Incontinence in persons with fetal alcohol spectrum disorders: a polish cohort.

INTRODUCTION: Fetal alcohol spectrum disorders (FASD) is an important preventable public health concern, associated to a number of common pediatric problems such as incontinence. Little is known about the prevalence and presentation of incontinence in FASD, which hinders effective management. OBJECTIVE: The aim of the present study was to investigate incontinence among people with FASD. STUDY DESIGN: Parental questionnaires were sent to all eligible FASD participants. To enable comparing the observed prevalence with typically developing, non-prenatally alcohol-exposed individuals, two clinical control groups of patients undergoing immunotherapy for pollen allergy (GKA) and patients diagnosed with celiac disease (GKG) were selected. RESULTS: A total of 119 participants were included in the study (FAS: n = 24, partial fetal alcohol syndrome [pFAS]: n = 19, alcohol-related neurodevelopmental disorder [ARND]: n = 28, GKA: n = 34, and GKG: n = 14). Overall incontinence for FASD was estimated to be 24% (confidence interval [CI] ranges from 15 to 36); nocturnal enuresis (NE) was present in 10% (CI ranges from 4 to 19), daytime urinary incontinence (DUI) in 11% (CI ranges from 5 to 21), and fecal incontinence (FI) in 13% (CI ranges from 6 to 23). Symptoms of urgency were present for 52%, voiding postponement for 10%, and straining for 2%. These data are both consistent with higher prevalence in individuals with FASD and with similar prevalence (the CIs overlap). CONCLUSION: Children and adolescents with FAS, pFAS, ARND, GKA, and GKG are affected by incontinence. Highest rates were observed in pFAS and ARND. Persons with FAS were mostly affected by DUI, those with pFAS by NE, and those with ARND by FI.

Detailed Assessment of Incontinence, Psychological Problems and Parental Stress in Children with Autism Spectrum Disorder.

Incontinence, psychological symptoms, parental stress and psychopathology were examined in 51 children (43 boys, mean age = 9.7 years) presented in an outpatient clinic for autism spectrum disorders (ASD) and in 53 matched controls (43 boys, mean age = 10.2 years). All children were clinically assessed for ASD, incontinence and psychopathology according to current guidelines. ASD was confirmed in 37 children and excluded in 14. Enuresis (16.2%) and daytime urinary incontinence (16.2%), but not fecal incontinence (8.2%) were more common in ASD than in controls. Children with ASD showed significantly more comorbid psychiatric disorders. Parents of children with ASD experience more stress. Parental stress was predicted by parental psychopathology, role restriction and group (patient/control), but not by incontinence.

Central Nervous System Processing of Emotions in Children with Fecal Incontinence and Constipation.

OBJECTIVE: Fecal incontinence and constipation are common disorders in childhood. The enteric nervous system and the central nervous system are highly interactive along the brain-gut axis. The interaction is mainly afferent. These afferent pathways include centers that are involved in the central nervous processing of emotions as the mid/posterior insula and the anterior cingulate cortex. A previous study revealed altered processing of emotions in children with fecal incontinence. The present study replicates these results. METHODS: In order to analyze the processing of emotions, we compared the event-related potentials of 25 children with fecal incontinence and constipation to those of 15 control children during the presentation of positive, negative, and neutral pictures. RESULTS: Children with fecal incontinence and constipation showed altered processing of emotions, especially in the parietal and central cortical regions. CONCLUSIONS: The main study results of the previous study were replicated, increasing the certainty and validity of the findings.

Psychometric properties of the "parental questionnaire: Enuresis/urinary incontinence" (PQ-EnU).

