ORIGINAL PAPER

Dieter Baeyens Æ Herbert Roeyers Æ Johan Vande Walle

Piet Hoebeke

Behavioural problems and attention-deficit hyperactivity disorderin children with enuresis: a literature review

Received: 15 November 2004 / Accepted: 29 April 2005 / Published online: 12 July 2005� Springer-Verlag 2005

Abstract Nearly all studies on the co-morbidity betweenenuresis and psychopathology in children suggest anincreased prevalence of behavioural disorders in generaland of attention-deficit hyperactivity disorder (ADHD)in particular. Depending strongly on characteristics ofthe study design, the extent to which this prevalence isincreased fluctuates heavily. In the current literaturereview we found a lack of standardization in the defi-nitions of both enuresis and psychopathology, whichmakes comparison of research findings difficult. A seriesof confounding factors that possibly bias study results isalso covered. Psychopathology in enuresis seems to beassociated with older age, male gender, low socio-eco-nomic status and admission to specialized (university)paediatric clinics. Research that fails to report or tocontrol for these factors will not be able to make gen-eralizations to the total population of enuretic children.It is highly important for paediatricians to be aware ofthe effect of these methodological factors in order toread critically and appreciate the co-morbidity studieson the one hand and to understand better the associa-tion between enuresis and psychopathology on the otherhand. Future research would benefit from diagnosesbased on international diagnostic classification systemsmade within a well-defined sample.

Keywords Enuresis Æ ADHD Æ Behavioural Æ review

Introduction

The relationship between enuresis and behaviouralproblems has been researched extensively for several

decades. Results have been reported that range fromwell-adjusted enuretic children without marked emo-tional, social, or behavioural problems [34] to childrenwith a 4.3-times increase in psychological difficultiescompared with their non-enuretic peers [21]. This varia-tion can be explained by the diversity in conceptualisa-tion of the disorder and in the difference inmethodological design of these studies. In order forstudies and their findings to be assessed at their truevalue, these effects on study results need to be clarified.The aim of this literature review is to determine the rel-evant confounding factors in these studies and to inves-tigate their relative impact in enuresis research focusingon behavioural problems in general and on attention-deficit hyperactivity disorder (ADHD) in particular.

Literature review

In what follows we present a survey of recent studiesthat focus on the relationship between enuresis and bothADHD and other behavioural problems. Epidemiolog-ical studies (Table 1) and clinical studies (Tables 2 and3) are presented separately, since their respective aimsvary considerably. The various variables in these tablesare further discussed.

Diagnosis of enuresis

First of all, the conceptualisation of enuresis is takeninto account. In international diagnostic classificationsystems, such as the international statistical classifica-tion of diseases and related health problems (ICD)-10[35] and diagnostic and statistical manual of mentaldisorders (DSM)-IV-TR [2], enuresis is defined as theinvoluntary voiding of urine in a child of 5 years orolder in whom organic causes are excluded. Bothclassification systems do not agree on the frequency atwhich the wetting problem should be present; a

D. Baeyens (&) Æ H. RoeyersDepartment of Psychology, Developmental Disorders,Faculty of Psychology and Educational Sciences,Ghent University, Henri Dunantlaan 2,9000 Ghent, Belgium

D. Baeyens Æ J. Vande Walle Æ P. HoebekePaediatric Uro-nephrological Centre,Ghent University Hospital, Ghent, Belgium

Eur J Pediatr (2005) 164: 665–672DOI 10.1007/s00431-005-1712-1

Table

1Epidem

iologicalstudiesonenuresisandADHD/behaviouralproblems(N

Enocturnalenuresis,PEprimary

enuresis,SEsecondary

enuresis,PNEprimary

nocturnalenuresis,

HShyperkinetic

syndrome,

extern.externalizingproblems)

Study

Sample

Diagnostics

Instruments

and

inform

ants

Controlenuresis

variables

Control

dem

ographic

variables

Results

Relativerisk

Byrd

etal.,1996[8]

n=10,960

NE:questions

Questionnaire

NE

Age

NE:16.5%

behavioural

problems

Age:

