Mental health and professional outcomes in parents of children with chronic kidney disease.

BACKGROUND: This study evaluated parenting stress, anxiety, and depression symptoms and their associated factors in parents of children with chronic kidney disease (CKD). METHODS: This cross-sectional study compared parents of patients with CKD (0-18 years) with a matched control group of parents of healthy children. Both groups completed the Parenting Stress Index - Short Form, the Hospital Anxiety and Depression Scale, and a sociodemographic questionnaire. RESULTS: The study group consisted of 45 parents (median age 39; 32 mothers) of CKD patients (median age 8; 36% female). Nearly 75% of children had CKD stages 2, 3, or 4, and 44.5% had congenital anomaly of the kidney and urinary tract. Five children (11%) were on dialysis, and 4 (9%) had a functioning kidney graft. Compared with parents of healthy children, more stress and anxiety symptoms were reported. Since the CKD diagnosis, 47% of parents perceived a deterioration of their own health, and 40% reduced work on a structural basis. Higher levels of stress, anxiety, and depression symptoms were associated with a more negative perception of own health, and more child medical comorbidities and school absence. CONCLUSIONS: This study showed higher levels of parenting stress and anxiety symptoms in parents of children with CKD compared with parents of healthy children. This was associated with a less positive perception of their own health, especially if the child had more medical comorbidities or more absence from school. Psychosocial interventions to reduce the parental burden should be integrated in the standard care of pediatric nephrology departments.

Working towards convergence of the clinical management of differences of sex development/intersex conditions and the human rights framework: A case study.

OBJECTIVE: Medical treatments that aim to modify the appearance of the genitals in children who are born with a difference of sex development/intersex (DSD/I*) condition are highly controversial. Human Rights bodies worldwide have argued that such treatments are conflicting with the child's right of personal autonomy and should be legally restricted to the unique situation where the child's physical health is in danger. DESIGN: We here review the current status of legal initiatives in Europe that have addressed the issue of medical treatments in minors who have a DSD for which they have not been able to give personal informed consent due to their young age. PATIENTS: The management of a 3 years old child who has congenital adrenal hyperplasia (CAH) and grows up with atypical-looking genitals is discussed. RESULTS: In spite of extensive psychosocial support to the child and family from birth onwards, and good medical control of CAH, the child develops signs of emotional distress, suspected to be attributable to the genital difference. Our discussions include perspectives from the multidisciplinary DSD team caring for the child, a human rights specialist, and an intersex activist. From our discussions, we conclude that with evolving medical care, new ethical and human rights challenges are raised. A truly holistic human rights approach should not only consider physical but also mental health and psychosocial and psychosexual adaptation of the child to the medical condition, when reflecting on the acceptability of medical treatments in minors for which no personal informed consent can be obtained due to their young age. In addition it is paramount to include the meaningful participation of the child in the clinical management at the earliest possible stage. CONCLUSIONS: Continued convergence of clinical management and the human rights framework can be realised based on constructive discussions involving all stakeholders, and with the best interest of the child - and adult that they will become - as a common goal.

Illness-related parental stress and quality of life in children with kidney diseases.

BACKGROUND: This cross-sectional study investigated quality of life (QoL) and illness-related parental stress in children with kidney diseases by (1) comparing mean levels of these two variables between several kidney disease categories; (2) exploring correlations between QoL and parental stress; and (3) describing which disease category reports lowest QoL and highest parental stress. METHODS: We included 295 patients with a kidney disease (0-18 years) and their parents, followed at 6 reference centers for pediatric nephrology. Children's QoL was assessed by the PedsQL™ 4.0 Generic Core Scales, and illness-related stress by the Pediatric Inventory for Parents. All patients were divided into 5 kidney disease categories according to the multidisciplinary care program criteria prescribed by the Belgian authorities: (1) structural kidney diseases, (2) tubulopathies and metabolic diseases, (3) nephrotic syndrome, (4) acquired diseases with proteinuria and hypertension, and (5) kidney transplantation. RESULTS: Child self-reports showed no differences in QoL between kidney disease categories, in contrast to parent proxy reports. Parents of transplant patients reported lower QoL in their child and more parental stress compared with the 4 non-transplant categories. QoL and parental stress were negatively correlated. Lowest QoL and highest parental stress scores were mainly found in transplant patients. CONCLUSIONS: This study showed lower QoL and higher parental stress in pediatric transplant patients compared with non-transplants, based on parent reports. Higher parental stress is associated with worse QoL in the child. These results highlight the importance of multidisciplinary care for children with kidney diseases, with special attention to transplant patients and their parents. A higher resolution version of the Graphical abstract is available as Supplementary information.

