Nocturnal enuresis: a suggestive endophenotype marker for a subgroup of inattentive attention-deficit/hyperactivity disorder

Prevalence of Lower Urinary Tract Symptoms in Children with Attention-Deficit/Hyperactivity Disorder: Comparison of Hospital and Population-Based Cohorts of 13,000 Patients

Background: This study investigates the prevalence of lower urinary tract symptoms (LUTS) in school-age children with Attention-Deficit/Hyperactivity Disorder (ADHD) based on hospital-based and population-based cohorts. Methods: The hospital-based sample comprised 42 children with ADHD and 65 without ADHD aged 6−12 years. Voiding dysfunction was assessed by the Dysfunctional Voiding Scoring System (DVSS) questionnaire. We compared the baseline data, DVSS score, and uroflowmetry between the two groups. For the population-based cohort in the national insurance database, we included 6526 children aged 6−12 years, whose claims record included the diagnosis of ADHD, and another 6526 control subjects matched by gender and age. We compared the presence of LUTS diagnosis codes between the two groups. Results: Our results showed that, for the hospital-based cohort, the mean total DVSS score and the proportion of significant LUTS in children in the ADHD group were significantly higher than in subjects in the non-ADHD group. The DVSS subscales showed that the item “I cannot wait when I have to pee” item was significantly higher in the ADHD group (1.62 ± 1.17 vs. 0.90 ± 1.09, p = 0.002). For the population-based cohort, children with ADHD had a significantly higher likelihood of storage symptoms (5.53% vs. 2.91%, p < 0.001) and enuresis (3.28% vs. 1.95%, p < 0.001) compared with those of the no ADHD group. Conclusions: Children with ADHD have a higher prevalence of significant LUTS, especially storage symptoms and enuresis, than children without ADHD. The observed correlations between ADHD and LUTS provided the supporting evidence to evaluate the concomitant voiding dysfunction in children with ADHD.

Attention deficit and hyperactivity disorder and nocturnal enuresis co-occurrence in the pediatric population: a systematic review and meta-analysis

BACKGROUND

Attention deficit and hyperactivity/impulsivity disorder (ADHD) and enuresis are common behavioral disorders in childhood, impacting adolescence and adult life. Enuresis (NE) is an incontinence disorder frequently observed in children with ADHD. The relationship between ADHD and NE has been a matter of debate.

OBJECTIVES

We aimed to verify the relationship between ADHD and enuresis and how these conditions can modify each other during development. Using PRISMA guidelines, under the PROSPERO registration number CRD42020208299, we systematically searched the literature and conducted a meta-analysis to answer the following question: how frequent is ADHD and enuresis comorbidity? Twenty-five studies were fully read, and data from seven less heterogeneous case-control studies were pooled to estimate enuresis prevalence comparing ADHD and control samples, whereas six studies were combined to evaluate ADHD frequencies in children with and without enuresis.

RESULTS

We found the ADHD rates in children with enuresis are similar to the enuresis rates in the group of children with ADHD. The presence of ADHD and enuresis comorbidity does not seem to play a role in gender distribution and the presence of other comorbidities in comparison to controls. However, enuresis seems to persist for more time in children with ADHD.

LIMITATIONS

The selected papers differed in study type, research question, samples, and controls utilized.

CONCLUSIONS

Our systematic review with meta-analysis supports the reciprocal association between enuresis and ADHD. Further studies are necessary to build more robust evidence.

Urine metabolic phenotyping in children with nocturnal enuresis and comorbid neurobehavioral disorders

Nocturnal enuresis (NE) is a common problem among 10% school-aged children. The etiologies underlying childhood NE is complex and not fully understood nowadays. Nevertheless, increasing evidence suggests a potential link between neurobehavioral disorders and enuresis in children. In this study, we aimed to explore novel metabolomic insights into the pathophysiology of NE and also, its association with pediatric psychiatric problems. Urine collected from 41 bedwetting children and 27 healthy control children was analyzed by using ¹H-nuclear magnetic resonance spectroscopy from August 2017 to December 2018. At regular follow-up, there were 14 children with refractory NE having a diagnosis of attention deficient hyperactivity disorder (ADHD) or anxiety. Eventually, we identified eight significantly differential urinary metabolites and particularly increased urinary excretion of betaine, creatine and guanidinoacetate linked to glycine, serine and threonine metabolism were associated with a comorbidity of neurobehavioral disorders in refractory bedwetting children. Notably, based on physiological functions of betaine acting as a renal osmolyte and methyl group donor, we speculated its potential role in modulation of renal and/or central circadian clock systems, becoming a useful urinary metabolic marker in diagnosis of treatment-resistant NE in children affected by these two disorders.

