Evidence of Need to Use Self-Report Measures of Psychosocial Functioning in Older Children and Adolescents with Voiding Dysfunction

Evidence of Need to Use Self-Report Measures of Psychosocial Functioning in Older Children and Adolescents with Voiding Dysfunction

Pediatric Urology Evidence of Need to Use Self-Report Measures of Psychosocial Functioning in Older Children and Adolescents with Voiding Dysfunction...

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Pediatric Urology

Evidence of Need to Use Self-Report Measures of Psychosocial Functioning in Older Children and Adolescents with Voiding Dysfunction Cortney Wolfe-Christensen, William C. Guy, Megan Mancini, Larisa G. Kovacevic and Yegappan Lakshmanan From the Department of Pediatric Urology, Children’s Hospital of Michigan, Detroit, Michigan, and Department of Pediatrics, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma (CW-C)

Abbreviations and Acronyms BMI ¼ body mass index DVSS ¼ Dysfunctional Voiding Scoring System NMNE ¼ nonmonosymptomatic nocturnal enuresis PSC ¼ Pediatric Symptom Checklist Accepted for publication November 18, 2015. No direct or indirect commercial incentive associated with publishing this article. The corresponding author certifies that, when applicable, a statement(s) has been included in the manuscript documenting institutional review board, ethics committee or ethical review board study approval; principles of Helsinki Declaration were followed in lieu of formal ethics committee approval; institutional animal care and use committee approval; all human subjects provided written informed consent with guarantees of confidentiality; IRB approved protocol number; animal approved project number.

Purpose: Previous reports have revealed significantly higher rates of psychosocial difficulties in children and adolescents with voiding dysfunction compared to their healthy peers. However, these findings are based solely on parental reporting and do not include self-reporting of psychosocial problems in older pediatric patients. Materials and Methods: We collected data from 200 consecutive patients 11 to 16 years old during outpatient clinic visits. Patients completed the Pediatric Symptom ChecklisteYouth Report, parents completed the parental report of the same measure, and patients and parents collaboratively completed the Dysfunctional Voiding Scoring System. Results: Of the patients 25.5% met the cutoff score for clinically significant levels of psychosocial difficulties. However, only a fourth of those patients met the cutoff on the parent and self-report measures. Additionally patient self-reports of internalizing and externalizing problems were significantly related to severity of voiding dysfunction. Conclusions: Screening for psychosocial problems in older children and adolescents with voiding dysfunction should include reports from the parent and the child. In our sample 37.3% of patients needing a mental health followup would have been missed if only 1 version of the measure had been administered. Key Words: adolescent, child, health promotion, urination disorders

See Editorial on page 1327.

INCONTINENCE is defined by the International Children’s Continence Society as “Involuntary wetting at an inappropriate time and place in a child of 5 years or more.”1 The prevalence of daytime incontinence in children ranges from 30% in those 4 years old to 1.8% in those 15 to 18 years old.2 Daytime incontinence has been associated with lower urinary tract symptoms such as urgency and frequency in addition to holding maneuvers for postponement of voiding.1




It has previously been recommended that all children presenting with urinary and/or fecal incontinence be screened for psychosocial problems.3,4 However, studies examining the rates of psychosocial difficulties in children with voiding dysfunction and/or enuresis have relied on parent reporting of patient functioning. The broader literature on proxy reporting in children and adolescents suggests that parents may underreport symptoms in their child, especially in


http://dx.doi.org/10.1016/j.juro.2015.11.045 Vol. 195, 1570-1574, May 2016 Printed in U.S.A.


terms of internalizing difficulties such as those related to depression, anxiety and somatization.5 We investigated the level of self-reported psychosocial difficulties in this population, and examined the relationship between patient self-reporting and parent reporting of patient difficulties. Additionally we examined relationships between self-reported psychosocial problems and severity of voiding dysfunction. We hypothesized that including a self-report measure of psychosocial difficulties would allow us to identify at risk patients whose condition would not otherwise have been detected based on parental report alone.