5–17years

Behavioural

problems

Parent

Gender

CuredNE:10.2%

behaviouralproblems

1.62

SES

Feehanet

al.,1990[13]

n=

1,037

Enuresis:DSM-III

Interview,

questionnaire

PE/SE

Age

ADHD:dry

at13years

andenuresisat

11years

>noenuresis

at11years

or13years

–

Age:

3,5,11,13years

ADHD:DSM-III

Parent,child

Gender

ADHD:SE>

PE

Fergussonand

Horw

ood,1994[14]

n=

1,265

Enuresis:questions

Interview,

questionnaire

PE/SE

Age

Enuresisatage11years

and13years:no

increase

inADHD

–

Age:

4months,annual

year1–15

ADHD:DSM-III

Parent,

teacher,child

Gender

Enuresisatage15years:

increase

inADHD

SES

Hirasinget

al.,

1997[17]

n=1,652

NE:questions

Questionnaire

PE/SE

Age

At8–9years:23%

overallproblems

2.3

Age:

8–9and9–10years

Behavioural

problems

Parent

NE

Gender

Atage9–10years:17%

overallproblems

1.7

Norm

group:1%

overallproblems

Liu

etal.,2000[21]

n=

3,344

Enuresis:one

question

Questionnaire

–Age

Enuresis:29.3%

extern.

(parent)

Age:

6–16years

Behavioural

problems

Parent,teacher

Gender

Non-enuretic:

9.3%

extern.

(parent)

3.57

SES

Enuresis:25.5%

extern.

(teacher)

Non-enuretic:

11.1%

extern.

(teacher)

3.28

Moilanen

etal.,

1998[23]

n=

5,603

Enuresis:one

question

Questions

––

Antisocial:never

episode

<sometim

es<weekly

–

Age:

8years

Behavioural

problems

Parent,teacher

Hyperactive:

never

episode

<sometim

es<weekly

666

Table

2Clinicalstudieswithbetween-subject

andwithin-subject

designontheprevalence

ofADHD/behaviouralproblemsin

enureticchildren(D

Ediurnalenuresis,NE

nocturnal

enuresis,PEprimary

enuresis,SEsecondary

enuresis,PNEprimary

nocturnalenuresis,VPvoidingpostponem

ent,UIurgeincontinence,UTIurinary

tract

infection,HShyperkinetic

syndrome,

extern.externalizingproblems)

Study

Sample

Diagnostics

Instruments

and

inform

ants

Setting

Control

enuresis

variables

Control

dem

ographic

variables

Results

Relative

risk

Between-subject

Changet

al.,2002[9]

PNE,n=

93

Enuresis:

‡three

episodes/w

eek

Questionnaire

Paediatric

clinic

PNE

Age

PNE:28%

extern.

Control,n=

131

Behaviouralproblems

Parent,expert

Gender

Control:8%

extern.

3.52

Age:

7–15years

Frimanet

al.,1998[15]

PNE,n=

92

Enuresis:

‡one

episode/week,

over

6months

Questionnaire

Paediatric

clinic

PNE

Age

PNE:32%

behaviour

problem

Clinical,n=

92

Behaviouralproblems

Parent

Gender

Clinic:61%

behaviour

problem

0.52

Control,n=

92

Control:17%

behaviour

problem

1.88

Age:

5–13years

Rey

andHensley,

1995[26]

Clinical,n=

2,325

Enuresis:tw

oquestions

Questionnaire

Mentalhealth

service

community

DE/N

EGender

Hyperactivity

associatedwith

bedwetting

1.66

Control,n=

528

Behaviouralproblems

Parent

Age

Age:

12–16years

SteinhausenandGobel,

1989[28]

Enuresis,n=386

Enuresis:DSM-III-R

ICD

schem

ePsychiatric

clinic

––

Enuresis:4%

HS

Clinical,n=

2,404

HS:IC

D-9

Expert

Clinical:7%

HS

0.61

Age:

6to

‡14years

VanHoeckeet

al.,

2003[30]

Enuresis,n=

154

Enuresis:notspecified

Questionnaire

Paediatric

clinic

-Age

Enuresis:17%

extern.