Validity and reliability of the Dutch version of the PedsQL™ 3.0 End Stage Renal Disease Module in children with chronic kidney disease in Belgium.

BACKGROUND: Children with chronic kidney disease (CKD) have a low quality of life (QoL). The PedsQL™ 4.0 Generic Core Scales are widely used to assess general QoL in children. The aim of this cross-sectional study was to translate the original version of the CKD-specific PedsQL™ 3.0 End Stage Renal Disease Module into a Dutch version and to evaluate its validity and reliability. METHODS: The forward-backward translation method based on the guidelines from the original developer was used to produce the Dutch version of the PedsQL™ 3.0 ESRD Module. Fifty-eight CKD patients (aged 8-18 years) and their parents (n = 31) filled in both generic and disease-specific modules. The non-clinical control group consisted of the same number of healthy children (matched for gender and age) and their parents. RESULTS: Cronbach's alpha coefficients (α's) for the PedsQL™ 3.0 ESRD Module demonstrated excellent reliability for the Total Scale scores. For all 7 subscales, α's were greater than 0.60, except for Perceived Physical Appearance. Overall, intercorrelations with the PedsQL™ 4.0 Generic Core Scales were in the medium to large range, supporting construct validity. Parent proxy reports showed lower generic QoL for all domains in CKD patients compared to healthy children. Child self-reports only demonstrated lower QoL on the domain School Functioning in children with CKD compared to healthy children. CONCLUSIONS: This study shows good validity and reliability for the Dutch version of the PedsQL™ 3.0 ESRD Module. However, testing with a larger study group is recommended in order to make final conclusions about the psychometric qualities of this measure. A higher resolution version of the Graphical abstract is available as Supplementary information.

Mental Health Outcomes Among Parents of Children With a Chronic Disease During the COVID-19 Pandemic: The Role of Parental Burn-Out.

OBJECTIVE: The COVID-19 pandemic and associated quarantine measures highly impacted parental psychological well-being. Parents of children with chronic diseases might be specifically vulnerable as they already face multiple challenges to provide adequate care for their child. The research questions of the current study were twofold: (a) to examine whether parents of children with a chronic disease experienced more anxiety and depression compared to parents of healthy children and (b) to examine a series of risk factors for worsened well-being (i.e., depression, anxiety, and sleep problems), such as sociodemographic variables, COVID-19-specific variables (i.e., financial worries, living space, and perceived quality of health care), and parental psychological experiences (i.e., parental burn-out and less positive parenting experiences). METHODS: Parents of children with a chronic disease (i.e., the clinical sample; N = 599 and 507 for Research Questions 1 and 2, respectively) and parents of healthy children (i.e., the reference sample: N = 417) filled out an online survey. RESULTS: Findings demonstrated that the parents in the clinical sample reported higher levels of anxiety than parents in the reference sample. Analyses within the clinical sample indicated that COVID-19-specific stressors and parental psychological experiences were associated with higher levels of anxiety, depression, and sleep problems. Mediation analyses furthermore indicated that the association of COVID-19-specific stressors with all outcome measures was mediated by parental burn-out. CONCLUSIONS: Parents of children with a chronic disease constitute a vulnerable group for worse well-being during the current pandemic. Findings suggest interventions directly targeting parental burn-out are warranted.

Parental Catastrophizing and Goal Pursuit in the Context of Child Chronic Pain: A Daily Diary Study.

