Self-Image and Performance in Children with Nocturnal Enuresis

Abstract

Objective: To study the self-image of children between 8 and 12 years with nocturnal enuresis, and to correlate the findings with age, sex, clinical symptoms, primary versus secondary enuresis and treatment failures.

Methods: The study-group embraced 50 university hospital, and therefore selected therapy-resistant nocturnal enuresis-children, 27 boys and 23 girls. The mean age was 9.8, which means children aged between 8 and 12 years. Children were classified into two age groups: I=8–9 years and II=9–12 years. A total of 41 out of 50 had primary nocturnal enuresis. The mean number of treatments before intake was 5.6, A=1–4, B=5–8, C=9–12. Seventy-seven children without nocturnal enuresis were included in the control group, 31 boys and 46 girls.

The method we used to measure the perceived competence of the children on specific domains of their life was the Dutch translation and also validation of the “Self-Perception Profile for Children” by Harter. The testing was performed before and after therapy.

Results: Children with nocturnal enuresis have a significantly lower perceived competence than children without nocturnal enuresis, concerning physical appearance (p<0.05) and global self-esteem (p<0.01). There is a main effect of gender (p<0.01) and age (p<0.05) concerning scholastic skills. There is a correlation with the number of treatment failures. The more treatment failures, the lower the self-esteem. After successful treatment, there is an improvement of ‘athletic competence’ and ‘global self-esteem’, but it is not significant.

Conclusion: Nocturnal enuresis has important negative effects on the self-image and performance of children. Perceived competence was lower in girls than in boys with enuresis, and it was significantly lower in the higher age than in the lower. Children with day-time and night-time incontinence have a significantly decreased perceived competence on scholastic skills compared to children with nocturnal problems only. Successful treatment tended to increase athletic competence and global self-esteem.

Introduction

There is less evidence of psychological causes in the pathogenesis of nocturnal enuresis, now that nocturnal polyuria, bladder dysfunction and hereditary factors are identified [1], [2]. Recent data show that there may be a significant impact of the nocturnal enuresis on the child’s emotional state, social development and self-esteem [3], [4].

About 85% of the children are continent at the age of 5–6 years. So, 15% of the children do not succeed in becoming continent, and some are still enuretic as teenagers. Nocturnal enuresis is defined as the involuntary voiding of urine in bed beyond the age at which bladder control is normally obtained in the absence of organic pathology [2], [5]. Children who have never achieved a period of up to 6 months free of wetting are usually considered to have primary nocturnal enuresis. Secondary nocturnal enuresis, according to DSM-IV, is the re-emergence of wetting after a period of established urinary continence [3], [6].

Not being continent at the normal age increases the feeling of failure of the body. It does not succeed in obtaining the necessary capacities to become dry. The majority of the older enuretic children cannot participate (school) camps. So they feel very unsure and have the impression they are missing important milestones in their life. The symptom of wetting might become a chronic stress, and if persistent might have a negative effect on the child’s personality and on the child’s self-concept. Some studies, e.g. by Hägglof et al. [7] and Moffatt et al. [8], indicate that self-esteem is impaired among children with wetting symptoms. If low self-esteem persists over years in enuretic children, later psychological and psychiatric dysfunction may be expected. We suggest that low self-concept may be a secondary effect of chronic stress rather than a cause of the nocturnal enuresis: “earlier views that wetting problems are almost a symptom of underlying psychological disorders or problems have given way to evidence that most children with wetting problems have rather secondary consequences” [8].

The self-esteem of children is an important psychological variable that is supposed to be associated with mental health. Low self-esteem is seen in different psychiatric disorders as depression, eating disorders and identity problems. Harter [9] suggests that the self-concept of children has important implications on the experience of their competencies on different dimensions. The impaired self-esteem is the consequence of their physical as well as psychological experience of their body.

Butler [3] and Harter [9] suggest that nocturnal enuresis may generate negative reactions of the ‘significant others’, that possibly increase the child’s negative self-concept.

Therefore, wetting problems require ‘successful’ therapy. Treatment should follow careful evaluation of the type of enuresis and should involve the parents of the child. So, the percentage of therapy-failure should be as small as possible.