Prevalence of incontinence, attention deficit/hyperactivity disorder and oppositional defiant disorder in preschool children

Prevalence of previously undiagnosed psychiatric symptom groupings in pediatric patients with bladder and bowel dysfunction

INTRODUCTION AND OBJECTIVE

The incidence of concomitant psychiatric disorders in conjunction with bladder and bowel dysfunction (BBD) is thought to be higher than the general population. The identification of these disorders with validated tools followed by management may improve urological outcomes. The objective of this study was to determine the prevalence of undiagnosed psychiatric symptom groupings in children presenting with BBD.

METHODS

Consecutive patients 6-18 yrs with a clinical diagnosis of BBD, a score ≥11 on the Vancouver Symptom Score (VSS) and no prior psychiatric diagnoses were recruited. Two validated questionnaires (Child Behavior Checklist for Ages 6-18 (CBCL) and Autism Spectrum Quotient 10 (AQ-10)) were used to screen for psychiatric comorbidities. Descriptive statistics for demographic variables were presented. Distribution of VSS for normal & abnormal categories (borderline/clinical) of CBCL scores were compared by Mann-Whitney U test. Spearman correlation coefficient was used to examine the relationship between VSS domain scores and CBCL.

RESULTS

From Sept 2017-May 2022, 50 (17 male) of 110 eligible patients completed the study. Median VSS was 18 (11-33), indicating significant BBD. In 36 patients (72 %), at least one of the CBCL subscales scored as borderline/clinical. Thirty-two patients (64 %) scored in the abnormal range for Internalizing symptoms, 21 (42 %) for Externalizing symptoms, and 31 (62 %) for Total problem scores. Four patients of 48(8 %) scored ≥6 on the AQ-10. The only significant correlation found between CBCL and VSS sub scores was with the Bowel Habit Domain of VSS and Internalizing CBCL T-scores (P = 0.02).

CONCLUSION

This study identified a high prevalence of previously undiagnosed psychiatric symptom groupings in patients presenting with BBD, with a higher prevalence of internalizing and externalizing symptoms and autism traits than reported in the general population. These findings should encourage urologists to use validated tools to screen for psychiatric comorbidities with referral for further assessment as appropriate. This may prevent unnecessary urological testing, save valuable health resources and potentially improve treatment outcomes of BBD in this population.

Attention-deficit/hyperactive-impulsive disorder symptoms among grade 1 students with reading disorder in Thailand

BACKGROUND

Reading disorder is the most common comorbid condition with attention-deficit/hyperactive-impulsive disorder (ADHD) in school-aged children.

PURPOSE

This study compared symptoms of ADHD among children in grade 1 at risk of reading disorder with children not at risk.

METHODS

This cross-sectional study included 703 students in grade 1 aged 6-8 years from 8 schools in Pathumthani Province, Thailand, in 2019. Reading disorder was assessed using tools developed by Vibulpatanavong and Evans for Thai teachers, whereas the Thai parent and teacher versions of the Swanson, Nolan, and Pelham IV Rating Scale (SNAP-IV) was used to evaluate ADHD symptoms. Demographic data were collected from parents using a self-reported questionnaire.

RESULTS

Among the 703 students with almost equal number of male (n=350) and female (n=353), and the average age of 6.56±0.57 years, 95 (13.51%) were classified (significantly male) at risk of reading disorder. The mean SNAP-IV scores of children with reading disorder reported by parents and teachers (20.23±10.95 and 20.75±15.08, respectively) were significantly higher than those of neurotypical children (16.04 ±8.59 and 9.00±10.14, respectively, P<0.05). Of the 95 students with reading disorder reported by parents and teachers, 29 (30.53%) and 20 (21.05%) respectively, were defined as having ADHD according to the standard cutoff SNAP-IV scores, which were significantly higher than 608 neurotypical students at 108 (17.76%) and 20 (5.59%) (P<0.05). The odds ratios of children with reading disorder having ADHD symptoms according to teacher reports were 3.32 (95% confidence interval [CI], 1.14-9.67; P<0.05), 3.75 (95% CI, 1.60-8.79; P<0.05), and 4.41 (95% CI, 1.20-16.15; P<0.05) for inattentive, hyperactive, and combined presentations, respectively.

CONCLUSION

Grade 1 students with reading disorder had a significantly higher prevalence of ADHD symptoms than neurotypical students. Therefore, children with reading disorders should undergo ADHD assessments and receive proactive intervention.