Background: Despite daily variability in children's chronic pain experiences, little is known about how parents' emotions and goals toward their child's pain are influenced by these daily changes. This diary study examined how daily child pain intensity (as perceived by parents) moderates the associations between parental catastrophic thoughts about child pain on the one hand, and daily parental distress and parents' goals with regard to their child's pain (pain control vs. activity engagement) on the other hand. Method: Participants were 25 parents of 20 different children (N = 18; 90% girls). Children, aged 8-14 years (M = 9.5, SD = 2.09), experienced either chronic headache or functional abdominal pain with an average pain duration of 22.5 months (SD = 24.5 months). Daily parental responses (i.e., perceived child pain intensity, distress and goal endorsement) were collected through a 3-week daily diary (resulting in 413 valid diary reports). Parents completed the Pain Catastrophizing Scale for Parents prior to starting the diary (PCS-P general) and a daily measure (PCS-P daily) included in the diary. To account for the interdependence of the data, the data were analyzed using multilevel modeling. Results: Perceived daily child pain intensity moderated the impact of parental general and daily catastrophic thoughts on parents' daily distress. Only for parents experiencing low general catastrophic thoughts an increase in distress was observed on days when they perceived their child's pain intensity as high. For all parents, high levels of perceived child pain intensity were related to more distress on days where parents reported high levels of catastrophic thinking (i.e., PCS-P daily). Perceived daily child pain intensity also moderated the impact of parental general catastrophic thinking on parents' daily endorsement of goals. Parents with high levels of general catastrophic thinking reported a lower focus on child pain control on days when child pain intensity was perceived to be low. Parents with low general catastrophic thinking reported lower endorsement of the activity engagement goal on days where the child's pain intensity was perceived to be low. Conclusion: These findings highlight the complexity of daily fluctuations in parental distress and goals regarding their child's pain. Clinical implications and future directions are critically assessed.

Study protocol for You.Mind!: boosting first-line mental health care for YOUngsters suffering from chronic conditions with mindfulness: a randomised staggered within-subjects design.

INTRODUCTION: Adolescents with chronic conditions often experience high levels of stress, anxiety and depression, and reduced quality of life. Mindfulness-based interventions (MBIs) have been found to improve emotional distress in clinical and non-clinical populations and are a promising technique to support adolescents with chronic conditions in managing their symptoms and ultimately enhance their quality of life. METHODS AND ANALYSIS: To test the effects of an MBI on emotional distress and quality of life and delineate the underlying mechanisms, the You.Mind! study uses a randomised staggered within-subjects design. Thirty adolescents with a chronic condition will be randomised to a baseline phase of 14-28 days followed by an MBI, consisting of four online group sessions and online support spread over 8 weeks. Outcomes will be assessed by short, repeated measurements throughout the baseline, intervention and follow-up phases and by standardised questionnaires and experience sampling measures before randomisation, at postintervention and at 3-months follow-up. Analysis will be based on general linear modelling and multilevel mixed-effects modelling. ETHICS AND DISSEMINATION: Ethical approval was obtained from the Ethics Committee Research UZ/KU Leuven and the Ethics Committee of Ghent University Hospital and Ghent University (S63485). Results will be disseminated through presentations at public lectures, scientific institutions and meetings, and through publication in peer-reviewed journals. TRIAL REGISTRATION NUMBER: NCT04359563.

Psychosexual Outcome, Sexual Function, and Long-Term Satisfaction of Adolescent and Young Adult Men After Childhood Hypospadias Repair.

