distress (N = 19; 33 .31%). (Tabl e
4)

Table 4 . Psychological evaluation

Psychologic al exa mination No. of cases Percentage
Psychomotor agitation 9 15.78%
Anxiety 22 38.59%
Panic attack 1 1.75%
Tic disorder 2 3.5%
Affective deprivation 30 52.63%
Social adjustment difficulties 13 22.81%
Low average IQ 2 3.51%
Negativism 7 12.28%
Irritabi lity, irascibility 6 10.52%
Acute reaction to stress 1 1.75%
Depressive syndrome 8 14.03%
Shyness 12 21.05%
Low tolerance to frustration 11 19.29%
Speech disorders 5 8.76%
Emotional distress 5 8.76%
Hypochondriac tendencies 1 1.75%

Discu ssions
The average age in our group of patients with encopresis was 10. 82 years . The data resulting
from this study were different from other data in the literature, which indicate a higher
prevalence in small children . A population -based study conducted in the Ne therlands which
involved 13,111 parents and their 5 – to 6-year-old children and 9,780 parents and their 11 – to
12-year-old children, revealed that the prevalence of encopresis was 4.1% in the 5 -to-6 age
group and 1.6% in the 11 -to-12 age group. Encopresis was more frequent among boys and

children from the poorest areas of the city. [19] Similar results were also discovered in the
population of southeast Nigeria . The authors of the study showed that encopresis affect ed 3%
of 4-year-old and 1.6% of 10 -year-old children. It occur s more commonly in the 5 – to 10 –
year-old group and less frequently in adolescence , and it predominantly affects males . [20]
Encopresis also occurs in adolescents and even among adults; however, the prevalence is
unknown in those age gro ups. [21] As far as gender distribution is concerned , our results are
consistent with the studies of the authors mentioned above . [19, 20]. The patients ’ geographic
area of origin was predominantly urban. The low frequency of patients from rural areas in o ur
study could be a result of delayed diagnosis due to reduced access to medical services in some
disadvantaged communities, as well as the ignorance of the symptomatology by the patients ’
next of kin with a lower leve l of education . This idea is also supp orted by the fact that the
average time lapsed from the onset of the disorder to the patients’ seeing a doctor was longer
in rural areas compared to urban areas (11.7 weeks /7.8 weeks ). A highlight in our study is that
only 59.7% of the patients lived with both parents . Children from broken homes can present a
higher risk of developing emotional and behavioral disorders. Literature data confirms that the
structure of the famil y into which a child develops entails some disadvantages that
subsequently affect c ognitive, socio -emotional and even physical health outcomes. Studies
observing younger children found that those born to married parents had fewer socio –
emotional and health problems , as well as higher cognitive scores [22, 23] . Time allocated to
raising and caring for children is expected to be positively c orrelated with their wellbeing
[24]. While the quality of the time a parent spends with the child is important, studies have
shown that quantity of such time also has positive consequences for child co gnition and health
[25]. This research points specifically to the likely negative effects of paternal absence. Not
only do single mothers have less time to spend with their children (since they bear more of the
household and parental responsibilities relat ive to their married counterparts), but absent
fathers also tend to spend less time with their children than resident fathers do [26]. Changes
in family structure are typically accompanied by changes in economic, time, and parental
resources; th ese in turn place stress on families and thus adversely affect child outcomes.
Family instability also yields residential instability and a sense of insecurity conc erning
household rules [27, 28] . Empirical studies have shown that family instability is associated
with lower child cognitive scores, increased behavior al problems, and poorer health [28, 29] .
In our study, most of the parents (65.78%) of children with enco presis had a low educational
level. The m edical history analysis highlighted that most of the childre n that did not observe
the previous prescribed courses of treatment came from rural areas and their parents had a low
level of education (85.71%), while all the children that had seen a psychologist were from
urban areas and their parents had completed secondary or higher education. Considering that
the treatment for encopresis is based particularly on the close observance of therapeutic
indications [30, 31] , we can speculate that parents with a higher level of education might be
more compliant . Parental ed ucation was reported both as a competence marker for toilet
training and as a factor of protection against the stress of living in an underprivileged family
[32]. In our study , children whose mothers had a high educational level reported a lower
number of encopretic episodes per month (F= 2.684, p=0.008, 95%Cl) An important question
is whether the frequency of encopretic episodes influences school performances. The analysis
on the rate of enrollment , school absent eeism and the children’s capacity to comple te the
academic year showed that children with encopresis have learning disabilities, poor school
performances and miss school days more frequently . As reported by Stern et al. , children with
encopresis scored lower on two of the three subscales of the Wid e Range Achievement Test
(WRAT): spelling and arithmetic [33]. The relationship between health status and academic
achievement is more complex than it would seem at first glance. While there is strong
evidence that children whose health care needs are met are less likely to miss school days

