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a Department of Community Based Medicine, Unit of Perinatal and Paediatric Epidemiology, University of Bristol, Bristol, United Kingdom
b Sheffield Children's Trust, Sheffield, United Kingdom
c Department of Child and Adolescent Psychiatry, Saarland University Hospital, Homburg, Germany
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ABSTRACT |
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 TOP ABSTRACT METHODSRESULTSDISCUSSIONREFERENCES |
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METHODS. A total of 8242 children aged 7–8 years born to mothers in the United Kingdom–based Avon Longitudinal Study of Parents and Children were studied. Parents completed postal questionnaires assessing common childhood emotional and behavioral problems, and children were asked questions at a research clinic concerning their behavior, friendships, bullying, and self-esteem. The rate of psychological problems was compared in children who soil frequently (once a week or more), those who soil occasionally (less than once a week), and those with no soiling problems (controls). Analyses were adjusted for developmental delay, gender, sociodemographic background, and stressful life events.
RESULTS. Children who soil were reported by their parents to have significantly more emotional and behavioral problems compared with children who do not soil. Children who soil frequently had significantly more problems than those who soil occasionally. The rate of attention and activity problems, obsessions and compulsions, and oppositional behavior was particularly high in frequently soiling children. Children with soiling problems reported significantly higher rates of involvement in overt bullying (as both perpetrator and victim) and antisocial activities compared with controls.
CONCLUSIONS. The current study finds significantly higher rates of behavior and emotional problems, bullying, and antisocial activities in children who soil compared with those who do not soil. Children who soil frequently are more likely to have these problems than those who soil occasionally.
Key Words: child behavior • incontinence • encopresis • constipation • psychological impact
Abbreviations: DSM-IV—Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition • ALSPAC—Avon Longitudinal Study of Parents and Children • DAWBA—Development and Well-Being Assessment • SPPC—Self-Perception Profile for Children • WISC-III—Wechsler Intelligence Scale for Children III • SEN—special educational needs
Soiling is a common childhood problem presenting to pediatric, psychiatric, and psychological settings and has a significant impact on children's social and emotional functioning and on the family.1,2 Constipation is the underlying cause of soiling in 
80% of children.3,4 Currently, the Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition (DSM-IV)5 uses the term encopresis to describe fecal soiling, defining it as the repeated passage of feces in inappropriate places, with a frequency of at least once a month for 3 months in children aged 
4 years and in the absence of a physical cause. However, this definition has not been universally adopted, leading to wide variation in the reported prevalence figures for soiling (4.1% of children aged 5–6 years and 1.6% of children aged 11–12 years6; 1.5–7.5% of children aged 6–12 years7; and 2.4% of boys and 0.7% of girls aged 7 years8).
Psychological factors have often been implicated in the development of soiling. An early study reported that children who soil are more anxiety prone, less self-assured, less tolerant of demands, and less able to control aggression compared with control children.9 A recent population-based study reported that psychosocial problems were far more common among children who soil than among controls.6 The majority of studies, based on clinic samples, report an increased rate of behavior problems in children who soil compared with controls.10–16 Two studies report that the overall severity of behavior problems in children who soil is below that found in children referred to clinics for behavior problems.2,17 Self-esteem levels have also been investigated, with 2 studies reporting reduced self-esteem in children who soil compared with controls,18,19 whereas another found no difference between soiling and nonsoiling children.14
Overall, the results of previous studies provide evidence for an association between soiling and psychological problems (mostly behavior problems and reduced self-esteem). However, the generalizability of the findings is limited, because all but 16 of the studies are based on relatively small clinic samples, and some do not include a suitable comparison group of children without soiling problems (or include only a small control group). Another limitation is that most of the findings of previous studies are based on parental reports of psychological problems in their children. Only 3 studies have included reports from children (on self-esteem levels),14,18,19 but there are no studies asking children about problems with behavior, friendships, and bullying.
The present study, based on a population of >8000 children, is an investigation of the psychological problems associated with soiling in children aged 7.5 years. Based on reports from parents and children, the study compares the rate of problems with emotions, behavior, self-esteem, bullying, and friendships in children who soil compared with children who do not soil.