MATERIALS AND METHODS We conducted an institutional review board approved, prospective, 2-year data collection of consecutive patients 11 to 16 years old who were being treated for voiding dysfunction (ie presence of lower urinary tract symptoms with or without daytime incontinence) or NMNE (ie presence of lower urinary tract symptoms with or without daytime incontinence plus nocturnal enuresis) in the pediatric urology department at a single institution. As part of the paperwork required for the initial clinic visit, adolescents completed the Youth Self-Report of the Pediatric Symptom Checklist,6 while their parents completed the Parent Report version of the same measure.7 PSC is a validated screening tool that assesses level of psychosocial difficulties in a child, with a cutoff score that indicates clinically significant levels. It is recommended that children who meet or exceed the cutoff receive referral for mental health followup. Both versions of the PSC include the same 35 items, with grammatical changes to reflect first vs third person differences. All items are rated on a 3-point Likert scale (scored 0 to 2), ranging from “never” to “often.” Examples of the items include “Spend(s) more time alone,” “Has/ Have trouble with teacher,” “Get(s) hurt frequently” and “Daydream(s) too much.” The PSC Parent Report was validated for use in children 4 to 16 years old, with a clinical cutoff score of 24 in children 4 and 5 years and a score of 28 in children 6 to 16 years.7 The self-report is validated for use in children 11 to 16 years old and has a clinical cutoff score of 30.6 There are also 3 subscales that can be calculated on the PSC, ie internalizing problems (eg depression, anxiety), externalizing problems (eg fighting, defiance) and attention problems (eg, fidgety, easily distracted), with clinical cutoff scores of 5 on the internalizing scale, and 7 on the attention and externalizing scales. Additionally patients and their parents collaboratively completed the Dysfunctional Voiding Scoring System.8 DVSS is a validated 10-item measure that objectively assesses the severity of symptoms of voiding dysfunction. Items are rated on a 4-point Likert type scale (scored 0 to 3), ranging from “Almost never” to “Almost every time.” Examples of the items include “When I wet myself, my underwear is soaked,” “I have to push to pee” and “When I have to pee, I cannot wait.” The last question on


the DVSS assesses whether the child has experienced a psychosocial stressor, such as “new school,” “new baby” and “abuse.” Items are summed to create a total score, with higher scores indicative of more severe voiding dysfunction. Finally, clinical information, including patient BMI, and Bristol Stool Form Scale score was extracted from the medical chart. Constipation was diagnosed in patients with a Bristol Stool Form Scale score of 3 or less. Preliminary analyses, including t-tests, chi-square tests and bivariate correlations, were conducted to examine relationships between demographic variables, clinical characteristics, and PSC and DVSS scores. The primary analyses involved using paired t-tests to compare the total scores on the parent and self-reported PSC, given the dependency in the data. The scores were then categorized based on whether they met the clinical cutoff on the measures, and comparisons between patients and their parents were examined. Next, hierarchical regression was used to examine the relationship between the patient self-reported PSC scores and severity of voiding dysfunction. For the regression equations covariates were entered on step 1, while the total scores from the PSC and the 3 PSC subscales were entered as the predictors on step 2 of separate equations, and the total score from the DVSS served as the dependent variable. All analyses were conducted with SPSSÒ, version 23.

