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. 2023 Jul 27;3(3):e12185. doi: 10.1002/jcv2.12185

Relationship between elimination disorders and internalizing‐externalizing problems in children: A systematic review and meta‐analysis

Claudia Aymerich 1,2,3,✉, Borja Pedruzo 1, Malein Pacho 1, Jon Herrero 1, María Laborda 1, Marta Bordenave 1, Gonzalo Salazar de Pablo 4,5,6, Eva Sesma 1,2,3,7, Aranzazu Fernández‐Rivas 1,2,3,7, Ana Catalan 1,2,3,7,8, Miguel Ángel González‐Torres 1,2,3,7
PMCID: PMC10501701  PMID: 37720580

Abstract

Background

Elimination disorders are highly prevalent in childhood and often associated with clinically relevant comorbid psychological disorders. The aim of this study is to determine if, and to what extent, children with elimination disorders show higher internalizing and externalizing problems than their healthy peers.

Methods

A multistep literature search was performed from database inception until May 1st, 2022. PRISMA/MOOSE‐compliant systematic review (PROSPERO: CRD42022303555) were used to identify studies reporting on internalizing and/or externalizing symptoms in children with an elimination disorder and a healthy control (HC) group. First, a systematic review was provided. Second, where data allowed for it, a quantitative meta‐analysis with random effects model was conducted to analyze the differences between the elimination disorder and the HC groups for internalizing and externalizing symptoms. Effect size was standardized mean difference. Meta‐regression analyses were conducted to examine the effect of sex, age, and study quality. Funnel plots were used to detect a publication bias. Where found, the trim and fill method was used to correct it.

Results

36 articles were included, 32 of them reporting on enuresis (n = 3244; mean age = 9.4; SD = 3.4; 43.84% female) and 7 of them on encopresis (n = 214; mean age = 8.6; SD = 2.3; 36.24% female). Children with an elimination disorder presented significantly lower self‐concept (ES:0.42; 95%CI [0.08; 9.76]; p = 0.017) and higher symptom scores for thought problems (ES:−0.26; 95%CI: −0.43;−0.09]; p = 0.003), externalizing symptoms (ES: −0.20; 95%CI [−0.37;−0.03]; p = 0.020), attention problems (ES:−0.37; 95%CI [−0.51;−0.22]; p = 0.0001), aggressive behavior (ES:−0.33; 95%CI [−0.62;−0.04]; p = 0.025) and social problems (ES:−0.39; 95%CI [−0.58;−0.21]; p = 0.0001). Significant publication biases were found across several of the studied domains. No significant effect of sex, age or quality of the study score was found.

Conclusions

Children with an elimination disorder may have significant internalizing and externalizing problems, as well as impaired self‐concept. It is recommendable to screen for them in children with enuresis or encopresis and provide appropriate interventions.

Keywords: comorbidities, elimination disorder, encopresis, enuresis, externalizing, internalizing, self‐concept

This is the first systematic review and meta‐analysis to assess the relationship between elimination disorders and internalizing and externalizing symptoms. Enuresis is associated to lower self‐concept and higher symptom scores for thought problems, externalizing symptoms, attention problems, aggressive behavior and social problems.

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Key Points.

  • What's known: Elimination disorders are highly prevalent among children, and often associated with clinically relevant psychological comorbid disorders.

  • What's new: This is the first systematic review to assess the relationship between elimination disorders and internalizing and externalizing symptoms. Such disorders are associated to lower self‐concept and higher symptom scores for thought problems, externalizing symptoms, attention problems, aggressive behavior and social problems. Most available studies assessing this topic are at high risk for bias.

  • What's relevant: Emotional and behavioral problems should be considered when evaluating children with enuresis or encopresis. Further research is needed to clarify the relationship between internalizing and externalizing symptoms and elimination disorders and the factors moderating it.

INTRODUCTION

Background

Elimination disorders include enuresis, defined as wetting from 5 years, and encopresis, defined as soiling from 4 years onwards after organic causes are excluded (American Psychiatric Association, 2022). They constitute a very common group of disorders in childhood with similar rates worldwide; 1%–3% of 4‐year‐olds are affected by encopresis, while up to 10% of 7‐year‐olds suffer from nocturnal enuresis (Reese et al., 2013). Both conditions significantly decrease in prevalence over late childhood and adolescence, with a spontaneous rate of approximately 15% per year (Tai et al., 2016).

As interest in the physiopathology and etiology of elimination disorders has grown in the last decade, it has been described that psychological disorders are several times more frequent in children with enuresis or encopresis: the latest research indicates that 20%–30% of children with enuresis and 30%–50% with encopresis have clinically relevant comorbid disorders (vonGontard et al., 2011), which represents over a 4‐times increase compared with their healthy peers. The most common comorbid disorder in both encopresis and enuresis is ADHD (deSena Oliveira et al., 2021), followed closely by oppositional defiant disorder (Joinson et al., 2006). Other worrying findings include that patients and family members of patients with enuresis showed worse quality of life global scores when compared to healthy control children, similar to those found in individuals with chronic conditions such as asthma or epilepsy (Bachmann et al., 2009). Less is known, however, on the prevalence and severity of subclinical behavioral symptoms that cannot be technically classified as a disorder, such as sadness, embarrassment or aggressive behavior.

Internalizing and externalizing problems generally describe two broad groupings of behavioral, emotional, and social problems (Achenbach et al., 2016), conforming rather heterogeneous categories. Internalizing problems refer to inwardly focused negative behaviors, including anxiety, depression, and withdrawn conduct. On the other hand, externalizing problems describe outwardly focused negative behaviors such as aggression and disruptive conduct (Liu, 2004). Internalizing and externalizing problems during childhood predict later negative adolescent and adult psychological and physical health outcomes (Tien et al., 2019).

Although some previous systematic reviews examine the relationship and comorbidity between elimination disorders and specific psychiatric conditions (deSena Oliveira et al., 2021), there is no systematic review or meta‐analysis examining their co‐occurrence with internalizing and externalizing problems in children. We consider it to be a highly relevant topic both in terms of prevalence and the high psychological burden associated to these disorders.

Objectives

In this review we systematically researched the literature in order to try to answer the following research questions:

  1. To what extent do children with elimination disorders show higher internalizing and externalizing problems than controls (defined as age‐matched healthy peers)?

  2. Is the group standardized difference between elimination disorders and controls in the internalizing and externalizing problems moderated by (a) the nature of the primary disorder, age or sex? or (b) methodological factors, including sample size, or publication bias?

METHODS

This study protocol was registered on PROSPERO (registration number: CRD42022303555). The study was conducted in accordance with “Preferred Reporting Items for Systematic Reviews and Meta‐Analyses” (PRISMA) (Moher et al., 2009) (See Table S1) and “Meta‐analyses of Observational Studies in Epidemiology” (MOOSE) checklist (Stroup et al., 2000) (See Table S2), following “EQUATOR Reporting Guidelines” (Altman et al., 2008).

Search strategy and selection criteria

A systematic literature search was carried out by two independent researchers (C.A. and B.P.). Web of Science database (Clarivate Analytics) was searched, incorporating the Web of Science Core Collection, the BIOSIS Citation Index, the KCI‐Korean Journal Database, MEDLINE®, the Russian Science Citation Index, and the SciELO Citation Index as well as Cochrane Central Register of Reviews, and Ovid/PsycINFO databases, from inception until May 1st, 2022.

The following keywords were used: “encopresis” OR “enuresis” OR “elimination disorder*” AND “anxiety” OR “depression” OR “agressi*” OR “rule‐break*” OR “conduct” OR “opposition*” OR “self‐concept” OR “self‐esteem” OR “internalizing” OR “externalizing”.

Articles identified were first screened as abstracts, and after excluding those that did not meet the inclusion criteria, the full texts of the remaining articles were assessed for eligibility and inclusion. In case of disagreement a senior researcher (A.C.) made the final decision on the inclusion of the article.

Inclusion criteria for the systematic review and meta‐analysis were: (a) individual studies with original data, (b) focusing on participants up to 18 years of age with a clinical diagnosis of an elimination disorder (including enuresis, encopresis, or a combination of both) provided by specialists, (c) reporting quantitative data on internalizing and/or externalizing problems (including anxiety, depression, or a combination of both, aggressive behaviors, rule‐breaking behaviors, conduct problems, oppositional defiance, or their combination), (d) using validated, structured evaluation scales evaluating internalizing or externalizing problems as continuous variables through standard self‐report or parents‐report tools, (e) reporting cross‐sectional data or longitudinal data on internalizing and externalizing problems in children with an elimination disorder and a comparison group of age‐matched healthy controls children (healthy controls) on the outcomes of interest, and (f) written in English or Spanish. Exclusion criteria were (a) reviews, clinical cases, study protocols or qualitative studies, conferential proceedings, letters, and commentaries, (b) reporting on patients with cognitive impairment, and (c) written in languages other than English or Spanish.

Data extraction

Three researchers (M.P., M.L., and J.H.) independently extracted data from all the included studies. The three databases were then cross‐checked, and discrepancies were resolved through consensus under the supervision of a senior researcher (A.C.). A summary of selected variables included: first author and year of publication, country and city, sample size, mean age (mean ± standard deviation [SD]), primary disorder (enuresis, encopresis, or a combination of both), specifiers of the elimination disorder (e.g., diurnal, nocturnal), sex (% female), pharmacological treatment (as a dichotomic variable, when more than 30% of the clinical group were receiving pharmacological treatment for the elimination disorder), outcomes of interest (including the category, the nature of the internalizing or externalizing symptom, and the rating tool used to assess them), quality assessment (see below), and key findings.