AIMS: The "Parental Questionnaire: Enuresis/Urinary Incontinence" (PQ-EnU) is widely-used in clinical assessment of nocturnal enuresis (NE) and daytime urinary incontinence (DUI). It includes 18 items regarding daytime (DW) and nighttime wetting (NW), 24 items concerning toilet habits (TH), and 14 items regarding behavioral problems (BP). The aim of the study was to evaluate reliability and validity of the PQ-EnU. METHODS: Parents of 490 children (M = 8.7 years [SD = 2.9], 68.2% male) presented in an outpatient incontinence clinic completed the PQ-EnU and the Child Behavior Checklist (CBCL). Internal consistencies, factorial structure, and convergent validity regarding incontinence diagnoses and psychopathology were examined. RESULTS: 84.1% had NE, 38.8% DUI, and 20.8% fecal incontinence (FI). Internal consistencies were good for TH and BP. A factor analysis of the TH scale revealed three subscales ("Lower urinary tract symptoms (LUTS)," "Bowel symptoms," and "Voiding dysfunctions"). The LUTS and "Bowel symptoms" subscales were significantly correlated to clinical diagnoses of DUI and FI, respectively. A factor analysis of the BP scale revealed also three subscales ("attention/school deficits," "impulsive-aggressive behavior" and "internalizing problems," which were all significantly correlated with the CBCL. The questionnaire discriminated significantly between children with and without DUI or FI, and children with and without a clinical CBCL score. CONCLUSIONS: The PQ-EnU is a valid and reliable parental questionnaire to measure incontinence, bladder/bowel symptoms, and behavioral problems in children. Due to its shortness, the PQ-EnU is an efficient measurement, which can be used in clinical settings and also as a screening tool for psychological symptoms.

EEG Measurement of Emotion Processing in Children with Daytime Urinary Incontinence.

OBJECTIVE: Daytime urinary incontinence (DUI) is common in childhood. The aim of the study was to neurophysiologically analyse the central emotion processing in children with DUI. METHOD: In 20 children with DUI (mean age 8.1 years, 55 % male) and 20 controls (mean age 9.1 years, 75 % male) visual event-related potentials (ERPs) were recorded after presenting emotionally valent (80 neutral, 40 positive, and 40 negative) pictures from the International Affective Picture System (IAPS) as an oddball-paradigm. All children received a full organic and psychiatric assessment. RESULTS: Children with DUI did not differ significantly from controls regarding responses to emotional pictures in the frontal, central, and parietal regions and in the time intervals 250-450 ms, 450-650 ms, and 650-850 ms after stimulus onset. The patient group had more psychological symptoms and psychiatric comorbidities than the control group. CONCLUSIONS: EEG responses to emotional stimuli are not altered in children with DUI. Central emotion processing does not play a major role in DUI. Further research, including a larger sample size, a more homogeneous patient group (regarding subtype of DUI) or brain imaging techniques, could reveal more about the central processing in DUI.

Incontinence in autism spectrum disorder: a systematic review.

Autism spectrum disorders (ASD) are defined by persistent deficits in reciprocal social interaction, communication, and language, as well as stereotyped and repetitive behavior. Functional incontinence, as well as ASD are common disorders in childhood. The aim of this systematic review was to give an overview of the co-occurrence of nocturnal enuresis (NE), daytime urinary incontinence (DUI), and fecal incontinence (FI) in ASD, and vice versa, of ASD in children with incontinence. A systematic literature search of the terms "incontinence", "enuresis", and "encopresis" in combination with "autism" or "Asperger" in four databases (Scopus, PubMed, PsycInfo and Web of science) was conducted. All studies that examined incontinence frequencies in samples with ASD, and studies that measured frequencies of ASD diagnoses or symptoms in samples with incontinence were included. Risk of bias and limitations of each study were described. After eligibility assessment, 33 publications were included in the review. The published literature implies a higher prevalence of incontinence in children with ASD compared to typically developing children. Limitations and biases as inappropriate diagnostic criteria for ASD and incontinence, selected samples, or lack of control groups are reported. Associations of incontinence in ASD with psychopathological symptoms were found. Vice versa, ASD symptoms are found in incontinent children, but no study included a non-ASD control sample. Incontinence symptoms are also reported as an adverse effect of medication in ASD. Due to methodological problems and definitional discrepancies in some publications, results have to be interpreted cautiously. Research in ASD and incontinence is scarce. More systematic research including state-of-the-art assessments is needed.

