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Behavioral disorders and impairment of quality of life in children and adolescents with lower urinary tract dysfunction

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Abstract

Background: Lower urinary tract dysfunction (LUTD) is a broad term describing the full spectrum of disorders in any of the stages of bladder function-storage or voiding LUTD is a clinical condition associated with emotional and behavioral disorders in children. This cross-sectional study aimed to investigate the association of emotional and behavioral symptoms and their impact on the quality of life (QoL) in children and adolescents with LUTD. Methods: Eighty-eight patients and their parents enrolled in an interdisciplinary program for children and adolescents with LUTD were included in the analysis. Child Behavior Checklist (CBCL) was used to estimate the prevalence of behavioral and emotional problems through the assessment of 14 items. Pediatric Quality of Life Inventory (versions for parents and children) was applied in the versions for parents and children to evaluate the QoL. The Pediatric Quality of Life Inventory-PedsQL, version 4.0-was applied separately for parents and patients. The association of clinical variables and aspects related to QoL of patients were evaluated through non-parametric correlations (Spearman) and multiple linear regression analysis. Results: According to CBCL's clinical scores, 56% of the patients showed total behavioral problems, 55% internalizing, and 38% externalizing. When comparing the conditions of LUTD and the CBCL scores, patients with voiding postponement had the lowest rates of total problems (P = 0.036). Children and adolescents with LUTD who also had enuresis showed a higher frequency of externalizing problems (P = 0.001), especially aggressive behavior (P = 0.013). Scores of patients with LUTD were significantly lower in all domains of QoL than normative data. Presence of behavioral problems was associated with worse QoL in all evaluated aspects. The total QoL was most influenced by the CBCL school competence scale according to the regression model analysis. Conclusions: The study findings suggest the relevance of evaluation of behavioral and social repercussions of LUTD to improve the multidisciplinary approach for this condition in pediatric population.

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... Recently, in a review of literature by Marciano et al., 7 The prevalence of mental disorders in children and adolescents these disorders is high-ranging from about 20%-40%-in children with symptoms of LUTD. ...
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In the literature, it is well documented that children who have daytime incontinence issues have a higher chance of having some form of behavioral or learning problem. It has been speculated that these issues may be related to their incontinence. On the other hand correction of the central nervous system problem may make these wetting problems disappear. We explore the most recent literature in functional imaging of the brain and the relationship between inherited neuropsychiatric problems and daytime wetting. The findings appear to dispel the aforementioned conclusions and tend to support an inherited or at least an altered developmental pathway for the development of daytime wetting issues.
Article
Recent years has seen an increasing interest in the quality of life (QOL) of children with chronic kidney disease (CKD). The objective of this cross-sectional study was to investigate the prevalence of behavioral disorders and to assess the health-related QOL (HRQOL) in 136 patients with CKD. To estimate the prevalence of behavior disorders and analyze HRQOL, we used the Strengths and Difficulties Questionnaire (SDQ) and Pediatric Inventory of Quality of Life (PedsQL) Core Scales as assessment tools for both the patients and caregivers. When compared to healthy controls, the CKD group had significantly lower scores in almost all PedsQL domains. After adjustment, only absence of religion/other religions remained significantly associated with a lower global HRQOL score [odds ratio (OR) 6.2, P=0.009]. Among the parents, two factors remained significantly associated with a lower global HRQOL score: patients' age >10 years (OR 5.4, P=0.033) and absence of religion/other religions (OR 3.2, P=0.038). The CKD group demonstrated a higher proportion of behavioral and emotional disorders in all SDQ domains. There was a negative correlation between the presence of behavior and emotional disorders and HRQOL score (r= -0.552, P<0.001). Our findings suggest the importance of evaluating behavioral and social repercussions of CKD in order to improve the life quality of this pediatric population.
