AN ASSESSMENT OF INTERNALIZING PROBLEMS IN CHILDREN WITH ENURESIS

0022-5347/04/1716-2580/0 THE JOURNAL OF UROLOGY® Copyright © 2004 by AMERICAN UROLOGICAL ASSOCIATION

Vol. 171, 2580 –2583, June 2004 Printed in U.S.A.

DOI: 10.1097/01.ju.0000110521.20103.14

AN ASSESSMENT OF INTERNALIZING PROBLEMS IN CHILDREN WITH ENURESIS ELINE VAN HOECKE,* PIET HOEBEKE, CAROLINE BRAET

AND

JOHAN VANDE WALLE

From the Paediatric Uro/Nephrologic Centre, Ghent University Hospital and Department of Developmental, Personality and Social Psychology, Ghent University (JVW), Ghent, Belgium

ABSTRACT

Purpose: We examine the internalizing problems (anxiety and depression) and self-esteem among 9 to 12-year old children with enuresis to determine whether enuretic children are more in the clinical range, and to study the correlation between child and parent report questionnaires. Materials and Methods: A total of 84 children with daytime and/or nighttime wetting were compared to 70 without enuresis using 5 psychometric instruments adjusted for gender and type of enuresis. Differences in mean scores, percentages of children beyond the clinical range, and correlations between child and parent report questionnaires were evaluated. Results: Parental report revealed more internalizing problems (“withdrawn” and “anxious/ depressive”) for children with enuresis compared to controls. A higher percentage of the study group were in the clinical range of the “total problem” scale of the Child Behavior Checklist. Child report inventories yielded no differences between groups. Moderate agreement was found between child and parent report. Conclusions: There is no evidence of internalizing problems (anxiety/depression) and low self-esteem in the self-report of enuretic children. In contrast parents rate enuretic children as having more internalizing problems. Different explanations for this contradictory data are offered. Further research is necessary to explain why parents report psychological symptoms in children with enuresis. KEY WORDS: enuresis, children, self esteem

Bedwetting by children is definitely a complex multifactorial problem. Until 2 decades ago the majority of authors agreed on the importance of psychological factors in the etiology of bedwetting. New insights on causes, such as atypical nocturnal polyuria1 and non-neurogenic bladder dysfunction,2 led to a predominant attention to organic factors in the etiology. The discovery of a genetic predisposition is often considered to be final proof of a “pure physiological” disease.3 However, in the last years several studies on psychological adjustment of children with primary nocturnal enuresis were reported, which considered psychological factors as a comorbidity of a multifactorial pathogenesis complex rather than a primary cause. A great deal of attention has been focused on the association between enuresis and externalizing or behavioral disorders such as attention deficit hyperactivity disorder,4 oppositional defiant disorder and conduct disorder.5–7 Reliable research on internalizing or emotional problems is rare or derived primarily from parent report measures. Recent research has emphasized the need for using multiple informants in the assessment of child behavior problems. Hence, we need child report inventories focusing on emotional problems such as anxiety or depression. Internalizing problems in children may also have negative effects on selfesteem or vice versa.8 Previous studies have shown that self-esteem of the enuretic child is decreased.9 –12 In this pilot study we establish the link between enuresis, and self-esteem and internalizing problems such as anxiety and depression. Gender effects are analyzed as well as differences between children with monosymptomatic enuresis and those with daytime and nighttime wetting. We also determine whether enuretic children are significantly more in

the clinical ranges (hence the presence of the disorder) for internalizing disorders compared to those without enuresis. Finally, we evaluate the correlations between child and parent reports for all questionnaires. MATERIALS AND METHODS

A total of 154 children 9 to 12 years old, participated in this prospective study. The study group included 84 patients with nighttime and/or daytime wetting who were recruited during the second visit to the Paediatric Uro/Nephrologic Centre of the Ghent University Hospital. Children with anatomical/ neurological abnormalities and mentally retarded children were excluded from this study. There were 63 (75%) males and 21 (25%) females with a mean age of 10.0 years (range 9 to 12). Of the children 54 (77%) had night wetting problems, and 30 (23%) had day and night wetting problems. The control group included 36 (51.4%) boys and 34 (48.6%) girls without enuresis who were recruited from a regular primary school in Ghent. Children with enuresis were excluded from the control group. Mean age was 10.2 (range 9 to 12). Chisquare analysis showed a significantly different distribution of gender type between the groups (␹ 2 [1] ⫽ 8.69, p ⱕ0.01). Approval by the Ethical Comity of the Ghent University Hospital was obtained (1999/43) and a written consent was requested. The children completed 4 questionnaires that are nondiagnostic screening instruments valid for preliminary research. All have shown good reliabilities. The Social Anxiety Scale for Children (SAS-C).13 This selfreport questionnaire measures cognitive and affective anxious reactions in different situations in 9 to 12-year-old children. The scale is constructed on 4 different kinds of social situations based on 4 subscales of situations in which social skills are at issue, situations in which intellectual skills are at issue, situations in which athletic skills are at issue and