Anxiety disorders, depression and incontinence in preschool children-A population-based study

OBJECTIVE

The aim was to examine associations of specific anxiety disorders, depressive symptoms, and incontinence in a representative, population-based sample of preschool children.

METHODS

All preschool children of a defined geographical area examined before school-entry were included. Parents completed a questionnaire including the Preschool Feelings Checklist (PFC), eight questions referring to nocturnal enuresis (NE), daytime urinary incontinence (DUI), fecal incontinence (FI) and constipation, and 30 items regarding Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition (DSM-5) diagnostic criteria of separation anxiety disorder (SAD), social phobia (SOC), specific phobia (PHOB), and generalized anxiety disorder (GAD). Data of 1206 children (mean age = 5.7 years; 53.5% boys) are presented.

RESULTS

34.6% of incontinent children had an anxiety disorder based on DSM-5 criteria and 13.3% had clinically relevant depressive symptoms (measured by the PFC). Rates of incontinence overall were 14.1% (11.9% NE, 3.1% DUI, and 1.8% FI) and 6.3% for constipation. Rates of SOC and PHOB were increased in NE (20.8% and 25.4%), DUI (39.3% and 34.5%) and FI (35.3% and 50.0%) compared to continent children (13.5% and 17.2%). Children with constipation had higher rates of SOC, PHOB, and GAD than those without. Compared to continent children (9.7%), depressive symptoms were more frequent in children with NE (26.8%), DUI (50.0%), and FI (61.9%).

CONCLUSION

Anxiety disorders and depressive symptoms are common in children with incontinence. The most specific DSM-5 disorders associated with incontinence are SOC and PHOB, which can be incapacitating and may require treatment. Due to the high rates of anxiety disorders, it is important to screen all children with incontinence, for example, with specific questionnaires.

Systematic review and meta-analysis: relationships between attention-deficit/hyperactivity disorder and urinary symptoms in children

Lower urinary tract symptoms (LUTS), e.g., urinary frequency, pressure, urgency, and overactive bladder syndrome, are commonly reported in children with attention-deficit/hyperactivity disorder (ADHD). Understanding the co-occurrence of these conditions has implications regarding clinical approaches, treatments, and improved quality of life. We conducted a systematic review and meta-analysis to examine the relationships between LUTS and ADHD in children. We searched for articles published between January 1990 and July 2019, in PubMed, CENTRAL, and PsycNet. Two authors independently screened all articles and extracted data. We performed random-effect meta-analyses for ADHD with pooled outcomes for LUTS. We identified 119 relevant articles in the literature and 18 articles fulfilled the inclusion criteria for the systematic review, of which, 5 articles had sufficient data for meta-analysis. Examining ADHD among individuals with LUTS, the odds ratio was 2.99 (95% CI 1.13, 7.88, p < 0.001), compared to controls. In multiple studies, the mean overall score for LUTS, using a standardized measure, was significantly higher in patients with ADHD in comparison to controls, and the severity of ADHD was positively associated with the severity of LUTS. Younger age in children was correlated with a higher LUTS score. Different subtypes of urinary incontinence demonstrated differences in behavioral problems and psychiatric comorbidity. Sex differences in LUTS were not consistent across articles. Our results indicate clinically significant associations between ADHD and LUTS in children. Because LUTS and ADHD are common disorders in children, clinicians should be aware of these associations as they inform optimal assessment and treatment strategies.

Attention deficit and hyperactivity disorder and nocturnal enuresis co-occurrence in the pediatric population: a systematic review and meta-analysis

BACKGROUND

Attention deficit and hyperactivity/impulsivity disorder (ADHD) and enuresis are common behavioral disorders in childhood, impacting adolescence and adult life. Enuresis (NE) is an incontinence disorder frequently observed in children with ADHD. The relationship between ADHD and NE has been a matter of debate.

OBJECTIVES

We aimed to verify the relationship between ADHD and enuresis and how these conditions can modify each other during development. Using PRISMA guidelines, under the PROSPERO registration number CRD42020208299, we systematically searched the literature and conducted a meta-analysis to answer the following question: how frequent is ADHD and enuresis comorbidity? Twenty-five studies were fully read, and data from seven less heterogeneous case-control studies were pooled to estimate enuresis prevalence comparing ADHD and control samples, whereas six studies were combined to evaluate ADHD frequencies in children with and without enuresis.

