Assessment of Behavioral Mechanisms Maintaining Encopresis:

Virginia Encopresis-Constipation Apperception Test

Daniel J. Cox, PhD, Lee M. Ritterband, PhD, Warren Quillian, MD, Boris Kovatchev, PhD,
James Morris, PhD, James Sutphen, MD, PhD, and Stephen Borowitz, MD
University of Virginia Health System

Objective To develop and test a scale for parent and child, evaluating theoretical and clinical

Key words encopresis, constipation, bowel habits, tests, diagnosis, assessment.

Encopresis is a relatively common but treatment-resistant

condition (McGrath, Michael, & Murphy, 2000). We have
proposed a biopsychobehavioral model of encopresis to
better understand its development and maintenance as
well as to guide treatment (Cox, Sutphen, Ling, Quillian,
& Borowitz, 1996). The model has the following steps:
(A) Historically, encopretic children experience some physical (e.g., transition from a liquid to a solid diet) or psychological (e.g., birth of a sibling) constipating event. (B) This
event results in a fecal impaction and a large, hard stool.
(C) Passage of this stool may be both difficult and painful,
and (D) subsequently the child may anticipate future defecation to be painful/difficult. (E) Rectal distention cues
(urges to defecate) may then be experienced as unpleasant
and /or the child may attempt to ignore these cues, and
(F) avoid using the toilet. (G) Chronic constipation may

ensue, allowing fecal matter above the impaction to leak

around and out (overflow incontinence). (H) Parents may
respond by requesting their child use the toilet more often,
which the child may resist. (I) This resistance and continued fecal soiling can set the stage for parent-child conflict over toileting. ( J) Persistent soiling can then lead the
child to experience shame and rejection and engage in
deception such as hiding or lying about dirty underwear.
While this is an attempt to describe possible contributors to encopresis, not all elements of this model are expected to be relevant for every child with encopresis. From
a theoretical perspective, it is important to test each step
and determine whether in fact these behavioral issues are
more prevalent among children with encopresis and their
parents compared with nonsymptomatic children and
their parents. If this is the case, determining whether these

All correspondence should be sent to Daniel J. Cox, Behavioral Medicine Center, P.O. Box 800223, University of
Virginia Health System, Charlottesville, VA 22908.
Journal of Pediatric Psychology, Vol. No. , , pp. Society of Pediatric Psychology
DOI: ./jpepsy/jsg

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parameters relevant to children with encopresis. Encopretic children were hypothesized to

have more bowel-specific, but not more generic, psychological problems, as compared with
nonsymptomatic control children. In addition, mothers were also believed to be more discerning than children. Methods The Virginia Encopresis-Constipation Apperception Test
(VECAT) consists of 9 pairs of bowel-specific and 9 parallel generic drawings. Respondents
selected the picture in each pair that best described them/their child. It was administered to
encopretic children (N = 87), nonsymptomatic siblings (N = 27), and nonsymptomatic nonsiblings (N = 35). The mothers of all the participants also completed the VECAT. Encopretic
children were retested 6 and 12 months posttreatment with Enhanced Toilet Training.
Results The VECAT demonstrated good test-retest reliability and internal consistency. Encopretic children and their mothers reported more bowel-specific, but not more generic, problems. Bowel-specific scores improved significantly posttreatment only for those patients who
demonstrated significant symptom improvement. Mothers were significantly more discerning
than children. Conclusion The VECAT is a reliable, valid, discriminating, and sensitive
test. Bowel-specific problems appear to best differentiate children with and without encopresis.

Cox et al.

VECAT consists of nine bowel-specific items that address

particular steps in the biopsychobehavioral model.
The hypotheses were as follows: Hypothesis 1: The
VECAT would demonstrate internal consistency and testretest reliability; Hypothesis 2: The VECAT would demonstrate more bowel-specific than generic psychological
problems within a group of encopretic children (withingroup differences); Hypothesis 3: The VECAT would
demonstrate more bowel-specific problems among encopretic children compared with control children, but there
would be no differences between these groups on general
functioning (between-group differences); Hypothesis 4:
The bowel-specific VECAT would be sensitive to positive
treatment effects among encopretic children (responsive vs.
nonresponsive encopretic children); and Hypothesis 5:
Due to such factors as embarrassment, defensiveness, and
denial, childrens responses would be less discerning than
mothers responses (between-rater comparison).

