Published online November 1, 2006
PEDIATRICS Vol. 118 No. 5 November 2006, pp. 1985-1993 (doi:10.1542/peds.2006-0894)
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ARTICLE

Psychological Problems in Children With Daytime Wetting

Carol Joinson, PhDa, Jon Heron, PhDa, Alexander von Gontard, MDb and the ALSPAC Study Team

a Department of Social Medicine, University of Bristol, Bristol, United Kingdom
b Department of Child and Adolescent Psychiatry, Saarland University Hospital, Homburg, Germany


   ABSTRACT
TOP
 ABSTRACT
METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
OBJECTIVE. This population-based study investigated the psychological problems associated with daytime wetting in children.

METHODS. 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.

RESULTS. {chi}2 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.

CONCLUSIONS. 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.

Key Words: child behavior • incontinence • daytime wetting • psychological problems

Abbreviations: DSM-IV—Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition • UTI—urinary tract infection • ADHD—attention-deficit/hyperactivity disorder • ALSPAC—Avon Longitudinal Study of Parents and Children • DAWBA—Development and Well-Being Assessment • WISC-III—Wechsler Intelligence Scale for Children III • SEN—special educational need • OR—odds ratio • CI—confidence interval

Daytime wetting (also referred to as diurnal enuresis) is defined in Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition (DSM-IV), as an involuntary voiding of urine during the day, with a severity of at least twice a week, in children >5 years of age in the absence of congenital or acquired defects of the central nervous system.1 The prevalence of daytime wetting in children aged 7 years has been found to be ~2% to 3% of boys and 3% to 4% of girls.2–4 The vast majority of cases can be considered to represent a functional type of urinary incontinence. Only a small minority wet during the day because of neurogenic, structural, or other pediatric causes.5

Children are usually reliably dry during the day between the ages of 2 and 5 years,6 and wetting accidents during this stage are not generally considered to be a problem. However, when children start school, daytime wetting is likely to pose a serious problem in terms of embarrassment and ridicule from peers.7 As a reflection of this, wetting pants in class was rated as the third most stressful of 20 different life events when school-age children were asked to grade them in terms of severity.8

Despite the concern of children and parents, there is little research into the psychological problems associated with daytime wetting. A few studies have found evidence to suggest that children with daytime wetting are more psychologically disturbed than those who wet the bed.9–13 Other studies, instead of treating daytime wetting as a homogenous condition, have investigated the psychological problems associated with different syndromes of daytime wetting. They find a higher rate of behavior problems in children with voiding postponement (associated with infrequent urination of large volumes, postponement of urination, and retention of urine) compared with those with urge incontinence (wetting of small volumes coupled with sudden and frequent urination [>7 times per day] and holding maneuvers [jumping and sitting on heel]).13–15 Another study reported a tendency toward internalizing problems (withdrawn, anxious, or depressed) in children with daytime wetting and a urinary tract infection (UTI) and a higher rate of attention-deficit/hyperactivity disorder (ADHD) in children with daytime wetting and no infection.11

The findings of previous studies, mainly based on small clinic samples, suggest that there is an association between daytime wetting and psychological problems and that certain subgroups of children with daytime wetting might be more vulnerable to these problems than others. However, the findings may be limited, because children with daytime wetting who present to clinics are likely to have more serious psychological problems than a nonclinical population of children with daytime wetting. Also, the majority of these studies have not included a nonwetting comparison group, making the findings difficult to interpret. The present study, based on a population of >8000 children, seeks to examine the rate of psychological problems associated with daytime wetting in children aged ~7.5 years compared with children who have no daytime wetting. A secondary descriptive analysis examines whether certain factors related to daytime wetting, such as frequency of toilet trips and having to dash to the toilet when needing to urinate, are associated with an increased risk of psychological problems. Gender differences in these factors related to daytime wetting were also examined.


