The Toileting Habit Profile Questionnaire-Revised: Screening for Sensory-Based Toileting Difficulties in Turkish Children with Functional Defecation Disorders

Abstract

Background  The Toileting Habit Profile Questionnaire – Revised (THPQ-R) assesses sensory integration differences in children experiencing toileting and defecation participation issues. Sensory integration disorders (SIDs) are frequent in children with functional defecation disorders (FDDs) and may affect participation in toileting routines, a key feature of conventional medical management. Understanding a child's SIDs and their impact on participation in toileting routines can contribute to more effective interventions.

Objective  To develop a translated and culturally adapted Turkish version of the THPQ-R for use in clinical practice and research.

Materials and Methods  The process of translating the THPQ-R and adapting the questionnaire for use in Turkey was performed following accepted guidelines. The analysis was performed using data gathered from the Turkish THPQ-R (TR-THPQ-R) to explore its reliability and validity.

Results  The TR-THPQ-R was found to be highly reliable, with a Cronbach alpha value of 0.833. The test–retest analysis determined that the scale measured reliably over a short period of time (p < 0.05) and discriminated adequately between children with and without FDDs (p < 0.05). The hyperreactivity items of the TR-THPQ-R correlated with the hyperreactivity items of the Sensory Processing Measure, supporting convergent validity.

Conclusions  Turkish clinicians and researchers have a tool to assess sensory hyperreactivity concerns in children with defecation disorders. This study paves the way for new research that focuses on the relationship between toileting participation, FDDs, and SIDs in this population.

Keywords
sensory function; occupational therapy; constipation; fecal incontinence

Introduction

Childhood functional defecation disorders (FDD) are prevalent (5.3–17.4%), and their rising incidence is making them a significant public health concern.¹,² These include functional constipation (FC) and functional nonretentive fecal incontinence (FNRFI).³ The first, FC, is characterized by painful and infrequent defecation; a common symptom is fecal incontinence in the form of soiling (). It should not be mistaken for FNRFI, which is characterized by fecal incontinence without evidence of stool accumulation in the rectum. Both conditions are linked to issues participating in toileting routines⁴ and are known to have a negative impact on the quality of life.⁵

Numerous biopsychosocial factors have been identified and believed to contribute to defecation disorders, even though the exact cause of FDD remains unknown. Diet, behavior, lifestyle, social environment, and abnormal defecation dynamics are all factors linked to FDD, while a combination of medical, behavioral, and biomechanical interventions comprises the conventional treatment.¹,⁶,⁷ However, conventional methods don't always work, and some individuals' symptoms persist throughout adolescence and adulthood.⁸ Therefore, it is imperative to gain a deeper understanding of the underlying factors associated with FDD.

Several studies have shown that sensory integration disorders (SID) are associated with atypical toileting habits and gastrointestinal issues.⁴,⁹,¹⁰ However, SID is rarely considered in FDD interventions. This disorder was first described by Dr. Jean Ayres, an occupational therapist with advanced knowledge of neuroscience.¹¹ Ayres defined sensory integration as "the neurological process by which sensory information from one's own body and the environment is organized and makes it possible to use one's body effectively in the environment'.¹¹ The body of knowledge first created by Ayres, which includes the theoretical framework, assessment methods and intervention for SID, is currently referred to as Ayres Sensory Integration (ASI).¹² This condition may impact defecation and toileting in several ways: (1) poor perception of body sensations may lead the child to misinterpret or fail to attend to the need for a bowel movement; (2) postural and praxis issues may impact the child's ability to sit on the toilet and manage the multiple steps involved in autonomous toilet use; (3) hyperreactivity to sensations involved in toilet use and defecation (passage of stool, wiping, water splashing, etc.) may transform the process into an unpleasant or even traumatic experience which may lead to withholding or toilet refusal.⁴,⁹,¹³–¹⁵