When multiple data points were available, the point in which the elimination disorder was diagnosed was coded. For longitudinal studies, data for the first time point were extracted.

Studies were examined for potential sample overlap. When studies had a high sample overlap (determined by looking at the inclusion dates, type of population and country in which the study was carried out), the study with the largest sample was selected.

Risk of bias (quality) assessment

Risk of bias was assessed using Newcastle‐Ottawa Scale for cross‐sectional and cohort studies (Wells et al., 2012) (See Table S3). No article was excluded from the systematic review or meta‐analyses regardless of their NOS score.

Certainty of evidence assessment

Certainty of evidence of the included studies was assessed using the GRADE approach: Grading of Recommendations Assessment, Development and Evaluation (Higgins et al., 2022).

Strategy for data synthesis and statistics

First, we provided a systematic synthesis (Table 1 and Table 2) of the findings from the included studies.

TABLE 1.

Articles included in the systematic review for the enuresis sample.

Author year Country N EN N HC Age mean (SD) % Female NT/CB Medicaltreatment Domain (scale) EN mean (SD)/cutoff % HC mean (SD)/cutoff % NOS
Gulisano et al. (2016) Italy 200 200 11.7 (3.3) 36.7 NT No

  • Internalizing (CBCL)

  • Externalizing (CBCL)

  • Withdrawn behavior (CBCL)

  • Somatic complaint (CBCL)

  • Anxious/Depressed (CBCL)

  • Social problems (CBCL)

  • Thought problems (CBCL)

  • Attention problems (CBCL)

  • Delinquent behavior (CBCL)

  • Aggressive behavior (CBCL)

  • Depression (CDI)

  • Anxiety (MASC)

  • 50.5 (8.9)

  • 6.7 (3.8)

  • 15.2 (2.3)

  • 14.8 (4.6)

  • 20.0 (3.3)

  • 2.1 (0.9)

  • 1.8 (0.7)

  • 18.0 (1.1)

  • 3.5 (2.8)

  • 2.9 (1.1)

  • 10.3 (6.1)

  • 52.9 (8.3)

  • 13.6 (5.7)

  • 6.5 (2.9)

  • 3.7 (2.2)

  • 4.3 (5.1)

  • 5.6 (2.8)

  • 1.9 (1.2)

  • 1.7 (0.9)

  • 4.0 (1.6)

  • 4.1 (1.9)

  • 3.0 (1.2)

  • 6.8 (5.1)

  • 40.9 (12.7)

 8
van Hoecke et al. (2003) Belgium 154 153 8.5 (1.8) 38.1 CB No

  • Internalizing (CBCL)

  • Externalizing (CBCL)

  • Withdrawn behavior (CBCL)

  • Somatic complaint (CBCL)

  • Anxious/Depressed (CBCL)

  • Social problems (CBCL)

  • Thought problems (CBCL)

  • Attention problems (CBCL)

  • Delinquent behavior (CBCL)

  • Aggressive behavior (CBCL)

  • Attention problems (DBDRS)

  • Hyperactive problems (DBDRS)

  • 56.9 (11.1)

  • 52.5 (11.2)

  • 2.4 (2.5)

  • 1.4 (2.0)

  • 5.0 (4.6)

  • 2.4 (2.5)

  • 0.8 (1.3)

  • 5.2 (3.9)

  • 1.6 (2.2)

  • 8.0 (6.6)

  • 7.4 (5.9)

  • 6.9 (6.3)

  • 53.4 (10.5)

  • 49.2 (11.3)

  • 1.5 (1.9)

  • 1.3 (1.9)

  • 3.4 (3.7)

  • 1.8 (2.3)

  • 0.3 (0.7)

  • 3.4 (3.3)

  • 1.0 (1.3)

  • 5.6 (5.0)

  • 5.7 (5.4)

  • 4.7 (5.4)

 6
Niemczyk et al. (2014) Germany 134 1466 5.7 (0.4) 50.2 CB N.a. Externalizing (DYSPIS) 13.4% 9.5% 6
De Bruyne et al. (2009) Belgium 78 110 8.8 (2.0) 45.2 CB No

  • Internalizing (CBCL)

  • Externalizing (CBCL)

  • Withdrawn behavior (CBCL)

  • Somatic complaint (CBCL)

  • Anxious/Depressed (CBCL)

  • Social problems (CBCL)

  • Thought problems (CBCL)

  • Attention problems (CBCL)

  • Delinquent behavior (CBCL)

  • Aggressive behavior (CBCL)

  • Attention problems (DBDRS)

  • Hyperactive problems (DBDRS)

  • 7.9 (8.1)

  • 9.3 (9.7)

  • 2.5 (2.6)

  • 1.3 (2.1)

  • 4.5 (5.0)

  • 2.2 (2.7)

  • 0.8 (1.9)

  • 4.9 (4.7)

  • 1.2 (1.8)

  • 8.0 (8.2)

  • 6.8 (7.1)

  • 5.1 (6.2)

  • 6.5 (7.4)

  • 6.0 (7.8)

  • 1.7 (2.3)

  • 1.5 (2.0)

  • 3.5 (4.5)

  • 1.5 (2.2)

  • 0.5 (1.1)

  • 3.1 (3.3)

  • 1.1 (2.1)

  • 4.9 (6.0)

  • 3.6 (4.4)

  • 3.0 (3.6)

 6
Azimi et al. (2019) Iran 100 100 7.3 (1.8) 39.5 NT No Anxiety (SCARED) 22.0% 6.0% 6
Karaca Ünlü et al. (2020) Turkey 52 44 9.7 (N.a.) N.a. NT No Anxiety (SCARED) 32.5 (10.7) 26.7 (10.6) 9
Mattheus et al. (2021) Germany 10 42 5.6 (0.8) 40.4 CB No

  • Internalizing (CBCL)

  • Externalizing (CBCL)

  • Depression (PFC)

  • 55.4 (10.7)

  • 51.9 (15.4)

  • 1.3 (2.1)

  • 44.8 (10.5)

  • 44.3 (11.7)

  • 0.7 (1.3)

 7
Coppola et al. (2011) Italy 22 22 9.8 (3.0) 37.37 CB Yes

  • Self‐esteem (MSCS)

  • Behavioral problems (SDQ)

  • 89.3 (8.7)

  • 14.2 (5.8)

  • 110.1 (12.0)

  • 6.2 (4.1)

 5
Theunis et al. (2002) Belgium 50 77 9.5 (N.a.) N.a. N.a. Yes Self‐esteem (SPPC) 18.3 (3.3) 20.1 (3.3) 4
Ertan et al. (2009) Turkey 44 27 10.4 (3.0) N.a. NT No Sleep (PSQI) 3.6 (2.1) 3.4 (1.7) 6
Robinson et al. (2003) United Kingdom 25 25 9.9 (2.0) 52.0 NT No Self‐esteem (CSEI) 62.4 (17.7) 67.8 (17.9) 6
Yaradilmiş et al. (2020) Turkey 120 109 9.1 (2.2) 27 NT No Depression (CDI) 9.5 (6.0) 7.8 (5.6) 5
Gozmen et al. (2008) Turkey 19 32 9.5 (1.5) 43.1 NT Yes Sleep (PSQI) 5.5 (2.7) 2.5 (1.0) 7
Bahnasy et al. (2018) Egypt 40 20 11.6 (3.1) N.a. NT Yes

  • Internalizing (CBCL)

  • Anxious/Depressed (CBCL)

  • Attention problems (CBCL)

  • Social problems (CBCL)

  • 57.5 (8.5)

  • 55.6 (10.9)

  • 57.4 (7.2)

  • 60.3 (7.1)

  • 51.7 (2.3)

  • 45.8 (2.6)

  • 52.9 (3.2)

  • 54.1 (4.5)

 8
Al‐Zaben and Sehlo (2014) Saudi Arabia 65 40 9.3 (1.8) 24.8 NT Yes Depression (CDI) 13.7 (1.7) 8.0 (1.3) 7
Kanata et al. (2016) Japan 407 3997 10.2 (0.3) 47.1 NT No

  • Emotional symptoms (SDQ)

  • Hyperactivity‐inattention (SDQ)

  • Conduct problems (SDQ)

  • Peer relationship problems (SDQ)

  • 1.8 (1.9)

  • 3.8 (2.3)

  • 2.2 (1.7)

  • 1.8 (1.7)

  • 1.6 (1.7)

  • 3.0 (2.1)

  • 1.8 (1.5)

  • 1.5 (1.6)

 8
Ucer and GumuA (2013) Turkey 101 38 11.0 (2.0) 37.3 NT No

Sleep (PSQI)

Depression (CDI)

2.6 (2.5)

11.7 (6.1)

1.2 (1.1)

7.0 (3.4)

 6
Akyüz et al. (2016) Turkey 38 46 10.8 (7.1) 52.0 NT No

  • Withdrawn behavior (CBCL)

  • Somatic complaint (CBCL)

  • Anxious/Depressed (CBCL)