   METHODS
TOP
 ABSTRACT
 METHODS
RESULTS
 DISCUSSION
 REFERENCES
 
Participants
The Avon Longitudinal Study of Parents and Children (ALSPAC)16 is an ongoing population-based study investigating a wide range of environmental and other influences on the health and development of children. Pregnant women resident in the former Avon Health Authority in southwest England, having an estimated date of delivery between April 1, 1991, and December 31, 1992, were invited to take part, resulting in a cohort of 14541 pregnancies and 13971 children alive at 12 months of age. The primary source of data collection was via self-completion questionnaires administered at 4 points during the antenatal period, then at regular intervals after birth. The representative nature of the ALSPAC sample has been investigated by comparison with the 1991 national census data of mothers with infants <1 year of age who were residents in the county of Avon. The ALSPAC sample had a slightly greater proportion of mothers who were married or cohabiting, who were owner-occupiers, and who had a car in the household. All of the aspects of the study were reviewed and approved by the ALSPAC Law and Ethics Committee, which is registered as an institutional review board. Approval was also obtained from the local research ethics committees, which are governed by the Department of Health. More detailed information on the ALSPAC study is available on the Web site at www.alspac.bris.ac.uk.

Measures
A self-report questionnaire, administered when children were ~7.5 years old (one of a series of questionnaires administered at regular intervals during the course of the study) asked parents a set of detailed questions about their child's toileting behavior (Appendix). The number of children who met DSM-IV criteria for diurnal enuresis was determined. Also included in this questionnaire was the Development and Well-Being Assessment (DAWBA)17 composed of questions relating to a number of common emotional and behavioral problems in children. The small numbers of children meeting DSM-IV criteria for psychiatric disorders in the ALSPAC study population (range: 0.2% [social phobia] to 1.9% [oppositional-defiant disorder]) precluded a multivariable regression analysis. Consequently, a set of dichotomous outcome variables was derived from the lists of symptoms in the DAWBA relating to each psychiatric disorder to permit a more rigorous multivariable analysis of the association of daytime wetting with emotional and behavior problems with adjustments for confounding variables.18 Developmental delay (IQ <70) was assessed using Wechsler Intelligence Scale for Children III (WISC-III) IQ,19 obtained from a clinic that children attended at age 8 years. A subset of children did not attend the clinic; consequently, a statement of special educational needs (SENs) was used as an alternative indicator of delayed development. Family sociodemographic background (home ownership status, car ownership, crowding, mother's education, mother's age, birth order, and marital status) were mainly derived from questionnaires administered during the antenatal period, and stressful life events were assessed at 7.5 years using the question, "has anything exceptionally stressful happened to him/her that would really upset almost anyone?" (12.2% responded positively).

Analysis
The primary analysis, performed using Stata version 8 (Stata Corp, College Station, TX) using {chi}2 tests of association and multivariable logistic regression, compared the rate of psychological problems in children with any daytime wetting to those with no daytime wetting (control subjects). The analysis also adjusted for potential confounding variables. This was done in stages, first of all adjusting for developmental delay (WISC-III IQ < 70 or SEN) and further adjusting for gender, family sociodemographic background, and stressful life events. The analyses also adjusted for associated daytime soiling, because this is thought to be a possible confounder of the association between daytime wetting and psychological problems, especially when soiling is associated with constipation.

In the multivariable models, the starting sample was composed of children for whom information on daytime wetting and psychological problems was available. Missing data on confounding variables resulted in a loss of ~3% of this sample when the fully adjusted models were derived. In an attempt to avoid any potential bias that might result from performing a complete-case model on these variables, a missing data imputation technique was used (Missing Imputation for Chained Equations20) using the procedure in Stata known as "ice."21 Imputation was restricted to the confounding variables.

A secondary descriptive analysis concentrated on the group of children with daytime wetting. The aim was to investigate whether certain factors related to daytime wetting, such as frequency of toilet trips and having to dash to the toilet when needing to urinate, are associated with an increased risk of psychological problems. To maintain a reasonable degree of power, the psychological variables were merged, resulting in 2 outcomes, namely internalizing problems (separation anxiety, social fears, general anxiety, and sadness/depression) and externalizing problems (attention/activity problems, oppositional behavior, and conduct problems). A binary variable was derived, indicating the presence of symptoms of any of the internalizing behaviors considered and similarly for externalizing behaviors. Gender differences in the daytime wetting factors were also examined.


   RESULTS
TOP
 ABSTRACT
 METHODS
 RESULTS
DISCUSSION
 REFERENCES
 
There were 8242 responses (51.4% boys and 48.6% girls) to the questionnaire, and in 98% of cases, the respondent was the mother of the study child. There was no information on daytime wetting for 29 children, with the result that the starting sample for the analysis was 8213 cases. The age range was 7 years 6 months to 9 years 3 months with 99% completing the questionnaire by the time their child was 8 years 3 months of age.