BACKGROUND: The psychosexual outcome in adolescents and young adults (AYA) men born with hypospadias is precarious. However, the factors responsible for impaired outcome in some AYA men have been understudied. AIM: To explore the outcome after hypospadias repair in childhood of AYA men aged 16-21 years and examine their opinion and their parents' opinion about this type of surgery. METHODS: Cross-sectional assessment of 193 AYA men born with hypospadias and 50 male controls was performed. Questionnaires such as the Decision Regret Scale, Pediatric Penile Perception Score, Sexual Quality of Life-Male, International Index of Erectile Function, and a custom-made questionnaire were used. The Decision Regret Scale and a custom-made questionnaire were also completed by the participants' parents. Physical examination including Hypospadias Objective Penile Evaluation and measuring stretched penile length was performed. OUTCOMES: This study reports the psychosexual functioning (ie, social, relational, and sexual), erectile and sexual function after childhood hypospadias repair, using ad hoc measures. In addition, the opinion about hypospadias repair of patients and their parents is represented. RESULTS: The number of surgeries and satisfaction regarding penile appearance were the most important factors associated with the opinion on hypospadias repair and the psychosexual outcome. Most AYA men were more satisfied with their penile appearance than the physician. 80% of men were satisfied with having had a childhood hypospadias repair, even though they had not been able to consent to surgery themselves. Erectile and ejaculation problems were mild and seen in approximately 10% of the population. CLINICAL IMPLICATIONS: Based on our data, deferring hypospadias repair until the patient can decide himself is not warranted. However, physicians who accept a suboptimal esthetic outcome and withdraw from repeated surgery may contribute importantly to the patient's well-being, especially in proximal forms of hypospadias. STRENGTHS & LIMITATIONS: This is one of the rare studies addressing the AYA's psychosexual outcome after childhood hypospadias repair. Strengths include the combination of clinical and psychosexual data from a very large cohort of men and their parents to provide a more holistic view. By entering this study, participants might have a different comfort level regarding their sexuality or have a different body image than the overall population of young men. CONCLUSION: Uncomplicated hypospadias surgery results in equal psychosexual outcome as controls and in high satisfaction rates; multiple surgeries are a risk factor for poorer outcomes. 80% of men are satisfied with childhood hypospadias repair. Tack LJW, Springer A, Riedl S, et al. Psychosexual Outcome, Sexual Function, and Long-Term Satisfaction of Adolescent and Young Adult Men After Childhood Hypospadias Repair. J Sex Med 2020;17:1665-1675.

A pilot study of the effectiveness of a serious game CliniPup® on perioperative anxiety and pain in children.

INTRODUCTION/AIM: Children experience important anxiety before surgery. Anxiety and pain are positively correlated. Serious gaming is a non-pharmacological intervention to prepare children and parents for an operation. We aimed to evaluate the effectiveness of the serious game CliniPup® on anxiety and pain in children undergoing ambulatory surgery. METHOD: A prospective randomized controlled pilot trial in 72 children aged 5 to 11 years old scheduled for day-care surgery (general surgery, dentistry, otorhinolaryngology, urology) was performed. Participants were randomly assigned into 3 groups: A (CliniPup®), B ("Empty game" without educational information), or C (no game, oral information at the outpatient clinic, current standard of care). Anxiety, pain, and behaviour were evaluated by validated instruments at six time-points: T0: baseline, T1: 1 week preoperatively, T2: at hospital admission, T3: before discharge, T4: 1 week postoperatively, T5: 1 month postoperatively. RESULTS: After playing the game (T1), the estimated mean anxiety score (VASa) was lower in Group A (1.9 units) versus Group B (2.7 units). The estimated mean VASa at T1 for Group A was 2.6 units lower compared to Group C (p = 0.003). For Group B, VASa levels were 1.8 units lower than in Group C (p = 0.045). After correction for "surgery type", Group A continued to show a significantly lower VASa compared to Group C (p = 0.044). On the other time points, no difference in anxiety and pain were observed, nor in post-hospitalization behaviour. CONCLUSION: Children that played the CliniPup® game one week before surgery had a significant reduction in preoperative anxiety after playing the game, but not on the other time points. No differences on peri-operative pain were observed during the different time points. TYPE OF STUDY: Randomized Trial. LEVEL OF EVIDENCE: Level II.

Resilience Factors in Children with Juvenile Idiopathic Arthritis and Their Parents: The Role of Child and Parent Psychological Flexibility.

