Abstract
Background
Mental health problem impacts the life of children, adolescents, and their family. Different physiological factors were implicated as etiology of Nocturnal Enuresis (NE). Small body of research examined the impact of mental health problem on NE in children and adolescents.
Method
At Wolaita Sodo University Comprehensive Specialized Hospital, a cross-sectional study was carried out between September 22, 2022, and November 22, 2022 to examine association between mental health problems and NE among children and adolescents. A Sample of 423 research participants was recruited using systematic random sampling. A structured, in-person interviewer-administered questionnaire was used to collect the data. A Diagnostic Statistical Manual (DSM-5) were used to assess NE and Strengths and Difficulties questionnaire (SDQ) parent report version were used to screen for child and adolescent mental health problems. Bi-variate and multivariate analysis were used to determine the association between independent and outcome variables. A 95% confidence interval (CI) with a corresponding p-value < 0.05 was used to determine the strength of the association.
Result
Out of 423 participants 417 were participated in the study. The mean age of the participants was 8.3 ± 2.3 years. Two hundred forty seven (n 247, 59.2%) of the participants were between 5 and 8 years and (n 271, 65%) were boys. Regarding living status of the participated children and adolescents (n 297, 71.2%) were living with their parents. According to the educational level of children and adolescents (n 270, 64.7%) were primary school and above, while education level for (n 151, 36.2%) parents were high school and above. The magnitude of NE was (n 57, 13.7%). The overall magnitude of behavioral and emotional problem was, (n 154, 36.9%) and specifically (n 139, 33.3%) had emotional problems, (n 73, 17.5%) had hyperactive-inattention, (n 89, 21.3%) had conduct problems, and (n 134, 32.1%) had peer problems. NE occurred among 29.8% (n 17) of children with abnormal total difficulty score, 22.8% (n 13) of children with conduct problem, 10.5% (n 6) of children with emotional problems, 21.1% (n 12) of children with hyperactive-inattention problem, and 10.5% (n 6) of children with peer problems. The total difficulty score (AOR = 0.94; 95% CI: 0.46, 1.93), conduct problems (AOR = 0.72; 95% CI: 0.35, 1.48) and hyperactivity-inattention problems (AOR = 0.49; 95% CI: 0.23, 1.04) were not found to be associated with NE. But Emotional problems (AOR = 3.7; 95% CI: 1.52, 9.04) and peer problems (AOR = 3.4; 95% CI: 1.39, 8.31) found to independently associated with NE.
Conclusion and recommendation
In this study emotional and peer-problems - but not the total difficulty score, conduct or hyperactivity problems – were associated with NE. Thus, targeted early intervention focusing on emotional and peer problems should be designed to improve children’s and adolescents NE.
Keywords: Children, Adolescents, Mental health problems, Nocturnal enuresis
Introducation
Diagnostic and statistical Manual (DSM-5) defines Nocturnal Enuresis (NE) as the involuntary or repeated voiding of urine into clothing or the bed at night in a child at least 5 years old, with a frequency of 2 times a week for at least 3 consecutive months, or the presence of clinically significant distress or impairment in social, academic (occupational), or other critical areas of functioning [1]. By the age of five, the percentage of childern with NE is 20%, and by the age of fifteen, only roughly 1% of adolescents had a problem with NE, with a spontaneous resolution rate of nearly 15% per year [2, 3]. NE in children and adolescents is linked to a number of social and psychological problems, such as poor mental wellbeing, low self-esteem [4, 5], higher anxiety-depressive symptoms [6, 7], and behavioral problems such asconduct, and hyperactivity [8, 9] problems [10]. These associations are particularly pronounced above the age of 8 years [11]. Some studies shows a diuretic and bladder irritant effect of caffeine has been shown to aggravate NE, while reducing its intakecan improve symptoms and drecrease episode of severity [12].
Mental health problems frequently causes NE in children and adolsecnts [13] notably, NE is placed eighth among stressful life events for both parents and childerns, including not getting along with friends or doing poorly academically, and is thought to be a very common distressing life experience during early adolescence [14].
