1. Background
Fecal incontinence (FI), also known as encopresis or soiling, is one of the common gastrointestinal problems in children. It indicates the passage of the stool in the underwear by children four years of age and older who have completed toilet training (1). Initially, FI was considered only for children with neurological disabilities, but further studies showed that approximately one to four percent of four-year-old children (2) and one to two percent of children aged ten to sixteen years old experienced FI (3). FI usually is related to underlying constipation. Constipation leads to hardening and build-up of stool in the colon resulting in leakage of stool. Therefore in most cases, constipation is well recognized before the child presents with FI (4).
Losing the control of fecal continence is a stressful condition for children and their parents. It negatively affects their quality of life (5, 6). Incontinence can lead to embarrassment for the child and disappointment for parents, so children with incontinence are at higher risk for psychological disorders (7). The effect of psychological factors on the development and persistence of fecal incontinence is debatable. Nevertheless, incontinence in children and adolescents with neurodevelopmental and psychological disorders is common and vice versa (8, 9). Treating incontinence can reduce the severity of psychological disorders (7). However, understanding the patients’ psychosocial status may provide clues as to whether there are psychosocial stressors that either exacerbate the problem or interfere with treatment (4).
The majority of the studies have focused on the prevalence of psychological comorbidities and problems in adults with FI. A population-based study in Australia showed that FI is associated with depression and anxiety in adults over 18 years old (10). Another study on 996 adult patients with functional gastrointestinal disorders showed that patients with FI had specific personality characteristics (11). The studies on children usually evaluated the comorbidity of specific psychological disorders such as attention‐deficit/hyperactivity disorder (ADHD) (12, 13), autism spectrum disorder (ASD) (14, 15), intellectual disability (ID) (16), and anxiety disorders (17) with FI. A few studies, especially in Iran, focused on emotional and behavioral problems in children with FI.
2. Objectives
This study aimed to assess the emotional, behavioral, and social problems in children with FI who were referred to the pediatric gastroenterology clinic at Mofid Children’s Hospital.
3. Methods
3.1. Study Design and Participants
This cross-sectional study was conducted at Mofid Children’s Hospital (Tehran, Iran) between April 2021 and April 2022. The study was approved by the Research Ethics Committee (REC) of the Shahid Beheshti University of Medical Sciences (IR.SBMU.MSP.REC.1397.654). Children over four years old with a diagnosis of chronic constipation and FI were included consecutively. The diagnosis of chronic constipation and FI were made according to Rome-IV criteria. All patients received standardized therapy for FI, depending on their clinical conditions. Subsequently, a pediatric psychiatrist evaluated the patients for emotional, behavioral, and social problems.
3.2. Measures
The emotional, behavioral, and social problems in patients were assessed with the Child Behavior Checklist (CBCL). The CBCL is a widely used parental questionnaire that contains 113 empirically derived behavioral items (18). It is subdivided into eight subscales, namely withdrawn/depressed, somatic complaints, anxious/depressed, rule-breaking behavior, social problems, thought problems, attention problems, and aggressive behavior. Also, the CBCL provides internalizing, externalizing, and total problems. Internalizing behaviors mirror mood problems, including anxiety, depression, and social withdrawal. Externalizing behaviors reflect the patient's oppositional and delinquent behaviors. The parents were requested to evaluate their child’s behavior on a 3-point Likert scale for each item (0 = not true; 1 = somewhat or sometimes true; 2 = very true or often true). According to the normative data of the CBCL, a t-score ≤ 59 indicates non-clinical symptoms, a t-score between 60 and 64 indicates that the child is at risk for problem behaviors, and a t-score ≥ 65 indicates clinical symptoms. The reliability and validity of CBCL is approved across different clinical groups (19-22).
3.3. Data Analysis
Statistical analyses were performed using IBM SPSS statistics ver. 23 (IBM. Armonk, NY, USA). Quantitative and qualitative variables were expressed as mean ± standard deviation and number (percent), respectively. The relationship between the CBCL scores (subscales and total) and gender was analyzed using the student t-test. Also, the relationship between the CBCL scores and age groups was analyzed using ANOVA. Statistical significance was presented when the P-value was less than 0.05.
