Social Competencies, Behavioral, Psychological and Cognitive Correlates in Children with Nocturnal Enuresis M. Hassib El- Defrawi, Salma El- Gandour Arnin, A. E. Zeitoun and H. A. Ragab. One hundred and ten school age children (110), with DSM- IV diagnostic crilieria of Nocturnal Enuresis (NE), were randomly selected from those seeking treatment from pediatric, psychiatry, and urology clinics in Suez Canal University Terrching Hospital and were compared to a sex and age matched control group (n= 11Cl) as regard their social competencies, behavioral problems, cognitive, and psychological characteristics as well as their school performance and achievement. Instruments used Included: Conners Rating Scale, Child Behavior Checklist (CIICL), Goodenough test, Token Test for Children, Johns Hopkins Depression Scale, and their mid-year test scores in academic subjects including Arabic lan;:uage, arithmatic and other subjects. Results revealed that NE was significantly associated with being described by their parents as hyperactive, socially withdrawn, uncommunicative and depressed. Furthermore, children with NE were reported to be less socially competent than the nonenuretic control group. Moreover, NE children were significantly more likely to perform poorly on cognitive tasks of nonverbal intellectual maturation and functional language ability and to obtain significantly lower scores in Arabic language and arithmatic subjects than nonenuretic children. The results suggest that NE should be considered as a risk factor for comorbid psychiatric and developmental difficulties and those children with NE deserve to receive a comprehensive and integrated neuropsychological & behavioual assessment. The implications of our findings are discussed. (EgyptJ. Psychiat.,l997,20: 109- 126 ). Introduction Nocturnal Enuresis (NE) has been highlighted as the most prevalent aid chronic of all childhood problems (Col- lins, 1080) with epidemiological surveys ranging across different countries indi- cating between 9 -13% of 9 year old children wetting their bed at least once a month (Feehan et al., 1990, @pel el al, - M. Hassib El- Defrawi: M.D., Assistant Professlx of Psychiatry, Faculty of Medicine. Suez Cimal University. Sahna El Gandour: M.D., Professor and Chairm m of Pediatrics, Faculty of Medicine. Suez Canal University. A.E. Zeitoun : M.D., Assistant Professoer in Pedi:8trics, Faculty of Medicine. Suez Ca- nal U~l~ersity. And H.A. Ragah Pediatrician, Suez Canal University Hospital. Suez Canal University. 1068, Rutter et al, 1973, and Verhulst et al, 1985). In a previous report (El - De- frawi, 1995) the prevalence of NE has been estimated to reach 12% in school age children in Suez Canal Area. NE can also prove a devastating experience for children, with a sense of perplexity, humiliation, alienation, and a vulnerabil- ity to verbal and physical abuse all par- ticularly evident (Abrasion, et al. 1978, and Anon, 1987 and Butler et al., 1994). Evidence from epidemiological stud- ies documents an association between enu~esis and psychiatric disorders (Swa- di, 1N6). Epidemiological data show that the numbers of children with devi- ant behavior is two to four times higher among enuretic boys and three to six times higher among enuretic girls , de- Egypt. J. Psychiat. 20: 1. January 1997
Transcript
Social Competencies, Behavioral, Psychological and Cognitive Correlates in Children with
Nocturnal Enuresis
M. Hassib El- Defrawi, Salma El- Gandour Arnin, A. E. Zeitoun and H. A. Ragab.
One hundred and ten school age children (110), with DSM- IV diagnostic crilieria of Nocturnal Enuresis (NE), were randomly selected from those seeking treatment from pediatric, psychiatry, and urology clinics in Suez Canal University Terrching Hospital and were compared to a sex and age matched control group (n= 11Cl) as regard their social competencies, behavioral problems, cognitive, and psychological characteristics as well a s their school performance and achievement. Instruments used Included: Conners Rating Scale, Child Behavior Checklist (CIICL), Goodenough test, Token Test for Children, Johns Hopkins Depression Scale, and their mid-year test scores in academic subjects including Arabic lan;:uage, arithmatic and other subjects. Results revealed that NE was significantly associated with being described by their parents as hyperactive, socially withdrawn, uncommunicative and depressed. Furthermore, children with NE were reported to be less socially competent than the nonenuretic control group. Moreover, NE children were significantly more likely to perform poorly on cognitive tasks of nonverbal intellectual maturation and functional language ability and to obtain significantly lower scores in Arabic language and arithmatic subjects than nonenuretic children.
The results suggest that NE should be considered as a risk factor for comorbid psychiatric and developmental difficulties and those children with NE deserve to receive a comprehensive and integrated neuropsychological & behavioual assessment. The implications of our findings are discussed.
(EgyptJ. Psychiat.,l997,20: 109- 126 ).
Introduction Nocturnal Enuresis (NE) has been
highlighted as the most prevalent aid chronic of all childhood problems (Col- lins, 1080) with epidemiological surveys ranging across different countries indi- cating between 9 -13% of 9 year old children wetting their bed at least once a month (Feehan et al., 1990, @pel el al,
- M. Hassib El- Defrawi: M.D., Assistant
Professlx of Psychiatry, Faculty of Medicine. Suez Cimal University.
Sahna El Gandour: M.D., Professor and Chairm m of Pediatrics, Faculty of Medicine. Suez Canal University.