Nocturnal incontinence in children with fetal alcohol spectrum disorders (FASD) in a South African cohort.

INTRODUCTION: Fetal alcohol spectrum disorders (FASD) are one of the leading preventable causes of intellectual disabilities (ID). Not much is known about the topic of pediatric incontinence related to FASD, for example nocturnal enuresis (NE), daytime urinary incontinence (DUI), and fecal incontinence (FI). So far, incontinence problems have been examined among children with other specific syndromes. OBJECTIVE: The aim of the present study is to investigate the possible presence of incontinence among children with FASD in a South African cohort. STUDY DESIGN: The South African version of the combined questionnaire including the "Parental Questionnaire: Enuresis/Urinary Incontinence" and "Encopresis Questionnaire - Screening Version"; and lower urinary tract symptoms (LUTS) were assessed by the "International-Consultation-on-Incontinence-Questionnaire - Pediatric Lower Urinary Tract Symptom" (ICIQ-CLUTS) among 99 interviewees (e.g. mothers, grandparents) of children with FASD. Moreover, scores on the "Griffiths Mental Development Scales - Extended Revised" (GMDS-ER) were obtained of all included children for further statistical analysis. RESULTS: The overall incontinence rate was 20% (n = 20), in children diagnosed within the FASD spectrum (fetal alcohol syndrome or FAS n = 17, partial fetal alcohol syndrome or pFAS, n = 1, alcohol related neurodevelopmental disorder or ARND n = 2). NE affected 16% (n = 16) of children with a FASD (FAS n = 13, pFAS n = 1, and ARND n = 2). DUI was reported in one child (FAS), and FI in 4% (n = 4) of children (again, only FAS). No indication of lower urinary tract symptoms (LUTS) in the clinical range was reported (sample mean score = 5.17). Based on the GMDS-ER, 88% of the children scored lower than 10th percentile. DISCUSSION: This is a first study to examine the problems of incontinence among children diagnosed within the spectrum of FASD. The rates for children with a FASD are lower than the rates for many children with special needs, but much higher than for typically developing children. Children with a FASD are mainly affected by NE. CONCLUSION: The problem of incontinence among children with a FASD in South Africa needs to be assessed and considered for clinical management. Future research is necessary to examine problems of incontinence in relation to cognitive and behavioral functioning among children with a FASD, as well as identifying possible causes.

Incontinence and psychological symptoms in individuals with Mowat-Wilson Syndrome.

BACKGROUND: Mowat-Wilson Syndrome (MWS) is caused by deletion/mutation of the ZEB2 gene on chromosome 2q22. MWS is characterized by a distinctive facial appearance, severe intellectual disability and other anomalies, e.g. seizures and/or Hirschsprung disease (HSCR). Most individuals have a sociable demeanor, but one third show psychological problems. AIMS: The aim was to investigate incontinence and psychological problems in MWS. METHODS AND PROCEDURES: 26 children (4-12 years), 13 teens (13-17 years) and 8 adults (>18years) were recruited through a MWS support group. The Parental Questionnaire: Enuresis/Urinary Incontinence, as well as the Developmental Behaviour Checklist (DBC) were completed by parents or care-givers. OUTCOMES AND RESULTS: 97.7% of persons with MWS had incontinence (nocturnal enuresis 74.4%; daytime urinary incontinence 76.2%; fecal incontinence 81.4%). Incontinence remained high over age groups (children 95.8%, teens 100%, adults 100%). 46.2% of children, 25% of teens and 37.5% of adults exceeded the clinical cut-off on the DBC. The ability to use the toilet for micturition improved with age. CONCLUSIONS AND IMPLICATIONS: MWS incontinence rates are very high. All had physical disabilities including anomalies of the genitourinary and gastrointestinal tract. Due to the high prevalence rates, a screening for incontinence and psychological problems in MWS is recommended.