4. Results
Of the 101 patients, 68 were males, and 33 were females, with a mean age of 7.96 years (3 - 15 years). Concerning the total problems of the CBCL, the results show that 88.12% (89 patients) of all participants obtained scores in the non-clinical range, 1.98% (one boy and one girl) were at risk, and 9.90% (10 boys) had clinical symptoms. According to the scores, we detected anxious/depressed problems in five (4.95%), withdrawn/depressed problems in eight (7.92%), somatic complaints in seven (6.93%), social problems in eight (7.92%), thought problems in nine (8.91%), attention problems in seven (6.93%), rule-breaking behavior in two (1.98%), and aggressive behavior in nine (8.91%) patients. All of them were in the at-risk or clinical range. Totally, 0.99% of patients under six years old, 7.92% of patients six to nine years old, and 2.97% of over 9-year-olds had emotional and behavioral problems. According to CBCL scores, four (3.96%) and five (4.95%) patients were at risk of internalizing and externalizing disorders, respectively. Also, eight (7.92%) and seven (6.93%) patients had clinical symptoms of internalizing and externalizing disorders, respectively (Table 1).
| Factors | Female (n = 33) | Male (n = 68) | ||||
|---|---|---|---|---|---|---|
| Age ≤ 6 | 6 < Age < 9 | Age ≥ 9 | Age ≤ 6 | 6 < Age < 9 | Age ≥ 9 | |
| Anxious/depressed | ||||||
| Non-clinical | 4 (12.12) | 17 (51.52) | 12 (36.36) | 22 (32.35) | 26 (38.24) | 15 (22.06) |
| At-risk | 0 | 0 | 0 | 0 | 0 | 0 |
| Clinical | 0 | 0 | 0 | 0 | 3 (4.41) | 2 (2.94) |
| Withdrawn/depressed | ||||||
| Non-clinical | 4 (12.12) | 16 (48.48) | 11 (33.31) | 22 (32.35) | 25 (36.77) | 15 (22.06) |
| At-risk | 0 | 1 (3.04) | 0 | 0 | 2 (2.94) | 1 (1.47) |
| Clinical | 0 | 0 | 1 (3.04) | 0 | 2 (2.94) | 1 (1.47) |
| Somatic complaints | ||||||
| Non-clinical | 3 (9.09) | 17 (51.52) | 11 (33.31) | 22 (32.35) | 25 (36.77) | 16 (23.53) |
| At-risk | 1 (3.04) | 0 | 1 (3.04) | 0 | 2 (2.94) | 0 |
| Clinical | 0 | 0 | 0 | 0 | 2 (2.94) | 1 (1.47) |
| Social problems | ||||||
| Non-clinical | 4 (12.12) | 17 (51.52) | 12 (36.36) | 21 (30.88) | 23 (33.83) | 16 (23.53) |
| At-risk | 0 | 0 | 0 | 1 (1.47) | 5 (7.35) | 1 (1.47) |
| Clinical | 0 | 0 | 0 | 0 | 1 (1.47) | 0 |
| Thought problems | ||||||
| Non-clinical | 4 (12.12) | 16 (48.48) | 12 (36.36) | 20 (30.1) | 25 (36.77) | 14 (20.10) |
| At-risk | 0 | 1 (3.04) | 0 | 1 (1.47) | 3 (4.41) | 1 (1.47) |
| Clinical | 0 | 0 | 0 | 1 (1.47) | 1 (1.47) | 1 (1.47) |
| Attention problems | ||||||
| Non-clinical | 4 (12.12) | 16 (48.48) | 11 (33.31) | 21 (30.88) | 25 (36.77) | 16 (23.53) |
| At-risk | 0 | 0 | 1 (3.04) | 0 | 2 (2.94) | 1 (1.47) |
| Clinical | 0 | 0 | 0 | 1 (1.47) | 2 (2.94) | 0 |
| Rule-breaking behavior | ||||||
| Non-clinical | 4 (12.12) | 17 (51.52) | 12 (36.36) | 22 (32.35) | 27 (37.71) | 17 (25.00) |
| At-risk | 0 | 0 | 0 | 0 | 2 (2.94) | 0 |
| Clinical | 0 | 0 | 0 | 0 | 0 | 0 |
| Aggressive behavior | ||||||
| Non-clinical | 4 (12.12) | 17 (51.52) | 12 (36.36) | 21 (30.88) | 22 (32.35) | 16 (23.53) |
| At-risk | 0 | 0 | 0 | 0 | 3 (4.41) | 0 |
| Clinical | 0 | 0 | 0 | 1 (1.47) | 4 (5.88) | 1 (1.47) |
| CBCL internalizing | ||||||
| Non-clinical | 4 (12.12) | 15 (45.45) | 10 (30.27) | 21 (30.88) | 24 (35.29) | 15 (22.07) |
| At-risk | 0 | 1 (3.04) | 1 (3.04) | 0 | 1 (1.47) | 1 (1.47) |
| Clinical | 0 | 1 (3.04) | 1 (3.04) | 1 (1.47) | 4 (5.88) | 1 (1.47) |
