Psychological Factors and Family Communication in Children with Elimination Disorders: A Comparative Study

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M. Hossein Mousavi Nasab, Mehrdad Hosseinpour, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3943446/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Objective This comparative study aims to assess psychological symptoms and family communication in children with elimination disorders in comparison to their healthy counterparts. Methods Utilizing a quantitative approach with a comparative design, the study employed the General Health Questionnaire, Dyadic Adjustment Scale, Child Behavior Inventory, and Mother-Child Relationship Evaluation Questionnaire. The sample consisted of 25 children with urinary incontinence, 24 with fecal incontinence (treated at Imam Hossein and Milad Hospitals), and 23 healthy children, selected through convenience sampling. Results While there were no significant differences in general health and marital satisfaction among the groups, children with urinary and fecal incontinence exhibited higher intensity of behavior problems. Additionally, specific components of the mother-child relationship, including acceptance, overprotection, and rejection, were significantly elevated in the incontinence groups compared to the controls. Conclusion This study underscores the potential benefits of health measures, awareness programs, and family counseling in preventing socio-functional and emotional consequences in children with elimination disorders. Despite no significant differences in general health and marital satisfaction, timely treatment interventions are crucial to address behavior problems and enhance specific aspects of the mother-child relationship. Such interventions have the potential to improve the physical and mental well-being of both affected children and their parents. Elimination Disorders Children General Health Marital Satisfaction Family Communication Introduction Among the digestive disorders that are directly and indirectly influenced by psychological variables are elimination disorders. Any elimination disorder can indicate an underlying problem in the excretory or nervous systems, and on the other hand, difficulty in the excretion of urine and feces has a definite and proven association with psychological and developmental disorders [ 1 ]. Elimination disorders include urinary and fecal incontinence. Urinary incontinence refers to the frequent excretion of urine during the day or night in clothes or bed, with no urinary tract injury or any other neurological cause [ 2 ]. According to the definition by DSM-5, urinary incontinence is a disorder in which the child is at least 5 years old and which continues 2 times a week for 3 consecutive months or leads to clinically significant distress or functional impairment. One of the accepted divisions about this disorder is its division into two types of primary and secondary enuresis. In primary enuresis, the child never finds the ability to control urine, but in secondary enuresis, the child experiences urinary incontinence after a period of urinary control, which must last at least six months. 80–90% of urinary incontinence cases are identified as primary enuresis, which is mainly caused by biological factors. On the other hand, secondary enuresis is often caused by psychological factors [ 3 ]. Daytime urinary incontinence and nocturnal enuresis are common problems in school-aged children. Fecal incontinence is a common problem among school-aged children, affecting 1.5–7.5% of children aged between 6 and 12 years and accounting for more than 25% of pediatric gastroenterologists’ visits and 3–6% of psychiatric referrals [ 4 – 5 ]. This condition is characterized by frequent defecation in inappropriate places (such as clothing or the floor), and these episodes must occur at least once a month for three months [ 1 ]. Parental neglect, ignorant behaviors, and sometimes physical punishment can exacerbate these problems [ 6 – 7 ]. Family factors such as maternal depression and anxiety symptoms are associated with school-age elimination disorders [ 8 ]. On the other hand, maternal depression has adverse effects on the child’s health [ 9 ]. Since depression and anxiety reduce the capacity to cope with stress, elimination disorders may accelerate or worsen [ 10 ]. Thus, primary enuresis is a condition that negatively affects the psychosocial life of patients and their families. It is estimated that more than 20–30% of children with urinary incontinence have behavior problems, and this rate is 2 to 4 times as much as the same rate in children without urinary incontinence [ 11 ]. Patients with primary enuresis suffer from embarrassment and anxiety, which may decrease their self-esteem and academic performance and can even be physically and mentally punished [ 12 ]. In their research, Castillo and Pham [ 13 ] concluded that participants with nocturnal enuresis had lower scores on the scales of adaptive skills and socialization compared to healthy children, and scored higher on the scales of anxiety, depression, and post-traumatic stress. Further, children with nocturnal enuresis and primary enuresis, compared to healthy children, have a higher risk of behavior problems, especially emotional symptoms and related attention-deficit/hyperactivity, aggression, and internalizing and externalizing behaviors [ 14 – 15 ]. The higher the frequency of bed-wetting, the higher the parental stress level and the lower the level of social activities, school performance, and communication skills and the greater the emotional, social, and behavior problems will be in children. Numerous studies focusing on emotional and behavioral changes in patients with nocturnal enuresis have concluded that children with bed-wetting are nervous, anxious, impatient, and unhappy [ 16 ]. Early literature suggests that the emotional problems observed in children with urinary incontinence are not the cause of this disease, but rather the result of negative parental reactions to the child’s urinary incontinence [ 17 ]. In a study conducted by Huang et al. [ 18 ] it was concluded that parents of children with nocturnal enuresis show a high percentage of psychological symptoms such as anxiety and stress. In addition, nocturnal enuresis makes a negative effect on the child’s quality of life, family dynamics, and relationships with peers, resulting in negative emotional and social consequences. Using the Beck Depression Inventory, Yaradilmish et al. [ 19 ] found that mothers of children with urinary incontinence get significantly higher scores in minor depression. Moreover, communication problems between parents and psychological experiences including aggression and rejection can lead to depression, anxiety, and vulnerability in children [ 20 – 21 ]. In the study conducted by Cox et al. [ 22 ] about fecal incontinence, teachers and mothers agreed that children with fecal incontinence have disruptive behaviors and attention, and social and school problems. School-age adolescents may experience harassment and rejection due to chronic fecal soiling, which can negatively affect their self-esteem, create learned helplessness, or increase hostility [ 5 , 23 ]. Parental stress for the child’s fecal incontinence is commonly reported in clinical settings, mainly arising from the child’s lack of honesty about the occurrence of fecal incontinence and the psychological burden parents feel because of repeatedly washing dirty clothes [ 24 ]. In fact, many parents think that the child’s laziness, carelessness, or will are the main cause of incontinence [ 25 ]. Mothers are usually the primary caregivers, especially in developing countries [ 26 ]. In addition to being responsible for general care, they are also responsible for providing toilet training and health education to their children. Therefore, studies evaluating patterns of toilet training or bed-wetting frequency mainly focus on the mother’s characteristics [ 27 – 28 ] In this research, given the important role of the mother in the vulnerability of the child, we have considered the relationship between the mother and the child, the marital relationship between the mother and the father, as well as the general health of the mother and intend to compare three groups of children (children with urinary incontinence, children with fecal incontinence and healthy children) in psychological variables and family communication. The main focus of this study is whether these disorders themselves cause an increase in tension, or whether the family environment and the relationships within it play the main role in this tension. Considering that few studies have been conducted on the comparison of two groups with elimination disorders, it seemed necessary to achieve more accurate results by separating these groups. The present research is important in that by controlling these variables in the family environment, the adverse effects of this disorder in children can be prevented. By being aware of the psychological factors underlying this disorder, psychological interventions can be used for its early treatment, and since these children suffer from multiple problems and exhibit harmful behaviors, the results of this research can raise the level of information about this group of children and minimize these problems. Materials and methods Participants The target population includes children with urinary incontinence, children with fecal incontinence, and healthy children. The research sample consists of 25 people with urinary incontinence, 24 people with fecal incontinence who have visited the doctor for treatment, and 23 healthy children as the control group. The research inclusion criteria were as follows: 1) The child’s age between 4 and 16 years; 2) diagnosis of urinary or fecal incontinence by a specialist physician; 3) informed consent of the child’s mother to answer the questions; 4) lack of psychiatric disorders in the child. All procedures performed in studies involving human research participants at Shahid Bahonar University of Kerman were conducted in accordance with the ethical standards of the national research committee. The study, approved by the Ethics Committee with the code E.A.1401.02.25.01, ensured informed consent was obtained from all individual participants included in the study. Measures General Health Questionnaire (GHQ) The General Health Questionnaire was first designed by Goldberg and Hillier [ 29 ]. This questionnaire has good validity and reliability in England and other countries, and accordingly, Goldberg and Williams [ 30 ] have reported average validity coefficients of 0.83 and 0.87 for this questionnaire. The 28-item General Health Questionnaire contains 4 subscales, each of which has 7 questions. The questions of each subtest are presented in sequence so that questions 1 to 7 are related to the physical symptoms subtest, questions 8 to 14 are related to the anxiety and insomnia subtest, questions 15 to 21 are related to the social dysfunction subtest, and questions 22 to 28 are related to the depression subtest. All the items in this questionnaire include 4 options and a Likert scale has been used for scoring. Dyadic Adjustment Scale (DAS) Dyadic Adjustment Scale (DAS) was developed by Graham B. Spanier [ 31 ] to measure the adjustment between married or cohabiting couples. This scale contains 32 questions and 4 subscales, including dyadic satisfaction, dyadic cohesion, dyadic consensus, and affectional expression. On this scale, the total score is between 0 and 151, and the cut-off point for determining marital distress is 101. Spanier [ 31 ] has estimated the reliability of this tool to be 0.96 in all scores. The construct validity has been confirmed through its use in more than a thousand studies and its convergent validity through its relationship with the Locke-Wallace Marital-Adjustment Scale (r = .86) [ 32 ]. Eyberg Child Behavior Inventory (ECBI) This Questionnaire was designed by Eyberg [ 33 ], which evaluates disruptive behavior, aggressiveness, defiance, and conduct problems in the home. It contains 36 questions, which provide information about the frequency and intensity of problem