RESULTS A total of 200 patients were included in the study (table 1). All patients completed the paperwork as part of their initial clinical evaluation at the outpatient pediatric urology clinic, and while all patients had a completed parent and self-reported PSC, 158 (79.0%) also had a completed DVSS. Examination of these patients showed differences between the evaluations of 3 treating physicians. Results of the preliminary analyses demonstrated no significant differences between males and females (all p >0.05) or between diagnostic groups (voiding dysfunction vs NMNE) on any of the measures (ie PSC parent reported total score, PSC self-reported total score and DVSS total score). Similarly no significant relationships emerged between BMI or presence of constipation and level of Table 1. Patient demographic and clinical characteristics No. gender: Male Female Mean  SD yrs age (range) Mean  SD kg/m2 BMI (range) No. race/total No. (%): Black White Other Not reported No. diagnosis/total No. (%): NMNE Voiding dysfunction Constipation

87 113 12.81  1.65 (11e16) 24.03  7.10 (12e48) 87/200 56/200 15/200 42/200

(43.5) (28) (7.5) (21.0)

123/200 77/200 104/200

(61.5) (38.5) (52.0)



psychosocial difficulties or severity of voiding dysfunction (all p >0.05). However, for theoretical purposes patient age, gender, BMI and presence of constipation were included as covariates on subsequent analyses. The primary analyses revealed that the parent and self-reported total scores were not significantly different (p ¼ 0.17) and showed a strong correlation (r[169] ¼ 0.64, p <0.001). When the scores were categorized based on the cutoff scores of 28 and 30 on the parent and self-report versions, respectively, 51 patients (25.5%) were identified as having clinically significant psychosocial difficulties on at least 1 measure. However, only 13 of these patients (25.5%) met the clinical cutoff score on both measures (see figure). Additionally analyses indicated that the 51 patients who met the cutoff had significantly more severe voiding symptoms (mean  SD 12.11  4.14) than those who did not meet the cutoff (8.34  4.54, p <0.001). Examination of the cutoff scores on the subscales of the PSC demonstrated that the patients were significantly more likely to report clinically relevant levels of internalizing problems than the parents (p <0.001), while parents were more likely to report clinically significant problems with attention (p <0.001) and externalizing behaviors (p ¼ 0.002, table 2). The hierarchical regressions revealed that after controlling for age, gender, BMI and presence of constipation the overall model for self-reported PSC total score was significant (p <0.001), with the PSC total score emerging as a significant predictor of voiding severity (t[145] ¼ 6.55, p <0.001), accounting for 21.3% of the variance above and beyond the variance accounted for by the covariates (adjusted R2 ¼ 0.29). The model for the self-reported PSC subscales of internalizing problems, externalizing

Parent Report Only N=19 (37.2%)

Self Report Only N=19 (37.2%)

Both Parent and Self Report N=13 (25.5%) Positive PSC results (patients met clinical cutoff on PSC)

Table 2. Percentage of respondents meeting clinical cutoffs on PSC subscales

Attention problems Internalizing problems Externalizing problems

% Self-Report

% Parent Report

p Value

12.5 17.1 7.0

14.6 13.1 11.1

<0.001 <0.001 0.002

problems and attention problems was significant (F[6,143] ¼ 8.25, p <0.001), with internalizing problems (p ¼ 0.001) and externalizing problems (p ¼ 0.005) but not attention problems (p ¼ 0.67) emerging as significant predictors of severity of voiding dysfunction.

DISCUSSION Results from the current study emphasize the importance of screening patients with voiding dysfunction for psychosocial difficulties. While the overall scores on the PSCs were not significantly different between the patients and their parents, the cutoff scores are of clinical importance. In our practice patients with scores above the cutoff are provided mental health referrals by our psychologist. Of the patients 11 to 16 years old 25.5% met the clinical cutoff for significant psychosocial difficulties on at least 1 of the PSC reports (ie parent or self). Interestingly only a fourth of these 51 patients were rated in the clinically significant range on both measures. As such, if only the Parent Report of the PSC had been administered in this population, more than a third of children and adolescents (37.3%) with significant psychosocial difficulties would have been missed. Consistent with previous reports, the percentage of parents who rated their child as having clinically significant difficulties with internalizing problems was significantly lower than the patient self-reports. This finding provides additional evidence of the importance of obtaining self-report measures of functioning in older children and adolescents, as their parents may underreport internalizing difficulties since they are not outwardly visible. Additionally the level of patient psychosocial difficulties was predictive of severity of voiding dysfunction, with higher levels of internalizing, externalizing and overall psychosocial difficulties being associated with more severe voiding dysfunction. Importantly, internalizing symptoms such as those related to anxiety and depression are less outwardly visible, making them more difficult for parents to accurately report. The presence of depression, and to a lesser extent anxiety, in adolescents puts them at risk for poorer treatment outcomes.9 Depression and anxiety have been