Comorbidity between enuresis and attention deficit hyperactivity disorder: a case-control study

Background

Although there is a strong association between enuresis and psychopathology, little is known about the prevalence of specific psychiatric disorders. We investigate the prevalence of attention-deficit/hyperactivity disorder (ADHD) in children with enuresis and study the impact on child behavior, self-esteem, and different EEG findings. A total number of one hundred 6 to 12 years old children diagnosed as functional enuresis taken from specialized university setting for enuresis at Mansoura Pediatric Outpatient Clinic, in which they could be subdivided into 2 groups after assessment of attention deficit hyperactivity disorder (ADHD); according to DSM-IV criteria, we also compare them with a third ADHD group taken from Mansoura Psychiatric Outpatient Clinic n = 40 to match the co-morbid “enuresis with ADHD” group. All were subjected to a diagnostic interview conducted and completed with parents and developmental and family history as well, also they subjected to Conner’s parent rating scale-93(CPRS-93), Rosenberg self-esteem assessment scale, and EEG examination.

Results

There was high prevalence of ADHD in our study with about 40% in children with enuresis especially who met the DSM–IV criteria of inattention attending a specialized setting for enuresis at Mansoura Pediatric Outpatient Clinic which is a tertiary setting where the older the children of enuresis, the higher the prevalence of ADHD, also there is a relationship between abnormal epileptiform discharge in EEG finding and enuresis as same as ADHD which became greatly increased in the children who had both disorders who was the most affected group as regard behavioral problems and lowered self-esteem levels.

Conclusions

The strong association between ADHD and enuresis suggests that the presence of enuresis should motivate diagnostic assessment of ADHD especially the inattentive subtype. Abnormal EEG finding in the form of generalized slow and sharp waves may be useful as a predictor for the presence of ADHD in children with enuresis. Also, the co-morbidity increases the negative impact on child behavior and self-esteem.

ADHD: Current Concepts and Treatments in Children and Adolescents

Attention deficit hyperactivity disorder (ADHD) is among the most frequent disorders within child and adolescent psychiatry, with a prevalence of over 5%. Nosological systems, such as the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) and the International Classification of Diseases, editions 10 and 11 (ICD-10/11) continue to define ADHD according to behavioral criteria, based on observation and on informant reports. Despite an overwhelming body of research on ADHD over the last 10 to 20 years, valid neurobiological markers or other objective criteria that may lead to unequivocal diagnostic classification are still lacking. On the contrary, the concept of ADHD seems to have become broader and more heterogeneous. Thus, the diagnosis and treatment of ADHD are still challenging for clinicians, necessitating increased reliance on their expertise and experience. The first part of this review presents an overview of the current definitions of the disorder (DSM-5, ICD-10/11). Furthermore, it discusses more controversial aspects of the construct of ADHD, including the dimensional versus categorical approach, alternative ADHD constructs, and aspects pertaining to epidemiology and prevalence. The second part focuses on comorbidities, on the difficulty of distinguishing between "primary" and "secondary" ADHD for purposes of differential diagnosis, and on clinical diagnostic procedures. In the third and most prominent part, an overview of current neurobiological concepts of ADHD is given, including neuropsychological and neurophysiological researches and summaries of current neuroimaging and genetic studies. Finally, treatment options are reviewed, including a discussion of multimodal, pharmacological, and nonpharmacological interventions and their evidence base.

Polychlorinated Biphenyls (PCBs): Risk Factors for Autism Spectrum Disorder?

Autism spectrum disorder (ASD) includes a group of multifactorial neurodevelopmental disorders defined clinically by core deficits in social reciprocity and communication, restrictive interests and repetitive behaviors. ASD affects one in 54 children in the United States, one in 89 children in Europe, and one in 277 children in Asia, with an estimated worldwide prevalence of 1-2%. While there is increasing consensus that ASD results from complex gene x environment interactions, the identity of specific environmental risk factors and the mechanisms by which environmental and genetic factors interact to determine individual risk remain critical gaps in our understanding of ASD etiology. Polychlorinated biphenyls (PCBs) are ubiquitous environmental contaminants that have been linked to altered neurodevelopment in humans. Preclinical studies demonstrate that PCBs modulate signaling pathways implicated in ASD and phenocopy the effects of ASD risk genes on critical morphometric determinants of neuronal connectivity, such as dendritic arborization. Here, we review human and experimental evidence identifying PCBs as potential risk factors for ASD and discuss the potential for PCBs to influence not only core symptoms of ASD, but also comorbidities commonly associated with ASD, via effects on the central and peripheral nervous systems, and/or peripheral target tissues, using bladder dysfunction as an example. We also discuss critical data gaps in the literature implicating PCBs as ASD risk factors. Unlike genetic factors, which are currently irreversible, environmental factors are modifiable risks. Therefore, data confirming PCBs as risk factors for ASD may suggest rational approaches for the primary prevention of ASD in genetically susceptible individuals.