Control,n=

153

Behaviouralproblems

Parent

Gender

Control:9%

extern.

1.89

Age:

6–12years

SES

Enuresis:11%

inattention

Control:9%

inattention

1.22

Enuresis;14%

hyperactivity

Control:6%

hyperactivity

2.33

Wille

andAnveden,

1995[34]

PNE,n=

14

Enuresis:

‡three

episodes/w

eek

32questions

Paediatric

clinic

PNE

Age

PNE:

median

„antisocial

CuredPNE,n=

15

Behaviouralproblems

Parent

Gender

CuredPNE:

median

„antisocial

1

Control,n=

15

Control:

median

„antisocial

1

Age:

notspecified

Within-subject

Baeyenset

al.,2004[3]

Enuresis,n=

120

Enuresis:nephro-/

urologists

Interview,

questionnaire

Paediatric

clinic

PE/SE

Age

Interview:

ADHD-IA

22.5%

,ADHD-H

YP2.5%

,ADHD-C

OM

15%

–

Age:

6–12years

ADHD:DSM-IV

Parent,teacher

DE/N

EGender

Questionnaire:

36%

extern.(parent),21%

extern.(teacher)

Behaviouralproblems

SES

667

frequency of twice a month under the age of 7 yearsand once a month over the age of 7 years is requiredfor research purposes by ICD-10 [35] and twice a weekby DSM-IV-TR [2]. There is consensus on a minimumduration of at least 3 months for the respective fre-quencies.

These criteria can be criticized, since they fail to dif-ferentiate between phenotypes of enuresis with andwithout lower urinary tract dysfunctions. According tothe terminology of the International Children’s Conti-nence Society (ICCS), enuresis refers to wetting withnormal micturition and without bladder dysfunction butat a socially unacceptable place and time, whereas uri-nary incontinence/wetting usually results from bladderdysfunction such as urge incontinence or dysfunctionalvoiding [18, 24]. Since this classification requires veryspecific data on patient characteristics, very few studieson the relationship between enuresis and psychologicalproblems adopt the ICCS standardization. Nevertheless,available reports suggest that more complex phenotypesof enuresis are associated with a higher prevalence ofICD-10 behavioural disorders than enuresis withoutlower urinary tract dysfunctions [32]. Since the debateon the definition of enuresis and its subtypes is stillongoing, and only DSM and ICD diagnoses are wide-spread in the relevant literature, the term ‘‘enuresis’’ inits broadest sense will be used throughout this review.

Apart from the (pertinent) addition to the interna-tional classification systems made by ICCS criteria, aseries of studies on the relationship between enuresis andbehavioural disorders even fail to meet the non-committal ICD-10 and DSM-IV criteria. As shown inTable 1, in epidemiologic and cohort studies, durationand frequency of signs are ignored, and the presence orabsence of involuntary voiding of urine is not ques-tioned. The assessment of enuresis is solely based onsome questions that are part of an existing question-naire, such as item 108 ‘‘wets the bed’’ of the childbehaviour checklist (CBCL) [1, 26]. Others use a self-constructed questionnaire that retrospectively assessesenuresis among other disorders [8].

These inconsistencies in questioning result in highlyvarying percentages of clinically increased problemscores on parental reports measuring behaviouralproblems; percentages range from 16.5% [8] to 29.0%[21]. In (ADHD) co-morbidity studies, with a cross-sectional design (Tables 2 and 3), the same shortcomingsare observed, seen in the strong diversity in the defini-tion of enuresis that results in a co-occurrence rangebetween 28.6% and 40% [3, 4, 5, 25]. The lack ofstandardization hampers the comparison and interpre-tation of research findings.