Nocturnal enuresis often creates tension and conflict between the child and parents, while also exposing the child to teasing or stigma from siblings [15]. These experiences can negatively affect the child’s self-esteem, emotional security, and overall psychological wellbeing. Beyond the home, nocturnal enuresis may also interfere with children’s school attendance, concentration, and academic performance, further compounding the psychosocial burden and developmental challenges they face.” “Despite the pervasiveness of nocturnal enuresis (NE), limited research has explored its relationship with mental health problems in children and adolescents. To the best of the researcher’s knowledge, there is a lack of sufficient data examining this link, particularly in low- and middle-income settings. The small body of existing studies has reported mixed findings regarding the association between NE and mental health difficulties. Therefore, this study aimed to assess the impact of mental health problems on nocturnal enuresis among children and adolescents aged 5–14 years attending Wolaita Sodo University Comprehensive Specialized Hospital, South Ethiopia, in 2022.
Objective of the study
To assess association between mental health problems and nocturnal enuresis among Children and Adolescents at Wolaita Sodo University Comprehensive Specialized Hospital paediatric outpatient clinic who are aged 5–14 years old in South Ethiopia 2022.
Hypothesis
Null Hypothesis (H₀): Mental health problems not predicts nocturnal enuresis among children and adolescents.
Alternative Hypothesis (H₁): Mental health problems predicts nocturnal enuresis among children and adolescents.
Methods and materials
Study area and period
This study is carried out between September 22, 2022, and November 22, 2022 at Wolaita Sodo University Comprehensive Specialized Hospital, located 329 km south of Addis Ababa. About 450–500 patients receive inpatient, outpatient, and emergency care services daily from the hospital. The hospital provides service for more than three million residents in the catchment region [16].
Study design
This is a hospital-based cross-sectional study design.
Population
All children and adolescents ages 5–14 years who attended WSUCSH Paediatric outpatient department services during the study period.
Inclusion and exclusion criteria
For this study, participants aged 5–14 years were included. Children and adolescents who were in critical illness, unable to communicate during data collection and those with urinary system anatomical anomalies or enuresis due to medical conditions were excluded from the study. In this study, an eligibility assessment was conducted on the 423 study sample, of which 417 fulfilled the eligibility criteria and were included in the analysis.
Sampling technique and procedure
The sample size was calculated using a single population proportion formula. The following assumptions were considered: the proportion of (P) of NE to be 50%, 95% Confidence Interval (CI), a 5% margin of error (W), and a 10% non-response rate. Accordingly, the final sample size was 423. A systematic random sampling method was employed to recruit participants for the study. To determine the sampling framework, the average number of paediatric patients visiting the outpatient department over the three months preceding the study was obtained from the registration records. Based on this data, the estimated patient flow during the study period was estimated to be 2350. The sampling interval (k) was then calculated by dividing the estimated number of patients (N) by the required sample size (n), resulting in an interval of 5. The first participant was randomly selected using the lottery method from the range of 1 to k, and subsequent participants were chosen at every k− th interval until the target sample size was reached [16].
Study variables
The dependent variable was Nocturnal enuresis and independent variable were mental health problems were - total difficulty score, emotional problems, conduct problems, peer problem, and hyperactive problems.
Data collection instrument
Strengths and difficulties questionnaire parent report (SDQ-PR)
The exposure variable was measured using the strength and difficult questionnaire (SDQ-PR). The five subscales contain twenty-five items. Peer problem, conduct problem, emotional problem, hyperactivity, and pro-social behavior. The total difficulty score ranges from 0 to 40 (excluding pro-social behavioral subscale). Each item was assessed on a 3-point Likert scale. The cutoff for abnormal total difficulty score is ≥ 17 for screening overall behavioral and emotional problems (total difficulty score); with a sensitivity of 70.96% and a specificity of 69.15%. Cut offs for abnormal hyperactivity is ≥ 7, for conduct problem ≥ 4, peer problems ≥ 4, and for emotional problems ≥ 5 [17]. Cronbach’s alpha for internal consistency for overall SDQ in the current study’s setting was 0.79.