because of illness, school performance is multi -determined. These risk factors include
parental attitudes and beliefs, patterns of mother -child interaction, maternal education,
socioeconomic status , family social suppor t, family size, stressful life events, and the child’s
cognitive functioning. It was proved that t here are psychosocial factors which affect academic
outcomes as well as emotional development. Children exposed to these factors are at
heightened risk for em otional and behavioral problems and school failure. [34] Children in
homeless families experience a high rate of academic failure consistent with the need for
special education evaluation and services. [35]
Encopretic children are a particularly vulnerable social group, being exposed to social risks in
terms of losing their sense of belonging both to their own generation group and the entire
society, reaching a marginal position in society. Stigmatized by parents, peers, neighbor s and
society, encopretic pa tients have fragile personalities that need tolerance, intercommunication
and a lot of trust from other people. Several authors have reported finding poorer self -esteem
in children with en copres is. For example, Landman et al. observed that children with
encopresis had lower feelings of self -worth than children with other chronic physical
problems [36]. Owens -Stively , using the Piers -Harris Self -Concept Scale, found that children
with encopresis had lower self -esteem than a group of nonsymptomatic children [37]. The
most frequent changes encountered in our study included emotional distress, anxiety and
social adjustment difficulties . There was a high rate of somatization and behavioral disorders
in our group and their composition was largely heterogeneous . Literature data shows that the
association of encopresis with behavioral disorders has led to an unfavorable prognosi s of this
disorder . [38, 39] Levine et al. found that children with encopresis who did not respond to
treatment scored higher on antisocial -aggressive behaviors before treatment [40]. 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 depre ssion). Johnston and W right , 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 [41]. A number of studies have demonstrated
poorer soci al skills [42] and higher withdraw al behavior [40] in children with encopresis.
Some authors believe that in predisposing to and perpetuating encopresis, the approach of
toilet training and not the time of its initiation, seems to be the factor that matter s [43].
Regarding the psychological treatment, attention and behavior problems may be the target.
Treatment of these problems may increase treatment compliance and prevent conflicts that
may occur within the family in relation to these problems because a lot of studies pointed the
impact of child behavior related on family conflicts [44 -46]. On the other hand, familial
factors such as maternal depression and/or anxiety symptoms are associated with elimination
disorders at school age and including factors r elated to family functioning must be included in
the psychological intervention [47].
Our study has some limitations. Th is is a single center report and is limite d to children
addressed to our gastroenterology center. It is not clear whether the results would hold for a
nationally representative sample of childre n in Romania . Because the period covered by the
study was also relatively short, it is not clear whether the disparities between children of
paren ts with more or less education remain as children age and how they affect a larger set of
outcomes.
Our analysis leaves many questions for future research. The behavioral disorders noticed in
children with encopresis could be either a result of their excessive concern with
uncontrollable encopretic accide nts and the resulting social tension, or a result of some
developmental delays that could ultimately play a part in the development or persistence of
encopresis . Another critical question is the extent to which specific policies and programs can
help addre ss the observed deficits in terms of access to health services and for cognitive

development purposes , both for preschoolers and school -age. Future research is necessary in
this direction.

Conclusion s
The findings of this study allow to outline a profile of encopretic patients with respect to some
of the psychosocial factors involved in the multifactorial determinism of this disorder .
Educa ting parents on the association with somatization and behavioral disorders can lead to a
more effective diagnosis a nd a better response to treatment for children with constipation and
fecal incontinence . Screening for behavioral disorders in enco pretic patients could be useful
for their therapeutic management . A more aggressive treatment for constipation can be
justifi ed in these patients . In the cases that associate severe behavioral disorders, early
diagnosis and multidisciplinary therapeutic approach can be useful both for the child and
families.

Conflict of interest : The authors declare that there is no conflict of interes t
regarding the publication of this article.