behaviors in children and adolescents aged between 2 and 16 years using Intensity and Problem Scales. The correlation of ECBI scores with the total score of the Child Behavior Checklist (CBCL) was found to be significant and high, which indicates the appropriate construct validity of the tool. The internal consistency was obtained to be 0.88 through Cronbach’s alpha and the test-retest reliability coefficient with an interval of three weeks was 0.86 for the intensity subscale and 0.88 for the problem subscale [ 33 ]. Mother-Child Relationship Evaluation (MCRE) Questionnaire This scale was developed by Robert M. Roth [ 34 ] evaluates the mother’s attitude toward interaction with the child in four subscales including acceptance of the child, excessive ease, overprotection, and child rejection. It contains 48 questions and the responses are scored on a 5-point Likert scale, ranging from 1 (totally disagree) to 5 (totally agree). The reliability and validity of this questionnaire was confirmed in Iran, and the Cronbach’s alpha coefficients of 0.77, 0.71, 0.78, and 0.72 were reported, respectively, for the subscales of acceptance of the child, excessive ease, overprotection, and child rejection [ 35 ]. Procedure The current research is a comparative study in terms of the type of design and a quantitative study in terms of the data collection method. For the research implementation, the subjects of the groups with urinary and fecal incontinence who went to Imam Hossein Hospital and Milad Hospital in Isfahan Province were introduced by a pediatric surgeon. The sample members (mothers) who met the research inclusion criteria took the relevant tests with informed consent. Then, the subjects of the healthy children group, who were similar to the other two groups in terms of age and inclusion criteria, were selected by the purposive sampling method. The research data were analyzed at two levels of descriptive and inferential findings. In the inferential findings section, to test the research hypotheses and compare the groups, univariate analysis of variance (ANOVA) and multivariate analysis of variance (MANOVA) were used. Data analysis was done using SPSS-27 and the maximum level of alpha error for hypothesis testing was considered to be 0.05 (p < 0.05). Results Table (1) displays the descriptive statistics of quantitative background variables including the child’s age and mother’s age. The results of Table (1) indicated that there was not much difference between the three groups in terms of the child’s age and mother’s age, and the groups were almost homogeneous. Table (2) describes all the scales in the three groups including children with urinary incontinence, children with fecal incontinence, and normal children. Normal distribution was investigated using skewness and kurtosis values and the Shapiro-Wilk test for each of the three groups (children with urinary incontinence, children with fecal incontinence, and healthy children). Skewness and kurtosis values for all groups were obtained in the range of -2 to + 2 or close to this range. The significance level of the Shapiro-Wilk test for all variables was greater than the criterion of 0.001, indicating that the data distribution is almost normal. The Levene’s test was also used to establish homogeneity of variance. The Levene’s test results suggested that the assumption of homogeneity of variance was confirmed for all variables and the significance level was greater than 0.05 (p > 0.05). Multivariate analysis of variance test was used to compare the mean of general health components in three groups of children with urinary incontinence, children with fecal incontinence and healthy children. The Box’s M test value was equal to 28.11, and the corresponding significance level was equal to 0.175. Based on the criterion of 0.001, the assumption of homogeneity of variance-covariance matrices was met (p > 0.001). Table (3) provides the results of Wilks’ Lambda multivariate test. Table (3) indicates the non-significance of the multivariate analysis and it can be concluded that there is no difference between the three groups in the linear combination of scores (p > 0.05). The univariate analysis of the variance test (Table 4 ) revealed that there was no difference between the groups in the total scores of general health and dyadic satisfaction (p > 0.05). As a result, no difference was found between the three groups of children with urinary incontinence, children with fecal incontinence, and healthy children in general health and dyadic satisfaction and its components. Table 1 Describing the respondents’ age for each group Group Variable Mean SD Minimum Maximum Urinary incontinence Child’s age 9.38 2.81 5 14 Mother’s age 40.75 4.81 32 47 Fecal incontinence Child’s age 9.50 2.84 6 14 Mother’s age 38.25 3.95 34 45 Healthy children Child’s age 8.53 2.98 5 14 Mother’s age 39.50 5.33 30 50 Table 2 Mean and standard deviation of the variables for three groups Scale Children with urinary incontinence Children with fecal incontinence Healthy children Mean SD Mean SD Mean SD General health (overall) 55.56 12.99 55.92 13.67 57.96 7.85 Dyadic satisfaction (overall) 104.32 17.82 104.17 22.75 109.52 21.13 Behavior problem 17.32 11.59 17.83 22.21 9.87 8.51 Behavior problem intensity 92.84 21.91 85.71 28.28 75.83 14.35 Acceptance 39.92 5.23 38.21 5.28 42.57 4.04 Overprotection 35.80 5.77 35.50 7.49 31.17 5.86 Excessive ease 37.48 4.44 36.75 5.67 35.48 5.17 Rejection 35.12 4.82 36.33 5.68 32.22 4.00 Table 3 Results of Wilks’ Lambda multivariate test to check the difference between the variables in the total score combination Variable Value F statistic P-value Effect size General health 0.902 0.875 0.540 0.050 Dyadic satisfaction 0.917 0.726 0.668 0.042 Child behavior 0.874 2.37 0.056 0.065 Mother-child relationship 0.799 1.95 0.057 0.106 Table 4 Results of univariate analysis of variance (ANOVA) to examine the difference between the groups in the mean score of general health Dependent variable Mean of urinary incontinence Mean of fecal incontinence Mean of healthy children Mean square F-value P-value Effect size General health (overall) 55.56 55.92 57.96 78.83 0.280 0.756 0.008 Dyadic satisfaction (overall) 104.32 104.17 109.52 436.14 0.513 0.601 0.015 Table 5 Results of multivariate analysis of variance to examine the mean difference of the behavior problems, the intensity of behavior problems and the mother-child relationship components among the three groups Dependent variable Mean of urinary incontinence Mean of fecal incontinence Mean of healthy children Mean square F-value P-value Effect size Behavior problem 17.32 17.83 9.87 931.73 1.99 0.145 0.054 Behavior problem intensity 92.84 85.71 75.83 3484.32 3.49 0.036 0.092 Acceptance 39.92 38.21 42.57 225.83 4.69 0.012 0.120 Overprotection 35.80 35.50 31.17 315.14 3.82 0.027 0.100 Excessive ease 37.48 36.75 35.48 48.84 0.936 0.397 0.026 Rejection 35.12 36.33 32.22 209.43 4.37 0.016 0113 Table (5) shows the results of the multivariate analysis of variance for behavior problems, the intensity of children’s behavior, and the mother-child relationship components among the three groups. Table (5) indicated that the mean intensity of behavior problems in the group of healthy children was significantly lower than in the other two groups (children with urinary incontinence and children with fecal incontinence) (p < 0.05). Further, the mean intensity of behavior problems in the group with urinary incontinence was higher than the other two groups and was significantly higher than the normal children group (p < 0.05). At the 90% confidence level, a difference was observed between the three groups in behavior problems, and the mean of behavior problems in the two groups with urinary and fecal incontinence was significantly higher than in normal children (p < 0.10). Regarding the mother-child relationship components, Table (5) demonstrated that in the acceptance component, the mean of the group with fecal incontinence was lower than the other two groups, and statistically, it was significantly lower than the mean in healthy children. Moreover, in the two components of overprotection and rejection, the mean of the two groups with urinary and fecal incontinence was significantly higher than the mean in healthy children (p 0.05). Discussion The findings demonstrated that the three groups under study were not significantly different in terms of general health. In other words, there was no difference between the three groups of children with urinary incontinence, children with fecal incontinence, and normal children in general health and its components. Inconsistent with the results of this research, Yaradilmish et al. [ 19 ] conducted a study with the aim of investigating depression in mothers of children with nocturnal enuresis and concluded that the depression scores of the mothers of these children were significantly higher than those of the control group. Besides, Roccella et al. [ 36 ] found that the parents of children with nocturnal enuresis had significantly higher stress level than the parents of the control group. No significant difference was observed between the three groups in terms of overall dyadic satisfaction and its components. Environment-related chronic pressures such as marital disputes and parents’ problems with compromise due to the lack of proper education for the child are effective in causing children to develop elimination disorders. The result of previous studies suggests that excessive tension in the family is involved in these conditions due to the parents’ inability to control the situation and the child going to bed with anxiety. Sudden stress and its various types, which have caused disturbance and crisis in the family, and parents who argue and fight with each other are all associated with children’s elimination disorder. In line with the results of the present study, one can refer to the research by Cederbald et al. [ 37 ] who stated that parents’ sense of competence or the quality of relationships between parents does not necessarily affect children with bed-wetting. Inconsistent with the results of this research, Huang et al. [ 18 ] came to the conclusion that long-term bed-wetting often causes a serious disease burden and mental pressure on both children and their parents, leading to anxiety, depression and life dissatisfaction. Further, the findings indicated that there is a difference between the three groups in the intensity of the behavior problem, and the mean intensity of the behavior problem in the two groups with urinary and fecal incontinence is significantly higher than the mean in healthy children. This result is consistent with the research by Friman et al. [ 38 ]. Using the Eyberg Child Behavior Inventory, they found that the intensity, but not the frequency, of the problem in the nocturnal enuresis sample was greater than the non-clinical sample. Chang et al. [ 14 ] also found that children with nocturnal enuresis have more problems related to attention, aggression and externalizing behaviors compared to healthy children. Epidemiological studies also demonstrate that 20–30% of all children with nocturnal enuresis show clinically relevant behavior problems 4 to 6 times as much as children without nocturnal enuresis [ 39 ]. Additionally, in a study conducted by Levine et al. (1980), it was found that children with fecal incontinence score higher in antisocial and aggressive behaviors and experience learned helplessness at school age, which increases hostility in them [ 5 , 23 ]. In the variable of the mother-child relationship and its components, the findings suggested that in all variables, the mean of the two groups with urinary and fecal incontinence was not significantly different and its value was almost the same, but both groups were significantly different from the group of normal children. Childhood is the beginning of life and adult personality development, and in order for the children to achieve the best conditions for growth, they must be provided with an emotionally and psychologically suitable environment. There is a difference between a child who lives in a peaceful and law-abiding family and whose parents love them, strengthen