Diagnostic and statestical manual of mental disorder fifth edition
The outcome, NE, was assessed using the DSM-5 criteria. Accordingly, children and adolescents with wetting at night with a frequency of at least two times a week for at least 3 consecutive months are classified as having NE.
Data collection procedure
For children aged 5 to 8, data were collected from parents. Children and adolescents aged 9 to 14 years were interviewed by the data collectors using SDQ-PR and DSM-5 data collection tools. Children under 9 years of age may not understand the questions while those age 9 years and above understand the questions properly [18, 19]. Six BSc psychiatry graduates collected the data under the supervision of two MSc mental health specialists.
Data quality management
The questionnaire was first developed in English, translated into Amharic and Wolaita, and then back-translated into English by experts fluent in all the three languages, including mental health professionals, to ensure content validity. Supervisors and data collectors received two days of training prior to fieldwork. A pretest was conducted on 5% of the sample outside the study area to evaluate the reliability of the instruments and to identify potential issues with questionnaire modifications and data collection procedures. During data collection, supervisors and the principal investigator regularly monitored and supported data collectors, and they verified the accuracy and consistency of the data on a daily basis.
Data processing, analysis and presentation
For analysis, the data was exported from Epi Data Version 4.6 to the Statistical Package for Social Sciences (SPSS) Version 25. To describe sample characteristics and estimate the magnitude of NE and mental health issues, descriptive statistics were employed. The association between mental health problems and NE was conducted by logistic regression analysis. Variables with a p-value < 0.25 in bivariate analysis were entered into multivariable analysis to control confounding effects and variables with a p-value < 0.05 in multivariable analysis were considered to have a significant association with NE. A 95% CI and Odds ratio with corresponding p-value < 0.05 were used to determine the predictors of the outcome variable.
Result
The current study included 417 children and adolescents. The mean age of the participants was 8.3 ± 2.3 years, ranging from five to fourteen years. More than half (n 247, 59.2%) of the participated children were age between 5 and 8 years and (n 146, 35%) of participated children and adolescents were girls. Regarding living status of the participated children and adolescents (n 297, 71.2%) were living with their parents. According to the educational level of children and adolescents (n 270, 64.7%) were primary school and above, while education level for (n 151, 36.2%) parents were high school and above (Table 1).
Table 1.
Socio-demographic and family related characteristics of children and adolescents age 5–14 year old attending paediatric outpatient, at Wolaita Sodo university comprehensive specialized hospital, Wolaita Sodo, South Ethiopia, 2022
| Variable | Category | Frequency | Percentage (%) |
|---|---|---|---|
| Age | 5–8 year old | 247 | 59.2 |
| 9–11 year old | 113 | 27.1 | |
| 12–14 year old | 57 | 13.7 | |
| Child sex | Male | 271 | 65.0 |
| Female | 146 | 35.0 | |
| Residency | Urban | 241 | 57.8 |
| Rural | 176 | 42.2 | |
| Religion | Orthodox | 124 | 29.7 |
| Muslim | 64 | 15.3 | |
| Protestant | 185 | 44.4 | |
| Others* | 44 | 10.6 | |
| Ethnicity | Wolaita | 287 | 68.8 |
| Amhara | 56 | 13.4 | |
| Gurage | 38 | 9.1 | |
| Oromo | 13 | 3.1 | |
| Others** | 23 | 5.5 | |
| Educational level of child | Kindergarten (KG) | 147 | 35.3 |
