Psychological  and  psychiatric  comorbid  disorders  in  urinary  and  

faecal  incon6nence  Cape  Town  2012  

Dr. Anne Wright

Introduc6on  All forms of incontinence are associated with higher rates of behavioural and emotional disorder compared to possible organic causes

Comparison  of  percentage  organic  causes  and  behavioural  comorbidity  in  normal  children  and  in  children  with  different  

types  of  incon9nence  von  Gontard  A,  Neveus  T.  Mackeith  Press  2006  

%

Subclinical  and  clinical  emo9onal  and  behavioural  disorders  in  children  with  incon9nence  

Presenta6on  of  behavioural  and    emo6onal    disorders  

Subclinical  symptoms  

•  Emo6onal  distress  •  Behavioural  symptoms  •  Self  esteem  •  Quality  of  life  •  Parental  stress  and  anxiety  

 •  May  resolve  with  treatment  

Clinical    Psychological  disorder  

•  Clinically  significant  psychological  disorder  associated  with  

–  Present  distress,  disability  or  impairment  

–  Poses  risk  for  future  development  

•  Diagnosed  according  to  classified  systems  

–  DSM  IV  –  ICD  10  

•  Clinical  symptom  scores  (ques6onnaires)  

•  Do  not  resolve  with  treatment  •  Interfere  with  compliance  and  

outcomes  

             Subclinical  symptoms                  as  reported  by  children        

•  Popula9on  study:  BedweJng  (ALSPAC,  UK  n=8209;  age  9  years)  •  Asked  children  to  rate/rank  difficulty  with  21  situa6ons  eg:  

•  Don’t  have  friends  •  Being  teased  •  Being  leV  out    •  Being  shy  •  WeXng  the  bed  •  Always  being  in  trouble  •  GeXng  into  fights  •  Not  liking  how  they  look  

•  36.7%  perceive  bed  weXng  as  being  “really  difficult”    •  BedweJng:  rank  number  eight  out  of  21  for  being  most  difficult  situa6on  •  Boys  found  bedweXng  more  difficult  than  girls  •  BedweQers  (>2x/week)  found  weJng  and  not  liking  their  appearance  significantly  

more  difficult  than  those  who  were  non-­‐weders          Butler  R,  Heron  J,  Child:  Care,  Health  and  Dev  2007  

Subclinical  symptoms  in  children  as  reported  by  parents  

•  Popula9on  study:ALSPAC,  UK  n=  8000  Age  7.5  years  –  BedweQers  more  likely  to  show:      

•  Separa9on  anxiety  •  General  anxiety  •  Social  fears  and  sadness  •  All  worsen  with  severity  of  bedweJng  

Joinson  C,  J  Ped  Psychol  2007  

•  Popula9on  study:Finland  n=  156    Age  7  years  –  Day  and  night  weQers  showed  ff  personality  traits  in  rela6on  to  controls  

•  More  fiZul  •  More  fearful  •  More  impa9ent  •  More  anxious  •  More  inferiority  feelings  

Moilanen  I,  JarvelinM  et  al,  Psychiatrica  Fennica  1987  

•  Popula9on  study:  Sweden  n=  75  boys  –  Faecal  incon9nence  

•  Food  refusal,  nega9vism,  anxiety,stress,  difficulty  with  rela9onships    Bellman  M,  Acta  Paed  Scand    1966  

 

Impact  on  Parents  •  Popula9on  study:  ALSPAC,  UK  n=213  

–  Coping  strategies  in  parents  whose  children  wet  bed  >2x/week  •  LiVing  74  %  •  Fluid  restric6on  65  %  •  Rewards  52  %  •  Nappies  49  %  •  Regular  day6me  toile6ng  34  %  •  Displeasure  22  %  

Butler  R  Child  Care  Health  Dev    2005  

 •  Popula9on  study:  America  n=1753,  age  5-­‐13  yrs  

–  Parental  worry  in  response  to  child’s  bedweJng  •  62%  reported  worry  •  17%  reported  worried  a  great  deal  

Foxman  B,  Valdez  B,  Brook  R    Pediatrics  1986  

Clinically  significant  Psychological  disorders    

Externalising  disorders  –  visible  behaviours  –eg  opposi6onal  

defiant  disorder  (ODD),  conduct  disorder  (CD),  Aden6on  Deficit  Hyperac6vity  Disorder  (ADHD)  

