Abstract
Nocturnal enuresis, daytime urinary incontinence, lower urinary tract symptoms and faecal incontinence are more common in children with special needs than in typically developing children. Children with intellectual disability, which can be attributed to a range of causes, are particularly affected. Indeed, the epidemiological and clinical studies conducted to date show clear associations that children with special needs have higher rates of urinary (and faecal) incontinence than children without development, physical or cognitive impairments. For example, low intelligence quotient (IQ)-associated physical disability and conditions such as Fragile X and Rett syndromes increase the risk for incontinence, which can persist into adulthood if left untreated. Although the association of attention deficit hyperactivity disorder and incontinence has been shown in many studies, further research is needed on other specific disorders, such as autism. As many children are not receiving adequate care, specific multimodal treatments based on rigorous assessment of the incontinence, underlying condition and associated comorbid disorders should be actively offered.
Key Points
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Children with special needs have higher rates of all types of incontinence than children without developmental or behavioural impairments; children with specific syndromes, such as Fragile X and Rett syndromes, are particularly affected
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Intellectual disability—an intelligence quotient (IQ) <70—is a major risk factor for incontinence, with increasing rates as IQ decreases; lower urinary tract symptoms, overactive bladder, dysfunctional voiding and low fluid intake are also typical
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In children with physical disability, organic and functional types of incontinence can overlap
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Although attention deficit hyperactivity disorder and incontinence are clearly associated, further research on other conditions (such as autism) is required
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Assessment and treatment of incontinence should be offered actively to children with special needs using multimodal urological, paediatric and child psychiatric care
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References
von Gontard, A. & Nevéus, T. Management of Disorders of Bladder and Bowel Control in Children (MacKeith Press, 2006).
von Gontard, A., Baeyens, D., Van Hoecke, E., Warzak, W. & Bachmann, C. Psychological and psychiatric issues in urinary and fecal incontinence. J. Urol. 185, 1432–1437 (2011).
Nevéus, T. et al. The standardization of terminology of lower urinary tract function in children and adolescents: report from the Standardisation Committee of the International Children's Continence Society. J. Urol. 176, 314–324 (2006).
Rasquin, A. et al. Childhood functional gastrointestinal disorders: child/adolescent. Gastroenterology 130, 1527–1537 (2006).
Hoebeke, P., Van Laecke, E., Van Camp, C., Raes, A. & Vande Walle, J. One thousand video-urodynamic studies in children with non-neurogenic bladder sphincter dysfunction. BJU Int. 87, 575–580 (2001).
Tikkinen, K. A. O., Heikkilä, J., Rintala, R. J., Tammela, T. L. & Taskinen S. Lower tract symptoms in adults treated for posterior urethral valves in childhood: matched cohort study. J. Urol. 186, 660–666 (2011).
World Health Organization. International Classification of Diseases ICD-10: version 2010 [online], (2010).
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Text Revision (DSM-IV-TR) (American Psychiatric Association, 2000).
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (DSM-5) [online], (2013).
Rey, J. M. (Ed.) IACAPAP Textbook of Child and Adolescent Mental Health [online], (2012).
Strømme, P. Aetiology in severe and mild mental retardation: a population-based study of Norwegian children. Dev. Med. Child. Neurol. 42, 76–86 (2000).
von Wendt, L., Similä, S., Niskanen, P. & Järvelin, M. R. Development of bowel and bladder control in the mentally retarded. Dev. Med. Child. Neurol. 32, 515–518 (1990).
Joinson, C., Heron, J. & von Gontard, A. Psychological problems in children with daytime wetting. Pediatrics 118, 1985–1993 (2006).
Joinson, C., Heron, J., Butler, U., von Gontard, A. & Avon Longitudinal Study of Parents and Children Study Team. Psychological differences between children with and without soiling problems. Pediatrics 117, 1575–1584 (2006).
Yang, P. Y., Meng, N. H. & Chou, E. C. Voiding dysfunctions in children with mental retardation. Neurourol. Urodynam. 29, 1272–1275 (2010).
Van Laecke, E. et al. Voiding disorders in severely mentally and motor disabled children. J. Urol. 166, 2404–2406 (2001).
Van Laecke, E., Raes, A., Vande Walle, J. & Hoebeke, P. Adequate fluid intake, urinary incontinence, and physical and/or intellectual disability. J. Urol. 182, 2079–2084 (2009).
Bagni, C., Tassone, F., Neri, G. & Hagerman, R. Fragile-X syndrome: causes, diagnosis, mechanisms, and therapeutics. J. Clin. Invest. 122, 4314–4322 (2012).
Backes, M. et al. Cognitive and behavioral profile of Fragile X boys: correlations to molecular data. Am. J. Med. Genet. 95, 150–156 (2000).
Equit, M., Sambach, H. & von Gontard, A. Fragile X syndrome and elimination disorders in a 6-year-old girl. Klin. Padiatr. 223, 430–433 (2011).
