Child maltreatment is a major public health and social welfare problem globally (1). It has deleterious effects on the physical and mental health of victims throughout their lives. Maltreatment is defined as all forms of physical, sexual, and emotional ill treatment and neglect that result in actual or potential harm to the child's health, development, or dignity (2). The prevalence of child abuse is significantly high in both developed and developing countries. In the developed world, 4% to 16% of children are physically abused, 5% to 10% children are exposed to penetrative sexual abuse, and 10% are neglected or psychologically abused (1). In the developing world, the rates of psychological and physical abuse are 83% and 64%, respectively (3). The association between abuse and gastrointestinal illnesses in children has been studied only rarely.
Studies in adults have shown that being abused as a child increases the vulnerability to develop functional gastrointestinal diseases (FGIDs), including functional dyspepsia and irritable bowel syndrome (IBS) (4,5). These patients have more intense symptoms, poor status of health, and higher health care utilisation (6). Detailed physiological studies have shown that adults experiencing IBS with a history of abuse have abnormalities in functional magnetic resonance imaging and the hypothalamo-pituitary-adrenal axis (HPA axis) (7,8). These findings indicate long-term repercussions of abuse on the physiology of bodily function; however, all of these studies in adults inquire about child abuse as a retrospective event. Although there is evidence showing a significant association between abuse and chronic pain in adults, others have questioned the relation between the 2 entities (1,9).
Nonetheless, there is a clear dearth of evidence evaluating the association between child maltreatment and development of FGIDs in children. Van Tillburg et al (10) have shown that abused children had developed unexplained abdominal pain during childhood. Furthermore, 2 hospital-based surveys in psychiatric clinics have also illustrated that faecal incontinence is commonly associated with sexual abuse in children (11,12).
Constipation is common in children and adolescents across the world (13). The studies have suggested low socioeconomic status, living in war zones, consumption of junk food, and diet low in fibre to be potential contributors towards constipation (14–17). We have shown that constipation and faecal incontinence are associated with stressful life events (18). There is a large body of evidence that child maltreatment leads to posttraumatic stress disorders (19). Therefore, it is possible that these events can contribute to the development of constipation as well.
Somatisation is a common clinical issue in patients with FGID. The studies in adults have also clearly shown that abuse history was associated with more somatic symptoms (7). The association between these factors has not been studied in children.
In the present study, we specifically aimed to assess any associations between history of child maltreatment and constipation in children and adolescents, the impact of child maltreatment on somatisation in children with constipation, and the relation between abuse and health care consultation in children with constipation.
Study Type and Subjects
This was a cross-sectional survey conducted in Gampaha District, Sri Lanka. Four schools in the district were randomly selected from 427. From each school, all classes from grades 9 to 12 were chosen and children in these classes were invited to take part in the study.
Conduction of Data Collection
Researchers visited all of the selected schools, the questionnaire was discussed with school authorities, and permission was obtained to conduct the study. All of the children in the selected classes and their parents/guardians received an invitation to participate in the study. The consent was obtained from parents and children. Participants were asked to fill out all parts of the survey. Four research assistants were available in the classroom to supervise the children.
We used previously validated questionnaires for data collection. They were in the native language (Sinhala).
Rome III Questionnaire for FGID
This questionnaire was developed based on the Rome III diagnostic questionnaire for paediatric FGIDs (20). We used parts A and B (section on abdominal pain–related FGID) and part C (section on bowel habits) of the questionnaire.
Questionnaire on Child Maltreatment
The questionnaire on child maltreatment included questions to identify all 3 main domains of child abuse, namely, physical, sexual, and psychological components. The prevalence of abuse of any form was considered positive if a participant answered affirmatively to a question about the type of abuse.
Childhood Somatisation Inventory
The Childhood Somatisation Inventory is designed to assess somatic symptoms and their severity that do not necessarily imply an organic aetiology. There were 24 somatic symptoms on the scale ranging from 0 (not at all) to 4 (a whole lot). The number of somatic symptoms and the total score (calculated by summing up scores given by study participant for all of the 24 symptoms) were taken into account when the final score was calculated (21).
Symptom Severity Assessment
Symptom severity of abdominal pain, bloating, and severity of bowel symptoms were assessed using a visual analogue scale (10 cm) rating between 0% and 100%, wherein 0% is not having symptoms at all and 100% is having extremely severe symptoms.