  • Social problems (CBCL)

  • Thought problems (CBCL)

  • Attention problems (CBCL)

  • Delinquent behavior (CBCL)

  • Aggressive behavior (CBCL)

  • 3.2 (2.8)

  • 0.8 (1.1)

  • 6.3 (4.4)

  • 2.8 (2.5)

  • 1.1 (1.4)

  • 5.6 (3.3)

  • 2.1 (2.8)

  • 8.9 (7.6)

  • 2.9 (2.5)

  • 0.7 (0.9)

  • 5.5 (3.8)

  • 1.5 (1.7)

  • 1.0 (1.3)

  • 4.0 (2.8)

  • 1.7 (2.1)

  • 7.4 (6.0)

 5
Wagner et al. (2015) Germany 9 44 8.3 (2.0) 43.7 NT No

  • Internalizing (CBCL)

  • Externalizing (CBCL)

  • 59.3 (10.1)

  • 54.1 (7.4)

  • 50.3 (9.5)

  • 49.7 (9.7)

 7
Koca et al. (2014) Turkey 38 46 10.8 (3.5) 52.0 NT N.a.

  • Self‐esteem (PHCSCS)

  • Depression (CDI)

  • 54.3 (13.0)

  • 10.4 (4.3)

  • 63.4 (9.1)

  • 7.1 (4.4)

 6
Erdogan et al. (2008) Turkey 53 303 6.0 (1.0) 51.0 N.a. N.a.

  • Internalizing (CBCL)

  • Externalizing (CBCL)

  • Withdrawn behavior (CBCL)

  • Somatic complaint (CBCL)

  • Anxious/Depressed (CBCL)

  • Social problems (CBCL)

  • Thought problems (CBCL)

  • Attention problems (CBCL)

  • Delinquent behavior (CBCL)

  • Aggressive behavior (CBCL)

  • 56.3 (10.2)

  • 53.0 (8.6)

  • 54.9 (6.2)

  • 54.6 (8.0)

  • 58.3 (7.7)

  • 55.0 (5.4)

  • 57.6 (6.4)

  • 57.8 (6.4)

  • 54.3 (7.7)

  • 55.3 (7.5)

  • 54.4 (10.1)

  • 50.1 (10.2)

  • 54.8 (6.5)

  • 54.8 (6.9)

  • 57.3 (7.0)

  • 5.4 (7.6)

  • 7.3 (24.2)

  • 7.3 (12.6)

  • 6.6 (17.0)

  • 8.0 (11.7)

 6
van Hoecke et al. (2004) Belgium 84 70 10.1 (2.0) 36.5 CB N.a.

  • Withdrawn behavior (CBCL)

  • Somatic complaint (CBCL)

  • Anxious/Depressed (CBCL)

  • Social problems (CBCL)

  • Anxiety (SAS‐C)

  • Anxiety (STAI‐C)

  • Depression (SDQ‐C)

  • Self‐esteem (SPPC)

  • 2.8 (2.7)

  • 1.7 (2.3)

  • 5.7 (5.2)

  • 3.0 (2.9)

  • 10.5 (8.3)

  • 33.3 (5.8)

  • 1.8 (1.9)

  • 18.3 (4.0)

  • 1.8 (2.3)

  • 1.3 (1.9)

  • 3.8 (4.3)

  • 2.2 (2.6)

  • 11.0 (10.5)

  • 33.1 (8.2)

  • 2.3 (2.7)

  • 18.9 (4.0)

 7
Kanaheswari et al. (2012) Malaysia 63 63 10.3 (6.0) 47.6 NT N.a. Self‐esteem (ITIA) 28.3 (16.9) 35.7 (16.8) 8
Natale et al. (2009) Germany 49 32 7.0 (5.0) 42.9 CB N.a. Self‐esteem (PHCSCS) 49.3 (7.2) 51.5 (7.3) 7
Ma et al. (2020) China 158 168 N.a. 48.8 NT No Self‐esteem (PHCSCS) 55.2 (6.1) 56.6 (5.2) 7
Birdal and Doğangün (2016) Turkey 30 30 9.21 (N.a.) N.a. CB No

  • Anxious/Depressed (CBCL)

  • Somatic complaint (CBCL)

  • Social problems (CBCL)

  • Thought problems (CBCL)

  • Aggressive behavior (CBCL)

  • 4.2 (3.3)

  • 5.7 (4.6)

  • 4.0 (2.8)

  • 2.1 (2.5)

  • 3.6 (4.2)

  • 1.6 (1.8)

  • 2.3 (2.3)

  • 1.9 (1.8)

  • 0.7 (1.1)

  • 0.8 (1.7)

 5
Desta et al. (2007) Ethiopia 511 1890 10.1 (N.a.) 51.2 N.a. No

  • Disruptive behavior (DICA)

  • Anxiety (DICA)

  • 2.7%

  • 11.9%

  • 1.1%

  • 7.6%

 6
Van Hoecke et al. (2006) Belgium 141 155 8.5 (1.8) 38.5 CB No

  • Internalizing (CBCL)

  • Externalizing (CBCL)

  • Attention problems (DBDRS)

  • Hyperactive problems (DBDRS)

  • 57.4 (10.8)

  • 50.3 (11.1)

  • 7.5 (5.8)

  • 7.2 (6.4)

  • 52.5 (10.7)

  • 49.2 (10.0)

  • 5.7 (5.4)

  • 4.7 (5.4)

 6
Ş et al. (2019) Turkey 56 42 14.0 (1.7) 22.9 NT No

  • Anxiety (SCARED)

  • Depression (CDI)

  • Social anxiety (SAS‐A)

  • 31.7 (16.1)

  • 14.7 (7.7)

  • 48.7 (15.0)

  • 26.3 (13.3)

  • 16.1 (8.6)

  • 35.8 (11.6)

 7
Equit et al. (2013) Germany 279 1799 6.2 (0.4) 48.8 NT No Anxious/Depressed (CBCL) 57.5 (8.1) 56.0 (7.2) 7
Ertan et al. (2009) Turkey 44 27 10.8 (3.1) 67.6 NT No Sleep (PSQI) 3.6 (2.1) 3.4 (1.7) 6
Hamed et al. (2021) Egypt 80 60 13.0 (1.3) 37.9 NT No

  • Emotional symptoms (SDQ)

  • Hyperactivity‐inattention (SDQ)

  • Conduct problems (SDQ)

  • Peer relationship problems (SDQ)

  • 7.2 (1.6)

  • 6.9 (1.8)

  • 8.6 (1.7)

  • 7.6 (1.7)

  • 3.8 (0.8)

  • 3.0 (0.8)

  • 4.5 (1.0)

  • 3.2 (1.0)

 8
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Abbreviations: CB, Combined; CBCL, Child Behavior Checklist; CDI, Children's Depression Inventory; DBDRS, Disruptive Behavior Disorder Rating Scale; DYPSIS, Diagnostic Interview for Mental Disorders in Children and Adolescent; EN, Enuresis; HC, Healthy Controls; ITIA, I Think I Am Test; DICA, Diagnostic Interview for Children and Adolescents; MASC, Multidimensional Anxiety Scale for Children; MSCS, Multidimensional Self Concept Scale; NOS, Newcastle Ottawa Score; NT, Nocturnal; PFC, Preschool Feelings Checklist; PHCSCS, Piers‐Harris Children's Self‐Concept Scale; PSQI, Pittsburgh Sleep Quality Index; SAS‐A, Social Anxiety Scale for Adolescents; SAS‐C, Social Anxiety Scale for Children; SCARED, Screen for Child Anxiety Related Disorders; SD, Standard Deviation; SDQ, Strengths and Difficulties Questionnaire; SPPC, Self‐Perception Profile for Children; STAI‐C, State Trait Anxiety Inventory for Children.

TABLE 2.

Articles included in the systematic review for the encopresis sample.

Author year Country N EC N HC Age mean (SD) % Female Domain (scale) EC mean (SD)/cutoff % HC mean (SD)/cutoff % NOS
Niemczyk et al. (2014) Germany 12 1466 5.7 (0.4) 50.2 Externalizing disorders (DYSIPS) 50% 9.5% 6
Mattheus et al. (2021) Germany 28 43 5.42 (0.8) 45.7

  • Internalizing (CBCL)

  • Externalizing (CBCL)

  • Depression (PFC)

  • 52.33 (9.07)

  • 52.56 (11.7)

  • 1.18 (1.58)

  • 44.76 (10.51)

  • 44.33 (11.7)

  • 0.7 (1.29)

 7
Akça et al. (2011) Turkey 30 30 N.a. 43.7

  • Depression (K‐SADS)

  • Anxiety (K‐SADS)

  • ADHD (K‐SADS)

  • OD disorder (K‐SADS)

  • 23.3%

  • 40.0%

  • 36.7%

  • 40.0%

  • 6.6%

  • 33.3%

  • 16.7%

  • 3.33%

 5
Wagner et al. (2015) Germany 17 44 8.25 (2.0) 30.1

  • Internalizing (CBCL)

  • Externalizing (CBCL)

  • 61.44 (11.1)

  • 64.56 (12.5)

  • 50.27 (9.5)

  • 49.73 (9.7)

 7
Cox et al. (2002) USA 86 62 9.16 (2.23) 30.1

  • Attention problems (CBCL)