OBJECTIVE: Chronic pain is central to juvenile idiopathic arthritis (JIA) and is predictive of impaired functioning. Whereas most work has focused on identifying psychosocial risk factors for maladaptive outcomes, we explored the idea that child and parental psychological flexibility (PF) represent resilience factors for adaptive functioning of the child. We also explored differences between general vs pain-specific PF in contributing to child outcomes. METHODS: Children with JIA (age eight to 18 years) and (one of) their parents were recruited at the Department of Pediatric Rheumatology at the Ghent University Hospital in Belgium. They completed questionnaires assessing child and parent general and pain-specific PF and child psychosocial and emotional functioning and disability. RESULTS: The final sample consisted of 59 children and 48 parents. Multiple regression analyses revealed that child PF contributed to better psychosocial functioning and less negative affect. Child pain acceptance contributed to better psychosocial functioning, lower levels of disability, and lower negative affect, and also buffered the negative influence of pain intensity on disability. Bootstrap mediation analyses demonstrated that parental (general) PF indirectly contributed to child psychosocial functioning and affect via the child's (general) PF. Parent pain-specific PF was indirectly linked to child psychosocial functioning, disability, and negative affect via child pain acceptance. CONCLUSIONS: Our findings indicate that child and parental PF are resilience factors and that pain acceptance buffers the negative impact of pain intensity. Implications for psychosocial interventions that target (pain-specific) PF in children and parents are discussed.

Development and validation of a spina bifida-specific pediatric quality of life questionnaire: the Spina Bifida Pediatric Questionnaire, SBPQ.

PURPOSE: Based on existing questionnaires and patient interview, a health-related quality of life (HRQoL) questionnaire in spina bifida (SB) children is created and validated, the Spina Bifida Pediatric Questionnaire (SBPQ). METHODS: SB patients from the SB reference centre Ghent University Hospital, Belgium, with mental ability between 6 and 18 years old and their parents were asked to participate in the study, together with a control group. RESULTS: Thirty-nine patients and parents answered the questionnaire once, 20 patients and their parents the test-retest. Thirty-five controls answered the questionnaire once, 34 controls and their parents the test-retest. The final questionnaire was retained when 3 consecutive patients approved all items. Visual clues were added for children with a mental ability below 10 years of age. The test-retest showed a good to excellent agreement for child self-report in 5 domains (not for social functioning), for parent proxy report in all domains (6), for control self-report in 4 domains (not for domain home) and for control parent proxy report in all domains (5). Internal consistency reliability was good in child self-report and in parent proxy report, except for physical functioning in child self-report. There was parent-child agreement for 4 out of 6 domains. Regarding social and emotional functioning, QoL was rated lower by parents than by children themselves. CONCLUSION: A SB HRQoL questionnaire was developed and validated. Because of visual aid, this questionnaire can be used by both young children and adolescents.

Vaginal dilation treatment in women with vaginal hypoplasia: a prospective one-year follow-up study.

OBJECTIVE: Vaginal dilation treatment has been shown to be a (cost) effective first-line alternative to surgery in normalizing vaginal length and improving sexual function in women with vaginal hypoplasia. There remains, however, a need for prospective studies, with long-term assessment of multiple outcomes. STUDY DESIGN: This was a prospective, single-centre observational study of 16 women with Mayer-Rokitansky-Küster-Hauser syndrome (n = 12) or 46,XY disorders of sex development (n = 4). All women underwent an outpatient vaginal dilation program supervised by a psychologist and physiotherapist. At baseline (T0), stop of treatment (T1) and 1 year follow-up (T2), semistructured interviews, and validated questionnaires assessed sexual function and distress, self-esteem, vaginal perceptions, and health-related quality of life. Gynecological examinations evaluated vaginal dimensions. RESULTS: Ten women completed the program, 3 are still in the program, and dilation failed in 3 and chose vaginoplasty. Sixty-nine percent reached a normal vaginal length (≥6.5 cm) in 5.8 ± 3.3 months. Seventy percent were sexually active with pleasurable experiences at T1, 57% at T2. The significant decrease in sexual distress at T1 (P < .05) was followed by a nonsignificant increase at T2. Depressive mood symptomatology remained high at T1 and T2, related to loss of bodily integrity and fertility. The majority refused further psychological counseling. CONCLUSION: Vaginal dilation treatment should remain the cornerstone of treatment in women with vaginal hypoplasia. However, the diagnosis remains to have a negative impact on emotional well-being in the long term. The role of psychological intervention as both a primary and adjuvant treatment needs clear evaluation.