Internalising  disorders  –  inwardly-­‐directed  –  eg.  anxiety,  

depression,  phobias  

Other-­‐  eg  anorexia  nervosa,  6c  disorders,  au6s6c  spectrum  

disorders  

Rela9onships  between  Psychological  disorder    and  incon6nence    

     

Incon6nence   Psychological  disorder  

Psychological    disorder  

Gene6c  predisposi6on         Incon6nence  

• Coexist  

Incon6nence  

• Chance  

Psychological  disorder  

Common  neurobiological  dysfunc6on  

ADHD  

Enuresis  

NOCTURNAL  ENURESIS:  Rela9ve  risk    of  clinical  behavioural  disorders  compared  to  controls:  popula9on  studies  

STUDY   AGE  yrs   N   DETAILS   RELATIVE  RISK   Ref  

Isle  of  Wight,  UK       5-­‐15   4481   Boys   3.2   Ruder  1973  

Girls   3.7  

Christchurch,  NZ   7-­‐9   1037   Primary   1.4   McGee  1984  

Secondary   2.4  

Christchurch  FU   11-­‐15   1037   Primary   2.5   Feehan  1990  

Secondary   4.5  

China   6-­‐18   3344   4.3   Liu  2000  

Netherlands   9   1652   2.3   Hirasing  1997  

USA   5-­‐17   10960   1.6   Byrd  1996  

After von Gontard A ICI

Nocturnal  enuresis  and  psychological  disorders  

Secondary  enuresis  >>  primary  NE  

Non-­‐monosymptoma9c  enuresis  >  monosymptoma9c  enuresis        Butler  RJ  et  al  Scand  J  Urol  Nephrol  2006  

Externalising>>internalising  

Most  common  disorder  ADHD  

Nocturnal  enuresis  and  ADHD  

0  2  4  

6  

8  

10  

12  

14  

16  

18  

NO  WETTING  

BEDWETTING  

*

* *

* P<0.001

Comparison  of    percentage  behavioural  disorders  in  dry  and  bedweJng  children.  N=8242,  ALSPAC,  UK  AGE  7.5  years.    Joinson  C  et  al  J  Pediatr  Psychol  2007  

ADHD  •  Diagnosis  DSM  IV  (prevalence  5-­‐10%)  •  Three  features:  

•  Inaden6on/cannot  concentrate  •  Hyperac6vity/cannot  keep  s6ll  •  Impulsive/don’t  think  before  they  act  

•  Three  subtypes  •  Pred  inaden6ve  •  Pred  hyperac6ve-­‐impulsive  •  Combined  

•  Comorbid  condi6ons;  ODD,  CD,  Tic  disorder,Depression,  Anxiety,  Specific  developmental  disorder  

ADHD  and  Nocturnal  enuresis  •  Lower  compliance  with  treatment  

– More  difficult  to  treat  – Worse  outcome  on  alarm  – Less  dry  at  6  and  12  months  – Less  compliant  

•  Both  condi6ons  require  treatment  •  Imipramine  has  been  shown  to  be  effec6ve  for  enuresis  in  ADHD  

•  Atomoxe6ne  used  in  treatment  of  ADHD  has  resulted  in  resolu6on  of  enuresis    

Day6me  weXng    

NO  WETTING  

DAY  AND  NIGHT  WETTING  0  

5  

10  

15  

20  

25  

NO  WETTING  

BEDWETTING  

DAY  AND  NIGHT  WETTING  

* P<0.001

*

*

Comparison of percentage behavioural disorders in dry, bedwetting and day and night wetting children.N=8242, ALSPAC, UK AGE 7.5 years. Joinson, C.Pediatrics 118, 1985-1993, 2006

* *

Day9me  weJng  

•  Externalising  disorders  predominate  

•  Sep  anxiety,  aQen9on  deficit,  opp  behav,  conduct  problems  

•  No  popula9on  data  on  different  subgroups  •  Selec9ve  clinic-­‐based  studies  show:  

–  Urge  incon.nence  assoc  with  only  slightly  increased  rates    –  of  disorder  with  mostly  internalising  problems  Von  Gontard  A,  ICI  –  Voiding  postponement  37.3%  of  children  had  psychological  disorder  with  predominantly  externalising  symptoms  par9cularly  ODD  Von  Gontard  A  et  al,  BJU  1998,  Ledgen  B  et  al  Acta  Paediatrica  2002        

