Objective Parenting factors are assumed to play a role in the development and maintenance of childhood constipation. However, knowledge about the association between parenting factors and childhood constipation is limited. This study investigates the association between parental child-rearing attitudes and prominent symptoms of functional constipation and assesses the strength of this association.
Design Cross-sectional data of 133 constipated children and their parents were collected.
Setting The gastrointestinal outpatient clinic at the Emma Children's Hospital in the Netherlands.
Patients Children with functional constipation aged 4–18 years referred by general practitioners, school doctors and paediatricians.
Main outcome measures Parental child-rearing attitudes were assessed by the Amsterdam version of the Parental Attitude Research Instrument (A-PARI). Symptoms of constipation in the child were assessed by a standardised interview. Negative binomial and logistic regression models were used to test the association between child-rearing attitudes and constipation symptoms.
Results Parental child-rearing attitudes are associated with defecation and faecal incontinence frequency. Higher and lower scores on the autonomy attitude scale were associated with decreased defecation frequency and increased faecal incontinence. High scores on the overprotection and self-pity attitude scales were associated with increased faecal incontinence. More and stronger associations were found for children aged ≥6 years than for younger children.
Conclusions Parental child-rearing attitudes are associated with functional constipation in children. Any parenting issues should be addressed during treatment of children with constipation. Referral to mental health services is needed when parenting difficulties hinder treatment or when the parent–child relationship is at risk.
Trial registration number ISRCTN2518556.
- Child Psychology
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What is already known on this topic?
The role of parents in the development and maintenance of functional constipation in childhood has long been acknowledged; however, research on this topic is limited.
Guidelines for childhood constipation recommend intensive support, education and explanation and a positive and non-accusatory approach to change negative parental attitudes.
What this study adds?
This study shows parenting factors and functional constipation in childhood are interdependent.
These data suggest that as the child grows older, the parent–child relationship becomes more complicated.
Any parenting issues should be addressed during the treatment of children with functional constipation.
Childhood constipation is often a major problem for the child and their family, and is characterised by painful infrequent bowel movements often in combination with faecal incontinence.1 The pathophysiological mechanisms underlying childhood constipation are multifactorial and poorly understood, and no specific organic cause can be found in 90% of patients.2 However, stool-withholding is probably the major cause of the development and persistence of childhood constipation.3–9 Children with functional constipation are primarily treated with oral laxatives in combination with toilet training in paediatric settings.10 Education and explanation are the first steps in treating functional constipation to change negative parental attitudes.11
The early literature on constipation and faecal incontinence always highlighted the role of family relationships and the personality of the parents.12–14 Nowadays, parenting factors are still assumed to play a role in the development and maintenance of childhood constipation.15–19 Recently, a large study showed a difference in personality between the mothers of children with and without functional constipation.20 The mothers of children with functional constipation were described as forceful, restrictive and orderly, which traits are suggested to result in resistance responses by the child. Parental child-rearing attitudes and the parent–child relationship have long been recognised as major contributors to a child's behavioural, emotional and cognitive development.21–26 Moreover, parental attitudes have been related to negative psychological outcomes in adulthood.27 However, knowledge about the association between parenting factors and childhood constipation is limited.
This study aimed to investigate whether there are associations between parental child-rearing attitudes and three prominent symptoms of functional constipation (defecation frequency, faecal incontinence frequency and passage of large amounts of stool), and to assess the strength of the associations.
Materials and methods
Participants and procedure
Between November 2002 and August 2004, all consecutive children with functional constipation aged 4–18 years referred by general practitioners, school doctors and paediatricians to our gastrointestinal tertiary outpatient clinic in the Netherlands were eligible for enrolment in this cross-sectional study.15 ,28
For assessment of constipation, children and parents were asked to record defecation frequency, faecal incontinence frequency and large amounts of stools in a diary for 1 week before their visit to the outpatient clinic, without laxatives. At the first visit, a standardised interview was conducted to assess clinical symptoms.29 An abdominal and rectal examination was also performed to evaluate the presence of faecal impaction. Children with at least two of the following four symptoms were classified as having paediatric functional constipation: defecation frequency <3 times per week, faecal incontinence episodes ≥2 per week, passage of large-diameter stools that may obstruct the toilet, or palpable abdominal or rectal mass on physical examination.30 Children with organic causes of constipation were not eligible for the study.