their abilities according to their needs and avoid physically punishing and verbally harassing them and a child who lives in an environment where they are beaten by their parents who are indifferent to their needs. In this sense, family restrictions and lack of access to an emotionally and socially safe environment can lead to the child’s behavior disorders. In this regard, Yaradilmish et al. [ 19 ] found that elimination disorder in children is associated with their interaction with the family, especially the mother. Children with incontinence are less accepted than healthy children, and the level of rejection by the mother is significantly higher in children with incontinence compared to normal children [ 6 , 21 , 40 ]. This means that elimination disorders can cause rejection of the child by others, especially the parents, and the rejection of the child by the parents can also lead to elimination problems. In explaining these results, it can be mentioned that the child’s lack of learning and ability to control urine and feces can be considered a severe family stress, which, due to its strong physical components, creates a feeling of hopelessness in the family, ultimately manifesting itself as non-acceptance and rejection. But it is believed that despite the related problems, normal children have the ability to control the excretion and will eventually regain it [ 41 ]. In another explanation, it can be said that children who have low social skills and are extremely aggressive have usually grown up in families where the members have poor communication. In such families, minor disputes become a major problem and parents do not have a clear and fixed method for implementing the rules, and if the interactions between mother and child are not formed in a healthy way, it causes the development of psychological symptoms such as anxiety, and anxious children perceive ambiguous events as threatening, and since the human urinary system is controlled by the nervous system, this organ is closely related to the autonomic nervous system, i.e. sympathetic and parasympathetic [ 42 ]. In a general explanation, it can be stated that elimination disorder, in addition to indicating the existence of an organic, psychological or developmental disorder, can also cause problems for the child. Elimination disorder can cause a sense of incompetence in academic activities, a decrease in self-confidence, stress and psychological reactions, withdrawal from social activities, a sense of being a child, worthlessness and decreased self-esteem. Most importantly, parents’ inattention to this problem, ignorant behaviors and sometimes physical punishments and humiliation by the family and relatives exacerbate these problems. According to the results of the present research, it seems that many factors, including the child’s behavior and the type of interaction between the parents (especially the mother) and the child, are considered to be effective in most of the studies and were also identified as significant factors associated with this phenomenon in the findings of the present research. On the other hand, the mother’s general health and marital satisfaction in this research were not significant between the three groups, and it can be said that at worst and despite the lack of mother’s general health and the existence of tension between the parents, it is possible to prevent the impact of the consequences of this disorder on the child through proper and effective communication only by focusing on this factor. Health measures, awareness and family counseling can prevent socio-functional and emotional consequences and with treatment, these children will gain more self-confidence and improve in terms of physical and mental health. By improving the relationships within the family, including the relationship with the spouse and the children and also the relationship between children and family members, parents can keep the family environment as calm as possible and prevent tension and stress. Despite the useful and practical results concerning elimination disorder (urinary and fecal incontinence), the current research, like any other study, was subject to certain limitations including: 1) small sample size, which can limit the generalizability of the research results; 2) according to the categories of primary and secondary enuresis, nocturnal enuresis and daytime urinary incontinence, further studies can achieve clearer and better results by separating these groups; 3) it would be very desirable if the effectiveness of the treatment protocol was also examined. But since this was not among the present research goals, it was not addressed in this period of time. Conclusion The results of this research can be considered by the authorities and those involved in the issues of children. They are recommended to consider the intensity of this disorder and the factors related to its occurrence and take subsequent preventive measures. Timely diagnosis and treatment of behavior disorders and nocturnal enuresis is essential in order to prevent the continuation of this disorder and the occurrence of other mental and behavior disorders in these children. Thus, it is suggested that children with primary enuresis who are referred to medical centers be checked for other mental and behavior disorders so that more effective steps can be taken to solve the problem and improve their health and their families’ health. It is also recommended to provide information through mass media in order to properly recognize this disorder and learn how to properly deal with this group of children. Declarations Data availability Data supporting the conclusions of this article are not publicly available due to patient confidentiality rules at Shahid Bahonar University of Kerman but are available upon reasonable request, e.g., for use by academic researchers. Requests should be directed to the corresponding author, S. M. Hossein Mousavi Nasab. Conflict of interest There is no conflict of interest associated with any of the authors that contributed to this manuscript. All authors have confirmed no support from any organization for the submitted work. Acknowledgments The authors sincerely acknowledge Mrs. Ghanei (Master of Physiotherapy) for providing some of the cases. We are also very grateful to all the parents who participated in this study. References Joinson, C., Heron, J., von Gontard, A., & ALSPAC Study Team. (2006). Psychological problems in children with daytime wetting. Pediatrics, 118 (5), 1985–1993. American Psychiatric Association, D., & American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders: DSM-5 (Vol. 5, No. 5). Washington, DC: American psychiatric association. Aksoy, H. (2016). Nocturnal enuresis frequency in children and anxiety-depression risks of parents. Journal of Clinical and Experimental Investigations, 7 (2), 150–156. Ollendick, T. H. (2013). Handbook of child psychopathology . Springer Science & Business Media. Shepard, J. A., Ritterband, L., Thorndike, F. P., & Borowitz, S. M. (2014). Elimination disorders. Comprehensive evidence-based interventions for school-aged children and adolescents , 243. Liu, J. (2004). Childhood externalizing behavior: Theory and implications. Journal of child and adolescent psychiatric nursing, 17 (3), 93–103. Kalo,B.B.,& Bella, M. (1996). Enuresis: Prevalence and associated factors among primary school children in Saudi Arabia. Acta Pediatrica Scandinavica, 85 , 1217–1222. Hackett, R., Hackett, L., Bhakta, P., & Gowers, S. (2001). Enuresis and encopresis in a south Indian population of children. Child: Care, Health and Development, 27 (1), 35–46. McKillop, H. N., & Connell, A. M. (2018). Physiological linkage and affective dynamics in dyadic interactions between adolescents and their mothers. Developmental Psychobiology, 60 (5), 582–594. Egemen, A., Akil, I., Canda, E., Ozyurt, B. C., & Eser, E. (2008). An evaluation of quality of life of mothers of children with enuresis nocturna. Pediatric nephrology (Berlin, Germany), 23 (1), 93–98 Hirasing, R. A., Van Leerdam, F. J. M., Bolk-Bennink, L. B., & Bosch, J. D. (1997). Bedwetting and behavioural and/or emotional problems. Acta Paediatrica, 86 (10), 1131–1134. Avanoğlu, A., Baskın, E., Söylemezoğlu, O., Tekgül, S., Ziylan, O., & Zorludemir, Ü. (2010). Türkiye enürezis çalışma grubu. Türkiye Enürezis Tedavi Kılavuzu, 1–16. Castillo, J., & Pham, S. (2022). Enuresis and psychological concerns in a foster care population. Psychological Trauma: Theory, Research, Practice, and Policy . Chang, S. S. Y., Ng, C. F. N., Wong, S. N., & Hong Kong Childhood Enuresis Study Group. (2002). Behavioural problems in children and parenting stress associated with primary nocturnal enuresis in Hong Kong. Acta paediatrica , 91 (4), 475–479. Hamed, S. A., Fawzy, M., & Hamed, E. A. (2021). Behavioral problems in children with primary monosymptomatic nocturnal enuresis. Comprehensive psychiatry, 104 , 152208. Üçer, O., & Gümüş, B. (2014). Quantifying subjective assessment of sleep quality, quality of life and depressed mood in children with enuresis. World Journal of Urology, 32 , 239–243. Scharf, M. B., & Jennings, S. W. (1988). Childhood enuresis: Relationship to sleep, etiology, evaluation, and treatment. Annals of Behavioral Medicine, 10 (3), 113–120. Huang, W. J., Liang, Y. Y., Yang, Q., & Ma, X. (2022). Nocturnal enuresis in children: Parents' perspectives. Nursing Open, 9 (5), 2335–2341. Yaradilmiş, R. M., Büyükkaragöz, B., Yilmaz, A. Ç., & Tayfur, A. Ç. (2020). Severity of self-reported depressive symptomatology and relevant factors in children with primary monosymptomatic nocturnal enuresis and their mothers. Pediatric Nephrology, 35 (7), 1277–1285. Meydan EA, Civilibal M, Elevli M, Duru NS, Civilibal N.(2012). The quality of life of mothers of children with monosymptomatic enuresis nocturna. Int Urol Nephrol;44:655e9 Tanrıverdi, M. H., Palancı, Y., Yılmaz, A., Penbegül, N., Bez, Y., & Dağgülli, M. (2014). Effects of enuresis nocturna on parents of affected children: Case–control study. Pediatrics International, 56 (2), 254–257. Cox, D. J., Morris Jr, J. B., Borowitz, S. M., & Sutphen, J. L. (2002). Psychological differences between children with and without chronic encopresis. Journal of Pediatric Psychology, 27 (7), 585–591. Campbell, L. K., Cox, D. J., & Borowitz, S. M. (2009). Elimination disorders: Enuresis and encopresis. Cox, D. J., Ritterband, L. M., Quillian, W., Kovatchev, B., Morris, J., Sutphen, J., & Borowitz, S. (2003). Assessment of behavioral mechanisms maintaining encopresis: Virginia encopresis-constipation apperception test. Journal of Pediatric Psychology, 28 (6), 375–382. Fishman, L., Rappaport, L., Schonwald, A., & Nurko, S. (2003). Trends in referral to a single encopresis clinic over 20 years. Pediatrics, 111 (5), e604-e607. Albayrak, I., Biber, A., Çalışkan, A., & Levendoglu, F. (2019). Assessment of pain, care burden, depression level, sleep quality, fatigue and quality of life in the mothers of children with cerebral palsy. Journal of Child Health Care, 23 (3), 483–494. Akis N, Irgil E, Aytekin N (2002) Enuresis and the effective factors–a case-control study. Scand J Urol Nephrol 36:199–203 Koc I, Camurdan AD, Beyazova U, Ilhan MN, Sahin F (2008) Toilet training in Turkey: the factors that affect timing and duration in different sociocultural groups. Child Care Health Dev 34:475–481 Goldberg, P. (1972). The detection of psychiatric illness by questionnaire. Maudsley monograph Goldberg, D. P. (1988). User's guide to the General Health Questionnaire. Windsor . Spanier, G. B. (1976). Measuring dyadic adjustment: New scales for assessing the quality of marriage and similar dyads. Journal of Marriage and the Family, 15–28. Fowers, B. J. (1990). An interactional approach to standardized marital assessment: A literature review. Family Relations, 368–377. Eyberg, S. M. (1999). Eyberg child behavior inventory and sutter-eyberg student behavior inventory-revised: Professional manual. Phychological Assessment Resources . Roth, R. M. The mother-child relationship evaluation manual, 1980. Los Angeles: Western Psychological Services . Khanjani, Z., Hashemi, T., Peymannia, B., & Aghagolzadeh, M. (2014). Relationship between the quality of mother-child interaction, separation anxiety and school phobia in children. Studies in Medical Sciences , 25 (3), 231–240. Roccella, M., Smirni, D., Smirni, P., Precenzano, F., Operto, F. F., Lanzara, V., Quatrosi, G., & Carotenuto, M. (2019). Parental stress and parental ratings of behavioral problems of enuretic children. Frontiers in neurology, 10 , 1054. Cederblad, M., Engsheden, N., Ghaderi, A., Enebrink, P., Engvall, G., Nevéus, T., & Sarkadi, A. (2016). No difference in relationship satisfaction between parents of children with enuresis and normative data. Journal of Child and Family Studies, 25 (4), 1345–1351. Friman, Patrick C., Michael L. Handwerk, Susan M. Swearer, J. Christopher McGinnis, and William J. Warzak. "Do children with primary nocturnal enuresis have clinically significant behavior problems?." Archives of pediatrics & adolescent medicine 152, no. 6 (1998): 537–539. Von Gontard, A., & Nevéus, T. (2006). The management of disorders of bladder and bowel control in childhood . McHeath. von Gontard, A. (2014). Encopresis. Psychiatric Drugs in Children and Adolescents: Basic Pharmacology and Practical Applications , 443–447. Moosaarab, N., & Haghayegh, S. A. (2019). The Comparision of Interactions Parent–Child and the Behavioral Problems Between Primary and Secondary enuresis. Rooyesh-e-Ravanshenasi Journal (RRJ), 8 (5), 27–36. Axelrod, M. I., Larsen, R. J., Jorgensen, K., & Stratman, B. (2021). Psychological differences between toilet trained and non-toilet trained 4‐year‐old children. Journal for Specialists in Pediatric Nursing, 26 (2), e12319. