DISTURBANCES IN CHILDREN WITH ENURESIS / URINARY

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INCONTINENCE:

CLINICAL STUDIES

III. CLINICAL BEHAVIORAL

DISTURBANCES IN CHILDREN

WITH ENURESIS / URINARY

INCONTINENCE: EPIDEMIOLOGY

Table 1. Epidemiological studies: Percentage of children with clinically relevant behavioural problems in comparison to controls and their increased risk (odd-ratios)

Study Measure Enuretics Controls Higher risk

(odds ratio)

Rutter 1973, U.K., Isle of Wight, Rutter Child Scale [parent]; n=4481, cross-sect., 5-14 years cut-off>13

Age 5 years Boys: 30.8% 8.1% 3.8 Girls: 14.3% 4.4% 3.2 Age 7 years Boys: 25.6% 7.9% 3.2 Girls: 28.6% 7.8% 3.7 Age 9/10 years Boys: 27.4% 6.5% 4.2 Girls: 16.3% 5.3% 3.1 Age 14 years Boys: 27.6% 10.2% 2.7 Girls: 43.8% 6.8% 6.8 McGee et al., 1984, New Zealand, Rutter child scale

longitudinal, n=1037 [parent]; cut-off>13

Age 7 years Primary: 30.8% 21.6% 1.4 Secondary: 51.9% 2.4 Age 9 years Primary: 23.1% 17.5% 1.3 Secondary: 37.0% 2.1 Feehan et al. 1990, New Zealand, DSM-III, age 11years Total: 23.4% 9.5% 2.5 longitudinal, n=1037 Primary: 0%

Secondary: 42.3% 4.5 DSM-III, age 13 years Total: 17.5% 9.1% 1.9 Primary: 10.5% 1.2 Secondary: 23.8% 2.6 DSM-III, age 15 years Total: 13.3% 9.8% 1.4 Primary: 10.5% 1.1 Secondary: 20.0% 2.0 Liu et al., 2000, China, cross-sect., CBCL Intern. >90th p. 31.0% 10.4% 4.5 n=3344, 6-18 years CBCL Extern.> 90th p. 29.0% 9.3% 3.6 CBCL Total > 90th p. 30.3% 9.1% 4.3

Byrd et al. 1996, USA, cross-sect., BPI > 90th p. 16.5% 10.2% 1.6 n=10960, 5-17 years [includes

infrequent bedwetting > 1x/per year]

Feehan et al. 1990, New Zealand, DSM-III, age 11years Total: 23.4% 9.5% 2.5 longitudinal, n=1037 Primary: 0%

Secondary: 42.3% 4.5 DSM-III, age 13 years Total: 17.5% 9.1% 1.9 Primary: 10.5% 1.2 Secondary: 23.8% 2.6 DSM-III, age 15 years Total: 13.3% 9.8% 1.4 Primary: 10.5% 1.1 Secondary: 20.0% 2.0

Table 2. Clinical studies: Percentage of children with clinically relevant behavioral problems in comparison to controls and their increased risk (odd-ratios)

Study Measure Enuretics Normative Higher risk

values (odds ratio)

Berg et al., 1981, U.K., n=41, Rutter A questionnaire 29.3% 6-13 years, pediatric clinic, Cut off > 18

nocturnal enuresis

Interview: “clinically 26.8% disturbed“

Bayens et al., 2001, CBCL Total >90th p. 26% 10.0% 2.6 Belgium, n=100, 6-12 years, CBCL Intern. >90th p. 25% 10.0% 2.5 pediatric clinic, nocturnal and mixed CBCL Extern. >90th p. 14% 10.0% 1.4 D/N wetting

Von Gontard et al., 1999, Germany, CBCL Total>90th p. 28.2% 10% 2.8 n=167, 5-11 years, child psychiatric CBCL Intern. >90th p. 20,9% 10% 2.1 clinic CBCL Extern. >90th p. 22,1% 10% 2.2 ICD-10 40.1% 12% 3.3 CBCL Total >90th p. Primary ICD-10 nocturnal enuresis 10.0% 2.0 20.0% 12.0% 1.6 19.5% CBCL Total>90th p. Primary ICD-10 mono symptomatic nocturnal 10.0% 1.4 enuresis 12.0% 0.8 14.3% 10.0% CBCL Total >90th p Primary 10.0% 2.9 ICD-10 non-. monosymptomatic nocturnal 10.0% 2.9 enuresis 12.0% 2.9 29.0% 34.4% CBCL Total>90th p. Secondary ICD-10 nocturnal 10.0% 3.9 enuresis 12.0% 6.3 39.3% 75.0%