| CBCL externalizing | ||||||
| Non-clinical | 4 (12.12) | 15 (45.42) | 11 (33.31) | 21 (30.88) | 22 (32.35) | 16 (23.53) |
| At-risk | 0 | 1 (3.04) | 1 (3.04) | 0 | 3 (4.41) | 0 |
| Clinical | 0 | 1 (3.04) | 0 | 1 (1.47) | 4 (5.88) | 1 (1.47) |
| CBCL total | ||||||
| Non-clinical | 4 (12.12) | 16 (48.48) | 12 (36.36) | 21 (30.88) | 22 (32.35) | 14 (20.60) |
| At-risk | 0 | 1 (3.04) | 0 | 0 | 0 | 1 (1.47) |
| Clinical | 0 | 0 | 0 | 1 (1.47) | 7 (10.29) | 2 (2.94) |
Participants’ Emotional and Behavioral Status in CBCL Based on Gender and Age Group
There were no significant differences in CBCL scores between males and females for all subscales (Table 2).
| Factors | Female (n = 33) | Male (n = 68) | P-Value |
|---|---|---|---|
| Anxious/depressed | 48.59 ± 8.10 | 50.57 ± 10.77 | 0.15 |
| Withdrawn/depressed | 50.43 ± 9.62 | 49.90 ± 10.21 | 0.93 |
| Somatic complaints | 50.78 ± 10.66 | 49.62 ± 9.62 | 0.36 |
| Social problems | 48.36 ± 8.03 | 50.61 ± 10.74 | 0.29 |
| Thought problems | 49.42 ± 9.76 | 50.08 ± 10.15 | 0.74 |
| Attention problems | 48.78 ± 8.97 | 51.52 ± 10.43 | 0.96 |
| Delinquent behavior | 48.87 ± 5.75 | 50.49 ± 5.21 | 0.34 |
| Aggressive behavior | 47.36 ± 8.56 | 51.15 ± 10.41 | 0.36 |
| CBCL internalizing | 50.95(8.74) | 49.43(8.13) | 0.37 |
| CBCL externalizing | 48.57(6.40) | 50.85(8.57) | 0.12 |
| CBCL total | 48.49 ± 8.60 | 50.66 ± 10.54 | 0.53 |
Participants’ Degree of Emotional and Behavioral Problems Based on Gender
No statistically significant relationship existed between patients’ age groups and CBCL scores in any subscales (P > 0.05). However, there was a statistically significant difference in the total score among the age groups (Table 3).
| Factors | Age Groups | P-Value | ||
|---|---|---|---|---|
| Age ≤ 6 (n = 38) | 6 < Age < 9 (n = 35) | Age ≥ 9 (n = 28) | ||
| Anxious/depressed | 47.64 ± 8.95 | 53.66 ± 9.74 | 48.49 ± 10.76 | 0.19 |
| Withdrawn/depressed | 45.91 ± 7.10 | 52.67 ± 10.98 | 52.44 ± 10.48 | 0.24 |
| Somatic complaints | 47.28 ± 7.87 | 52.25 ± 10.95 | 50.78 ± 10.50 | 0.61 |
| Social problems | 47.28 ± 7.31 | 54.19 ± 10.80 | 48.16 ± 10.65 | 0.14 |
| Thought problems | 47.65 ± 9.54 | 52.01 ± 10.60 | 50.24 ± 9.51 | 0.56 |
| Attention problems | 46.13 ± 7.39 | 52.56 ± 10.94 | 52.02 ± 10.52 | 0.35 |
| Delinquent behavior | 49.37 ± 4.61 | 51.47 ± 6.37 | 48.99 ± 4.86 | 0.14 |
| Aggressive behavior | 48.99 ± 9.51 | 53.51 ± 10.46 | 46.96 ± 9.00 | 0.14 |
| CBCL internalizing | 47.87 ± 6.44 | 51.19 ± 8.92 | 50.14 ± 8.89 | 0.26 |
| CBCL externalizing | 50.25 ± 6.16 | 51.32 ± 7.93 | 47.69 ± 6.57 | 0.10 |
| CBCL total | 46.97 ± 8.16 | 54.01 ± 10.52 | 49.08 ± 10.23 | 0.04 |
Participants’ Degree of Emotional and Behavioral Problems Based on Age Group
5. Discussion
The first-line therapy for children with FI is intervention by medication(s) for alleviating the symptoms of constipation and incontinence. However, psychological disorders and behavioral problems are common in patients with FI that should be noticed. In connection therewith, this study focused on behavioral problems of children with FI. Our results demonstrate that out of the 101 examined patients, around 12% (12 patients) exhibited emotional and behavioral problems, with CBCL scores in the clinical or at-risk range. The externalizing and internalizing problems were observed almost equally in patients.