Diagnosis of ADHD and other externalizing problems

The same limitations are encountered in studies assess-ing psychological problems and psychiatric disordersassociated with enuresis.T

able

2(C

ontd.)

Study

Sample

Diagnostics

Instruments

and

inform

ants

Setting

Control

enuresis

variables

Control

dem

ographic

variables

Results

Relative

risk

Kodman-Jones

etal.,

2001[19]

Enuresis,n=54

Enuresis:notspecified

Questionnaire

Urologicalclinic

DE/N

E-

ADHD:NE22%,

DEwithoutUTI21%

,DEwithUTI0%

–Age:

8–15years

ADHD:notre-evaluated

Parent

Lettgen

etal.,2002[20]

DE,n=94

Enuresis:IC

CS

Questionnaire

Paediatric

clinic

VP/U

IGender

VP:31%

extern.

–Age:

5–10years

Behaviouralproblems

Parent

Psychiatric

clinic

UI:8%

extern.

VonGontard

etal.,

1998[31]

DE,n=94

Enuresis:IC

CS

Questionnaire

Paediatric

clinic

VP/U

I-

Extern.:VP31%,UI8%

–Age:

5–10years

Expansivedisorders:

ICD-10

Parent,expert

Psychiatric

clinic

Expansive:

VP31%

,UI5%

Behaviouralproblems

VonGontard

etal.,

1999[32]

Enuresis:n=

167

Enuresis:

‡1

episode/week

Questionnaire

Paediatric

clinic

PE/SE

-DE:29%

extern,28%

expansive

–

Age:

5–10years

Expansivedisorders:

ICD-10

Parent,expert

DE/N

ENE:19%

extern,17%

expansive

Behaviouralproblems

VP/U

IPNE:16%

extern,12%

expansive

SNE:25%

extern,32%

expansive

VP:37%

extern,39%

expansive

UI:19%

extern,14%

expansive

Wagner

etal.,1988[33]

Enuresis,n=

134

Enuresis:

‡3episodes/w

eek

Questionnaire

Paediatric

clinic

DE/N

E-

Delinquency:day/night>night

–Age:

5–16years

Behaviouralproblems

Parent

Familypractice

668

The diagnosis of psychiatric disorders follows criteriaset by the international classification systems. Consid-ering ADHD, the DSM-IV-TR [2] demands that thesymptoms of inattention, hyperactivity and impulsivitybe present in at least two different settings (e.g. at homeand at school), the so-called pervasiveness criterion. Thebest way to obtain a valid diagnosis is by using a multi-method (e.g. rating scales as well as diagnostic interview)multi-informant (e.g. parents as well as teachers)assessment of ADHD [16, 29]. Most studies on therelationship between enuresis and ADHD recruitedsubjects from a population of children with ADHD(Table 3). Although the use of DSM criteria is reportedin these studies, the description of instruments andinformants was not mentioned [4, 27].

In spite of this, the co-occurrence of ADHD andenuresis is consistently reported in approximately 30%of patients [4, 5]. Robson et al. [27] worked out that a 6-year-old child with ADHD has 2.7-times more chance ofsuffering co-morbid nocturnal enuresis than its peersand 4.5-times more chance of suffering diurnal enuresis.As far as we know, we were the first to take ADHDsubtypes into account in this area of research [3]. Wereported that the DSM-IV criteria for inattention weremet significantly more than for hyperactivity/impulsivityin children with enuresis.

Contrary to ADHD co-morbidity research, theprevalence of externalizing problems in subjects re-cruited from an enuretic population is relatively welldocumented. Externalizing problems, such as aggres-siveness and disobedience, are strongly associated withADHD symptomatology [12]. The diagnostic criteria forthe description of these psychological problems are notdeveloped. Information gathered from more generalquestionnaires should be sufficient to guarantee a rep-resentative description. Most studies prefer to comparethe number of clinical cases (i.e. cases that cross theclinical cut-off score) between the study groups ratherthan the average group scores [8, 21, 32], which are lessinformative. Nearly all epidemiological (Table 1) andclinical (Tables 2 and 3) studies reveal an increasedprevalence of clinical behavioural problems in enureticchildren, with the relative risk often being up to three-times as high as for non-enuretic controls [9, 21].