A.E. Zeitoun : M.D., Assistant Professoer in Pedi:8trics, Faculty of Medicine. Suez Ca- nal U ~ l ~ e r s i t y .
And H.A. Ragah Pediatrician, Suez Canal University Hospital. Suez Canal University.
1068, Rutter et al, 1973, and Verhulst et al, 1985). In a previous report (El - De- frawi, 1995) the prevalence of NE has been estimated to reach 12% in school age children in Suez Canal Area. NE can also prove a devastating experience for children, with a sense of perplexity, humiliation, alienation, and a vulnerabil- ity to verbal and physical abuse all par- ticularly evident (Abrasion, et al. 1978, and Anon, 1987 and Butler et al., 1994).
Evidence from epidemiological stud- ies documents an association between enu~esis and psychiatric disorders (Swa- di, 1N6). Epidemiological data show that the numbers of children with devi- ant behavior is two to four times higher among enuretic boys and three to six times higher among enuretic girls , de-
Egypt. J. Psychiat. 20: 1. January 1997
pending on age and source of informa- tion with regard lo behavioral deviance , i.e. parents or teachers. Mikkelsen (195)3), among a very small sample of 20 disturbed enuretic children, reported the following diagnoses : depressive disor- der, mixed disturbance of adjustment and conduct, mixed anxiety- depressive disorder, generalized anxiety disorder, attention- deficit disorder with hyperac- tivity, and undersocialized conduct dis- order, aggressive type. Jarvelin et al., (1991) documented that NE children ex- hibited delayed development, such as slower growth and poorer visuomotor and spatial perception than controls.
On the other hand, and of the data presented showing the negative impact of enuresis on social, psychosexual, be- hav~oral and developmental adaptive as- pects of children, there is a growing con- sensus that enuretic chiIdren do not suffer from an underlying psychological disturbance as a primary cause of bed wetting and, however, that bed wetting might result in impaired social adapta- tion later on in life.(Bloom et al., 1994).
It is obvious from the current slate of the art on NE that there are different atti- tudes, both public and professional to the problem, and that the enuretic child de- serves an increased research activity in the field, not only to get a better under- standing of the pathophysiology hehind the problem, but also to improve the treatment.
This study was designed and launched with the objective of detecting the association hetween NE and social competencies, behavioral, cognitive, aca- demic school performance and psycho- lorical disturbances in comparison to
may affect the ourcome (social compe- tencies, behavioral, cognitive, and psy- chological dysfunction ) due to the pres- ence of NE.
The study sample size was decided according to the estimated prevalence of behavioral, cognitive and psychological abnormalities in normal (22%) and the expected in children with enuresis (40%) (Steinhausen and Gobel, 1989), taking the level of significance at the 95% and using Leslie et al., (1991) sam- ple size equation, which resulted in a sample number of 110 in each the study and control groups.
Children referred with NE to the out- patient clinics of pediatrics, urology and psychiatry of Suez Canal University Teaching Hospitals and who met the fol- lowing criteria were include:
(1) Diagnoses of NE according to the DSM - IV criteria (American Psychiatric Association,l994 ), (2) Aged between 6- 12 years, (3) No urological or neurologi- cal cause for the enuresis, (4) Attending mainsueam public schools and not schools for tetarded or developmentally handicapped children, and (5) Parent and child consent,
110 age and sex matched children with no history of NE or chronic or any physical disability, randomly selected from the pediatric clinic population, were used as controls.
At the initial interview with child and parent the demographic, develop- mental, psychosocial and NE related items were obtained including methods of parental handling of the problem to reach complete urinary continence.
Instruments used were: u
nonenuretic children. I) For Behavioral Assessment Subjecl and Methods a- The Conners Parent-Teacher
This is a c s e - colluol study that Rating Scale: This is one of the most controls the confoundillg factors which widely used scales in rating behavior
problems and it distinguishes th good
Egypt. 1. Psychiat. 20:l. January 1997
and accepted precision, between nonnal and behaviorally disturbed children. It has k e n used widely in assessment a ~ d treatment studies of attention deficit hy- pera:tivity disorders (El-Defrawi et al., 199:1), and with good reliability and va- lidity (El-Defrawi et a]., 1992).
h)The Child Behavior Checklist (CRCL) (Achenbach and Edelbrock, 1983, Achenbach et al, 1989, 1987, Wei ;z et al., 1987, Verhulst, et al, 1990. Offcrd, 1993, Fromhonne, 1993, and El- Defrawi et al., 1995).This is the most ac- ceptable and widely used behavior checklist. This instrument was initially ded,;ned to provide menlal health pro- fess~onals with a reliable means of ah-
sess ng the behavioral problems and \o- cia1 competencies of children referred for t reamlent.
li contains 20 sttcial colnptence items , which cover the child's memher- ship in groups, its participation and skill in sports, school functioning and peer re- laticnships ; and 118 behavior problem items , with 3- point responses of-not verq m e (score 0) to very m e (score?).
I>escription of this instriunent and 11s application in Egypt, applicability :lilii
use in its standardized form are found elsewhere (El- Defrawi et al, 1995 a. h). Thi5 scale was used for assessment of' hehi~vioral problems and social compe- tencies (adopted version of the scale) wick, only the items &scribing the inter- cali ting factors which were according ro partnt report : a) Anxious ior sd~izoidi. b) Depressed, cj Uncommunicative. d? Obsessive compulsive e) Somatic corn- plaim, and f) Social withdrawal. Inter- nali ~ i n g factors according to teacher rc- pofl form were: a) Anxious, b) Sociill wiilulrawal, c) Unpopular, d) Self- tle- stru:live, and e) Obsessive compulsive items.
