Acta Pædiatrica ISSN 0803–5253

REGULAR ARTICLE

Socio-demographic and psychopathologic correlates of enuresis in urban

Ethiopian children
Menelik Desta ([email protected])1 , Bruno Hägglöf2 , Derege Kebede3 , Atalay Alem4
1.Amanuel Hospital, Addis Ababa, Ethiopia
2.Division of Child and Adolescent Psychiatry, Department of Clinical Sciences, Umeå University, Umeå, Sweden
3.World Health Organization, Regional Office for Africa, Brazzaville, Congo
4.Department of Psychiatry Addis Ababa University, Ethiopia

Keywords Abstract
Children, Developing country, Enuresis,
Aim: To examine the association between enuresis and psychopathology in urban Ethiopian children.
Psychopathology
Methods: A two-stage mental health survey of 5000 urban children found enuresis to be by far the
Correspondence
Menelik Desta, P.O. Box 10389, most common disorder. Logistic regression modelling was carried out to determine the independent
Addis Ababa, Ethiopia. associations of a number of socio-demographic and psychopathological characteristics with enuresis.
Tel: ++251 11768776 | Fax: ++25115511079 | Results: Male sex, younger age and lower achieved educational grade of the child were all
Email: [email protected]
independently associated with childhood enuresis. The odds of having enuresis were significantly
Received
22 September 2006; revised 24 November 2006; higher for children in families with significant financial worries and in children from homes where
accepted 3 January 2006. parents were separated. Children with DSMIII-R anxiety disorders, especially simple phobia, or
DOI:10.1111/j.1651-2227.2007.00229.x disruptive behaviour disorders were found to have significantly higher odds of having enuresis.
Conclusion: Psychopathology, both anxiety and behavioural disorders, as well as family stressors in urban
Ethiopian children were found to be risk factors for enuresis. Although a cause-effect relationship could not be
ascertained, the findings of higher association of psychopathology with enuresis in this and other studies indicate
that there is a need for evaluating children with enuresis for the presence of concurrent psychopathology,
especially in traditional societies where undetected psychopathology may be more common.

few have been carried out in developing countries. In view

INTRODUCTION
of the relatively high prevalence of enuresis in our setting,
Enuresis is a common childhood problem. The prevalence
the objective of this study was therefore to describe the re-
varies according to age, with highest levels in the preschool
lationship between enuresis and other psychiatric diagnoses
period, decreasing as the child reaches adolescence (1).
as well as identify associated socio-demographic factors.
Enuresis is known to cause considerable distress to children
and their parents (2,3), with affected children frequently de-
veloping low self esteem (4). PATIENTS AND METHODS
In Ethiopia, conflicting estimates for the prevalence of We used two-phase sampling.
enuresis in children have been reported by different stud- First-phase sample includes 5000 children randomly se-
ies: 5% in a small town (5), 0.8% in a predominantly rural lected from the total population of Addis Ababa. Of these,
sample (6) and 9% in a group of urban child labourers and 864 children turned to be screen positive while the rest
their controls (7). None of these studies examined the asso- (4136) were screen negative.
ciation between enuresis and other demographic, social or Second-phase sample includes 2401 children (involving
psychopathologic factors. all of the 864 screen positive and 1537 ‘controls’ from the
During 2002–2003, a cross-sectional survey of psychiatric screen-negative children).
disorders was carried out on children aged 6–15 years in The source of study subjects was the total population of
Addis Ababa, Ethiopia, with diagnostic assessment accord- Addis Ababa. From the total of 306 subdistricts (Kebeles) of
ing to the revised third edition of the Diagnostic Statistical the city, 50 were selected by the probability-proportionate-
Manual (DSM-III-R) criteria. The results of that survey to-size sampling method. For the first-phase sample, 100
showed that enuresis had by far the highest prevalence of all children aged 6–15 years residing in systematically selected
conditions. While the weighted prevalence for any DSM-III- households in each of the 50 subdistricts, were assessed. For
R diagnosis was 16.9%, the weighted prevalence of enuresis the second-phase sampling, we took all the 864 children who
alone amounted to 12.3%. Except for simple phobia, present were screened positive in the first phase. In addition, 1537
in 5.5% of the children, the weighted prevalence of all other screen-negative children were included in the second-phase
identified conditions were below 1% (8). sample.
Recent studies have supported the notion that enuresis is Interviews of parents or caretakers were carried out by
a genetic/developmental disorder rather than a manifesta- trained high school graduates at the home of selected sub-
tion of childhood behavioural or mental disorder, although jects. For the first phase of the study, interviews started

