- Email: [email protected]
Parental perception and factors associated with treatment strategies for primary nocturnal enuresis
Accepted Manuscript Parental perception and factors associated with treatment strategies for primary nocturnal enuresis Thomson T. Tai, Brent T. Tai, Yu-Jun Chang, Kuo-Hsuan Huang PII:
S1477-5131(17)30046-3
DOI:
10.1016/j.jpurol.2016.12.025
Reference:
JPUROL 2435
To appear in:
Journal of Pediatric Urology
Received Date: 30 May 2016 Accepted Date: 13 December 2016
Please cite this article as: Tai TT, Tai BT, Chang Y-J, Huang K-H, Parental perception and factors associated with treatment strategies for primary nocturnal enuresis, Journal of Pediatric Urology (2017), doi: 10.1016/j.jpurol.2016.12.025. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Parental perception and factors associated with treatment strategies for primary nocturnal enuresis
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Thomson T. Taia, Brent T. Taib, Yu-Jun Changc* and Kuo-Hsuan Huangd,e
a
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Department of Neuroscience, Hamilton College, Clinton, New York, USA Department of Biology, College of the Holy Cross, Worcester, Massachusetts, USA c Epidemiology and Biostatistics Center, Changhua Christian Hospital, Changhua, Taiwan d Department of Surgery, Erlin Christian Hospital, Chanhua, Taiwan
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Division of Urology, Changhua Christian Hospital, Changhua, Taiwan
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*Correspondence Yu-Jun Chang, PhD, Epidemiology and Biostatistics Center, Changhua Christian Hospital, 135 Nanhsiao Street, Changhua 50006, Taiwan. Tel: +886 4 7238595 Email: [email protected]
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Running head: Factors associated with treatment strategies for primary nocturnal enuresis
Ethical Approval
The study procedures were approved by the institutional review board of the Changhua Christian Hospital in Changhua, and written informed consent was obtained from all participants.
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Parental perception and factors associated with treatment strategies for primary nocturnal enuresis Thomson T. Tai a, Brent T. Tai b, Yu-Jun Chang c,*, and Kuo-Hsuan Huang d,e Department of Neuroscience, Hamilton College, Clinton, NY, USA
b
Department of Biology, College of the Holy Cross, Worcester, MA, USA
c
Epidemiology and Biostatistics Center, Changhua Christian Hospital, Changhua, Taiwan
d
Department of Surgery, Erlin Christian Hospital, Chanhua, Taiwan
e
Division of Urology, Changhua Christian Hospital, Changhua, Taiwan
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a
* Corresponding author. Epidemiology and Biostatistics Center, Changhua Christian Hospital, 135 Nanhsiao Street, Changhua 50006, Taiwan. Tel.: +886 4723 8595.
Summary
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Objective
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E-mail address: [email protected] (Y.-J. Chang).
The aim was to investigate the factors influencing parents seeking reasonable managements for their
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child and their overall outlook toward primary nocturnal enuresis (PNE). Study design: We recruited 93 children with PNE from enuresis clinics and requested their parents to
complete questionnaires regarding their child’s medical history and behavior, their methods for coping with PNE, and their perception of enuresis. Logistic regression models were applied to investigate
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factors influencing the parents to adopt a positive approach toward enuresis and to subsequently seek a medical consultation.
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Results
One-third of the parents had an encouraging attitude toward children with PNE, whereas slightly less
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than half reacted with anger. The more educated the father or the younger the child with NE, the larger the possibility of the parents utilizing a positive approach, such as encouragement, for coping with NE.
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Factors that influenced parents to seek medical consultation for NE were socioeconomic status, maternal educational level, and the age and birth order of their child. Discussion
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From our results, angry and frustrated parents (43.0%) were significantly more likely to punish their child for bedwetting than were parents who approached NE positively (comfort and encouragement; 33.3%). A lack of encouragement may negatively affect the self-esteem of children with NE. Moreover,
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an individual’s self-esteem or confidence, both of which can help them eliminate NE, determines the
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person’s behavioral response to bedwetting. In our study, approximately 50% of the parents who approached NE positively (comfort and encouragement) or inconsistently (ambivalence) reported that they comforted their child after bedwetting.
Conclusions
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Nearly half the parents reacted angrily to children with NE, and some parents even punished their child. The parents’ socioeconomic background, education, and the age and birth order of the child were the
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factors associated with their seeking active treatment for NE. A father’s education and young age of the child were factors that influenced parents who preferred positive approaches, such as encouragement,
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for coping with NE.
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Table Reasons parents believe children are bedwetting (multiple choice)
Total (n = 93) Conservative (n = 34) N
Bad habits Too much water intake
Physically immature Urinary system diseases/disorders Psychological factors
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Incapable of awakening from deep sleep
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Laziness, unwillingness to get out of bed
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Other factors (fear of the dark, nightmares, fatigue)
%
N
%
Active (n = 59) N
%
20
21.5
9
26.5
11
18.6
31
33.3
12
35.3
19
32.2
42
45.2
13
38.2
29
49.2
12
12.9
4
11.8
8
13.6
25
26.9
8
23.5
17
28.8
20
21.5
5
14.7
15
25.4
24
25.8
8
23.5
16
27.1
12
12.9
5
14.7
7
11.9
KEYWORDS
Behavior; Childhood development; Nocturnal enuresis; Primary nocturnal enuresis; Parental perception.
Introduction
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Nocturnal enuresis (NE), commonly known as “bed wetting,” is a disorder in which episodes of urinary incontinence (uncontrollable leakage of urine) occur during sleep in children ≥ 5 years of age [1]. It can
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be divided into primary and secondary forms. NE is considered primary (PNE) when bladder control has never been attained and secondary (SNE) when incontinence recurs after at least 6 months of
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continence [2,3].
Recent epidemiological studies have estimated that approximately 15–22% and 7–15% of male and
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female children, respectively, have experienced NE at 7 years of age, and this percentage reduces to 7% and <1% at ages 10 and 18, respectively [4–9]. An overall prevalence of 8%, similar to that in Western populations, has been reported in Taiwan, indicating that NE affects numerous children
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worldwide [10,11]. NE, specifically PNE, can be frustrating, and many parents responded to their child’s bedwetting with resigned helplessness [12]. In addition, a concerning number of parents respond with anger and annoyance, particularly to older children. One-third of all parents of children
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with NE have been reported to resort to punitive methods [13,14] and blame their child, believing that
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the problem is associated with the child’s control over the bladder. Studies have consistently shown that punishment is ineffective for treating NE and that such an approach can induce psychological problems [15,16]. Moreover, parental intolerance of NE is closely associated with discontinuing other types of therapy, such as bed alarm therapy, which in turn can potentially exacerbate punitive methods for coping [15,17]. Thus, assessing the factors influencing parents in seeking standard management for their child with NE is critical.
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Although researchers in Taiwan have conducted epidemiological studies on NE, the literature is incomplete, as these studies have either psychologically assessed NE or examined the factors
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influencing parents for seeking medical attention for their child. For further investigation, we
conducted a study that extends our previous case–control study that examined the difference in NE
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perception between parents and their child [18]. In that study, we found that parents perceived NE differently from their children, and as a result, parents have a different perspective from their child on
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the influence of NE on the child’s emotional and behavioral wellbeing. The purposes of our current study were to analyze the self-reported questionnaires completed by the parents in order to understand the parental perception and examine the factors that influence the treatment and coping strategy that
Methods
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Participants and procedure
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parents utilize in response to PNE.