  • Social problems (CBCL)

  • Withdrawn behavior (CBCL)

  • Delinquent behavior (CBCL)

  • Aggressive behavior (CBCL)

  • Self‐esteem (PHCSCS)

  • 58.88 (8.29)

  • 87.8 (8.71)

  • 57.0 (8.47)

  • 57.0 (7.21)

  • 57.45 (8.24)

  • 61.29 (12.61)

  • 23.62 (5.79)

  • 53.57 (6.0)

  • 52.11 (3.7)

  • 52.36 (4.91)

  • 54.39 (7.46)

  • 63.43 (10.03)

 6
Landman et al. (1986) USA 31 35 11.0 (0.9) 37.5 Self‐esteem (PHCSCS) 18.5 (3.8) 20.7 (4.3) 5
Owens‐stively (1987) USA 10 10 9.0 (1.8) 30.0 Self‐esteem (PHCSCS) 59.4 (n.a.) 69.5 (n.a.) 4
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Abbreviations: CBCL, Child Behavior Checklist; DYPSIS, Diagnostic Interview for Mental Disorders in Children and Adolescent; EC, Encopresis; HC, Healthy Controls; K‐SADS, Kiddie Schedule for Affective Disorders and Schizophrenia; NOS, Newcastle Ottawa Score; PFC, Preschool Feelings Checklist; PHCSCS, Piers‐Harris Children's Self‐Concept Scale; SD, Standard Deviation.

Second, we performed meta‐analyses where data allowed for it. The comparison of effect sizes in each group was calculated using effect size (ES) formula. A negative ES indicates the elimination disorders group has more internalizing and/or externalizing problems than the control, except for the Piers‐Harris Children's Self‐Concept Scale, where a positive ES indicates the elimination disorders group has lower self‐concept. Effect sizes were calculated using the means, standard deviations (SDs), and sample size for the outcomes of interest for each sample. Meta‐regressions were performed to determine the effect of the (a) age, (b) sex, and (c) NOS score on the outcomes of interest. Heterogeneity among studies was assessed using the Q statistic, with the proportion of the total variability in effect size estimates evaluated using the I 2 index, classifying the heterogeneity as low (I 2 = 25%), medium (I 2 = 50%), and high (I 2 = 75%) (Lipsey & Wilson, 2009). The random‐effects model was used. Publication bias was assessed by visually inspecting funnel plots, and the trim and fill method (Duval & Tweedie, 2000) was used when funnel plot's asymmetry suggested a significant publication bias.

All analyses were conducted within R 1.4.1106 (R Foundation for Statistical Computing, 2021). The significance level was set at a p < 0.05, two‐sided.

RESULTS

The literature search yielded 3922 citations through electronic database, which were screened for eligibility; 121 articles were assessed in full text, and 85 were excluded. The final database for the systematic review and meta‐analysis included 36 studies, on which 32 report results for enuretic children and 7 for encopretic children, as it can be seen in Figure S1 (PRISMA Flow Diagram). Studies included samples from 13 countries in four continents: Europe (36.1%), Asia (47.2%, being 70.6% of them from Turkey), Africa (8.3%), and North America (8.3%). Mean NOS score for the included studies was 6.4 ± 1.1. 16.6% and 44.4% of the included studies presented a high or a moderate certainty of evidence, respectively, while 38.9% of them showed either a low or very low certainty of evidence (See Table S4). Enuresis.

Data were extracted from 32 studies for a total sample size of 3244 patients (mean age = 9.4; 43.84% female) and 11,277 controls (mean age = 10.1; 48.98% female). 62.5% of the studies reported on children with nocturnal enuresis, while 28.1% also included samples with combined enuresis (nocturnal and diurnal). 15.6% of the studies included children already receiving medical treatment for their elimination disorder. The included studies reported on a wide range of both internalizing and externalizing behavior (Table 1).

Internalizing problems meta‐analyses

Enough data was found to perform a meta‐analysis on 8 scales or subscales reporting on internalizing problems: Piers‐Harris Self‐Concept Scale (Piers, 1984) (a validated scale used to measure self‐concept), Children's Depression Inventory (Kovacs, 1981) (measuring depressive symptoms), Pittsburgh Sleep Quality Index (Buysse et al., 1989) (measuring sleep problems), Child Behavior Checklist (Achenbach & Edelbrock, 1983) (CBCL) Internalizing broad band factor, and four other CBCL subscales: Anxiety/Depression, Somatic complaints, Withdrawn behavior and Thought problems.

As it can be seen in Figure 1A and Table 3A, internalizing behaviors measured with CBCL's broad‐band factor did not significantly differ between children with enuresis and their non‐enuretic peers (ES = −1.37; 95% CI ‐2.80; 0.06; p = 0.061). As for specific internalizing behaviors, only two of the meta‐analyzed problems significantly differed between groups. Self‐concept was significantly lower in children with enuresis (ES = 0.42; 95% CI 0.08; 0.76; p = 0.017), while CBCL Thought Problems subscale scored higher in the enuretic group (ES = −0.26; 95% CI ‐0.43; −0.09; p = 0.003). Both groups did not significantly differ in Withdrawn behavior, Somatic complaints or Anxiety/Depression subscales, nor for Depression or Sleep problems (See Figure S2).

FIGURE 1.

FIGURE 1

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Forest plots for the standardized mean differences (SMD) of CBCL broad‐band internalizing scale (A) and CBCL broad‐band externalizing scale (B) in children with enuresis versus healthy controls.

TABLE 3.

Results summary for internalizing (A) and externalizing (B) problems in children with enuresis versus healthy controls.

A – INTERNALIZING PROBLEMS
Meta‐regressions
Domain Scale k (N) SMD [95% CI] (p value) Q (p value) I2 (%) Publication bias Corrected SMD [95% IC] (p value) Age (SE) (p value) NOS (SE) (p value) Sex (SE) (p value)
Internalizing symptoms CBCL 6 (1217) −1.37 [−2.80; 0.06] (p 0.061) 431.92 (p 0.0001) 98.69 Yes −1.90 [−3.14; −0.65] (p 0.0028)

  • −0.03 (0.20)

  • (p 0.87)

  • −4.15 (0.90)

  • (p 0.0001)*

  • 0.02 (0.05)

  • (p 0.67)
Depression CDI 6 (1055) −0.98 [−2.02; 0.07] (p 0.068) 110.88 (p 0.0001) 98.27 No ‐

  • 0.50 (0.23)

  • (p 0.03)*

  • −1.21 (0.55)

  • (p 0.03)*

  • 0.03 (0.04)

  • (p 0.47)
Anxiety/Depression CBCL 7 (1253) 0.68 [−1.35; 2.72] (p 0.510) 479.82 (p 0.0001) 99.59 No ‐

  • −0.01 (0.01)

  • (p 0.48)

  • −2.02 (6.08)

  • (p 0.74)

  • 1.0 (0.00)

  • (p 0.99)
Somatic complaints CBCL 6 (1193) −0.54 [−1.25; 0.16] (p 0.132) 212.03 (p 0.0001) 96.82 Yes

  • −0.67 [−1.32; −0.02]

  • (p 0.042)

  • −0.38 (0.17)

  • (p 0.02)*

  • −1.08 (0.52)

  • (p 0.04)*

  • −0.02 (0.05)

  • (p 0.67)
Self‐concept PHCSCS 3 (491) 0.42 [0.08; 0.76] (p 0.017)* 5.27 (p 0.07) 62.65 No ‐ N.a. N.a. N.a.
Sleep PSQI 3 (261) −0.77 [−1.61; 0.08] (p 0.075) 13.67 (p 0.001) 88.59 No ‐ N.a. N.a. N.a.
Withdrawn behavior CBCL 5 (1039) −1.30 [−3.17; 0.56] (p 0.171) 461.83 (p 0.0001) 99.32 No ‐ N.a. N.a. N.a.
Thought problems CBCL 5 (1039) −0.26 [−0.43; −0.09] (p 0.003)* 7.26 (p 0.12) 38.24 No ‐ N.a N.a. N.a.
B – EXTERNALIZING PROBLEMS.
Meta‐regressions
Domain Scale k (N) SMD [95% CI] (p value) Q (p value) I2 (%) Publication bias Corrected SMD [95% IC] (p value) Age (SE) (p value) NOS (SE) (p value) Sex (SE) (p value)
Externalizing symptoms CBCL 4 (757) −0.20 [−0.37; −0.03] (p 0.020)* 2.49 (p 0.48) 0.00 Yes −0.16 [−0,31; 0.002] (p 0.054) 0.12 (0.15) (p 0.41) N.a.

  • 0.02 (0.03)

  • (p 0.65)
Attention problems CBCL 5 (1039) −2.48 [−6.24; 1.28] (p 0.196) 639.93 (p 0.0001) 99.80 No ‐ N.a. N.a. N.a.
Attention DBDRS 3 (791) −0.37 [−0.51; −0.22] (p 0.0001)* 2.08 (p 0.35) 0.00 No ‐ N.a. N.a. N.a.
Aggressive behavior CBCL 5 (1039) −0.33 [−0.62; −0.04] (p 0.025)* 19.97 (p 0.0005) 78.41 Yes −0.24 [−0,55; 0,07] (p 0.127) N.a. N.a. N.a.
Social problems CBCL 7 (1253) −0.39 [−0.58; −0.21] (p 0.0001)* 13.17 (p 0.04) 57.07 Yes −0.35 [−0.58; −0.12] (p 0.002)

−0.04 (0.06)

(p 0.48)

  • 0.17 (0.20)

  • (p 0.38)

  • −0.01 (0.02)

  • (p 0.76)
Delinquent behavior CBCL 4 (979) −0.07 [−0.33; 0.20] (p 0.626) 14.54 (p 0.002) 74.88 Yes 0.1047 [−0.18; 0.38] (p 0.464) N.a. N.a. N.a.
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Note: Where publication bias exists, a Corrected SMD is proposed using the trim and fill method.