Assessment of the specific underlying sensory issues affecting participation in activities of daily living is a key feature of ASI and is essential for intervention planning for SID. The Toileting Habit Profile Questionnaire-Revised (THPQ-R) was developed to assess sensory hyperreactivity and perception vulnerabilities in children with FDD and other challenges participating in toileting routines.¹⁵ The THPQ-R has been shown to discriminate between children with and without FDD⁴ and is a validated tool for obtaining comprehensive information during the assessment of toileting routine participation in children aged 3 to 6 years.⁴,¹⁵ Culturally adapted, valid, and reliable tools to identify potential SID affecting participation in toileting are key to the successful multidisciplinary intervention of FDD.¹⁴,¹⁶ The main objective of this study was to develop and examine the reliability and validity of a culturally adapted Turkish version of the THPQ-R for use in clinical practice and research in the Turkish population.

Materials and Methods

This study took place in two phases. The first aimed to develop a translated and culturally adapted Turkish version of the THPQ-R. In the second, data were gathered from parents of 3 to 5-year-old children with and without FDD to explore the reliability and validity of the Turkish THPQ-R (TR-THPQ-R).

Phase 1: Translation and Cultural Adaptation of the THPQ-R

Toileting Habit Profile Questionnaire – Revised

The THPQ-R was developed by an occupational therapist and gastroenterologist, who noticed that many children did not respond to conventional medical management and complementary behavioral approaches.¹⁵,¹⁷ It was designed to identify challenging defecation behaviors and reactions related to SID in children with FDD. It is validated for children aged 3 to 6 years, an age range frequently associated with defecation concerns such as toilet refusal, pain upon defecation, and stool withholding.¹⁸

The scale consists of 17 items; the first 15 are related to sensory hyperreactivity, and the last 2 are related to sensory hyporeactivity and/or poor perception. Each item consists of two response options: (1) often or always, for a score of 1; and (2) never or rarely, for a score of 2. Only the first 15 items (hyperreactivity) are included in the total score. The last two items are not included in the total score as they represent a different construct, and the authors consider that the two items are insufficient to clearly identify sensory hyporeactivity and/or poor perception and its relationship to challenging defecation behaviors.¹⁵ Therefore, these items are not considered in the scoring but are nevertheless qualitatively considered in the clinician's assessment.

The hyperreactivity items of the THPQ-R and its earlier version (THPQ) have been shown to adequately discriminate between children with and without FDD and correlate with other measures of sensory hyperreactivity.⁴,¹⁷

Translation and Cultural Adaptation

Translation and cultural adaptation were done in several steps, according to accepted recommendations¹⁸ for user-completed assessments: 1) forward translation and reports by two independent translators (one with knowledge of the concepts being examined) whose first language is the target language (in this case Turkish); 2) synthesis of the two translations, working with the original questionnaire, to reach consensus and produce one common translation and written report documenting the synthesis process; 3) linguists or experts with advanced knowledge of the target language (at least two experts) examined the translations for comprehensibility and grammar; 4) back-translations produced by two professional translators to the source language (in this case English) and without previous knowledge of the concepts explored; 5) consolidation by an expert committee, in collaboration with the original developers, of both versions into a prefinal version of the questionnaire for field testing; 6) field test of the prefinal version in subjects from the target setting to explore comprehension; 7) audit of the translation and cultural adaptation process including all steps and reports.

Phase 2: Reliability and Validity

This phase of the investigation adopted a descriptive survey methodology in which parents of 3- to 5-year-old children with and without FDD were invited to complete two different questionnaires: TR-THPQ-R and Sensory Processing Measure – Preschool (SPM-P).¹⁹ The data were then used to explore internal consistency reliability, test-retest reliability, known-groups validity, and convergent validity of the TR-THPQ-R. Analyses were performed using the IBM SPSS Statistics for Windows (IBM Corp.), version 28.0.²⁰

Participants

Caregivers of typically developing, toilet-trained (accomplished or in process; using the potty or toilet at least once a day) 3- to 5-year-old children with and without FDD were recruited from the Pediatric Gastroenterology Department of Medipol University Mega Hospital, private clinics, and preschools of Istanbul between March 2023 and December 2023. Power analysis²⁰ determined that a minimum of 20 participants were required for each group (FDD and NO-FDD). The Rome IV³ diagnostic criteria for FC and FNRFI were used to classify children by FDD status.