Health Care Consultation
In this section of the questionnaire, the children were asked about visits to a doctor, especially owing to constipation, during the past 2 months.
Diagnosis of Constipation
Constipation was diagnosed using Rome III criteria (22). Children fulfilling 2 of the following criteria at least once per week for at least 2 months were diagnosed as having constipation:
- Two or fewer defecations in the toilet per week
- At least 1 episode of faecal incontinence per week
- Retentive posturing
- Painful or hard bowel movements
- Large-diameter stools that may obstruct the toilet
Definition of Child Abuse
Child abuse (physical, sexual, and emotional) was defined using standard definitions (23).
The ethical approval for the present study was obtained from the ethical review committee of the Sri Lanka College of Paediatricians.
The data were analysed using EpiInfo (EpiInfo 6, version 6.04 ; Centers for Disease Control and Prevention, Atlanta, GA). P < 0.05 was considered significant. Logistic regression analysis controlling for other demographic variables was conducted to determine the association between types of abuse and constipation. The Fisher exact test was used to analyse the association between categorical variables and constipation.
Sample Characteristics and Prevalence of Constipation
We received 1855 completed questionnaires, of which 1792 (96.7%) were properly filled out and were included in the analysis. Of the 1792 children included in the analysis, 975 (54.4%) were boys (mean age 14.4 years, range 13–18 years, standard deviation [SD] 1.3). Constipation was noted in 138 (7.7%) and was more prevalent among boys (68.8% vs 31.2% in girls, P < 0.0001). Children not meeting the Rome III criteria for constipation (1654) served as the control group.
Prevalence of Abuse in Patients With Constipation and Control Subjects
Four hundred thirty-eight (24.4%) children were physically abused, 396 (22.1%) were emotionally abused, and 51 (2.8%) were sexually abused. Physical (65.3% vs 34.7%, P < 0.0001) and sexual abuse (56.6% vs 43.4%, P = 0.008) were more common among boys (Fig. 1). Compared with controls, children with constipation had a significantly higher prevalence of physical, sexual, and emotional abuse (Table 1). Physical and emotional abuse were the strongest predictors of developing constipation (P < 0.0001).
Symptom Severity of Constipation and Abuse
The association between patient-perceived severity of bowel symptoms and abuse is shown in Table 2. The children with constipation with a history of physical and emotional abuse have more severe symptoms than children with constipation who were not exposed to abuse.
Somatisation in Children With Constipation Who Have Been Abused
Figure 2 shows mean somatisation scores of children who faced the 3 types of abuse. Among children with constipation, the somatisation index was higher in those who experienced emotional abuse (19.8 vs 13.5 P = 0.004). The somatisation index was higher in the total group of abused children with constipation (mean score 18.6, SD 12.5) compared with those without (mean score 13.9, SD 12.3; P = 0.03).
Health Care Consultation for Constipation in Children Who Have Been Abused
Table 3 depicts the association between child abuse and health care consultation in children with constipation. The prevalence of health care consultation was higher in children exposed to physical and emotional abuse and lower in those exposed to sexual abuse than in children not abused, but this was not statistically significant (P > 0.05).
To the best of our knowledge, this is the first study assessing the association between constipation and child maltreatment. We found that children with a history of abuse have a greater tendency to develop constipation during childhood. In addition, children with constipation develop more somatic symptoms and severe bowel symptoms when they had been exposed to abuse.
Child abuse is a problem worldwide. In developed countries, every year approximately 4% to 16% of children are physically abused, 1 in 10 is psychologically abused, and 5% to 10% are exposed to penetrative sexual abuse (1). Exposure to abuse as a child has far-reaching consequences such as psychological maladjustments, drug and alcohol misuse, risky sexual behaviour, obesity, and criminal behaviour (1). The gastrointestinal consequences of child abuse have, however, not been a research priority in the paediatrics literature. In the present study, we found that maltreatment is significantly associated with constipation in children. In accordance with an earlier study, constipation was more prevalent among boys (14). We also noted high prevalence of physical and sexual abuse in boys. Therefore, the higher prevalence of abuse may have contributed to higher prevalence of constipation among them.
We also found that the children with constipation exposed to abuse have much more severe bowel symptoms than children not exposed to such events. This association was much more significant in children who face physical and emotional abuse. The small number of sexually abused children among the group with constipation would have contributed to the lack of a significant difference in that group, although there is a trend. This finding indicates the deleterious effects of abuse on not only developing constipation but also it significantly contributing to the severity of bowel symptoms.