Abbreviations: CBCL, Child Behavior Checklist; CDI, Children's Depression Inventory; DBDRS, Disruptive Behavior Disorder Rating Scale; IC, Confidence Interval; PHCSCS, Piers‐Harris Children's Self‐Concept Scale; PSQI, Pittsburgh Sleep Quality Index; SE, Standard Error; SMD, Standardized Mean Difference.

Heterogeneity was significant across all of the meta‐analyzed subscales, except for Self‐concept and Thought problems. Funnel plots suggested the presence of a publication bias for Internalizing symptoms broad band factor (corrected ES = −1.90; 95% CI ‐3.14; −0.65; p = 0.003) and Somatic complaints subscales (corrected ES = −0.67; 95% CI ‐1.32; −0.02; p = 0.042) (See Figure S3) (Figure 2). After performing trim and fill method corrections, both subscales significantly differed between groups.

FIGURE 2.

FIGURE 2

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Funnel plots for the CBCL broad‐band internalizing scale meta‐analysis (A) and CBCL broad‐band externalizing scale meta‐analysis (B).

There was not enough data available in the original studies to perform meta‐regressions on those subscales where the two groups significantly differed.

Externalizing problems meta‐analyses

Enough data was found to perform a meta‐analysis on 6 subscales reporting on internalizing problems: Disruptive Behavior Disorder Rating Scale's (DBDRS) Attention subscale (Greenslade et al., 1992) (measuring attention problems), CBCL Externalizing symptoms broad band factor, and four other CBCL subscales: Attention problems, Aggressive behavior, Social problems and Delinquent behavior.

As shown in Figure 1B and Table 3B, externalizing behaviors measured with CBCL's broad‐band factor scored significantly higher in children with enuresis compared with healthy controls (ES = −0.20; 95% CI ‐0.37; −0.03; p = 0.020). Three other externalizing problems subscales also significantly differed between groups, in all cases presenting higher problematic scores for the enuretic group: Attention (ES = −0.37; 95% CI ‐0.51; −0.22; p = 0.0001); Aggressive behavior (ES = −0.33; 95% CI ‐0.62; −0.04; p = 0.025); Social problems (ES = −0.39; 95% CI ‐0.58; −0.21; p = 0.0001). That was not the case for Delinquent behavior and Attention problems measured by CBCL (Figure S4).

Again, heterogeneity was significant across all of the meta‐analyzed subscales except for the Externalizing broad band factor and Attention (measured by DBDRS). Funnel plots suggested the presence of a publication bias for 4 subscales: Externalizing symptoms broad band factor (corrected ES = −0.16; 95% CI ‐0.31; 0.0002; p = 0.054), Aggressive behavior (corrected ES = −0.24; 95% CI ‐0.55; 0.07; p = 0.127), Social problems (corrected ES = −0.35; 95% CI ‐0.58; −0.12; p = 0.002) and Delinquent behavior (corrected ES = 0.105; 95% CI ‐0.18; 0.38; p = 0.464) (See Figure S5).

Meta‐regressions were performed where available data allowed for it: age, NOS score and sex were not significantly associated with Externalizing symptoms nor Delinquent behavior.

Encopresis

After allowing for overlapping studies, data were extracted from 7 studies for a total sample size of 214 patients (mean age = 8.6; 36.24% female) and 1689 controls (mean age = 8.6; 47.82% female). The included studies reported on a range of both externalizing and internalizing behavior, as it can be seen in Table 2. No domain provided enough data to be meta‐analyzed. However, all the analyzed domains reflected more internalizing and externalizing problems in the encopretic group compared with their healthy peers.

DISCUSSION

The results of this systematic review and meta‐analysis reveal important findings. We have found evidence that there is a significant increase in some internalizing and externalizing symptoms and behaviors in those children with elimination disorders. However, original data available to meta‐analyze was limited and presented significant heterogeneity, as well as the existence of a publication bias for most of the studied domains.

The studies included reported on children from 13 countries across four continents. Surprisingly, there were no articles reporting on enuretic children from North America, while an overrepresentation of non‐overlapping Turkish samples (12 articles in total) was found. Nocturnal enuresis prevalence seems to vary significantly across countries, ranging from around 20% in Turkey (Gunes et al., 2009) to 4.5% in the United States (Shreeram S et al., 2009), which, along with cultural differences, could explain this atypical geographic distribution of the available literature.

A lower self‐concept was found in those children with enuresis compared with their non‐enuretic peers. This finding is consistent with previous reports in the literature, although some controversy exists. Most of the articles included in the systematic review reported lower self‐esteem scores for the elimination disorders group, as do several other studies that did not meet the criteria to be included. This lower self‐concept seems to be worsened by a growing number of failed treatments (Theunis et al., 2002), and significantly improves after enuresis is effectively treated, reaching the same levels as the HC group (Hägglöf et al., 1997). However, Natale did not report significant differences among groups, although it was a small clinical sample of exclusively nocturnal enuresis patients (Natale et al., 2009). A previous review on this topic including four small studies also found no evidence indicating that nocturnal enuresis led to a low self‐esteem. However, its effective treatment again seemed to result in a self‐concept improvement (Redsell & Collier, 2001).

As for other internalizing symptoms, we found no evidence that depression or anxiety scores might be increased in children with an elimination disorder. This differs substantially from previous reports in literature. Although some controversy exists regarding the presence of anxiety in enuretic children (Gulisano et al., 2016) (with some authors even finding lower anxiety rates compared to HC subjects (Koca et al., 2014)), literature is almost unanimous in pointing higher depressive symptoms in enuretic children (Gulisano et al., 2016; Koca et al., 2014; Ş et al., 2019; Ucer & GumuA, 2013), and some authors associated it with punishment for bedwetting (Al‐Zaben & Sehlo, 2014). However, some of the included samples are from clinical settings, possibly including especially symptomatic children and thus, incurring in a selection bias.

Regarding externalizing symptoms, our findings show increased symptomatic scores for almost all the studied domains, including attention problems, aggressive behavior and social problems. This is in line with previous evidence (Wagner et al., 2015). However, it is not that clear those increased scores translate to clinically relevant behavioral problems (Erdogan et al., 2008). Moreover, many authors reported these behavioral differences disappeared once some variables such as socioeconomic status (SES), male gender or school performance were added to the analyses (Ozden et al., 2007; VAN HOECKE et al., 2003). Biological substrate also seems to play an important role in behavioral alterations; in fact, some authors have recently found abnormal neural responses to emotional stimuli, increased excitability and reduced inhibitory processing in individuals with nocturnal enuresis history (Khedr et al., 2015; Wang et al., 2015), similar to those findings reported in neuropsychiatric conditions such as ADHD or Tourette syndrome (Ma et al., 2016; Morand‐Beaulieu et al., 2017).

Far less information has been found on encopresis and its psychological and behavioral correlates. The 7 articles included in our systematic review show a lower self‐esteem in patients with encopresis, as well as higher symptomatic scores for both internalizing and externalizing problems. Previous literature shows consistent findings, and often notes poorer family functioning in families where children with encopresis are raised (Akça et al., 2011; Lisboa et al., 2008).

Last but not least, it is necessary to point out that a significant proportion of the studies included in the analysis appear to be lacking in terms of their quality. 55% of the included studies presented a NOS score of 6 or below, which suggests there may be important limitations in the study design or methodology and, consequently, a higher risk of bias, thus compromising the reliability and validity of its findings. Along with this issues, great heterogeneity was found across most of the studied domains. Also, several of the internalizing symptoms studied (such as the CBCL Internalizing broad band factor or the Somatic complaints subscale) presented significant differences among groups once the trim and fill method was applied where funnel plots suggested a publication bias. In the case of some externalizing behaviors (as the CBCL Externalizing broad band factor, among others) the opposite occurred, with these differences disappearing when the results were corrected by the aforementioned method. This speaks of the existence of highly relevant biases in the available literature. Many studies included small samples, most of them from clinical settings, therefore possibly subjected to selection bias. Some authors also used siblings of enuretic children, or children with other chronic disorders, as healthy controls, thus potentially incurring in other, important biases. All of the above suggests the need to perform further, unbiased research on the topic.

Shaffer described four possible ways to interpret associations between enuresis and psychological symptoms, also applicable for encopresis (Shaffer, 1973). First, there is no causal relationship between the two conceptions because their association is the result of chance. Second, psychological elements like temperament or unfavorable life events cause enuresis. Third, psychological symptoms represent a consequence of enuresis. And fourth, both psychological problems and enuresis are related to common risk factors, such as the aforementioned low socio‐economic status or male sex. These four explanations are not mutually exclusive, and often complement each other. Although further longitudinal research is needed to explore the causal nature of these two entities, it is clear emotional and behavioral symptoms are to be considered in the evaluation and treatment of any children with an elimination disorder.