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This study recruited those children (aged 6–15 years) with bedwetting during a bedwetting seminar hosted by the urology department of Changhua Christian Medical Center in Changhua, Taiwan. As long as the participants were registered for the seminars on bedwetting, agreed to participate in our study, and fit the criteria of our study, their data were included for analysis. After explaining the study’s objectives to the children and their parents, we asked the parents to fill out questionnaires. Using the questionnaire (Electronic Supplementary Material), we obtained the
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child’s basic details and medical history. In addition, the parents’ knowledge of, attitude toward, and management of their child’s bedwetting were assessed. Based on the responses from the questionnaire,
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we categorized the parents’ attitude and approach toward their children’s bedwetting into three groups: (1) positive attitude: parents who comforted, rewarded, or encouraged their children; (2) negative
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attitude: parents who approached bedwetting with disgust and anger and scolded or punished their children; (3) ambivalence: parents who sometimes comforted their children, but sometimes scolded or
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punished them as well.
This study included only children with PNE. Exclusion criteria included chronic health conditions, delayed development (when a child does not achieve developmental milestones within the normal age
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range, such as walking or talking, as described by their parents), other organic illnesses, and secondary enuresis. Finally, a total of 93 children were recruited. The study procedures were approved by the institutional review board of the Changhua Christian Hospital in Changhua, and written informed
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consent was obtained from all participants.
Statistical analyses
For analysis, the chi-square and Fisher exact tests were used first for determining significant differences in the basic characteristics of the participants. We then compared these characteristics to determine whether the parents differed in their outlook (comfort and encouragement, ambivalence, and anger and frustration) toward enuresis and further evaluated significant differences in the methods
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(conservative or active) employed by the parents for coping with their child’s NE. Finally, we applied the logistic regression model to investigate the factors influencing the parents to adopt a positive
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approach toward enuresis and to subsequently seek a medical consultation. All statistical analyses were performed using the IBM SPSS Statistics for Windows, Version 22.0 (IBM Corp., Armonk, NY, USA),
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and p < 0.05 was considered statistically significant.
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Results
This study recruited 45 girls and 48 and boys, of whom 37.6% and 47.3% experienced NE at least once a week and once a day, respectively. Fifty-nine children (63.4%) were treated previously (Table 1).
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One-third of the parents adopted a positive outlook (comfort and encouragement) toward their child with NE, whereas 43.0% reacted with anger and berated their child. The other 23.7% of the parents reacted inconsistently (ambivalence). Most parents believed that NE was caused by deep sleep (45.2%),
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excessive water intake before going to bed (33.3%), or a genitourinary disease (26.9%).
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The method most frequently used by the parents for deterring NE was to regularly wake their child during the night and ask them to use the restroom (62.4%) and to limit the child’s water intake before going to bed (61.3%). Other methods included giving warnings and changing diapers (39.8% each). Only 17.2% of the parents persisted with medication. The logistic regression model revealed several factors affecting the possibility of parents seeking medical consultations: socioeconomic status, maternal educational level, and the age and birth order of
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their child. Parents from high socioeconomic and educational backgrounds were more active in seeking medical treatment. Furthermore, parents were more likely to seek treatment for older children or if the
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child was their first (Table 2). Multiple regression analyses showed that the more educated the father or younger the child with NE, the higher the possibility of the parents approaching NE positively and
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utilizing comfort and encouragement for coping with NE. However, the severity of NE was not correlated with the parental perception of NE and did not influence the treatment strategy selected by
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the parents (Table 3).
Discussion
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NE is one of the major concerns parents of young children face [19]. Approximately two-thirds of all parents are concerned about NE and its associated effects, such as its influence on the interpersonal relationships and emotional development of their child [20]. From our results, angry and frustrated
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parents (43.0%) were significantly more likely to punish their child for bedwetting than were parents
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who approached NE positively (comfort and encouragement, 33.3%). Several studies have reported that no fewer than 30% of parents punished their child for bedwetting [13,20–22], whereas this study reported 12% of the parents used punishments for coping with NE, suggesting that although more parents reported negative emotions in response to NE (anger and frustration), fewer parents adopted punishment as a treatment strategy.
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Child punishment because of NE has for a long time been reported in many parts of the world. However, the frequency of child punishment is difficult to estimate and compare. Different cultures
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have different norms as regards acceptable parenting practices. Korbin [23] postulated that crosscultural variability in child rearing beliefs and behaviors makes it clear that there is not a universal
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standard for optimal child care nor for child abuse and neglect. In Japan, suspicions of child neglect and physical and sexual abuse are based on history and physical findings [24]. Can et al. [25] reported
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that 42.1% of children who were abused as a result of their enuresis were spanked and 12.8% were beaten in Turkey. Among them, 40.6% of children who were abused as a result of their NE were neglected medically [25].
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NE can be present with or without lower urinary tract symptoms (LUTS). When only NE is present, the disorder is referred to as monosymptomatic enuresis (MNE). If NE presents with LUTS, it is referred to as non-monosymptomatic enuresis (NMNE) [1]. Most children in South Africa reported to
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be suffering from NE are not well treated. Overall, 42% of parents with children suffering from MNE
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were unaware that there are specific treatments available for MNE. However, 61.3% of parents in this study indicated a possible willingness to take their children for treatment of some kind if the problem did not resolve spontaneously. It was higher than those parents from Turkey and Malaysia, where 75% and 87% of parents were unwilling to seek medical consultation respectively [26–28]. In another study from Brazil, Sapi et al. [22] reported that 50.8% of the children with PMNE suffered physical punishment without physical contact; physical punishment with physical contact accounted for 48.5%
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of the cases. Furthermore, one child suffered an intentional severe genital injury. They concluded that children living with a population of low-educated people may be considered at risk of suffering
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domestic violence [22]. Healthcare providers should inform such parents that reacting with anger and berating their child for bedwetting are unproductive because enuresis is not a behavioral problem.
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Instead, creating awareness and helping parents who are more likely to negatively approach enuresis in understanding enuresis would be more beneficial for their children.