Toilet Phobia and Toilet Refusal In Children.

Objective: Toilet refusal syndrome (TRS) is a common disorder in toddlers, defined by use of diapers and refusal of toilet for defecation, while toilet phobia (TP) is a rare disorder in which toilets are avoided completely. Both disorders have not been described systematically in children, yet. Therefore, the aim was to present typical case vignettes illustrating different clinical presentations of TP and TRS. Methods: 5 typical cases were selected from all patients presented at a specialized outpatient clinic for incontinence at a tertiary university hospital during the last 3 years. Results: The first case is a girl with incontinence and no behavioral comorbidities, for whom treatment was more complicated than expected because of her TP. Second, a boy with an IQ on the border to mild intellectual disability will be presented, who revealed phobias regarding the toilet. Case 3 is exemplary for a group of patients with TRS, who also have ODD and show oppositional behavior in different situations. Cases 4 and 5 show "classical" TRS with constipation following painful defecation. Similarities and differences of TRS and TP, the current state of research, diagnostic and management recommendations are presented in detail. Conclusion: TRS in preschool children is a common condition, associated with high rates of constipation and behavioral problems. In contrast, TP is rarer and harder to recognize for pediatricians, but is often accompanied with somatic and behavioral problems, as well. Although there is a paucity of studies on these pediatric disorders, pediatricians should keep them in mind.

Incontinence in persons with Down Syndrome.

AIMS: To assess the rates of incontinence and associated psychological problems in children, adolescents and adults with Down Syndrome, a genetic syndrome caused by partial or complete triplication (trisomy) of chromosome 21 and characterized by typical facial features, a physical growth delay and mild or moderate intellectual disability. METHODS: Three hundred and seventeen persons with Down Syndrome (4-51 years) were recruited through a German parent support group (59.6% male, mean age 19.2 years). The Parental Questionnaire: Enuresis/Urinary Incontinence, the Incontinence Questionnaire-Pediatric Lower Urinary Tract Symptoms, as well as the Developmental Behavior Checklist (DBC) for parents or for adults were filled out by parents or care-givers. RESULTS: 17.2% of the sample had nocturnal enuresis, 15.9% had daytime urinary incontinence, and 14.2% had fecal incontinence. Incontinence was present in 64.0% of young children (4-12 years), 10.3% of teens (13-17 years), 12.8% of young adults (18-30 years) and in 22.4% of older adults (>30 years). 13.6% of children and 8.4% of adults had a DBC score in the clinical range. 19.5% of children and 27.8% of adults with incontinence had behavioral problems. There was a significant association between nocturnal enuresis, daytime urinary incontinence and clinical DBC scores in adults. CONCLUSIONS: Incontinence in Down Syndrome is mainly present in young children and increases in older adults. Behavioral comorbidity is associated with incontinence only in adults with Down Syndrome. Screening and treatment of incontinence in individuals with Down Syndrome is recommended.

Detailed assessment of incontinence in boys with fragile-X-syndrome in a home setting.