Typically developing children with a diagnosis of FC or FNRFI established by a gastroenterologist or pediatrician, and no other diagnoses were included in the FDD group. Those without FC, FNRFI, or any other diagnoses were placed in the NO-FDD group. To ensure correct group assignment, all participants whose children did not have a formal FDD diagnosis established by a gastroenterologist or pediatrician were asked to respond to a screening questionnaire based on the FC and FNRFI Rome IV criteria and referred for further assessment if needed.

Ethical Review and Informed Consent

This study was approved by the ethics review board of Üsküdar University (61351342/KASIM 2022-20). Potential participants were thoroughly informed about the study, and all those who chose to participate signed an informed consent form.

Turkish Toileting Habit Profile Questionnaire – Revised

The TR-THPQ-R, developed and field-tested as described in Phase 1, was used to gather data concerning challenging defecation behaviors and reactions potentially related to SID. A printed version was given to the participants who were instructed to respond at their own pace in the presence of one of the researchers, who were available for clarifications as needed.

Sensory Processing Measure – Preschool

The SPM-P¹⁹ is a caregiver questionnaire designed to evaluate behavioral responses associated with daily sensory experiences (Vision, Hearing, Touch, Taste & Smell, Body Awareness, Balance & Motion) and age-appropriate praxis challenges (Planning & Ideas) across diverse contexts and age demographics. The SPM-P also has a subscale pertaining to social competence (Social Participation), a functional ability reliant on sensory integrative capabilities. The SPM-P aligns with the ASI framework and seeks to identify potential issues related to sensory hyperreactivity (excessive response), sensory hyporeactivity (i.e. perception difficulties: reduced response, inability to recognize and interpret sensory stimuli), as well as challenges in postural control and praxis.

In this study, we used the Turkish version of the SPM-P²¹ for caregivers of children aged from 2 to 5 years. The questionnaire consists of 75 items divided across eight subscales (Vision, Hearing, Touch, Taste and Smell, Body Awareness, Balance and Motion, Planning and Ideas, Social Participation), which caregivers typically take approximately 15 to 20 minutes to complete.

Reliability

Cronbach's alpha was used to determine the degree of internal consistency. Responses to the items were expected to be highly correlated with other items and the total scale. An analysis was performed on the hyperreactivity items (1–15), given that these items intend to measure the same construct. Cronbach's alpha values range from 0 to 1, and although the interpretation of the coefficient is not unanimous among researchers, an α value ≥0.80 is generally considered high and indicates that the scale is highly reliable.²²

Test–retest reliability is the degree of agreement between two sets of measurements from two tests given to the same group. The correlation coefficient (r) between two sets of values indicates the degree of reliability. For subjective tests such as questionnaires, correlations greater than or equal to 0.50 are acceptable.²³ The TR-THPQ-R was administered twice with an interval of 3 weeks for a subgroup of participants who agreed to be contacted 3 weeks after the initial data collection.

Validity

The known groups validity, also known as extreme-group, is one method for determining construct validity. It is shown when an evaluation tool can distinguish between two groups that differ in the variable of interest.²⁴ The expectation was that the TR-THPQ-R would clearly distinguish between two extreme groups (lower and upper 27%). Additionally, we used the receiver operating characteristic (ROC) curve to determine the cut-off value and discriminate between normal and abnormal scores, as well as an independent sample t-test between the NO-FDD and FDD groups.