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In our study, the lack of comfort or encouragement was concerning. A lack of encouragement may negatively affect the self-esteem of children with NE, as discussed in our previous study [18]. Moreover, a review of literature on the psychosocial effects of enuresis showed that an individual’s
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self-esteem or confidence, both of which can help them eliminate NE, determines the person’s behavioral response to NE [12]. In our study, approximately 50% of the parents who approached NE positively (comfort and encouragement) or inconsistently (ambivalence) reported that they comforted
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their child after bedwetting. The psychological effects on the children and their families have been
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considered a burden on the community. The problem lies within the norms and culture of certain populations. Most of previous investigations about the psychological effect of NE revealed that the children and their families alike were affected [29–31]. However, in Lebanon, the psychological effect of NE between child and parent is different. The Merhi et al. [32] study had shown that more than 80% of children were psychologically affected whereas only less than 30% of parents were affected . Our previous study has also shown that parental attitude and perception towards bedwetting are
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fundamentally different from that of their children. It is the parents themselves that perceive the numerous psychosocial difficulties in their own children. In contrast, their enuretic children perceive
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themselves no differently from their peers. There is the possibility in which the enuretic children themselves are not completely honest, perhaps in an attempt to avoid the reality of the situation. These
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children may be attempting to cope with their increasing stress from their failure to meet parental expectations with denial. Therefore, parental encouragement and positive reinforcement of their self-
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esteem may be important in helping enuretic children to deter their bedwetting permanently [18]. Because the causes of enuresis are complex, children with PMNE, secondary enuresis, or children with urinary problems that range from diurnal enuresis to other lower urinary tract dysfunction can all
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have different underlying pathological factors causing their bedwetting. Moreover, researchers have also noted that children with intellectual disability or special needs have higher rates of bedwetting, further complicating the underlying causes of enuresis [33]. As a result, in order to simplify the
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analysis for our study, we only include children with PNE into our study. Because some children with
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primary NMNE might have complicated underlying pathology, we excluded those children with chronic health conditions, delayed development, other organic illnesses. A review of the literature by Ferrara et al. [34] had reported that the possible correlation of long term NE with language disorder and testicular pathology. These disorders might be a great burden for these children and their parents. Park et al. [35] reported that their research confirmed the association between enuresis and attention deficit hyperactivity disorder (ADHD) previously reported [36,37]. Previous research has suggested that both
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enuresis and ADHD are related to delays in central nervous system maturation [6]. And the increased behavioral symptoms reflect coping behaviors for dealing with the emotional and social burdens of
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enuresis [38]. Furthermore, parental attitudes about bedwetting management may be potential factors related to development of both enuresis and behavioral problems [38,39]. Therefore, when dealing with
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these kinds of diseases in enuretic children, the healthcare provider must use a biopsychical approach. However, there were four (4.3%) children in our study with serious emotional disorders. Considering
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the small sample size, statistically speaking, it is difficult to determine whether or not their behavior will influence parental attitude toward bedwetting. All four were referred to child psychologists from the Center for Child Development for further counseling and guidance.
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Notably, most parents in our study perceived no substantial improvement in their child’s bedwetting situation, specifically in those with severe NE, when they expressed anger or were ambivalent in their response to NE (35.0% and 63.6%, respectively). This perceived lack of improvement along with their
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reported fatigue may explain why parents who approached enuresis with a conflicted (ambivalence) or
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negative (anger and frustration) outlook sought medical treatment more actively than did the other parents (69.4% vs. 54.8%). In clinical practice, it may be appropriate to act quickly for reducing parental annoyance and encourage clinical attendance through practical methods, such as bedding protection and medication [40]. The next steps would be to follow interventions that improve parent– child interactions for reducing parental intolerance.
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Studies on enuresis have recommended using bed alarms in addition to other behavioral modifications as the mainstay of treatment [41,42]. There are treatment guidelines for enuresis in
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Taiwan [43]. The two main options of treatment are behavioral modification with an alarm system and pharmacotherapy with desmopressin or imipramine. NE may be a multifactorial disorder, and the use
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of combined treatment and long-term therapy is necessary. Lottmann et al. reported that monotherapy is likely to be refractory, and various combinations such as desmopressin and an alarm or imipramine
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and an alarm might be more effective than a single treatment modality [44]. However, bed alarms are often underutilized in Taiwan because they are considered time intensive. Our results suggested that most parents opted for such methods as limiting water intake, waking the child regularly for restroom
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use, using diapers, giving verbal warnings, or administering medications for coping with NE. Furthermore, we observed that parents who actively sought treatment for their child with NE were
response rate.
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more likely to utilize medications as a coping strategy, presumably because of its convenience and fast
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In China, only 6.08% of PNE cases had sought professional help, 49.15% families woke the child at night and/or restricted the child’s fluid intake to avoid NE, and 44.8% families would rather wait for their child to mature [45]. Traditionally, parents in the Chinese world, particularly in Taiwan, HongKong, or China, prefer Chinese medicine for treating illnesses and other disorders. In numerous Taiwanese households, elderly family members, such as grandparents, strongly influence the other
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family members. Furthermore, their belief and insistence on using traditional therapy might result in slower remission or NE persistence in children with NE.
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Consistent with the relevant literature, we found that parental educational level and socioeconomic status were associated with the possibility of parents seeking a medical consultation for their child with
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NE [30,46]. The multiple logistic regression analysis showed that mothers with a university or higher educational level were more likely to actively seek treatment than were mothers who were high school
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graduates; in addition, we found that upper middle class (above average income) parents were more likely to follow the aforementioned approach than were working class (low income) parents (Table 2). Because parental involvement is crucial for successfully treating enuresis, healthcare professionals
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should understand the social environment before planning any treatment [12,21]. In general, parents were more determined to seek medical care for older children with NE, possibly because of the perception of increased subsequent behavioral or emotional problems [18]. An increased
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risk of social maladjustment among older children with NE has been reported [18,47], especially
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because their parents begin to develop a negative outlook toward bedwetting; we confirm that parents eagerly seek treatment for their first-born child with NE. In Asian culture generally and in Chinese society specifically, parents often place great emphasis on the success of their first-born child, consequently investing greater effort into parenting their first-born child. This may explain why parents are more likely to be stricter with their first-born child and adopt a positive approach toward their youngest child. Furthermore, we hypothesize that through trial and error parents may realize that
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encouragement is more effective in preventing NE. According to our results, a high paternal educational level significantly influenced the approach adopted by parents toward their child’s
and preferred encouraging their children rather than punishing them.
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bedwetting condition. Highly educated fathers were extremely likely to approach enuresis positively
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The strengths of this study lie in that not only did we investigate the child’s bedwetting condition and previous utilized treatment methods, we also tried to understand the parents’ knowledge of, attitude
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toward, and management of their child’s bedwetting condition. As such, our study provides healthcare practitioners additional information to understand the patient’s feelings and needs in regards to bedwetting. Furthermore, since parents were the ones to answer the questionnaire, there is reason to
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believe that the responses provided are more reliable. This is because in general, children are more likely to lie about their bedwetting condition while parents will want to provide accurate information in order to search for treatment methods for their child’s bedwetting condition. The weakness of this study
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is that the sample size was not large enough for us to explore some notable questions, such as
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differences in parental perspective between children with no behavioral disorders and those with behavioral disorders, and the difference in the beliefs of mothers and fathers who disagree with the approach toward NE and the control parents believe they have over their children. These questions can be solved through further research.
Conclusions
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Parents’ perception of NE influences their choice of treatment strategy for their children and strong motivation for NE management from them are usually required. In our study, 43% of the parents
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reacted with anger and berated their child with NE; however, only few of them inflicted physical punishment. Several factors, namely socioeconomic status, maternal educational level, and the age and
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birth order of their child, affected the possibility of parents seeking medical intervention for NE. In addition, the more educated the father or the younger the child with NE, the higher the possibility of the
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parents approaching enuresis positively, such as with encouragement. Because parental involvement is crucial for successfully treating enuresis, healthcare professionals should understand the factors influencing parents seeking reasonable management for their child and their overall outlook toward
Acknowledgments
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PNE before helping these children.
None.
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Competing interests
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We thank the children and their parents for participating in the study.
Funding
None.
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[32] Merhi BA, Hammoud A, Ziade F, Kamel R, Rajab M. Mono-symptomatic nocturnal enuresis in
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Lebanese children: Prevalence, relation with obesity, and psychological effect. Clin Med Insights Pediatr 2014;8:5–9.
[33] Spee-van der Wekke J, Hirasing RA, Meulmeester JF, Radder JJ. Childhood nocturnal enuresis in The Netherlands. Urology 1998;51:1022–6.