References
1. Voskuijl WP, Heijmans J, Heijmans HS, et al. Use of Rome II criteria in childhood
defecation disorders: applicability in clinical and research practice. J Pediatr
2004;145: 213-217.
2. Loening -Baucke V, Cruikshank B, Savage C. Defecation dynamics and behavior
profiles in encopretic children. Pediatrics 1987;80:672 -679.
3. Benninga MA, Voskuijl WP, Akkerhuis GW, et al. Colonic transit times and
behaviour profiles in children with de fecation disorders. Arch Dis Child 2004;89:13 –
16.
4. Loening -Baucke V. Chronic constipation in children. Gastroenterology 1993;
105:1557 -1564.
5. Bernard -Bonnin A, Haley N, Belanger S, Nadeau D. Parental and patient perceptions
about encopresis and its treatment . J Dev Behav Pediatr 1993;14:397 -400.
6. Blum NJ, Taubman B, Nemeth N. During toilet training, constipation occurs before
stool toileting refusal. Pediatrics 2004;113:e520 -e522.
7. Cox DJ, Sutphen J, Borowitz S, et al. Contribution of behavior therapy and
biofe edback to laxative therapy in the treatment of pediatric encopresis. Ann Behav
Med 1998;20:70 -76.
8. Loening -Baucke V. Constipation in early childhood: patient characteristics, treatment,
and longterm follow up. Gut 1993;34:1400 -1404.
9. Ruben BD. Public percept ions of digestive health and disease: Survey findings and
communications implications. Pract Gastroenterol .1986;10:35 –42.
10. Trinkley KE, Porter K, Nahata MC. Prescribing patterns for the outpatient treatment of
constipation in the United States. Dig Dis Sci . 2010 Dec;55(12):3514 -20
11. Hunt R, Dhaliwal S, Tougas G, et al. Prevalence, impact and attitudes toward lower
gastrointestinal dysmotility and sensory symptoms and their treatment in Canada: A
descriptive study. Can J Gastroenterol . 2007 Jan;21(1):31 -7.
12. Johanson JF, Kralstein J. Chronic constipation: A survey of the patient
perspective. Aliment Pharmacol Ther . 2007 Mar 1;25(5):599 -608.
13. Sun SX, Dibonaventura M, Purayidathil FW, et al. Impact of chronic constipation on
health -related quality of life, work produ ctivity, and healthcare resource use: An
analysis of the National Health and Wellness Survey. Dig Dis Sci . 2011;56(9):2688 –
95

14. Belsey J, Greenfield S, Candy D, Geraint M. Impact of constipation on quality of life
in adults and children. Aliment Pharmacol Th er. 2010 May;31(9):938 -49.
15. Kalach N, Campeotto F , Arhan P et al.. Constipation fonctionnelle de l’enfant :
stratégie des explorations et orientations. Journal de Pédiatrie et de Puériculture –
2009;22:326 -336.
16. Montgomery F, Navarro F. Management of Con stipation and Encopresis in Children .
J Pediatr Health 2008 May -Jun;22(3):199 -204.
17. Van Wering H M, Tabbers M M, Benninga M A . Are constipation drugs effective and
safe to be used in children? A review of the literature . Expert Opin Drug Saf 2012 ;11
(1):71 -82
18. Achenbach, T. M. Manual for the Child Behavior Checklist/4 -18. 1991 Profile .
Burlington: University of Vermont, Department of Psychiatry.
19. Van der Wal MF , Benninga MA , Hirasing RA . The prevalence of encopresis in a
multicultural population. J Pediatr Gastroenterol Nutr. 2005 Mar;40(3):34 5-8
20. RE Roberts, CR Roberts, W Chan. One -year incidence of psychiatric disorders and
associated risk factors among adolescents in the community. Journal of Child
Psychology and Psychiatry. 2009;50:405 -415.
21. van Ginkel R, Reitsma JB, Büller HA, van Wijk MP, T aminiau JA, Benninga MA.
Childhood constipation: Longitudinal follow -up beyond puberty. Gastroenterology
2003;125:357 -63.
22. Brown, S.L., Family structure and child well -being: the significance of parental
cohabitation. Journal of Marriage and Family , 2004; 66, 351 -367.
23. Carlson, M.J., & Corcoran, M.E. Family structure and children’s behavioral and
cognitive outcomes. Journal of Marriage and Family , 2001 ; 63, 779 -792.
24. Scott -Jones, D. Family influences on cognitive development and school achievement”.
Review of R esearch in Education 1984; 11, 259 -304.
25. Antecol, H., & Bedard. K. Does single parenthood increase the probability of teenage
promiscuity, substance use and crime?” Journal of Population Economics 2007; 20,
55- 71.
26. McLanahan, S. S., & Sandefur, G. Growing up with a single parent: What hurts, what
helps. Cambridge, MA: Harvard University Press . (1994).
27. Amato, P.R. The consequences of divorce for adults and children. Journal of Marriage
and Family .2000; 62, 1269 – 1287.
28. Cavanagh, S. & Huston, A. Family instabili ty and children’s early problem behavior.
Social Forces . 2006; 85(1), 551 -581.
29. Osborne, C., Manning, W., & Smock, P. Married and cohabiting parents’ relationship
stability: A focus on race and ethnicity. Journal of Marriage and Family , 2004;
69(945 )
30. Nolan T, Debelle G, Oberkland F, Coffey C. Randomized trial of laxatives in
treatment of childhood encopresis . Lancet 1991 Aug 31;338(8766):523 -7
31. Rappaport L, Landman G, Fenton T, Levine MD. Locus of control as predictor of
compliance and outcome in treatment of encopresis. J Pediatr 1986 Dec;109(6):1061 –
4.
32. Hackett R, Hackett L, Bhakta P, Gowers S. Enuresis and encopresis in a south Indian
population of children. Child Care Health Dev 2001 Jan;27(1):35 -46
33. Stern, H. P., Lowitz, G. H., Prince, M. T., Altshuler, L, & Stroh, S. E.. The incidence
of cognitive dysfunction in an encopretic population in children. Neurotoxicology ,
1988 ; 9, 351-357.
34. PA Madrid, R Garfield, R Grant. Mental Health Services in Louisiana School -Based
Health Centers Post -Hurricanes Katrina and R ita, Professional Psychology: Research

