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ADC Online First, published on October 30, 2014 as 10.1136/archdischild-2014-305941
1
Psychosocial Department,
Emma Childrens Hospital/
Academic Medical Centre,
University of Amsterdam,
Amsterdam, The Netherlands
2 The role of parents in the development and
Department of Paediatric
Gastroenterology and Nutrition,
Emma Childrens Hospital/
Academic Medical Centre,
University of Amsterdam,
Amsterdam, The Netherlands
3 recommend intensive support, education and
Department of Developmental
Psychology, Vrije Universiteit,
Amsterdam, The Netherlands
4
Department of Psychiatry,
Academic Medical Centre,
University of Amsterdam,
Amsterdam, The Netherlands
Correspondence to
Marieke van Dijk, Psychosocial
Department and Department of
Paediatric Gastroenterology
and Nutrition, Emma Childrens
Hospital, Academic Medical
Centre, Room A3-241, PO Box
22700, Amsterdam 1100 DE,
The Netherlands;
m.vandijk@amc.uva.nl
Received 3 January 2014
Revised 8 October 2014
Accepted 13 October 2014
To cite: van Dijk M, de
Vries G-J, Last BF, et al.
Arch Dis Child Published
Online First: [ please include
Day Month Year]
doi:10.1136/archdischild-
2014-305941
Copyright Article author (or their employer) 2014. Produced by BMJ Publishing Group Ltd (& RCPCH) under licence.
Original article
Parental child-rearing attitudes are associated
with functional constipation in childhood
Marieke van Dijk,1 Giel-Jan de Vries, Bob F Last,1,3 Marc A Benninga,2
Martha A Grootenhuis1
ABSTRACT
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 Childrens Hospital in the Netherlands.
Patients Children with functional constipation aged
418 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 difculties hinder
treatment or when the parentchild relationship is at risk.
Trial registration number ISRCTN2518556.
INTRODUCTION
Childhood constipation is often a major problem
for the child and their family, and is characterised by
painful infrequent bowel movements often in com-
bination with faecal incontinence.1 The patho-
physiological mechanisms underlying childhood
constipation are multifactorial and poorly under-
stood, and no specic 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.39 Children
with functional constipation are primarily treated
van Dijk M, et al. Arch Dis Child 2014;0:15. doi:10.1136/archdischild-2014-305941
What is already known on this topic?
maintenance of functional constipation in
childhood has long been acknowledged;
however, research on this topic is limited.
Guidelines for childhood constipation
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 parentchild relationship becomes
more complicated.
Any parenting issues should be addressed
during the treatment of children with functional
constipation.
with oral laxatives in combination with toilet train-
ing in paediatric settings.10 Education and explan-
ation are the rst 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.1214
Nowadays, parenting factors are still assumed to
play a role in the development and maintenance of
childhood constipation.1519 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 func-
tional 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 parentchild relation-
ship have long been recognised as major contribu-
tors to a childs behavioural, emotional and
cognitive development.2126 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
1
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Original article
attitudes and three prominent symptoms of functional constipa-
tion (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 chil-
dren with functional constipation aged 418 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 fre-
quency and large amounts of stools in a diary for 1 week before
their visit to the outpatient clinic, without laxatives. At the rst
visit, a standardised interview was conducted to assess clinical
symptoms.29 An abdominal and rectal examination was also per-
formed to evaluate the presence of faecal impaction. Children
with at least two of the following four symptoms were classied
as having paediatric functional constipation: defecation fre-
quency <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 examin-
ation.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 ll 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.
Measures
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 ori-
ginally included 23 subscales. The reliability and validity of the
original instrument, especially compared with other existing par-
ental 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 inuence their child-rearing practices and thereby
the parentchild 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 inde-
pendence 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 childs
life). A strong overprotective attitude can result in intrusive par-
enting (control of the childs psychological world). The Self-pity
scale (5 items) refers to irritability and frustration regarding the
2 van Dijk M, et al. Arch Dis Child 2014;0:15. doi:10.1136/archdischild-2014-305941
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 (com-
pletely agree) to 1 (completely disagree). Higher scores reect
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 asso-
ciated clinical characteristics such as abdominal pain and painful
defecation.
Statistical analysis
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 corre-
sponding items was inputed.
We used regression models to examine the association
between parental child-rearing attitudes and functional constipa-
tion. 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
tted 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 tted 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 sug-
gested 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 statis-
tically signicant.
RESULTS
Characteristics of the study sample
A total of 134 patients participated in the study. One A-PARI
questionnaire was not lled out by parents, and so the baseline
data of 133 children were used for analysis. Table 1 shows the
study sample.
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Original article