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[34] Ferrara P, De Angelis MC, Caporale O, Malamisura M, Del Volgo V, Vena F, et al. Possible impact of comorbid conditions on the persistence of nocturnal enuresis: Results of a long-term
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follow-up study. Urol J 2014;11:1777–82.
[35] Park S, Kim BN, Kim JW, Hong SB, Shin MS, Yoo HJ, et al. Nocturnal enuresis is associated
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with attention deficit hyperactivity disorder and conduct problems. Psychiatry Investig 2013;10:253–8.
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[36] Baeyens D, Roeyers H, Van Erdeghem S, Hoebeke P, Vande Walle J. The prevalence of attention deficit-hyperactivity disorder in children with nonmonosymptomatic nocturnal enuresis: A 4-year followup study. J Urol 2007;178:2616–20.
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[37] Baeyens D, Roeyers H, D’Haese L, Pieters F, Hoebeke P, Vande Walle J. The prevalence of ADHD in children with enuresis: Comparison between a tertiary and non-tertiary care sample. Acta Paediatr 2006;95:347–52.
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[38] Liu X, Sun Z, Uchiyama M, Li Y, Okawa M. Attaining nocturnal urinary control, nocturnal
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enuresis, and behavioral problems in Chinese children aged 6 through 16 years. J Am Acad Child Adolesc Psychiatry 2000;39:1557–64. [39] Chiozza ML, Bernardinelli L, Caione P, Del Gado R, Ferrara P, Giorgi PL, et al. An Italian epidemiological multicentre study of nocturnal enuresis. Br J Urol 1998;81 Suppl 3:86–9. [40] Butler R, McKenna S. Overcoming parental intolerance in childhood nocturnal enuresis: A survey of professional opinion. BJU Int 2002;89:295–7.
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[41] Jain S, Bhatt GC. Advances in the management of primary monosymptomatic nocturnal enuresis in children. Paediatr Int Child Health 2016;36:7–14.
Cochrane Database Syst Rev 2005:CD002911.
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[42] Glazener CM, Evans JH, Peto RE. Alarm interventions for nocturnal enuresis in children.
Taiwan. Acta Paediatr Taiwan 2001;42:271–7.
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[43] Yang SS, Chiou YH, Lin CY, Cher TW, Yu TJ, Lin AT, et al. Treatment guideline of enuresis in
Int J Clin Pract Suppl 2007:8–16.
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[44] Lottmann HB, Alova I. Primary monosymptomatic nocturnal enuresis in children and adolescents.
[45] Wen JG, Wang QW, Chen Y, Wen JJ, Liu K. An epidemiological study of primary nocturnal
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enuresis in Chinese children and adolescents. Eur Urol 2006;49:1107–13. [46] Schlomer B, Rodriguez E, Weiss D, Copp H. Parental beliefs about nocturnal enuresis causes, treatments, and the need to seek professional medical care. J Pediatr Urol 2013;9:1043–8.
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[47] Schober JM, Lipman R, Haltigan JD, Kuhn PJ. The impact of monosymptomatic nocturnal
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enuresis on attachment parameters. Scand J Urol Nephrol 2004;38:47–52.
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Table 1 Personal and family characteristics of children with primary nocturnal enuresis.
N
%
N
%
%
N
p
Comfort and Ambivalence Anger and encouragement (n = 22) frustration (n = 31) (n = 40) N % N % N %
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Active (n = 59)
p
18 16
52.9 47.1
27 32
45.8 54.2
0.505
12 19
38.7 61.3
11 11
50.0 50.0
22 18
55.0 45.0
0.389
55 59.1 33 35.5 5 5.4
24 9 1
70.6 26.5 2.9
31 24 4
52.5 40.7 6.8
0.260
19 11 1
61.3 35.5 3.2
12 9 1
54.5 40.9 4.5
24 13 3
60.0 32.5 7.5
0.933
4 4.3 35 37.6 25 26.9 29 31.2
2 6 10 16
51 54.8 29 31.2 13 14.0
19 10 5
5.9 17.6 29.4 47.1
2 29 15 13
3.4 49.2 25.4 22.0
0.009
1 9 6 15
3.2 29.0 19.4 48.4
0 8 7 7
0.0 36.4 31.8 31.8
3 18 12 7
7.5 45.0 30.0 17.5
0.011
55.9 29.4 14.7
32 19 8
54.2 32.2 13.6
1.000
10 13 8
32.3 41.9 25.8
13 8 1
59.1 36.4 4.5
28 8 4
70.0 20.0 10.0
0.013
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45 48.4 48 51.6
26 7 1
76.5 20.6 2.9
35 18 6
59.3 30.5 10.2
0.217
18 8 5
58.1 25.8 16.1
14 8 0
63.6 36.4 0.0
29 9 2
72.5 22.5 5.0
0.204
62 66.7 31 33.3
20 14
58.8 41.2
42 17
71.2 28.8
0.223
21 10
67.7 32.3
17 5
77.3 22.7
24 16
60.0 40.0
0.381
5 5.4 9 9.7 35 37.6 44 47.3
1 5 13 15
2.9 14.7 38.2 44.1
4 4 22 29
6.8 6.8 37.3 49.2
0.576
3 3 12 13
9.7 9.7 38.7 41.9
1 3 7 11
4.5 13.6 31.8 50.0
1 3 16 20
2.5 7.5 40.0 50.0
0.849
44 47.3 18 19.4 31 33.3
15 12 7
44.1 35.3 20.6
29 6 24
49.2 10.2 40.7
0.008
14 7 10
45.2 22.6 32.3
11 2 9
50.0 9.1 40.9
19 9 12
47.5 22.5 30.0
0.712
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61 65.6 25 26.9 7 7.5
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Gender Female Male Age 6–9 10–12 13–15 Order of birth Only child First child Middle child Youngest child Paternal educational level High school or below Technical college University or above Maternal educational level High school or below Technical college University or above Difficult to awake from sleep Yes No Bedwetting frequency Semi-annual Monthly Weekly Daily Family history No family history Enuresis present in lineal family Enuresis present in relatives
Total Conservative (n = 93) (n = 34)
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Table 2 Logistic regression analysis of seeking medical treatment for the bedwetting. Active a
a
%
Univariate analysis Odds ratio
Multiple analysis (adjusted)
95% CI
p
0.988–1.501
0.065
Odds ratio 1.440
95% CI
p
1.015–2.044
0.041
1.000 28.506
2.598–312.789
0.006
0.098
1.000 43.857
0.747–2573.604
0.069
0.483–15.895
0.253
58 35
30 29
51.7 82.9
1.000 4.511
83 10
50 9
60.2 90.0
1.000 5.940
14 79
8 51
57.1 64.6
1.000 1.366
0.431–4.334
0.596
1.000 2.770
44 18 31
29 6 24
65.9 33.3 77.4
1.000 0.259 1.773
0.081–0.826 0.622–5.055
0.022 0.284
1.000 0.015 2.324
0.001–0.232 0.558–9.679
0.003 0.247
61 25 7
35 18 6
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9.48 ± 2.21 9.80 ± 2.25 1.218
0.696–5.244 0.505–39.310
0.209 0.178
1.000 1.083 46.577
0.238–4.930 1.123–1932.671
0.918 0.043
0.089–24.346 0.351–345.055
0.788 0.173
1.000 4.256 0.142–127.777 1456.538 7.647–277447.246
57.4 72.0 85.7
1 47 11
50.0 59.5 91.7
1.000 1.469 11.000
0.004
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1.629–12.495
0.719–49.104
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1.000 1.910 4.457
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2 79 12
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Age, years (mean ± SD) First-born child No Yes Time of bedwetting Night-time Daytime and night-time Bedwetting frequency < Once/week ≥ Once/week Family history No family history Enuresis present in lineal family Enuresis present in relatives Maternal educational level High school or below Technical college University or above Family economic status Low incomes Average incomes Above-average incomes
N
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Total
Active: parents actively seek medical consultation for their child.