Amplitude of low-frequency fluctuation of resting-state fMRI in primary nocturnal enuresis and attention deficit hyperactivity disorder

Children with attention deficit hyperactivity disorder (ADHD) and nocturnal enuresis (NE) have similar symptoms, for example, inattention and dysfunction of working memory. We investigate disorder-specific abnormal activity by using the simple resting-state functional magnetic resonance imaging (RS-fMRI) metric amplitude of low-frequency fluctuation (ALFF). About 18 ADHD, NE, and typically developing children were examined by RS-fMRI and the child behavior checklist (CBCL) test. One-way ANOVA were used to compare the ALFF values of the three groups and post hoc was done. We conducted Pearson correlation analysis on the results of the three groups' scales with ALFF values at the discrepant brain areas after then. Significant group effect was found in the bilateral medial prefrontal cortex (MPFC), left inferior temporal gyrus (ITG), left middle temporal gyrus (MTG), cerebellum anterior lobe (CAL), and left inferior parietal lobule (IPL). There was no shared abnormal region for ADHD and NE. Specially, ADHD showed increased ALFF in the bilateral MPFC, left ITG, and CAL and showed decreased ALFF in the left MTG. The children with NE showed increased ALFF in the left IPL. This study reveals the brain mechanism of cognitive changes on ADHD and NE, which provides neuroimaging basis for behavioral differences among different diseases.

Associations Between Psychiatric Disorders and Enuresis in Taiwanese Children: A National Population-Based Study

BACKGROUND

Psychiatric disorders such as attention-deficit/hyperactivity disorder may negatively impact drug compliance and the prognosis of enuresis. However, existing studies regarding associations between lifetime psychiatric disorders and childhood enuresis are primarily from Western countries, and studies from Taiwan are lacking.

METHODS

We conducted a population-based retrospective cohort analysis using the Taiwan Longitudinal Health Insurance Database 2010. A total of 1,146 children with enuresis (ICD-9-CM code: 307.6) and 4,584 randomly selected sex- and age-matched controls were identified between January 1, 1997 and December 31, 2011. Logistic regression was used to estimate the odds ratios (ORs) and 95% confidence intervals (CIs) for the development of psychiatric disorders in the children with enuresis.

RESULTS

Enuresis was more common in the younger children, and the rate was significantly higher in boys (58.7%) than in girls (41.3%). A total of 171 patients (14.9%) in the enuresis group had at least one psychiatric diagnosis vs 259 (5.7%) in the control group (p<0.001). Multivariate analysis showed that the presence of enuresis increased the odds of developing major depressive/dysthymic disorder (OR=2.841, 95% CI: 1.619, 4.987), attention-deficit/hyperactivity disorder (OR=3.156, 95% CI: 2.446, 4.073), autism spectrum disorder (OR=2.468, 95% CI: 1.264, 4.822), anxiety disorders (OR=3.113, 95% CI: 2.063, 4.699), intelligence disability (OR=3.989, 95% CI: 2.476, 6.426), disruptive behavior disorders (OR=3.749, 95% CI: 1.756, 8.004), and tic disorder (OR=2.660, 95% CI: 1.642, 4.308).

CONCLUSION

Children with enuresis are likely to have psychiatric disorders, and physicians should consider this during their evaluation.

Changes in attention variables in those who treated with anticholinergic agents for nonmonosymptomatic enuresis

Purpose

Brain dysfunction related to areas regarding attention and arousal may occur not only in patients with attention-deficit/hyperactivity disorder (ADHD) but also in patients with enuresis and daytime symptoms. This study aimed to investigate changes in computerized comprehensive attention tests (CATs), a psychometric test for ADHD when patients with nonmonosymptomatic enuresis (NME) were treated with anticholinergic agents.

Materials and Methods

Thirty patients with NME featuring overactive bladder were prospectively enrolled. They were treated with 5 mg of solifenacin to control daytime symptoms. Using CATs, patients were evaluated during 12 weeks of treatment. Four subtests of attention (visual and auditory selective attention, sustained attention, and flanker tests) were measured. For each subtest, four domains (omission error, commission error, response time [RT], and standard deviation of RT) were assessed.

Results

Only one domain of the flanker test was in the deficient range at baseline. The presence of urge incontinence affected follow-up results on the sustained attention tests. Treatment with anticholinergic agents did not significantly affect attention variables but changes in several variables were correlated with bladder symptoms and enuresis.

Conclusions

Minimal baseline defects in attention function were seen in patients with NME. Follow-up results for some attention variables were affected by daytime symptoms and enuresis. These results suggest that altered brain function in enuretic patients influences improvement in both attention and bladder function.

Association between the frequency of bedwetting and late preterm birth in children aged ≥5 years

AIM

We examined the associations between late preterm (LPT) birth children aged ≥5 years and the frequency of bedwetting. Moreover, those who were born full-term/low birthweight (BW), LPT/low BW, LPT/normal BW and LPT/low BW were compared.