Strengths and limitations

To the best of the authors' knowledge, this is the first systematic review and meta‐analysis to date to assess the relationship between elimination disorders and internalizing and externalizing problems. It evaluates a wide range of behaviors present in children with encopresis and enuresis, all of them measured through questionnaires with high validity and reliability.

Notwithstanding all the above, some important limitations must be mentioned.

Apart from the intrinsic limitations of the available literature (as detailed above), there was a significant lack of information on the patients studied, and therefore not enough data was available to perform meta‐regressions on several of the analyzed domains. Where analyses were possible, they failed to provide an explanation for the great heterogeneity found in the analyses. This could mean the results of the meta‐analysis could be related to, and partially explained by, third variables not studied, such as the type of enuresis (primary or secondary, diurnal or combined), the presence or absence of secondary physical punishment (Al‐Zaben & Sehlo, 2014), or socioeconomic status (VAN HOECKE et al., 2003). Likewise, elimination disorders, as well as their management by the child's caregivers, are strongly influenced by culture (Hurl, 2011). All of them are factors that have been extensively related in the past to both internalizing and externalizing symptoms as well as to elimination disorders, but it has not been possible to evaluate these potential moderators due to the lack of data in the original studies. Further research should consider and assess these issues, ideally using large, representative samples of children with elimination disorders and their healthy peers.

Implications for research and clinical practice

This systematic review and meta‐analysis holds several implications regarding future research and clinical practice. Practitioners should be aware that children with an elimination disorder may have internalizing and externalizing problems, as well as impaired self‐concept. This entails the need to consider these parameters when evaluating a child with encopresis and/or enuresis. Likewise, these findings seem to indicate that these disorders should not be approached from a purely behavioral or pharmacological point, but that psychological support and socio‐emotional training should be offered to both affected children and their main caregivers, in order to reduce and prevent the appearance of these symptoms.

Also, as discussed above, further research is needed to clarify for which particular internalizing and externalizing symptoms enuretic and encopretic children are at risk, as well as which factors might be moderating them. In order the study such symptoms, the authors suggest the need to use standardized definitions of elimination disorders, ideally differentiating between its subtypes: primary or secondary, diurnal or combined, as they could each have different psychopathological implications. Also, the authors consider CBCL to be the most comprehensive questionnaire to assess internalizing and externalizing symptoms in children, according to its validity and focus in symptomatologic domains.

CONCLUSION

Children with an elimination disorder presented higher scores for externalizing symptoms (including attention alterations, aggressive behavior and social problems), as well as a significantly lower self‐concept. On the other hand, no evidence has been found that depression or anxiety scores might be increased in children with an elimination disorder. Further, unbiased research is needed to clarify which factors might be moderating these findings.

AUTHOR CONTRIBUTIONS

Claudia Aymerich: Conceptualization; Data curation; Investigation; Methodology; Resources; Validation; Visualization; Writing – original draft. Borja Pedruzo: Conceptualization; Writing – original draft. Malein Pacho: Conceptualization; Data curation; Methodology. Jon Herrero: Data curation. Maria Laborda: Data curation. Gonzalo Salazar De Pablo: Conceptualization; Writing – review & editing. Eva Sesma: Writing – review & editing. Aranzazu Fernández‐Rivas: Writing – review & editing. Ana Catalan: Conceptualization; Investigation; Software; Supervision; Writing – review & editing. Miguel Ángel González‐Torres: Supervision; Writing – review & editing.

CONFLICT OF INTEREST STATEMENT

The authors have declared that they have no competing or potential conflicts of interest.

ETHICAL CONSIDERATIONS

No ethical approval was required for this research review.

Supporting information

Supporting Information S1

Click here for additional data file. (16.1MB, docx)

ACKNOWLEDGEMENTS

This research has received funding for publication charges from the Basque Country University.

Aymerich, C. , Pedruzo, B. , Pacho, M. , Herrero, J. , Laborda, M. , Bordenave, M. , Salazar de Pablo, G. , Sesma, E. , Fernández‐Rivas, A. , Catalan, A. , & González‐Torres, M. Á. (2023). Relationship between elimination disorders and internalizing‐externalizing problems in children: A systematic review and meta‐analysis. JCPP Advances, 3(3), e12185. 10.1002/jcv2.12185

Miguel Ángel González‐Torres and Ana Catalan have contributed equally and shared the senior position authorship.

DATA AVAILABILITY STATEMENT

The data that support the findings of this study are available from the corresponding author upon reasonable request.