The parent who accompanied the child to the outpatient clinic was asked to fill out the questionnaire measuring child-rearing attitudes.
The medical ethics committee of the Academic Medical Centre of Amsterdam approved the study protocol. All patients and/or parents gave written informed consent.
Amsterdam version of the Parental Attitude Research Instrument
Parental attitudes toward child-rearing styles were assessed by the Amsterdam version of the Parental Attitude Research Instrument (A-PARI).31 The A-PARI is a shorter Dutch version of the popular PARI developed by Schaeffer and Bell32 that originally included 23 subscales. The reliability and validity of the original instrument, especially compared with other existing parental attitude instruments,21 have been investigated and shown to be acceptable.32 This also applies to the shortened Dutch version. Based on psychometric and validity criteria, 20 items were selected from the original version, resulting in four subscales.31 ,33
The extent to which parents agree with various child-rearing styles21 ,31 ,34 ,35 reveals their attitudes towards child rearing, which in turn influence their child-rearing practices and thereby the parent–child relationship.21 ,36
The A-PARI yields scores for four subscales. The Autocratic scale (5 items) measures the degree to which parents believe their child needs authority and strictness (eg, ‘A child will thank you later for their strict upbringing’). The Autonomy scale (6 items) refers to the importance of parents encouraging independence in their child (eg, ‘Children need to learn as soon as possible to do everything by themselves’). The Overprotection scale (4 items) assesses the degree to which parents want to prevent disappointment and problems for the child and to know what the child is thinking and feeling (eg, ‘I must try to prevent all small disappointments that may occur in my child's life’). A strong overprotective attitude can result in intrusive parenting (control of the child's psychological world). The Self-pity scale (5 items) refers to irritability and frustration regarding the upbringing of the child. A high score indicates that the parent feels the child is a burden and implies rejection of the child (eg, ‘Children always disappoint you’). Agreement with statements was rated on a four-point Likert scale ranging from 4 (completely agree) to 1 (completely disagree). Higher scores reflect higher agreement with the particular child-rearing attitude. The subscales show neither relation to gender, age, and marital status of the parents, nor to the number of children in the family.31
Clinical characteristics of childhood constipation
Information was collected with our standardised defecation questionnaire37 about clinical characteristics, including duration of treatment before attendance at our outpatient clinic, age at onset of constipation, family history of constipation, frequency of defecation and faecal incontinence, size of stool and associated clinical characteristics such as abdominal pain and painful defecation.
All data analyses were performed using STATA V.12.1. In three individual cases a single score was missing for separate A-PARI scales. For these cases, the average value of the remaining corresponding items was inputed.
We used regression models to examine the association between parental child-rearing attitudes and functional constipation. Because defecation and faecal incontinence episodes were counted over 1 week, count models were used to model these measures. Separate negative binomial regression models were fitted with the four A-PARI scales divided into three categories (divided at −1 SD (16th percentile) and +1 SD (84th percentile) and labelled as low, average and high) as predicting factors, and defecation frequency and faecal incontinence frequency as dependent variables. A logistic regression model was fitted with large amounts of stools as the outcome measure. All three regression models were adjusted for gender and age, and the average category (−1 SD to +1 SD) was used as the reference group.
Identical but separate regression analyses were carried out for two age groups (age <6 and ≥6 years). In younger children, fear of painful bowel movements is assumed to be the primary reason for constipation. However, in older children it is suggested that other prominent factors contribute to long-standing constipation and that the mechanisms by which constipation is perpetuated may be different, more complex and ingrained.38 No additional analyses were performed for large amount of stools, because only two-thirds of the children in this study had this symptom. Incidence rate ratios (IRR) were calculated as the measure of association between the predictor variables and the measures in the negative binomial regression analyses, while ORs were calculated as the measure of association in the logistic regression analysis. Adjusted rates and proportions were based on marginal means derived from the regression models. In all regression analyses, the robust or sandwich estimator of variance was used to derive SEs. A p value <0.05 was considered statistically significant.