Study received Ethical Comity approval. * Correspondence: Ghent University Hospital, 1K5-Paediatric Uro/Nephrologic Centre, De Pintelaan 185, B-9000 Ghent, Belgium (telephone: ⫹32/9/240.24.09; e-mail: [email protected]). 2580

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situations in which physical appearance is at issue. Two other scales contain cognitive reactions and physiological reactions. The state-trait anxiety inventory for children (STAI-C).14, 15 This self-report inventory is a measure instrument to identify situation anxiety in 8 to 15-year-old children and contains 20 sentences that refer to the feelings of a child at a certain moment. Children rate themselves on a 3 Likert Scale, ranging from 1 (almost never) to 3 (often). Due to limitation of the study 120 children were administered the STAI-C. The shortened depression questionnaire for children (SDQC).16 This 9-item scale is a shortened version of the depression questionnaire for children, and was developed for early identification of depressive or declining depressive children. Children completed this questionnaire on a “that is true” or “that is not true” response format. A value equal or more than 4 is an indication of depressive mood in children. The Self-Perception Profile for Children by Harter (SPPC).17, 18 This scale measures the self-concept in 8 to 12-yearold children and consists of 6 subscales. Five subscales assess dimensions of perceived competence, namely scholastic competence, social acceptance, athletic competence, physical appearance and behavioral conduct. The final subscale measures global self-worth. In addition the parent completed the Child Behavior Checklist (CBCL).19, 20 The CBCL contains 3 broadband scales of internalizing, externalizing and total problems. For this study only the first and last broadband scales were used, and the 4 subscales of “withdrawal,” “somatic complaints,” “anxious/depressive” and “social problems.” On the broadband factors a T-score of 63 or higher is considered clinical. RESULTS

On the CBCL parents judged their enuretic children as more withdrawn (F [1,145] ⫽ 5.77, p ⱕ0.05) and more anxious/depressive (F [1,145] ⫽ 5.46, p ⱕ0.05) than parents of controls. For the internalizing subscale the mean problem score of the study group was significantly higher than that of the control group (F [1,145] ⫽ 9.21, p ⱕ0.01). Similarly, when all subscales of the CBCL were combined on the total problem behavior scale, significantly higher problem scores for the enuretic children were apparent (F [1,145] ⫽ 15.50, p ⱕ0.01, table 1). Internalizing problems and self-esteem of enuretic children were studied with 2 MANOVAs (SAS-C, SPP-C) and 2 ANOVAs (STAI-C, SDQ-C) with group as a factor. No significant group differences were found with the 4 questionnaires, except for 1 subscale of the Social Anxiety Scale for Children. Enuretic children had significantly higher scores on “social desirability” than the control children (F (1,149) ⫽ 4.71, p ⱕ0.05, table 2). A repeat MANOVA with group and gender as factors and the self-report inventories SPP-C, SAS-C, STAI-C and SDQ-C as well as the parent report CBCL as dependent variables was conducted. There was a main effect of gender

