Article Text


Psychological maladjustment and quality of life in adolescents with constipation
  1. Nishadi Ranasinghe1,
  2. Niranga Manjuri Devanarayana2,
  3. Marc Alexander Benninga3,
  4. Marieke van Dijk4,
  5. Shaman Rajindrajith5
  1. 1Department of Paediatrics, District General Hospital Killinochchi, Kilinochchi, Sri Lanka
  2. 2Department of Physiology, Faculty of Medicine, University of Kelaniya, Ragama, Sri Lanka
  3. 3Department of Pediatric Gastroenterology and Nutrition, Emma Children's Hospital, Academic Medical Centre, Amsterdam, The Netherlands
  4. 4Psychosocial Department and Department of Pediatric Gastroenterology and Nutrition, Emma Children's Hospital, Academic Medical Center, Amsterdam, The Netherlands
  5. 5Department of Pediatrics, Faculty of Medicine, University of Kelaniya, Ragama, Sri Lanka
  1. Correspondence to Dr Shaman Rajindrajith, Department of Pediatrics, Faculty of Medicine, University of Kelaniya, Thalagolla Road, Ragama 11010, Sri Lanka; shamanr0{at}


Objectives To assess psychological maladjustment in adolescents with functional constipation.

Study design We conducted a cross-sectional survey in five schools. Adolescents aged between 13 and 18 years were included in the study. Validated questionnaires were used to collect bowel habits and demographic data, health-related quality of life (HRQoL) and psychological maladjustment. Rome III criteria were used to diagnose constipation.

Results 1697 adolescents were recruited (boys 779 (45.9%), mean age 15.06 years and SD 1.6 years). Prevalence of constipation was 6.7%, of whom 52 were boys (45.6%) and 62 were girls (54.4%). 38 adolescents (33.3%) with constipation and 230 controls (14.5%) had significant psychological maladjustment. Among seven different personality dimensions used to assess psychological maladjustment, children with constipation had significantly more deficits than controls in hostility and aggression (14.2 vs 12.6 in controls (mean difference 1.54, 95% CI (0.89 to 2.19) p<0.001), negative self-esteem (12.0 vs 10.5 in controls, mean difference 1.54 95% CI (0.96 to 2.06) p<0.001), negative self-adequacy (11.9 vs 9.8 controls, mean difference 2.07 95% CI (1.46 to 2.67) p<0.001), emotional unresponsiveness (12.9 vs 11.5 controls, mean difference 1.44 95% CI (0.84 to 2.04) p<0.001), emotional instability (17.1 vs 15.6, mean difference 1.53 95% CI (0.86 to 2.2) p<0.001) and negative world view (12.1 vs 10.2 controls, mean difference 1.91 95% CI (1.24 to 2.59) p<0.001). The total HRQoL of adolescents with constipation was lower than controls (70.6 vs 79.0 mean difference 9.48 95% CI (1.4 to 6.7) p<0.05).

Conclusion A significant proportion of children with constipation are suffering from psychological maladjustment.

  • Adolescent Health
  • Gastroenterology

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What is already known on this topic?

  • Psychological maladjustment is a common problem in children with chronic diseases.

  • Although children with constipation have poor health-related quality of life (HRQoL), its relationship with psychological maladjustment is not known.

What this study adds?

  • Children with chronic constipation have significant psychological maladjustment.

  • They show personality traits such as aggression, dependency, poor self-esteem, self-inadequacy, emotional unresponsiveness, emotional instability and negative world view.

  • Psychological maladjustment has a significant negative impact on HRQoL of children with chronic constipation.


Constipation in children is a widespread health problem in the world and has significant repercussions on individuals and healthcare systems.1–4 Several studies have proved that children with constipation have poor health-related quality of life (HRQoL).5–7

The aetiology of childhood constipation is not well understood. Although several possible mechanisms have been suggested, psychological disturbances have been in the forefront of it. Stress related to home, school, civil unrest and child maltreatment are known to be associated with childhood constipation.8–10 Also, children with constipation tend to have more anxiety disorders.11 It has been shown that anxiety was associated with a 184% increase in total medical cost and 348% of inpatient cost compared with depression that had a 97% increase in total medical cost.2

Psychological maladjustment (individual's inability to react successfully and satisfactorily to the demands of one’s environment) is a common psychological morbidity in children. Studies have shown that a fair number of children exposed to traumatic life events and chronic diseases are psychologically maladjusted.12–14 However, the relationship between psychological maladjustment and functional gastrointestinal diseases such as constipation in adolescents and the relationship between psychological maladjustment and HRQoL have not been assessed previously.