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3943446","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":276937304,"identity":"0c2880ad-597d-4d1c-b9a2-8f92a5befcaa","order_by":0,"name":"Mehdi Ebrahimi","email":"","orcid":"","institution":"Shahid Bahonar University of Kerman","correspondingAuthor":false,"prefix":"","firstName":"Mehdi","middleName":"","lastName":"Ebrahimi","suffix":""},{"id":276937305,"identity":"27fa49ce-b056-479c-8fc5-92404b4d5422","order_by":1,"name":"S. M. Hossein Mousavi Nasab","email":"data:image/png;base64,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","orcid":"","institution":"Shahid Bahonar University of Kerman","correspondingAuthor":true,"prefix":"","firstName":"S.","middleName":"M. Hossein Mousavi","lastName":"Nasab","suffix":""},{"id":276937306,"identity":"0721577a-fd82-4328-b7a9-a16d5bdc8913","order_by":2,"name":"Mehrdad Hosseinpour","email":"","orcid":"","institution":"Isfahan University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Mehrdad","middleName":"","lastName":"Hosseinpour","suffix":""},{"id":276937307,"identity":"0aef39b0-871d-49e5-8c05-f87d278f807c","order_by":3,"name":"Noshirvan Khezri Moghadam","email":"","orcid":"","institution":"Shahid Bahonar University of Kerman","correspondingAuthor":false,"prefix":"","firstName":"Noshirvan","middleName":"Khezri","lastName":"Moghadam","suffix":""}],"badges":[],"createdAt":"2024-02-09 15:44:27","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3943446/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3943446/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":62250157,"identity":"058f73a1-0c34-4466-ae58-12af34c13f66","added_by":"auto","created_at":"2024-08-12 05:56:00","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":590204,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3943446/v1/72ba2829-473d-4912-a752-1eff400c305d.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Psychological Factors and Family Communication in Children with Elimination Disorders: A Comparative Study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eAmong the digestive disorders that are directly and indirectly influenced by psychological variables are elimination disorders. Any elimination disorder can indicate an underlying problem in the excretory or nervous systems, and on the other hand, difficulty in the excretion of urine and feces has a definite and proven association with psychological and developmental disorders [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Elimination disorders include urinary and fecal incontinence.\u003c/p\u003e \u003cp\u003eUrinary incontinence refers to the frequent excretion of urine during the day or night in clothes or bed, with no urinary tract injury or any other neurological cause [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. According to the definition by DSM-5, urinary incontinence is a disorder in which the child is at least 5 years old and which continues 2 times a week for 3 consecutive months or leads to clinically significant distress or functional impairment. One of the accepted divisions about this disorder is its division into two types of primary and secondary enuresis. In primary enuresis, the child never finds the ability to control urine, but in secondary enuresis, the child experiences urinary incontinence after a period of urinary control, which must last at least six months. 80\u0026ndash;90% of urinary incontinence cases are identified as primary enuresis, which is mainly caused by biological factors. On the other hand, secondary enuresis is often caused by psychological factors [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Daytime urinary incontinence and nocturnal enuresis are common problems in school-aged children.\u003c/p\u003e \u003cp\u003eFecal incontinence is a common problem among school-aged children, affecting 1.5\u0026ndash;7.5% of children aged between 6 and 12 years and accounting for more than 25% of pediatric gastroenterologists\u0026rsquo; visits and 3\u0026ndash;6% of psychiatric referrals [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. This condition is characterized by frequent defecation in inappropriate places (such as clothing or the floor), and these episodes must occur at least once a month for three months [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Parental neglect, ignorant behaviors, and sometimes physical punishment can exacerbate these problems [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Family factors such as maternal depression and anxiety symptoms are associated with school-age elimination disorders [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. On the other hand, maternal depression has adverse effects on the child\u0026rsquo;s health [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Since depression and anxiety reduce the capacity to cope with stress, elimination disorders may accelerate or worsen [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThus, primary enuresis is a condition that negatively affects the psychosocial life of patients and their families. It is estimated that more than 20\u0026ndash;30% of children with urinary incontinence have behavior problems, and this rate is 2 to 4 times as much as the same rate in children without urinary incontinence [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Patients with primary enuresis suffer from embarrassment and anxiety, which may decrease their self-esteem and academic performance and can even be physically and mentally punished [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. In their research, Castillo and Pham [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] concluded that participants with nocturnal enuresis had lower scores on the scales of adaptive skills and socialization compared to healthy children, and scored higher on the scales of anxiety, depression, and post-traumatic stress. Further, children with nocturnal enuresis and primary enuresis, compared to healthy children, have a higher risk of behavior problems, especially emotional symptoms and related attention-deficit/hyperactivity, aggression, and internalizing and externalizing behaviors [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. The higher the frequency of bed-wetting, the higher the parental stress level and the lower the level of social activities, school performance, and communication skills and the greater the emotional, social, and behavior problems will be in children. Numerous studies focusing on emotional and behavioral changes in patients with nocturnal enuresis have concluded that children with bed-wetting are nervous, anxious, impatient, and unhappy [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Early literature suggests that the emotional problems observed in children with urinary incontinence are not the cause of this disease, but rather the result of negative parental reactions to the child\u0026rsquo;s urinary incontinence [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. In a study conducted by Huang et al. [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] it was concluded that parents of children with nocturnal enuresis show a high percentage of psychological symptoms such as anxiety and stress. In addition, nocturnal enuresis makes a negative effect on the child\u0026rsquo;s quality of life, family dynamics, and relationships with peers, resulting in negative emotional and social consequences. Using the Beck Depression Inventory, Yaradilmish et al. [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] found that mothers of children with urinary incontinence get significantly higher scores in minor depression. Moreover, communication problems between parents and psychological experiences including aggression and rejection can lead to depression, anxiety, and vulnerability in children [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn the study conducted by Cox et al. [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] about fecal incontinence, teachers and mothers agreed that children with fecal incontinence have disruptive behaviors and attention, and social and school problems. School-age adolescents may experience harassment and rejection due to chronic fecal soiling, which can negatively affect their self-esteem, create learned helplessness, or increase hostility [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Parental stress for the child\u0026rsquo;s fecal incontinence is commonly reported in clinical settings, mainly arising from the child\u0026rsquo;s lack of honesty about the occurrence of fecal incontinence and the psychological burden parents feel because of repeatedly washing dirty clothes [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. In fact, many parents think that the child\u0026rsquo;s laziness, carelessness, or will are the main cause of incontinence [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Mothers are usually the primary caregivers, especially in developing countries [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. In addition to being responsible for general care, they are also responsible for providing toilet training and health education to their children. Therefore, studies evaluating patterns of toilet training or bed-wetting frequency mainly focus on the mother\u0026rsquo;s characteristics [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eIn this research, given the important role of the mother in the vulnerability of the child, we have considered the relationship between the mother and the child, the marital relationship between the mother and the father, as well as the general health of the mother and intend to compare three groups of children (children with urinary incontinence, children with fecal incontinence and healthy children) in psychological variables and family communication. The main focus of this study is whether these disorders themselves cause an increase in tension, or whether the family environment and the relationships within it play the main role in this tension. Considering that few studies have been conducted on the comparison of two groups with elimination disorders, it seemed necessary to achieve more accurate results by separating these groups. The present research is important in that by controlling these variables in the family environment, the adverse effects of this disorder in children can be prevented. By being aware of the psychological factors underlying this disorder, psychological interventions can be used for its early treatment, and since these children suffer from multiple problems and exhibit harmful behaviors, the results of this research can raise the level of information about this group of children and minimize these problems.