on the SAS-C “social situations” (F (1,113) ⫽ 10.95, p ⱕ0.01) and “cognitive reactions” (F (1,113) ⫽ 9.5, p ⱕ0.01) and the STAI-C (F (1,113) ⫽ 8.18, p ⱕ0.01). Post hoc analyses revealed that girls had more problems. Concerning the CBCL, gender failed to reach significance, and similar findings were noted for the main effect of group. However no interaction effects between group and gender were found. Next the same repeat MANOVA was conducted with “type of enuresis” (monosymptomatic vs combined daytime and nighttime wetting) as the factor, and there were no significant interaction effects. Significantly higher scores on the CBCL for the study group do not necessarily reflect an importantly higher frequency of clinical scores. Hence, chi-square tests were performed to compare the frequency of subjects from both groups in the clinical range (T score ⱖ63) on the total problems scale of the CBCL. Table 2 shows the frequency and percentage by sample, and the accompanying chi-square values. A higher percentage of children in the study group were in the clinical range of the 2 broadband factors of the CBCL, which was significant for total problems (␹ 2 [1] ⫽ 12.82, p ⱕ0.01) and not significant trend for internalizing problems (␹ 2 [1] ⫽ 3.05, p ⫽ 0.06, table 3). Correlations between the parent report (CBCL) and the self-report inventories (SPP-C, STAI-C and SDQ-S) for the entire sample are presented in table 4. These data indicate low to moderate association between the internalizing subscales and the internalizing broadband score of the CBCL and the self-report inventory scores. Significant negative correlations were found between the children report of perceived competence concerning social acceptance and the parents report of the CBCL subscales of withdrawn, physical complaints, anxious/depressive, social problems, internalizing problems and total problems. The perceived competence concerning behavioral conduct of the children was significantly negative correlated with the CBCL social problem subscale and CBCL total problems. The perceived competence concerning global self-worth negatively correlated with the CBCL withdrawn, anxious/depressive, social problems, internalizing problems and total problems. There was a significant positive correlation between the child anxiety scale and the CBCL anxious/depression and internalizing problems. A less strong positive correlation we noted between the child’s depression questionnaire and the CBCL anxious/depressive and internalizing problems. Within the group of bedwetting children there were no correlations between the internalizing self-report inventories and the CBCL. There was a negative correlation between the SPP-C social acceptance and CBCL anxious/depressive (r ⫽ ⫺0.34, p ⱕ0.05) and internalizing problems (r ⫽ ⫺0.31, p ⱕ0.05). There were strong, significant, positive correlations between the internalizing self-report inventories and the CBCL for children with bedwetting and daytime incontinence (table 5).

TABLE 1. CBCL values Mean (SD) Study Group (84 pts) CBCL subscales (raw scores): Withdrawal Physical complaints Anxious/depressive Social problems CBCL broadband factors (T scores): Internalizing problems Total problems * Significant p ⱕ0.05. † Significant p ⱕ0.01.

2.78 1.65 5.70 2.97

(2.7) (2.3) (5.2) (2.9)

58.71 (11.1) 58.08 (11.4)

F Value

p Value

(2.3) (1.9) (4.3) (2.6)

5.77 0.92 5.46 3.22

0.02* 0.34 0.02* 0.08

53.04 (11.6) 50.41 (12.9)

9.21 15.50

0.003† 0.000†

Control Group (70 pts) 1.79 1.31 3.84 2.17

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ENURESIS AND INTERNALIZING PROBLEMS TABLE 2. SAS-C, STAI-C, SDQ-C and SPP-C values Mean Raw Scores (SD)

F Value

df

p Value

2.96 (3.1) 3.03 (3.2) 1.77 (2.2) 3.20 (3.2) 4.80 (5.4) 6.16 (5.5) 2.61 (2.0) 10.96 (10.5) 33.12 (8.2) 2.26 (2.7)

1.06 0.01 0.00 0.02 0.40 0.00 4.71 0.09 0.05 0.43

(1, 149) (1, 149) (1, 149) (1, 149) (1, 149) (1, 149) (1, 149) (1, 149) (1, 120) (1, 147)

0.31 0.93 0.96 0.89 0.53 0.98 0.03* 0.80 0.83 0.51

16.67 17.71 17.81 18.84 16.87 18.91

1.37 0.03 0.00 0.18 0.00 0.86

(1, 145) (1, 145) (1, 145) (1, 145) (1, 145) (1, 145)

0.25 0.87 1.00 0.67 0.98 0.36

Study Group

Control Group

2.49 (2.5) 3.08 (2.9) 1.79 (2.0) 3.17 (2.6) 4.31 (4.2) 6.17 (4.8) 3.35 (2.2) 10.49 (8.3) 33.33 (5.8) 1.76 (1.9) 15.86 (4.3) 17.59 (4.4) 17.82 (4.6) 18.53 (4.7) 16.86 (3.4) 18.30 (4.0)

SAS-C-subscales: Social situations Intellectual situations Athletic situations Physical appearance Cognitive reactions Emotional reactions Social desirability Total anxiety STAI-C SDS-C SPP-C subscales: Scholastic competence Social acceptance Athletic competence Physical appearance Behavioral conduct Global self-worth * Significant p ⱕ0.05.