METHODS

In total, we evaluated 614 patients who underwent assessments for frequent bedwetting at the three hospitals from January 2014 to December 2016. Data at the initial visit were collected from the electronic medical records. We assessed the patients' bladder diaries and questionnaires containing detailed information on demographics and frequency of bedwetting per month. Neonatal data were collected from the Maternal and Child Health Handbook.

RESULTS

Frequency of bedwetting in the LPT/low BW group was higher than in the term/low BW group (28 vs. 22.5, p < 0.05). However, the frequency between the LPT/normal BW group and the LPT/low BW group was not significantly different (28 vs. 28, p = 1.00). Multiple regression analyses were conducted to eliminate potential confounding factors, attention-deficit/hyperactivity disorder and intellectual disability, but results were not changed.

CONCLUSION

This study revealed that LPT/low BW was associated with increased frequency of bedwetting in children. The results suggest that gestational age should be considered when examining patients with severe bedwetting.

Risk Factors of Nocturnal Enuresis in Children with Attention Deficit Hyperactivity Disorder

BACKGROUND

Presence of attention deficit hyperactivity disorder (ADHD) has a negative effect on the resolution of incontinence; however, there are few studies which investigated the risk factors of nocturnal enuresis (NE) in patients with ADHD.

AIMS

This study was conducted to investigate the prevalence of NE and its risk factors in children with ADHD.

METHODS

331 children, aged 6 to 10 years, diagnosed as having ADHD were enrolled in this study. The diagnosis of ADHD was confirmed by an experienced child and adolescent psychiatrist according to DSM-IV-TR. NE was defined as nighttime wetting with or without daytime incontinence, at least twice a week over a period of 3 months or longer in children 5 years old and older without anatomical abnormalities. Details on demographic data, perinatal history, medical history and developmental history were collected from parents or medical records.

RESULTS

Most of the ADHD patients with inattentional subtype (77.5%) had NE, compared to 31.7% in the hyperactive/Impulsive subtype and 22.5% in the combined subtype (p<0.001, t=42.71). Among children with enuresis, there were significantly higher rates of history of familial enuresis (26% vs. 18 %, p<0.001, t=16.9), cesarean delivery (47% vs. 33%, p=0.019, t=5.84) and history of neonatal sepsis (16% vs. 7%, p=0.018, t=5.62) than non-NE children. Moreover, patients with NE had lower birth weight than non-NE patients (2.93(0.65) vs. 3.09 (0.46), p=0.026, t=2.51). Also, low parental education was associated with increase in the rate of NE.

CONCLUSION

Children with ADHD have a high prevalence of NE. Male sex, low education level of parents, history of neonatal sepsis, positive family history of NE, low birth weight and caesarian delivery may be risk factors for NE in ADHD children. Most ADHD patients with inattentional subtype had NE.

ADHD research in India: A narrative review

INTRODUCTION

Attention Deficit Hyperactivity Disorder (ADHD) is a neurodevelopmental disorder with no clear etiopathogenesis. Owing to unique socio cultural milieu of India, it is worthwhile reviewing research on ADHD from India and comparing findings with global research. Thereby, we attempted to provide a comprehensive overview of research on ADHD from India.

METHODS

A boolean search of articles published in English from September 1966 to January 2017 on electronic search engines Google Scholar, PubMed, IndMED, MedIND, using the search terms "ADHD", "Attention Deficit and Hyperactivity Disorder", "Hyperactivity" ,"Child psychiatry", "Hyperkinetic disorder", "Attention Deficit Disorder", "India"was carried out and peer - reviewed studies conducted among human subjects in India were included for review. Case reports, animal studies, previous reviews were excluded from the current review.

RESULTS

Results of 73 studies found eligible for the review were organized into broad themes such as epidemiology, etiology, course and follow up, clinical profile and comorbidity, assessment /biomarkers, intervention/treatment parameters, pathways to care and knowledge and attitude towards ADHD.

DISCUSSION

There was a gap noted in research from India in the domains of biomarkers, course and follow up and non-pharmacological intervention. The prevalence of ADHD as well as comorbidity of Bipolar Disorder was comparatively lower compared to western studies. The studies found unique to India include comparing the effect of allopathic intervention with Ayurvedic intervention, yoga as a non pharmacological intervention. There is a need for studies from India on biomarkers, studies with prospective research design, larger sample size and with matched controls.

Atomoxetine ameliorates nocturnal enuresis with subclinical attention-deficit/hyperactivity disorder

BACKGROUND

Recent studies have shown that incontinence and attention-deficit/hyperactivity disorder (ADHD) coexist and there is an interaction between them. The treatment for nocturnal enuresis (NE) and ADHD, however, has not been established.