\u003c/p\u003e"},{"header":"Materials and methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eParticipants\u003c/h2\u003e \u003cp\u003eThe target population includes children with urinary incontinence, children with fecal incontinence, and healthy children. The research sample consists of 25 people with urinary incontinence, 24 people with fecal incontinence who have visited the doctor for treatment, and 23 healthy children as the control group. The research inclusion criteria were as follows: 1) The child\u0026rsquo;s age between 4 and 16 years; 2) diagnosis of urinary or fecal incontinence by a specialist physician; 3) informed consent of the child\u0026rsquo;s mother to answer the questions; 4) lack of psychiatric disorders in the child. All procedures performed in studies involving human research participants at Shahid Bahonar University of Kerman were conducted in accordance with the ethical standards of the national research committee. The study, approved by the Ethics Committee with the code E.A.1401.02.25.01, ensured informed consent was obtained from all individual participants included in the study.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eMeasures\u003c/h2\u003e \u003cdiv id=\"Sec5\" class=\"Section3\"\u003e \u003ch2\u003eGeneral Health Questionnaire (GHQ)\u003c/h2\u003e \u003cp\u003eThe General Health Questionnaire was first designed by Goldberg and Hillier [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. This questionnaire has good validity and reliability in England and other countries, and accordingly, Goldberg and Williams [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e] have reported average validity coefficients of 0.83 and 0.87 for this questionnaire. The 28-item General Health Questionnaire contains 4 subscales, each of which has 7 questions. The questions of each subtest are presented in sequence so that questions 1 to 7 are related to the physical symptoms subtest, questions 8 to 14 are related to the anxiety and insomnia subtest, questions 15 to 21 are related to the social dysfunction subtest, and questions 22 to 28 are related to the depression subtest. All the items in this questionnaire include 4 options and a Likert scale has been used for scoring.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section3\"\u003e \u003ch2\u003eDyadic Adjustment Scale (DAS)\u003c/h2\u003e \u003cp\u003eDyadic Adjustment Scale (DAS) was developed by Graham B. Spanier [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e] to measure the adjustment between married or cohabiting couples. This scale contains 32 questions and 4 subscales, including dyadic satisfaction, dyadic cohesion, dyadic consensus, and affectional expression. On this scale, the total score is between 0 and 151, and the cut-off point for determining marital distress is 101. Spanier [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e] has estimated the reliability of this tool to be 0.96 in all scores. The construct validity has been confirmed through its use in more than a thousand studies and its convergent validity through its relationship with the Locke-Wallace Marital-Adjustment Scale (r\u0026thinsp;=\u0026thinsp;.86) [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section3\"\u003e \u003ch2\u003eEyberg Child Behavior Inventory (ECBI)\u003c/h2\u003e \u003cp\u003eThis Questionnaire was designed by Eyberg [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e], which evaluates disruptive behavior, aggressiveness, defiance, and conduct problems in the home. It contains 36 questions, which provide information about the frequency and intensity of problem behaviors in children and adolescents aged between 2 and 16 years using Intensity and Problem Scales. The correlation of ECBI scores with the total score of the Child Behavior Checklist (CBCL) was found to be significant and high, which indicates the appropriate construct validity of the tool. The internal consistency was obtained to be 0.88 through Cronbach\u0026rsquo;s alpha and the test-retest reliability coefficient with an interval of three weeks was 0.86 for the intensity subscale and 0.88 for the problem subscale [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section3\"\u003e \u003ch2\u003eMother-Child Relationship Evaluation (MCRE) Questionnaire\u003c/h2\u003e \u003cp\u003eThis scale was developed by Robert M. Roth [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e] evaluates the mother\u0026rsquo;s attitude toward interaction with the child in four subscales including acceptance of the child, excessive ease, overprotection, and child rejection. It contains 48 questions and the responses are scored on a 5-point Likert scale, ranging from 1 (totally disagree) to 5 (totally agree). The reliability and validity of this questionnaire was confirmed in Iran, and the Cronbach\u0026rsquo;s alpha coefficients of 0.77, 0.71, 0.78, and 0.72 were reported, respectively, for the subscales of acceptance of the child, excessive ease, overprotection, and child rejection [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eProcedure\u003c/h2\u003e \u003cp\u003eThe current research is a comparative study in terms of the type of design and a quantitative study in terms of the data collection method. For the research implementation, the subjects of the groups with urinary and fecal incontinence who went to Imam Hossein Hospital and Milad Hospital in Isfahan Province were introduced by a pediatric surgeon. The sample members (mothers) who met the research inclusion criteria took the relevant tests with informed consent. Then, the subjects of the healthy children group, who were similar to the other two groups in terms of age and inclusion criteria, were selected by the purposive sampling method. The research data were analyzed at two levels of descriptive and inferential findings. In the inferential findings section, to test the research hypotheses and compare the groups, univariate analysis of variance (ANOVA) and multivariate analysis of variance (MANOVA) were used. Data analysis was done using SPSS-27 and the maximum level of alpha error for hypothesis testing was considered to be 0.05 (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eTable\u0026nbsp;(1) displays the descriptive statistics of quantitative background variables including the child\u0026rsquo;s age and mother\u0026rsquo;s age. The results of Table\u0026nbsp;(1) indicated that there was not much difference between the three groups in terms of the child\u0026rsquo;s age and mother\u0026rsquo;s age, and the groups were almost homogeneous.\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;(2) describes all the scales in the three groups including children with urinary incontinence, children with fecal incontinence, and normal children.\u003c/p\u003e \u003cp\u003eNormal distribution was investigated using skewness and kurtosis values and the Shapiro-Wilk test for each of the three groups (children with urinary incontinence, children with fecal incontinence, and healthy children). Skewness and kurtosis values for all groups were obtained in the range of -2 to +\u0026thinsp;2 or close to this range. The significance level of the Shapiro-Wilk test for all variables was greater than the criterion of 0.001, indicating that the data distribution is almost normal. The Levene\u0026rsquo;s test was also used to establish homogeneity of variance. The Levene\u0026rsquo;s test results suggested that the assumption of homogeneity of variance was confirmed for all variables and the significance level was greater than 0.05 (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\u003c/p\u003e \u003cp\u003eMultivariate analysis of variance test was used to compare the mean of general health components in three groups of children with urinary incontinence, children with fecal incontinence and healthy children. The Box\u0026rsquo;s M test value was equal to 28.11, and the corresponding significance level was equal to 0.175. Based on the criterion of 0.001, the assumption of homogeneity of variance-covariance matrices was met (p\u0026thinsp;\u0026gt;\u0026thinsp;0.001). Table\u0026nbsp;(3) provides the results of Wilks\u0026rsquo; Lambda multivariate test.\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;(3) indicates the non-significance of the multivariate analysis and it can be concluded that there is no difference between the three groups in the linear combination of scores (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\u003c/p\u003e \u003cp\u003eThe univariate analysis of the variance test (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e) revealed that there was no difference between the groups in the total scores of general health and dyadic satisfaction (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05). As a result, no difference was found between the three groups of children with urinary incontinence, children with fecal incontinence, and healthy children in general health and dyadic satisfaction and its components.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDescribing the respondents\u0026rsquo; age for each group\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGroup\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMean\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMinimum\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMaximum\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eUrinary incontinence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eChild\u0026rsquo;s age\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9.38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.81\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMother\u0026rsquo;s age\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e40.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4.81\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e47\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eFecal incontinence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eChild\u0026rsquo;s age\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMother\u0026rsquo;s age\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e38.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3.95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e45\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eHealthy children\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eChild\u0026rsquo;s age\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8.53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.98\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMother\u0026rsquo;s age\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e39.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e5.33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMean and standard deviation of the variables for three groups\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eScale\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eChildren with urinary incontinence\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eChildren with fecal incontinence\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003eHealthy children\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMean\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMean\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eSD\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGeneral health (overall)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e55.56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e12.99\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e55.92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e13.67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e57.96\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e7.85\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDyadic satisfaction (overall)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e104.32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e17.82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e104.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e22.