RESULTS

We found the ADHD rates in children with enuresis are similar to the enuresis rates in the group of children with ADHD. The presence of ADHD and enuresis comorbidity does not seem to play a role in gender distribution and the presence of other comorbidities in comparison to controls. However, enuresis seems to persist for more time in children with ADHD.

LIMITATIONS

The selected papers differed in study type, research question, samples, and controls utilized.

CONCLUSIONS

Our systematic review with meta-analysis supports the reciprocal association between enuresis and ADHD. Further studies are necessary to build more robust evidence.

Non-mental diseases associated with ADHD across the lifespan: Fidgety Philipp and Pippi Longstocking at risk of multimorbidity?

Several non-mental diseases seem to be associated with an increased risk of ADHD and ADHD seems to be associated with increased risk for non-mental diseases. The underlying trajectories leading to such brain-body co-occurrences are often unclear - are there direct causal relationships from one disorder to the other, or does the sharing of genetic and/or environmental risk factors lead to their occurring together more frequently or both? Our goal with this narrative review was to provide a conceptual synthesis of the associations between ADHD and non-mental disease across the lifespan. We discuss potential shared pathologic mechanisms, genetic background and treatments in co-occurring diseases. For those co-occurrences for which published studies with sufficient sample sizes exist, meta-analyses have been published by others and we discuss those in detail. We conclude that non-mental diseases are common in ADHD and vice versa and add to the disease burden of the patient across the lifespan. Insufficient attention to such co-occurring conditions may result in missed diagnoses and suboptimal treatment in the affected individuals.

Neurodevelopmental and psychiatric disorders in pediatric bladder and bowel dysfunction

BACKGROUND

Bladder and bowel dysfunction (BBD) is a common pediatric problem that describes a constellation of lower urinary tract symptoms associated with constipation and/or encopresis. Its association with neurodevelopmental and psychiatric (NDP) problems is not well understood.

OBJECTIVES

Our primary aim was to identify pre-existing NDP disorders in children with BBD. Secondarily, we aimed to screen for new behavioral problems and evaluate the association between bladder or bowel symptoms and behaviors symptoms.

METHODS

A cross sectional study was conducted in urology clinics. New patients referred for BBD between 4 and 17 years old were recruited and completed: a demographics survey, Dysfunctional Voiding Score System questionnaire, assessment of bowel movements with the Bristol Stool Scale, and Strength and Difficulties questionnaire (SDQ). Those with known spinal dysraphism were excluded. SDQ scores were evaluated for abnormal screens in different subscales and total difficulties scores. Pearson correlation analyses were conducted for association.

RESULTS

We included 61 participants (age 9.5 ± 4.1 years), including 33 females and 28 males. One or more pre-existing NDP disorder(s) was reported in 14 (23%) children; most commonly being learning disability (43%) and attention deficit hyperactivity disorder (29%). This cohort had more severe BBD symptoms as reflected in DVSS scores. SDQ scores demonstrated that 12 patients without pre-existing NDP diagnoses scored in the clinical range, with hyperactivity as the most common difficulty (6/12; 50%).

CONCLUSIONS

A significant proportion of children with BBD have a comorbid NDP disorder and present with more severe symptomatology. The SDQ can be used as a behavioral screening tool this population for the identification of children who may benefit from formal developmental pediatrics assessment.

Psychopathology and Parental Stress in 3-6-Year-Old Children with Incontinence

Objective: Incontinence and functional gastrointestinal disorders are common in young children and are associated with higher rates of psychological symptoms and mental disorders. This article focuses on the mutual association between incontinence and related toilet refusal syndrome, parental stress, and children's psychopathology especially in young children. Methods: Children's psychological symptoms, mental disorders, and parental stress levels were assessed in 38 parent-child dyads involving children with incontinence and 42 dyads of typically developing (TD) children. Results: Compared to TD children, patients had higher internalizing and externalizing CBCL scores and higher rates of clinically relevant externalizing problems. However, the rates of clinically relevant internalizing problems and mental disorders did not differ. The parents of children with incontinence reported significantly higher stress levels regarding child-related stress factors (PSI-CD) than did parents of TD children. However, there were no clinically relevant parental stress scores on a group level, which remained below the clinical range (T-value < 60). When simultaneously analyzed, children's (comorbid) mental disorders but not incontinence had a major impact on parental stress. Conclusions: Despite moderate stress levels, incontinence symptoms, urinary and fecal incontinence are highly prevalent in young children. However, stress among parents of young children was mainly elicited by any (comorbid) mental disorder.