Gabis, L. V., Baruch, Y. K., Jokel, A. & Raz, R. Psychiatric and autistic comorbidity in Fragile X syndrome across ages. J. Child. Neurol. 26, 940–948 (2011).
Equit, M., Piro-Hussong, A., Niemzcyk, J., Curfs, L. & von Gontard, A. Elimination disorders in persons with Prader–Willi and Fragile-X syndromes. Neurourol. Urodynam. 32, 986–992 (2013).
Cassidy, S. B. & Driscol, l. D. J. Prader–Willi syndrome. Eur. J. Hum. Genet. 17, 3–13 (2009).
von Gontard, A., Didden, R., Sinnema, M. & Curfs, L. Urinary incontinence in persons with Prader–Willi Syndrome. BJU Int. 106, 1758–1762 (2010).
Fung, L. K., Quintin, E. M., Haas, B. W. & Reiss, A. L. Conceptualizing neurodevelopmental disorders through a mechanistic understanding of fragile X syndrome and Williams syndrome. Curr. Opin. Neurol. 25, 112–124 (2004).
Martens, M. A., Wilson, S. J. & Reutens, D. C. Research review: Williams syndrome: a critical review of the cognitive, behavioral, and neuroanatomical phenotype. J. Child. Psychol. Psychiatry 49, 576–608 (2008).
Sammour, Z. M., Gomes, C. M., Duarte, R. J., Trigo-Rocha, F. E. & Srougi, M. Voiding dysfunction and the Williams-Beuren syndrome: a clinical and urodynamic investigation. J. Urol. 175, 1472–1476 (2006).
Furniss, F., Biswas, A. B., Gumber, R. & Singh, N. Cognitive phenotype of velocardiofacial syndrome: a review. Res. Dev. Disabil. 32, 2206–2213 (2011).
Antshel, K. M. et al. Cognitive and psychiatric predictors to psychosis in velocardiofacial syndrome: a 3-year follow-up study. J. Am. Acad. Child. Adolesc. Psychiatry 49, 333–344 (2010).
Laurvick, C. L. et al. Rett syndrome in Australia: a review of the epidemiology. J. Pediatr. 148, 347–352 (2006).
Neul, J. L. et al. Rett syndrome: revised diagnostic criteria and nomenclature. Ann. Neurol. 68, 944–950 (2010).
Giesbers, S. et al. Incontinence in individuals with Rett Syndrome: a comparative study. J. Dev. Phys. Disabil. 24, 287–300 (2012).
Sansome, A. Bladder and bowel management in physically disabled children. Paediatr. Child Health 21, 454–458 (2011).
Roijen, L. E., Postema, K., Limbeek, V. J. & Kuppevelt, V. H. Development of bladder control in children and adolescents with cerebral palsy. Dev. Med. Child. Neurol. 43, 103–107 (2001).
von Gontard, A., Laufersweiler-Plass, C., Backes, M., Zerres, K. & Rudnik-Schöneborn, S. Enuresis and urinary incontinence in children and adolescents with spinal muscular atrophy. BJU Int. 88, 409–413 (2001).
Zerres, K. & Davies, K. E. 59th ENMC International Workshop: spinal muscular atrophies: recent progress and revised diagnostic criteria. Neuromuscul. Disord. 9, 272–278 (1999).
Zerres, K. & Rudnik-Schöneborn, S. Natural history in proximal spinal atrophy. Clinical analysis of 445 patients and suggestions for a modification of existing classifications. Arch. Neurol. 52, 518–523 (1995).
von Gontard, A. et al. Intelligence and cognitive function in children and adolescents with spinal muscular atrophy. Neuromuscul. Disord. 12, 130–136 (2002).
Thapar, A., Cooper, M., Eyre, O. & Langley, K. What have we learnt about the causes of ADHD? J. Child. Psychol. Psychiatry 54, 3–16 (2013).
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) (American Psychiatric Association, 1994).
Shreeram, A., He, J. P., Kalaydijan, A., Brothers, S. & Merikangas, K. R. Prevalence of enuresis and its association with attention-deficit/hyperactivity disorder among, U. S. children: results from a nationally representative study. J. Am. Acad. Child. Adolesc. Psychiatry 48, 35–41 (2009).
von Gontard, A., Moritz, A. M., Thome-Granz, S. & Freitag, C. Association of attention deficit and elimination disorders at school entry: a population based study. J. Urol. 186, 2027–2032 (2011).
Baeyens, D. et al. Attention deficit/hyperactivity disorder in children with nocturnal enuresis. J. Urol. 171, 2576–2579 (2004).
Baeyens, D. et al. Attention-deficit/hyperactivity disorder (ADHD) as a risk factor for difficult to cure nocturnal enuresis in children: a two-year follow-up study. Acta Paediatr. 94, 1619–1625 (2005).