Characteristics of the study sample
A total of 134 patients participated in the study. One A-PARI questionnaire was not filled out by parents, and so the baseline data of 133 children were used for analysis. Table 1 shows the study sample.
Results of the regression analyses are shown in table 2.
Children with parents having low or high autonomy scores had about half the defecation frequency of children with parents scoring in the reference group (table 2). Age was significantly associated with defecation frequency, with the number of bowel movements increasing by about 17% for each year increment in age (IRR 1.2, 95% CI 1.1 to 1.3, p<0.001).
In the regression model comprising only the younger children, none of the variables proved significant (all p>0.052). However, for the older children, the autonomy scale was significantly associated with defecation frequency: children with parents having high autonomy scores had considerably lower defecation frequency than children with parents scoring in the reference group (IRR 0.3, 95% CI 0.2 to 0.6, p<0.001). Children with parents having a low self-pity score defecated about half as much as children with parents in the reference group (IRR 0.5, 95% CI 0.3 to 0.8, p=0.010). The older the child, the more likely defecation frequency increased (IRR 1.2, 95% CI 1.1 to 1.4, p<0.001).
Faecal incontinence frequency
Children with parents having low autonomy scores had significant more faecal incontinence episodes compared with children with parents in the reference group, while children of parents having high scores on the autonomy scale also had more faecal incontinence (table 2). When parents scored high on the overprotective scale, children showed significantly higher faecal incontinence rates compared with the reference group. Children with parents having a high self-pity score had a higher frequency of faecal incontinence than children with parents in the reference group. Being a girl and increasing age were both associated with a decrease in the number of faecal incontinence episodes (IRR 0.6, 95% CI 0.4 to 0.8, p<0.001 and IRR 0.9, 95% CI 0.8 to 0.9, p<0.001, respectively).
For the younger group, it was found that children with parents having low scores on the autonomy scale had significantly more faecal incontinence episodes than those with parents in the reference group (29.1 vs 16.0 times per week, respectively; IRR 1.8, 95% CI 1.1 to 2.9, p=0.012). In the older group, children with parents having high scores on the autonomy scale showed more faecal incontinence than those with parents with average scores (IRR 2.3, 95% CI 1.4 to 3.6, p<0.001). Additionally, children with parents having high scores on the overprotection scale had a higher faecal incontinence rate (IRR 2.0, 95% CI 1.2 to 3.4, p=0.008). Girls showed less faecal incontinence than boys in both the younger and older group (IRR 0.5, 95% CI 0.3 to 0.8, all p<0.005). For the older children, faecal incontinence frequency decreased by about 12% with each year increment in age (IRR=0.9, 95% CI 0.8 to 1.0, p=0.026).
Large amounts of stool
Parental attitude was not found to be statistically significantly associated with large amounts of stools. Age increased the likelihood of large amounts of stools (OR 0.9, 95% CI 1.0 to 1.5, p=0.045).
This study investigated the association between parental child-rearing attitudes and functional constipation in childhood. Our results show that parental child-rearing attitudes are associated with defecation and faecal incontinence frequency. In addition, more and stronger associations were found for children aged ≥6 years than for younger children.
Our results show that both high and low scores on the autonomy scale are associated with less defecation and more faecal incontinence episodes. The strong magnitude of effect on this scale is not surprising as developmental theories emphasise the relationship between gaining autonomy and toileting issues/bodily functions.39 For younger children, low autonomy scores were associated with worse constipation outcomes, whereas for older children, a strong parental attitude towards encouraging independence was associated with worse constipation. Parenting young constipated children is undoubtedly challenging because of the greater stubbornness40 and difficult temperament18 ,41 ,42 of these children. For older children, it is suggested that constipation is part of a broader psychosocial developmental delay with specifically low striving towards autonomy that is maintained by the family environment.43 The ‘goodness-of-fit’ theory44 ,45 might be useful for understanding the opposing findings regarding the attitudes of parents of younger and older children towards autonomy. This interactional model suggests that a particular problem is the result of incompatibility between the individual and the environment. Inadequate adjustment of parents to the specific characteristics and needs of their constipated child may contribute to the maintenance of chronic constipation. Consequently, managing constipation needs to be approached differently in younger and older children by parents and maybe also by health professionals.