Psychological differences between toilet trained and non-toilet trained 4-year-old children

OBJECTIVE

Late to complete toilet training has been associated with many psychological factors including behavior and mood problems. Unfortunately, the majority of the research is specific to children with elimination disorders or children identified as incontinent after the age of 7 years. The current study addressed gaps in the literature by comparing the psychological functioning of children not toilet trained by their 4-year-old well child care visit with their toilet trained peers.

DESIGN AND METHODS

Parent reports of internalizing and externalizing behavior using the Child Behavior Checklist (CBCL) were compared across groups, non-toilet trained and toilet trained, for 150 children recruited during their 4-year-old well child health care visit. Independent samples t tests of group means and χ² analyses were performed on all CBCL scales.

RESULTS

Results found no clinically or statistically significant differences between groups on parents' reports of internalizing and externalizing behavior. The current study provides no evidence that delays in successfully completing toilet training by 4 years of age were related to psychological problems for this sample of children.

PRACTICE IMPLICATIONS

Nursing professionals in primary care settings are positioned to provide anticipatory guidance to parents of children not yet toilet trained. Findings from the current study offer evidence that delays in toilet training might not be related to psychopathology, and these children are not likely to require intervention outside the pediatric setting and could be effectively managed by primary care health providers employing evidence-based toilet training protocols.

Psychiatric comorbidities of children with elimination disorders

Enuresis and encopresis can be stressful for children and parents. We investigated the comorbid psychiatric disorders and the emotional and behavioral symptoms associated with elimination disorders. A total of 97 children and adolescents (aged 4-17 years) with an elimination disorder participated in this study. The elimination disorder group consisted of three subgroups: 50 subjects with enuresis nocturna, 26 with encopresis, and 21 subjects with enuresis+encopresis. The control group with no elimination disorder comprised 50 healthy subjects. All children were interviewed by a child and adolescent psychiatrist. Comorbid psychiatric disorders were assessed using the Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime version (K-SADS-PL). Parents completed the Strengths and Difficulties Questionnaire. The most common diagnosis was attention-deficit/hyperactivity disorder, followed by oppositional defiant disorder. The highest rate of psychiatric comorbidity was observed in the enuresis+encopresis subgroup, followed by the enuresis nocturna and encopresis subgroups. All the subgroups had higher total difficulties scores than the control group. Screening for psychiatric disorders should be performed for all children with incontinence.

Reducing Aggression Using a Multimodal Cognitive Behavioral Treatment Approach: A Case Study of a Preschooler With Oppositional Defiant Disorder

Individual cognitive behavioral therapies (CBT) have been shown to be effective in decreasing disruptive behaviors in children and adolescents; however, less is known regarding their efficacy with preschoolers given the developmental limitations accompanying this age range. The current case study extends the use of individual CBT to a preschool aged girl with oppositional defiant disorder (ODD), and is the first to investigate its efficacy in combination with behaviorally-based parent training and classroom teacher consultation. A total of 18 CBT sessions with the child and her parents, in addition to school observations and on-site and phone consultations with teachers, were conducted over a 4-month period. Post-treatment and 2-month follow-up assessments demonstrated significant decreases in physical aggression and property destruction, as well as for parent and teacher reported internalizing and externalizing symptoms. Collectively, results of the case study provide preliminary evidence that a multimodal approach can be applied effectively to treat behavioral problems in preschool-age children.

Association between stress and lower urinary tract symptoms in children and adolescents

INTRODUCTION

Lower urinary tract dysfunction (LUTD) is a common clinical condition. Emotional and behavioral issues are increasing among children and adolescents, with stress indicating difficulties in personal and social functioning. This study evaluated whether urinary tract symptoms (LUTS) is associated with stress.

MATERIALS AND METHODS

A cross-sectional, analytical study with 6-14-year-old patients with LUTS and no anatomical/neurogenic urinary tract abnormalities was conducted using the Dysfunctional Voiding Scoring System, a psychological assessment and the Child Stress Scale. The overall stress score was analyzed in relation to the psychological assessment data. Answers to the seven specific DVSS urinary questions were compared with those for the four Child Stress Scale domains. Univariate and multivariate analyses were performed. The chi-square test and Pearson's correlation were used to determine associations. Significance was defined as p <0.05.