TABLE 3. Subjects in clinical range of 2 CBCL broadband factors No. Study Group (%)

No. Control Group (%)

29 (19.7) 30 (20.4)

17 (11.6) 9 (6.1)

CBCL internalizing CBCL total problems

DISCUSSION

To our knowledge there have been no specific studies on internalizing problems of enuretic children, as all previous reports are on externalizing problems and overall psychopathology.5–7 The self-report inventories showed no significant differences on (social) anxiety and depression. On the other hand, parents rated enuretic children as more withdrawn and anxious/depressive. A possible explanation for this phenomenon might be that these children often deny the problems they are faced with and the only solution is to live with that problem. The significant score on the subscale social desirability of the SAS-C is an indication of this fact. Another explanation may be that the children were tested at clinic visit 2. At visit 1 the medical staff explains to the child the problem of enuresis in regard to its epidemiology and possible causes. Of course this explanation may influence the results to some extent and can account for the under state-

(4.1) (4.6) (4.5) (4.4) (3.6) (4.0)

ment of the problem as rated by the child. Longstaffe et al suggested improvement in self-esteem when the children were treated.11 Also, parents notice more problem behavior because of their concerns about the voiding problem. The self-esteem of enuretic children was also investigated in our study. In contradiction with the expectations, no significant differences in perceived competence (SPP-C) concerning the 6 subscales between enuretics and controls were found. Moffatt et al reported significant improvement in selfconcept in a treated group vs a nontreated group of enuretic children but there were no data on comparisons with nonenuretic children.9 The study by Ha¨ gglof indicates that selfesteem is impaired among children with nocturnal enuresis and daytime incontinence compared to a control group.10 A possible explanation for the contradictory results is the variability of the questionnaires. In a previous study we found that enuretic children had a significantly lower perceived competence than controls in regard to physical appearance and global self-esteem. However, there was a reverse effect (not significant) of the number of treatment failures, that is the more treatment failures, the lower the self-esteem.12 The present study population included more primary and secondary referrals than the

TABLE 4. Correlations between CBCL and SPP-C, STAI-C, SDQ-C for the entire sample CBCL

SPP-C: Social acceptance Behavioral conduct Global self-worth STAI-C SDQ-C * Significant p ⱕ0.01. † Significant p ⱕ0.05.

Withdrawal

Physical Complaints

Anxious/Depressive

Social

Internalizing Problems

⫺0.23* ⫺0.08 ⫺0.18† 0.13 0.09

⫺0.18† ⫺0.04 ⫺0.13 0.16 0.15

⫺0.25* ⫺0.13 ⫺0.23* 0.29* 0.19†

⫺0.29* ⫺0.25* ⫺0.24* 0.12 0.10

⫺0.27* ⫺0.12 ⫺0.23* 0.25* 0.18†

Overall

⫺0.25* ⫺0.27* ⫺0.26* 0.12 0.16

TABLE 5. Correlations between CBCL and SAS-C, STAI-C, SDQ-C for bedwetting/daytime incontinent children CBCL

SAS-C: Intellectual situations Athletic situations Physical appearance Cognitive reactions Total anxiety STAI-C SDQ-C * Significant p ⱕ0.05. † Significant p ⱕ0.01.

Withdrawal

Physical Complaints

Anxious/Depressive

Social

Internalizing Problems

0.47* 0.39 0.42* 0.57† 0.48* 0.43 0.29

0.10 0.19 0.10 0.28 0.20 0.58* 0.23

0.36 0.30 0.25 0.42* 0.37 0.56* 0.42*

0.29 0.43* 0.27 0.46* 0.41* 0.46 0.29

0.36 0.32 0.29 0.46* 0.39 0.58* 0.39*

Overall

0.25 0.34 0.16 0.38 0.30 0.40 0.32

ENURESIS AND INTERNALIZING PROBLEMS

more therapy resistant population of our first study, and the majority of patients had the impression that there was a solution to the enuretic problem. Recent research has emphasized the need to use multiple informants in the assessment of child behavior problems given that children and parents provide unique perspectives on child functioning.21 Overall, the agreement between child and parent reports for the entire sample was low to moderate. Parents judged their children rather adequately. The agreement between child and parent for the study population was moderate to good. A possible explanation is that parents of children with enuresis communicate more with their children about experiencing problems associated with the enuresis, which results in higher agreement scores. A limitation of our study is the use of simple screening measures, which are important in psychological developmental assessments but cannot provide diagnoses. We know from epidemiological studies that the proportion of males and females with enuresis is 4 to 6:1. We had an excessive number of females in our study population, which led to sample bias, due to the fact that girls report more psychological problems.

6. 7. 8. 9. 10.

11. 12. 13.

CONCLUSIONS

Children with enuresis report no lower competence or more internalizing problems than control children. Parents of these children are more attentive to the internalizing problems than parents of controls. These results suggest a need for more formal and systematic evaluations of children with enuresis. REFERENCES

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