An evaluation of quality of life of mothers of children with enuresis nocturna

Abstract

The aim of this study was to evaluate the impact of enuresis nocturna on quality of life of the mothers. Mothers who have a child with monosymptomatic nocturnal enuresis (n = 28) and mothers who have a child without any health problems (n = 38) were enrolled in the study. Groups were in balance for background variables (child's age, gender, and number of siblings; mother's age, marital status, highest year of education completed, and occupation; presence of health insurance; and type of residence). Short-Form Health Survey (SF-36) Questionnaire, the Beck Depression Inventory (BDI), and Spielberg's State-Trait Anxiety Inventory (STAI) were applied to all mothers. The mothers of children with enuresis had significantly lower quality-of-life scores in the SF-36 for the bodily pain (p = 0.015) and role emotional (p = 0.014) subscales. We observed significant difference between groups according to BDI; mean score was higher in mothers who have a child with enuresis nocturna (p = 0.017). There was no significant difference between groups according to the STAI. Significant differences according to bodily pain and role emotional subscales of SF-36, and the BDI scores, show that the mothers were negatively affected by having a child with monosymptomatic nocturnal enuresis. [PUBLICATION ABSTRACT]

Pediatr Nephrol (2008) 23:9398 DOI 10.1007/s00467-007-0605-0

ORIGINAL ARTICLE

An evaluation of quality of life of mothers of children with enuresis nocturna

Ayten Egemen & Ipek Akil & Ebru Canda &

Beyhan Cengiz Ozyurt & Erhan Eser

Received: 5 April 2007 / Revised: 8 July 2007 / Accepted: 10 July 2007 / Published online: 25 September 2007 # IPNA 2007

Abstract The aim of this study was to evaluate the impact of enuresis nocturna on quality of life of the mothers. Mothers who have a child with monosymptomatic nocturnal enuresis (n=28) and mothers who have a child without any health problems (n=38) were enrolled in the study. Groups were in balance for background variables (childs age, gender, and number of siblings; mothers age, marital status, highest year of education completed, and occupation; presence of health insurance; and type of residence). Short-Form Health Survey (SF-36) Questionnaire, the Beck Depression Inventory (BDI), and Spielbergs State-Trait Anxiety Inventory (STAI) were applied to all mothers. The mothers of children with enuresis had significantly lower quality-of-life scores in the SF-36 for the bodily pain (p=0.015) and role emotional (p=0.014) subscales. We observed significant difference between groups according to BDI; mean score was higher in mothers who have a child with enuresis nocturna (p=0.017). There was no significant

difference between groups according to the STAI. Significant differences according to bodily pain and role emotional subscales of SF-36, and the BDI scores, show that the mothers were negatively affected by having a child with monosymptomatic nocturnal enuresis.

Keywords Enuresis nocturna . Quality of life . Mother . Depression . Anxiety

Introduction

Enuresis nocturna (EN) has been described as an involuntary urine voiding during sleep at least twice a week in children over 5 years of age in the absence of congenital or acquired defects of the central nervous system or by the effect of substances such as a diuretics [1]. According to The International Childrens Continence Society (ICCS), EN has been described as normal urination occurring at times or in places that are socially unacceptable. Some children with nocturnal enuresis could control urination during the daytime. Monosymptomatic nocturnal enuresis (MNE) is considered when children with urinary behavior are totally normal during the daytime, or when awake [2]. Nocturnal enuresis has been accepted as a biobehavioral problem common in early childhood that becomes more uncommon after the age of 7 years [3]. The overall prevalence of EN declines with increasing age, occurring in 7% of children aged 10 years, 6% aged 11 years, and0.5% aged 18 years [4].

EN is a chronic medical disorder that is distressing for

children and their parents [5]. Bedwetting has significant negative impacts on the self-image and performance of children [6]. It is generally expected by parents and society that nocturnal wetting will cease when the child