RESULTS

Most children were male (56%). Mean age was 9.0±2.25 years. Stress was detected in 20 out of 98 patients (20.4%; 95% CI: 13-30%).Of these, 90% were born from unplanned pregnancies and 67% were upset about their disorder. All the Child Stress Scale domains were significantly associated with urinary dysfunction, with dysuria being significantly associated with all four domains. In the multivariate analysis, dysuria was the only symptom that remained associated with stress. Associations with stress strengthened as the frequency of dysuria increased: physical reactions (p <0.01), emotional reactions (p <0.05), psychological reactions with a depressive component (p<0.01) and psychophysiological reactions (p <0.05).

CONCLUSION

Stress levels are higher in children and adolescents with LUTS who have more severe symptoms. Dysuria was the symptom most associated with stress, both in the physical reactions domain, in the psychological reactions domains with or without a depressive component and in the psychophysiological reactions domain.

Doctor, Snitch, and Weasel: Narrative Family Therapy With a Child Suffering From Encopresis and Enuresis

Children who experience enuresis and encopresis can face many difficulties, including social isolation, shame, embarrassment, anxiety, and depression. Due to the prevalence of enuresis and encopresis, it is essential for mental health professionals to understand the common symptoms and available treatment options for enuresis and encopresis, particularly to assist parents struggling to help their children overcome these challenges. Despite this need, there is very little clinical literature that incorporates a systemic approach for families who have a child diagnosed with enuresis and encopresis. Furthermore, common treatment approaches may unwittingly reinforce children’s perception that these problems are rooted in their identity. In an effort to address these concerns, the present case study aims to illustrate how a narrative therapy approach was utilized to effectively treat a child with enuresis and encopresis. Narrative therapy can uniquely assist children and their parents by helping them externalize the problem, overcome the problem-saturated view of their lives, and create new experiences where the problem is nonexistent.

The overlooked association between lower urinary tract dysfunction and psychiatric disorders: a short screening test for clinical practice

INTRODUCTION

Lower urinary tract dysfunction (LUTD) often presents with other associated comorbidities such as urinary tract infections, constipation, fecal incontinence, and vesicoureteral reflux. However, the psychiatric conditions that can be associated with LUTD tend to go unnoticed. The evaluation, diagnosis, and treatment of LUTD and psychiatric disorders in children are difficult and time-consuming. Moreover, there is currently no accepted consensus on this subject.

OBJECTIVE

In this study, the authors aimed to investigate the relationship between the subgroups of both LUTD and psychiatric disorders.

STUDY DESIGN

LUTD were divided into 4 groups by using voiding dysfunction symptom score (VDSS), bladder diary, and uroflowmetry/electromyography (UF/EMG) test. A short screening test for psychological problems was used to detect psychiatric disorders accompanying each LUTD group. In terms of psychiatric disorders, the patients were divided into two groups: externalizing and internalizing disorders.

RESULTS

A total of 156 children were diagnosed with LUTD. Seventy-six patients had overactive bladder (OAB), 53 had dysfunctional voiding (DV), 14 had primary bladder neck dysfunction (PBND), and 13 had underactive bladder (UAB). Psychiatric disorder was detected in 46 children (29.4%). Of these, 32 had an externalizing and 14 had an internalizing disorder. In terms of age, externalizing disorders were more common in children aged between 6 and 11 years (87.5%), whereas internalizing disorders were seen equally in both age groups. Among these, attention deficit hyperactivity disorder (ADHD) was the most common psychiatric disorder (16.1%). The LUTD groups with the most frequent psychiatric disorders were UAB (53.8%), PBND (35.7%), and OAB (28.9%).

DISCUSSION

Most of the studies investigating the relationship between the lower urinary tract and psychiatric disorders so far have been concerned with the lower urinary tract symptom (LUTS) (such as nighttime or daytime incontinence) and ADHD. However, the present study was performed according to the LUTD classification, which is primarily based on VDSS, bladder diary, and UF/EMG tests. Furthermore, psychiatric disorders were classified into their subgroups. The results have shown that around a quarter of children with LUTD also had comorbid psychiatric disorders. The relationship between LUTD and psychiatric disorders constitutes a critical point. Identifying this association can contribute to the comprehensive diagnosis and treatment for these patients.

CONCLUSIONS

LUTD and psychiatric disorders can be seen together, and this can be detected by the short screening test for psychological problems. Therefore, the authors think that patients who applied with LUTS should undergo this short test along with the routine urinary system examination and tests.