'rhe competence item5 include three parts :
The frist part entitled "aclivities " in- cludes : scores for number of sports and number of non- sports hobbies, games and activities , jobs and chores plus the mean score for parents, rating of the amount and quality of palicipation in each of these categories of activity .
The second part of the competence items entitled " social " includes scores for the number of organization , number of friends, contact with friends , how well the child get along with sibligs, olh- er childern and how he plays alone.
The thrid part the competence items entitled " schml " includes parents rat- ing of performance in academic subjects puls reports of special class placement, grade repetition and other academic problems.
The other part of the Child Behavior Checklist , the behavior problems scales comprises 11 8 behavior problem items which are analyzed into 9 behavior fac- tors and 2 second order factors, intemal- king and externalizing .
The internalizing and externalizing faclors represent a distinction between fearful, overcontrolled behavior (inter- nalizing ) and aggressive antisocial un- controlled behavior (externalizing) (Ross et al., 1990). The internalizing factors were the factors that have k e n assessed in this study. 7be parent score each items by circling @-if thc item is no! true for the child , l-if it is some- what or sometimes true and 2-if it is of'- tal or very Wue. Means of the toal scores of internalizing factore were O ~ J -
tained and compared between the study group and control group .
Total score, nine narrow - hand sub- scale scores (the internalizing are: with- rawal, somatic complaints, anxious un- communicative , depressive, and obsessive compulsive,) obtained by summing the relevant items according-
Egypt. J . Psychiat. 20: 1. January 1997
M . ihss ib El Dcfsawi. et al
Ing to the 1080 version of the manual ( Achenbachl983).
It consists of 38- items scale , and was developed from the criteria of DSM-I11 for the diagnosis of major de- pressive disorders . The diagnostic crite- ria were uasformed into descriptions of depressive symptoms, and the questions fall into five major symptom categories: mood, energy , behavior , somatic com- plaints and vegetative symptoms .
It is a self - roport inventory for par- ents of childer $ to 13 years old . It is used as screening insuurnent and di- agnostic tool of children suffering from major depressive disorders .
11"- Cognitive Assessment a) Goodenough Test (Draw-A-
Person Test): According to Leziak (1983) Goodenough test and its revision utilizing drawings of a man and a wom- an have provided the most popular sys- tems lor estimating developmen\al level m the United States. The quality and complexity of children's drawings in- crease with age at a sufficiently regular pat tern.
However. because drawmg tests are relatively independent of language skills, they can he used to obtain rough estimates of the general ability of chil- dren and adults with verbal impairment. Each test was administered with verbal i~!slructions to produce the dcqued draw- ing of a man and a woman, neither test was umrd. Jlurnan figure drawings pro- vide the neuropsychologlsl with a sam- ple of hehavior that is not only relatively culture free and language indepeudent but also sufficiently complex and close- ly related to normal human development which grves some measure of the intel- lectual endowment of children whose ability tn draw has remained essentially
intact. The test meawe intellectual mat- uration in the child and the level of intel- lectual organization of the visuographic response when used in the neuropsycho- logical assessment of children. It may provide an indication of brain damage (Gardner, 1985).
b) The Token Test For Children: The Token Test for Children (Disimoni , 1978) is a rapid and effective measure for assessing subtle receptive language dysfunction in childern . Lass and Gold- en (1975) sumarized the vdues of this test in its ability to sample various levels of linguistc difficulties within a rela- tively brief priod of time without the use of extensive memorization . The test is divided into five parts , each one pre- senting progressivly longer and more complex, uses 5 large cricles, 5 large squares 5 small circles, and 5 small squares in 5 cdors (blue, green, yellow, white, and red). Before starting each for- mal test administration, examiner infor- mally tested each child in order to be certain that the child understood the meaning of the words circles and squares, large and small, and could iden- tify colors. Only tile first founy (40) items in the fist four parts were used, and a value of one point was given for each correct response to a test command for a maximum of 40. Special tables were used to obtain the Z score accord- ing to age of the child tested.
XV- Academic Achievement Assess- ment:
Academic performance and school achievement were assessed using the child's own mid- year test score in Ara- bic language, arithmetic, wriiing or spelling (when available) and scores in olher suhjects when available (e.g. so- cial studies and sciences). Moreover, each child was assessed regarding fail- ure in academic subjects, repeating grades, school artendence and continua- tion or discontinuntion.
Egypt. J . Psychiat. 20:1. January 1997
Social Co~npctencies, Behavioral, Psychological i:) NE
All cognitive , neuropsychologicaI intellectual and psychological behavioral measures, scales and tests were obtained blindly to the child's status and psychiat- ric condition (whether enuretic or con- trol).