Article
Urge incontinence and voiding postponement are common subtypes of daytime wetting in children. We analyzed clinical and behavioral differences in children with urge incontinence, voiding postponement and healthy controls at 2 centers. A total of 49 consecutive children 5 to 13 years old with urge incontinence (22) or voiding postponement (27) who presented to the department of urology or child psychiatry were examined as well as 32 age and gender matched controls. Instruments included physical examination, sonography, uroflowmetry, urinalysis, a 48-hour bladder diary, the Child Behavior Checklist, a structured psychiatric interview and an intelligence test. The incontinent group consisted of 28 boys and 21 girls with a mean age of 7.35 years. Controls included 13 girls and 19 boys with a mean age of 7.31 years. Incontinent children had a higher rate of pathological uroflow curves (33% vs 25%) and urinary tract infection (6% vs 3%), greater post-void residual volume (6.3 ml vs 3.8 ml) and a thicker bladder wall. Mean IQ was the same in the 2 groups (103). The Child Behavior Checklist showed that significantly more incontinent children had clinical total behavior (41% vs 9%, p <0.01), and externalizing (35% vs 0%, p <0.001) and internalizing (29% vs 6%, p <0.05) scores than controls. Also, more children with voiding postponement had total clinical scores than those with urinary incontinence (56% vs 24%, p <0.05). Of incontinent children 49% fulfilled the criteria for at least 1 ICD-10 psychiatric diagnosis vs 9% of controls (p <0.001). There were no differences between children recruited at the departments of urology and child psychiatry. This study shows that urge incontinence and voiding postponement are significantly associated with somatic complaints and psychological abnormalities compared to a control population. Children with voiding postponement have more externalizing behavioral disorders. Children seen at urological departments carry the same psychiatric risks and require the same attention to behavioral problem diagnosis.
Article
We evaluated health related quality of life of pediatric patients with nonneurogenic urinary incontinence and determined potential influencing factors. Also, health related quality of life results in our sample were compared to those of other chronic childhood health conditions. This cross-sectional study was done at 3 tertiary referral centers for childhood urinary incontinence. From July 2007 to April 2008 we consecutively evaluated 65 boys and 38 girls with a mean +/- SD age of 9.3 +/- 2.2 years (range 6 to 18) and their parents. Of the patients 12 had monosymptomatic enuresis, 79 had nonmonosymptomatic enuresis and 12 had isolated daytime incontinence. To evaluate participants we used the self-reported and proxy versions of the 10-item DISABKIDS chronic generic measure, short version, a health related quality of life questionnaire with cross-cultural validity. Mean questionnaire total scores were 43.2 and 42.8 for the self-reported and proxy versions, respectively, which showed significant correlation (r = 0.628). Age, sex, urinary incontinence type and severity, fecal incontinence and constipation had no significant association with questionnaire total scores (each p >0.05). Compared to questionnaire results in a reference sample of children with chronic health conditions average scores in our sample did not differ significantly from those in pediatric patients with asthma, arthritis, atopic dermatitis, cystic fibrosis, diabetes or epilepsy on the self-reported version, and asthma, atopic dermatitis, cystic fibrosis or epilepsy in the proxy version. Health related quality of life of children and adolescents with urinary incontinence appears to be comparable to that in pediatric patients with other chronic conditions, eg asthma or epilepsy.
Article
Urge incontinence and voiding postponement are common subtypes of daytime wetting in children. We analyzed health related quality of life for children with urge incontinence and voiding postponement, and healthy controls at 2 centers. We examined a total of 49 consecutive children 5 to 13 years old who presented with urge incontinence (22) or voiding postponement (27), and 32 controls matched for age and sex. Health related and overall quality of life were measured with generic questionnaires, and self-esteem was measured with the Piers-Harris questionnaire. Health related quality of life was significantly reduced in parent rating but not in child rating in the incontinent vs control group (total mean parent score 73 vs 78, child 76 vs 76). Children with voiding postponement have the lowest health related quality of life. Overall quality of life was significantly reduced in children with incontinence, while self-esteem did not differ. Children with externalizing disorders generally have the lowest health related and overall quality of life. Health related and overall quality of life are useful constructs, and are reduced in children with daytime incontinence by parental rating. In comparison, children rate their quality of life as being higher. Quality of life is lowest with externalizing behavioral disorders, as in children with voiding postponement. Due to comorbid behavioral disturbances, children with voiding postponement often need additional assessment, counseling and treatment.