Emotional and behavioral problems in children and adolescents with lower urinary tract dysfunction: a population-based study

BACKGROUND

An association has been found between lower urinary tract dysfunction (LUTD) and emotional and behavioral problems, particularly in cases of urinary incontinence. Other associated symptoms and the coexistence of functional constipation require further investigation.

OBJECTIVE

To assess whether emotional and behavioral problems are more common in children and adolescents with LUTD.

STUDY DESIGN

A multicenter, cross-sectional, population-based study conducted in public places. Parents answered questions on urinary and psychological symptoms in their children aged 5-14 years. Children/adolescents with neurological problems or anatomical urinary tract abnormalities were excluded. The Dysfunctional Voiding Scoring System was used for assessing urinary symptoms, the Rome III Diagnostic Criteria for evaluating bowel symptoms, and the Strengths and Difficulties Questionnaire (SDQ) for evaluating emotional and behavioral problems.

RESULTS

Of the 806 children/adolescents included, 53% were female. The mean age was 9.1 ± 2.7 years. The prevalence of LUTD was 16.4%. Overall, 26.2% had abnormal scores in the overall SDQ scale, 29.2% in the emotional problems subscale, and 30% in the conduct problems subscale. Of the children with LUTD, 40.5% screened positive for emotional/behavioral problems, with a significant association being found for the overall SDQ scale (P < 0.001) and for the emotional problems (P < 0.001), conduct problems (P < 0.001), and hyperactivity (P = 0.037) subscales. Urinary urgency, urinary incontinence, and voiding postponement were significantly associated with a greater prevalence of abnormalities in the overall SDQ score (P = 0.05; P = 0.004, and P = 0.012, respectively). Bladder and bowel dysfunction was an aggravator of emotional and behavioral problems, with more intense symptoms, both in the overall SDQ scale and in the subscales. In the multivariate analysis, the factors independently associated with the presence of emotional and behavioral problems were LUTD (odds ratio [OR] = 1.91), constipation (OR = 1.7), studying in a government-funded school (OR = 2.2), and poor education of the head of the family (OR = 1.9).

CONCLUSIONS

Children and adolescents with LUTD have more emotional and behavioral problems, with bladder and bowel dysfunction being an aggravating factor for this association.

Attention Deficit Hyperactivity Disorder and Functional Defecation Disorders in Children

OBJECTIVES

The aim of the study was to assess the prevalence of attention deficit hyperactivity disorder (ADHD) in children presenting with functional defecation disorders (FDDs) and to assess the prevalence of FDDs in children with ADHD.

METHODS

A cross-sectional cohort study was carried out between September 2014 and May 2016. Group 1: Parents of children with FDDs according to the Rome III criteria completed the Child Behavior Checklist and the VvGK (Dutch questionnaire based on the American Disruptive Behavior Disorder rating scale). Patients with ADHD subarea scores ≥70 on the Child Behavior Checklist and/or ≥16 on the VvGK were referred for further psychiatric evaluation. Group 2: Parents of children treated for ADHD at a specialized ADHD outpatient clinic completed a standardized questionnaire regarding their child's defecation pattern.

RESULTS

In group 1 (282 children with FDDs), 10.3% (7.1%-13.5% bias-corrected and accelerate confidence interval) were diagnosed with ADHD. Group 2 consisted of 198 children with ADHD, 22.7% (17.6-28.8 bias-corrected and accelerate confidence interval) fulfilled the Rome III criteria for an FDD. Children with both an FDD and ADHD reported urinary incontinence significantly more often compared to children with an FDD or ADHD alone: 57.1% in FDD + ADHD versus 22.8% in FDD alone (P < 0.001) and 31.1% in ADHD + FDD versus 7.8% in ADHD alone (P < 0.001).

CONCLUSIONS

Approximately 10.3% of children with FDDs had ADHD and 22.7% of children with a known diagnosis of ADHD fulfilled the Rome III criteria for an FDD. This observation suggests that screening for behavioral disorders and FDDs should be incorporated into the diagnostic workup of these groups of children.

Nocturnal incontinence in children with fetal alcohol spectrum disorders (FASD) in a South African cohort

INTRODUCTION

Fetal alcohol spectrum disorders (FASD) are one of the leading preventable causes of intellectual disabilities (ID). Not much is known about the topic of pediatric incontinence related to FASD, for example nocturnal enuresis (NE), daytime urinary incontinence (DUI), and fecal incontinence (FI). So far, incontinence problems have been examined among children with other specific syndromes.