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METHODS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONREFERENCES |
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Measures
Parents (or Main Carer)
A self-report questionnaire, administered when children were 91 months of age, contained questions concerning how often the child usually soils during the day, with the following options: (1) never; (2) less than once a week; (3) approximately once a week; (4) 2 to 5 times a week; (5) nearly every day; and (6) more than once a day. Children who soiled were split into 2 groups: "frequent" (ie, those who soiled once a week or more) and "occasional" (ie, those who soiled less than once a week). Also included in the 91-month questionnaire was the Development and Well-Being Assessment (DAWBA),21 composed of questions relating to a number of common emotional and behavioral disorders in children occurring in the present and recent past.
Child
Children were invited to attend a clinic in which they were interviewed using the following schedules: (1) a modified version of the Bullying and Friendship Interview Schedule22 indicating whether or not the child had been a victim or perpetrator of overt (eg, name-calling and physical aggression) or relational bullying (eg, withdrawing friendship and spreading rumors); (2) 11 items from the Self-Reported Antisocial Behavior for Young Children Questionnaire23; (3) a reduced (12 item) version of Harter's Self-Perception Profile for Children (SPPC)24 composed of global self-worth (items 2, 4, 6, 8, 10, and 12) and scholastic competence subscales (items 1, 3, 5, 7, 9, and 11); and (4) 5 questions from the Cambridge Hormones and Moods Project Friendship Questionnaire25 to rate children's happiness with their friendships. Because of the sensitive nature of some of the questions, children were required to post their response in either a "yes" or "no" box. The interviewer could not see which box was chosen, and stressed that all of the answers would be confidential. Scores on the SPPC and the Friendship Questionnaire are continuous, but to aid comparison with the rest of the analyses, they were dichotomized so that children with the lowest scores on the SPPC (lowest self-esteem) and those with the highest scores on the Friendship Questionnaire (least happy with friendships) were in the top quartile.
Analysis
A 
2 test was used to compare the rate of DSM-IV psychiatric disorders derived from the DAWBA in children who soil (frequently or occasionally) and in a control group composed of children with no daytime soiling problems. The small numbers of children meeting DSM-IV criteria for psychiatric disorders in the ALSPAC study population (see Appendix 1) precluded a multivariable regression analysis. Because of the low rate of DSM-IV disorders in the current study, additional analyses were conducted using a set of dichotomous outcome variables derived from the lists of symptoms in the DAWBA relating to each psychiatric disorder. This permitted a more rigorous multivariable analysis of the association of soiling with emotional and behavior problems with adjustments for confounding variables. A description of how all of the outcome variables were derived from the lists of symptoms in the DAWBA, their prevalence in the study population, and the prevalence of the child-reported problems are provided in Appendices 1 and 2.
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In the multivariable models, missing data on confounding variables resulted in a loss of 10% of the sample when the fully adjusted models were derived. To correct for any bias in the final adjusted estimates because of dropout, a missing data imputation technique was used (missing imputation for chained equations27 using the procedure in Stata (Stata Corp, College Station, TX) known as "ice."28 Imputation was restricted to confounding variables (no imputation of the outcome or the soiling exposure variable was performed).
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RESULTS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONREFERENCES |
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There were 117 (1.4%) children who soiled in the day once a week or more (81 males, 36 females; age range: 91–105 months; median: 91 months). Another 448 (5.4%) children soiled in the day less than once a week (287 males, 161 females; age range: 91–108 months; median: 91 months). The control group consisted of 7673 children with no soiling problems (3868 males, 3805 females; age range: 90–111 months; median: 91 months). Males comprised significantly more of the group that had soiling problems (2 = 46.65; P < .001).
Of the original cohort, 6162 with information on level of soiling attended the 8-year clinic for the child assessment including 5741 (74.8%) of the children with no soiling problems, 340 (75.9%) of those with occasional soiling problems, and 81 (69.2%) of those with frequent soiling problems. There is no evidence to suggest a difference in clinic attendance within the soiling group (2 = 2.21; P = .331).