We hypothesised that adolescents with constipation have a higher tendency to have psychological maladjustment and have poorer HRQoL. Therefore, the aim of this study is to assess psychological maladjustment in adolescents with functional constipation (FC) and its association with HRQoL.

Patients and methods

Schools and the sample

We conducted this survey in the Ampare District of Sri Lanka. It is a rural district situated in the Eastern Province of the country. Five mixed schools were randomly selected from the list of schools of the district. Adolescents aged between 13 and 18 years were included in the study.

Preparation and consent of school authorities

We visited all schools that were selected at the planning stage. Permission for inclusion of the given school was obtained from relevant zonal educational director's office and school principals. The questionnaires used in the study were discussed with the school authorities and approval was obtained. Teachers were in agreement that the questionnaires were appropriate to use in the selected age group.

Data collection

We visited each selected school to explain the purpose of the study and handed over the information sheet and consent forms to be taken home. Parents were requested to read the information sheet and give the consent to include their children in the study. Adolescents were requested to bring back the completed consent form. All consent forms were checked and those who received written informed consent from parents to participate were included in the study. Furthermore, assent was taken from all participants of the study before filling the questionnaire.

Questionnaires were answered by the students in their classroom. The classrooms were rearranged in such a manner that students could not see questionnaires of the others. There were two research assistants in a classroom to help students during data collection and to clarify doubts. A brief physical examination was conducted to rule our major organic diseases and disabilities among participants.

Instruments of data collection

Following questionnaires were used for collection of data. All data collection tools were previously used in studies in Sri Lankan children/adolescents.

  1. Questionnaire on childhood functional gastrointestinal diseases:

    This questionnaire was based on the Rome III diagnostic questionnaire for paediatric functional gastrointestinal diseases.15 This questionnaire has been previously translated into native languages and undergone validation.

  2. Childhood personality assessment questionnaire (Child PAQ):

    The PAQ is a self-administered instrument to assess psychological maladjustment. It assesses an individual's perception of himself or herself with respect to seven behavioural dispositions (hostility and aggression, dependency, negative self-esteem, negative self-adequacy, emotional unresponsiveness, emotional instability and negative world view).16

    The Child PAQ has six items for each of the seven behavioural dispositions. All 42 items are arranged in a cyclical order. The Child PAQ asks respondents to reflect on their true, rather than their ideal or wished feelings about themselves. The response options available are as follows: (1) almost always true of me; (2) sometimes true of me; (3) rarely true of me and (4) almost never true of me. The child was asked to indicate how he or she really feels in response to each of the items and to tick the appropriate response option. By summing the scores of each of the seven scales, an overall assessment of the level of personality development of the respondent can be made. Higher total scores reflect poorer personality developments. Scores at or above 105 are reported to indicate problems in personality development.16 Cronbach's coefficient α was used as the principal measure of the instrument's reliability. A meta-analysis of the instrument involving nine studies revealed a full-scale mean α of 0.83, allowing for the full-scale's confident use in research, clinical and applied settings.17

    The Sinhala version was developed using internationally accepted translation namely back-translation method. The content validity and consensual-related validity are in the acceptable ranges for the PAQ. There is a good agreement between the clinician's rating and the PAQ including the cut-off scores.16

  3. HRQoL inventory (PedsQL):

    PedsQL is a tool used to assess HRQoL in children. We used the Quality of Life Inventory of teenagers from 13 to 18 years.18 It is a self-reported questionnaire and has been validated for the relevant age group. We obtained the translated and validated version of the Sinhala questionnaire from the MAPI institute with permission to use it for this particular research. The inventory has 23 items and encompasses physical (8 items), emotional (5 items), social (5 items) and school functioning (5 items). A 5-point response scale is used (0=never a problem; 4=almost always a problem). Items were reverse-scored and linearly transformed to a 0 to 100 scale (0=100, 1=75, 2=50, 3=25, 4=0) with higher scores indicating better HRQoL. Final HRQoL scores were computed out of 100.


FC was diagnosed by using the Rome III criteria for functional gastrointestinal diseases in children/adolescents.19

Statistical analysis

The sample size was determined using Epi Info V.6.04–1996 (Centers for Disease Control and Prevention, Atlanta, Georgia, USA, and WHO, Geneva, Switzerland). In previous studies the prevalence of FC in Sri Lanka ranged from 7% to 15%.1 ,5 Therefore, we considered that the prevalence of FC is 10%. Prevalence of psychological maladjustment in children in Sri Lankan school children is not known. Therefore, we assumed that 15% of normal children and 25% of children with constipation have psychological maladjustment. We used two sample proportion tests to calculate the sample size, at power of 80% and 0.05 significance level. Based on those parameters the minimum sample size was 1460.