Article
OBJECTIVE; To analyse prospectively the incidence of behavioural disorders and the subjective views of children with urge incontinence (defined by detrusor instability, sudden urge symptoms and frequent micturitions) and voiding postponement (characterized by delayed micturition in typical situations and a low voiding frequency) according to an identical protocol in a paediatric and a child psychiatric unit. Ninety-four consecutive or randomly selected children aged 5.0-10.9 years with either voiding postponement (52) or urge incontinence (42) were examined prospectively using an intelligence test (CFT1 or CFT20), the Child Behaviour Checklist (CBCL 4/18), the ICD-10 child psychiatric diagnoses and a structured interview. In the groups from both centres combined, those postponing voiding had a significantly higher incidence of externalizing behavioural symptoms (31% vs. 8%; P < 0.01) and total problems (37% vs. 13%; P < 0.05) in the clinical range (CBCL), and a higher rate of at least one ICD-10 child psychiatric diagnosis (54% vs. 29% P < 0.05) and of expansive disorders (31% vs. 5%; P < 0.01). The incidence of children with behavioural symptoms was lower in the paediatric centre, being exceptionally low among urge incontinent children (only 6%, CBCL). In contrast, from the children's subjective appraisal, there were no significant differences in concepts, explanations and implications of wetting; 79% of urge incontinent children and 64% of those postponing voiding suffered emotionally from the adverse effects of wetting. Only a minority (3% vs. 6%) saw any advantages at all. Children with voiding postponement had a significantly higher incidence of behavioural problems, especially expansive/externalizing behaviour, 3-4 times higher than in the normal population. Children with urge incontinence had a significantly lower incidence of behavioural problems, mainly emotional/ internalizing behaviour, that was only slightly higher (1-2 times) than that in the normal population. Because of selection, similar trends but lower incidences were found in the paediatric setting, with very few problems among urge incontinent children. In contrast, the children's subjective views did not differ; disadvantages associated with emotional suffering were reported by all children.
Article
Pediatric patients' self-report of health-related quality of life (HRQOL) has emerged as an important patient-based health outcome. A practical, validated generic measure of HRQOL facilitates assessing risk, tracking health status, and measuring treatment outcomes in pediatric populations. The PedsQL is a brief, standardized, generic assessment instrument that systematically assesses patients' and parents' perceptions of HRQOL in pediatric patients with chronic health conditions using pediatric cancer as an exemplary model. The PedsQL is based on a modular approach to measuring HRQOL and consists of a 15-item core measure of global HRQOL and eight supplemental modules assessing specific symptom or treatment domains. The PedsQL was empirically derived from data collected from 291 pediatric cancer patients and their parents at various stages of treatment. Both reliability and validity were determined. Cronbach's alpha coefficients for the core measure (alpha = .83 for patient and alpha = .86 for parent) were acceptable for group comparisons. Alphas for the patient self-report modules generally ranged from .70 to .89. Discriminant or clinical validity, using the known-groups approach, was demonstrated for patients on- versus off-treatments. The 11 scales showed small-to-medium positive intercorrelations, supporting the multidimensional measurement model. Further construct validity was demonstrated via a multimethod-multitrait matrix using standardized psychosocial questionnaires. The results support the PedsQL as a reliable and valid measure of HRQOL. The PedsQL core and modular design makes it flexible enough to be used in a variety of research and clinical applications for pediatric chronic health conditions.