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Desta et al. Enuresis and psychopathology

randomly from one of selected houses in each kebele. For ents/caretakers. Parents whose children were found positive
the selected cases and non-cases, the second-phase inter- for DSM-III-R disorders were advised to take their children
view was performed on the same date as the first-phase for medical assessment.
interview. The same informant was interviewed for both
phases.
For the first phase of the study, the World Health Orga- RESULTS
nization’s Reporting Questionnaire for Children (RQC) (9) A total of 2401 children (51.2% females) were assessed dur-
was used. In Ethiopia, RQC has been used in a couple of pre- ing the second phase of the study. With the number of screen-
vious studies and was found to be of acceptable validity (10). negative children included in the second-phase sample being
The RQC is a 10-item simple questionnaire with one of the 1537, the RQC positive to RQC negative ratio in the second-
items enquiring about the presence of wetting or soiling in phase sample was slightly less than the planned—1:2.
the child. The revised parent version of the Diagnostic Inter- Regarding demographic characteristics, children below
view for Children and Adolescents (DICA) (11) was the in- the age of 8 years made 18.5% of the sample whereas 41.45%
strument used for the second phase of the study. The revised and 40.1% were in the age group of 8–11 years and 12–
DICA (DICA-R) was a modified, less structured version (12), 15 years of age, respectively. Most of the subjects were in
of the initial DICA. DICA-R would classify the psychiatric elementary grades (74.8%). A total of 20.2% had achieved
disorders in children according to the revised third edition of high school level and 5% had never been to school. The ma-
the Diagnostic and Statistical Manual or DSM-III-R of the jority of the children came from Amhara (45.6%), Oromo
American Psychiatric association (1). Reliability and validity (24.2%) and Gurage (17.7%) ethnic groups and the rest be-
studies of the DICA have been satisfactory (11,13). longed to various other ethnic origins. Half of the subjects
In Ethiopia, The DICA-R is the only semistructured child lived in homes with 7–10 members, 37.5% in homes with less
instrument based on an accepted diagnostic algorithm that than 7 members and the rest lived in homes with more than
has been translated into the national working language— 10 members. Seventy-seven percent of children lived with
Amharic. Its reliability and content validity have also been both parents while the remaining lived with either parent.
found to be satisfactory (14). Over 35% of subjects lived in families with substantial fi-
Following data entry, DICA-R automatically generates nancial worries, defined as ‘shortage of money to the extent
DSM diagnoses based on a preloaded electronic algorithm, of being unable to afford basic necessities such as food and
thus giving a summary for each individual child regarding clothing’.
the presence or absence of a specific diagnosis. Of the 2401 study subjects, 511 had elimination disorders
For efficient statistical analyses, the diagnoses were (crude prevalence of 21.3%). Of these 511, 500 had enuresis
regrouped into three major clusters. Accordingly, attention- only, 2 had encopresis only and 9 had both conditions. In the
deficit hyperactivity disorder, conduct disorder and analysis for this report, we included only the 509 children
oppositional defiant disorder were grouped together under with enuresis.
‘Disruptive behaviour disorders’ (DBD). Simple phobia, Table S1 shows the demographic and Table S2 the social
separation anxiety, obsessive–compulsive disorder and and psychopathologic correlates of enuresis. The adjusted
posttraumatic stress disorder were categorized under odds of having enuresis were 25% lower in females com-
‘Anxiety Disorders’. The third group was ‘Elimination pared to males [adjusted odds ratio (adj. OR) (95% confi-
Disorder’, which consisted of enuresis and encopresis. dence interval (CI)) = 0.76 (0.62, 0.93)]. The odds of hav-
Other conditions were excluded from the analysis. ing enuresis decreased with increasing age. This trend was
Statistical analysis was done using the Statistical Package statistically significant (p for trend <0.001). The chances of
for Social Sciences (SPSS) software, (SPSS Inc, Chicago, having enuresis dropped significantly in high school children
IL, USA) version 11. Logistic regression modelling was per- compared to children who had not been to school [adj. OR
formed in order to test the significance of the relationship (95% CI) = 0.55 (0.32, 0.95)]. There was a significant trend
between enuresis and DBD and anxiety disorders as well as in which the higher the grade level of the child, the lesser
between enuresis and various socio-demographic variables. were the chances of having enuresis (p for trend = 0.006).
Enuresis was entered as the dependent variable whereas Enuresis was not significantly associated with ethnic group
sex, age, educational grade, ethnicity, family size, poverty, or household size.
parental separation, financial worries (defined as having There was an almost 30% higher chance of having enure-
problems covering costs of basics such as food and cloth- sis in those children with parental worry about substantial
ing for the family), anxiety disorder group and DBD groups financial difficulties [adj. OR (95% CI) = 1.29 (1.04, 1.60)].
were entered as independent variables in the logistic regres- Children not living with both parents because of parental
sion model. separation also had a higher risk of enuresis compared to
those children living with both parents [adj. OR (95% CI) =
1.41 (1.11, 1.80)].
Ethical matters Compared to those without anxiety disorders, children
Ethical clearance was obtained from the National Ethical with anxiety disorders had an almost 60% higher risk of hav-
Review Committee of the Ethiopian Science and Technol- ing enuresis [adj. OR (95% CI) = 1.59 (1.14, 2.21)]. Likewise,
ogy Commission. Verbal consent was obtained from par- children with DBD had more than twice the risk of having