χ2 test and Z test were performed using EpiInfo. Scores obtained for HRQoL and PAQ were compared using unpaired t-test. Pearson correlation coefficient was used to correlate scores obtained for HRQoL and PAQ. A p value of <0.05 was considered as significant.

Ethical approval

Ethical Review Committee of the Faculty of Medicine, University of Colombo, Sri Lanka, approved the study protocol.


Demographic data and prevalence of FC

In the five schools that were selected, there were 1750 adolescents aged between 13 and 18 years. Of them, 1697 adolescents (97%) had given sufficient data in the questionnaires to diagnose or exclude functional gastrointestinal disorders and therefore were included in the final analysis. The mean age of the sample was 15.06 years (SD 1.6 years) with 779 of the adolescents (45.9%) being boys.

A total of 114 children (6.7%) fulfilled the Rome III criteria for FC. Clinical features of children with constipation are given in table 1. There were 52 boys (45.6%) and 62 girls (54.4%). There was no statistically significant difference between the prevalence of constipation between boys and girls (p>0.05). The other 1583 adolescents without constipation served as controls.

Table 1

Clinical features of children with constipation

Psychological maladjustment

Thirty-eight children (33.3%) with constipation and 230 controls (14.5%) had a total personality score above the international cut-off value (105) indicating psychological maladjustment (OR 2.94, 95% CI 1.95 to 4.45, p<0.0001, χ2 test). Table 2 illustrates the scores obtained for the different individual personality traits. According to the data, except for dependency, adolescents with constipation had significantly higher scores for each personality types compared with controls.

Table 2

Scores obtained for different personality types that indicate psychological maladjustment in children with constipation

Table 3 compares the scores obtained for personality traits and HRQoL in children with constipation according to the presence of faecal incontinence. Scores obtained for the personality traits (except for dependency and emotional instability) were higher in children with constipation associated faecal incontinence, but none of these were statistically significant (p>0.05).

Table 3

Scores obtained for different personality types and quality of life in children with constipation according to the presence of faecal incontinence (FI)

HRQoL scores of children with constipation

Figure 1 shows the HRQoL score of adolescents with constipation and controls. Adolescents with constipation have lower scores for all four domains of HRQoL compared with controls (p<0.05). When scores obtained for HRQoL in children with constipation were compared, constipated children with faecal incontinence had lower HRQoL scores than those without faecal incontinence (p<0.05) (table 3).

Figure 1

Health-related quality of life (HRQoL) of children with constipation is shown; *p<0.05 two-tailed t-test.

Figure 2 graphically illustrates the correlation between personality scores and the total HRQoL scores. There was a negative correlation between the total personality maladjustment score and total HRQoL score (r=−0.49, 95% CI −0.61 to −0.35, p<0.0001).

Figure 2

Correlation between total health-related quality of life (HRQoL) score and total personality score is shown (r=−0.49, 95% CI −0.61 to −0.35, p<0.0001).


This study demonstrates a significant association between psychological maladjustment and FC in teenagers. They also have poor HRQoL for all domains of quality of life. In addition, among children with constipation, severity of psychological maladjustment had a negative impact on HRQoL.

In a series of previous studies, we have shown the burden of childhood constipation in Sri Lanka. The prevalence of childhood constipation varies from 4.2% to 15.4% in various parts of this island.5 ,20–22 In this study, we noted a prevalence rate of 6.7%, which is in alignment with our previous data. These percentages are lower compared with the prevalence rates of our Asian neighbours such as Hong Kong and Taiwan, where nearly one-third of the children are reported to be suffering from chronic constipation according to similar criteria.23 ,24 More recent data from the South America also indicate that FC is a significant burden in this area as well and falling into the range that we noted in our previous studies. Prevalence of FC in Panama, Colombia, Ecuador and El Salvador is 15.9%, 13%, 11.8% and 10%, respectively.25–28 In the USA, Lewis et al29 noted that 12.9% of young children are suffering from chronic constipation. In Turkey, the prevalence of constipation in children was found to be 4.7%.30 These figures indicate that constipation is an emerging gastroenterological problem across the world.

We evaluated the degree of psychological maladjustment of teenagers with constipation using the PAQ. According to our data, children with constipation have abnormal personality dimensions compared with their peer healthy controls, indicating a significant psychological maladjustment. Children with constipation were found to be more aggressive and hostile, have a negative self-esteem and have feelings of inadequacy. The scores also illustrate that these children have emotional problems such as emotional unresponsiveness and instability. In addition, they also have a negative view about themselves and the world. One-third of children with constipation had a higher total score for PAQ than the normative value, indicating a significant psychological maladjustment. This finding shows a significant association between constipation and psychological maladjustment in teenagers.