Sexual quality of life after hormonal and surgical treatment, including phalloplasty, in men with micropenis: a review.

INTRODUCTION: The term micropenis encompasses a range of congenital and acquired conditions that result in an abnormally short penis. Small penis size may persist into adulthood, becoming a major cause of dissatisfaction. AIM: To review the literature pertaining to the effects of hormonal and surgical treatment on psychosexual functioning and quality of life (QoL) in individuals with micropenis who were raised male. MAIN OUTCOME MEASURES: Long-term psychosexual and QoL outcomes after hormonal and surgical treatment, including phalloplasty. METHODS: PubMed search for relevant publications (1955-2012) on the role of hormonal and surgical treatment in sexual QoL in adult men with micropenis. RESULTS: Multiple variations in the etiology of micropenis make it difficult to draw firm conclusions that fit all of the patients within this disparate population. However, the literature review supports the conclusions that (i) male gender assignment is preferable for most 46,XY infants with congenital micropenis because of the likelihood of male gender development and genitosexual function; (ii) small penis size persisting into adulthood and dissatisfaction with genital appearance jeopardize sexual QoL; (iii) there is no known intervention, apart from phalloplasty, to guarantee that the penis will become normal in size; (iv) early data suggest that the phalloplasty technique considered the gold standard for gender reassignment in the transgender population can also be transferred to 46,XY patients with micropenis; (v) psychological support should be an integral part of management in order to alleviate the distress and impairment of QoL experienced by these individuals. CONCLUSIONS: Further publication of series with large numbers and longer follow-up is needed. Specific outcome kits should be designed to measure more precisely patients' degrees of satisfaction with cosmetic, anatomical, and functional variables. Only if health-care professionals fully appreciate the impact of this condition can optimal care be provided.

Psychological and psychiatric issues in urinary and fecal incontinence.

PURPOSE: We provide an overview of the psychological and psychiatric aspects of nocturnal enuresis, urinary and fecal incontinence. Clinical behavioral disorders and subclinical psychological symptoms are reviewed. Aspects of screening, assessment, counseling and in severe cases treatment are outlined, and recommendations are formulated. MATERIALS AND METHODS: Relevant publications on psychological and psychiatric aspects are reviewed. The recommendations passed several rounds of consensus finding, and were circulated among International Children's Continence Society members and external experts. RESULTS: In addition to subclinical effects on self-esteem, quality of life and distress, the rate of comorbid clinical behavioral disorders is increased. In fact, 20% to 30% of children with nocturnal enuresis, 20% to 40% with daytime urinary incontinence and 30% to 50% with fecal incontinence fulfill the criteria for ICD-10 or Diagnostic and Statistical Manual of Mental Disorders IV psychiatric disorders. These concomitant disturbances require assessment and counseling, and in severe cases treatment. They have a negative effect on compliance and outcome if not addressed and left untreated. CONCLUSIONS: Because the comorbidity rate is high, screening for psychological symptoms is recommended for all children in all settings with enuresis and/or daytime urinary and/or fecal incontinence. Standardized, validated questionnaires are recommended. In addition to clinical observation and history, a short screening questionnaire can be used as a first step. If problem behaviors are present a longer broadband questionnaire is recommended. If problem items in the clinical range are noted, a full child psychiatric or psychological assessment is recommended.

Body image and sexuality in adolescents after hypospadias surgery.