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e109.52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e21.13\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBehavior problem\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e17.32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e11.59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e17.83\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e22.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e9.87\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e8.51\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBehavior problem intensity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e92.84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e21.91\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e85.71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e28.28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e75.83\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e14.35\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAcceptance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e39.92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5.23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e38.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e5.28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e42.57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e4.04\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOverprotection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e35.80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5.77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e35.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e7.49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e31.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e5.86\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExcessive ease\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e37.48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4.44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e36.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e5.67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e35.48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e5.17\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRejection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e35.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4.82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e36.33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e5.68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e32.22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e4.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eResults of Wilks\u0026rsquo; Lambda multivariate test to check the difference between the variables in the total score combination\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eValue\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eF statistic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eEffect size\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGeneral health\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.902\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.875\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.540\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.050\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDyadic satisfaction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.917\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.726\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.668\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.042\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChild behavior\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.874\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.056\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.065\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMother-child relationship\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.799\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.057\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.106\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eResults of univariate analysis of variance (ANOVA) to examine the difference between the groups in the mean score of general health\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDependent variable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean of urinary incontinence\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMean of fecal incontinence\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMean of healthy children\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMean square\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eF-value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eEffect size\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGeneral health (overall)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e55.56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e55.92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e57.96\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e78.83\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.280\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.756\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.008\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDyadic satisfaction (overall)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e104.32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e104.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e109.52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e436.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.513\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.601\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.015\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eResults of multivariate analysis of variance to examine the mean difference of the behavior problems, the intensity of behavior problems and the mother-child relationship components among the three groups\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDependent variable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean of urinary incontinence\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMean of fecal incontinence\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMean of healthy children\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMean square\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eF-value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eEffect size\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBehavior problem\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e17.32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e17.83\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e9.87\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e931.73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1.99\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.145\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.054\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBehavior problem intensity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e92.84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e85.71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e75.83\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e3484.32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e3.49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.036\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.092\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAcceptance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e39.92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e38.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e42.57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e225.83\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e4.69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.012\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.120\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOverprotection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e35.80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e35.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e31.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e315.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e3.82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.027\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.100\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExcessive ease\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e37.48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e36.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e35.48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e48.84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.936\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.397\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.026\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRejection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e35.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e36.33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e32.22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e209.43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e4.37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.016\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0113\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;(5) shows the results of the multivariate analysis of variance for behavior problems, the intensity of children\u0026rsquo;s behavior, and the mother-child relationship components among the three groups.\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;(5) indicated that the mean intensity of behavior problems in the group of healthy children was significantly lower than in the other two groups (children with urinary incontinence and children with fecal incontinence) (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Further, the mean intensity of behavior problems in the group with urinary incontinence was higher than the other two groups and was significantly higher than the normal children group (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). At the 90% confidence level, a difference was observed between the three groups in behavior problems, and the mean of behavior problems in the two groups with urinary and fecal incontinence was significantly higher than in normal children (p\u0026thinsp;\u0026lt;\u0026thinsp;0.10).\u003c/p\u003e \u003cp\u003eRegarding the mother-child relationship components, Table\u0026nbsp;(5) demonstrated that in the acceptance component, the mean of the group with fecal incontinence was lower than the other two groups, and statistically, it was significantly lower than the mean in healthy children. Moreover, in the two components of overprotection and rejection, the mean of the two groups with urinary and fecal incontinence was significantly higher than the mean in healthy children (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). In all the variables of Table\u0026nbsp;(5), the mean of the two groups with urinary and fecal incontinence did not differ significantly and its value was almost the same (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe findings demonstrated that the three groups under study were not significantly different in terms of general health. In other words, there was no difference between the three groups of children with urinary incontinence, children with fecal incontinence, and normal children in general health and its components. Inconsistent with the results of this research, Yaradilmish et al. [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] conducted a study with the aim of investigating depression in mothers of children with nocturnal enuresis and concluded that the depression scores of the mothers of these children were significantly higher than those of the control group. Besides, Roccella et al. [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e] found that the parents of children with nocturnal enuresis had significantly higher stress level than the parents of the control group.