linked to increased health care use, lower quality of life and functional impairment in patients with acute and chronic medical conditions.10 In fact, a meta-analysis by DiMatteo et al found that depressed patients are 3 times more likely than nondepressed patients to be noncompliant with medical treatment recommendations.9 The treatment of voiding dysfunction and NMNE almost always includes a behavioral component consisting of timed voiding, restriction of fluids and maintenance of a voiding diary. Additionally patients may be prescribed adjunctive medication, which introduces the added concern of adherence to medication. As children become older, there is a slow transition from parent guided care to self-care responsibilities, which often include management of medical conditions. Behavioral treatment requires ongoing monitoring, which can quickly become monotonous, and medications can easily be forgotten or purposely not taken. Without strong motivation for symptom improvement and/or resolution it is likely that patients will not be compliant with their treatment recommendations. While the existence of psychosocial stress puts patients at increased risk for treatment noncompliance, there is some evidence that this stress might contribute to development and maintenance of voiding dysfunction. Research on animal models has established a causal link between exposure to social stress and development of voiding dysfunction. An early study by Desjardins et al found that the voiding patterns in mice reflected their status within the social hierarchy.11 For example the submissive mouse appeared to have urinary retention, while the dominant mouse had frequent, small volume voids. The development of urinary retention and bladder hypertrophy in mice exposed to social stress has been consistently reported in the literature.12,13 More recent studies using social defeat paradigms (ie exposure of novel mice to an aggressive mouse) have further characterized the effects of social stress by identifying specific urodynamic changes as well as providing evidence of the existence of a recognized neural mechanism. Wood et al reported that the up-regulation of corticotropin-releasing factor in the Barrington nucleus by social stress is a putative mechanism for urinary retention.12 Also Chang et al found that urinary retention secondary to social stress led to shifts in transcription factors,


changes in expression of a myosin heavy chain isoform and increases in DNA synthesis that mediate bladder wall remodeling.13 They also suggest that these mechanisms may be relevant to development of voiding dysfunction in humans. The current study has several strengths, as it focuses on the self-reporting of older children and adolescents in terms of psychosocial difficulties. This is a population that is often under studied but is at increased risk for social stress. We used validated measures to assess levels of psychosocial difficulties and severity of voiding dysfunction, and the 2 versions of the PSC allowed us to easily compare parent and patient reports. Additionally we recruited consecutive patients who presented to our clinic with symptoms of voiding dysfunction. As such, our sample represents the population of our geographic location. We are continuing to follow this cohort in terms of collecting data on treatment modalities and outcomes to better understand how psychological treatment affects these patients and their voiding symptoms. The current findings should be interpreted in light of several limitations. Due to the crosssectional nature of the study, no causal relationships could be established. As such, it is not possible to clearly identify the directional relationship between severity of voiding dysfunction and psychosocial difficulties. We also had an overrepresentation of black patients, which may limit the generalizability of the results to other racial and ethnic groups. Finally, given the urban population served by our clinic, it is possible that other environmental factors contribute to the psychosocial difficulties.

CONCLUSIONS It is necessary to assess older children and adolescents with voiding dysfunction using self-report measures of functioning, rather than simply relying on parental reporting. More than a third of our sample (37.3%) who met the clinical cutoff for needing a mental health referral would have been missed if the screening measure had only been administered to 1 respondent. Therefore, it is strongly recommended that these patients be screened with parental and self-report measures to identify all patients who are at increased risk for psychosocial difficulties so that they can be referred for mental health followup.

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