On one hand, it is possible that symptoms and suffering from constipation lead to psychological maladjustment. For example, children with constipation-associated faecal incontinence are likely to have significant negative self-esteem as they are more prone to be bullied in schools by their peers.31 ,32 When compared with children with constipation alone, scores obtained for psychological maladjustment and most of the personality traits were higher in children with constipation-associated faecal incontinence but the differences were not significant. This lack of significance may be due to small number of children with constipation-associated faecal incontinence in our sample. Furthermore, they also may have feelings of incompetency because of their inability to open up bowel, which feels as a loss of control of their bodily function. On the other hand, psychological maladjustment may be premorbid condition and can be the fertile ground in which constipation can develop into a chronic, severe problem by influencing the function of the brain-gut axis. Further studies are needed to clarify these speculations.

Previous studies have shown that children faced with victimisation and all forms of abuse have significant psychological maladjustment.12 ,33 In addition, researchers have noticed that children with chronic diseases such as bronchial asthma and repaired congenital heart diseases are psychologically maladjusted.13 ,34 Children with constipation were shown to have externalising and internalising behavioural problems that could lead to psychological maladjustment.35 However, these researchers have used different questionnaires to assess psychological maladjustment (mostly the Child Behavior Check List).34 ,35 Therefore, we could not make a comparison. However, our study, for the first time, showed a potential association between FC and abnormal personality traits leading to psychological maladjustment in teenagers.

Constipation is not a self-limiting disease. Although not directly contributed to child mortality, constipation and its associated symptoms lead to significant repercussions in the life of an affected individual. HRQoL is one way to measure these effects without using biomedical tests. Using generic PedsQL, we noted that teenagers with constipation have poor quality of life. The scores obtained for physical, emotional, social and school functioning showed significantly lower values compared with the controls. These results are not surprising as we have previously shown similar results in a group of younger school children.5 Similar to our previous results, we noted children with constipation-associated faecal incontinence have lower HRQoL than children with constipation alone.5

We have noted a significant negative correlation between the total PAQ scores (indicating the severity of psychological maladjustment) and total HRQoL score. This indicates that children with more psychological maladjustment have lower HRQoL. Both constipation-associated symptoms and psychological maladjustment may have contributed to the lower HRQoL in all domains. For an example, physical functioning is influenced by physical discomfort caused by symptoms of constipation. Then their social life is possibly affected by both abnormal personality traits such as hostility, aggression, negative world view, emotional unresponsiveness and symptoms of constipation such as faecal incontinence as well. All these can at least partly explain their lower HRQoL.

There are several strengths of our study. We included a large sample (1750) of children and questionnaires previously validated for Sri Lankan children. Since we performed physical examination on these children, the likelihood of the presence of organic disease is very minimal. However, we did not perform a rectal examination in these children. In addition, although we found an association between abnormal personality and constipation, it is difficult to determine whether constipation led to abnormal personality or vice versa.

There are several implications in this study. Our findings suggest the importance of psychological disturbances in teenagers with FC. Although considered as a disease with no serious repercussions, it could lead to significant psychological maladjustment. This in turn could be a potential source for poor social relationships which may lead to far-reaching consequences than one would anticipate. In addition, the association between personality scores and HRQoL shows the negative implications that psychological maladjustment has on constipated teenagers. Therefore, clinicians should explore the psychological aspects of children with chronic constipation to ensure early detection of maladjusted behaviour in view to offer a therapeutic option.

In conclusion, a significant proportion of children with constipation have a greater likelihood of suffering from psychological maladjustment. Moreover, the combination of constipation with psychological maladjustment among teenagers may lead to poorer HRQoL. These findings justify incorporation of behavioural screening in children with constipation, refractory to treatment. Positive screening should then lead to behavioural therapy or referral to mental health services.


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  • Contributors NR helped in designing the study, in data collection, made significant contribution to draft the initial manuscript and approved the final manuscript. SR conceptualised the study, helped in designing the study, drafted the initial manuscript and approved the final manuscript. NMD helped in designing the study, in data analysis and approved the final manuscript. MAB contributed with interpretation of data, with significant intellectual input for the manuscript, critically revised the manuscript and approved the final manuscript. MvD helped in interpreting the data, with significant intellectual input for the manuscript and approved the final manuscript.

  • Funding The work was carried out with personal funding from the first author, Dr Ranasinghe.

  • Competing interests None declared.

  • Patient consent Parental/guardian consent obtained.

  • Ethics approval Ethical Review Committee, Faculty of Medicine, University of Colombo, Sri Lanka.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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