Methods
Scale Development
Since encopresis affects both male and female children of
all ages and races with varying reading levels, a gender-,
age-, and race-neutral test was needed that did not rely
on reading skills. Consequently, a picture-based test was
created with the assistance of a professional artist, employing race- and gender-neutral child figures. Nine pairs
of bowel-specific and nine pairs of parallel generic pictures were developed. The bowel-specific pictures (exemplified on the left side of Figure 1) and their respective scripts were created to assess individual steps in our
model. Bowel-specific item 1s (s = specific) addresses Step
D of the model regarding anticipated defecation pain.
Items 2s and 3s address Step E, involving ignoring or negatively interpreting rectal distention cues. Item 4s addresses Step F, toilet avoidance. Item 5s addresses Step G,
resistance to parental toileting instructions. Item 6s addresses Step I, involving the issue of parent-child conflict.
Finally, items 7s 9s address the concern in Step J, regarding shame, deception, and rejection.
A parallel set of generic pictures were developed to assess problems similar to those in the bowel-specific items
but with general content. For example, the first pair of
bowel-specific pictures (1s) refers to anticipation of defecation pain versus relief upon expelling a stool, while the
parallel generic pair of pictures, 1g (g = generic), refers
to anticipation of pain from a medical procedure versus relief following the completion of the procedure. The second
pair of bowel-specific pictures (2s) focus on negatively

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issues reflect learned behaviors specific to bowel movements or more general behavioral traits is important. For
example, are children with encopresis more concerned
about defecation pain or more apprehensive about pain
in general? Are these children specifically noncompliant to
toileting instructions or are they generally noncompliant
children? Clarification of these issues would significantly
contribute to the understanding of encopresis.
This model has already been partially confirmed. Children with encopresis were more likely to report painful
and less frequent defecation, as reflected in daily defecation
diaries (Steps C and G; Cox et al., 1996). On manometric
examination, children with encopresis demonstrated paradoxical constriction when attempting to defecate a balloon (Step E; Sutphen, Borowitz, Ling, Cox, & Kovatchev,
1997). When children with encopresis were compared
with nonsymptomatic children, the encopretic children
demonstrated toilet avoidance (Step F, Borowitz, Cox, &
Sutphen, 1999). Based on teacher reports, encopretic children were sought out less by peers than those without
fecal soiling (Step J; Cox, Morris, Borowitz, & Sutphen,
2002).
From a clinical perspective, it is important to determine whether a particular child presenting with encopresis has a specific behavioral problem relevant to this model.
For example, determining if a childs behavior is characterized primarily by concerns over pain or by struggles
with parents over routine use of the bathroom is notable.
Additionally, it would be important to establish whether a
child has bowel-specific or more generic behavioral problems. Bowel-specific behaviors may be more easily modified than generic behavioral traits. Contrasting the parents and the childs perspective on the same issues could
identify possible denial, excessive concern, or some interfering style of parent-child interaction.
Currently, no published encopresis-specific test exists to address these concerns. The use of generic pediatric tests has resulted in equivocal differences between
children with and without encopresis (Loening-Baucke,
1993; Ling, 1994). In fact, when we compared the encopretic and nonencopretic children on traditional tests
(Child Behavioral Checklist [Achenbach, 1991a]; Teacher
Report Form [Achenbach, 1991b]; Family Environment
Scale [Moos & Moos, 1986]; and Piers-Harris Childrens
Self-Concept [Piers, 1984]), no clinically significant group
mean differences were found (Cox et al., 2002). In lieu
of this, and given our highly specific biopsychobehavioral
model, we developed a test to specifically examine these
issues. This is the first published data on the Virginia
Encopresis-Constipation Apperception Test (VECAT). The

Assessment of Children with Encopresis

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Figure 1. Sample pairs of gender- and age-neutral pictures depicting bowel-specific and generic scenes, with corresponding text that is read to the
child (Items 13). In the scenarios, male pronouns are used with male children and female pronouns are used for female children. Respondents
select which picture in the pair they/their child are most like, then indicate whether they/their child are a little or a lot like the child in the selected
picture.