Convergent validity pertains to the extent to which two measurements that are theoretically expected to be correlated are, indeed, correlated.²⁵ Consequently, when a test has a strong correlation with other tests designed to measure conceptually related domains, convergent validity is present.²³ Using Spearman's correlation, we examined the relationship of the hyperreactivity items of the TR-THPQ-R (1–15; few or no problems = high score) with the hyperreactivity items of the SPM-P (9,17, 20, 21, 23, 26–33, 35, 37–41, 45, 46, 56, 57, 62, 66; few or no problems = low score). Words commonly used to characterize exaggerated reactions to sensation, such as anxiety, discomfort, pain, avoidance, refusal, or stress,²⁶ were used to choose the items for a composite SPM-P sensory hyperreactivity score.

Results

Phase 1: Translation and Cultural Adaptation

A native Turkish-speaking professional occupational therapy assistant, with knowledge of English and a background in translation, translated the scale from English to Turkish and created a report highlighting uncertainties and the rationale for the choice of terms. Simultaneously, a native Turkish interpreter translated the THPQ-R into Turkish and produced a report. There was a high degree of agreement between the two versions, and synthesis into a single Turkish version was easily achieved.

The back translation into English was carried out by two different native Turkish translators; it was not possible to find translators whose mother tongue was the source language (English) and who were fluent in the target language (Turkish), as recommended. The back-translations and reports were analyzed in a meeting with the experts (2^nd and 3^rd authors) and the THPQ-R's author. The integrity of the intended meaning was confirmed.

In the pretesting phase, eight caregivers were questioned about their comprehension of the items; all reported clarity, and no recommendations to change items were made. Given the favorable responses of caregivers, no additional field tests were performed, and the TR-THPQ-R was considered ready for use in Phase 2.

Phase 2: Reliability and Validity

Participants

In the time interval planned for data collection, 108 participants were recruited, including 84 caregivers of children without FDD and 24 caregivers of children with FDD. Age, sex, and FDD status are shown in Table 1. There was no significant difference between the TR-THPQ-R scores (mean, standard deviation [SD]) of girls (28.200 ± 2.825) and boys (28.377 ± 2.322; t[106] = −0.356, p = 0.723); therefore, all subsequent analyses were performed collectively.

Table 1
Age, gender, and FDD status of the children

		No-FDD	FDD	Total
Gender
	Female	41	14	55
	Male	43	10	53
Age (years)
	3	15	6	21
	4	19	8	27
	5	50	10	60

• Abbreviation: FDD, functional defecation disorder.

Reliability

As expected for internal consistency reliability, Cronbach's alpha was high (0.833), and all items were found to contribute to the scale. The item-scale statistics for the effect of the items on internal consistency are presented in Table 2.

Table 2
Item scale statistics

Omitted item	Score when item deleted	Variance when item deleted	Item-total correlation	Cronbach's alpha when item is deleted
THPQ1	26.35	5.969	0.518	0.821
THPQ2	26.38	5.939	0.445	0.824
THPQ3	26.33	6.093	0.496	0.823
THPQ4	26.46	5.260	0.712	0.804
THPQ5	26.34	6.302	0.453	0.832
THPQ6	26.52	5.074	0.734	0.801
THPQ7	26.34	6.040	0.497	0.822
THPQ8	26.42	5.759	0.483	0.821
THPQ9	26.46	5.728	0.427	0.826
THPQ10	26.32	6.296	0.449	0.830
THPQ11	26.38	6.107	0.442	0.831
THPQ12	26.39	5.810	0.514	0.820
THPQ13	26.45	5.446	0.611	0.812
THPQ14	26.39	5.866	0.473	0.822
THPQ15	26.47	6.308	0.419	0.831

• Abbreviation: THPQ, toileting habit profile questionnaire.

The correlation within the test–retest measurements was found to be high (0.984). There was no significant difference between the test (28.69 ± 1.89) and retest (28.81 ± 1.83) values (t[15] = −1.464, p > 0.05).