•  LiQle  data  available  on  other  subtypes  of  day9me  weJng  

Psychological  disorders  in  Faecal  incon9nence  

Joinson C et al Pediatrics 117, 1575-1584, 2006

STUDY   AGE  yrs   N   DETAILS   RELATIVE  RISK  

ALSPAC,  UK   7-­‐8   8242   Separa6on  anxiety   5.4  

Specific  phobia   4.3  

Generalised  anxiety   8.5  

ADHD   4.8  

ODD   6.3  

• Characterised by both internalising and externalising disorders

ICCS  Recommenda6ons  

Screening  for  emo6onal  and  behavioural  disorders  in  all  children  with  any  form  of  incon6nence  • Acquire  basic  knowledge,  observe,  ask  relevant  ques6ons  and  explore  

• Screen  with  validatd  ques6onnaires  • For  children  with  clinically  relevant  scores  obtain  child  psychological  or  psychiatric  assessment  

• Counselling  and  treatment  in  appropriate  cases  

Screening  all  children  • History,  observa6on,  explora6on  

• Short  screening  ques9onnaires  

• Problem  items/behaviours  present?  

• Standard  long  ques9onnaires  

• Problem  items/behaviours  present?  

• Full  child  psychiatric/  psych  assessment  

• Child  psychiatric  disorder  present?  

• Treatment  of  disorder  • In  addi6on  to  NE/incon6nence  

• YES  

• YES  

• YES  

• Treatment  of  •   enuresis/incon6nence  only  

• NO  

• NO  

• NO  

• Counselling  in  addi6on  to  •   treatment  of  •   enuresis/incon6nence  

• A  • L  • T  • E  • R  • N  • A  • T  • I  • V  • E  

Ques9onnaires  

•  Short  –  Short  screening  instrument  for  psychological  problems  in  enuresis.  SSIPPE  (Van  Hoecke  2007)  Validated.  13  items.  Yes/No  

•  Standard  long  CBCL  (Achenbach  1991)  113  items  

•  Any  validated  parental  ques6onnaire  on  children’s  behaviour  

•  QoL  –generic,  disease  specific  eg  PinQ  (Bower  et  al.  2006)  

• Van Hoecke, E,: Journal of Urology 178, 2611-2615, 2007 • Achenbach, T.M.: Manual for the child behavior checklist / 4-18 and 1991 profile. Burlington, University of Vermont, 1991 • Bower WF,Neurourology and Urodynamics 25: 221-227, 2006

Psychiatric  assessment  

•  Professional  procedure  to  arrive  at  a  diagnosis  according  to  standardised  classifica6on  schemes  

•  Detailed  developmental,  behavioural  and  family  history  •  Child  and  parent-­‐child  observa6on  •  Ques6onnaires  •  IQ  test  not  rou6ne  as  this  is  normal  range  for  most  children  

with  i/c  –if  indicated    •  Disorders  of  speech/language/  dyslexia  etc  as  necessary  

Treatment  •  Before  –is  treatment  necessary  at  all?  

•  OVen  counselling  of  parents  and  child  is  all  that  is  necessary,  or  perhaps  changing  the  environment  

•  Detailed  psychiatric  treatment–eg  pharmacotherapy,  psychotherapy,  CBT,  psychodynamics  therapy,  social  competence  training,  combina6ons  

•  Other  therapies-­‐eg  speech,  support  for  specific  learning  impairment  etc  

Conclusion  •  Counselling  and  child  psychiatric/psychological  treatment  is  

offered  in  addi6on  to  treatment  of  incon6nence  

•  .........  “comorbid  disorders  interfere  with  treatment  for  enuresis/incon4nence.  Affected  children  show  lower  compliance  and  treatment  results  are  lower.  Therefore,  children  with  incon4nence  should  be  screened  for  psychological  disorders  even  in  pediatric  and  urological  se?ngs.  Children  with  a  severe  condi4on  should  be  referred  to  the  mental  health  service  (child  psychiatrists  and  child  psychologists).An  interdisciplinary  approach  is  needed  for  op4mal  care  in  day4me  we?ng  children.”  Kuhn  S:  Journal  of  Urology,  182(4  Suppl),  1967-­‐1972,  2009.  

Thank you