2
0.404 0.007
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Table 3 Logistic regression analysis of parental attitudes toward a child’s bedwetting. 95% CI
p
Odds ratio
51
10
19.6
1.000
29 13
13 8
44.8 61.5
3.331 6.560
1.217–9.116 1.763–24.407
0.019 0.005
3.284 6.534
64 29
16 15
25.0 51.7
1.000 3.214
1.278–8.084
0.013
1.000 3.064
44 35 9 5
13 12 3 3
29.5 34.3 33.3 60.0
1.000 1.244 1.192 3.577
0.480–3.224 0.258–5.505 0.534–23.982
95% CI
1.123–9.607 1.637–26.082
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1.000
1.000 1.502 0.838 5.939
0.653 0.822 0.189
p
1.120–8.383
0.510–4.418 0.160–4.386 0.781–45.152
0.030 0.008
0.029
0.460 0.834 0.085
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Positive: parents approached their child’s nocturnal enuresis with positive attitude such as comfort and encouragement.
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a
Odds ratio
Multiple analysis (adjusted)
%
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Paternal educational level High school or below Technical college University or above Last-born child No Yes Bedwetting frequency Daily Weekly Monthly Semi-annual
Univariate analysis
N
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Total
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Positive a
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S1477-5131(17)30046-3
DOI:
10.1016/j.jpurol.2016.12.025
Reference:
JPUROL 2435
To appear in:
Journal of Pediatric Urology
Received Date: 30 May 2016 Accepted Date: 13 December 2016
Please cite this article as: Tai TT, Tai BT, Chang Y-J, Huang K-H, Parental perception and factors associated with treatment strategies for primary nocturnal enuresis, Journal of Pediatric Urology (2017), doi: 10.1016/j.jpurol.2016.12.025. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Parental perception and factors associated with treatment strategies for primary nocturnal enuresis
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Thomson T. Taia, Brent T. Taib, Yu-Jun Changc* and Kuo-Hsuan Huangd,e
a
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Department of Neuroscience, Hamilton College, Clinton, New York, USA Department of Biology, College of the Holy Cross, Worcester, Massachusetts, USA c Epidemiology and Biostatistics Center, Changhua Christian Hospital, Changhua, Taiwan d Department of Surgery, Erlin Christian Hospital, Chanhua, Taiwan
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b
e
Division of Urology, Changhua Christian Hospital, Changhua, Taiwan
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*Correspondence Yu-Jun Chang, PhD, Epidemiology and Biostatistics Center, Changhua Christian Hospital, 135 Nanhsiao Street, Changhua 50006, Taiwan. Tel: +886 4 7238595 Email: [email protected]
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Running head: Factors associated with treatment strategies for primary nocturnal enuresis
Ethical Approval
The study procedures were approved by the institutional review board of the Changhua Christian Hospital in Changhua, and written informed consent was obtained from all participants.
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Parental perception and factors associated with treatment strategies for primary nocturnal enuresis Thomson T. Tai a, Brent T. Tai b, Yu-Jun Chang c,*, and Kuo-Hsuan Huang d,e Department of Neuroscience, Hamilton College, Clinton, NY, USA
b
Department of Biology, College of the Holy Cross, Worcester, MA, USA
c
Epidemiology and Biostatistics Center, Changhua Christian Hospital, Changhua, Taiwan
d
Department of Surgery, Erlin Christian Hospital, Chanhua, Taiwan
e
Division of Urology, Changhua Christian Hospital, Changhua, Taiwan
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a
* Corresponding author. Epidemiology and Biostatistics Center, Changhua Christian Hospital, 135 Nanhsiao Street, Changhua 50006, Taiwan. Tel.: +886 4723 8595.
Summary
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Objective
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E-mail address: [email protected] (Y.-J. Chang).
The aim was to investigate the factors influencing parents seeking reasonable managements for their
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child and their overall outlook toward primary nocturnal enuresis (PNE). Study design: We recruited 93 children with PNE from enuresis clinics and requested their parents to
complete questionnaires regarding their child’s medical history and behavior, their methods for coping with PNE, and their perception of enuresis. Logistic regression models were applied to investigate
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factors influencing the parents to adopt a positive approach toward enuresis and to subsequently seek a medical consultation.
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Results
One-third of the parents had an encouraging attitude toward children with PNE, whereas slightly less
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than half reacted with anger. The more educated the father or the younger the child with NE, the larger the possibility of the parents utilizing a positive approach, such as encouragement, for coping with NE.
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Factors that influenced parents to seek medical consultation for NE were socioeconomic status, maternal educational level, and the age and birth order of their child. Discussion
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From our results, angry and frustrated parents (43.0%) were significantly more likely to punish their child for bedwetting than were parents who approached NE positively (comfort and encouragement; 33.3%). A lack of encouragement may negatively affect the self-esteem of children with NE. Moreover,
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an individual’s self-esteem or confidence, both of which can help them eliminate NE, determines the
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person’s behavioral response to bedwetting. In our study, approximately 50% of the parents who approached NE positively (comfort and encouragement) or inconsistently (ambivalence) reported that they comforted their child after bedwetting.
Conclusions
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Nearly half the parents reacted angrily to children with NE, and some parents even punished their child. The parents’ socioeconomic background, education, and the age and birth order of the child were the
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factors associated with their seeking active treatment for NE. A father’s education and young age of the child were factors that influenced parents who preferred positive approaches, such as encouragement,
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for coping with NE.
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Table Reasons parents believe children are bedwetting (multiple choice)
Total (n = 93) Conservative (n = 34) N
Bad habits Too much water intake
Physically immature Urinary system diseases/disorders Psychological factors
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Incapable of awakening from deep sleep
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Laziness, unwillingness to get out of bed
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Other factors (fear of the dark, nightmares, fatigue)
%
N
%
Active (n = 59) N
%
20
21.5
9
26.5
11
18.6
31
33.3
12
35.3
19
32.2
42
45.2
13
38.2
29
49.2
12
12.9
4
11.8
8
13.6
25
26.9
8
23.5
17
28.8
20
21.5
5
14.7
15
25.4
24
25.8
8
23.5
16
27.1
12
12.9
5
14.7
7
11.9
KEYWORDS
Behavior; Childhood development; Nocturnal enuresis; Primary nocturnal enuresis; Parental perception.
Introduction
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Nocturnal enuresis (NE), commonly known as “bed wetting,” is a disorder in which episodes of urinary incontinence (uncontrollable leakage of urine) occur during sleep in children ≥ 5 years of age [1]. It can
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be divided into primary and secondary forms. NE is considered primary (PNE) when bladder control has never been attained and secondary (SNE) when incontinence recurs after at least 6 months of
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continence [2,3].