The prevalence of psychiatric symptoms and behavioral disorders in children with functional incontinence (including nocturnal enuresis, daytime urinary incontinence, and FI) varies in different studies. For example, Von Gontard et al. estimated the prevalence of psychological disturbances between 30 to 50 percent in children with FI (23). They used ICD-10 or Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV) as diagnostic criteria. Another study on children with functional incontinence reported that 41% of patients had clinically relevant psychological symptoms based on CBCL (5). Also, a study on 25 children with FI claimed that 44% (11/25) had behavioral problems and successful treatment of FI normalized their emotional processing (24). The reported prevalence of behavioral problems in our study was relatively high but significantly less than in previous studies. It could be due to differences in diagnostic criteria and population.
According to our findings, thought problems and aggressive behaviors were the most prevalent problems in children with FI. The CBCL thought problems subscale is clinically helpful in identifying psychotic symptoms in children (25). However, it should be noted that not all children who report unusual beliefs or concerning behavior to their parents will have a psychiatric disorder. Almost 17% of children (ages 9 - 12) experience psychotic-like beliefs or behaviors (26). A positive screen on any CBCL subscales does not guarantee a disorder diagnosis. It is only an alarm for the physician and psychiatrist to consider the child’s psychological well-being. The psychiatrists are usually cautious while interpreting the CBCL findings and rely on clinical examinations and other potential risk factors for valid diagnosis.
Withdrawal and social problems were other common problems we screened in children with FI. Children with FI usually show lower social functioning and self-esteem (27). Sometimes parents punish a child with FI because they think the child voluntarily does it. This reaction can worsen the patient’s psychological condition and eventually exacerbate FI. So, it is necessary that the psychiatrist or physician provides the required information to the parents and alert them about the nature of the problem. They should be prepared for a long-lasting treatment process. Additionally, children with FI may need psychological interventions such as counseling, psychotherapy, and pharmacotherapy based on the patient’s clinical examinations. It seems that the combined medical-behavioral treatment approach is more effective in treating children with FI (28, 29). A pilot study on children with FI who fail traditional outpatient treatment showed that group therapy (including sessions about the gastrointestinal system, medications, toilet sitting posture, hydration fiber, and behavior contracts) could improve the results (30). Also, another study in Iran revealed that a bowel management training program could be effective for treating FI and improving the quality of life in children (31).
The findings indicated that emotional and behavioral problems were more common in patients aged six to nine years. The incidence of the problems was much lower in patients under six years old. Similar findings were reported in a study on children with ASD by Guerrera et al. (21). The authors evidenced that there was a correlation between age and CBCL scores. It could be interpreted in light of the increasing social and environmental demands of children by aging. The younger patients have more limited social relationships, and the expectations of those around them are lower, so they experience fewer difficulties adjusting their behavior. According to national health statistics reports in the USA about behavioral problems in children, males were more likely to experience emotional and behavioral problems (32). In our study, there was no statistically significant relationship between the CBCL subscales and the total scores with the gender of patients. However, most patients with emotional and behavioral problems were male.
This study had some limitations. First, we had a small sample size in one center, which could affect our results. Also, our study was cross-sectional research without a controlled group. Therefore, we cannot provide a causal relationship between children’s emotional, behavioral, and social problems and FI. For that purpose, it is recommended to conduct a study including three groups: children in the clinical or at-risk range of CBCL, children with FI, and a control group.
5.1. Conclusions
The relatively high prevalence of emotional and behavioral problems in our study highlights the magnitude of the issue in children with FI and the need for better psychological screening and interventions. Screening patients using particular scales for evaluating their psychological well-being during treatment and advising parents to understand their child’s condition could promote the outputs.