UNLABELLED: Fragile-X-syndrome (FXS) is caused by a mutation on the X chromosome (Xq27.3). Males with a full mutation have typical dysmorphic signs, moderate intellectual disability and psychological disorders. Twenty-five to fifty percent are affected by incontinence. The aim of the study was to assess subtypes of incontinence and psychological problems in children with FXS in their home environments. Twenty-two boys with FXS (mean age 11.0 years) and 22 healthy controls (mean age 11.1 years) were examined with sonography, uroflowmetry, 48-h bladder diary, physical examination, IQ test, parental psychiatric interview and questionnaires regarding incontinence and psychological symptoms in a home setting. Boys with FXS had higher rates of incontinence than controls (59.1 vs. 4.8 %). The most common subtypes in FXS boys were primary non-monosymptomatic nocturnal enuresis, urge incontinence and nonretentive faecal incontinence. 90.9 % boys with FXS had a psychological comorbidity. Incontinence and behavioural symptoms were not associated. CONCLUSION: Boys with FXS have a higher risk for physical disabilities, psychological disorders and incontinence than healthy boys. Constipation is not a major problem in FXS. As effective treatment is available for children with ID, we recommend offering assessment and therapy to all children with FXS and incontinence. WHAT IS KNOWN: • Boys with fragile-X-syndrome (FXS) have higher rates of incontinence, psychological disorders and somatic conditions than typically developing boys. What is New: • Constipation is a rare condition in FXS in contrast to other genetic syndromes. • Although incontinence rates are higher, urological findings (uroflowmetry, sonography) are not more pathological per se in FXS.

Voiding postponement in children-a systematic review.

Voiding postponement (VP) has been defined as a habitual postponement of micturition using holding maneuvers. VP can represent both a symptom, as well as a condition. As divergent definitions are used internationally, the aim was to review the current state of knowledge on VP and provide recommendations for assessment, diagnosis and treatment. A Scopus and a Pubmed search was conducted, entering the terms 'voiding postponement' without any restrictions or specifications. Other publications relevant to the topic were added. VP can represent a symptom in healthy children. As a condition, VP in combination with nocturnal enuresis (NE) is a subtype of non-monosymptomatic NE. Most studies have focused on daytime urinary incontinence (DUI) with VP, or more aptly termed voiding postponement incontinence (VPI). It is a behaviorally defined syndrome, i.e., by the habitual deferral of micturition and DUI. VPI is associated with a low micturition frequency, urgency and behavioral problems. The most common comorbid disorder is oppositional defiant disorder (ODD). VP as a symptom and VPI as a condition should be differentiated. VPI is a common disorder with many associated problems and disorders. Urotherapy and timed voiding are the main treatment approaches. Due to the high rate of comorbid ODD, other forms of treatment, especially cognitive behavioral therapy, are often needed.

Incontinence in children, adolescents and adults with Williams syndrome.

AIMS: Williams Syndrome (WS) is a microdeletion syndrome (chromosome 7q11.23) characterized by typical facial features, cardiovascular disease, behavioural symptoms, and mild intellectual disability (ID). The aim of this study was to assess the rates of incontinence and psychological problems in persons with WS. METHODS: 231 individuals with WS were recruited through the German parent support group (52.0% male, mean age 19.4 years). Faecal incontinence (FI) was diagnosed from the age of 4 years and nocturnal enuresis (NE) and daytime urinary incontinence (DUI) of 5 years onwards. The Parental Questionnaire: Enuresis/Urinary Incontinence, the International-Consultation-on-Incontinence-Questionnaire-Pediatric LUTS (ICIQ-CLUTS), as well as the Developmental Behavior Checklist for parents (DBC-P) or for adults (DBC-A) were filled out by parents or caregivers. RESULTS: 17.8% of the sample had NE, 5.9% DUI and 7.6% FI. NE was present in 44.9% of children (4-12 years), 13.5% of teens (13-17y), 3.3% of young adults (18-30y) and in 3.6% of adults (> 30y). DUI (and FI) decreased from 17.9% (21.4%) in children to 0% in adults. 3.5% of the sample had an ICIQ-CLUTS score in the clinical range. 30.5% of children and 22.1% of adults had a clinical DBC score. Children and teens with clinically relevant DBC-P-scores had significantly higher DUI rates. CONCLUSIONS: Children with WS have high rates of incontinence and LUTS, which decrease with age. Most adults are continent. NE is the most common subtype. Except for DUI in children, incontinence is not associated with behavioural problems. Screening, assessment and treatment of incontinence in individuals with WS is recommended. Neurourol. Urodynam. 35:1000-1005, 2016. © 2015 Wiley Periodicals, Inc.