Results Tiible (1) shows the age and sex dis-
tribution of both group (NE and con- trols). In table, (2). Children with NE were most likely to be described by their parent to have problems with them and with their sihling and other children (p< 0.05), to participate less in house chores table, (3) (p< 0.05). to have no or one .!riend only table (4) (p<0.05), to have difficulties playing and working by themselves (table, 5) (P<O.O5), to have no hoppies (P<0.05), to be less skillf~l in lhoppies (p<0.05), to discontinue schoAing (table, 6) ( ~ 0 . 0 5 ) . to fail in schoal (p<0.05), to receive remedial edu- caticn (table 7) ( ~ 0 . 0 5 ) to have f '1 we and less than average performance in al- mosl all academic sub.jects (Arabic readmg, spelling, writing, and arithmatic suhjlxa) (table, 8) (p<O.OS), to h;~ve proklems participating, practicing or shlling sport aclivities (p<0.05) (la- hle,:O).
72.7% children with NE have pri- mary NE, 55.5% oi them were either first or second in birth order, 30%were from families composed of hree lo four persons, 61.8% have no reporled family history of NE$ and the age of sphincteric control in enuretic relatives ranged from the sixth year (1 1.9%), the seventh year (33.3%), the eighth year (21.5%) and after the age nine years (33.3%), 88.2% have no associated urinary complaints, and 64.5% were reported to have have deep sleep and to be awakened with dif- ficulty, 96.4%) have had their toilet train- ing, 91.5% were awakened at night for voiding of urine, and 58.4% were pun- ished hy parents to achieve dry bed.
Table (I 1) showed that children with NE were reported to exhibit significant disruptive behavioral problems (p<0.05), to be reported to be more un- communicative, depressed and soially withdrawn, tab1e (12) (p<0.05), to be de- scribed as more likely depressed using Johns Hopkins scale (p<0.05), table, (13), to score poorly on nonverbd cog- nitive intellectual tasks mble (14), ( ~ ~ 0 . 0 5 ) and to perform poorly on func- tional language listening ability test (p<0.05) table(l5).
Disrrihutinn 01 Children w i t h and wifhotrl Enuresis Acccwdinp 10 A p e and Sex
* Sex:
-Boys
- G ~ r l s
-
13gypt. J . Psychiat. 20: 1. Januuy 1997
Tahle ( 2 ) Conlparison ktween Children with and withoul
Euresis according to Social Cornperence
llem
-About the scune 73 66.4 71 64.5
B - Geltine alone with sihlins
-worse
-About the same
C - G e l h e alone with other children: iN=llO) (N=110)
-Worse IS 16.4 7 6.4 S.*
-Ahout thr same X? 74.5 79 71 .R
Table (3) C'or~iparisori hetween Children with and witl~our
EIIU~~;SIS Accordi11g to Participai~~r! in Houre Chores
Enurc l i c Non-enurrtic Statistical Significance
Item N % N %
A - Particivation in house chores: (N= lIO) ( N = m
-Participation 74 57.3 QX 89.1
L e s s than average 1 F. 24.3 i!! 2!).4
Egypt. J. Psychiat. 20: 1. January 1997
Social ( 'ompcterlcics. Behuvioral. I'sycholugical ill Nli
Tahk (4) Distrihulion of Childrcn with and wthoul Enuresis
Social Competencies, Bchavioral. Psychological in NE
Discussion: As with most human behavior, the
causality of hed wetting is not simple, it consists of multiple and simple factors interrelated in various ways. Most cases of M: appeared unexplained, but it is widely believed that organic, genetic, developmental, psychological and so- cio-c~lltural factors are involved (Krantz et al., 1994).
OM current study is a case-control research with a large number of random- ly sel1:cted children to ensure even distri- butioli between both groups of the back- ground variables that could affect the outcc'me, i.e. behavioral, cognitive, and psychological characteristics.
Our results have shown that approxi- mately 40% of the enuresis groups have a farlily history of NE, this can be ex- plained on the basis of both biological and experiential factors acting separately or in conjunction (Rittig,l996). Children with NE tend to show reduced social comletencies and poorer quality of lite compared lo normal (Swadi, 1996). In discussing the impact of enuresis on the psychosexual maturation of children Graxiottin and Chiozzd., (1994) have pointed out to prolongation of the attach- ment phase, increased difficulty in sep- arat ng from the mother, delayed autono- my attainment, ambivalence towards depmdence, vulnerable and insecure sex identity, and reduced self esteem.
2hildren with NE were rated by llxir parrmls to have significantly more be- havioral difficulties and uncontrolled hy- peractive behavior than enuretic children (uncommunicative, social withdrawal anc depressive symptoms). This is high- ly supported by similar findings of Colrches et d. (1989) who reported that children with NE have quantitative dif- f e n c e in the number of behaviord symptom and that a higher proportion of
enuretic children were maladjusted than their dry counterparts. Also, in a recent study by Ferguson and Norwood (1995) bed wetting after the age of 10 years was associated with an increased risk for conduct problems, attention deficit prob- lems and anxiety withdrawal symptom and withdrawals. In United Arab Ernar- ates, Swami (1996) showed that while younger enuretic children exhibited little difference in emotional measures from controls, older children with NE were rated by their parents and teachers to have increased behavioral problems.
One explanation for our findings is that children with NE who seek treat- ment or help for enuresis are under more smss and have more behavioral symp- toms than those who do not. Couchells et a1 (1986) and Moffat (1989) have pointed out that the clin~cal group with NE have more conduct problems and more immature behavior than nonclini- cal enuretic. However, Norgaard (1991) hac; pointed out that the cause or nature of the association between psychiatric disorders and enuresis is not known, al- though each shares common antece- dents.