In the sample, there were 643 children (7.8%) who suffered from daytime wetting, composed of 291 boys and 352 girls (age range: 7 years 6 months to 9 years; median: 7 years 6 months). The control group consisted of 7570 children ([92.2%] 3933 boys and 3637 girls; age range: 7 years 6 months to 9 years 3 months; median: 7 years 6 months) who had no daytime wetting. Girls composed a higher proportion of the group of children with daytime wetting (54.7%), compared with only 48% of the control group ({chi}2 = 10.65; P = .001). Among the 643 children with daytime wetting, 82 attained DSM-IV criteria, of whom 50 (61%) were girls compared with 302 girls (53.8%) in the non-DSM-IV daytime wetting group ({chi}2 = 1.47; P = .225).

A total of 276 children were classified as having developmental delay, either by having a WISC-III IQ <70 or by having been issued with a SEN. A full measure of IQ was available for 5542 of the 8242 children in the study sample, and so a SEN was used as proxy to highlight children without a WISC-III measurement. For the children with both indicators, children with a SEN were, on average, 21 points lower in WISC-III IQ, suggesting that SEN is a suitable proxy for developmental delay in this sample. Of the children with daytime wetting, 44 (6.8%) fitted the criteria for developmental delay compared with 229 (3.0%) of children who had no daytime wetting ({chi}2 = 26.9; P < .001).

Table 1 summarizes the results of the analysis comparing the rates of psychological problems reported by parents in the DAWBA for children with any daytime wetting compared with those with no daytime wetting (control subjects). The overall results indicate that children with daytime wetting have a higher rate of all of the parent-reported psychological problems (except social fears) than children who have no daytime wetting. It is particularly notable that the reported rates of externalizing problems, including attention and activity problems (24.8%), oppositional behavior (10.9%), and conduct problems (11.8%), in children with daytime wetting are approximately twice the rates reported in children with no daytime wetting. Adjusting for developmental delay resulted in a large reduction in the odds ratios (ORs) for oppositional behavior, and a reasonable reduction in the ORs for social fears and attention/activity problems. Further adjusting for gender, stressful life events and variables relating to family sociodemographic background had only a moderate effect on the ORs. The effect of adjusting for soiling was often considerable, with the OR for the association of oppositional behavior with daytime wetting reduced by 40% and smaller reductions in the ORs for conduct problems (28%) and attention activity problems (17%).


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  		TABLE 1 Comparison of the Rate of Psychological Problems in Children With and Without Daytime Wetting Adjusting for Developmental Delay, Gender, Sociodemographic Background, Stressful Life Events, and Soiling

 
Table 2 shows the unadjusted ORs (95% CIs [confidence intervals]) for parent-reported psychological problems in subgroups of children with daytime wetting. Among the children with daytime wetting, 206 (32%) had some externalizing problems, and 188 (29.2%) had some internalizing problems. The rate of externalizing problems (attention and activity problems, oppositional behavior, and conduct problems) was higher in children whose daytime wetting was severe enough to meet DSM-IV criteria (of the 643 children with daytime wetting, 12.7% met DSM-IV criteria), but there was no increased rate of internalizing problems in these children. There was also evidence for a higher rate of externalizing problems in children with daytime wetting who were reported by parents to have to dash to the toilet straight away when they felt the need to urinate, who had ≥10 toilet trips a day, who suffered from associated soiling or bedwetting, and in boys. Of the children with daytime wetting, 6.4% had suffered from a UTI in the past 12 months and, although not statistically significant, the results suggested an increased rate of both externalizing and internalizing problems in children with a UTI.


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  		TABLE 2 Unadjusted ORs (95% CIs) for Parent-Reported Psychological Problems in Subgroups of Children With Daytime Wetting

 
Table 3 shows the results of an analysis of the daytime wetting subgroups by gender. There was a strong gender difference in the rate of UTIs (85.4% of girls compared with only 14.6% of boys), and slightly more girls met DSM-IV criteria for daytime wetting. Boys with daytime wetting were more likely than girls to have ≥10 toilet trips a day and to suffer from associated bedwetting or soiling. The rates of reported dashing to the toilet were similar in boys and girls in the study sample, but boys were less likely than girls to be able to hold on for >5 minutes when needing to urinate.