Recent epidemiological studies have estimated that approximately 15–22% and 7–15% of male and
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female children, respectively, have experienced NE at 7 years of age, and this percentage reduces to 7% and <1% at ages 10 and 18, respectively [4–9]. An overall prevalence of 8%, similar to that in Western populations, has been reported in Taiwan, indicating that NE affects numerous children
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worldwide [10,11]. NE, specifically PNE, can be frustrating, and many parents responded to their child’s bedwetting with resigned helplessness [12]. In addition, a concerning number of parents respond with anger and annoyance, particularly to older children. One-third of all parents of children
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with NE have been reported to resort to punitive methods [13,14] and blame their child, believing that
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the problem is associated with the child’s control over the bladder. Studies have consistently shown that punishment is ineffective for treating NE and that such an approach can induce psychological problems [15,16]. Moreover, parental intolerance of NE is closely associated with discontinuing other types of therapy, such as bed alarm therapy, which in turn can potentially exacerbate punitive methods for coping [15,17]. Thus, assessing the factors influencing parents in seeking standard management for their child with NE is critical.
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Although researchers in Taiwan have conducted epidemiological studies on NE, the literature is incomplete, as these studies have either psychologically assessed NE or examined the factors
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influencing parents for seeking medical attention for their child. For further investigation, we
conducted a study that extends our previous case–control study that examined the difference in NE
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perception between parents and their child [18]. In that study, we found that parents perceived NE differently from their children, and as a result, parents have a different perspective from their child on
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the influence of NE on the child’s emotional and behavioral wellbeing. The purposes of our current study were to analyze the self-reported questionnaires completed by the parents in order to understand the parental perception and examine the factors that influence the treatment and coping strategy that
Methods
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Participants and procedure
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parents utilize in response to PNE.
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This study recruited those children (aged 6–15 years) with bedwetting during a bedwetting seminar hosted by the urology department of Changhua Christian Medical Center in Changhua, Taiwan. As long as the participants were registered for the seminars on bedwetting, agreed to participate in our study, and fit the criteria of our study, their data were included for analysis. After explaining the study’s objectives to the children and their parents, we asked the parents to fill out questionnaires. Using the questionnaire (Electronic Supplementary Material), we obtained the
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child’s basic details and medical history. In addition, the parents’ knowledge of, attitude toward, and management of their child’s bedwetting were assessed. Based on the responses from the questionnaire,
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we categorized the parents’ attitude and approach toward their children’s bedwetting into three groups: (1) positive attitude: parents who comforted, rewarded, or encouraged their children; (2) negative
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attitude: parents who approached bedwetting with disgust and anger and scolded or punished their children; (3) ambivalence: parents who sometimes comforted their children, but sometimes scolded or
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punished them as well.
This study included only children with PNE. Exclusion criteria included chronic health conditions, delayed development (when a child does not achieve developmental milestones within the normal age
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range, such as walking or talking, as described by their parents), other organic illnesses, and secondary enuresis. Finally, a total of 93 children were recruited. The study procedures were approved by the institutional review board of the Changhua Christian Hospital in Changhua, and written informed
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consent was obtained from all participants.
Statistical analyses
For analysis, the chi-square and Fisher exact tests were used first for determining significant differences in the basic characteristics of the participants. We then compared these characteristics to determine whether the parents differed in their outlook (comfort and encouragement, ambivalence, and anger and frustration) toward enuresis and further evaluated significant differences in the methods
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(conservative or active) employed by the parents for coping with their child’s NE. Finally, we applied the logistic regression model to investigate the factors influencing the parents to adopt a positive
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approach toward enuresis and to subsequently seek a medical consultation. All statistical analyses were performed using the IBM SPSS Statistics for Windows, Version 22.0 (IBM Corp., Armonk, NY, USA),
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and p < 0.05 was considered statistically significant.
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Results
This study recruited 45 girls and 48 and boys, of whom 37.6% and 47.3% experienced NE at least once a week and once a day, respectively. Fifty-nine children (63.4%) were treated previously (Table 1).
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One-third of the parents adopted a positive outlook (comfort and encouragement) toward their child with NE, whereas 43.0% reacted with anger and berated their child. The other 23.7% of the parents reacted inconsistently (ambivalence). Most parents believed that NE was caused by deep sleep (45.2%),
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excessive water intake before going to bed (33.3%), or a genitourinary disease (26.9%).
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The method most frequently used by the parents for deterring NE was to regularly wake their child during the night and ask them to use the restroom (62.4%) and to limit the child’s water intake before going to bed (61.3%). Other methods included giving warnings and changing diapers (39.8% each). Only 17.2% of the parents persisted with medication. The logistic regression model revealed several factors affecting the possibility of parents seeking medical consultations: socioeconomic status, maternal educational level, and the age and birth order of
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their child. Parents from high socioeconomic and educational backgrounds were more active in seeking medical treatment. Furthermore, parents were more likely to seek treatment for older children or if the
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child was their first (Table 2). Multiple regression analyses showed that the more educated the father or younger the child with NE, the higher the possibility of the parents approaching NE positively and
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utilizing comfort and encouragement for coping with NE. However, the severity of NE was not correlated with the parental perception of NE and did not influence the treatment strategy selected by
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the parents (Table 3).
Discussion
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NE is one of the major concerns parents of young children face [19]. Approximately two-thirds of all parents are concerned about NE and its associated effects, such as its influence on the interpersonal relationships and emotional development of their child [20]. From our results, angry and frustrated
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parents (43.0%) were significantly more likely to punish their child for bedwetting than were parents
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who approached NE positively (comfort and encouragement, 33.3%). Several studies have reported that no fewer than 30% of parents punished their child for bedwetting [13,20–22], whereas this study reported 12% of the parents used punishments for coping with NE, suggesting that although more parents reported negative emotions in response to NE (anger and frustration), fewer parents adopted punishment as a treatment strategy.
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Child punishment because of NE has for a long time been reported in many parts of the world. However, the frequency of child punishment is difficult to estimate and compare. Different cultures
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have different norms as regards acceptable parenting practices. Korbin [23] postulated that crosscultural variability in child rearing beliefs and behaviors makes it clear that there is not a universal
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standard for optimal child care nor for child abuse and neglect. In Japan, suspicions of child neglect and physical and sexual abuse are based on history and physical findings [24]. Can et al. [25] reported
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that 42.1% of children who were abused as a result of their enuresis were spanked and 12.8% were beaten in Turkey. Among them, 40.6% of children who were abused as a result of their NE were neglected medically [25].
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NE can be present with or without lower urinary tract symptoms (LUTS). When only NE is present, the disorder is referred to as monosymptomatic enuresis (MNE). If NE presents with LUTS, it is referred to as non-monosymptomatic enuresis (NMNE) [1]. Most children in South Africa reported to
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be suffering from NE are not well treated. Overall, 42% of parents with children suffering from MNE
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were unaware that there are specific treatments available for MNE. However, 61.3% of parents in this study indicated a possible willingness to take their children for treatment of some kind if the problem did not resolve spontaneously. It was higher than those parents from Turkey and Malaysia, where 75% and 87% of parents were unwilling to seek medical consultation respectively [26–28]. In another study from Brazil, Sapi et al. [22] reported that 50.8% of the children with PMNE suffered physical punishment without physical contact; physical punishment with physical contact accounted for 48.5%
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of the cases. Furthermore, one child suffered an intentional severe genital injury. They concluded that children living with a population of low-educated people may be considered at risk of suffering
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domestic violence [22]. Healthcare providers should inform such parents that reacting with anger and berating their child for bedwetting are unproductive because enuresis is not a behavioral problem.