The association of behavioral prob- lems with NE has been reported in Egypt by El-Fiky et al. 1990 who dem- onstrated that about 6% of enuretic chil- dren also have attention deficit hyperac- tivity syndrome and or arousal deficit. This association could be explained on the b=es that behavioral and social diffi- culties of enuretic children mainly result from the primary illness leading to poor self-image, decreased self-esteem, social embarassment and restriction (Hindi et al, 1995). Furthermore, it could be that hecause of the negative attitude and bias of the family towards enuretic children parents tend to report positively on be- havioral symptoms and to consider those children difficult and problem;~tic (Jave-
Egypt. J . Psychiat. 20: 1. January 1997
M. Nassih El Defrawi. et a1
lin et al, 1990). Enuretic children have also exhibited more depressive syrnp- toms and were reported by tlleir parenb to be more depressed than nonenuretic children which is similar to Hindi el al. (1'995) findings that enuretic children are more immature, less-self reliant, less am- bitious and insecure than nonenuretic controls. Self-esteem in children h?s a direct impact on the affective state which in turn influences motivation and interest in various activities this can lead to so- cial isolation which has been recognized as an antecedent to psychiatric problems in children (Hindi et al. 1996). On the other hand, Verhulst et al (1985) report- ed that the majority of enuretic children do not have coexisting psychiatric proh- lems, hut psychiatric disorders are twice as common in this group as general pop- ulation.
Another important finding in our study is that children with NE performed poorly on tests of cognitive functions than non enuretic children. For example while 18% of enuretic children appeared to score below d ~ e normal range on non- verbal intelleciud test (Goodenough), only 8%, of nonenuretic children did so (p<0.05). Steinhausen and Goblet (1989) have reported a significant difference in I.Q. performance between enuredc and nonenuretic child psychiatric patients. Although this finding is suggestive of a possible biological vulnerability of NE children and a highly selective sample. Children with NE exhibit poorer visuo- motor and spatial perception than control (Jamelin, 1991).
In support of the finding that enuretic children performed poorly on cognitive intellectual tests, is the statistically sig- nificant lower means scored by enuretic children on language tests (Token Test) than nonenuretic control gmup, which suggest a subtle language dysfunction associated with enuresis. Language abil-
ities and skills are one of the higher cor- tical function that is extremely sensitive to biological conditions interfering with normal development. For example, on studying language comprehension (us- ing the token test for children), Mab- moud (1995) has found a highly statisti- cal significant difference between nourished and malnourished groups of children suggesting that the token test is a sensitive measure of subtle language deficits. This could be partly explained on the basis that it is possible that only severely affected children with enuresis who consume medical outpatient servic- es seeking treatment for their sphincteric dyscontrol problem show resistant and severe subtype of NE that is associated with neuropsychological deficts. Thus Ihe enuretic group could appear to be biased in the direction of a more biologi- cally vulnerable and heavily loaded cas- es with developmental factors.
In support of this possibility is the point raised by Al-Kuwaiti (1995) that enuretic children have generally delayed developmental patterns than non - enuretic children. If this is m e , i.e. with more evidence of the developmental ha- sis of enuresis, NE should be classified on Axis I1 for specific developlnental disorders in a similar way language and academic (school) disorders are classi- fied as specific developmental disorders.
Our interesting finding was that chil- dren with NE exhibited a statistically significant association related to aca- demic underachievement in reading, writing, spelling and arithmatic school skills than nonenuretic controls. This is supported hy-and is similar to-studies showing that NE is significantly asso- ciated with specific developmental dis- orders (reading, writing, spelling and ar- ithmatic skills) and with significantly lower full - scale and verbal I.Qs. than in nonenuretic nonnal conuols. In addition,
122 Egypt. J . Psychiat. 20:l. January 1997
Social Competel~cics. Behavioral, Psychological in NE
Kaplan and Sadock (1989) have pointed out th2.t children with NE were about twice 2s likely to have concomitant de- velopmental delays as were dry children. They explained these findings on the ba- sis that these abilities and normal blad- der control are influenced by neuromus- cular md cognitive developments, so difficulties in one or more of these areas may delay urinary continence. The link betwe~:n enuresis and developmental de- lays which are also linked to psychopa- tholog;y, would suggest that there is a comm~on underlying maturational factor that predisposes vulnerable children to mani jest both behavioral disturbances and enuresis (Devlin, 1992)
Fmhermore, NE group was signili- cantly associated with school failure whicn could be explained by the previ- ous two findings of poor performance on tests of cognitive functions leading to re- duced I.Q. scores and because of in- creased association with learning diffi-
;U ure culties and disabilities leading to f '1 to work up to full potential and resulting in school failure and repeating grades. Fut~rre studies should investigate the im- pacl of treaunent received for NE on be- hav~oral and school performance.