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  		TABLE 3 Analysis of Gender Differences in Subgroups of Children With Daytime Wetting

 

   DISCUSSION
TOP
 ABSTRACT
 METHODS
 RESULTS
 DISCUSSION
REFERENCES
 
The present study, based on a large epidemiologic sample of >8000 children, found a higher rate of parent-reported psychological problems in children aged ~7.5 years with daytime wetting compared with those with no daytime wetting. The largest differences were found for externalizing problems, including attention and activity problems, oppositional behavior, and conduct problems, with rates of these problems in daytime wetting children approximately twice the rates reported in children with no daytime wetting. It is also notable that there was a higher rate of externalizing problems in children with the most severe daytime wetting (those meeting DSM-IV criteria).

The analyses in this study were adjusted for the presence of developmental delay, because it is often associated with a heightened risk for behavior problems and mental disorder,22,23 as well as daytime wetting.24 Although adjusting for developmental delay resulted in a reduction in the ORs for oppositional behavior and attention/activity problems, there was still a strong association with daytime wetting.

There was a slightly higher rate of daytime wetting in girls (8.8%) in the study sample compared with boys (6.9%). Other studies have generally found no gender difference in the rate of daytime wetting.3,25,26 When adjusting for gender, the effect was different for internalizing compared with externalizing problems. The moderate increase in ORs with the latter is likely to reflect the fact that externalizing behaviors were more common in boys in the study sample. Further adjusting for stressful life events and variables relating to family sociodemographic background also had only a moderate effect on the ORs indicating that differences in the rate of psychological problems between children with and without daytime wetting were not explained by differences in these variables.

In the current study, approximately one third of the children with daytime wetting had associated soiling. Boys were more likely to have comorbid soiling than girls, and there was a higher rate of externalizing and internalizing problems in this group. These findings are supported by a previous study reporting a higher rate of externalizing and internalizing problems in children with comorbid wetting and soiling.27 The comorbidity of daytime wetting and soiling is well documented.27–29 This is possibly because of the relationship between the external urethral sphincter, the anal sphincter, and the pelvic floor muscles, so that contraction of one will activate the other, leading to stool and urine retention. An accumulation of fecal mass in the rectum can lead to the compression of the bladder neck, which induces uninhibited detrusor contractions and thereby enhances the risk for daytime wetting.30,31 In addition, soiling and constipation carry a higher risk for UTIs, which, in turn, can result in daytime wetting.29 Adjusting for soiling had the biggest effect of all the confounding variables with substantial reductions in the ORs associated with oppositional behavior, conduct problems, and attention activity problems. However, there was still an independent association of daytime wetting with these behavior problems even after taking this into account.

The current study found a higher rate of externalizing problems in children with daytime wetting who were reported by parents to have to dash straight away to the toilet when needing to urinate and in those who went to the toilet to urinate ≥10 times a day. Strong urges to rush to the toilet to urinate, the inability to hold off going for more than a few minutes, and a high frequency of toilet trips are symptoms associated with urge incontinence. However, urgency as a marker for urge incontinence is often combined with high voiding frequency.15 Because of small numbers of children in the daytime wetting subgroups, an analysis combining these 2 symptoms was not possible (of the 28 children who were reported to go to the toilet to pass water ≥10 times a day, 21 were also reported to have to dash straight away when needing to urinate). All that can be inferred is that there is an association of these separate daytime wetting symptoms with behavior problems. In addition, because the data rely on parental reports and not clinical assessment, it is not possible to say whether the observed urgency is because of an overactive bladder associated with urge incontinence or because of the retention of urine until the bladder is distended and the subsequent rushing to the toilet associated with voiding postponement.

Among the children with daytime wetting, 6.4% were reported by parents to have suffered from a UTI in the past year, and there was strong evidence for a higher rate of UTIs in girls. This is a low rate of UTIs compared with other studies, for example, 1 study reported that >50% of 17 girls with daytime wetting investigated by a pediatrician had a UTI.9 Because of the reliance on parental reports, it is likely that some cases of UTI were not identified in the current study, because parents may have been unaware of the condition. Although not overwhelming (because of small numbers of children with reported UTI), the results suggest an increased rate of externalizing and internalizing problems in children with daytime wetting who had suffered from a UTI in the past 12 months. A previous study reported a higher risk for behavioral problems in children with daytime wetting without UTIs,11 whereas another study found significantly more behavioral abnormalities in 90 girls with recurrent UTIs compared with control subjects.32 The issue of behavioral problems in children with daytime wetting with and without UTIs remains to be settled.