Article
Aim: To analyse the number of urinary tract infections, uroflowmetry, behavioural symptoms and intrafamilial interaction in two groups of daytime wetting children in a paediatric and a child psychiatric unit. Methods: Ninety-four children with either voiding postponement (52) or urge incontinence (42) were examined prospectively for history of urinary tract infections (UTIs), uroflowmetry, the syndrome scales of the Child Behaviour Checklist (CBCL 4/18-Achenbach) and the Family Adaptability and Cohesion Evaluation Scales (FACES-III) (Olson) questionnaire. Results: Children with urge incontinence had a significantly higher rate of previous urinary tract infections (50%) than children with voiding postponement (19.2%; p < 0.001), who showed a high rate of plateau (12.2%) and staccato (20.4%) curves and were characterized by a wide variety of behavioural symptoms, including withdrawn (11.6%), aggressive (11.8%), delinquent (19.6%) behaviour and attention problems (13.7%). Clinically relevant behavioural scores were 4-10 times higher for the voiding postponers, and 2-3 times higher for children with urge incontinence. Furthermore, families of voiding postponers had significantly fewer balanced types of intrafamilial function (FACES-III). Problematic "rigid/disengaged" and "rigid/separated" types predominated. Conclusion: Urge incontinence is characterized by a higher rate of UTIs, a lower urine volume in uroflowmetry, a lower rate of behavioural scores in the clinical range and well-functioning families. Voiding postponement children, on the other hand, have a higher, though not significant, rate of abnormal uroflow curves, a wide variety of clinically relevant behavioural symptoms, which were significantly higher for attention and delinquent problems. Conduct problems predominated; only 13.7% of the children had attention problems in the clinical range. The findings lend empirical support to the entity of voiding postponement as an acquired or behavioural syndrome characterized by wetting in association with a delay of micturition and other externalizing conduct problems.
Article
Although the relationship between enuresis and psychopathology has been studied intensively, little is known about the prevalence of specific psychiatric disorders. We investigate the prevalence of attention deficit/hyperactivity disorder (ADHD) in children with nocturnal enuresis and correlate these data with clinical subtypes of enuresis/incontinence. A total of 120 children with nocturnal enuresis 6 to 12 years old participated in a prevalence study. A diagnostic interview was conducted with parents, questionnaires were completed by parents and teachers, and medical files were consulted. Of all enuretic children 15% were diagnosed with the full syndrome of ADHD and 22.5% met the criteria of the ADHD inattentive subtype. Data revealed that the older the children (9 to 12 years), the higher prevalence of attention deficit disorder or ADHD. Nocturnal polyuria had a significantly higher incidence in hyperactive/impulsive children but there was no significant difference in bladder function between enuretic children with or without a comorbid diagnosis of ADHD. The prevalence of attention deficit disorder or ADHD in nocturnal enuresis is significantly increased, especially in older children. The incidence of nocturnal polyuria is slightly increased in children who meet at least the criteria of ADHD hyperactive/impulsive subtype. No other associations between enuresis and ADHD were found.
Article
This population-based study investigated the psychological problems associated with daytime wetting in children. A sample of 8213 children (age range: 7 years 6 months to 9 years 3 months) who were enrolled in the population-based Avon Longitudinal Study of Parents and Children participated in this study. Parents completed a postal questionnaire asking about their children's toileting behavior and assessing psychological problems, including childhood emotional and behavioral problems (99% completed the questionnaire by the time their child was 8 years 3 months of age). The rate of psychological problems was compared in children with daytime wetting and in those with no daytime wetting. Analyses adjusted for developmental delay, gender, sociodemographic background, stressful life events, and soiling. Chi2 tests of association and multivariable logistic regression indicate that children with daytime wetting have a higher rate of parent-reported psychological problems than children who have no daytime wetting. It is particularly notable that the reported rates of attention and activity problems, oppositional behavior, and conduct problems in daytime wetting children were around twice the rates reported in children with no daytime wetting. The increased vulnerability to psychological problems in children as young as 7 years of age with daytime wetting highlights the importance of parents seeking early intervention for the condition to help prevent later psychological problems. Although treatment in a pediatric setting is often successful, clinicians should be aware of the increased risk of disorders, such as attention-deficit/hyperactivity disorder, in children with daytime wetting, because this is likely to interfere with treatment.