Cox et al.

Participants
All children in the encopretic group were participants in
a study examining the additive benefits of laxative, toilettraining, and external anal sphincter biofeedback therapies
in the treatment of pediatric encopresis (see Cox, Sutphen, Borowitz, Kovatchev, & Ling, 1998; Borowitz, Cox,
Sutphen, & Kovatchev, 2002). These children (N = 87)
were recruited through physicians in the University of
Virginia catchment area (radius of 150 miles), who were

notified about the study via a direct mailing. To be included in the study, the children had to be between the
ages of 6 and 15 years and to have been experiencing at
least one encopretic accident a week for at least one year.
Exclusion criteria included documented mental retardation
or any neuromuscular or gastrointestinal dysfunction
(e.g., cystic fibrosis, Hirschsprungs disease, spina bifida)
discernible through history taking or physical examination. Participants were not excluded for such disorders
as attention deficit /hyperactivity disorder or obsessivecompulsive disorder. All participants had previously failed
various types of therapy for encopresis. Of the 105 patients
who were referred to the study, 6 declined to participate because of parental concerns regarding possible assignment
to an experimental treatment group, 5 did not want to
continue treatment, 3 did not want to delay treatment
while baseline data were gathered, and 4 dropped out during baseline evaluation, leaving a total of 87.
Two comparison groups were used. These children
did not meet the exclusion criteria and had no history of
chronic constipation or encopresis. The members of the
first comparison group (N = 27) were siblings of the children with encopresis. All appropriately aged siblings were
asked to participate, and 28 of these children met criteria
and agreed to participate in all phases of pretreatment assessment. However, one sibling did not complete all test instruments, and was therefore not included. The second
comparison group (N = 35), recruited through advertisements in local publications, comprised children without
bowel disorders who were willing to participate in the
evaluation. Descriptive data are shown in Table 1 for the
three groups.

Procedures
Following the signing of an institutional review board
approved informed consent form, all mothers and children were administered the VECAT separately and privately, while completing a series of generic psychometric

Table I. Descriptive Information of the Three Groups

Encopretic Children

N
Age, M/SD*
Gender, female/male*
Race, white/black
Maternal years of education, M/SD
Paternal years of education, M/SD
Length of symptoms, months
M/SD
Median
*Symptomatic vs. nonsymptomatic groups, p < .05.

Participating Siblings

Nonsibling Group

87
8.48/1.93
15/71
67/19
13.44/2.71
13.56/3.26

27
9.15/2.44
13/14
21/6
15.11/2.58
15.04/3.39

35
9.85/2.34
16/19
29/6
14.62/1.74
15.67/3.16

58/39
48

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evaluating the internal sensation of rectal distention or

urge to defecate, while its parallel generic pictures (2g)
deal with interpreting the internal abdominal sensation
of hunger.
A descriptive scenario was written for each pair of
pictures (see Figure 1). In the scenarios, male pronouns
were used for male children and female pronouns were
used for female children. Participants were first shown
the pair of pictures and then read the scenario. They were
then instructed to select the child in one of the two pictures that they/their child was most like. After selecting this
picture, participants were asked if they/their child was a
little or a lot like the picture. This forced-choice format
rendered a 4-point ordinal scale for each pair of pictures,
where a score of 1 was assigned to a selection a lot like
the picture that did not reflect our model, and a score of 4
indicated a choice a lot like the picture that did reflect
our model. For example, if the respondent said they/their
child was a lot like the left picture in 1s, a score of 1 would
be recorded. If the respondent said they/their child was a
lot like the left picture in 2s, a score of 4 would be
recorded. The total scores for the bowel-specific and the
generic scale range from 9 to 36.
The VECAT was pilot-tested on 10 consecutive patients. Figures were revised to improve gender neutrality
and to better convey information consistent with scenario
content. Scenarios were revised to reduce confusion and
differences in social desirability.