\u003c/p\u003e \u003cp\u003eNo significant difference was observed between the three groups in terms of overall dyadic satisfaction and its components. Environment-related chronic pressures such as marital disputes and parents\u0026rsquo; problems with compromise due to the lack of proper education for the child are effective in causing children to develop elimination disorders. The result of previous studies suggests that excessive tension in the family is involved in these conditions due to the parents\u0026rsquo; inability to control the situation and the child going to bed with anxiety. Sudden stress and its various types, which have caused disturbance and crisis in the family, and parents who argue and fight with each other are all associated with children\u0026rsquo;s elimination disorder. In line with the results of the present study, one can refer to the research by Cederbald et al. [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e] who stated that parents\u0026rsquo; sense of competence or the quality of relationships between parents does not necessarily affect children with bed-wetting. Inconsistent with the results of this research, Huang et al. [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] came to the conclusion that long-term bed-wetting often causes a serious disease burden and mental pressure on both children and their parents, leading to anxiety, depression and life dissatisfaction.\u003c/p\u003e \u003cp\u003eFurther, the findings indicated that there is a difference between the three groups in the intensity of the behavior problem, and the mean intensity of the behavior problem in the two groups with urinary and fecal incontinence is significantly higher than the mean in healthy children. This result is consistent with the research by Friman et al. [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. Using the Eyberg Child Behavior Inventory, they found that the intensity, but not the frequency, of the problem in the nocturnal enuresis sample was greater than the non-clinical sample. Chang et al. [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] also found that children with nocturnal enuresis have more problems related to attention, aggression and externalizing behaviors compared to healthy children. Epidemiological studies also demonstrate that 20\u0026ndash;30% of all children with nocturnal enuresis show clinically relevant behavior problems 4 to 6 times as much as children without nocturnal enuresis [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. Additionally, in a study conducted by Levine et al. (1980), it was found that children with fecal incontinence score higher in antisocial and aggressive behaviors and experience learned helplessness at school age, which increases hostility in them [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn the variable of the mother-child relationship and its components, the findings suggested that in all variables, the mean of the two groups with urinary and fecal incontinence was not significantly different and its value was almost the same, but both groups were significantly different from the group of normal children. Childhood is the beginning of life and adult personality development, and in order for the children to achieve the best conditions for growth, they must be provided with an emotionally and psychologically suitable environment. There is a difference between a child who lives in a peaceful and law-abiding family and whose parents love them, strengthen their abilities according to their needs and avoid physically punishing and verbally harassing them and a child who lives in an environment where they are beaten by their parents who are indifferent to their needs. In this sense, family restrictions and lack of access to an emotionally and socially safe environment can lead to the child\u0026rsquo;s behavior disorders. In this regard, Yaradilmish et al. [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] found that elimination disorder in children is associated with their interaction with the family, especially the mother. Children with incontinence are less accepted than healthy children, and the level of rejection by the mother is significantly higher in children with incontinence compared to normal children [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. This means that elimination disorders can cause rejection of the child by others, especially the parents, and the rejection of the child by the parents can also lead to elimination problems. In explaining these results, it can be mentioned that the child\u0026rsquo;s lack of learning and ability to control urine and feces can be considered a severe family stress, which, due to its strong physical components, creates a feeling of hopelessness in the family, ultimately manifesting itself as non-acceptance and rejection. But it is believed that despite the related problems, normal children have the ability to control the excretion and will eventually regain it [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. In another explanation, it can be said that children who have low social skills and are extremely aggressive have usually grown up in families where the members have poor communication. In such families, minor disputes become a major problem and parents do not have a clear and fixed method for implementing the rules, and if the interactions between mother and child are not formed in a healthy way, it causes the development of psychological symptoms such as anxiety, and anxious children perceive ambiguous events as threatening, and since the human urinary system is controlled by the nervous system, this organ is closely related to the autonomic nervous system, i.e. sympathetic and parasympathetic [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn a general explanation, it can be stated that elimination disorder, in addition to indicating the existence of an organic, psychological or developmental disorder, can also cause problems for the child. Elimination disorder can cause a sense of incompetence in academic activities, a decrease in self-confidence, stress and psychological reactions, withdrawal from social activities, a sense of being a child, worthlessness and decreased self-esteem. Most importantly, parents\u0026rsquo; inattention to this problem, ignorant behaviors and sometimes physical punishments and humiliation by the family and relatives exacerbate these problems.\u003c/p\u003e \u003cp\u003eAccording to the results of the present research, it seems that many factors, including the child\u0026rsquo;s behavior and the type of interaction between the parents (especially the mother) and the child, are considered to be effective in most of the studies and were also identified as significant factors associated with this phenomenon in the findings of the present research. On the other hand, the mother\u0026rsquo;s general health and marital satisfaction in this research were not significant between the three groups, and it can be said that at worst and despite the lack of mother\u0026rsquo;s general health and the existence of tension between the parents, it is possible to prevent the impact of the consequences of this disorder on the child through proper and effective communication only by focusing on this factor. Health measures, awareness and family counseling can prevent socio-functional and emotional consequences and with treatment, these children will gain more self-confidence and improve in terms of physical and mental health. By improving the relationships within the family, including the relationship with the spouse and the children and also the relationship between children and family members, parents can keep the family environment as calm as possible and prevent tension and stress.\u003c/p\u003e \u003cp\u003eDespite the useful and practical results concerning elimination disorder (urinary and fecal incontinence), the current research, like any other study, was subject to certain limitations including: 1) small sample size, which can limit the generalizability of the research results; 2) according to the categories of primary and secondary enuresis, nocturnal enuresis and daytime urinary incontinence, further studies can achieve clearer and better results by separating these groups; 3) it would be very desirable if the effectiveness of the treatment protocol was also examined. But since this was not among the present research goals, it was not addressed in this period of time.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe results of this research can be considered by the authorities and those involved in the issues of children. They are recommended to consider the intensity of this disorder and the factors related to its occurrence and take subsequent preventive measures. Timely diagnosis and treatment of behavior disorders and nocturnal enuresis is essential in order to prevent the continuation of this disorder and the occurrence of other mental and behavior disorders in these children. Thus, it is suggested that children with primary enuresis who are referred to medical centers be checked for other mental and behavior disorders so that more effective steps can be taken to solve the problem and improve their health and their families\u0026rsquo; health. It is also recommended to provide information through mass media in order to properly recognize this disorder and learn how to properly deal with this group of children.\u003c/p\u003e "},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eData availability\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData supporting the conclusions of this article are not publicly available due to patient confidentiality rules at Shahid Bahonar University of Kerman but are available upon reasonable request, e.g., for use by academic researchers. Requests should be directed to the corresponding author, S. M. Hossein Mousavi Nasab.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThere is no conflict of interest associated with any of the authors that contributed to this manuscript. All authors have confirmed no support from any organization for the submitted work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors sincerely acknowledge Mrs. Ghanei (Master of Physiotherapy) \u0026nbsp;for providing some of the cases. We are also very grateful to all the parents who participated in this study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eJoinson, C., Heron, J., von Gontard, A., \u0026amp; ALSPAC Study Team. (2006). Psychological problems in children with daytime wetting. Pediatrics, \u003cem\u003e118\u003c/em\u003e(5), 1985\u0026ndash;1993.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAmerican Psychiatric Association, D., \u0026amp; American Psychiatric Association. (2013). \u003cem\u003eDiagnostic and statistical manual of mental disorders: DSM-5\u003c/em\u003e (Vol. 5, No. 5). Washington, DC: American psychiatric association.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAksoy, H. (2016). Nocturnal enuresis frequency in children and anxiety-depression risks of parents. Journal of Clinical and Experimental Investigations, \u003cem\u003e7\u003c/em\u003e(2), 150\u0026ndash;156.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOllendick, T. H. (2013). \u003cem\u003eHandbook of child psychopathology\u003c/em\u003e. Springer Science \u0026amp; Business Media.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShepard, J. A., Ritterband, L., Thorndike, F. P., \u0026amp; Borowitz, S. M. (2014). Elimination disorders. \u003cem\u003eComprehensive evidence-based interventions for school-aged children and adolescents\u003c/em\u003e, 243.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLiu, J. (2004). Childhood externalizing behavior: Theory and implications. Journal of child and adolescent psychiatric nursing, \u003cem\u003e17\u003c/em\u003e(3), 93\u0026ndash;103.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKalo,B.B.,\u0026amp; Bella, M. (1996). Enuresis: Prevalence and associated factors among primary school children in Saudi Arabia. Acta Pediatrica Scandinavica, \u003cem\u003e85\u003c/em\u003e, 1217\u0026ndash;1222.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHackett, R., Hackett, L., Bhakta, P., \u0026amp; Gowers, S. (2001). Enuresis and encopresis in a south Indian population of children. Child: Care, Health and Development, \u003cem\u003e27\u003c/em\u003e(1), 35\u0026ndash;46.