A. EgemenDepartments of Pediatrics, Division of Social Pediatrics, Medical Faculty of Ege University,Izmir, Turkey

I. Akil : E. Canda Departments of Pediatrics, Medical Faculty of Celal Bayar University, Manisa, Turkey

B. C. Ozyurt : E. EserPublic Health, Medical Faculty of Celal Bayar University, Manisa, Turkey

I. Akil (*)6345 sok., No:50/10, Bostanl, Izmir, Turkeye-mail: [email protected]

94 Pediatr Nephrol (2008) 23:9398

is 56 years old [4]. Most parents tolerate EN well; however, as the child gets older, parental expectations of the childs level of responsibility and self-control increases [7]. Families with low socioeconomic status and particularly those who are migrants seem to be less tolerant of EN [8]. Once EN is persistent, it might cause chronic stress on the child and could have a negative effect on the childs self-concept [9]. Impairment of the self-esteem, behavioral problems, and delay in autonomy has been reported in children with EN and persistence of this condition might lead to future psychological and psychiatric problems [7, 10]. It has been suggested that parents of children with EN complain from psychological problems that might be due to confidence lost in parenting skills and disappointment in performing the parental role [8]. The parents might consider the childs inattention to modify his/ her behaviors regarding bedwetting as the source of the burden. Washing bed linen, changing bedclothes, replacing mattresses, etc., are considered a significant burden of additional time, effort, and financial impact by these families. Parents who suffer a great deal from their childs bedwetting have been shown to be more intolerant [7, 11]. To the best of our knowledge, no study has been reported assessing the quality of life of mothers with an enuretic child.

The aim of this study was to evaluate the quality of life, and consequent burden of care, on parents who have child with MNE compared with those who have a child without any health problems.

Methods

During the period May 2005August 2006, this comparative study was conducted between 28 mothers who have children diagnosed with MNE and 38 mothers who have

children without any health problems. Details of mothers with a child having MNE (group 1) and the control sample (group 2) are summarized in Table 1. The main question was whether the perceived quality of life differs between the two groups. The study also focused on whether there is an association between mothers quality of life and EN severity. Clinical severity was defined as infrequent: one to two wetting episodes per week; moderate: three to five wetting episodes per week; and severe: six to seven wetting episodes per week [12, 13].

Participants

Participation was open to mothers of children who had MNE or who had not any health problems. Mothers who had a child with MNE were selected from those who applied for treatment at Celal Bayar University Hospital, Department of Pediatric Nephrology. Mothers in the control group were selected consecutively among those with their children for outpatient service at the same hospital. Exclusion criteria, which were applied to both groups, were providing care for an elderly, chronically ill, or disable relative; carrying for another child younger than 2 years; having another child at home who needs special health care and has history of chronic illness; pulmonary disease; cardiovascular disease; and psychiatric disorder. Each mother was informed about the study and gave their consent to be included in the study.

Enuresis care

All patients who enrolled in the study have been managed at our department since their diagnosis of enuresis. All parents were informed about the disease and treatment strategies and the prognosis. A strong relationship between physician, patient, and family was established. Also,

Table 1 Characteristics of children and mothers of the study groups

Group 1 Group 2 P value

Children Mean age (SD), years 8.5 2.5 8.3 2.5 0.630*

Male, n (%) 14 (50) 18 (47) 0.522** Number of sibling, median 2 2 0.822* Mothers Mean age (SD), years 34.0 (4.3) 36.2 (6.8) 0.121*

Married, n (%) 27 (96) 38 (100) 1.00*** Highest year of education completed, mean (SD) 7.3 (3.7) 9.2 (4.1) 0.093* Occupation n (%) Employed 5 (18) 9 (24) 0.567**

Unemployed 23 (82) 29 (76)

Type of residence n (%) Urban 19 (68) 32 (84) 0.117***

Rural 9 (32) 6 (16)

Had health insurance n (%) 28 (100) 38 (100) 1.00***

* t test, ** Pearson chi-square, *** continuity correction

Pediatr Nephrol (2008) 23:9398 95

treatment strategy was discussed, with the patient talking about their illness and strategies to control and treat it.

Instruments

Short-Form Health Survey (SF-36) Questionnaire, the Beck Depression Inventory (BDI), and Spielbergs State-Trait Anxiety Inventory (STAI) were applied to all mothers. The SF-36 is the most widely used general health status instrument. The Turkish version of the Medical Outcomes SF-36 includes eight multi-item scales containing between two and ten items each, plus a single item to compare current health with a persons health 1 year ago. The scale covers the dimensions of physical functioning (PF), role physical (RP), bodily pain (P), general health (GH), vitality (V), social functioning (SF), role emotional (RE), and mental health (MH). All items are summed and transformed to form a scale from 0 to 100, where a higher score indicates a better state of health or well-being [14]. The BDI is a 21-item test presented in multiple-choice format, which purports to measure presence and degree of depression in adolescents and adults. Each of the 21 items of the BDI attempts to assess a specific symptom or attitude "which appear(s) to be specific to depressed patients, and which are consistent with descriptions of the depression contained in the psychiatric literature. The maximum total BDI score is 63. As the score rises, the severity of depression increases. In 1961, the BDI was described by Beck et al., and the first Turkish version was used by Hisli et al. in 1989 [15, 16]. For the anxiety assessment, the STAI was used, which compromises two axes (y1 for state anxiety, y2 for trait anxiety), both consisting of 20 multiple-choice items in which a score of >40 is considered a state of high anxiety [17].