Study designs

Prior to the recruitment of subjects, a researcher shouldtake several factors into account that might possiblyinfluence the study results if not controlled for. Theseconfounding factors can be biases by the recruitmentsetting, ignorance of enuresis subtyping, boys-versus-girls ratio, age range and socio-economic status.

Setting

As shown in Tables 2 and 3, most co-morbidity studiesrecruit their subjects from paediatric clinics rather than T

able

3Clinicalstudieswithbetween-subject

designontheprevalence

ofenuresisin

childrenwithADHD

(DE

diurnalenuresis,

NE

nocturnalenuresis,

PE

primary

enuresis,

SE

secondary

enuresis,PNE

primary

nocturnalenuresis,DVSSdysfunctionalvoidingsymptom

survey)

Study

Sample

Diagnostics

Instruments

and

inform

ants

Setting

Controlenuresis

variables

Controldem

ographic

variables

Results

Relative

risk

Bhatiaet

al.,1991[4]

ADHD,n=

112

Enuresis:notmentioned

Questionnaire

Paediatric

clinic

–Age

ADHD:28.6%

enuresis

Controls,n=

112

ADHD:DSM-III

Parent

Gender

Control:5.2%

enuresis

5.5

Age:

3–12years

SES

Biedermanet

al.,

1995[5]

ADHD,n=

140

Enuresis:DSM-III-R

Interview

Paediatric

clinic

PE/SE

Age

ADHD:32%

enuresis

Control,n=

120

ADHD:DSM-III-R

Parent,expert

Psychiatric

clinic

DE/N

EGender

Control:14%

enuresis

2.29

Age:

6–17years

SES

Duel

etal.,2003[11]

ADHD,n=

28

Enuresis:DVSS

questionnaire

Notspecified

Development

centre

DE/N

EGender

Voidingsymptoms:

ADHD

>control

–

Control,n=

22

ADHD:notspecified

Parent,child

Paediatric

clinic

Age:

6–12years

Robsonet

al.,

1997[27]

ADHD,n=

153

Enuresis:3item

questionnaire

Expert

Paediatric

clinic

DE/N

EAge

Atage6:

Control,n=142

ADHD:DSM-III-R

Gender

NE:ADHD

20.9%,

control7.8%

2.7

Age:

6–14years

DE:ADHD

6.5%

,control2.1%

4.5

669

from a primary care sample. This could hamper thegeneralization of the study results to the total popula-tion. In many countries health care consists of severalhierarchically organized departments. Primary care willdeal with a spectrum of common problems that can berecognized and treated rather easily. However, when thesituation is complex to such an extent that it requiresadditional expertise concerning diagnosis or treatment,referral to a more specialized, often university,paediatric or psychiatric, clinic will be appropriate.Consequently, these specialized centres often attracttherapy-resistant patients with increased rates ofco-morbid disorders and problems [31]. In order to givean adequate interpretation to research findings, oneshould always be alert for the kind of setting.

Subtyping of enuresis

Tables 1, 2 and 3 reveal that subtypes of enuresis are notsufficiently taken into account. Enuresis is defined by twocomplementary classification categories. According thedevelopmental path, primary (i.e. at least one wettingepisode in every 6 months) and secondary enuresis (i.e.relapse after 6 months without wetting episodes) can bedistinguished.Depending on the time atwhich thewettingepisodes occur, a child can be diagnosed with nocturnal,diurnal, or combined enuresis. A number of studies sug-gest that these categories should be taken into account.