OBJECTIVE

The aim of the present study is to investigate the possible presence of incontinence among children with FASD in a South African cohort.

STUDY DESIGN

The South African version of the combined questionnaire including the "Parental Questionnaire: Enuresis/Urinary Incontinence" and "Encopresis Questionnaire - Screening Version"; and lower urinary tract symptoms (LUTS) were assessed by the "International-Consultation-on-Incontinence-Questionnaire - Pediatric Lower Urinary Tract Symptom" (ICIQ-CLUTS) among 99 interviewees (e.g. mothers, grandparents) of children with FASD. Moreover, scores on the "Griffiths Mental Development Scales - Extended Revised" (GMDS-ER) were obtained of all included children for further statistical analysis.

RESULTS

The overall incontinence rate was 20% (n = 20), in children diagnosed within the FASD spectrum (fetal alcohol syndrome or FAS n = 17, partial fetal alcohol syndrome or pFAS, n = 1, alcohol related neurodevelopmental disorder or ARND n = 2). NE affected 16% (n = 16) of children with a FASD (FAS n = 13, pFAS n = 1, and ARND n = 2). DUI was reported in one child (FAS), and FI in 4% (n = 4) of children (again, only FAS). No indication of lower urinary tract symptoms (LUTS) in the clinical range was reported (sample mean score = 5.17). Based on the GMDS-ER, 88% of the children scored lower than 10th percentile.

DISCUSSION

This is a first study to examine the problems of incontinence among children diagnosed within the spectrum of FASD. The rates for children with a FASD are lower than the rates for many children with special needs, but much higher than for typically developing children. Children with a FASD are mainly affected by NE.

CONCLUSION

The problem of incontinence among children with a FASD in South Africa needs to be assessed and considered for clinical management. Future research is necessary to examine problems of incontinence in relation to cognitive and behavioral functioning among children with a FASD, as well as identifying possible causes.

Importance of neuropsychiatric evaluation in children with primary monosymptomatic enuresis

BACKGROUND

Nocturnal enuresis (NE) is an involuntary voiding during sleep. It is a very common disorder in school-age children. Comorbid psychopathologies are common in patients affected by enuresis. According to the ICCS, the rate of behavioral and emotional disorders in children with enuresis is doubled compared with healthy control (HC) children.

OBJECTIVE

The aim of the present study was to investigate the prevalence of neuropsychiatric comorbidities in children affected by NE.

STUDY DESIGN

Two hundred children with a diagnosis of enuresis were recruited from the Neuropsychiatric Unit of Catania University and 200 age-matched neurologically intact HC children were recruited from local schools. The inclusion criteria were a normal IQ and the absence of other pathological clinical conditions such as diabetes or kidney malformation. The exclusion criteria were failure to complete the initial evaluation or clinical/diagnostic procedures, inability (because of young age) to complete study questionnaires, and severe neurological or physical impairment.

RESULTS

Age and gender proportions were not significantly different between the groups. In the NE group, 138 subjects (69%) had a familial history of NE, compared with 24 subjects (12%) in the HC group (p < 0.01). The NE group demonstrated significantly higher scores in the Child Behavior Check List, Conners' Multidimensional Anxiety Scale for Children, and the Child Depression Inventory compared than the HC group as well as the Yale Global Tic Severity Score and Child-Yale-Brown Obsessive Compulsive Scale scores (p < 0.01). Quality of life scores were significantly lower in the NE group than in the HCs group; specifically, between-group differences were significant in the relationship and self domains (p > 0.01 for both comparisons) (Figure).

DISCUSSION

The present case-control study evaluates the prevalence of different neuropsychiatric comorbidities in children with NE as diagnosed according to the new ICCS criteria. An important finding was that neuropsychiatric conditions were more prevalent in NE patients than in age-matched HC subjects. To the best of our knowledge, this is the first study to report associations between enuresis and obsessive compulsive disorder as well as tic disorder, and is the first to describe the comparative psychopathological profiles of 200 children with enuresis and 200 matched HC children.

CONCLUSION

The results suggest that clinicians should not underestimate the effects of enuresis on psychosocial development. Childhood NE should be managed carefully and comprehensively in order to prevent the development of more serious behavioral problems in the future.