There were 276 children who were classified as having developmental delay, either by having a WISC-III IQ < 70 or by having been issued with a statement of special educational needs (SEN). WISC-III IQ was assessed in the 8-year clinic, and a full measure was only available for 5542 of the 8242 children in the study sample, and so the statement of SEN was used as proxy to highlight children without a WISC-III measurement. For the children with both indicators, children with an SEN were, on average, 21 points lower in WISC-III IQ, suggesting that SEN is a suitable proxy for developmental delay in this sample. Of the children who soil frequently, 24 (20.5%) fit the criteria for developmental delay compared with 31 (6.9%) of children who soil occasionally and 221 (2.9%) of the children with no soiling problems (2 = 129.3; P < .001).
Table 1 shows the results of the 2 tests comparing the rates of DSM-IV psychiatric disorders derived from the DAWBA in children who soil (frequently or occasionally) compared with those with no soiling problems. Many of the cells were sparse, and, hence, little can be concluded with any confidence from these figures. Table 2 shows the rate of emotional and behavioral problems reported by parents (from the symptom-based dichotomous outcome variables derived from the DAWBA) and child-reported problems (from the clinic-based assessments) in children who soil (frequently or occasionally) and in children with no soiling problems.
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Table 3 shows the odds ratios and 95% confidence intervals for the analyses with the parent-reported measures derived from the DAWBA, as well as the results from the clinic-based assessment of the children. The unadjusted model indicates the odds ratios associated with each psychological problem for children who soil (frequent or occasional) compared with controls, with no adjustment for the effects of confounding variables. The other columns indicate the odds ratios after adjusting for developmental delay (adjusted 1) and then further adjusting for gender, sociodemographic background, and stressful life events (adjusted 2).
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In the unadjusted models for the child-reported measures (Table 3), the odds of being a perpetrator or a victim of overt bullying and engaging in antisocial activities were significantly greater in children who soil compared with controls. In the final adjusted models, the effect of most confounders on the estimates was negligible with the exception of the overt bullying variables (bully and victim) and antisocial activities where adjustment for gender resulted in a small reduction in the odds ratios (these problems were more common in boys irrespective of soiling).
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DISCUSSION |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONREFERENCES |
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8000 children, was an investigation into the psychological problems associated with soiling. The findings are important, not only because they show a significantly higher rate of emotional and behavioral problems reported by parents of children with soiling problems compared with those without, but also because there were significantly more problems in children who soil frequently (once a week or more) compared with those who soil occasionally (less than once a week). Particularly striking were the significantly higher rates of attention and activity problems, obsessions and compulsions, and oppositional behavior reported by parents of children who soil frequently compared with those who soil occasionally. The only other population-based study of psychological problems in children who soil, although not using standardized questionnaires, also reported significantly higher rates of emotional and behavioral problems in children who soil.6 These results provide evidence for an association between soiling and psychological problems, even in nonclinical samples. In comparison to previous studies of childhood soiling, which are mainly based on parental reports of psychological problems, the current study also included reports from children about bullying, behavior, self-esteem, and friendships. In particular, this is the first study in which children who soil are significantly more likely to report being victims or perpetrators of overt bullying behaviors (eg, name-calling and physical aggression) and antisocial activities (eg, aggression toward people and animals and destruction of property) than children with no soiling problems. The increased rates of bullying and antisocial activities reported by children who soil concur with the parental reports of oppositional and conduct problems, because these behaviors are often related.
Children were also asked questions about self-esteem in the current study, but there was no strong evidence for reduced self-esteem in children who soil compared with children with no soiling problems (global self-worth scores were slightly reduced in soiling compared with nonsoiling children). Previous studies comparing children's reports of self-esteem levels have either found reduced self-esteem in those who soil18,19 or no difference in self-esteem level.14 These equivocal findings may be because of the self-report measure used or because of a tendency for children to deny experiencing problems or to underestimate their severity in self-reports.14 However, the way in which children in this study were asked sensitive questions in the interview (by posting their responses in either a yes or no box that the interviewer could not see) should have helped to minimize any such problems.
