State and trait anxiety in children with incontinence and their parents.

BACKGROUND: Maternal anxiety increases the risk for incontinence in children. The aim was to analyze anxiety in children with incontinence and their parents before (t1) and after 6 months of incontinence treatment (t2). METHODS: 40 children with incontinence and 40 controls completed the State-trait Anxiety Inventory for Children, their parents the Child Behavior Checklist (CBCL) and the State-trait Anxiety Inventory at baseline (t1) and 6 months later (follow-up, t2). Psychiatric disorders were assessed by a standardized parental diagnostic interview (Kinder-DIPS), IQ was tested by a one-dimensional test. All children were neurologically examined. Children with incontinence underwent a guideline-based treatment during the 6 months. RESULTS: At baseline, child and parental state and trait anxiety scores, as well as all CBCL scores were significantly higher in the patient group compared to the control group. At t2, parental anxiety, CBCL scores, and child trait anxiety were significantly higher in patients versus controls, whereas child state anxiety decreased, and parental state anxiety increased from t1 to t2. CONCLUSIONS: Incontinence and anxiety are associated. While state anxiety decreases, trait anxiety can remain stable over time. Higher levels of anxiety can influence incontinence treatment and should be assessed in every patient.

Psychopathology and Parental Stress in 3-6-Year-Old Children with Incontinence.

Objective: Incontinence and functional gastrointestinal disorders are common in young children and are associated with higher rates of psychological symptoms and mental disorders. This article focuses on the mutual association between incontinence and related toilet refusal syndrome, parental stress, and children's psychopathology especially in young children. Methods: Children's psychological symptoms, mental disorders, and parental stress levels were assessed in 38 parent-child dyads involving children with incontinence and 42 dyads of typically developing (TD) children. Results: Compared to TD children, patients had higher internalizing and externalizing CBCL scores and higher rates of clinically relevant externalizing problems. However, the rates of clinically relevant internalizing problems and mental disorders did not differ. The parents of children with incontinence reported significantly higher stress levels regarding child-related stress factors (PSI-CD) than did parents of TD children. However, there were no clinically relevant parental stress scores on a group level, which remained below the clinical range (T-value < 60). When simultaneously analyzed, children's (comorbid) mental disorders but not incontinence had a major impact on parental stress. Conclusions: Despite moderate stress levels, incontinence symptoms, urinary and fecal incontinence are highly prevalent in young children. However, stress among parents of young children was mainly elicited by any (comorbid) mental disorder.

Incontinence in persons with tuberous sclerosis complex.

AIMS: Tuberous sclerosis complex (TSC) is a multisystem genetic disorder caused by a mutation in the TSC1 or TSC2 gene with a broad spectrum of physical and psychological manifestations. The aim of the study was to examine incontinence, psychological problems, and adaptive behavior skills in patients with TSC. METHODS: Through a worldwide TSC support group, 26 children (4-17 years) and 15 adults (18-50 years) with TSC were recruited (38.1% male, mean age 16.4 years). Parents or care-givers completed the Developmental Behavior Checklist (DBC), the Parental Questionnaire: Enuresis/urinary Incontinence, and the Vineland Adaptive Behavior Scales (3rd edition). RESULTS: A total of 60.0% of the participants had nocturnal enuresis (NE), 51.3% daytime urinary incontinence (DUI) and 52.4% fecal incontinence (FI). 65.4% of children and 50.0% of adults had a clinically relevant DBC score. Psychological symptoms were associated with at least one subtype of incontinence. The mean adaptive behavior composite (ABC) score of the patients was 57.2 (SD = 26.1), with 38.1% in the average or below-average range (IQ >70), 26.2% with a mild, 11.9% with a moderate and 23.8% with a severe/profound intellectual disability. The incontinence rate was significantly higher in the groups with a lower ABC score. CONCLUSION: A substantial proportion of patients with TSC are affected by incontinence and psychological symptoms. Incontinence was higher in persons with lower adaptive skills and those with at least one type of incontinence showed a significantly higher DBC score. As incontinence and psychological problems affect daily functioning and well-being, assessment, and treatment are recommended.

Bladder and bowel control in a population-based sample: Associations to quality of life and behavioral problems of 4-6-year-old children participating in the German Health Interview and Examination Survey (KiGGS).

BACKGROUND: Prevalence rates for psychiatric comorbidities are high in incontinent children. We analyzed data from the KiGGS survey in order to assess the rate of preschool children with delayed or regular continence, the mean age of gaining continence, psychiatric problems, and quality of life in a nation-wide, representative sample. METHODS: Parental questionnaire data of 3875 preschool children (4-6 years) were analyzed. Percentages of children with daytime, nighttime, and complete continence, and mean ages of gaining continence were calculated. Psychological and behavioral problems (SDQ), as well as Quality of life (KINDL-R), were assessed. RESULTS: 16.9% showed delayed gaining of continence. Percentages of children with nighttime bladder continence were lower for boys (76.3%) than for girls (80.6%), and lower for children without (78.2%) than those with a migration status (79.2%). Complete continence was gained by more girls (83.9%) than boys (78.2%), more children from the former East Germany (82.4%) than former West Germany (81.1%), and by more migrants (82.7%) than nonmigrants (81.9%). Girls, children living in the former East of Germany, and migrants achieved continence consistently at an earlier age. Children with incontinence or continence ≥4 years showed significantly more psychological problems, less prosocial behavior and low quality of life. CONCLUSION: The age at gaining continence is moderated by gender, German region, and migration status. Delayed achievement of continence is associated with more psychological problems and a lower quality of life. The importance of effective treatment of incontinence is emphasized by the results of this study.