OBJECTIVE: Patients operated on for hypospadias often display a range of emotional and functional postoperative problems at an early age. This study explores the social, psychosocial and sexual development of adolescent boys operated on for hypospadias at an early age. PATIENTS AND METHOD: Ten boys between the ages of 11 and 18 years and an age-matched reference group of 10 boys completed three mailed questionnaires: the Child Behavior Checklist/4-18, the Youth Self Report, and the Self-Perception Profile for Adolescents. Data on body image and genital perception, and on social, psychosocial and sexual development were gathered by interview and standardized questionnaire. RESULTS: Internalizing or externalizing problems were not reported to be increased. Boys operated on for hypospadias had a significantly lower score on the Self-Perception Profile for Adolescents, Social Acceptance subscale. Fewer boys in the clinical group considered their penis to be normal or judged their penis as similar to that of friends. No difficulties were found regarding psychosocial or sexual development; there was however a tendency towards a more negative genital appraisal. CONCLUSION: Boys operated on for hypospadias appear to experience normal social, psychosocial and sexual development.

Problem behavior, parental stress and enuresis.

PURPOSE: We determined maternal and paternal ratings of problem behavior in 5 to 13-year-old children with (non)monosymptomatic enuresis and investigated parental stress and the association between parental ratings of child behavior and parental stress. MATERIALS AND METHODS: We compared problem behavior in 78 children with (non)monosymptomatic enuresis vs that in 110 without enuresis using the Child Behavior Checklist and the Disruptive Behavior Disorders Rating Scale. Parental stress was measured using the Parenting Stress Index. RESULTS: Maternal results replicated previous findings of significantly higher Child Behavior Checklist scores for externalizing and total problems compared with those in the control group, whereas no significant differences were found for paternal ratings. Mothers and fathers of enuretic children reported significantly higher scores on the Disruptive Behavior Disorders Rating Scale inattention, hyperactivity/impulsivity and oppositional defiant disorder subscales than parents of children without enuresis. The Parenting Stress Index revealed significantly higher overall stress in mothers and fathers of children with (non)monosymptomatic enuresis compared with that in parents of controls. Especially parental stress related to child characteristics was associated with a greater report of child behavior problems. CONCLUSIONS: Each parent but especially mothers reported more problem behavior in children with (non)monosymptomatic enuresis than in controls. They also reported more stress, which correlates highly with parental ratings of problem behavior in children with (non)monosymptomatic enuresis.

Behavior profiles in children with functional urinary incontinence before and after incontinence treatment.

OBJECTIVE: The purpose of this work was to analyze prospectively the prevalence of behavioral disorders in children with urinary incontinence because of nonneuropathic bladder-sphincter dysfunction before and after treatment for incontinence. METHODS: A total of 202 children with nonneuropathic bladder-sphincter dysfunction were enrolled in the European Bladder Dysfunction Study, in branches for urge syndrome (branch 1) and dysfunctional voiding (branch 2); 188 filled out Achenbach's Child Behavior Checklist before treatment and 111 after treatment. Child Behavior Checklist scales for total behavior problems were used along with subscales for externalizing problems and internalizing problems. RESULTS: After European Bladder Dysfunction Study treatment, the total behavior problem score dropped from 19% to 11%, the same prevalence as in the normative population; in branch 1 the score dropped from 14% to 13%, and in branch 2 it dropped from 23% to 8%. The prevalence of externalizing problems dropped too, from 12% to 8%: in branch 1 it was unchanged at 10%, and in branch 2 it dropped from 14% to 7%. The decrease in prevalence of internalizing problems after treatment, from 16% to 14%, was not significant. CONCLUSION: More behavioral problems were found in dysfunctional voiding than in urge syndrome, but none of the abnormal scores related to the outcome of European Bladder Dysfunction Study treatment for incontinence. With such treatment, both the total behavior problem score and the score for externalizing problems returned to normal, but the score for internalizing problems did not change. The drops in prevalence are statistically significant only in dysfunctional voiding.

Early detection of psychological problems in a population of children with enuresis: construction and validation of the Short Screening Instrument for Psychological Problems in Enuresis.