Overall, there were fewer significant group differences between the soiling and nonsoiling groups on the measures reported by the children compared with those reported by parents. It is possible that the findings were compounded by a bias in parental rating, with parents of children who soil viewing their children more negatively, perhaps because of the unpleasant nature of the problem or the belief that the soiling is intentional.15 Another possible explanation for the difference in the rate of problems reported by parents and children is that parents were asked about different issues (emotional and behavioral problems) compared with children (bullying, friendships, and self-esteem), which may imply that children with soiling have distinct psychological problems.
It is well known that children with developmental delay are at heightened risk for behavior problems and mental disorder.29,30 In the current study, adjusting for developmental delay led to a reduction in the odds ratios for the parent-reported psychological problems, with the largest reductions found for social fears, obsessions/compulsions, attention and activity problems, and oppositional behavior. However, even after adjusting for developmental delay, the association of these problems with soiling remained highly significant.
As in other population-based studies, the rate of soiling was significantly more common in boys than girls.6,9,31–33 In addition, there was also an association between soiling and having highly stressful life events. As a consequence, there were modest reductions in the regression estimates for soiling after adjusting for these variables.
Adjusting for the effect of confounding variables relating to sociodemographic status had a negligible effect on the relationship between soiling and psychological problems in this study suggesting that these variables do not represent underlying risk factors for psychological problems in the study population. This is in agreement with a recent population-based study reporting that differences in behavioral and emotional problems between soiling and nonsoiling children remained even after correction for sociodemographic factors.6
The majority of studies of psychological problems in children who soil have included only a very small number of children with nonretentive soiling (where there is no evidence of constipation) compared with those with retentive soiling (where there is evidence of constipation). Only 2 studies compare children with retentive and nonretentive soiling, and they report no difference in the rate of behavior problems between the 2 groups.10,13 Comparison of retentive and nonretentive types of soiling was not possible in the present study because of a number of concerns with the constipation measure that was used. These concerns were mostly because of the fact that the constipation measure was not based on clinical assessment but on parental reports of whether or not their child had suffered from constipation in the past 12 months. This may have resulted in the low rate of constipation found in children who soil the present study (19.4% of those soiling less that once a week, 31.3% of those soiling once a week, and 46.4% of those soiling twice a week or more). It is possible that parents of children who soil in the present study underreported the presence of constipation, because, unless the child has seen a health professional for their soiling problem, parents might be unaware that the child is constipated. However only a small proportion of children see a doctor for soiling problems,6 and this is possibly because parents are unaware that soiling is a condition for which they could seek medical advice.
There are also potential weaknesses associated with the parent-reported measure of soiling used in the current study. First of all, there is no information on the quantity of feces lost in the underwear. Some parents included a note in the questionnaire to clarify their response to the soiling question, for example, child has soiled his/her pants only because of diarrhea or pants were soiled because of insufficient cleaning after defecation. It was reassuring to see that in cases such as these, parents did not place their children in the soiling category.
The fact that parents in the present study were not asked about the duration of soiling is another potential weakness of the soiling measure. According to DSM-IV5 and the Rome II criteria,34 soiling should be present for 3 or 2 months as published in a recent article.35 However, rates of soiling measured at a previous time point in the ALSPAC data suggest that soiling is a persistent problem in these children (of the children who were soiling at 91 months, 83.2% of those soiling once a week or more, and 54.5% of those soiling less than once a week were also reported to be soiling at 78 months).
Another weakness of the study is that the small numbers of children who met DSM-IV criteria for psychiatric disorders prevented an adequate multivariable statistical analysis using the proper diagnoses derived from the DAWBA. Instead, the study compared children on the rate of symptoms of behavioral and emotional disorders. Although this had the advantage of permitting a more rigorous multivariable statistical analysis, the impact of the symptoms in terms of resultant distress and interference with family life, learning, friendships, and leisure activities was not considered. The fact that children can have symptoms of disorders but are not necessarily significantly impaired by them means that the rate of parent-reported psychological problems may have been overestimated in the present study. However, in deriving the dichotomous outcome variables based on reported symptoms of psychiatric disorders, only the children with the most "severe" symptoms (children who were reported to have suffered from the symptoms the most often or a lot more than others of the same age) were included in the group with emotional or behavioral problems.