| Primary and above | 270 | 64.7 | |
| Currently living | With parents | 297 | 71.2 |
| Steep parents | 62 | 14.9 | |
| Residential institution | 30 | 7.2 | |
| Gordian | 28 | 6.7 | |
| Family size | < 4 | 214 | 51.3 |
| >= 4 | 203 | 48.7 | |
| Occupation of parents | Government employ | 144 | 34.5 |
| Private | 54 | 12.9 | |
| Merchant | 64 | 15.3 | |
| Farmer | 62 | 14.9 | |
| Housewife | 19 | 4.6 | |
| Unemployed | 35 | 8.4 | |
| Daily labor | 39 | 9.4 | |
| Educational status of parents | Illiterate | 84 | 20.1 |
| Primary school | 182 | 43.6 | |
| High school and above | 151 | 36.2 | |
| Parents marital status | Married | 298 | 71.5 |
| Divorced | 48 | 11.5 | |
| Separated | 37 | 8.9 | |
| Widowed | 23 | 5.5 | |
| Single | 11 | 2.6 | |
| Average family monthly income | < 1000 | 61 | 14.6 |
| 1000–2500 | 60 | 14.4 | |
| 2500–3400 | 70 | 16.8 | |
| >= 3400 | 226 | 54.2 |
Magnitude of NE and mental health problem
The overall magnitude of nocturnal enuresis was (n 57, 13.7%) (Fig. 1) with (n 45, 16.6% in boys) and (n 12, 8.2% in girls) (Fig. 2). The total difficulty score was (n 154, 36.9%). The magnitude of specific emotional and behavioral problems were(n 139, 33.3%) for emotional problem, (n 73, 17.5%) for hyperactivity problems, (n 89, 21.3%) for conduct problem, and (n 134, 32.1%) for peer problems (Fig. 3). NE occurred in (n 17, 29.8%) of children with abnormal total difficulty score, (n 13, 22.8%) in children with conduct problems, (n 6, 10.5%) in children with emotional problems, (n 12, 21.1%) in children with hyperactive-inattention, and (n 6, 10.5%) in children with peer problems (Table 2).
Fig. 1.
magnitude of nocturnal enuresis among children and adolescents age 5–14 year old attending paediatric outpatient, at Wolaita sodo university comprehensive specialized hospital, Wolaita sodo, south Ethiopia, 2022
Fig. 2.
Magnitude of nocturnal enuresis by sex of children and adolescents age 5–14 year old attending paediatric outpatient, at Wolaita sodo university comprehensive specialized hospital, Wolaita sodo, south Ethiopia, 2022
Fig. 3.
Distribution of mental health status of children and adolescents age 5–14 year old attending paediatric outpatient, at Wolaita sodo university comprehensive specialized hospital, Wolaita sodo, south Ethiopia, 2022
Table 2.
The magnitude of nocturnal enuresis among children and adolescents have mental health problems who aged 5–14 year old attending paediatric outpatient, at Wolaita Sodo university comprehensive specialized hospital, Wolaita Sodo, South Ethiopia, 2022
| Variable | Category | Mental health problems | |||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| Behavioral and emotional problems | Conduct problems | Hyperactive-inattentive problems | Emotional problems | Peer problems | |||||||
| No N (%) |
Yes N (%) |
No N (%) |
Yes N (%) |
No N (%) |
Yes N (%) |
No N (%) |
Yes N (%) |
No N (%) |
Yes N (%) |
||
| Nocturnal enuresis | Yes | 40(70.2%) | 17(29.8%) | 44(77.2%) | 13(22.8%) | 45(78.9%) | 12(21.1%) | 51(89.5%) | 6(10.5%) | 51(89.5%) | 6(10.5%) |
| No | 225(62.5%) | 135(37.5%) | 284(78.9%) | 76(21.1%) | 299(83.1%) | 61(16.9%) | 227(63.1%) | 133(36.9%) | 232(64.4%) | 128(35.6%) | |
Association of mental health problems and nocturnal enuresis
Table 3 shows the association between mental health problems and nocturnal enuresis among children and adolescents. In bivariable analysis total difficulty score, emotional and peer problems were significantly associated with NE at p-value < 0.25. Multivariable analysis show that total difficulty score, (AOR = 0.94; 95%CI: 0.46, 1.93), were not associated with NE and emotional problems (AOR = 3.7, 95%CI: 1.52, 9.04) and peer problems (AOR = 3.4, 95%CI: 1.39, 8.31) were significantly association with NE at p-value < 0.05.