PURPOSE: The current study focuses on the construction and validation of the Short Screening Instrument for Psychological Problems in Enuresis, for emotional problems and symptoms of attention deficit hyperactivity disorder, in a population of children with enuresis. MATERIALS AND METHODS: In phase I factor analyses were performed on 31 items of the Internalizing scale of the Child Behavior Checklist and on 18 items of the Attention Deficit Disorder scale of the Disruptive Behavior Disorders Rating Scale to select the most discriminating items. The question format and cutoff score for referral were determined by maximization of correctly classified patients, with the full Child Behavior Checklist and Disruptive Behavior Disorders Rating Scale as standards. In phase II 109 children with enuresis (76 males and 33 females, mean age 8.5 years, SD 2.4) admitted to a tertiary care university hospital entered the validation study. The parents completed the Short Screening Instrument for Psychological Problems in Enuresis and the original questionnaires, ie Child Behavior Checklist and Disruptive Behavior Disorders Rating Scale. RESULTS: Seven items (factor loading greater than 0.65) were selected for "emotional problems," 3 (greater than 0.80) for "attention problems" and 3 (greater than 0.75) for "hyperactivity/impulsivity problems." Full screening was indicated when at least 2 problem behaviors occurred at least "sometimes" for Child Behavior Checklist items or "frequently" for Disruptive Behavior Disorders Rating Scale items. Validation of the Short Screening Instrument for Psychological Problems in Enuresis revealed good accuracy for all subscales (approximately 88%), excellent specificity (0.91 to 0.99) and low to fair sensitivity (0.29 to 0.75). CONCLUSIONS: The Short Screening Instrument for Psychological Problems in Enuresis meets its goal because it leads to time efficient and early detection of problems of emotion, attention and hyperactivity/impulsivity. The implementation of this short questionnaire can contribute to better followup of medical treatment.

Enuresis and daytime wetting as a biopsychosocial problem: a review.

Enuresis is considered to be the most prevalent of all childhood problems with important psychosocial consequences. Thorough research by both medical and psychological disciplines has resulted in a lack of agreement concerning definitions and terminology. Psychiatric classification systems stress phenomenological aspects such as age, frequency and duration of wetting episodes, but are not based on pathophysiologic aspects, whereas the International Children's Continence Society recommend distinguishing between monosymptomatic enuresis and complex/non-monosymptomatic enuresis depending on the absence or presence of bladder dysfunctions. Several epidemiological and cross-sectional studies show higher scores for behavioral problems in children with enuresis. Parental reports suggest more externalizing problems, attention/hyperactive problems and anxious/withdrawn behavior, however, no difference has been demonstrated in children's self-report concerning internalizing problems. Four different viewpoints relating to the association between enuresis and psychopathology are described, including their clinical implications. In conclusion, enuresis and daytime wetting is seen as a 'biopsychosocial' problem with evidence for pathophysiologic causes and is often associated psychiatric/psychological problems.

Internalizing and externalizing problem behavior in children with nocturnal and diurnal enuresis: a five-factor model perspective.

OBJECTIVES: To describe personality traits, internalizing, and externalizing problems of 6- to 12-year-old children with nocturnal and diurnal enuresis, examining differences from healthy referents, and investigating the association between personality traits and problem behavior. METHODS: Eighty-five children with combined nocturnal and diurnal enuresis were compared with 56 children with nocturnal enuresis and 155 healthy children on personality characteristics and problem behavior. RESULTS: Post hoc analyses of multivariate analyses indicated that parents of children with combined nocturnal and diurnal enuresis reported on average lower conscientiousness and higher neuroticism scores in their children than parents of healthy children, although the magnitude of these differences was moderate. Considerable differences in mean scores were found for the Child Behavior Checklist (CBCL) total problem scale and moderate differences for internalizing, externalizing, and attention deficit hyperactivity disorder (ADHD) problems in children with nocturnal and diurnal enuresis compared with healthy referents. Regression analyses across enuretic and healthy groups demonstrated that personality trait and problem behavior scales share substantial variance. CONCLUSION: Moderate to substantially higher levels of problem behavior is demonstrated in children with nocturnal and diurnal enuresis, who also display slightly higher neuroticism and lower conscientiousness scores.