Incontinence in persons with Noonan Syndrome.

OBJECTIVE: Noonan Syndrome (NS) is an autosomal neurodevelopmental disorder with a high phenotypic variability. Mutations in several genes of the RASMAPK signaling pathways are now known to be responsible for NS. Most of the children with NS are of average intelligence, one-third have a mild intellectual disability (ID) (IQ 50-79). So far, no studies have assessed incontinence in persons with NS. The aim of this study therefore was to investigate the prevalence of incontinence and psychological problems in persons with NS. SUBJECTS AND METHODS: Nineteen children (5-17 years) and 10 adults (18-48 years) with NS were recruited through a German parent support group (58.6% male, mean age 15.26 years). The "Parental Questionnaire: Enuresis/Urinary Incontinence", "Encopresis Questionnaire - Screening Version" and the German version of the International Consultation on Incontinence Questionnaire - Pediatric Lower Urinary Tract Symptom (ICIQ-CLUTS) were completed by parents or caregivers to assess incontinence and lower urinary tract symptoms (LUTS). The Developmental Behavior Checklist for parents (DBC-P) or the Developmental Behavior Checklist for adults (DBC-A) were filled out to assess psychological symptoms. RESULTS: In total, 27.3% of the children (4-12 years) had nocturnal enuresis (NE), 36.4% had daytime urinary incontinence (DUI), and 11.1% had fecal incontinence (FI). Only one adolescent (13-17 years) had NE (14.3%) and one young adult (18-30 years) had FI (11.1%); 36.4% of the children, 33.3% of the adolescents and 12.5% of young adults had a DBC score in the clinical range. No adult (>30 years) had incontinence or a critical DBC score. Children and adolescents with NE had significantly higher scores in the DBC total score as well in the "self-absorbed" and "social relating" subscales than continent children and adolescents, whereas no significant difference was found between children and adolescents with DUI compared with the continent group. CONCLUSIONS: A significant proportion of children with NS are affected by incontinence. Incontinence is a relevant problem in children and adolescents with NS, but does not persist into adulthood. In particular, psychological problems are present in children and adolescents with NE. Screening for both incontinence and psychological symptoms are recommended in children with NS. As most of the children with NS have average intelligence or a mild ID, they can be treated effectively with standard methods.

Obesity, overweight, and eating problems in children with incontinence.

OBJECTIVE: The aim was to analyze the prevalence of eating problems and specific associations between overweight, obesity, and eating behavior in children with incontinence. SUBJECTS AND METHODS: Forty-three consecutively presented children with incontinence, diagnosed to International Children's Continence Society standards, and 44 matched continent controls were examined prospectively. All children received a physical examination, sonography, and a one-dimensional intelligence test. Child psychopathology was measured with the Child Behavior Checklist (CBCL/4-18). Eating problems were assessed with the German version of the Dutch Eating Behaviour Questionnaire for Children (DEBQ-C) and a 40-item-parental questionnaire referring to atypical eating problems. RESULTS: Of the 43 children with incontinence, 23.3% had nocturnal enuresis (NE) only, 37.2% had any form of daytime urinary incontinence (DUI) (isolated or combined with NE) and 39.5% had fecal incontinence (FI) (isolated or combined with NE and/or DUI). Incontinent children showed significantly more CBCL externalizing symptoms (35.7% vs. 6.8%) and total problems (46.3% vs. 6.8%) in the clinical range (>90th percentile), as well as significantly lower mean IQ (105.5 vs. 120.6) than continent controls. Of the children with incontinence, 16.9% were affected by obesity (≥95th body mass index [BMI] percentile) compared with none of the continent controls. Especially in children with FI, the rate of obesity was significantly increased (23.5%). In addition, 46.5% of incontinent children, but none of the controls, had constipation. Again, children with FI (82.4%) had the highest rate of constipation (>DUI: 25% > NE only: 20%). "Food refusal" (FR) and "intense fear of gaining weight" (GW), but not other eating problems, were significantly more common among incontinent children (FR mean score 7.3; GW mean score 1.4) than in controls (FR mean score 5.6; GW mean score 0.7). After controlling for BMI percentiles, FR still was significantly higher in incontinent children. Children with FI had the highest score of FR among all subgroups of incontinence (mean score 9.1). CONCLUSIONS: This study shows that overweight, obesity, behavioral and eating problems are especially associated with disorders of the gastrointestinal tract (FI and constipation), and only to a lesser degree with those of the urinary tract (DUI and NE). These problems should be addressed routinely in the clinical care of children with incontinence.