and Practice. 2008; 39:45 -51.
35. BT Zima, R Bussing, SR Forness, B Benjamin. Sheltered homeless children: Their
eligibility and unmet need for special education services. American Journal of Public
Health. 1997;87:236 -240
36. Landman, G. B., Rappaport, L., Fenton, T., & Levine, M. D. Locus of control and self –
esteem in children with encopresis. Developmental and Behavioral Pediatrics ,
1986 ;7, 111-113.
37. Owens -Stively, J. A. Self -esteem and compliance in encopretic children. Child
Psychiatry and Human Development , 1987 ;18, 13 -21.
38. Taitz LS, Wales JK, Urwin OM, Molnar D. Factors associated with outcome in
management of defecation disorders Arch Dis Child 1986 May;61(5):472 -7
39. Young MH, Brennen LC, Baker RD, Baker SS. Functional en copresis: symptom
reduction and behavioral improvement. J Dev Behav Pediatr 1995 Aug;16(4):226 -32.
40. Levine, M. D., Mazonson, P., & Bakow, H. Behavioral symptom substitution in
children cured of encopresis. American Journal of Diseases of
Children , 1980 ;134, 663-667.
41. Johnston, B. D., & Wright, J. A. Attentional dysfunction in children with
encopresis. Developmental and Behavioral Pediatrics , 1993 ;14, 381 -385.
42. Gabel, S., Hegedus, A. M., Wald, A., Chandra, R., & Chiponis, D. Prevalence of
behavior problems and mental health utilization among encopretic children:
Implications for behavioral pediatrics. Developmental and Behavioral Pediatrics ,
1986 ; 7, 293-297.
43. Zaky E, Rashad M, Elsafoury H, Ismail E. Psychosocial profile of encopretic children
and their caregive rs in relation to parenting style. European Psychiatry . 2016 Mar
31;33:S362.
44. Joinson C, Heron J, Butler U. Psychological differences between children with and
without soiling problems. Pediatrics 2006; 117: 1575 -82.
45. Mellon, M. W., Natchev, B. E., Katusic, S. K., Colligan, R. C., Weaver, A. L., Voigt,
R. G., & Barbaresi, W. J. Incidence of enuresis and encopresis among children with
attention -deficit/hyperactivity disorder in a population -based birth cohort. Academic
pediatrics , 2013; 13(4), 322 -327.
46. Van Dijk , M., de Vries , G. J., Last, B. F., Benninga, M. A., & Grootenhuis, M. A..
Parental child -rearing attitudes are associated with functional constipation in
childhood. Archives of disease in childhood , 2015; 100(4), 329 -333.
47. Akdemir, D., Çengel Kültür, S. E., Saltık Temizel, İ. N., Zeki, A., & Șenses Dinç, G.
Familial psychological factors are associated with encopresis. Pediatrics
International , 2015; 57(1), 143 -148.