A retrospective observational study of enuresis, daytime voiding symptoms, and response to medical therapy in children with attention deficit hyperactivity disorder and autism spectrum disorder
Introduction
Enuresis is the most common urologic health problem affecting children in the Western world. As per International Children’s Continence Society guidelines, enuresis is defined as incontinence in discreet episodes while asleep [1]. Other daytime voiding symptoms (DVS) common in children include daytime incontinence (DI), or the uncontrollable leakage of urine, either continuously or intermittently while awake, urgency, or the sudden and unexpected experience of an immediate need to void; and frequency, or when a child voids eight or more times daily [1]. The prevalence of enuresis is estimated at 20% in 5 year olds, 10% in 10 year olds, and 3% in 15 year olds [2]. While 3% of children will remain enuretic as adults, most children outgrow enuresis at a rate of about 14% per year. Enuresis is more common in young boys than girls; however this gender disparity disappears by adolescence [3]. A quarter to a half of children with enuresis also have associated daytime symptoms that include frequency and urgency, with or without daytime incontinence [2], [4]. Enuresis has a complex etiology involving genetic, somatic, and behavioral factors [5].
Attention deficit hyperactivity disorder (ADHD) is the most common pediatric neurobehavioral disorder, and is estimated to occur in 6%–10% of children between 5 and 17 years of age in the United States [6], [7], [8]. Hyperactivity, impulsivity, and inattentiveness are hallmarks of ADHD. It is well documented that children with ADHD show an increased prevalence of enuresis and other DVS [5], [9], [10], [11]. Deficits in arousal may contribute to both enuresis and inattentive ADHD [12]. Enuresis may be a useful clinical marker in identifying a subgroup of the inattentive phenotype in ADHD genetic studies [12].
Autism spectrum disorder (ASD) includes autism, Asperger syndrome, and pervasive developmental disorders not otherwise specified. Autism is highlighted by cognitive language and social deficits along with repetitive, stereotyped behaviors. Asperger syndrome is similar to autism save for its preservation of linguistic and cognitive development. It has been shown that among children with articulation disorders, as seen in ASD, there is an increased prevalence of enuresis [13]. ASD is a highly discussed condition with a rising incidence due in part to more robust screening [14]. There is a paucity of data on the subject of enuresis and DVS in children with ASD. One study assessing comorbid conditions in children with ASD found enuresis occurring in 11% of their children aged 10–14 years [15]. Another small study in Tokyo evaluating sleep disorders in children with autism discovered 25% (22/88) were enuretic [16]. Neither of these studies provided further insight into enuresis and ASD. Considering enuresis occurs in 10% and 5% of children 10 and 15 years of age respectively, it appears that enuresis may be more prevalent in children with ASD.
Enuresis and DVS have a profound social, psychological, and scholastic impact on children [2], [17], [18]. Both ADHD and ASD also negatively impact these aforementioned parameters. Accordingly, children with enuresis/DVS and ADHD and/or ASD are at risk for more severe impairment. It has been established that desmopressin (DDAVP), tricyclic antidepressants, anticholinergics, and nocturnal alarms are all effective in alleviating symptoms of enuresis and DVS in children without ADHD or ASD [18], [19], [20], [21]. Treating enuresis has been shown to be more difficult, but still possible. To our knowledge there are no publications assessing these parameters in ASD; therefore, assessing enuresis and DVS, along with treatment outcomes in children with ASD (autism and Asperger syndrome) may prove beneficial in the urological management of these complex individuals.
Section snippets
Materials and methods
We performed a retrospective observational study on the incidence of enuresis and DVS along with response to treatment with anticholinergic medications or DDAVP in children with and without ADHD or ASD. Recruitment for this study included every patient referral to a pediatric urology clinic for enuresis from January 1999 through November 2008. Patients with ADHD and ASD must have had a formal psychiatric diagnosis of their respective condition. Six hundred and seventy-one children were
Results
Of the 671 children identified, there were 412 boys and 259 girls. Mean age was 8.6 years; 521 did not have ADHD or ASD, 130 had ADHD, and 20 had ASD. Enuresis was noted in 99% (518/521) of children without ADHD or ASD, 99% (129/130) of children with ADHD, and 90% (18/20) of children with ASD. DI was seen in 35% (182/521) of patients without ADHD or ASD, 43% (56/130) of patients with ADHD, and 55% (11/20) of children with ASD. Frequency was noted in 34% (179/521) of patients without ADHD or
Discussion
Enuresis and DVS are debilitating for both the afflicted child and their family. ADHD and ASD also are debilitating conditions for both parties. Children who experience enuresis and/or DVS along with ADHD or ASD are therefore at an arguably higher risk of psychological, social, and scholastic impairment. Prior to studies showing the efficacy of conventional treatment of enuresis and DVS in children with ADHD, it was assumed that these conditions were due to inattention, leading to further
Conclusion
Our data replicate results from previous studies showing the efficacy of DDAVP and anticholinergics in improving and treating enuresis and DVS in children with ADHD. Although no conclusion can be derived from the small sample size of patients with ASD, we feel that a favorable trend is shown toward efficacy of DDAVP and anticholinergic therapy in these children with enuresis and DVS.
Ethical approval
No approval required.
Funding source
No funding source.
Conflicts of interest
No conflict of interest.
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2021, Journal of Pediatric UrologyCitation Excerpt :Evidence suggests a high prevalence of enuresis in children with neurodevelopmental disorders [24–27]. However, due to the paucity of research in relation to treatment for these children [20,28], this study sought to examine the treatment of enuresis in children with neurodevelopmental disorders using the bell and pad alarm system in Australia. The neurodevelopmental disorders examined were Autism Spectrum Disorder (ASD), Attention Deficit Disorder (ADD) and Intellectual Disability (ID).
Identification of genetic loci associated with nocturnal enuresis: a genome-wide association study
2021, The Lancet Child and Adolescent HealthCitation Excerpt :This finding suggests that common variants have a major role in nocturnal enuresis risk and that nocturnal enuresis is a highly polygenic disorder. Behavioural disorders, such as oppositional defiant disorder, ASD, and ADHD in particular, are well documented as common comorbidities in children with nocturnal enuresis.6,20 We found that nocturnal enuresis risk is significantly associated with an increased burden of common variants associated with ADHD, indicating that individuals who are genetically vulnerable to ADHD are at higher risk of presenting with nocturnal enuresis than those who are less vulnerable.
The overlooked association between lower urinary tract dysfunction and psychiatric disorders: a short screening test for clinical practice
2019, Journal of Pediatric UrologyCitation Excerpt :Most of the studies investigating the relationship between LUTD and psychiatric disorders so far have been concerned with the relationship between nocturnal enuresis and ADHD [5,15]. While the rate of ADHD was reported to range between 5% and 10% among seven-year-old children [16,17], the rate of ADHD incidence was shown to vary between 9.1% and 53.2% among children who had nocturnal enuresis [18–21]. In the study of Niemczyk et al. [13], they saw externalizing disorders in 14.5% of the individuals with monosymptomatic nocturnal enuresis.
Children with nocturnal enuresis and attention deficit hyperactivity disorder: A separate entity?
2018, Journal of Pediatric UrologyCitation Excerpt :Among children with NE seen in our clinic, a small but significant number have coexisting ADHD. Scarce data exist in the literature regarding the severity of symptoms and treatment effectiveness of enuresis in children with ADHD compared with those without ADHD [8,9]. Additionally, few studies have addressed the impact of pharmacological therapy for ADHD on voiding dysfunction symptoms and/or NE in this population subgroup [4].
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