Incontinence and parent-reported oppositional defiant disorder symptoms in young children--a population-based study.

BACKGROUND: Oppositional defiant disorder (ODD) and incontinence are common disorders of childhood. We have examined associations between ODD symptoms and incontinence in a representative sample of young children. METHODS: A questionnaire with seven questions referring to incontinence, eight DSM-IV items of ODD, 15 items of the Home Situations Questionnaire and six items regarding eating, drinking or toileting refusal was administered to the parents of 718 children at school-entry from a defined geographical area at school-entry. RESULTS: Of the 718 6-year-old children included in the analysis, 8.2% had nocturnal enuresis (NE), 1.5% had daytime urinary incontinence (DUI) and 1.1% had faecal incontinence (FI). Significantly more boys than girls had NE (12 vs. 4.3%). Overall, 6.7% of children had ODD symptoms. Rates of ODD symptoms were significantly higher in incontinent children (19.5%) than in continent children (5.2%), with the highest rate of ODD symptoms in children with DUI (36.4%). Children with incontinence (mean 6.1 episodes) or ODD symptoms (mean 8.4 episodes) showed non-compliant behaviours in more problem situations than continent children (mean 4.5 episodes) or children without ODD symptoms (mean 4.5 episodes). CONCLUSIONS: Incontinence and ODD are common comorbid disorders at school-entry age. Boys are more affected by both disorders. Children with DUI have the highest rate of ODD symptoms. As ODD symptoms affect many daily family situations, ODD needs to be diagnosed and treated in children with incontinence, as it can negatively affect compliance.

Specific behavioral comorbidity in a large sample of children with functional incontinence: Report of 1,001 cases.

AIMS: Psychological comorbidity among children with functional incontinence is high: 20-30% of children with nocturnal enuresis (NE), 20-40% of those with daytime urinary incontinence (DUI) and 30-50% of those with fecal incontinence (FI) have clinically relevant comorbid disorders. The aim of this study was to analyze specific comorbid behavioral symptoms for different subtypes of incontinence in a large group of children. METHODS: All 1,001 consecutive children and adolescents (67.5% boys) with a mean age of 8.5 years presented at a tertiary outpatient department between 2004 and 2011 were examined with a full pediatric and child psychiatric assessment. Prevalence of different subforms of incontinence and associated behavioral symptoms were analyzed. The internalizing, externalizing, and total problem scores of the Child Behavior Checklist (CBCL) were evaluated. RESULTS: Of all children, 70.1% (702 children) had NE, 36.1% (361 children) had DUI, and 36.8% (368 children) were affected by FI. More than 43% of all children had clinically relevant psychological symptoms (CBCL total score, cut-off at 90th percentile). Children with non-retentive FI had highest rates of clinically relevant psychological symptoms (58.8%). Children with combined subtypes of incontinence (any combination of NE, DUI, and FI) were more affected by psychological comorbidities than children with isolated subtypes (NE or DUI or FI). CONCLUSIONS: Children with incontinence have high rates of comorbid behavioral symptoms-three to six times higher than norms. Especially children with FI and combined subtypes of incontinence were affected. As behavioral symptoms and disorders will interfere with incontinence treatment, a general screening is recommended.

Prevalence of incontinence, attention deficit/hyperactivity disorder and oppositional defiant disorder in preschool children.