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMcKillop, H. N., \u0026amp; Connell, A. M. (2018). Physiological linkage and affective dynamics in dyadic interactions between adolescents and their mothers. Developmental Psychobiology, \u003cem\u003e60\u003c/em\u003e(5), 582\u0026ndash;594.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEgemen, A., Akil, I., Canda, E., Ozyurt, B. C., \u0026amp; Eser, E. (2008). An evaluation of quality of life of mothers of children with enuresis nocturna. Pediatric nephrology (Berlin, Germany), \u003cem\u003e23\u003c/em\u003e(1), 93\u0026ndash;98\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHirasing, R. A., Van Leerdam, F. J. M., Bolk-Bennink, L. B., \u0026amp; Bosch, J. D. (1997). Bedwetting and behavioural and/or emotional problems. Acta Paediatrica, \u003cem\u003e86\u003c/em\u003e(10), 1131\u0026ndash;1134.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAvanoğlu, A., Baskın, E., S\u0026ouml;ylemezoğlu, O., Tekg\u0026uuml;l, S., Ziylan, O., \u0026amp; Zorludemir, \u0026Uuml;. (2010). T\u0026uuml;rkiye en\u0026uuml;rezis \u0026ccedil;alışma grubu. T\u0026uuml;rkiye En\u0026uuml;rezis Tedavi Kılavuzu, 1\u0026ndash;16.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCastillo, J., \u0026amp; Pham, S. (2022). Enuresis and psychological concerns in a foster care population. \u003cem\u003ePsychological Trauma: Theory, Research, Practice, and Policy\u003c/em\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChang, S. S. Y., Ng, C. F. N., Wong, S. N., \u0026amp; Hong Kong Childhood Enuresis Study Group. (2002). Behavioural problems in children and parenting stress associated with primary nocturnal enuresis in Hong Kong. \u003cem\u003eActa paediatrica\u003c/em\u003e, \u003cem\u003e91\u003c/em\u003e(4), 475\u0026ndash;479.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHamed, S. A., Fawzy, M., \u0026amp; Hamed, E. A. (2021). Behavioral problems in children with primary monosymptomatic nocturnal enuresis. Comprehensive psychiatry, \u003cem\u003e104\u003c/em\u003e, 152208.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e\u0026Uuml;\u0026ccedil;er, O., \u0026amp; G\u0026uuml;m\u0026uuml;ş, B. (2014). Quantifying subjective assessment of sleep quality, quality of life and depressed mood in children with enuresis. World Journal of Urology, \u003cem\u003e32\u003c/em\u003e, 239\u0026ndash;243.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eScharf, M. B., \u0026amp; Jennings, S. W. (1988). Childhood enuresis: Relationship to sleep, etiology, evaluation, and treatment. Annals of Behavioral Medicine, \u003cem\u003e10\u003c/em\u003e(3), 113\u0026ndash;120.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHuang, W. J., Liang, Y. Y., Yang, Q., \u0026amp; Ma, X. (2022). Nocturnal enuresis in children: Parents' perspectives. Nursing Open, \u003cem\u003e9\u003c/em\u003e(5), 2335\u0026ndash;2341.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYaradilmiş, R. M., B\u0026uuml;y\u0026uuml;kkarag\u0026ouml;z, B., Yilmaz, A. \u0026Ccedil;., \u0026amp; Tayfur, A. \u0026Ccedil;. (2020). Severity of self-reported depressive symptomatology and relevant factors in children with primary monosymptomatic nocturnal enuresis and their mothers. Pediatric Nephrology, \u003cem\u003e35\u003c/em\u003e(7), 1277\u0026ndash;1285.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMeydan EA, Civilibal M, Elevli M, Duru NS, Civilibal N.(2012). The quality of life of mothers of children with monosymptomatic enuresis nocturna. Int Urol Nephrol;44:655e9\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTanrıverdi, M. H., Palancı, Y., Yılmaz, A., Penbeg\u0026uuml;l, N., Bez, Y., \u0026amp; Dağg\u0026uuml;lli, M. (2014). Effects of enuresis nocturna on parents of affected children: Case\u0026ndash;control study. Pediatrics International, \u003cem\u003e56\u003c/em\u003e(2), 254\u0026ndash;257.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCox, D. J., Morris Jr, J. B., Borowitz, S. M., \u0026amp; Sutphen, J. L. (2002). Psychological differences between children with and without chronic encopresis. Journal of Pediatric Psychology, \u003cem\u003e27\u003c/em\u003e(7), 585\u0026ndash;591.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCampbell, L. K., Cox, D. J., \u0026amp; Borowitz, S. M. (2009). Elimination disorders: Enuresis and encopresis.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCox, D. J., Ritterband, L. M., Quillian, W., Kovatchev, B., Morris, J., Sutphen, J., \u0026amp; Borowitz, S. (2003). Assessment of behavioral mechanisms maintaining encopresis: Virginia encopresis-constipation apperception test. Journal of Pediatric Psychology, \u003cem\u003e28\u003c/em\u003e(6), 375\u0026ndash;382.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFishman, L., Rappaport, L., Schonwald, A., \u0026amp; Nurko, S. (2003). Trends in referral to a single encopresis clinic over 20 years. Pediatrics, \u003cem\u003e111\u003c/em\u003e(5), e604-e607.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlbayrak, I., Biber, A., \u0026Ccedil;alışkan, A., \u0026amp; Levendoglu, F. (2019). Assessment of pain, care burden, depression level, sleep quality, fatigue and quality of life in the mothers of children with cerebral palsy. Journal of Child Health Care, \u003cem\u003e23\u003c/em\u003e(3), 483\u0026ndash;494.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAkis N, Irgil E, Aytekin N (2002) Enuresis and the effective factors\u0026ndash;a case-control study. Scand J Urol Nephrol 36:199\u0026ndash;203\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKoc I, Camurdan AD, Beyazova U, Ilhan MN, Sahin F (2008) Toilet training in Turkey: the factors that affect timing and duration in different sociocultural groups. Child Care Health Dev 34:475\u0026ndash;481\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGoldberg, P. (1972). The detection of psychiatric illness by questionnaire. Maudsley monograph\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGoldberg, D. P. (1988). User's guide to the General Health Questionnaire. \u003cem\u003eWindsor\u003c/em\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSpanier, G. B. (1976). Measuring dyadic adjustment: New scales for assessing the quality of marriage and similar dyads. Journal of Marriage and the Family, 15\u0026ndash;28.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFowers, B. J. (1990). An interactional approach to standardized marital assessment: A literature review. Family Relations, 368\u0026ndash;377.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEyberg, S. M. (1999). Eyberg child behavior inventory and sutter-eyberg student behavior inventory-revised: Professional manual. \u003cem\u003ePhychological Assessment Resources\u003c/em\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRoth, R. M. The mother-child relationship evaluation manual, 1980. \u003cem\u003eLos Angeles: Western Psychological Services\u003c/em\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKhanjani, Z., Hashemi, T., Peymannia, B., \u0026amp; Aghagolzadeh, M. (2014). Relationship between the quality of mother-child interaction, separation anxiety and school phobia in children. \u003cem\u003eStudies in Medical Sciences\u003c/em\u003e, \u003cem\u003e25\u003c/em\u003e(3), 231\u0026ndash;240.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRoccella, M., Smirni, D., Smirni, P., Precenzano, F., Operto, F. F., Lanzara, V., Quatrosi, G., \u0026amp; Carotenuto, M. (2019). Parental stress and parental ratings of behavioral problems of enuretic children. Frontiers in neurology, \u003cem\u003e10\u003c/em\u003e, 1054.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCederblad, M., Engsheden, N., Ghaderi, A., Enebrink, P., Engvall, G., Nev\u0026eacute;us, T., \u0026amp; Sarkadi, A. (2016). No difference in relationship satisfaction between parents of children with enuresis and normative data. Journal of Child and Family Studies, \u003cem\u003e25\u003c/em\u003e(4), 1345\u0026ndash;1351.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFriman, Patrick C., Michael L. Handwerk, Susan M. Swearer, J. Christopher McGinnis, and William J. Warzak. \"Do children with primary nocturnal enuresis have clinically significant behavior problems?.\" Archives of pediatrics \u0026amp; adolescent medicine 152, no. 6 (1998): 537\u0026ndash;539.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVon Gontard, A., \u0026amp; Nev\u0026eacute;us, T. (2006). \u003cem\u003eThe management of disorders of bladder and bowel control in childhood\u003c/em\u003e. McHeath.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003evon Gontard, A. (2014). Encopresis. \u003cem\u003ePsychiatric Drugs in Children and Adolescents: Basic Pharmacology and Practical Applications\u003c/em\u003e, 443\u0026ndash;447.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMoosaarab, N., \u0026amp; Haghayegh, S. A. (2019). The Comparision of Interactions Parent\u0026ndash;Child and the Behavioral Problems Between Primary and Secondary enuresis. Rooyesh-e-Ravanshenasi Journal (RRJ), \u003cem\u003e8\u003c/em\u003e(5), 27\u0026ndash;36.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAxelrod, M. I., Larsen, R. J., Jorgensen, K., \u0026amp; Stratman, B. (2021). Psychological differences between toilet trained and non-toilet trained 4‐year‐old children. Journal for Specialists in Pediatric Nursing, \u003cem\u003e26\u003c/em\u003e(2), e12319.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Elimination Disorders, Children, General Health, Marital Satisfaction, Family Communication","lastPublishedDoi":"10.21203/rs.3.rs-3943446/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3943446/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eObjective\u003c/h2\u003e \u003cp\u003eThis comparative study aims to assess psychological symptoms and family communication in children with elimination disorders in comparison to their healthy counterparts.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eUtilizing a quantitative approach with a comparative design, the study employed the General Health Questionnaire, Dyadic Adjustment Scale, Child Behavior Inventory, and Mother-Child Relationship Evaluation Questionnaire. The sample consisted of 25 children with urinary incontinence, 24 with fecal incontinence (treated at Imam Hossein and Milad Hospitals), and 23 healthy children, selected through convenience sampling.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eWhile there were no significant differences in general health and marital satisfaction among the groups, children with urinary and fecal incontinence exhibited higher intensity of behavior problems. Additionally, specific components of the mother-child relationship, including acceptance, overprotection, and rejection, were significantly elevated in the incontinence groups compared to the controls.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThis study underscores the potential benefits of health measures, awareness programs, and family counseling in preventing socio-functional and emotional consequences in children with elimination disorders. Despite no significant differences in general health and marital satisfaction, timely treatment interventions are crucial to address behavior problems and enhance specific aspects of the mother-child relationship. Such interventions have the potential to improve the physical and mental well-being of both affected children and their parents.\u003c/p\u003e","manuscriptTitle":"Psychological Factors and Family Communication in Children with Elimination Disorders: A Comparative Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-03-11 06:33:58","doi":"10.21203/rs.3.rs-3943446/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"cd416fdd-ce71-4b2a-b800-5a8c8041a500","owner":[],"postedDate":"March 11th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-08-12T05:47:53+00:00","versionOfRecord":[],"versionCreatedAt":"2024-03-11 06:33:58","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3943446","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3943446","identity":"rs-3943446","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}