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Instead, creating awareness and helping parents who are more likely to negatively approach enuresis in understanding enuresis would be more beneficial for their children.
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In our study, the lack of comfort or encouragement was concerning. A lack of encouragement may negatively affect the self-esteem of children with NE, as discussed in our previous study [18]. Moreover, a review of literature on the psychosocial effects of enuresis showed that an individual’s
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self-esteem or confidence, both of which can help them eliminate NE, determines the person’s behavioral response to NE [12]. In our study, approximately 50% of the parents who approached NE positively (comfort and encouragement) or inconsistently (ambivalence) reported that they comforted
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their child after bedwetting. The psychological effects on the children and their families have been
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considered a burden on the community. The problem lies within the norms and culture of certain populations. Most of previous investigations about the psychological effect of NE revealed that the children and their families alike were affected [29–31]. However, in Lebanon, the psychological effect of NE between child and parent is different. The Merhi et al. [32] study had shown that more than 80% of children were psychologically affected whereas only less than 30% of parents were affected . Our previous study has also shown that parental attitude and perception towards bedwetting are
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fundamentally different from that of their children. It is the parents themselves that perceive the numerous psychosocial difficulties in their own children. In contrast, their enuretic children perceive
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themselves no differently from their peers. There is the possibility in which the enuretic children themselves are not completely honest, perhaps in an attempt to avoid the reality of the situation. These
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children may be attempting to cope with their increasing stress from their failure to meet parental expectations with denial. Therefore, parental encouragement and positive reinforcement of their self-
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esteem may be important in helping enuretic children to deter their bedwetting permanently [18]. Because the causes of enuresis are complex, children with PMNE, secondary enuresis, or children with urinary problems that range from diurnal enuresis to other lower urinary tract dysfunction can all
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have different underlying pathological factors causing their bedwetting. Moreover, researchers have also noted that children with intellectual disability or special needs have higher rates of bedwetting, further complicating the underlying causes of enuresis [33]. As a result, in order to simplify the
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analysis for our study, we only include children with PNE into our study. Because some children with
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primary NMNE might have complicated underlying pathology, we excluded those children with chronic health conditions, delayed development, other organic illnesses. A review of the literature by Ferrara et al. [34] had reported that the possible correlation of long term NE with language disorder and testicular pathology. These disorders might be a great burden for these children and their parents. Park et al. [35] reported that their research confirmed the association between enuresis and attention deficit hyperactivity disorder (ADHD) previously reported [36,37]. Previous research has suggested that both
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enuresis and ADHD are related to delays in central nervous system maturation [6]. And the increased behavioral symptoms reflect coping behaviors for dealing with the emotional and social burdens of
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enuresis [38]. Furthermore, parental attitudes about bedwetting management may be potential factors related to development of both enuresis and behavioral problems [38,39]. Therefore, when dealing with
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these kinds of diseases in enuretic children, the healthcare provider must use a biopsychical approach. However, there were four (4.3%) children in our study with serious emotional disorders. Considering
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the small sample size, statistically speaking, it is difficult to determine whether or not their behavior will influence parental attitude toward bedwetting. All four were referred to child psychologists from the Center for Child Development for further counseling and guidance.
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Notably, most parents in our study perceived no substantial improvement in their child’s bedwetting situation, specifically in those with severe NE, when they expressed anger or were ambivalent in their response to NE (35.0% and 63.6%, respectively). This perceived lack of improvement along with their
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reported fatigue may explain why parents who approached enuresis with a conflicted (ambivalence) or
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negative (anger and frustration) outlook sought medical treatment more actively than did the other parents (69.4% vs. 54.8%). In clinical practice, it may be appropriate to act quickly for reducing parental annoyance and encourage clinical attendance through practical methods, such as bedding protection and medication [40]. The next steps would be to follow interventions that improve parent– child interactions for reducing parental intolerance.
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Studies on enuresis have recommended using bed alarms in addition to other behavioral modifications as the mainstay of treatment [41,42]. There are treatment guidelines for enuresis in
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Taiwan [43]. The two main options of treatment are behavioral modification with an alarm system and pharmacotherapy with desmopressin or imipramine. NE may be a multifactorial disorder, and the use
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of combined treatment and long-term therapy is necessary. Lottmann et al. reported that monotherapy is likely to be refractory, and various combinations such as desmopressin and an alarm or imipramine
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and an alarm might be more effective than a single treatment modality [44]. However, bed alarms are often underutilized in Taiwan because they are considered time intensive. Our results suggested that most parents opted for such methods as limiting water intake, waking the child regularly for restroom
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use, using diapers, giving verbal warnings, or administering medications for coping with NE. Furthermore, we observed that parents who actively sought treatment for their child with NE were
response rate.
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more likely to utilize medications as a coping strategy, presumably because of its convenience and fast
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In China, only 6.08% of PNE cases had sought professional help, 49.15% families woke the child at night and/or restricted the child’s fluid intake to avoid NE, and 44.8% families would rather wait for their child to mature [45]. Traditionally, parents in the Chinese world, particularly in Taiwan, HongKong, or China, prefer Chinese medicine for treating illnesses and other disorders. In numerous Taiwanese households, elderly family members, such as grandparents, strongly influence the other
13
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family members. Furthermore, their belief and insistence on using traditional therapy might result in slower remission or NE persistence in children with NE.
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Consistent with the relevant literature, we found that parental educational level and socioeconomic status were associated with the possibility of parents seeking a medical consultation for their child with
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NE [30,46]. The multiple logistic regression analysis showed that mothers with a university or higher educational level were more likely to actively seek treatment than were mothers who were high school
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graduates; in addition, we found that upper middle class (above average income) parents were more likely to follow the aforementioned approach than were working class (low income) parents (Table 2). Because parental involvement is crucial for successfully treating enuresis, healthcare professionals
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should understand the social environment before planning any treatment [12,21]. In general, parents were more determined to seek medical care for older children with NE, possibly because of the perception of increased subsequent behavioral or emotional problems [18]. An increased
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risk of social maladjustment among older children with NE has been reported [18,47], especially
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because their parents begin to develop a negative outlook toward bedwetting; we confirm that parents eagerly seek treatment for their first-born child with NE. In Asian culture generally and in Chinese society specifically, parents often place great emphasis on the success of their first-born child, consequently investing greater effort into parenting their first-born child. This may explain why parents are more likely to be stricter with their first-born child and adopt a positive approach toward their youngest child. Furthermore, we hypothesize that through trial and error parents may realize that
14
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encouragement is more effective in preventing NE. According to our results, a high paternal educational level significantly influenced the approach adopted by parents toward their child’s
and preferred encouraging their children rather than punishing them.