A potential weakness of the current study is that both psychological problems and daytime wetting are based on parental reports and not clinical assessment. There is a possibility that parents of children with daytime wetting view them more negatively than children with no daytime wetting, perhaps because of the belief that a child's lack of responding to the sensations of bladder fullness is because of noncooperation or laziness.33

It has also been reported that parents of children with daytime wetting were more likely to view the wetting as because of disobedience more so than mothers of children who wet the bed.9 The increased rate of parent-reported psychological problems in children with daytime wetting could be a reflection of parents' negative perceptions of their children. Parents reporting on their children's toileting behavior, especially frequency of toilet trips, is also potentially problematic. It is possible that low micturition frequency in children in the current study has been underestimated, because it often goes unnoticed by parents, whereas parents are more likely to notice frequent micturitions. Accurate reports of micturition frequency often emerge only when a micturition chart is filled out as part of an ongoing clinical assessment.

Another potential weakness of the study is that there was differential attrition in the cohort, with the subsample of the ALSPAC families who responded to the questionnaire and the subsample of children attending for follow-up at age 8 being more socially advantaged than those who defaulted. However, there does not seem to be a relationship between dropout and daytime wetting, and controlling for sociodemographic variables had only a negligible effect on the regression estimates. Because sociodemographic variables are good predictors of attrition, this would lead us to infer that there is not a great deal of bias present in our final adjusted models and that the results can be generalized to the ALSPAC population as a whole.

As with all cross-sectional studies, it is not clear whether the behavioral problems found in the present study are a cause or a consequence of daytime wetting. Behavioral symptoms are often attributed to secondary effects of daytime wetting, especially where there is bladder dysfunction associated with urge incontinence, and not as a cause of the wetting.34,35 However, daytime wetting associated with voiding postponement is thought to be an oppositional type of disorder with a psychogenic or behavioral etiology and is associated with a higher rate of familial dysfunction.14,15 Future longitudinal investigations are planned with the study sample to look at the association between daytime wetting and the development of psychological problems.

The results of this study have important implications for the treatment of children with daytime wetting. Many parents do not know that daytime wetting is a condition for which they can seek medical help. For instance, in a study of voiding habits in schoolchildren, only 10% of parents who reported isolated daytime wetting sought medical intervention, whereas parents of children with bedwetting and associated daytime wetting were more likely to seek help.36 Problems such as low self-esteem and other subclinical psychological symptoms have a high likelihood of resolving after successful treatment for daytime wetting.10,37 If, however, manifest psychiatric disturbances are present (either externalizing, eg, ADHD, or internalizing, eg, depressive or anxiety disorders), these may not resolve and will require child psychiatric/psychological assessment and treatment. Manifest disorders, such as ADHD, are also likely to interfere with treatment of daytime wetting and are associated with lower treatment compliance and less successful treatment outcomes.38 The presence of psychological problems, particularly the increased vulnerability to behavior problems, in children with daytime wetting as young as 7 years old highlights the importance of parents seeking early intervention for the condition to help prevent later psychological problems.


Figure 1
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  		APPENDIX Items taken from the self-report questionnaire given to parents when children were approximately 7.5 years old.

 


   ACKNOWLEDGMENTS
 
A grant to support this research was given by the Big Lottery Fund to the charity Education and Resources for Improving Childhood Continence, and the study was conducted in collaboration with the ALSPAC. Financial support for the establishment of the ALSPAC cohort was provided by the Medical Research Council, the Wellcome Trust, the United Kingdom Department of Health, the Department of the Environment, the Department for Education and Skills, the National Institutes of Health, and a variety of medical research charities and commercial companies. The ALSPAC study is part of the World Health Organization–initiated European Longitudinal Study of Pregnancy and Childhood.

We are extremely grateful to all the families who participate in the ALSPAC and to the midwives for their cooperation and help in recruitment. The whole ALSPAC study team is composed of interviewers, computer technicians, laboratory technicians, clerical workers, research scientists, managers and volunteers who continue to make the study possible.


   FOOTNOTES
 
Accepted Jun 27, 2006.

Address correspondence to Carol Joinson, PhD, Avon Longitudinal Study of Parents and Children, Department of Social Medicine, 24 Tyndall Ave, Bristol BS8 1TQ, United Kingdom. E-mail: Carol.Joinson{at}bristol.ac.uk

The authors have indicated they have no financial relationships relevant to this article to disclose.


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 DISCUSSION
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PEDIATRICS (ISSN 1098-4275). ©2006 by the American Academy of Pediatrics



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