Assessment of Children with Encopresis

tests (Cox et al., 2002). Children with encopresis were

administered the VECAT two weeks before beginning
treatment and again 6 and 12 months following the initiation of treatment. Each pair of pictures was presented
separately by an examiner, who read aloud the scenario
and recorded the participants response. The bowel-specific
and generic stimuli were presented with the picture reflecting the theoretical model appearing equally often on
the right and left sides of the 11 5.5 cards. The administration of the VECAT took approximately 10 minutes.

Data Analyses

Results
Reliability
For mothers responses, the Cronbach alpha for the bowelspecific and generic items was .68, (p < .001) and .43 (p <
.01), respectively. Child responses yielded coefficient alphas
of .70 (p < .001) for bowel-specific and .33 (p < .01) for
generic items. This indicates greater internal consistency
among bowel-specific than generic items, which was anticipated, since all of the bowel-specific items were related to various aspects of bowel habits, while the generic
items represented unrelated topics.
All bowel-specific items were significantly correlated
with the bowel-specific total score for the mothers. The
correlations were all .48 (p < .0001), except for the
item regarding shame over accidents (Item 8s, r = .12, p =
.14). Similarly, all generic items correlated significantly
with the generic total score (r = .24 to .58, p .01).
For childrens responses, all bowel-specific items significantly correlated with the bowel-specific total score.
All correlations were .50 (p < .0001), except for shame

over accidents (Item 8s, r = .18, p = .047) and compliance

with toileting (Item 5s, r = .29, p = .003). Similarly, all
generic items correlated significantly with the generic total score (r = .20 to .54, p < .03). Thus, individual items
contributed to the respective total scores.
When the VECAT scores were correlated at 6 and 12
months posttreatment, there were no significant changes
in mean bowel-specific scores for mothers (t = .38, df =
61, p = .71) or children (t = .72, df = 63, p = .48). Testretest reliability over these six months, when there was
no treatment, was significantly reliable both for mothers
(r = .60, p < .001) and for children (r = .56, p < .001).

Validity
Total Scores
An analysis of covariance was conducted, with age as a
covariate, using a 2 (Bowel-specific vs. Generic stimuli)
2 (Patients vs. Controls) 2 (Mother vs. Child responses)
design. This yielded a significant bowel-specific versus
generic effect (F = 19.6, df = 1, p < .001), patients versus
controls effect (F = 54.5, df = 1, p < .001), and mother
versus child responder effect (F = 41.8, df = 1, p < .01).
This indicates (1) bowel-specific items were more strongly
endorsed than generic items, (2) patients were more symptomatic than controls, and (3) mothers were more discerning than children. The 2-way and 3-way interactions
were also highly significant, indicating that patients had
more bowel-specific but not more generic problems compared with controls (Hypothesis 3; F = 79.5, df = 1, p <
.001), that mothers endorsed more symptoms than children when comparing patients versus controls (Hypothesis 4; F = 21.2, df = 1, p < .001), and that mothers, compared with children, endorsed more bowel-specific versus
generic problems among patient versus control children
(Hypothesis 4; a 3-way interaction, F = 42.3, df = 1, p <
.001). As illustrated in Figure 2, encopretic children were
reported to have greater difficulty with bowel-specific issues as compared with generic issues by both mothers of
encopretic children and encopretic children themselves.
Bowel-specific versus generic score means (SD) for mothers were 23.7 (5.5) vs. 17.4 (3.8); and for children, 17.3
(5.1) vs. 15.7(3.5). As illustrated in Figure 2, the controls mean scores for bowel-specific items were lower than
those for generic items, as reported both by mothers (14.7
[4.3] vs. 16.5 [4.4]) and by children (14.7 [3.7] vs. 15.3
[3.8]), while the controls bowel-specific mean ratings
were nearly identical to the patients generic mean ratings.
Mothers responses were also evaluated in two additional ways to determine whether they were more discerning than childrens responses (Hypothesis 4). First,
difference scores (bowel-specific minus generic total