Concerning the developmental path of enuresis, VonGontard et al. [32] revealed that 32.1% of the childrenwith secondary nocturnal enuresis also meet the criteriaof a co-morbid ICD-10 diagnosis of behaviouraldisorders, compared to only 12.2% of the children withprimary nocturnal enuresis. This significant groupdifference could not be reconfirmed in studies onexternalizing problems on the CBCL [1]. The prevalencerates are 16.3% and 25% for primary and secondarynocturnal enuresis, respectively [32]. As opposed toemotional disorders, behavioural problems are not moreprevalent in diurnal enuresis than in nocturnal enuresis[32].

Gender

Enuresis is more prevalent in boys than in girls, i.e. oddsratio of 1.5 to 2:1 [7, 10], as are behavioural disorderssuch as ADHD, i.e. odds ratio of 4 to 9:1 [2]. Thus, thechance for enuretic boys to have increased problemscores on behavioural rating scales is twice as high as forenuretic girls [8, 15]. Therefore, most published studiescontrol for gender (e.g. [5, 15, 21, 27]).

Age

Most studies in the literature control for age (e.g. [5, 15,21, 27]) since evidence suggests that the older the age at

which the child attains urinary control, the more clini-cally increased the problem scores on rating scales willbe observed, starting from 12.1% in the age range 5–8years, over 22.5% in the age range 9-12 years, to 30.1%in the age range of 13–17 years [8]. Fergusson andHorwood [14] refine this finding by revealing that afterthe age of 10 years, bedwetting is associated with limitedincrease in risk for conduct problems, attention deficit,and anxiety in early adolescence.

Socio-economic status

Enuresis is strongly associated with social disadvantage[28, 29], as is psychopathology such as ADHD [6].Although only a few studies actually control for socio-economic status, it has been postulated that socio-economic status (SES) is a common underlying factor bywhich behavioural problems and enuresis emergesimultaneously [29].

Associations

As the exact nature of the relationship betweenbehavioural problems and enuresis cannot be deter-mined on the basis of the applied research designs,defining associations between conditions is better thanlooking for causal relationships. Nevertheless, moststudies seem to adopt such causal relationships implic-itly, since they refer to effects. By stating that the in-creased prevalence of enuresis in children with ADHD isbest explained by the inhibition deficits of this neuro-developmental disorder, Kodman-Jones et al. [19] stressthat psychological problems have an effect on enuresis.However, Bhatia et al. [4] adopt the reverse effect bysuggesting that ADHD symptomatology could be anexpression of the underlying emotional problems due tofrustration and failure. A second argument for consid-ering psychopathology to be reactive to enuresis is thedecrease in attention problems and externalizing prob-lems once the child has been treated for enuresis [22].Nevertheless, it is not unthinkable that psychiatricsymptoms and enuresis are influenced by a common riskfactor. The studies on male gender and lower SES stressthis option [4, 30]. Maturational delay is another com-mon underlying factor that has previously been sug-gested [14]. Finally, the relationship betweenpsychopathology and enuresis could be based on chance,an option that is not taken into account in researchfindings.

Conclusions

Despite the extensive criticism of conceptualisation andresearch methods, nearly all studies, either epidemio-logical or clinical, consistently reveal an increasedchance of co-morbid behavioural problems and

670

disorders such as ADHD in enuretic children. The lackof standardization of study design and the concisereporting of the study methods makes comparison ofresearch findings difficult. The research topic of thecurrently reviewed studies could best be referred to as(bed)wetting, since most research does not follow thespecific ICCS criteria of enuresis, which require veryspecific data on patients’ characteristics. However, sincethis would be incompatible with the (more broadly de-fined) DSM and ICD diagnosis of enuresis, we used theterm enuresis, in its broadest sense, throughout this re-view. Although the debate on an adequate definition ofenuresis is still fierce and, to date, hardly observable instudy designs on the relationship with psychopathology,there is evidence that more complex phenotypes ofenuresis are associated with a higher prevalence ofADHD and externalizing problems.