Validity

The independent samples t-test between the lower and upper 27% of scores on the TR-THPQ-R clearly distinguished between the groups (p < 0.05; Table 3). The areas under the ROC curves (Fig. 1) were statistically significant (p < 0.05), and the optimum cutoff point was determined to be ≤ 27. The sensitivity and specificity at the cutoff point were 100 and 94.05, respectively (Youden index J = 0.941 [0 < J = 0.941 < 1]). The positive (n = 24) and negative (n = 84) groups matched the actual positives (FDD = 24) and negatives (NO-FDD = 84). Moreover, an independent samples t-test to compare the scores of the NO-FDD and FDD groups revealed a clear difference. As expected, the TR-THPQ-R scores of the NO-FDD group (x = 29.381 ± 1.161) were significantly higher than those of the FDD group (x = 24.458 ± 2.5369), t[106] = 13.586, p < 0.05).

Table 3
Independent samples t-test of extreme groups' TR-THPQ-R scores

Groups	Lower 27% (n = 29)		Upper 27% (n = 29)		t	SD	p-value
	Mean	SD	Mean	SD
TR-THPQ-R score	24.690	2.436	30.000	0.000	-11.738	56	0.000

• Abbreviations: SD, standard deviation; TR-THPQ-R, Turkish toileting habit profile questionnaire – revised.

Fig. 1
Receiver operating characteristic curve.

Spearman's rank-order correlation was used to assess the relationship between the TR-THPQ-R and SPM hyperreactivity items of both scales. Preliminary analysis showed that the relationship was monotonic, as assessed by visual inspection of a scatterplot. As expected, there was a statistically significant, moderate negative (THPQ-R high score and SPM low score represent few problems) correlation between the items (r_s = −484, p < 0.001).

Discussion

The THPQ-R now has a culturally adapted, valid, and reliable Turkish version for use in clinical practice and research. In our study, we evaluated the validity and reliability of the TR-THPQ-R, a screening questionnaire used to help identify challenging defecation behaviors and reactions related to sensory hyperreactivity in children aged 3 to 6 years. Findings related to internal consistency reliability, known-group validity, and concurrent validity are similar to previous studies carried out with the original THPQ-R. This study adds test–retest reliability, a feature that has not been previously explored.

The fundamental characteristics of sensory hyperreactivity, a subtype of SID, are well understood and can be recorded through caregiver surveys, family interviews, and observation.²⁷ However, tools to examine the sensory responses during toileting are lacking. This void is addressed by the THPQ-R, which offers specific data to substantiate the relationship between sensory hyperreactivity and toileting participation. Considering that children with FDD have been found to have sensory problems and that participation in toileting routines is part of conventional medical management, this is of utmost importance.⁴,⁹,¹⁰

Internal consistency analysis demonstrated the high reliability of the TR-THPQ-R (α = 0.833). The internal consistency data of the original (α = 0.93)¹⁵ and Italian versions of the THPQ-R (α = 0.760)²⁸ are in accordance with our data and support the reliability of the Turkish version. Additionally, all items were found to be pertinent and contribute to the scale, as previously reported by Berardi et al.,²⁹ who used the Italian version with children with autism (α = 0.763).

The replicability and time-dependent invariance of the TR-THPQ-R were examined using test-retest applications and revealed reliable measurements (ICC: 0.856; p < 0.05). The test–retest reliability has not previously been examined, and the findings of our study provide additional data supporting the reliability of the THPQ-R.

To explore known-group validity, an independent samples t-test between the lower and upper 27% of scores, as well as between the scores of the NO-FDD and FDD groups, was carried out. In both analyses, the questionnaire discriminated between groups. These findings are in line with research using both the current and previous versions of the questionnaire, which successfully differentiated between children with and without FDD.⁴,¹⁷

The original version of the THPQ demonstrated discriminative validity by effectively identifying children with FDD, who had not responded to an initial course of conventional medical treatment prescribed by their pediatrician.¹,⁷ Subsequently, the revised THPQ was also shown to differentiate between children aged 3 to 6 years with and without FDD in cases characterized as uncomplicated.⁴ Collectively, these findings and our current results provide evidence that the THPQ-R is a reliable instrument for identifying atypical toileting behaviors associated with FDD.