,% and associated behavioral, cogni- tive, and psychological difficulties could by :xplained in biological terms and un- derstood as a sign of newopsychologi- cal. neurodevelopmental and neurohe- lra\ioral disturbances. This is supported by the recent findings of the most prom- ising area of investigation of biological factors which is sleep pattern. Parenrs of' ch,'ldren with NE and investigators of sleep patterning often describe tlwse children as very heavy sleepers com- pared to their nonenuretic siblings (Scharf ard Jennings, 1988). This is sup- pc~rted by our findings that 64.5% of ck.ildren with NE were described by their parents as deep sleepers. However, there
is some evidence that the nature of the behavioral distubance in enuredc chil- dren is non-specific (Mikkelsen 1993) and that no physiological marker can be found that reliably differentiate psycho- logically disturbed from non-disturbed enuretic children (Cochat et al, 1994).
Gandhi (1994) has pointed out that the type of psychiauic disorder asso- ciated with enuresis has important irn- plications for the choice of treatment intervention and oursome. Certainly, symptom - oriented behavioral inter- ventions (e.g., bell and pad training) will not be sufficient to treat enuretic children who, in addition, have highly complex psychiatric disorders, combi- nation of different treatment interven- tions is warranted for these conditions, while behavioral techniques clearly in- dicated and are effective in monosymp- tomatic enuretic children, for this rea- son, a comprehensive psychiatric, behavioral, developmental and neuro- psychological assessment should be done for children presenting with NE. Furthermore, the outcome of enuretic may differ with regard to whether or not additional psychiatric problems ex- ist (Lewis, 1991). Follow up studies on the continuation of the presence of psy- chiatric problems in different gmups of NE children who received treatment for the enuresis and those who did not, should he carried out.
In conclusion , our results suggest that children with NE who seek mat- ment are at risk to have an assoiated impairment in their social competen- cies, parental and teacher's reports indi- cating high level of behavioral difficul- ties, tend to perform poorly on cognitive and intellectual tasks of non- verbal and language skills, to be de- scribed with significantly more depres- sive symptoms , and to obtain a sgnificantly lower scores on academic
Egypt. J. Psychiat. 20: 1. January 1997
M . Hassih El Defrawi, el al.
subjects possibly learning difficultis, are prone to school failure and poor acadcm- ic performance which might indicate the need for educational remedies than nor- mal controls. Those children with NE should recevie a comprehensive and in- tegrated psychosocial, neuropsychologi- cal and educational assessment . Moreo- ver, future research should investigate the follow up response of the associated social, psychiatric and educalional proh- lerns when NE is being the focus for treatment.
References
Abrasion, L.Y., Seligman. ha E. P., and Teased J.D. (1987): Learned helplessness in humans: Critique and reformulation. J. Abnormal. Psycho. 87: 49-74.
Achenbach, T. M. and Edelhrock C.S. (1983) Manual for the child and Behavior check- list and Revised Child Behavior Profile. University Associates in Psychiatry Bur- lington, VT.
Achenhach, T.M.. Conners. C.K.. Quay. H.C., Verhulst, F. C., and Howell. C. T. (1989) Replication of empixically derived syndrome as a hasis for taxonomy of child adolescent psychopathology. J. Ab- nor. Child Psychol.. 17: 299-323.
Achenbach, T.M., Verhulst, F.C. Baron, D. and Alckerhuis, C; (1987) Epidetniologi- cal comparison of American and Dutch Children: I. Behavioral, emotional prob- lems and competencies reported by par- ents for ages 4 to 16. J . Amer. Acad. Child adolex. Psychiat. 26: 317-325.
Al-Kuwaiti, M.. Moshaddeque Hossain, M. and Absood. G (1995) Behavior disorders in primary school children in Al-Ain. United Arab Emirates. Annals Tropical Pediatrics., 15: 97-104.
Anon (1987): My Enuresis Archieves Dis- ease in Childhood. 62: 866-868.
Bloom, D.A., Pohl, J. and Norgaard, J. P. (1994) Comments on Enuresis, particular- ly the Nocturnal type Scand. J. Urol. Ncphrol. Suppl. 163 : 7-13.
Butler, R.J., Redfern E.J. .and Holland, P. (1994): Children's Notions about Enuresis and the Implications for Treatment. Scan- dinavian J. Ural. Nephrol. Supple., 163: 39-47.
Collins. R.W. (1980): Enuresis and Encopre- sis. In: R. H. Woody (Ed.) Encyclopedia of Clinical Assessment. San Francisco, Joey - Bass, 1980.
Couchels, S.M. Johnosn. S.B. Carter, R. and Walker, D. (1986): Behavioral and envi- ronmental characteristics of treated and untreated children and nonenuretic con- trols. J . Pediatrics, 99: 812-816.
Cochat, P., Cochat, N., Collet. J., Sinlore, ha. and Cavailles, M. (1994) Nocturnal enure- sis: Social and treatment perspectives in france. Nephrol., Suppl 163 : 15 - 19 Scand. J . Urol .
Disimoni, F. (1978) The Token Test for chil- dren. Manual Teaching Resources C o r p - ration. A New York Times Company. Massachusetts.
Devlin, J. B. (1992) Prevalence and risk fac- tors for childhood nocturnal enuresis. Ir. Med. J., 84 (4): 118 - 120.
El- Defrawi, M.H., Sobhy, S.A., Atef. A., and Ahdel Khalic, S., (1995) I1. Psychiat- ric and behavioral prohlems of primary school children in Ismaila. Relationship to Academic Achievement. Egypt. 3. Psychi- at., 18: 283-300.
El-Fiky, M.R. AMul - Baqui, M.S. and Sheath, M.O. (1990): Enuresis and Atten- tion Deficit Disorder. A possible Co- morbidity in children. Egypt. J. Psychiat, 13: 231-238.