Table 1 Characteristics of constipated children (n=133)
Demographics
Age at enrolment, mean (SD), years
Boys, n/N (%)
History
Age at onset of constipation, mean (SD), years
Duration of treatment, mean (SD), months*
Parental constipation, n/N (%)
Clinical symptoms
Defecation frequency/week, median (IQR)
Faecal incontinence frequency/week, median (IQR)
Large amount of stool, n/N (%)
Painful defecation, n/N (%)
Abdominal pain, n/N (%)
Physical examination
Abdominal scybalum, n/N (%)
Rectal scybalum, n/N (%)
*Missing values for five parents.
Missing value for one parent.
Missing values not known by parents.
Missing physical examination (the child too frightened to be examined or refused
examination).
Regression models
Results of the regression analyses are shown in table 2.
Defecation frequency
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 signicantly
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 chil-
dren, none of the variables proved signicant (all p>0.052).
However, for the older children, the autonomy scale was signi-
cantly associated with defecation frequency: children with
parents having high autonomy scores had considerably lower
6.7 (2.3) defecation frequency than children with parents scoring in the
75/133 (56.4) 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
2.9 (1.9) about half as much as children with parents in the reference
18.1 (20.5) group (IRR 0.5, 95% CI 0.3 to 0.8, p=0.010). The older the
37/132 (28.0) child, the more likely defecation frequency increased (IRR 1.2,
95% CI 1.1 to 1.4, p<0.001).
1.0 (02.5)
10.0 (3.525.3)
91/133 (68.4) Faecal incontinence frequency
66/124 (53.2) Children with parents having low autonomy scores had signi-
91/132 (68.9) cant more faecal incontinence episodes compared with children
with parents in the reference group, while children of parents
44/126 (34.9) having high scores on the autonomy scale also had more faecal
65/120 (54.2) incontinence (table 2). When parents scored high on the over-
protective scale, children showed signicantly 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 refer-
ence 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 signi-
cantly 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

Table 2 The effect of parental child-rearing attitudes on measures of functional constipation (n=133)
Defecation frequency Faecal incontinence frequency Large amounts of stool
Parental child-rearing
attitude n (%) Rate IRR (95% CI) p Value Rate IRR (95% CI) p Value % OR (95% CI) p Value