Incontinence and constipation in adolescent patients with anorexia nervosa-Results of a multicenter study from a German web-based registry for children and adolescents with anorexia nervosa.

OBJECTIVE: Nocturnal enuresis (NE), daytime urinary incontinence (DUI), and fecal incontinence (FI) are common disorders in childhood and are frequently accompanied by comorbid psychiatric disorders. Despite a high association between urinary and fecal incontinence with psychiatric and neurodevelopmental disorders, research on comorbidity between incontinence and anorexia nervosa (AN) remains scarce. Yet, it is well known that somatic consequences of AN include metabolic and gastrointestinal disorders. The study sought to assess the prevalence of incontinence and constipation in children and adolescents with AN and to examine associations of these two symptoms with body weight at admission and with BMI changes during inpatient treatment. METHODS: Data collected between 2015 and 2017 by a multicenter German web-based registry for AN were analyzed. Three hundred and forty-eight patients with AN (96.3% female, mean age = 15.1 ± 1.8 years) were assessed regarding AN subtype, psychiatric comorbidity, body weight, incontinence, and constipation. RESULTS: Overall, 27.6% of patients had constipation, 1.8% had NE and 1.8% DUI. Prevalence of constipation did not significantly differ between AN subtypes. Constipation did not lead to any significant differences in weight/BMI changes during inpatient treatment. DISCUSSION: This is the largest study of incontinence and constipation in patients with AN, so far. Our results indicate that constipation is highly prevalent in adolescent patients with AN and reflects a clinically relevant condition. Despite, patients with AN do not have an increased prevalence of incontinence compared with the general population. Future studies should include medical examinations like ultrasound and physical examination of the lower abdomen to evaluate the severity of constipation.

Incontinence and psychological symptoms in Phelan-McDermid syndrome.

AIMS: Phelan-McDermid syndrome (PMD) is a congenital syndrome caused by a deletion on chromosome 22q13.3. About 600 cases have been identified worldwide. PMD is characterized by neonatal hypotonia, moderate/severe intellectual impairment, impaired expressive language, and typical dysmorphic features. Psychological symptoms as hyperactivity, attention problems, restlessness, and stereotyped-repetitive behavior were reported. The aim of the study was to assess incontinence and associated psychological problems in PMD. METHODS: Forty-one individuals with PMD were recruited through a German support group (48.8% male; mean age 13.4 years; range, 4-55 years). Parents or caregivers completed the developmental behavior checklist (DBC), as well as the parental questionnaire: enuresis/urinary incontinence, including six questions on adaptive toileting skills. RESULTS: Rates of nocturnal enuresis (NE), daytime urinary incontinence, and fecal incontinence were 86%, 73%, and 79%. Rates were similar in all age groups (children, teens, adults). Constipation was present in 19%. Forty-two percent of the sample had a clinically relevant DBC score, with adults more affected than teens. Persons with NE had significantly higher "anxiety/depression" subscale scores. Toileting skills were more developed in adults than in children. Sixty-eight percent had further physical disabilities. CONCLUSIONS: Incontinence rates in PMD are high in all age groups. However, persons with PMD can improve their toilet skills. Therefore, the assessment and treatment of incontinence in persons with PMD is recommended. Constipation does not seem to be a major problem in PMD. Due to the high prevalence rates of somatic conditions, an assessment for organic and functional incontinence is recommended.

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.

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.

[The inpatient treatment of patients with anorexia nervosa in German clinics]. / Die Versorgung von Kindern und Jugendlichen mit Anorexia nervosa in deutschen Kliniken.

Objective: The medium- and long-term effects and side effects of inpatient treatment of patients with anorexia nervosa is still a matter of debate. The German S3-guidelines underline the importance of providing specialized and competent treatment. In this article we focus on the inpatient service structure in German child and adolescent psychiatric clinics with regard to their diagnostic and therapeutic concepts. Methods: A self-devised questionnaire was sent to 163 German child and adolescent psychiatric clinics. The questionnaire focused on the characteristics of the respective clinic as well as its diagnostic and therapeutic strategies. Results: All clinics with an inpatient service for patients with anorexia nervosa (N = 84) provide single-therapy, family-based interventions and psychoeducation. A target weight is defined in nearly all clinics, and the mean intended weight gain per week is 486 g (range: 200 g to 700 g/week; SD = 117). Certain diagnostic tests and therapeutic interventions are used heterogeneously. Conclusions: This is the first study investigating the inpatient service structure for patients with anorexia nervosa in German clinics. Despite the provision of guideline-based therapy in all clinics, heterogeneous approaches were apparent with respect to specific diagnostic and therapeutic concepts.

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.

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.

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.