METHODS

At the first visit to the outpatient clinic, physical examination and history taking were carried out in 265 new patients with NE. After excluding the possibility of comorbid ADHD and related disorders, patients with monosymptomatic NE (MNE) were treated with desmopressin and/or alarm, and those with non-monosymptomatic NE (NMNE) were treated with anti-cholinergics and/or alarm. This 12 week treatment did not work in 65 patients, and they were re-assessed for comorbid ADHD. A total of 24 were diagnosed with ADHD, and they were treated with atomoxetine (1.8 mg/kg/day) in addition to ongoing therapy for NE.

RESULTS

After 8 weeks of atomoxetine, the average wet nights per months was significantly decreased: 18.5-4.6 in the MNE group (P = 0.001), and 22.1-12.4 in the NMNE group (P = 0.0251). Overall, atomoxetine was beneficial in 19 of 24 patients.

CONCLUSIONS

Atomoxetine may be a suitable option for refractory NE with comorbid ADHD.

Attention-deficit/hyperactivity disorder in children with overactive bladder; a case-control study

Introduction: Attention-deficit/hyperactivity disorder (ADHD) is the most common childhood psychiatric disorder. This disorder is more prevalent in some chronic diseases.

Objectives: To investigate ADHD in children with overactive bladder.

Patients and Methods: A number of 92 children with overactive bladder and 92 healthy children without overactive bladder (age range of both groups 5 to 12 years old) were included in this study as case and control groups, respectively. Participants were selected from children who had referred to a pediatric clinic in Arak city, Iran. ADHD types (inattentive, hyperactive-impulsive, and mixed) were diagnosed by Conner’s Parent Rating Scale and Diagnostic and Statistical Manual of Mental Disorders IV-TR (DSM-IV-TR) criteria. Data were analyzed by chi-square and t tests.

Results: In both groups, 51 children (27.7%) had ADHD. The prevalence of ADHD in the case group (33 cases, 35.9%) was significantly higher than the control group (18 cases, 19.6%) (P = 0.021). Inattentive ADHD was observed in 22 participants (23.9%) of the case group and nine participants of the control group (9.7%) (P = 0.047). Despite this significant difference, three (3.2%) and four (4.3%) children were affected by hyperactive-impulsive ADHD (P = 0.73), and eight (8.6%) and five (5.4%) children were affected by mixed ADHD (P = 0.42) in the case and control groups, respectively.

Conclusion: ADHD bladder is significantly more common in children with overactive bladder than healthy children. The observed correlation between ADHD and overactive bladder makes psychological counseling mandatory in children with overactive bladder.

Attention deficit hyperactivity disorder in children with primary monosymptomatic nocturnal enuresis: A case-control study

Attention deficit hyperactivity disorder (ADHD) is one of the most common childhood neurological disorders. The aim of this study was to investigate ADHD in children with primary monosymptomatic nocturnal enuresis (PMNE) and compare it with healthy children. A total of 100 five to 16-year-old children with PMNE and 100 healthy children without NE were included in this case-control study as the cases and control groups, respectively. Subjects were selected from children who were referred to the pediatric clinic of the Amir Kabir Hospital of Arak, Iran, based on inclusion and exclusion criteria. ADHD was diagnosed by Conner's Parent Rating Scale-48 and the Diagnostic and Statistical Manual of Mental Disorders, fourth edition criteria and was confirmed by consultation with a psychiatrist. Data were analyzed by binomial test using SPSS18. ADHD inattentive type was observed in 16 cases (16%) with PMNE and five controls (5%) (P=0.01). Despite these significant differences in the case and control groups, 25 (25%) and 16 (16%) children were affected by ADHD hyperactive-impulsive type (P=0.08) and 15 (15%) and 16 (16%) children were affected by ADHD mixed type (P=0.84), respectively. ADHD inattentive type in children with PMNE was significantly more common than that in healthy children. The observed correlation between ADHD inattentive type and PMNE makes psychological counseling mandatory in children with PMNE.

Early childhood psychological factors and risk for bedwetting at school age in a UK cohort

There is evidence for a link between psychological factors and bedwetting, but the direction of this association is unclear. Using data on 8769 children from the Avon Longitudinal Study of Parents and Children, we examined whether difficult temperament (Toddler Temperament Scale at 24 months; Emotionality Activity Sociability Questionnaire at 38 months) and psychological problems (Revised Rutter Parent Scale for Preschool Children at 42 months) are linked to bedwetting at school age. We examined the association between these risk factors and different patterns of bedwetting from 4 to 9 years using multinomial regression. Difficult temperament and psychological problems in early childhood were associated with increased odds of bedwetting at 4-9 years. The strongest associations were most often found for the pattern of bedwetting that was both frequent (at least twice a week) and persistent (up to age 9) e.g. the temperament traits of 'adaptability' and 'mood' were associated with a 33 % increase (95 % confidence interval = 1.14-1.55) and a 27 % increase (1.10-1.47) respectively in the odds of persistent and frequent bedwetting per one standard deviation increase in risk score. Early behaviour problems (e.g. conduct problems [1.43 (1.25, 1.63)] and hyperactivity [1.29 (1.11, 1.50), p < 0.001]) were also associated with frequent and persistent bedwetting, but there was less evidence that early emotional difficulties were risk factors for bedwetting. Adjustment for confounders did not alter these conclusions. The presence of difficult temperament and behaviour problems in early childhood might help to identify children who will continue to experience bedwetting at school age.