Feeham, M., McGee, R., Stanton, W. and Silva, P.A. (1990): A 6 year follow up of childhood enuresis: Prevalence in adoles- cence and consequences for mental health. J. Pediatric Child Health, 26: 75- 79.
Frombonne, E. (1993) The Charters Study: prevalence of psychiatric disorders among French school aged children I. Amer. Or- thopsychiat; 4: 69-79.
Egypt. J . Psychiat. 20:l. January 1997
Ferguson, D.M. and Hardwood, L. (1995): Nocturnal enuresis and behavior problems in adolescence: a 15 year longitudinal study. Pediatrics, 94: 662-668.
Gandhi, K. K. (1994) Diagnosis and manage- me it of nocturnal enuresis Curr. Opin Pe- diatric, 6(2): 194-197.
Gardve, A. R. (1985) the initial clinical eval- uation of the child. In : Dr Shaffer, A. Eh- rhxdt, I,. Greenhill (eds). The clinical Glide to child psychiatry. The Free Press. Nt.w York.
Graziottin, A, and Chiozza. M. L. (1 994) So- ciid aspects and treatment perspectives in Italy. Scand. J. Uml. Nephrol., Supp. 163: 21 - 28.
Hind, M. Hjertonsson, M. and Broherg. A. (1995): Poor self - esteem in children - with enuresis. Mental and soical health in d~fferent groups. Lakertidningen, 92 (36): 3 225-3224.
Hintle, M. Hjertonsson. M. Broberg. A. and Hellstrom, A. (1996) Low self - esteem in childrer~ with enuresis. Ferring Literature Service. Pediatrics, 5 (11): 1-3.
Janfelin, M.R. (1989) Developmental history :ind neurological findings in enuretic chil- dren. Devel. Med. Child Neurol. 31: 728- 736.
Jarvelin, M.R. Moilanen, I. Vikevainen . Ter- vonen, L. and Huttunen, N.P. (1990): Life changes and protective capacities in enu- retic atid non - enuretic children.
Jarvelin, M.R., Molanen. I., and Kangas. P (1991) Aetiological and precipitating (ac- tors for childhood enuresis. Acta Pediatric Scand, SO: 361-370.
K3plan, H. and Sadock, B. (1989) Science of Human Behavior, Contribution of the Psy- chological Science. In: Comprehensive Testbook of Psychiaby. 5th ed. Williams and Wilkins, Baltimore, London.
Krantz, 1. Jykas, E., Ahlberg. B.M. and Wedel, H. (1994) On the Epidemiology of Nocturnal Enuresis- A critical review of methods used in descriptive epidemiologi- cal studies on nocturnal enuresis. Scandi- navian J. of ural. hTEphrol. Sup. 163: 75- 82.
Egypt. J. Psychiat. 20: 1. January 1997
Lass, N and Golden, S. (1975) A correla- tional stutly of children performance on three rests for receptive lenguage abilities J Audit Resear.. 15: 177-182.
Ixslie. E. Gesffery, I. and James. M.C. (1991) Sample size formula, interpreta- tion and uses of medical statistics. Black well scientific publications (pp 427).
Lewis, M. (1991) Incontinence Disorders In Child and Adolescent Psychiatry, A com- prehensive Texthook. Williams and Wil- kins. Baltimore.
Ixzak., M.D. (1983) Neuropsychological As- sessment Second edition, Oxford Univer- sity Press. New york.
Mahmoud, N.A.H. (1995) Neuropsychiatric Correlates of malnutrition in school chil- dren in El Minia. Unpubolished Master thesis. Department of Psychiatry, Faculty of Medicine. El Mmia University.
Mikkelsen, E.. J. (1993) Modern Approaches to enuresis and encopresis . In: compre- hensive Handbook of Psychopathology Sutker. P. 3. and Adans, H.E. Plenum Press. New york.
Moffat, M.E. K. (1989) Nocturnal enuresis: Psychologic implication of treatment and nontreatment J Pediatric, 114 (Suppl.): 697-702.
Norgaard, J. P. (1991) Pattopthophysiology of nocturnal enuresis. Scand. J. Urol. Nephrol, Suppl: 140.
Offord, D., Boyle, M.. Peace, A., Racine, Y. and Stanford, M. (1993) Ontario child health study: Social and school impair- ments in children aged 6-16 years. J. Amer. Acad. child Adolesc. Psychiat. , 31:66-76.
Oppel, W. C.. Harper, P.A. and Rider, R.V. (1968) The age of attaining bladder Con- trol. Pediatrics. 42: 614-620.
Rittig. S. (1994): Enuresis Research: Current status and future prospects. International Chidern Continence Society Monograph Series No. I: 17-24. ISSN: 1363-3457.
Rutter, M.. Yule, W. and Graham, P. (1973) Enuresis and hehavioral deviance: Some epidemiological considerations. In: I Kol-
viry R.C. Mackeith and S.K. Meadows (Eds). Bladder Control and Enuresis. Lon- don: Heinernarnn.
Scharf, M.B. and Jennings. S. W. (1988) Childhood Enuresis: Relationship to sleep. etiology, evaluation, and treatment. Ann. Behav. Med., (3): 133-200.