Autocratic
Low 23 (17.3) 2.0 1.1 (0.7 to 1.7) 0.662 10.7 0.6 (0.4 to 1.1) 0.081 75.0 1.7 (0.5 to 5.6) 0.414
Average 87 (65.4) 1.9 Ref 16.6 Ref 65.3 Ref
High 23 (17.3) 2.3 1.2 (0.6 to 2.4) 0.568 16.6 1.0 (0.7 to 1.5) 0.994 74.4 1.6 (0.4 to 6.0) 0.479
Autonomy
Low 23 (17.3) 1.2 0.5 (0.3 to 0.8) 0.006 20.0 1.6 (1.1 to 2.4) 0.019 59.2 0.5 (0.2 to 1.4) 0.176
Average 83 (62.4) 2.4 Ref 12.5 Ref 74.0 Ref
High 27 (20.3) 1.4 0.6 (0.3 to 1.0) 0.036 21.1 1.7 (1.2 to 2.4) 0.004 59.0 0.5 (0.2 to 1.3) 0.159
Overprotection
Low 23 (17.3) 3.1 1.8 (0.9 to 3.6) 0.087 16.7 1.3 (0.9 to 2.0) 0.133 66.6 1.1 (0.3 to 3.3) 0.915
Average 77 (57.9) 1.7 Ref 12.4 Ref 65.3 Ref
High 33 (24.8) 1.9 1.1 (0.6 to 2.1) 0.701 21.4 1.7 (1.2 to 2.6) 0.007 76.7 1.8 (0.6 to 5.6) 0.278
Self-pity
Low 29 (21.8) 1.5 0.7 (0.5 to 1.1) 0.095 15.0 1.1 (0.7 to 1.7) 0.573 63.7 0.6 (0.2 to 1.6) 0.309
Average 70 (52.6) 2.1 Ref 13.4 Ref 74.1 Ref
High 34 (25.6) 2.1 1.0 (0.6 to 1.7) 0.994 20.0 1.5 (1.1 to 2.1) 0.022 60.3 0.5 (0.2 to 1.3) 0.158
IRR: incidence rate ratio, derived from negative binomial regression models with gender (not shown), A-PARI child-rearing attitude scales as factors, and age (not shown) as covariate
included in the model; Rate: adjusted rate based on the marginal means of the negative binomial regression models; OR: derived from logistic regression model with gender (not
shown), A-PARI child-rearing attitude scales as factors, and age (not shown) as covariate included in the model; %: adjusted proportion based on the marginal means of the logistic
models; Low: 1 SD and lower; Average: between 1 SD and +1 SD; High: +1 SD and higher; Ref: reference group; rates and odds in the Low and High groups are compared to the
Average group.
A-PARI, Amsterdam version of the Parental Attitude Research Instrument.

van Dijk M, et al. Arch Dis Child 2014;0:15. doi:10.1136/archdischild-2014-305941 3

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Original article
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 signicantly
associated with large amounts of stools. Age increased the likeli-
hood of large amounts of stools (OR 0.9, 95% CI 1.0 to 1.5,
p=0.045).
DISCUSSION
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 auton-
omy 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 difcult temperament18 41 42
of these children. For older children, it is suggested that consti-
pation is part of a broader psychosocial developmental delay
with specically low striving towards autonomy that is main-
tained by the family environment.43 The goodness-of-t
theory44 45 might be useful for understanding the opposing
ndings 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 adjust-
ment of parents to the specic 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 epi-
sodes. Higher levels of overprotection were shown in parents of
children with cancer, asthma,35 46 epilepsy,47 physical disabil-
ities48 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 investigat-
ing parental child-rearing attitudes with the A-PARI in chronic-
ally 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 parentchild relationship can be
dened as parenting with a double message and can lead to
distress and behavioural problems in the child,50 which in con-
stipated 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
4 van Dijk M, et al. Arch Dis Child 2014;0:15. doi:10.1136/archdischild-2014-305941
parents with a chronically constipated child, with most children
having faecal accidents, over-reactions may arise around toilet-
ing.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 childrens behaviour lowers the thresh-
old 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 irrit-
ability18 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 conicting
interests.48 While the growing child strives for independence, the
parents of a child with a chronic medical condition may uninten-
tionally prevent the development of normal autonomy. They per-
ceive 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 parentchild
relationship. The question remains whether constipation leads to
a problematic parentchild relationship or vice versa. We
hypothesise that a dysfunctional parentchild relationship can
cause constipation to develop into a chronic condition.
Some limitations of this study need to be addressed. This study
specically 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 meas-
urement 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 signicance
(type I error). Finally, given the cross-sectional nature of this
study, causality cannot be determined and therefore we are
unable to state whether specic 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
parentchild relationship, our ndings make a substantial contri-
bution 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 treat-
ment. Referral to mental health services is needed when parent-
ing difculties hinder treatment or when the parentchild
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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Parental child-rearing attitudes are

associated with functional constipation in
childhood
Marieke van Dijk, Giel-Jan de Vries, Bob F Last, Marc A Benninga and
Martha A Grootenhuis

Arch Dis Child published online October 30, 2014

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http://adc.bmj.com/content/early/2014/10/30/archdischild-2014-30594
1

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References This article cites 52 articles, 9 of which you can access for free at:
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Topic Articles on similar topics can be found in the following collections

Collections Child health (2559)
Constipation (40)
Child and adolescent psychiatry (paedatrics) (477)
Urology (331)

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