Article
Risk factors for renal scarring in children with lower urinary tract dysfunction (LUTD) were evaluated. The medical records of 120 patients were assessed concerning gender, presence of vesicoureteric reflux (VUR), bladder capacity, detrusor overactivity, residual urine, febrile urinary tract infection (UTI), bacteriuria, constipation, detrusor sphincter incoordination (DSI), high detrusor pressure at maximal cystometric capacity (PMCC), low compliance, and thickness and trabeculation of the bladder wall. Renal scarring was diagnosed by 99mtechnetium-dimercaptosuccinic acid renal scan (DMSA). Renal scarring was detected in 38 patients (31%). VUR, UTI, decreased bladder capacity, urinary residue, and trabeculated and thick bladder wall were associated with scarring at univariate analysis. Multivariate analysis showed VUR (P < 0.0001) as the independent risk factor for renal scarring. Thickness of the bladder wall was a marginal risk factor (P = 0.07). Although UTI was not a risk factor, it was associated with VUR (P = 0.03). In our analysis, VUR was the main risk factor; however, renal scarring was probably due to multifactorial causes, as VUR was associated with UTI.
Article
The aim of this prospective study is to describe the association of comorbid behavioral and somatic factors in children with different forms of nocturnal enuresis and daytime incontinence referred to a tertiary center. A total of 166 consecutive children 5.1 to 16.4 years old were referred for detailed assessment between January 2004 and July 2006. Evaluation included a detailed history, pediatric examination, 24 to 48-hour voiding protocols, sonography and uroflow. Parents filled out the Child Behavior Checklist, a standardized parental questionnaire consisting of 113 problem items. ICD-10 diagnoses were given based on standardized mental state examination and mutual consensus conferences. In the full sample externalizing disorders were more than twice as common as internalizing disorders. Differences were found between children with nocturnal enuresis and daytime incontinence regarding parent reported externalizing behavior scores as well as rates of "at least 1 ICD-10 psychiatric diagnosis" and comorbid encopresis. Children with monosymptomatic nocturnal enuresis showed fewer internalizing disorders and lower rates of "at least 1 ICD-10 psychiatric diagnosis" and comorbid encopresis compared to those with nonmonosymptomatic nocturnal enuresis, urge incontinence and voiding postponement. The results of sonography and uroflow measures also differed between groups. Different subtypes of enuresis and urinary incontinence demonstrate differences in behavioral problems and psychiatric comorbidity. The highest rates of psychiatric comorbidity were found in the group of children with voiding postponement and the lowest were in children with monosymptomatic nocturnal enuresis. We recommend screening for comorbid psychiatric disorders in children with enuresis and urinary incontinence. Further investigations in a larger group of children are necessary.
Article
Previous studies based on clinical samples report that enuresis in children is associated with behavioural problems and reduced self-esteem, but the relationship between behavioural problems and enuresis remains controversial. This population-based study investigated the prevalence and behavioural correlates of enuresis in a group of preparatory school children. This cross-sectional survey involved 356 parents and their children aged 5-7 years, all residents of Istanbul, Turkey. Parents completed the Child Behaviour Checklist and socio-demographic data form (response rate: 90%). Fifty-three children with enuresis were compared with 303 non-symptomatic children. Differences in the mean scores and the percentages of children falling beyond pre-selected clinical thresholds were compared between the groups. The prevalence of enuresis was 14.9%, and enuresis was more frequent among boys. Children with enuresis were reported by their parents to have greater social problems and higher total problem scores than control children (P = 0.019, P = 0.048, respectively). However, there were no differences in the percentages of children falling beyond pre-selected clinical thresholds between the groups. Children with enuresis had higher mean scores for total and social behavioural problems than controls; however, clinically relevant behavioural problems did not show differences between the groups. Given the inconsistent research findings across studies, longitudinal research and outcome studies could help determine whether there is a causal relationship between psychopathology and enuresis.
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  • Friedrich Sadowksi
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Validacao da versao brasileira do
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Investigation of voiding dysfunction in a population-based sample of children aged 3 to 9 years
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The standardization of terminology of lower urinary tract function in children and adolescents: update report from the Standardization Committee of the International Children's Continence Society
  • Austin
Validacao da versao brasileira do ‘Child Behavior Checklist’ (CBCL) (Inventario de Comportamentos da Infancia e Adolescencia): dados preliminares
  • Bordin
Urge incontinence and voiding postponement in children: somatic and psychosocial factors
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