Community-based studies to assess the association between child abuse and defecation disorders in children are nonexistent; however, 1 clinic-based study assessed the predictive value of faecal soiling as an indicator of child sexual abuse. It compared healthy controls, children attending a psychiatry unit, and children who experienced sexual abuse. The soiling rate in the abused group differed significantly from that in healthy controls, but not from that in the psychiatric group. Similar rates of soiling were reported among abused children with and without penetration and the psychiatric sample (12). Another study noted that 36% of 23 children with a history of sexual abuse had faecal soiling (11); however, lack of a control group in this study makes it difficult to interpret the results. Several studies among adults have shown a possible association between abuse as a child and development of IBS later in life (24,25).
Underlying neurobiological mechanisms for this phenomenon has also not received much attention from paediatric researchers. Exposure to abuse generates significant psychological stress over the short and long term. Stress has a significant impact on the gastrointestinal tract. We have shown that an exposure to home- and school-related stress is a significant risk factor in developing constipation in children (18). Animal studies have shown that an exposure to stress predisposes them to develop stress-induced visceral hypersensitivity (26), altered defecation (27), intestinal mucosal dysfunction (28), and alterations in the HPA axis (29). The HPA axis has been implicated in the pathophysiology of posttraumatic stress disorders in children (30,31). In general, traumatised children show significantly elevated cortisol levels compared with control groups. A study of children with posttraumatic disorders living in stable situations showed increased levels of 24-hour urinary cortisol in comparison with those in healthy controls (32).
In addition, studies in adults with IBS have revealed stress-induced alterations in gastrointestinal motility, visceral sensitivity, autonomic dysfunction, and HPA dysfunction (33). Several functional magnetic resonance imaging studies have also shown that abuse leads to the activation of the anterior midcingulate and posterior cingulate cortex with deactivation in the anterior cingulate cortex supragenual region, an area associated with the downregulation of pain signals in adults with FGIDs, including constipation (7). These suggest that abuse leads to the alteration of both the HPA and brain–gut axes, which predispose individuals to develop FGIDs. Although these studies were conducted in adults, it is likely that they are applicable to children as well. Therefore, it is likely that in children exposed to stress induced by abuse, these pathophysiological mechanisms may play an important role in initiating and perpetuating symptoms of constipation.
Somatic symptoms are an integral part of FGIDs in children and adults. We have shown that children with abdominal pain–predominant FGIDs (34) and aerophagia (35) had a number of somatic symptoms. Creed et al (36) found higher level of somatisation in adults with IBS when there was a history of sexual abuse. We found higher mean somatisation scores among children with constipation when there was a history of abuse than children without a history of abuse. These findings suggest the development of adverse health effects of child abuse, which is diverse and not limited only to psychological consequences.
In the present study, children with constipation who experienced abuse did not seek medical care for their symptoms more frequently when compared with those who did not have a history of abuse. Contrary to this, studies among adults have noted that history of abuse is associated with more health care seeking for FGIDs such as IBS (37). In Sri Lanka, parents take children to medical consultations. Our study sample mainly consists of adolescents who are independent and they may not be prone to discussing their bowel habits with parents. Therefore, parents may not be aware that their children are experiencing constipation. Previous studies have shown that most of the time, the perpetrator of abuse is a close family member (38). It may also be possible that strained relationships resulting from repeated abuse by parents prevent children discussing their personal problems such as bowel symptoms with them, thereby delaying seeking health care.
The potential limitations of the present study include the possibility of recall bias. Nevertheless, it may be low because we only questioned children about recent events (up to 2 months) in the questionnaire. Underreporting of both abuse and bowel symptoms because of shame may also be a potential limitation. The questionnaire was, however, anonymous and this was explained to the participants. Lack of physical examination of study subjects is another limitation that we could not overcome in this large epidemiological survey.
In conclusion, we found that physical, sexual, and emotional abuse is more prevalent in children experiencing constipation. In addition, somatisation scores are higher in children with constipation who have a concomitant history of abuse. In light of these findings, it is recommended that a history of abuse in children and adolescents with a history of severe constipation must be queried for. Furthermore, addressing these issues by therapeutic interventions such as counselling and targeted cognitive-behavioural therapy will improve the overall management of chronic constipation and psychosocial well-being of children.
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Keywords:© 2014 by European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology,
child abuse; constipation; health care seeking; somatisation; symptom severity