To establish an optimal cutoff score for the scale, the ROC curve analysis was conducted. This method allows for evaluation of the scale's discriminative ability by quantifying its sensitivity and specificity across a range of threshold values. The cut-off point of the THPQ-R was established at ≤ 27. Thus, scores ≤ 27 can be considered atypical and indicative of possible underlying sensory hyperreactivity issues. This finding is consistent with the original study⁴ of the THPQ-R, in which only one child in the NO-FDD group (n = 140) scored 27, with all other children in the group scoring 28 or above.

Regarding convergent validity, the hyperreactivity items of the TR-THPQ-R correlated with the hyperreactivity items of the SPM-P (r_s = −0.484). These values are comparable to those found in prior studies examining the convergent validity of the revised⁴ and original THPQ¹⁷ with data from the hyperreactivity items of the Short Sensory Profile (SSP), with low scores indicating more problems).³⁰ Beaudry-Bellefeuille et al. reported a Spearman correlation of r_s = 0.423 between hyperreactivity items of the THPQ and the SSP.¹⁷ Similarly, using the THPQ-R, a moderate positive correlation with the hyperreactivity items of the SSP was again reported (r_s = 0.485).⁴ Collectively, these results reveal that higher levels of sensory hyperreactivity are associated with a higher frequency of challenging defecation and toileting behaviors described in the hyperreactivity section of the THPQ-R, thus supporting convergent validity and contributing to the construct validity of the THPQ-R.

Conclusion

The THPQ-R screens for sensory-based defecation difficulties and investigates child participation challenges that may contribute to ongoing FDD.⁴,¹⁵ The implementation of regular toileting routines, such as sitting on the toilet after meals and acceptance of the sensation related to passing stools to break the habit of stool withholding, are central components of conventional medical management for FDD⁶ which may be impacted by SID. Occupational therapists are actively involved in the identification and treatment of sensory concerns that impact engagement and participation. Therefore, multidisciplinary teams that include occupational therapists with knowledge and tools to identify the underlying sensory factors linked to toileting participation issues may improve outcomes for children and families struggling with FDD. Turkish clinicians and researchers now have access to the TR-THPQ-R, a unique tool that complements conventional assessment and treatment planning for FDD.

• Funding
  The authors declare that they did not receive funding from agencies in the public, private, or non-profit sectors to conduct the present study.
• What is already known on this topic:
  Sensory issues are common in children with defecation disorders and can impact conventional medical management. The THPQ-R screens for sensory-based defecation difficulties and investigates child participation challenges that may contribute to ongoing defecation disorders. However, there are no culturally valid and reliable tools to assess these problems.
• What this study adds:
  Data from the Turkish sample confirms previous validity and reliability studies using the THPQ-R in other populations. Additionally, this study contributes to the questionnaire's overall reliability by reporting adequate test–retest reliability.
• How this study might affect research, practice or policy:
  Turkish clinicians and researchers now have access to the Turkish version of the THPQ-R, a unique tool that complements conventional assessment and treatment planning for defecation disorders in children.

Acknowledgements

The authors would like to kindly acknowledge all the parents who took the time to answer the questionnaires as well as the Pediatric Gastroenterology Department of Medipol University Mega Hospital for referring participants to the present study. They would also like to thank the translators (Ahmet Burak Can, Halil İbanoğlu, Setan Ceylan, Deniz Hemen Aydınand) and Dr. Sevda Asqarova for their support throughout this project.

Data Availability

Data will be available upon request to the corresponding author.

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Edited by

• Editor-in-Chief:
  Henrique Sarubbi Fillmann.

Publication Dates

• Publication in this collection
  22 June 2026
• Date of issue
  Jan-Mar 2026

History

• Received
  08 Aug 2025
• Accepted
  06 Feb 2026