In this literature review we have covered a series ofconfounding factors that possibly bias the study resultsand of which nephrologists, urologists, and paediatri-cians should be aware in order to read critically andappreciate the co-morbidity studies. Moreover, it ishighly important to note that most co-morbidity studiesare able to look at only the association between enuresisand behavioural disorders rather than at their (causal)relationship. Longitudinal research and outcome effectstudies could help determine whether there is a causalrelationship between psychopathology and enuresis or ifthe association between both concepts is merely basedon a common risk factor. Either way, future researchwould benefit from diagnoses based on internationaldiagnostic classification systems made within a well-de-fined sample.

Acknowledgements This paper was prepared with the support of adoctoral fellowship awarded to Dieter Baeyens by the Fund forScientific Research, Flanders.

References

1. Achenbach TM (1991) Manual for the child behavioral check-list/4–18 and 1991 profile.University of Vermont, Burlington, Vt

2. American Psychiatric Association (2000) Diagnostic and sta-tistical manual of mental disorders, 4th edn, text revision. APA,Washington, DC

3. Baeyens D, Roeyers H, Hoebeke P, Verte S, Van Hoecke E,Vande Walle J (2004) Attention-deficit/hyperactivity disorderin children with nocturnal enuresis. J Urol 171:2576–2579

4. Bhatia MS, Nigam VR, Bohra N, Malik C (1991) Attentiondeficit disorder with hyperactivity among pediatric outpatients.J Child Psychol Psychiatry 32:297–306

5. Biederman J, Santangelo SL, Faraone SV, Kiely K, Guite J,Mick E, Reed ED, Kraus I, Jellinek M., Perrin J (1995) Clinicalcorrelates of enuresis in ADHD and non-ADHD children.J Child Psychol Psychiatry 36:865–877

6. Biederman J., Faraone SV, Monuteaux MC (2002) Differentialeffect of environmental adversity by gender: Rutter’s index ofadversity in a group of boys and girls with and without ADHD.Am J Psychiatry 158:1556–1562

7. Butler RJ (1998) Annotation. night wetting in children: psy-chological aspects. J Child Psychol Psychiatry 39:453–463

8. Byrd RS, Weitzman M, Lanphear NE, Auinger P (1996) Bed-wetting in US children: epidemiology and related behavioralproblems. Pediatrics 98:414–419

9. Chang SSY, Ng CFN, Wong SN (2002) Behavioral problems inchildren and parenting stress associated with primary nocturnalenuresis in Hong Kong. Acta Paediatr 91:475–479

10. Cher TW, Lin GJ, Hsu KH (2002) Prevalence of nocturnalenuresis and associated familial factors in primary schoolchildren in Taiwan. J Urol 168:1142–1146

11. Duel BP, Steinberg-Epstein R, Hill M, Lerner M (2003) Asurvey of voiding dysfunction in children with attention deficithyperactivity disorder. J Urol 170:1521–1524

12. Faraone S, Biederman J, Weber W, Russell R (1998) Psychi-atric, neuropsychological, and psychosocial features of DSM-IV subtypes of attention-deficit/hyperactivity disorders: resultsfrom a clinically referred sample. J Am Acad Child AdolescPsychiatry 37:185–193

13. Feehan M, McGee R, Stanton W, Silva PA (1990) A 6 yearfollow-up of childhood enuresis: prevalence in adolescence andconsequences for mental health. J Paediatr Child Health 26:75–79

14. Fergusson DM, Horwood LJ (1994) Nocturnal enuresis andbehavioral problems in adolescence: a 15-year longitudinalstudy. Pediatrics 94:662–667

15. Friman PC, Handwerk ML, Swearer SM, McGinnis JC,Warzak WJ (1998) Do children with primary nocturnalenuresis have clinically significant behavioral problems? ArchPediatr Adolesc Med 152:537–539

16. Hechtman L (2000) Assessment and diagnosis of attention-deficit/hyperactivity disorder. Child Adolesc Psychiatr Clin NAm 9:481-487

17. Hirasing RA, van Leerdam FJM, Bolk-Bennink LB, Bosch JD(1997) Bedwetting and behavioral and/or emotional problems.Acta Paediatr 86:1131–1134