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In the results section, the mothers data are presented first,

followed by the childrens data. There were no differences
between the two control groups by either mothers or children on any of the generic or bowel-specific items. Also, no
gender differences were found. Therefore, data from the
two control groups and both genders were combined in all
further comparisons of patient and control children. The
control group had older children (t = 2.71, df = 147, p <
.05) and a greater percentage of girls (Z = 3.08, p < .05)
than the encopretic group. All data analyses were conducted while controlling for age, but not gender, both because gender is a dichotomous variable and because direct
comparison of males with females yielded no significant
differences. Nonparametric analyses were used when analyzing individual items that had 4-point ordinal scales,
while parametric analyses were used when comparing total scores.

Cox et al.

Figure 2. Mean scores for mothers and children, on bowel-specific and

generic items, for those with and without encopresis.

Sensitivity to Treatment Effects

The VECAT was readministered to encopretic children
and their mothers 12 months following treatment. Regardless of treatment condition, patients were dichotomized as those who demonstrated a significant reduction (p < .001) in daily fecal accidents from baseline to
12 month follow-up. Hypothesis 5 stated that those children who demonstrated significant symptom improvement (responders, N = 40) would have greater improvement on the bowel-specific subscale, compared with
nonresponsive children (N = 34). Analyses of variance
with a 2 (Pretreatment vs. Follow-up) 2 (Responders
vs. Nonresponders) design revealed that while both mothers (F = 42.12, df = 1, p < .001) and children (F = 13.422,
df = 1, p < .001) demonstrated a significant pretreatment
versus follow-up improvement, only mothers demonstrated a significant interaction, where responders had
significantly more improvement (F = 8.56, df = 1, p < .01).
Maternal bowel-specific mean scores for responders decreased from 24.0 to 17.5 from pretreatment to follow-

Item Analysis
The means/SDs for the nine bowel-specific and nine
generic stimuli appear in Table II, with mother and child
responses relative to patient and control children. Means >
2 on bowel-specific items reflect our model. The following
analyses compared the 4-point rating data for individual
items with the nonparametric Wilcoxon test. Contrasts
indicated that mothers ratings of encopretic children and
control children did not differ on any of the generic items
(Table II, columns E vs. F). Similarly, encopretic children
and control children rated the generic items equally (columns G vs. H). However, as illustrated in Table II columns A vs. B, mothers reported that encopretic children
differed from control children on seven bowel-specific
items: greater defecation pain (Item 1s; Z = 6.83, p <
.0001), distress over rectal distention cues (Item 2s; Z =
7.85, p < .0001), avoidance of a bowel movement (Item 3s;
Z = 8.88, p < .0001), nonresponsiveness to rectal cues
(Item 4s; Z = 8.52, p < .0001), noncompliance with maternal requests to use the toilet (Items 5s; Z = 5.02, p <
.0001), more aversive parenting around toileting (Item
6s; Z = 3.12, p < .002), and more deception around dirty
underwear (Item 7s; Z = 3.37, p < .001). Columns C vs. D
show that encopretic children, compared with control
children, endorsed more problems with only three bowelspecific items: more defecation pain (Item 1s; Z = 5.39,
p < .0001), greater distress with rectal distention cues
(Item 2s; Z = 3.43, p < .001), and more nonresponsiveness to rectal cues (Item 4s; Z = 2.32, p = .02).