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

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

Incontinence in children with treated attention-deficit/hyperactivity disorder

INTRODUCTION

Attention-deficit/hyperactivity disorder (ADHD) and incontinence (nocturnal enuresis, daytime urinary incontinence and fecal incontinence) are common disorders in childhood. Both disorders are strongly associated with each other.

OBJECTIVE

ADHD can affect compliance to incontinence therapy in a negative way; it can also affect outcome. The aim of the present study was to assess the prevalence of incontinence, age of bladder and bowel control, and psychological symptoms in children having treatment for ADHD compared to a control group.

STUDY DESIGN

Forty children having treatment for ADHD (75% boys, mean age 11.4 years) and 43 matched controls (60.5% boys, mean age 10.7 years) were assessed. Their parents filled out questionnaires to assess: child psychopathology (Child Behavior Checklist), incontinence (Parental Questionnaire: Enuresis/Urinary Incontinence; Encopresis Questionnaire - Screening Version) and symptoms of the lower urinary tract (International-Consultation-on-Incontinence-Questionnaire - Pediatric Lower Urinary Tract Symptoms). The ICD-10 diagnoses and children's IQ were measured by standardized instruments (Kinder-DIPS, Coloured Progressive Matrices/Standard Progressive Matrices).

RESULTS

Rates of incontinence in the ADHD group (5% nocturnal enuresis, 5% daytime urinary incontinence, 2.5% fecal incontinence) did not differ significantly from incontinence rates in the control group (4.7% daytime urinary incontinence). More children in the ADHD group had Child Behavior Checklist scores in the clinical range. Further ICD-10 disorders were present in eight children with ADHD and in one control child. More children with ADHD had delayed daytime and nighttime bladder control, as well as delayed bowel control, than the controls.

DISCUSSION

The present study showed that if children are treated for their ADHD, according to standard practice guidelines, incontinence rates are similar to those without ADHD. More children with ADHD reached continence at a later age than the controls, which could be an indicator of maturational deficits in the central nervous system. Additionally, children with ADHD showed higher rates of clinically relevant psychological symptoms.

CONCLUSION

This study provides further information of the association between ADHD and incontinence. Treatment of ADHD may be associated with positive effects on incontinence outcomes. Therefore, children with ADHD should always be screened for incontinence problems and children with incontinence problems should also be screened for ADHD if symptoms of hyperactivity, inattention and/or impulsivity are also present.

Comorbidity of ADHD and incontinence in children

ADHD and incontinence are common childhood disorders which co-occur at much higher rates than expected by chance. The aim of this review was to provide an overview both of the comorbidity of nocturnal enuresis (NE), daytime urinary incontinence (DUI) and faecal incontinence (FI) in children with ADHD; and, vice versa, of the co-occurrence of ADHD in children with NE, DUI and FI. Most clinical studies have focussed on the association of ADHD and NE. Population-based studies have shown that children with DUI have an even greater risk for ADHD than those with NE. While children with FI have the highest overall comorbidity rates of psychological disorders, these are heterogeneous with a wide range of internalising and externalising disorders--not necessarily of ADHD. Genetic studies indicate that ADHD and NE, DUI and FI do not share the same genetic basis. The comorbidity is conferred by non-genetic factors. Possible aetiological and pathogenetic links between ADHD and incontinence are provided by neurophysiological, imaging and pharmacological studies. The co-occurrence has clinical implications: children with ADHD and NE, DUI and FI are more difficult to treat, show lower compliance and have less favourable treatment outcomes for incontinence. Therefore, both groups of disorders have to be assessed and treated specifically.

Central nervous system processing of emotions in children with nocturnal enuresis and attention-deficit/hyperactivity disorder

AIM

Nocturnal enuresis (NE) and attention-deficit/hyperactivity disorder (ADHD) are common in childhood. We analysed the central processing of emotions in children with NE, ADHD, NE + ADHD and controls.

METHODS

We examined 13 children with NE, 13 with ADHD, 14 with NE + ADHD and 14 controls. Acoustic evoked potentials were recorded using standardised methodology. For the event-related potentials, positive, negative and neutral pictures were presented and time intervals of 250-450, 450-650 and 650-850 msec evaluated. Hypotheses were tested with repeated-measures analyses of variance.