Children with nocturnal enuresis have posture and balance disorders

INTRODUCTION

Integration of the neuromuscular system is required for maintaining balance and adequate voiding function. Children with enuresis have delayed maturation of the motor cortex, with changes in the sensory and motor systems. Along with various alterations, including the genetic, hormonal, behavioral, and sleep disturbances, and neuromotor and sensory deficits associated with nocturnal enuresis (NE) in children and adults, a consistent alteration in the posture of children with NE has been observed in the current practice. Because posture and the balance control system are strongly connected, this study aimed to investigate posture and balance in children and teenagers with NE.

MATERIAL AND METHODS

A total of 111 children with enuresis were recruited to the enuretic group (EG) and 60 asymptomatic children made up the control group (CG). The participants were divided into two age subgroups: (A) 7-11 years old, N = 77 for EG/A, N = 38 for CG/A; and (B) 12-16 years old, N = 34 for EG/B, N = 22 for CG/B. Balance was assessed using an electronic force plate (100 Hz) to calculate the area of the center of pressure (COP) displacement. The COP is the point that results from the action of vertical forces projected onto the force plate. Sensory integration was analyzed using a 60-s trial with the subject standing under four conditions: (1) eyes open, stable surface; (2) eyes closed, stable surface; (3) eyes open, unstable surface; (4) eyes closed, unstable surface. Posture was assessed by placing reflective anatomical landmarks on the anterior superior iliac spine, the posterior superior iliac spine, the greater trochanter, and lateral malleolus. A photograph was taken while the subject stood quietly. The angles were obtained from landmark connections using software to assess the following posture variables: pelvic ante/retroversion and pelvic ante/retropulsion.

RESULTS

The EG showed a greater area of COP displacement compared with the CG under all four sensory conditions and both subgroups, except for EG/B in condition 3. Regarding posture, EG showed higher pelvic anteversion angles than CG.

CONCLUSIONS

Enuretic children showed forward inclination of the pelvis and had worse balance compared with control children.

Impact of a multidisciplinary evaluation in pediatric patients with nocturnal monosymptomatic enuresis

BACKGROUND

Enuresis (NE) is a clinical condition of multifactorial etiology that leads to difficulties in child/adolescent social interaction.

METHODS

This was a prospective study on the impact of multidisciplinary assessment of 6- to 17-year-old patients with monosymptomatic nocturnal enuresis (MNE), including a structured history, clinical/neurological examination, bladder and bowel diaries, sleep diary and questionnaires, psychological evaluation [Child Behavior Checklist (CBCL) and PedsQL 4.0 questionnaires], urinary sonography, blood and urine laboratory tests, polysonography (PSG), and balance evaluation.

RESULTS

A total of 140 enuretic participants were evaluated, of whom 27 were diagnosed with NE complicated by urinary disorder, four with hypercalciuria, three with nephropathy and one with attention-deficit hyperactivity disorder. Among the 87 participants who underwent PSG, six were diagnosed with severe apnea. Of the 82 MNE patients who underwent full assessment, 62 were male (75.6 %), and the mean age was 9.5 (±2.6) years. A family history of NE was diagnosed in 91.1 % of first- and second-degree relatives, constipation in 89.3 % and mild/moderate apnea in 40.7 %. Balance control alteration was identified by physical therapy evaluation of MNE patients. Participants' quality of life evaluation scores were significantly lower than those of their parents.

CONCLUSION

Enuresis is a multifactorial disorder that requires a structured diagnostic approach.

Incontinence and psychological problems in children: a common central nervous pathway?

Nocturnal enuresis is caused by a mismatch between the nocturnal bladder capacity and the nocturnal diuresis rate, in the presence of a deficient arousability in the majority of patients, according to the pediatric and urologic literature. Psychiatric and psychologic literature are still concentrating on the potential role of psychological factors and central nervous mechanisms in the pathogenesis, as is reflected in the DMS-5 criteria. However, research has clearly shown several important comorbidities between neuropsychological dysfunctions and nocturnal enuresis. Due to the increased comorbidity of (neuro)psychological problems, sleep problems, circadian rhythms, and enuresis, the question arises as to whether there is a possible common central pathway in the pathogenesis. It is likely that the coexistence of these problems can be attributed to a common central nervous system involvement. The specific role of the central nervous system remains unclear, but several pathways are possible. The high comorbidity between enuresis, sleep, and (neuro)psychological functioning is probably attributable to a common pathogenetic pathway, emphasizing the importance of a multidisciplinary focus in screening and treatment in children with nocturnal enuresis.