Socioeconomic evaluation

This study was conducted by personal interview and consists of a background questionnaire and a quality-of-life and mental health assessment. The background questionnaire collected information on the sociodemographic characteristics of the mothers such as age, highest educational level, occupation, number of children, marital status, type of residence, as well as asking about availability of durable consumer goods to the household such as car, bicycle, refrigerator, washing machine, dishwasher, vacuum cleaner, television, telephone, mobile telephone, and computer. Information about household durable goods was used to determine the welfare level of the household-derived wealth index (WI). The following formula was used to construct the WI [18]: WI =car 0.782 +bicycle 0.007 +refrigerator 0.028 + washing machine 0.039 + dishwasher 0.045 + telephone 0.006 + mobile telephone 0.014 + computer 0.036.

Statistical evaluation

Quantitative variables are expressed as mean (+ SD) or median (and range). Relationship between qualitative variables was compared by Pearson chi-square test or by continuity correction where appropriate and between quantitative variables by Pearsons correlation or Spear-mans ranks correlation. MannWhitney U test and the t test were used for comparison of quantitative variables. Standard probability cutoff, p0.05, was chosen as the significance level.

Results

A total of 66 mothers were involved in the study in two groups: group 1 (n=28) consisting of mothers with a child having MNE, and group 2 (n=38) consisting of mothers who have a child without any health problems. There were no statistical significant differences between groups according to sociodemographic parameters (Table 1). Eighteen (64%) children had severe, eight (29%) moderate, and two (7%) infrequent EN. We further grouped enuretic children into two groups: group 1a, mothers of children with severe (n=18) and group 1b, mothers of children with infrequent and moderate (n=10) EN.

We used the SF-36 to evaluate mothers quality of life and found statistically significant difference in P (p=0.015) and RE (p=0.014) subscales between groups 1 and 2 (Table 2). There was no statistical difference between groups 1a and 1b (Table 3).

We performed correlation analysis between SF-36 scores and mothers age, childs age, disease severity, the number of siblings, and wealth index. There was no significant correlation between them. After taking cutoff values as 3, 5, and 7 years for the duration of EN, we detected no significant correlation between SF-36 subscales and the extent of EN period (p>0.05). The mean BDI score in group 1 was 33.55.7 and in group 2 29.55.2. We observed significant difference between groups according to BDI (p=0.005). There was no significant difference between groups according to the STAI, with the median state anxiety scores being 43.4 in group 1 and 41.2 in group 2(p=0.337). and the median trait anxiety scores being 46.0 in group 1 and 44.2 in group 2 (p=0.087).

Discussion

Most papers published regarding bedwetting assess the psychological impact of this condition on the children rather than on their families. In our study, we investigated the impact of this disorder on mothers who have a child

96 Pediatr Nephrol (2008) 23:9398

Table 2 Short-Form Health Survey (SF-36) Questionnaire scale scores according to study groups

Scores of SF-36 scale Group 1 Group 2 P value*

Mean (SD) Mean (SD)

Physical functioning 85.4 16.9 89.2 32.0 0.530 Role physical 71.4 38.9 76.3 31.8 0.589 Bodily pain 61.7 21.1 74.5 19.7 0.015 General health 65.5 18.3 64.4 18.9 0.815 Vitality 61.6 18.1 61.1 20.0 0.929 Social functioning 75.4 22.4 83.5 21.3 0.144 Role emotional 52.3 43.9 78.0 34.8 0.014 Mental health 62.1 17.8 63.1 16.6 0.815

* t test

with EN, and to the best of our knowledge, this is the first study evaluating this issue. Haque et al. developed the Family Perspectives on Bed Wetting Questionnaire to explore family members feelings. In their study, they detected that 61% of the parents considered EN as a significant problem [19]. In Turkish culture, it is the mothers responsibility to take care of the children in general; therefore, quality of life and psychosocial status of mothers might be affected when trying to overcoming this problem.