Discussion
Compared with control children and their mothers, both
children with encopresis and their mothers reported sig-

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scores) were calculated for each mother and child. The

difference scores for mothers and the encopretic children
were 6.3 versus 1.5 (t = 7.0, df = 87, p < .001). However,
difference scores for mothers and the control children
were 1.98 vs. .68 (t = 2.13, df = 61, p = .036). This indicates that mothers of patients endorsed more bowelspecific problems than their encopretic children. Inversely,
mothers of control children, compared with the control
children, endorsed significantly fewer bowel-specific than
generic problems. Second, using two discriminant analyses, the percentage of children correctly classified as patients and controls was calculated. Using the mothers ratings of Items 1s, 3s, 4s, 5s, and 9s, 87% of the children
were correctly classified, while 69% of the children were
correctly classified using child ratings of Items 1s, 2s, 3s,
6s, 8s, and 9s.

up, while pretreatment to follow-up scores for nonresponders decreased from 23.4 to 20.9. This suggests that
mothers of children whose encopresis improved also reported improvement in bowel-specific behaviors.
These data support the five hypotheses: 1) VECAT is
reliable; 2) children with encopresis have more behavioral problems specific to bowel habits than parallel generic
problems; 3) children with encopresis differ from nonsymptomatic children on bowel-specific but not on generic
problems; 4) the VECAT bowel-specific subscale was sensitive to successful treatment intervention; and 5) mothers of encopretic children identified more bowel-specific
problems among their encopretic children than did the
children themselves. The remaining data analyses evaluate
individual items, including whether these items support
the proposed model.

Assessment of Children with Encopresis

Table II. Means and Standard Deviations for Ratings of the Nine Bowel-Specific and GenericItems by both Parents and Children for both
Symptomatic and Nonsymptomatic Children.
Bowel Specific
Mothers

Generic
Children

Mothers

Children

Item no./Theme

Patient (A)

Control (B)

Patient (C)

Control (D)

Patient (E)

Control (F)

Patient (G)

Control (H)

1. Pain
2. Evaluating internal cues
3. Avoidance
4. Responding to internal cues
5. Compliance
6. Aversive parenting
7. Deception
8. Shame
9. Peer rejection
Mean total score

2.4 1.3
2.9 1.2
3.4 0.9
3.3 1.0
2.4 1.2
1.8 1.0
2.2 1.3
2.8 1.2
2.5 1.2
23.75.5

1.1 0.4**
1.30.7**
1.50.8**
1.40.9**
1.40.7**
1.30.6**
1.40.7**
2.91.2
2.31.1
14.7 4.3

2.2 1.1
2.1 1.2
2.0 1.1
2.0 1.1
1.7 1.0
1.3 0.8
1.6 0.9
2.3 1.2
2.0 1.1
17.3 5.1

1.3 0.5**
1.4 0.0**
1.8 0.9
1.7 0.8*
1.5 0.7
1.3 0.6
1.5 0.7
2.1 1.1
2.0 1.1
14.7 3.7

2.8 1.2
1.2 0.5
2.1 1.2
1.4 0.8
2.7 1.2
2.0 1.0
1.6 0.9
2.0 1.2
1.5 0.9
17.4 3.8

2.4 1.3
1.2 0.6
1.8 1.2
1.4 0.7
2.5 1.2
1.8 0.9
1.7 1.0
2.3 1.2
1.4 0.6
16.54.4

2.0 1.2
1.3 0.7
1.6 0.9
1.3 0.7
2.2 1.3
1.7 1.0
1.4 0.8
2.6 1.3
1.4 0.9
15.7 3.5

2.3 1.1
1.2 0.4
1.6 0.7
1.3 0.6
2.1 1.0
1.8 1.0
1.5 0.8
2.2 1.2
1.2 0.6**
15.3 3.8

nificantly more problems with the process of defecation.