It is also possible that, in the present study, symptom categories may not be independent and that the psychological problems identified in children who soil are indicators of comorbid psychiatric disorders. For example, attention and activity problems and oppositional behavior often occur together, as do anxiety and depression. In the present study, there was some overlap between domains in the DAWBA, but of the children who were reported to have behavioral or emotional problems, many (70%) had symptoms in only 1 domain.
There is also a potential difficulty associated with the DAWBA being given as a self-report questionnaire in that parents might mistake symptoms of 1 disorder for another. However, the lists of symptoms in the DAWBA that were used to derive the dichotomous outcome variables for the current study were composed of closed questions, for example, "Has he/she ever worried about sleeping alone?" and "Is he scared of dentists or doctors?" Such a format means that there is minimal opportunity for misinterpretation.
Another potential weakness of the study is that there was differential attrition in the cohort, with the subsample of the ALSPAC families who responded to the questionnaire and the subsample of children attending for follow-up at age 8 being more socially advantaged than those who defaulted. However, there does not seem to be a relationship between dropout and soiling, and controlling for sociodemographic variables had only a negligible effect on the regression estimates. Because sociodemographic variables are good predictors of attrition, this would lead us to infer that there is not a great deal of bias present in our final adjusted models and that the results can be generalized to the ALSPAC population as a whole.
As with all cross-sectional studies, it is unclear whether the psychological problems found in the present study are a cause or a consequence of soiling. Early studies suggest that emotional and behavior problems are a primary cause,36,37 whereas other approaches view behavior problems as secondary to soiling.38 In the majority of children, it is hypothesized that childhood constipation is the result of a painful experience, such as the passage of hard stools.39 The presence of significant behavior problems in children who soil does not necessarily mean that a child should be treated in a psychiatric setting. Successful treatment in a pediatric setting often results in a resolution or reduction of behavioral difficulties and other psychological problems.15,40,41
There is likely to be a complex interrelationship of biological, dietary, neurologic, psychological, and genetic factors involved in causal mechanisms related to soiling. Future plans include longitudinal studies looking at the association between soiling and the development of psychological problems, particularly in relation to toilet training, parental child-rearing practices, child's temperament, and early stresses, and to determine the interaction of these factors in the persistence of a child's incontinence.
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ACKNOWLEDGMENTS |
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We are extremely grateful to all the families who participate in ALSPAC and to the midwives for their cooperation and help in recruitment. The whole ALSPAC study team comprises interviewers, computer technicians, laboratory technicians, clerical workers, research scientists, managers, and volunteers who continue to make the study possible.
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FOOTNOTES |
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Address correspondence to Carol Joinson, PhD, Avon Longitudinal Study of Parents and Children, Department of Community Based Medicine, Unit of Perinatal and Paediatric Epidemiology, 24 Tyndall Ave, Bristol BS8 1TQ, United Kingdom. E-mail: carol.joinson{at}bristol.ac.uk
The authors have indicated they have no financial relationships relevant to this article to disclose.
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REFERENCES |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONREFERENCES |
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This article has been cited by other articles:
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  C. Joinson, J. Heron, A. von Gontard, U. Butler, J. Golding, and A. Emond Early Childhood Risk Factors Associated with Daytime Wetting and Soiling in School-age Children J. Pediatr. Psychol., August 1, 2008; 33(7): 739 - 750. [Abstract] [Full Text] [PDF]
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 C. Joinson, J. Heron, A. von Gontard, and and the ALSPAC Study Team Psychological Problems in Children With Daytime Wetting Pediatrics, November 1, 2006; 118(5): 1985 - 1993. [Abstract] [Full Text] [PDF]
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