Shafer, D. (1985h) Enuresis. In: M. Kuller and L. Hersov (eds). Chid and Adolescent Psychiatry: Modern Approaches. Black- well Scientific Publications. Oxford.
Shaffer, D. (1989) Nocturnal enuresis: its in- vestigation and treatment. In: D. Shaffes. A. A. Erharat, and L.L. Greenhill (eds.). The Clinical Gurde to Child Psychiatry. Free Press. New York.
Steinhausen. H.C. and Gohlet D. (1989): Enuresis in child psychiatric clinical pa- tients J. Arner. Aced. Child Adolesc. Psy- chiatry 28: 279-287.
Swadi, H. (1996) Nocturnal enuresis and psy- chopathology: Associrltions in a col~unuu~li-
1). sample. The Arab J. IJsyrhiutry. 17: I 1 1-1 18.
Verhulst. F.C., Van Der Lee, 1. H. Akke- rhuis. G.W. (1985) The prevalence of nocturnal enwesis: Do DSM-III criteria need to be changed? J. Child Psycho Psy- chiary 26: 989-993.
Verhulst, J., Akkerhuis, G., Sanders- woud- stra, J.. Timmer, F., and Donkhorst, I. (1993) The prevalence of nocturnal enure- sis. I. Child Psy~ lw l Psyrhir~t., 26: 989- 993.
Verhulst, F.C., Koot, H.M., and Burden, F.M. (1990) Four years follow- up of an epidemiological sample. .1. h e r . Acad. Child. Adolesc. Psychiat., 29: 440-448.
Weisz, Z., Smamiet, S., Chalyasit, W. (1987) Epidemiology of behavioral and emotion- al problems among hailan and American children. J . Amer. Acad. Child. Adolex. Psychiat., 26: 890-897.
CosrClation Psychologique , Behavioriste , Congnitive et Sociale chit2 les Enfants Souffrants de l'inurisie Nocturne
On a choisix au hasard 110 enfants h 1'Pge de 1 ' k6le diagnosk sel- on le "DSM-IV" comme ayant une EnusLsik Nocturne. Cette ichantillon a kt6 choisie de la clinique psychiatrique, urologique et pkdiatricjue de 1' universit4 du Canal El Suez, et a Lti compark avec un groupe tCmoin de mGme age et sex (110) concernat leurs prol>l6mes behavioristes , leurs charactires psychologiques et congnitives , leurs comp6tences sociales , et aussi leurs rkalisations P 1 '6cble . Les rksultats ont dkmontrk que I'knur&ie nocturne doit Ctre considiri comme un facteur de risque pour avoir d'autres difficultks psychiatriques et developmentalles chez ces enfants.
Egypt. J. Psychiat. 20:l. January 1997
Social ('ompetencies, Behavioral. l'sychological i n N H
J U Y l j elJJII ;b;J!,LLLLPiJl ' U h C ; d l $IJ.iJl& .. & U I ...
~ ~ L d , y k h \ \ . ~ ~ ~ $ L ~ ~ ~ ~ L J ~ ~ ~ ~ ~ i k i G t e J. -- - - - -j L u l L) yl+9 $6 p% &k $3 (u \ ) J ~ I 2 &k
,&I - JUJI jult;ZisU ' . ; L . ~ p & J ~ l ~ ~ ~ L I Y ~ ~ 4 ; j J l
- G&JI 4 . ~ ~ 1 &,dl +I -- J U N $dl @I &sUl Ail J*
L d l -. d l j eljJll tWI &A &lj4;;1 o k j d tl&I t; dj J! +iL?Lc, .LU;YI JIJ~ J! + i L Y G UYjd! ww ,wlj
alp.\ , j f +LA1 +I!, $lgl& +Lnll JUYI -. tijU1 $ii a&f JiJ i + d ~ J J lid k& b=4;,1 I d d I& Ji ($91 JL) JjVI c&I .kid eli-Ylj b.+Y!,~j?JIJL ciWI +a + +L+-;JI rWl +Lii;l J! a41dlj j l g l 4 5 +I, ,&-Yl J J ~ J @;;I1 JLY I .Id j dI+JIj
w&l J!+WIJeIdJI +WI p 3 L l j J I j+.kJI tlxJ!,-
d l ) +l,JI JIAI j &;I1 j +dl 4 4 1 CT.J .'tcUJg
&yI &.~ljd JW!, y &k ~ej J! (uu!, +&j clg + ~ e a L@ dI>Jlj-+~JI U J l ~ u j L J.LU +Ci;jl pj
+ S J I j &L;tJI JI;;1?1 e> &lpl 44;;Jl +J L U I L_j &A j & ~ I J Y I p L ? ; L I ~ J J li $GJ! JejJ! CiGJb ';)?+Yl y p ~ j , JUYI .Jp j 3;illl+ .Kill 2 J! JE >(-;;-;I
dijZ+J+Il + L J I ~ ~ J I t 9 l r&l ,L?;;I & ~IJYI +Li;;l diSj
.+UI L;UI Lp+ 4iJc;,Lill
~ J l - - w~&UI + + . S j aJJJlj 4.+Lll aJLJl., +I LljJll &G,,
~ & , j I ; , ~ - ~ Y , ~ l l ) - i l l J I J G S C L ~ ~ ~ I JUYIcJ~ , jLG~Cf ;J