Specifically, they reported that defecation hurt, rectal distention urges to defecate were distressing, and they avoided
responding to urges to defecate. Additionally, mothers,
but not children, reported less compliance by the child
with instructions to use the toilet, more aversive parenting
around toileting, and more deception concerning fecal accidents. In contrast, neither children nor mothers reported
any differences on parallel generic issues, except that
encopretic children reported slightly more peer teasing
with general embarrassing situations (falling in a mud
puddle). Neither mother nor child data support shame or
peer rejection as a common element of encopresis. The
finding that shame is not a significant problem is consistent with the observation that these encopretic and control
children did not differ in terms of their responses on the
Piers-Harris Childrens Self-Concept scale. However, inconsistent with these findings was the observation that
teachers reported these encopretic children to be more
socially isolated (Cox et al., 2002). Consequently, our
model may need to be modified by minimizing issues of
shame.
In general, the findings indicate that treatment of encopresis should focus on bowel habits, that is, use of laxatives to keep stools soft and painless, teaching children
how to relax their external anal sphincter and to appropriately strain to effectively expel a stool, and helping
children to interpret rectal distention positively and know
how to respond to these internal cues promptly. The findings also suggest that parents need assistance in positively
managing their childrens toileting behaviors. These are
the basic elements of Enhanced Toilet Training, found to be
twice as effective as intensive medical management with

enemas and laxatives (Cox et al., 1998; Borowitz et al.,

2002). However, these results do not indicate that treatment of such children should routinely address more general behavioral issues, which is consistent with the literature (Cox, 2002; Taitz, Wales, Urwin, & Molnar, 1986).
Consistent with McGraths recent review of treatment procedures (McGrath et al., 2000), the VECAT may be useful
in identifying different subgroups of patients that might differentially respond to different treatment procedures.
While these findings indicate that treatment of encopretic children should be symptom focused, the items
large standard deviations (relative to the means) and clinical experience indicate that any one of the items in the
VECAT may represent clinically significant issues for any
particular child. For example, aversive parenting and its
subsequent child/parent power struggles, child deception
of fecal accidents, and attempts to avoid dealing with the
problem, or the shame and rejection associated with public
soiling and subsequent dissociation from the problem,
may be central issues for a specific patient.
The VECAT, administered to both parent and child,
may be an expedient way of accessing such issues. Given
the mean ratings and standard deviations of both control
mothers and children, a rating of 3 or 4 (mean plus one
SD, 86th percentile) would be considered clinically significant on all bowel-specific items, except for shame (8s)
and peer rejection (9s), which would require a 4. Not only
could the VECAT identify significant bowel-specific issues, but it could also identify when these issues reflect
more general problems. If there are 3s and 4s on both the
specific and generic issues, then the clinician should consider a more generic assessment and intervention. For example, if the child gives a rating of 3 to both bowel-specific

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Larger means reflect more behavioral problems.

Between-subject contrasts: *p < .05 and **p < .001 comparing symptomatic and nonsymptomatic children.

Cox et al.

Acknowledgments
This research report was supported by NIH grant RO1
HD 28160. The authors would like to thank Dr. Robert
Pianta for suggestions on scoring the VECAT.
Received September 25, 2000; revisions received April 2,
2002, and December 1, 2002; accepted December 28, 2002

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and generic aversive parenting, then a clinical focus on

positive parenting should be more general in its focus.
Discrepancies between parent and child ratings may reflect either denial or exaggeration. The clinician would
need to help clarify such discrepancies.
The current data indicate that bowel-specific items
on the VECAT were internally consistent, reliable, discriminating, and sensitive and have both theoretical and
clinical implications. All items, except shame, contributed
to the total scores of the bowel-specific and generic subscales. There was little internal consistency among generic
items, which verifies the specificity of the model. Also,
the generic items did not differentiate symptomatic from
nonsymptomatic children. While intriguing and potentially useful, the VECAT should be used in other facilities to demonstrate its external validity. It also needs to
be tested with older and younger samples. It is anticipated
that constipated children, without fecal soiling, should
have similar responses to Items 1s6s, but not have problems around deception, shame, and peer rejection. Because mothers were more discerning than children, a selfadministered, text-based version of this instrument might
be easier to administer to parents and be equally informative. A computerized version of the VECAT is currently
being developed and will be able to be delivered over the
Internet (www.ucanpooptoo.com).