Objective: Genetic and neurobiological factors interact with environmental inşuences in the pathogenesis of enuresis and encopresis. Control over bladder and bowel movements is an important developmental milestone at childhood. Parents’ expectations play a very important role in this process, since parents believe that their children should achieve continence at a younger age than that of the natural history of human continence. This belief makes the child’s toilet training phase a stressful period for the child, the parents and the teachers, which may result in severe punishments and traumas. The aims of the present study are to describe the types and to determine the rate of parental punishment among children and adolescents with elimination disorders and also to investigate the parents’ psychological and socio-cultural factors associated with punishment.
Method: We carried out a cross-sectional study involving 112 patients aged from 5.20-14 years. Enuresis and encopresis diagnoses were defined according to the Diagnostic and Statistical Manual for Mental Disorders (DSM V). A semi-structured interview was done with the patients and their parents by two child and adolescent psychiatrists, to collect information about the medical history of patients and characteristics of the parental reactions to the child’s enuresis and/or encopresis were widely investigated. Also caregiver parents completed the Turkish version of Symptom Check List 90-R (SCL-90-R).
Results: The study sample consisted of 112 patients (28 females, 84 males) with a mean age of 8.23±2.09 years. It was determined that there was enuresis in 92.0% (n=103) of these cases and encopresis in 22.3% (n=25). Comorbid psychiatric disorder was found in 50.9% of the cases (n= 57). Among all patients, the rate of being exposed to verbal punishment was 42.0% (n=47); the rate of being exposed to physical punishment without physical contact was 9.8% (n= 11) of the cases while the rate of being exposed to physical punishment with physical contact was 21.4% (n= 24). Of the cases, 26.8% (n= 30), were not exposed to any type of punishment. It was established that punishment and violence were at a higher rate in cases with low socioeconomic status and in cases with living in a large or divorced family (p<0.05). When comparing caregiver parents on SCL-90-R and the subscales scores, the punitive parents had significantly higher scores on somatization, depression, anxiety, obsessive-compulsive disorder, interpersonal sensitivity and hostility subscales of the SCL-90 than the non-punitive parents.
Conclusion: Elimination disorders are associated with high levels of distress for both children and parents. The rate of punishment of almost 75% found in the present study is alarming and it suggests that both physical and verbal aggression against children and adolescents, as an educational measure and a training method are common and culturally accepted among the Turkish families. In the assessment of enuretic or encopretic children, features of family and parents are must be evaluated carefully and these features must be considered in treatment.