RESULTS

In the frontal region, children with NE showed more intense responses to positive and negative pictures than controls measured with event-related potentials. Viewing positive pictures, children with NE + ADHD differed from children with ADHD in the central and parietal and for all types of stimuli in the parietal region. Children with NE + ADHD elicited the strongest responses. Children with ADHD did not differ from controls. There was an unspecific interaction effect of the acoustic evoked potentials in children with NE compared to the controls.

CONCLUSION

Children with NE processed emotions differently from children with ADHD and controls. Children with NE + ADHD processed emotions the most intense, displaying interaction effects of the central nervous system that cannot be explained by each disorder alone.

Treating enuresis in a patient with ADHD: application of a novel behavioural modification therapy

We report the case of a 6-year-old patient diagnosed with attention-deficit hyperactivity disorder (ADHD) and comorbid enuresis disorder, who was treated with methylphenidate for the past 3 months and a novel behavioural modification therapy by using an application called 'Enuresis Trainer'. This therapeutic application is basically an interactive 'Bedwetting Calendar', based on traditional cognitive behavioural modification therapies and positive reinforcement systems. Enuresis is defined as the failure of voluntary control of the urethral sphincter. The prevalence of enuresis is 15-20% in the child population; however, children with ADHD had a 2.7 times higher incidence of nocturnal enuresis. Bedwetting is a common cause of isolation in children as well as loss of self-esteem and other psychological distress for the child and the family.

Nocturnal enuresis is associated with attention deficit hyperactivity disorder and conduct problems

OBJECTIVE

There are no published prevalence estimates of elimination disorders and their association with disruptive-behavior disorders among children in the Asian region using standardized diagnostic interviews. This study was conducted to determine the prevalence of elimination disorders and its association with disruptive-behavior disorders in a representative sample of children in Seoul, Korea.

METHODS

The diagnosis of enuresis and encopresis was derived from parent-reported data for "enuresis and encopresis," collected using the Diagnostic Interview Schedule for Children, from a representative sample of 6- to 12-year-old children (n=1,645) who participated in the 2005 Seoul Child and Adolescent Mental Health Survey. Prevalence data for attention deficit and disruptive-behavior disorders were collected from the same sample.

RESULTS

The overall 12-month prevalence of nocturnal enuresis and encopresis was 1.8% and 0.6%, respectively. Enuresis and encopresis prevalence in boys was significantly greater than that in girls. Enuresis and encopresis was most common at 7 to 9 years of age. Enuresis was significantly associated with ADHD (OR 2.6, 95% CI 1.0-6.9) and conduct disorder (CD; OR 4.7, 95% CI 1.0-22.4).

CONCLUSION

Enuresis is significantly associated with ADHD and CD, so these conditions must be assessed together during the evaluation of children with enuresis.

Visuomotor competencies and primary monosymptomatic nocturnal enuresis in prepubertal aged children

BACKGROUND

Primary monosymptomatic nocturnal enuresis (PMNE) is a common problem in the developmental ages; it is the involuntary loss of urine during the night in children older than 5 years of age. Several clinical observations have suggested an association between bedwetting and developmental delays in motricity, language development, learning disability, physical growth, and skeletal maturation. The aim of the present study is to evaluate the prevalence of fine motor coordination and visuomotor integration abnormalities in prepubertal children with PMNE.

METHODS

The study population included 31 children (16 males, 15 females; mean age 8.14 years ± 1.36 years), and the control group comprised 61 typical developing children (32 males, 29 females; mean age 8.03 years ± 1.44 years). The whole population underwent a clinical evaluation to assess total intelligence quotient level, visuomotor integration (VMI) skills, and motor coordination performance (using the Movement Assessment Battery for Children, or M-ABC).

RESULTS

No significant differences between the two study groups were found for age (P = 0.725), gender (P = 0.886), z-body mass index (P = 0.149), or intellectual abilities (total intelligence quotient) (P = 0.163). The PMNE group showed a higher prevalence of borderline performance on M-ABC evaluation and in pathologic performance on VMI Total Task compared to controls (P < 0.001). No significant differences between the two study groups were found for pathologic performances on the M-ABC (P = 0.07), VMI Visual Task (P = 0.793), and VMI Motor Task (P = 0.213).

CONCLUSION

Our findings pinpointed that PMNE should not be considered as a voiding disorder alone and, consequently, the children affected should be referred to specific rehabilitative programs that aim to improve motor coordination and visuomotor integration.

A retrospective observational study of enuresis, daytime voiding symptoms, and response to medical therapy in children with attention deficit hyperactivity disorder and autism spectrum disorder

INTRODUCTION

Children with attention deficit hyperactivity disorder (ADHD) show an increased prevalence of enuresis and other daytime voiding symptoms (DVS). There is also some evidence toward an increased prevalence of enuresis among children with autism spectrum disorder (ASD), but with no data available with respect to DVS or response to medical treatment. The aim of this study was to assess enuresis and DVS, along with treatment outcomes, in children with ASD, to aid urological management.