REFERENCES

  1. Achenbach, T. M. , & Edelbrock, C. S. (1983). Manual for the child behavior checklist and revised child behavior profile. Dep. of Psychiatry. [Google Scholar]
  2. Achenbach, T. M. Ivanova, M. Y. , Rescorla, L. A. , Turner, L.V., Althoff, R. R.. (2016). Internalizing/externalizing problems: Review and Recommendations for clinical and research applications. Journal of the American Academy of Child & Adolescent Psychiatry, 55(8), 647–656. 10.1016/j.jaac.2016.05.012 [DOI] [PubMed] [Google Scholar]
  3. Akça, ÖF. , Aysev, A. , & Aycan, İÖ (2011). Familial features and comorbid psychiatric disorders in children with encopresis. Klinik Psikofarmakoloji Bülteni, 21(4), 345–352. 10.5455/bcp.20110502050441 [DOI] [Google Scholar]
  4. Akyüz, M. , Koca, O. , Karaman, B. , Özcan, Z. Y. , Öztürk, M. İ. , Kutluhan, M. A. , & Karaman, M. İ. (2016). Evaluation of behavioral problems in patients with monosymptomaticnocturnal enuresis: A prospective controlled trial. Turkish Journal of Medical Sciences, 46, 807–811. 10.3906/sag-1502-90 [DOI] [PubMed] [Google Scholar]
  5. Altman, D. G. , Simera, I. , Hoey, J. , Moher, D. , & Schulz, K. (2008). Equator: Reporting guidelines for health research. Lancet, 371(9619), 1149–1150. [doi]. 10.1016/S0140-6736(08)60505-X [DOI] [PubMed] [Google Scholar]
  6. Al‐Zaben, F. N. , & Sehlo, M. G. (2014). Punishment for bedwetting is associated with child depression and reduced quality of life. Child Abuse & Neglect, 43, 22–29. 10.1016/j.chiabu.2014.11.007 [DOI] [PubMed] [Google Scholar]
  7. American Psychiatric Association . (2022). Diagnostic and statistical manual of mental disorders (5th ed.). American Psychiatric Association Publishing. [Google Scholar]
  8. Azimi, M. S. , Shabestari, A. A. , Yousefichaijan, P. , Salehi, B. , & Habibi, D. (2019). Investigating the relationship between primary nocturnal enuresis with daily urinary problems and generalized anxiety disorder. Journal of Evolution of Medical and Dental Sciences, 8(30), 2429–2433. 10.14260/jemds/2019/531 [DOI] [Google Scholar]
  9. Bachmann, C. , Lehr, D. , Janhsen, E. , Sambach, H. , Muehlan, H. , von Gontard, A. , & Bachmann, H. (2009). Health related quality of life of a tertiary referral center population with urinary incontinence using the DCGM‐10 questionnaire. The Journal of Urology, 182(4S), 2000–2006. 10.1016/j.juro.2009.03.065 [DOI] [PubMed] [Google Scholar]
  10. Bahnasy, W. S. , El‐Heneedy, Y. A. E. , El‐Seidy, E. A. S. , Ibrahim, I. S. E. , Seleem, M. A. H. , & Ahmed, A. Y. (2018). Primary monosymptomatic nocturnal enuresis: An etiological study. Egypt J Neurol Psychiatry Neurosurg, 54(1), 19. 10.1186/s41983-018-0020-4 [DOI] [Google Scholar]
  11. Birdal, S. , & Doğangün, B. (2016). Behavioural problems in children with enuresis. Turk Pediatri Arsivi, 51(3), 142–147. 10.5152/TurkPediatriArs.2016.2967 [DOI] [PMC free article] [PubMed] [Google Scholar]
  12. Buysse, D. J. , Reynolds, C. F. , Monk, T. H. , Berman, S. R. , & Kupfer, D. J. (1989). The Pittsburgh sleep quality index: A new instrument for psychiatric practice and research. Psychiatry Research, 28(2), 193–213. 10.1016/0165-1781(89)90047-4 [DOI] [PubMed] [Google Scholar]
  13. Coppola, G. , Costantini, A. , Gaita, M. , & Saraulli, D. (2011). Psychological correlates of enuresis: A case–control study on an Italian sample. Pediatric Nephrology, 26(10), 1829–1836. 10.1007/s00467-011-1880-3 [DOI] [PubMed] [Google Scholar]
  14. Cox, D. J. , Morris, J. B. , Borowitz, S. M. , Sutphen, J. L. (2002). Psychological differences between children with and without chronic encopresis. Journal of Pediatric Psychology, 27(7), 585–591. 10.1093/jpepsy/27.7.585 [DOI] [PubMed] [Google Scholar]
  15. De Bruyne, E. , Van Hoecke, E. , Van Gompel, K. , Verbeken, S. , Baeyens, D. , Hoebeke, P. , & Vande Walle, J. (2009). Problem behavior, parental stress and enuresis. The Journal of Urology, 182(4S), 2015–2021. 10.1016/j.juro.2009.05.102 [DOI] [PubMed] [Google Scholar]
  16. de Sena Oliveira, A. C. , Athanasio, BdS. , Mrad, F. C.C. , Vasconcelos, M. M., Rodriguez‐Albuquerque, M., Marques‐Miranda, D., Simoes e Silva A. C.  (2021). Attention deficit and hyperactivity disorder and nocturnal enuresis co‐occurrence in the pediatric population: A systematic review and meta‐analysis. Pediatric Nephrology. 10.1007/s00467-021-05083-y [DOI] [PubMed] [Google Scholar]
  17. Desta, M. , Hagglof, B. , Kebede, D. , & Alem, A. (2007). Socio‐demographic and psychopathologic correlates of enuresis in urban Ethiopian children. Acta Paediatrica, 96(4), 556–560. 10.1111/j.1651-2227.2007.00229.x [DOI] [PubMed] [Google Scholar]
  18. Duval, S. , & Tweedie, R. (2000). Trim and fill: A simple funnel‐plot–based method of testing and adjusting for publication bias in meta‐analysis. Biometrics, 56(2), 455–463. 10.1111/j.0006-341X.2000.00455.x [DOI] [PubMed] [Google Scholar]
  19. Equit, M. , Klein, A. , Braun‐Bither, K. , Gräber, S. , & von Gontard, A. (2013). Elimination disorders and anxious‐depressed symptoms in preschool children: A population‐based study. European Child & Adolescent Psychiatry. 10.1007/s00787-013-0468-9 [DOI] [PubMed] [Google Scholar]
  20. Erdogan, A. , Akkurt, H. , Boettjer, N. K. , Yurtseven, E. , Can, G. , & Kiran, S. (2008). Prevalence and behavioural correlates of enuresis in young children. Journal of Paediatrics and Child Health, 44(5), 297–301. 10.1111/j.1440-1754.2007.01255.x [DOI] [PubMed] [Google Scholar]
  21. Ertan, P. , Yilmaz, O. , Caglayan, M. , Sogut, A. , Aslan, S. , & Yuksel, H. (2009). Relationship of sleep quality and quality of life in children with monosymptomatic enuresis. Child: Care, Health and Development, 35(4), 469–474. 10.1111/j.1365-2214.2009.00940.x [DOI] [PubMed] [Google Scholar]
  22. Gozmen, S. , Keskin, S. , & Akil, I. (2008). Enuresis nocturna and sleep quality. Pediatric Nephrology, 23(8), 1293–1296. 10.1007/s00467-008-0817-y [DOI] [PubMed] [Google Scholar]
  23. Greenslade, K. E. , Milich, R. , & Pelham, W. E., Jr. (1992). Teacher ratings of DSM‐III‐R symptoms for the disruptive behavior disorders. 10.1097/00004583-199203000-00006 [DOI] [PubMed]
  24. Gulisano, M. , Domini, C. , Capelli, M. , Pellico, A. , & Rizzo, R. (2016). Importance of neuropsychiatric evaluation in children with primary monosymptomatic enuresis. Journal of Pediatric Urology, 13(1), 36.e1–36.e6. 10.1016/j.jpurol.2016.10.019 [DOI] [PubMed] [Google Scholar]
  25. Gunes, A. , Gunes, G. , Acik, Y. , & Akilli, A. (2009). The epidemiology and factors associated with nocturnal enuresis among boarding and daytime school children in southeast of Turkey: A cross sectional study. BMC Public Health, 9(1), 357. 10.1186/1471-2458-9-357 [DOI] [PMC free article] [PubMed] [Google Scholar]
  26. Hägglöf, B. , Andrén, O. , Bergström, E. , Maklund, L., Wendelius, M.. (1997). Self‐esteem before and after treatment in children with nocturnal enuresis and urinary incontinence. Scandinavian Journal of Urology and Nephrology. [PubMed] [Google Scholar]
  27. Hamed, S. A. , Fawzy, M. , & Hamed, E. A. (2021). Behavioral problems in children with primary monosymptomatic nocturnal enuresis. Comprehensive Psychiatry, 104, 152208. 10.1016/j.comppsych.2020.152208 [DOI] [PubMed] [Google Scholar]
  28. Higgins, J. P. T. , Thomas, J. , Chandler, J. , Cumpston, M. , Li, T. , Page, M. J. , & Welch, V. A. (Eds.) (2022)., Cochrane handbook for systematic reviews of interventions. (updated February 2022). [Google Scholar]
  29. Hurl, C. (2011). Urine trouble: A social history of bedwetting and its regulation. History of the Human Sciences, 24(2), 48–64. 10.1177/0952695111400957 [DOI] [PubMed] [Google Scholar]
  30. Joinson, C. , Heron, J. , Butler, U. , & von Gontard, A. (2006). Psychological differences between children with and without soiling problems. Pediatrics, 117(5), 1575–1584. 10.1542/peds.2005-1773 [DOI] [PubMed] [Google Scholar]
  31. Kanaheswari, Y. , Poulsaeman, V. , & Chandran, V. (2012). Self‐esteem in 6‐ to 16‐year‐olds with monosymptomatic nocturnal enuresis. Journal of Paediatrics and Child Health, 48(10), E178–E182. 10.1111/j.1440-1754.2012.02577.x [DOI] [PubMed] [Google Scholar]
  32. Kanata, S. , Koike, S. , Ando, S. , Nishida, A. , Usami, S. , Yamasaki, S. , Morimoto, Y. , Toriyama, R. , Fujikawa, S. , Sugimoto, N. , Sasaki, T. , Furukawa, T. A. , Hiraiwa‐Hasegawa, M. , & Kasai, K. (2016). Enuresis and hyperactivity‐inattention in early adolescence: Findings from a population‐based survey in Tokyo (Tokyo Early Adolescence Survey). PLoS One, 11(7), e0158786. 10.1371/journal.pone.0158786 [DOI] [PMC free article] [PubMed] [Google Scholar]
  33. Karaca Ünlü, A. , Aksu, B. , Ağbaş, A. , & Elevli̇, M. (2020). Evaluation of anxiety levels in children and their mothers with monosymptomatic nocturnal enuresis. İstanbul Tıp Fakültesi Dergisi, 83(2). 10.26650/IUITFD.2018.0031 [DOI] [Google Scholar]
  34. Khedr, E. M. , Abo‐Elfetoh, N. , Elbeh, K. A. , Baky, A. , Gamal, R. , El Hammady, D. , & Korashy, F. (2015). Transcranial magnetic stimulation identifies cortical excitability changes in monosymptomatic nocturnal enuresis. Neurophysiologie Clinique, 45(2), 151–158. 10.1016/j.neucli.2015.02.001 [DOI] [PubMed] [Google Scholar]
  35. Koca, O. , Akyüz, M. , Karaman, B. , Özcan, Z. Y. , Öztürk, M. , & Sertkaya, Z. (2014). Evaluation of depression and self‐esteem in children with monosymptomatic nocturnal enuresis: A controlled trial. Archivio Italiano di Urologia, Andrologia, 86(3), 212. 10.4081/aiua.2014.3.212 [DOI] [PubMed] [Google Scholar]