Externalizing disorders as attention deficit/hyperactivity disorder (ADHD) and oppositional defiant disorder (ODD) are common in children with nocturnal enuresis (NE), daytime urinary incontinence (DUI) and faecal incontinence (FI). We examined the prevalence rates of ADHD, ODD and incontinence in a defined geographical area and analysed the association between externalizing disorders and subtypes of incontinence. 1,676 parents of children who were presented at the mandatory school-entry medical examination completed a questionnaire with all DSM-IV items of ADHD, ODD and six questions regarding incontinence. 50.2% were male and mean age was 5.7 years. 9.1% had at least one subtype of incontinence (8.5% had NE, 1.9% DUI and 0.8% FI). Boys were significantly more affected by incontinence overall, NE, FI and ADHD than girls. 6.4% had ADHD, 6.2% had ODD and 2.6% were affected by ADHD and ODD. 10.3% of the children with incontinence had ADHD and 10.3% ODD. Children with FI were significantly more affected by externalizing disorders (50%) than children with isolated NE (14.5%), children with DUI (9.5%) and continent children (9.5%). Children with incontinence, especially those with FI, are at much higher risk of externalizing disorders. An additional effect of children with both ADHD and ODD having higher rates of incontinence than children with only one disorder could not be found. However, these children represent a high-risk group with lower compliance to treatment and worse outcome. Therefore, screening not only for ADHD but also for ODD should be implemented for all children with incontinence.

Toilet refusal syndrome in preschool children: do different subtypes exist?

OBJECTIVES: Toilet refusal syndrome (TRS) is a common, benign disorder in toddlers defined by the use of diapers and refusal of toilet for defaecation, but has not been described systematically in preschool children yet. The aim of the study was to analyse and identify possible subgroups of TRS. METHODS: Retrospective analysis of all of the consecutive children with TRS presented as outpatients in a clinic for elimination disorders. Patients had received a detailed paediatric and child psychiatric assessment, including the Child Behavior Checklist questionnaire. Three typical case vignettes are presented of TRS with constipation, oppositional defiant disorder, and sibling rivalry. RESULTS: Twenty-five children (10 boys) with a mean age of 5.2 (3.4-7.3) years were included-representing 2.5% of all of the children (n = 1001) presented. They had high rates of constipation (60%) and elimination disorders (24%-44%). Child psychiatric International Classification of Diseases-10th Edition disorders were common (40%) and heterogeneous, with significantly more boys affected, but no differences between children with and without constipation. CONCLUSIONS: This study shows that TRS occurs also in older preschool (and even school) children. At this later age, it is associated with constipation and behavioural disorders. The case vignettes show differences in therapy and may represent different subgroups of TRS. TRS is associated with constipation, elimination disorders, and psychiatric disorders. Owing to this variety of comorbid disorders, different therapeutic approaches are needed. A general screening for behavioural symptoms is recommended.

Children's concepts of the urinary tract.

OBJECTIVE: To assess children's body concepts about anatomy and physiology of the urinary tract, children drew pictures responding to the question 'Where do you believe urine comes from?' SUBJECTS AND METHODS: A total of 152 children in three groups were examined. 81 children were out-patients. Of these, 36 children were being seen for the first time and 45 children had previously undergone bladder and bowel group training. They were compared to 71 continent controls. Children were given a body silhouette, in which they drew their view of the urinary tract. RESULTS: Half of the children (52.6%) drew a bladder and other organs; nearly 43% drew a tube or other anatomically incorrect pictures. Significant differences were found for group and age. Children who had undergone the group training more often drew a bladder and other organs (80%). Correct pictures and pictures of bladder and other organs were more common from children aged 11-16 years. CONCLUSION: Children have subjective concepts of the urinary tract which do not follow actual anatomy and physiology. For medical interventions as well as any training programmes, it is essential to understand these concepts and provide instructions in a child-centred and developmentally adequate way.