METHODS

A retrospective observational study on the incidence of enuresis and other DVS in 671 children with/without ADHD/ASD was performed. Symptomatic improvement ≥50% was required to be considered positive. Complete resolution of symptoms for 3 months after cessation of treatment was considered cure.

RESULTS

Symptomatic improvement with desmopressin or anticholinergic treatment was seen in 76% of patients without ADHD/ASD, 85% of patients with ADHD, and 100% of patients with ASD. Cure was seen in 61% of patients without ADHD/ASD, 48% of patients with ADHD, and 50% patients with ASD. Mean time to cure was 9 months in those without ADHD/ASD (N = 319), 10 months in those with ADHD (N = 62), and 8 months in those with ASD (N = 10) (P = 0.69).

CONCLUSION

Despite the small sample size of patients with ASD, our data show a favorable trend toward efficacy of desmopressin and anticholinergic therapy in these children with enuresis and DVS.

Associations between psychiatric comorbidities and sleep disturbances in children with attention-deficit/hyperactivity disorder

OBJECTIVE

Children with attention-deficit/hyperactivity disorder (ADHD) often have sleep complaints and also higher rates of psychiatric comorbidities such as mood and anxiety disorders that may affect sleep. The authors hypothesized that children with ADHD and psychiatric comorbidities would have higher overall sleep disturbance scores as measured by a sleep questionnaire than children with ADHD without comorbidities.

METHODS

This cross-sectional analysis in an academic center studied 317 children with ADHD; 195 subjects had no comorbid conditions, 60 were anxious and 62 were depressed. Participants completed the Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present State, 4th Revised Edition and the Children's Sleep Habits Questionnaire.

RESULTS

Median age (range) was 8.9 (6-18.7) years; 78% were male. Median (interquartile range) Total Sleep Disturbance Score (TSDS) on Children's Sleep Habits Questionnaire for subjects with no comorbidities was 44 (40-49); anxiety, 48 (43-54); and depression, 46 (41-52). Compared with subjects without comorbidities, TSDS in anxious subjects was greater (p = .008). TSDS in depressed subjects was not significantly different. Compared with subjects without comorbidities, anxious subjects had higher Bedtime Resistance, Sleep Onset Delay, and Night Wakings subscales (p = .03, .007, and .007, respectively); depressed subjects had higher Sleep Onset Delay and Sleep Duration subscales (p = .003 and .01, respectively).

CONCLUSIONS

Anxiety in children with ADHD contributed to higher overall sleep disturbance scores, compared with children with ADHD alone. Both comorbidities were associated with higher Sleep Onset Latency subscale scores. Further study of the impact of psychiatric comorbidities on sleep in children with ADHD is warranted.

Altered brain activation during response inhibition in children with primary nocturnal enuresis: an fMRI study

Nocturnal enuresis is a common developmental disorder in children, and primary nocturnal enuresis (PNE) is the dominant subtype. The main purpose of this study was to investigate brain functional abnormalities specifically related to motor response inhibition in children with PNE using fMRI in combination with a Go/NoGo task. Twenty-two children with PNE and 22 healthy children, group-matched for age and sex, took part in this experiment. Although no significant between-group differences in task performance accuracy were observed, PNE patients showed significantly longer response times on average. There were several brain regions with reduced activation during motor response inhibition in children with PNE: the bilateral inferior frontal gyri, right superior and middle frontal gyri, right inferior parietal lobe, bilateral cingulate gyri and insula. Our data indicate that response inhibition in children with PNE is associated with a relative lack of or delay in the maturation of prefrontal cortex circuitry that is known to suppress inappropriate responses. This result might give clues to understanding the pathophysiology of PNE.

Nocturnal enuresis-theoretic background and practical guidelines

Nocturnal polyuria, nocturnal detrusor overactivity and high arousal thresholds are central in the pathogenesis of enuresis. An underlying mechanism on the brainstem level is probably common to these mechanisms. Enuretic children have an increased risk for psychosocial comorbidity. The primary evaluation of the enuretic child is usually straightforward, with no radiology or invasive procedures required, and can be carried out by any adequately educated nurse or physician. The first-line treatment, once the few cases with underlying disorders, such as diabetes, kidney disease or urogenital malformations, have been ruled out, is the enuresis alarm, which has a definite curative potential but requires much work and motivation. For families not able to comply with the alarm, desmopressin should be the treatment of choice. In therapy-resistant cases, occult constipation needs to be ruled out, and then anticholinergic treatment-often combined with desmopressin-can be tried. In situations when all other treatments have failed, imipramine treatment is warranted, provided the cardiac risks are taken into account.