Baeyens, D. et al. The prevalence of ADHD in children with enuresis: comparison between a tertiary and non-tertiary care sample. Acta Paediatr. 95, 347–352 (2006).
Baeyens, D., Roeyers, H., Van Erdeghem, S., Hoebecke, P. & Vande Walle, J. The prevalence of attention deficit/hyperactivity disorder in children with nonmonosymptomatic nocturnal enuresis: a 4-year followup study. J. Urol. 178, 2616–2620 (2007).
Crimmins, C. R., Rathbun, S. R. & Husman, D. A. Management of urinary incontinence and nocturnal enuresis in attention-deficit hyperactivity disorder. J. Urol. 170, 1347–1350 (2003).
Biederman, J. et al. Clinical correlates of enuresis and ADHD and non-ADHD children. J. Child. Psychol. Psychiatry 36, 865–877 (1995).
Robson, W. L., Jackson, H. P., Blackhurst, D. & Leung, A. K. Enuresis in children with attention-deficit hyperactivity disorder. South. Med. J. 90, 503–505 (1997).
Elia, J. et al. Nocturnal enuresis: a suggestive endophenotype marker for a subgroup on inattentive attention-deficit/hyperactivity disorder. J. Pediatrics 155, 239–244 (2009).
Duel, B. P., Steinberg-Epstein, R., Hill, M. & Lerner, M. A survey of voiding dysfunction in children with attention deficit-hyperactivity disorder. J. Urol. 170, 1521–1524 (2003).
Ghanizadeh, A. Comorbidity of enuresis in children with attention-deficit/hyperactivity disorder. J. Atten. Disord. 13, 464–467 (2012).
Taurines, R. et al. Developmental comorbidity in attention-deficit/hyperactivity disorder. Atten. Defic. Hyperact. Disord. 2, 267–289 (2010).
Williamson, L. B., Gower, M. & Ulzen, T. Clinical case rounds in child and adolescent psychiatry: enuresis and ADHD in older children and an adolescent treated with stimulant medication: a case series. J. Can. Acad. Child Adolesc. Psychiatry 20, 53–55 (2011).
Kaye, J. D. & Palmer, L. S. Characterization and management of voiding dysfunction in children with attention deficit hyperactivity disorder. Urology 76, 220–224 (2010).
Morris, J. in IACAPAP Textbook of Child and Adolescent Mental Health (ed. Rey, J.) H1, 1–21 [online], (2012).
Kanbur, N. et al. Nocturnal enuresis in adolescents with anorexia nervosa: prevalence, potential causes, and pathophysiology. Int. J. Eat. Disord. 44, 349–355 (2011).
Weintraub, Y. et al. Enuresis—an unattended comorbidity of childhood obesity. Int. J. Obes. (Lond.) 37, 75–78 (2013).
Schwartz, B., Wyman, J. F., Thomas, W., Schwarzenberg, S. J. Urinary incontinence in obese adolescent girls. J. Pediatr. Urol. 5, 445–450 (2009).
Teitelbaum, J. E., Sinha, P., Micale, M., Yeung, S. & Jaeger, J. Obesity is related to multiple functional abdominal diseases. J. Pediatr. 154, 444–446 (2009).
Fuentes, J. et al. in IACAPAP Textbook of Child and Adolescent Mental Health (ed. Rey, J.) C2, 1–27 [online], (2012).
Gor, R. A., Fuhrer, J. & Schober. J. M. 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. J. Pediatr. Urol. 8, 314–317 (2012).
Cicero, F. R. & Pfadt, A. Investigation of reinforcement-based toilet training procedure for children with autism. Res. Dev. Diabil. 32, 319–331 (2002).
Kroeger, K. A. & Sorensen-Burnworth, R. Toilet training individuals with autism and other developmental disabilities: a critical review. Res. Autism Spectr. Disord. 3, 607–618 (2009).
Smith, L. J. A behavioral approach to the treatment of nonretentive nocturnal encopresis in an adult with severe learning disabilities. J. Behav. Ther. Exp. Psychiatry 25, 81–86 (1994).
Smith, L., Smith, P. & Lee, S. K. Behavioural treatment of urinary incontinence and encopresis in children with learning disabilities: transfer of stimulus control. Dev. Med. Child. Neurol. 42, 276–279 (2000).
Lancioni, G. E., O'Reilly, M. F. & Basili, G. Treating encopresis in people with intelectual disabilities: a literature review. J. Appl. Res. Intellect. Disabil. 14, 47–63 (2001).
Rogers, J. One step at a time: how to toilet train children with learning disabilities. Nurs. Times 106, 19–20 (2010).
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von Gontard, A. Urinary incontinence in children with special needs. Nat Rev Urol 10, 667–674 (2013). https://doi.org/10.1038/nrurol.2013.213
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DOI: https://doi.org/10.1038/nrurol.2013.213
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