Table 3.
Bivariate and multivariable analysis for associations of mental health problems and nocturnal enuresis among children and adolescents age 5–14 year old attending paediatric outpatient, at Wolaita Sodo university comprehensive specialized hospital, Wolaita Sodo, South Ethiopia, 2022
| Factors | Category | Nocturnal Enuresis | COR (95%CI) | AOR(95%CI) | P-value | |
|---|---|---|---|---|---|---|
| No (N) | Yes (N) | |||||
| Behavioral and emotional problems | No | 223 | 40 | 1 | 1 | 1 |
| Yes | 137 | 17 | 1.45(0.79, 2.65) | 0.94(0.46,1.93) | 0.87 | |
| Conduct problems | No | 284 | 44 | 1 | 1 | 1 |
| Yes | 76 | 13 | 0.91(0.46, 1.77) | 0.72(0.35, 1.48) | 0.38 | |
| Emotional Problems | No | 227 | 51 | 1 | 1 | 1 |
| Yes | 133 | 6 | 4.98(2.08, 11.92) | 3.7(1.52, 9.04 | 0.004* | |
| Hyperactivity-inattention | No | 299 | 45 | 1 | 1 | 1 |
| Yes | 61 | 12 | 0.76(0.38, 1.53) | 0.49(0.23, 1.04) | 0.62 | |
| Peer Problems | No | 232 | 51 | 1 | 1 | 1 |
| Yes | 128 | 6 | 4.69(1.96, 11.23) | 3.4(1.39, 8.31 | 0.007* | |
* Factors that have association at p-value < 0.05, 1 indicates reference category
COR Crude Odds Ratio, AOR Adjusted Odds Ratio, CI confidence interval
Discussion
Epidemiological studies have reported that mental health problems in children and adolescents contribute nocturnal enuresis. In this study we found that the magnitude of NE in children with abnormal total difficulty score was 29.8% (n 17), 22.8% (n 13) in children with conduct problems, 10.5% (n 6) in children with emotional problems, 21.1% (n 12) in children with hyperactive-inattention problem, and 10.5% (n 6) in children with peer problems. These findings are consistent with several studies where a prevalence of NE was reported to range between 4% and 80% in children with attention deficit hyperactivity disorder (ADHD) contributes 4.1% to 74.9% of NE in children and adolescents [20, 21]. Thus, the occurrence of high rate of nocturnal enuresis in children and adolescents with mental health problems in our study is supported by previous studies [22–24].
The relationship between NE and mental health problems in children and adolescents is complex and often bidirectional. While enuresis can trigger psychological distress, pre-existing psychological problems can also contribute or intensify enuresis [25–27].
Studies show that the occurrence of nocturnal enuresis was higher among children and adolescents with conduct problems. This relationship is due to a child with underlying impulsivity and behavioral dysregulation may be less compliant with treatment strategies (e.g., refusing to limit evening drinks, not using a bedwetting alarm). Furthermore, stressful home environments associated with conduct problems can be a contributing factor to enuresis [28].
Attention deficit hyperactivity disorder (ADHD) are one of the major mental health problems among children and adolescents contributing for NE. Children with ADHD are statistically more likely to have enuresis (and other elimination disorders like encopresis), and vice versa [29]. This link is believed to be primarily neurobiological rather than psychological. Theoretically, both ADHD and enuresis involve a delay in the maturation of the central nervous system, and this could affect both bladder control and the brain’s executive functions (impulse control, attention, and regulation). For this reason children with ADHD often have dysregulated sleep patterns and are notoriously deep sleepers, and this profound sleep makes it even harder for them to awaken to the sensation of a full bladder [30–32].