  36. Kovacs, M. (1981). Rating scales to assess depression in school‐aged children. Acta Paedopsychiatrica. [PubMed] [Google Scholar]
  37. Kovacs, M. (1981). Rating scales to assess depression in school‐aged children. Acta Paedopsychiatrica, 46(5‐6), 305–315. [PubMed] [Google Scholar]
  38. Landman, G. B. , Rappaport, L. , Fenton, T. , & Levine, M. D. (1986). Locus of control and self‐esteem in children with encopresis. Journal of Developmental and Behavioral Pediatrics, 7(2), 111–113. 10.1097/00004703-198604000-00007 [DOI] [PubMed] [Google Scholar]
  39. Lipsey, M. W. , & Wilson, D. B. (2009). Practical meta‐analysis. Nachdr. Sage. Thousand Oaks [u.a. [Google Scholar]
  40. Lisboa, V. C. A. , Felizola, M. C. M. , Martins, L. A. N. , Tahan, S. , Neto, U. F. , & de Morais, M. B. (2008). Aggressiveness and hostility in the family environment and chronic constipation in children. Digestive Diseases and Sciences, 53(9), 2458–2463. 10.1007/s10620-008-0230-1 [DOI] [PubMed] [Google Scholar]
  41. Liu, J. (2004). Childhood externalizing behavior: Theory and implications. Journal of Child and Adolescent Psychiatric Nursing, 17(3), 93–103. 10.1111/j.1744-6171.2004.tb00003.x [DOI] [PMC free article] [PubMed] [Google Scholar]
  42. Ma, I. , van Duijvenvoorde, A. , & Scheres, A. (2016). The interaction between reinforcement and inhibitory control in ADHD: A review and research guidelines. Clinical Psychology Review, 44, 94–111. 10.1016/j.cpr.2016.01.001 [DOI] [PubMed] [Google Scholar]
  43. Mattheus, H. K. , Kiefer, K. , Freund, R. , Hussong, J. , Wagner, C. , Equit, M. , In‐Albon, T. , Bolten, M. I. , & von Gontard, A. (2021). Psychopathology and parental stress in 3‐6‐year‐old children with incontinence. Zeitschrift für Kinder‐ und Jugendpsychiatrie und Psychotherapie, 49(4), 249–258. 10.1024/1422-4917/a000804 [DOI] [PubMed] [Google Scholar]
  44. Ma, Y. , Shen, Y. , & Liu, X. (2020). Self‐concept in children with primary nocturnal enuresis and related influencing factors. Iranian Journal of Public Health. 10.18502/ijph.v49i4.3190 [DOI] [PMC free article] [PubMed] [Google Scholar]
  45. Moher, D. , Liberati, A. , Tetzlaff, J. , & Altman, D. G. (2009). Preferred reporting items for systematic reviews and meta‐analyses: The PRISMA statement. BMJ, 339(jul21 1), b2535. 10.1136/bmj.b2535 [DOI] [PMC free article] [PubMed] [Google Scholar]
  46. Morand‐Beaulieu, S. , Grot, S. , Lavoie, J. , Leclerc, J. B. , Luck, D. , & Lavoie, M. E. (2017). The puzzling question of inhibitory control in tourette syndrome: A meta‐analysis. Neuroscience & Biobehavioral Reviews, 80, 240–262. 10.1016/j.neubiorev.2017.05.006 [DOI] [PubMed] [Google Scholar]
  47. Natale, N. , Kuhn, S. , Siemer, S. , Stöckle, M. , & von Gontard, A. (2009). Quality of life and self‐esteem for children with urinary urge incontinence and voiding postponement. The Journal of Urology, 182(2), 692–698. 10.1016/j.juro.2009.04.033 [DOI] [PubMed] [Google Scholar]
  48. Niemczyk, J. , Equit, M. , Braun‐Bither, K. , Klein, A. M. , & von Gontard, A. (2014). Prevalence of incontinence, attention deficit/hyperactivity disorder and oppositional defiant disorder in preschool children. European Child & Adolescent Psychiatry, 24(7), 837–843. 10.1007/s00787-014-0628-6 [DOI] [PubMed] [Google Scholar]
  49. Owens‐stively, J. A. (1987). Self‐esteem and compliance in encopretic children. Child Psychiatry and Human Development. [DOI] [PubMed] [Google Scholar]
  50. Ozden, C. , Ozdal, O. L. , Altinova, S. , Oguzulgen, I. , Urgancioglu, G. , & Memis, A. (2007). Prevalence and associated factors of enuresis in Turkish children. International Braz J Urol, 33(2), 216–222. 10.1590/S1677-55382007000200013 [DOI] [PubMed] [Google Scholar]
  51. Piers, E. V. (1984). Piers‐harrrs children's SelJ‐concept scale (revised manual). Western Psychological Services. [Google Scholar]
  52. R Foundation for Statistical Computing (2021). Radiokhimiya: A language and environment for statistical computing, 14, 1106. [Google Scholar]
  53. Redsell, S. A. , & Collier, J. (2001). Bedwetting, behaviour and self‐esteem: A review of the literature. Child: Care, Health and Development, 27(2), 149–162. 10.1046/j.1365-2214.2001.00195.x [DOI] [PubMed] [Google Scholar]
  54. Reese, A. A. , Bhojani, S. , & Heller, D. (2013). In JosephGeneva M. R. (Ed.), IACAPAP e‐textbook of child and adolescent mental health, International association for child and adolescent psychiatry and allied professions. Journal of the American Academy of Child and Adolescent Psychiatry. 10.1016/j.jaac.2013.01.001 [DOI] [Google Scholar]
  55. Robinson, J. C. , Butler, R. J. , Holland, P. , & Doherty‐Williams, D. (2003). Self‐construing in children with primary mono‐symptomatic nocturnal enuresis, an investigation of three measures. Scandinavian Journal of Urology and Nephrology, 37(2), 124–128. 10.1080/00365590310008857 [DOI] [PubMed] [Google Scholar]
  56. Ş, E. , Tekcan, D. , & Baran, Y. (2019). More anxious or more shy? Examining the social anxiety levels of adolescents with primary enuresis nocturna: A controlled study. Journal of Pediatric Urology, 15(4), 343.e1–343.e5. 10.1016/j.jpurol.2019.04.002 [DOI] [PubMed] [Google Scholar]
  57. Shaffer, D. (1973). Bladder control and enuresis. William Heinemann Medical Books.118. [Google Scholar]
  58. Shreeram S, M. D. , He, J. , Kalaydjian, A. , & Brothers, S. (2009). Prevalence of enuresis and its association with attention‐deficit/hyperactivity disorder among U.S. Children: Results from a nationally representative study. Journal of the American Academy of Child & Adolescent Psychiatry, 48(1), 35–41. 10.1097/CHI.0b013e318190045c [DOI] [PMC free article] [PubMed] [Google Scholar]
  59. Stroup, D. F. , Berlin, J. A. , & Morton, S. C. (2000). Meta‐analysis of observational studies in epidemiology: A proposal for reporting. Meta‐Analysis of observational studies in epidemiology (MOOSE) group. JAMA, the Journal of the American Medical Association. [DOI] [PubMed] [Google Scholar]
  60. Tai, B. T. , Tai, T. T. , Chang, Y. , & Huang, K. H. (2016). Factors associated with remission of primary nocturnal enuresis and changes of parental perception towards management strategies: A follow‐up study. Journal of Pediatric Urology, 13(1), 44.e1–44.e9. 10.1016/j.jpurol.2016.09.012 [DOI] [PubMed] [Google Scholar]
  61. Theunis, M. , Van Hoecke, E. , Paesbrugge, S. , Hoebeke, P. , & Vande Walle, J. (2002). Self‐image and performance in children with nocturnal enuresis. European Urology, 41(6), 660–667. 10.1016/S0302-2838(02)00127-6 [DOI] [PubMed] [Google Scholar]
  62. Tien, J. , Lewis, G. D. , & Liu, J. (2019). Prenatal risk factors for internalizing and externalizing problems in childhood. World J Pediatr, 16(4), 341–355. 10.1007/s12519-019-00319-2 [DOI] [PMC free article] [PubMed] [Google Scholar]
  63. Ucer, O. , & GumuA, B. (2013). Quantifying subjective assessment of sleep quality, quality of life and depressed mood in children with enuresis. World Journal of Urology, 32(1), 239–243. 10.1007/s00345-013-1193-1 [DOI] [PMC free article] [PubMed] [Google Scholar]
  64. Van Hoecke, E. , De Fruyt, F. , De Clercq, B. , Hoebeke, P. , & Vande Walle, J. (2006). Internalizing and externalizing problem behavior in children with nocturnal and diurnal enuresis: A five‐factor model perspective. Journal of Pediatric Psychology, 31(5), 460–468. 10.1093/jpepsy/jsj037 [DOI] [PubMed] [Google Scholar]
  65. van Hoecke, E. , Baeyens, D. , Vande Walle, J. , Hoebeke, P. , & Roeyers, H. (2003). Socioeconomic status as a common factor underlying the association between enuresis and psychopathology. Journal of Developmental and Behavioral Pediatrics, 24(2), 109–114. 10.1097/00004703-200304000-00006 [DOI] [PubMed] [Google Scholar]
  66. van Hoecke, E. , Hoebeke, P. , Braet, C. , & Walle, J. V. (2004). AN assessment of internalizing problems in children with enuresis. The Journal of Urology, 171(6 Part 2), 2580–2583. 10.1097/01.ju.0000110521.20103.14 [DOI] [PubMed] [Google Scholar]
  67. von Gontard, A. , Baeyens, D. , & Van Hoecke, E. (2011). Psychological and psychiatric issues in urinary and fecal incontinence. The Journal of Urology. 10.1016/j.juro.2010.11.051 [DOI] [PubMed] [Google Scholar]
  68. Wagner, C. , Equit, M. , Niemczyk, J. , & von Gontard, A. (2015). Obesity, overweight, and eating problems in children with incontinence. Journal of Pediatric Urology, 11(4), 202–207. 10.1016/j.jpurol.2015.05.019 [DOI] [PubMed] [Google Scholar]
  69. Wang, M. , Zhang, K. , Zhang, J. , Dong, G. , Zhang, H. , & Du, X. (2015). Abnormal neural responses to emotional stimuli but not go/NoGo and stroop tasks in adults with a history of childhood nocturnal enuresis. PLoS One, 10(11), e0142957. 10.1371/journal.pone.0142957 [DOI] [PMC free article] [PubMed] [Google Scholar]
  70. Wells, G. A. , Shea, B. , O’Connell, D. , Peterson, J. , Welch, V. , & Losos, M. (2012). The Newcastle‐Ottawa Scale (NOS) for assessing the quality of non‐randomized studies in meta‐analyses.
  71. Yaradilmiş, R. M. , Büyükkaragöz, B. , Yilmaz, A. Ç , & Tayfur, A. Ç. (2020). Severity of self‐reported depressive symptomatology and relevant factors in children with primary monosymptomatic nocturnal enuresis and their mothers. Pediatric Nephrology, 35(7), 1277–1285. 10.1007/s00467-020-04512-8 [DOI] [PubMed] [Google Scholar]

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Supplementary Materials

Supporting Information S1

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Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.

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