It was found that a strong overprotective attitude towards child rearing worsened the number of faecal incontinence episodes. Higher levels of overprotection were shown in parents of children with cancer, asthma,35 ,46 epilepsy,47 physical disabilities48 and atopic dermatitis.49 It is assumed that overprotection is an satisfactory coping mechanism for adjusting to the chronic disease of the child. In accordance with another study investigating parental child-rearing attitudes with the A-PARI in chronically ill children,46 high levels of overprotection and autonomy encouraging attitudes were found to co-occur. It is suggested that on the one hand, parents want to protect their chronically ill and vulnerable child, but on the other hand they want to empower their sick child. This parent–child relationship can be defined as parenting ‘with a double message’ and can lead to distress and behavioural problems in the child,50 which in constipated children may help perpetuate the condition.
Finally, a high score on the self-pity scale, referring to a high level of irritability and frustration with bringing up children, was also related to more episodes of faecal incontinence. For parents with a chronically constipated child, with most children having faecal accidents, over-reactions may arise around toileting.16 ,51 Before they seek help, many parents do not recognise faecal incontinence as a sign of constipation52 and may assume the child is soiling intentionally. A tendency to have negative attributions about their children's behaviour lowers the threshold for hostile reactions towards a child, resulting in power struggles53 or fear around toileting which subsequently may worsen the constipation. On the other hand, previous studies found a weak relationship between parenting stress54 and irritability18 and the development of toileting problems in children.
More and stronger associations were found for children aged ≥6 years. These results are in line with the literature on paediatric conditions suggesting that as children grow older, the parent–child relationship becomes more complicated due to conflicting interests.48 While the growing child strives for independence, the parents of a child with a chronic medical condition may unintentionally prevent the development of normal autonomy. They perceive their child as vulnerable and feel responsible for their health. The older children in this study likely have a long history of defecation problems which may result in a worse parent–child relationship. The question remains whether constipation leads to a problematic parent–child relationship or vice versa. We hypothesise that a dysfunctional parent–child relationship can cause constipation to develop into a chronic condition.
Some limitations of this study need to be addressed. This study specifically measured the child-rearing attitudes of parents, but these are only one of many factors determining actual child-rearing behaviour.21 ,55 There is generally a moderate association between parental attitudes and actual parenting practices,21 although this is still debated in the literature.24 ,25 ,36 Observing parenting behaviour and using the child as an informant can be helpful in assessing actual rearing behaviour. Still, attitude measurement is better than observing parenting behaviour because attitudes are generally more stable over time.55 While the total sample size may be considered quite large, in some instances the numbers of observations per category were rather low. This may have led to the inability to demonstrate statistical significance (type I error). Finally, given the cross-sectional nature of this study, causality cannot be determined and therefore we are unable to state whether specific child-rearing attitudes are risk factors for constipation developing in a child.
This study showed an association between parental child-rearing attitudes and childhood constipation. Although future studies are needed to further unravel the role of parents and the parent–child relationship, our findings make a substantial contribution to our understanding of the multiple factors involved in functional constipation in childhood. Because clinicians work with parents collaboratively to manage constipation,11 ,52 ,56 addressing parenting issues should be incorporated into treatment. Referral to mental health services is needed when parenting difficulties hinder treatment or when the parent–child relationship is at risk.
Funding This research was funded by grants from the Dutch Digestive Disease Foundation (SWO 02-16).
Competing interests None.
Ethics approval The medical ethics committee of the Academic Medical Center of Amsterdam approved this study.
Provenance and peer review Not commissioned; externally peer reviewed.
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