Washing bed linen, changing bedclothes, replacing mattresses, etc., are considered a significant burden of additional time, effort, and financial impact by these families [7, 11]. In our study, we evaluated the impact of bedwetting on the quality of life of mothers with enuretic children. We demonstrate statistically significant difference in P and RE subscales of the SF-36 between the two groups. Changes in mental health status affect RE, SF, and MH subscales of the SF-36 [20]. The RE subscale cross-examines feelings or physical sensations, which might be related to anxiety or depression. Depression, anxiety, and behavioralemotional control might lead to the detection of lower scores in this subscale [21]. Association of signifi-

cantly low RE and high BDI scores detected in mothers with enuretic children might be related to occurrence or predisposition to depression.

In the SF-36, the P subscale identifies the subjective intensity of pain and the effect of pain on normal work both inside and outside the home [22]. In this study, a statistically significant difference in the P subscale between groups 1 and 2 was detected. Physical complaints related to extra daily work load because of having a child with EN (washing bed linen, changing bedclothes, replacing mattresses, etc.) might lead to the detection of significantly high scores in pain scales. On the other hand, no organic diseases that could cause pain were present in these mothers, and significant differences in BDI score and RE subscales of the SF-36 between groups are important because affective and cognitive symptoms of depression are often hidden behind a variety of somatic complaints so-called masked depression [23]. This might be a possible explanation for significant difference in bodily pain. We think that psychological assessment of mothers with enuretic children should be performed in more detail.

Maternal attitudes might play important roles in relation to successful treatment [7]. The impact of maternal variables

Table 3 Comparison of scores of Short-Form Health Survey (SF-36) Questionnaire of enuretic childrens mothers due to disease severity

Scores of SF-36 scale Group 1a (mean SD) Group 1b (mean SD) P value*

Physical functioning 81.1 19.3 93.0 7.1 0.067 Role physical 65.2 42.1 82.5 31.2 0.359 Bodily pain 60.5 24.5 63.9 14 0.827 General health 62.4 21.5 71.1 9.0 0.276 Vitality 62.5 16.5 60.0 21.4 0.790 Social functioning 79.1 23.4 68.7 19.7 0.146 Role emotional 50.0 44.6 56.6 44.5 0.762 Mental health 62.8 17.0 60.8 20.0 0.845

* Mann-Whitney U test

Pediatr Nephrol (2008) 23:9398 97

such as depression and poverty might also have an effect on

treatment outcome, which warrants further research.

The symptom of wetting might becomes a chronic stress, and if persistent, might have a negative effect on the childs personality and on the self-concept [9]. Theunis et al. also showed that EN has important negative effects on the childs self-image and performance. They applied Dutch translation and the Self-Perception Profile for Children to enuretic children and control groups. Enuretic children had significantly lower perceived competence [6]. Many similar studies are present related with having negative impacts on children. The results of the present study reveal that mothers are also affected negatively due to the detection of significantly high BDI scores with additional significantly low SF-36 P and RE subscales.

The literature shows that EN causes distress and low self-esteem for the child. It also has major social and economic implications for the family, with an increasing intolerance as the child grows [7]. Absence of the voluntary control of micturition causes concern about the health of the child; also, the burden of enuresis will increase and the control of the problem will be more difficult as the child grows. Chang et al., by applying the Child Behavior Checklist (CBCL) and parenting stress index questionnaires showed that primary EN was associated with more childhood behavioral problems and increased levels of parenting stress [24]. Chronic stress is thought to be a risk factor for psychosomatic psychiatric illnesses, such as anxiety and depression disorders [25]. This might become a vicious circle, suggesting that children with bedwetting might be a cause of stress and anxiety for their mothers.

In our study, there was no significant difference between groups according to the STAI; however, trait and state anxiety scores were above 40 in the study group, which shows a high anxiety score. For this reason, the more mothers with enuretic children are evaluated, the more it would be possible to detect a significant difference related with anxiety.

Although we observed no significant change in quality of life of mothers who have children with EN, a significant difference according to the BDI and SF-36 P and RE subscales shows that mothers were negatively affected for having a child with EN.

Conclusion

In treating children with enuresis, it may also be important to assess and manage the childs psychosocial well-being and the parents stress level. Because enuresis might cause social stress, we suggest therapies that require a high degree of motivation for the child and parents.

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