18. Hjalmas K, Arnold T, Bower W, Caione P, Chiozza LM,von Gontard A, Han SW, Husman A, Kawauchi A,Lackgren G, Lottmann H, Mark S, Rittig S, Robson L,Vande Walle J, Yeung CK (2004). Nocturnal enuresis: aninternational evidence based management strategy. J Urol171:2545–2561

19. Kodman-Jones C, Hawkins L, Schulman SL (2001) Behavioralcharacteristics of children with daytime wetting J Urol166:2392–2395

20. Lettgen B, Von Gontard A, Olbing H, Heiken-Lowenau E,Gaebel E, Schmitz I (2002) Urge incontinence and voidingpostponement in children: somatic and psychosocial factors.Acta Paediatr 91:978–984

21. Liu X, Zhenxiao S, Uchiyama M, Li Y, Okawa M (2000)Attaining nocturnal urinary control, nocturnal enuresis, andbehavioral problems in Chinese children, aged 6 through 16years. J Am Acad Child Adolesc Psychiatry 39:1557–1564

22. Longstaffe S, Moffat MEK, Whalen JC (2000) Behavioral andself-concept changes after six months of enuresis treatment: arandomized, controlled trial. Pediatrics 105:935–940

23. Moilanen I, Tirkkonen T, Jarvelin MR, Linna SL, Almqvist F,Piha, J, Rasanen E, Tamminen T (1998) A follow-up studyfrom childhood to adolescence. Br J Urol 81:94–97

24. Norgaard JP, van Gool JD, Hjalmas K, Djurhuus JC, Hell-strom AL (1998) Standardization and definitions in lower uri-nary tract dysfunction in children. Br J Urol 81:1–16

25. Ornitz EM, Russell AT, Hanna GL, Gabikian P, Gehricke JG,Song D, Guthrie, D. (1999) Prepulse inhibition of startle andthe neurobiology of primary nocturnal enuresis. Biol Psychia-try 45:1455-1466

26. Rey JM, Hensley VR (1995) Bedwetting and psychopathologyin adolescents. J Paediatr Child Health 31:508–512

27. Robson WL, Jackson HP, Blackhurst D, Leung ARC (1997)Enuresis in children with attention-deficit hyperactivity disor-der. South Med J 90:503–505

28. Steinhausen H-C, Gobel D (1989) Enuresis in child psychiatricclinic patients. J Am Acad Child Adolesc Psychiatry 28:279–281

671

29. Taylor E, Dopfner M, Sergeant J, Asherson P, Banaschewski T,Buitelaar J, Coghill D, Danckaerts M, Rothenberger A,Sonuga-Barke E, Steinhausen HC, Zuddas A (2004) Europeanguidelines for hyperkinetic disorder—first upgrade. Eur ChildAdolesc Psychiatry 13:I7–30

30. Van Hoecke E, Baeyens D, Vande Walle J, Hoebeke P, RoeyersH (2003) Socio-economic status as a common factor underlyingenuresis and psychopathology. J Dev Behav Pediatr 24:109–114

31. Von Gontard A, Lettgen B, Olbing H, Heiken-Lowenau C,Gaebel E, Schmitz I (1998) Behavioral problems in childrenwith urge incontinence and voiding postponement: a compari-son of a pediatric and child psychiatric sample. Br J Urol81:100–106

32. Von Gontard A, Mauer-Mucke K, Pluck J, Berner W,Lehmkuhl G (1999) Clinical behavioral problems in day- andnight-wetting children. Pediatr Nephrol 13:662–667

33. Wagner WG, Smith D, Norris WR (1988) The psychologicaladjustment of enuretic children: a comparison of two types.J Pediatr Psychol 13:33–38

34. Wille S, Anveden I (1995) Social and behavioral perspectives inenuretics, former enuretics and non-enuretic controls. ActaPaediatr 84:37–40

35. World Health Organization (1992) ICD-10 internationalstatistical classification of diseases and related health problems,10th edn. World Health Organization, Geneva

672