Von Gontard et al., 1998; Urge

Lettgen et al., 2002, Germany, CBCL Total>90th p. incontinence 10.0% 1.4 n=94, 5-11 years, two centres: ICD-10 13.5% 12.0% 2.4 pediatric and child psychiatric 28.6%

clinics

CBCL total>90th p. Voiding ICD-10 postponement

37.3% 10.0% 3.7 53.8% 12.0% 4.5

years later [14]. These rates are almost identical as the results from von Gontard [15].

In addition, the behavioral comorbidity using the CBCL and ICD-10 diagnoses were analyzed for spe- cific subtypes of incontinence [15]. Primary noctur- nal enuretics showed behavioral problems less fre- quently than secondary nocturnal enuretics. The group with the lowest comorbidity – no higher than in the normative population – were monosymptoma- tic nocturnal enuretics without any daytime symp- toms such as urge, postponement or dysfunctional voiding.

In a two-centre study in a pediatric and child psy- chiatric clinic, of the children with daytime inconti- nence, those with urge incontinence were less ‘deviant’ than those with voiding postponement [16,17]. The data on children with dysfunctional voi- ding is even more sparse. In the study by von Gon- tard, 10 of 167 children showed dysfunctional voi- ding [15]. The absolute rate of behavioral disorders was higher than in other forms of urinary inconti- nence, thus only 40% had an ICD-10 diagnosis and 40% a CBCL total score in the clinical range. In summary, clinical studies came to remarkably similar results as those in the general population with 20-40% being affected for most types of incontinen- ce– independent of the type of institution. They do, however point to the fact, that the comorbidity dif- fers greatly between different forms of incontinence: the lowest comorbidity is found among primary monosymptomatic nocturnal enuretics, the highest among the secondary nocturnal enuretics. Among the children with daytime incontinence, those with urge incontinence have the lowest rate of concomitant problems.

These global findings from epidemiological and cli- nical studies do not reveal what type of behavioral disorder is most common. Contrary to common belief, children with incontinence problems are prone to show externalizing disturbances more often than internalizing disorders. As shown in table 3,

21% had externalizing disorders according to the ICD-10 criteria [15]. Of these 9.6%, had hyperkine- tic disorders, characterized by hyperactivity, impul- sivity, short concentration span and distractibility. 11.4% showed conduct disorders, defined by a trans- gression of norms and rules, most of which were

oppositional-defiant disorders. Only 12% showed internalizing, emotional disorders such as depres- sion, anxiety and phobias.

Hyperkinetic disorders (ICD-10 criteria; affecting 1.7% of the population) are more stringently defined than ADHD (DSM-IV criteria; affecting at least 5% of the population). ADHD seems to be a common type of co-morbid disorder. Thus, in a retrospective analysis of 153 children with ADHD and 152 controls, the risk for nocturnal enuresis in a 6-year old child with ADHD was 2.6 times higher, for day- time incontinence the risk was even 4.5 times higher [18]. The causal, possibly neurobiological relation- ship between nocturnal enuresis and ADHD is not known, but according to formal genetic analyses, the two disorders are not inherited together [19].

Theoretically four different types of associations bet- ween behavioral disorders and incontinence have to be considered [20]:

• The behavioral disorder might be a consequence

of the incontinence problem – and might recede upon attaining dryness.

• The behavioral disorder might precede and thus

induce a relapse, which has been shown in epide- miological studies [8]. Often, a genetic disposition for enuresis is present even in these secondary forms [21].

• Incontinence and behavioral disorder might be due

to a common neurobiological disorder, which has

VI. RELATIONSHIPS BETWEEN

BEHAVIORAL DISORDERS AND

INCONTINENCE

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