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bedwetting condition. Highly educated fathers were extremely likely to approach enuresis positively
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The strengths of this study lie in that not only did we investigate the child’s bedwetting condition and previous utilized treatment methods, we also tried to understand the parents’ knowledge of, attitude
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toward, and management of their child’s bedwetting condition. As such, our study provides healthcare practitioners additional information to understand the patient’s feelings and needs in regards to bedwetting. Furthermore, since parents were the ones to answer the questionnaire, there is reason to
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believe that the responses provided are more reliable. This is because in general, children are more likely to lie about their bedwetting condition while parents will want to provide accurate information in order to search for treatment methods for their child’s bedwetting condition. The weakness of this study
EP
is that the sample size was not large enough for us to explore some notable questions, such as
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differences in parental perspective between children with no behavioral disorders and those with behavioral disorders, and the difference in the beliefs of mothers and fathers who disagree with the approach toward NE and the control parents believe they have over their children. These questions can be solved through further research.
Conclusions
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Parents’ perception of NE influences their choice of treatment strategy for their children and strong motivation for NE management from them are usually required. In our study, 43% of the parents
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reacted with anger and berated their child with NE; however, only few of them inflicted physical punishment. Several factors, namely socioeconomic status, maternal educational level, and the age and
SC
birth order of their child, affected the possibility of parents seeking medical intervention for NE. In addition, the more educated the father or the younger the child with NE, the higher the possibility of the
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parents approaching enuresis positively, such as with encouragement. Because parental involvement is crucial for successfully treating enuresis, healthcare professionals should understand the factors influencing parents seeking reasonable management for their child and their overall outlook toward
Acknowledgments
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PNE before helping these children.
None.
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Competing interests
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We thank the children and their parents for participating in the study.
Funding
None.
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Table 1 Personal and family characteristics of children with primary nocturnal enuresis.
N
%
N
%
%
N
p
Comfort and Ambivalence Anger and encouragement (n = 22) frustration (n = 31) (n = 40) N % N % N %
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Active (n = 59)
p
18 16
52.9 47.1
27 32
45.8 54.2
0.505
12 19
38.7 61.3
11 11
50.0 50.0
22 18
55.0 45.0
0.389
55 59.1 33 35.5 5 5.4
24 9 1
70.6 26.5 2.9
31 24 4
52.5 40.7 6.8
0.260
19 11 1
61.3 35.5 3.2
12 9 1
54.5 40.9 4.5
24 13 3
60.0 32.5 7.5
0.933
4 4.3 35 37.6 25 26.9 29 31.2
2 6 10 16
51 54.8 29 31.2 13 14.0
19 10 5
5.9 17.6 29.4 47.1
2 29 15 13
3.4 49.2 25.4 22.0
0.009
1 9 6 15
3.2 29.0 19.4 48.4
0 8 7 7
0.0 36.4 31.8 31.8
3 18 12 7
7.5 45.0 30.0 17.5
0.011
55.9 29.4 14.7
32 19 8
54.2 32.2 13.6
1.000
10 13 8
32.3 41.9 25.8
13 8 1
59.1 36.4 4.5
28 8 4
70.0 20.0 10.0
0.013
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45 48.4 48 51.6
26 7 1
76.5 20.6 2.9
35 18 6
59.3 30.5 10.2
0.217
18 8 5
58.1 25.8 16.1
14 8 0
63.6 36.4 0.0
29 9 2
72.5 22.5 5.0
0.204
62 66.7 31 33.3
20 14
58.8 41.2
42 17
71.2 28.8
0.223
21 10
67.7 32.3
17 5
77.3 22.7
24 16
60.0 40.0
0.381
5 5.4 9 9.7 35 37.6 44 47.3
1 5 13 15
2.9 14.7 38.2 44.1
4 4 22 29
6.8 6.8 37.3 49.2
0.576
3 3 12 13
9.7 9.7 38.7 41.9
1 3 7 11
4.5 13.6 31.8 50.0
1 3 16 20
2.5 7.5 40.0 50.0
0.849
44 47.3 18 19.4 31 33.3
15 12 7
44.1 35.3 20.6
29 6 24
49.2 10.2 40.7
0.008
14 7 10
45.2 22.6 32.3
11 2 9
50.0 9.1 40.9
19 9 12
47.5 22.5 30.0
0.712
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61 65.6 25 26.9 7 7.5
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Gender Female Male Age 6–9 10–12 13–15 Order of birth Only child First child Middle child Youngest child Paternal educational level High school or below Technical college University or above Maternal educational level High school or below Technical college University or above Difficult to awake from sleep Yes No Bedwetting frequency Semi-annual Monthly Weekly Daily Family history No family history Enuresis present in lineal family Enuresis present in relatives
Total Conservative (n = 93) (n = 34)
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Table 2 Logistic regression analysis of seeking medical treatment for the bedwetting. Active a
a
%
Univariate analysis Odds ratio
Multiple analysis (adjusted)
95% CI
p
0.988–1.501
0.065
Odds ratio 1.440
95% CI
p
1.015–2.044
0.041
1.000 28.506
2.598–312.789
0.006
0.098
1.000 43.857
0.747–2573.604
0.069
0.483–15.895
0.253
58 35
30 29
51.7 82.9
1.000 4.511
83 10
50 9
60.2 90.0
1.000 5.940
14 79
8 51
57.1 64.6
1.000 1.366
0.431–4.334
0.596
1.000 2.770
44 18 31
29 6 24
65.9 33.3 77.4
1.000 0.259 1.773
0.081–0.826 0.622–5.055
0.022 0.284
1.000 0.015 2.324
0.001–0.232 0.558–9.679
0.003 0.247
61 25 7
35 18 6
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9.48 ± 2.21 9.80 ± 2.25 1.218
0.696–5.244 0.505–39.310
0.209 0.178
1.000 1.083 46.577
0.238–4.930 1.123–1932.671
0.918 0.043
0.089–24.346 0.351–345.055
0.788 0.173
1.000 4.256 0.142–127.777 1456.538 7.647–277447.246
57.4 72.0 85.7
1 47 11
50.0 59.5 91.7
1.000 1.469 11.000
0.004
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1.629–12.495
0.719–49.104
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1.000 1.910 4.457
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2 79 12
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Age, years (mean ± SD) First-born child No Yes Time of bedwetting Night-time Daytime and night-time Bedwetting frequency < Once/week ≥ Once/week Family history No family history Enuresis present in lineal family Enuresis present in relatives Maternal educational level High school or below Technical college University or above Family economic status Low incomes Average incomes Above-average incomes
N
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Total
Active: parents actively seek medical consultation for their child.
2
0.404 0.007
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Table 3 Logistic regression analysis of parental attitudes toward a child’s bedwetting. 95% CI
p
Odds ratio
51
10
19.6
1.000
29 13
13 8
44.8 61.5
3.331 6.560
1.217–9.116 1.763–24.407
0.019 0.005
3.284 6.534
64 29
16 15
25.0 51.7
1.000 3.214
1.278–8.084
0.013
1.000 3.064
44 35 9 5
13 12 3 3
29.5 34.3 33.3 60.0
1.000 1.244 1.192 3.577
0.480–3.224 0.258–5.505 0.534–23.982
95% CI
1.123–9.607 1.637–26.082
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1.000
1.000 1.502 0.838 5.939
0.653 0.822 0.189
p
1.120–8.383
0.510–4.418 0.160–4.386 0.781–45.152
0.030 0.008
0.029
0.460 0.834 0.085
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Positive: parents approached their child’s nocturnal enuresis with positive attitude such as comfort and encouragement.
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a
Odds ratio
Multiple analysis (adjusted)
%
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Paternal educational level High school or below Technical college University or above Last-born child No Yes Bedwetting frequency Daily Weekly Monthly Semi-annual
Univariate analysis
N
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Total
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Positive a
3