In this study we reported that NE is strongly associated with emotional problems, which is consistent with studies from Taiwan [33]. This association might arise from the direct effect of emotional problems on NE [34, 35]. Many children experience NE due to cognitive, social, behavioral and emotional problems, like low self-esteem, embarrassment, loss of dignity, aggressive behavior, loneliness, and anxiety symptoms. These psychosocial issues lead to the high risk of NE in children and adolescents in later life [36]. Furthermore, one of the prominent causes of nocturnal enuresis is emotional problem. A child’s likelihood of bedwetting may increase if they are experiencing emotional problems, such as moving to a new home or school, witnessing their parents’ divorce or other conflicts, losing a parent or other loved one, or going through another significant life event [37, 38].
Finally in this study there is significant association between nocturnal enuresis and peer problems which is in line with studies reported from Turkey [39]. A plausible rationale for this association could be the risk of having NE among children and adolescents with peer problems is high due to feelings of shame, embarrassment, and social isolation related with low self-confidence. This may increase the likelihood of peer problems in the paediatric population contributes NE. In comparison to their peers who are healthy, bedwetting children also have a poor self-image, poor self-esteem, decreased self-confidence, social avoidance and lower school performance. Consequently, there is a greater chance of NE in one-third of children with peer problems and psychological distress [40, 41]. Moreover, nocturnal enuresis is prevalent among children and adolescents with peer problems due to peer relationship problems take great effort to hide their condition from their friends, believing they are the only ones who suffer from the problem [42–44]. Moreover, peer problems impair children’s ability to participate in social activities, which leads children to stress and anxiety when they want basic needs from their parents or friends. This can cause stress and anxiety-related urine incontinence in children and adolescents [44, 45].
There were a few limitations to this study: it was single-cross-sectional and hospital-based, so the clinical severity of the cases may have been higher than average, and the results might be not generalized to community settings; and certain variables were susceptible to recall bias when being measured. In conclusion, the present study revealed that NE is associated with emotional and peer problems among children and adolescents. According to the findings, it is critical to address the co-occurrence of NE among children and adolescents with emotional and behavioral problems. Therefore, early detection and management of emotional and peer problems in children and adolescent will reduce the burden of NE among these age groups.
Acknowledgements
The authors express their gratitude to Jimma University for its financial assistance and to the study participants for supplying study data.
Abbreviations
- ADHD
Attention-deficit/hyperactivity disorder
- CI
Confidence Interval
- DSM-5
Diagnostic and statestical manual of mental disorder fifth edition
- IRB
Institutional Review Board
- NE
Nocturnal enuresis
- SDQ-PR
Strength and Difficulty Questionnaire Parent Report
- WSUCSH
Wolaita Sodo University Comprehensive Specialized Hospital
Author contributions
TB developed the proposal, was extensively involved in the data analysis, interpreted the data, and wrote the draft manuscript. YT, MA and SG; - revised the proposal, checked the data analysis, revised the manuscript, and read and approved the final manuscript.
Funding
The study was supported financially by Jimma University. Regarding the study’s design, data collecting, analysis, and interpretation, as well as the manuscript’s composition, Jimma University has no official involvement.
Data availability
The datasets used and/or analyzed during the current study are available from the corresponding authors on reasonable request.
Declarations
Ethics approval and Consent to participate
The Jimma University Institute of Health’s Institutional Review Board (IRB) granted ethical approval for this study (Ref. No.JUIH/IRB/63/22). All study participants received comprehensive information about the study on an information sheet that complied with pertinent rules and regulations of Ethiopian medical research ethics standards, which are similar to those of the 1964 Declaration of Helsinki. All parents of participating children and adolescents provided written informed consent, and the children and adolescents verbally consented to participate. Children and adolescents have nocturnal enuresis and mental health problems after screen was linked to a health care service for further treatment.
Consent for publication
Not applicable.
Clinical trial
Not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The datasets used and/or analyzed during the current study are available from the corresponding authors on reasonable request.