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Enuresis and psychopathology Desta et al.

enuresis compared to children who did not have that con- nal enuresis (26). There was no possible explanation for this
dition [adj. OR (95% CI) = 2.20 (1.10, 4.50)]. finding in Sudan.
Our findings show that urban children coming from fam-
DISCUSSION ilies with large financial worries had a significantly higher
The findings in this study are with regard to the presence or risk of having enuresis. This finding concurs with reports of
absence of enuresis. This is because the questionnaire was studies in other countries (3,22). The present study’s find-
not able to differentiate primary from secondary enuresis, ing of parental separation as a risk for enuresis in children
and because there was inadequate information from the field is also similar to most previous reports. Child distress can
data on the majority of the subjects regarding the presence or follow parental separation especially if growing up without
absence of daytime wetting. This was an important limitation both parents is perceived as being inferior to those peers
of this study in that it made it impossible to compare the who live with both parents, as is the case in Ethiopia. An ar-
co-occurrence of psychopathology with night time wetting ticle from Saudi Arabia, which also reported enuresis to be
with the co-occurrence with day time wetting. The other more frequent in children of separated parents (27), claimed
limitation of the report is that the frequency of wetting was that it is the absence of the father after parental separation
not included in the analysis. that exposes the child to stress. The prevailing attitude in
Enuresis in our study was the most prevalent DSM-III-R Ethiopia is such that, if a contest arises between divorced
condition in children between the ages of 6–15 years. This parents over the care of a child under 15 years of age, both
finding is similar to the study that looked at the association the traditional and the public legal system favour the mother
between child labour and psychopathology in Ethiopia (7). as the best guardian.
Enuresis was also the commonest finding in studies from Our results indicate a significantly higher association be-
India (15,16). Interestingly, the prevalence of enuresis in a tween psychopathology and enuresis than has been found
predominantly rural population in Ethiopia was 0.8% (6). in previous studies. There was one similar finding in a pre-
A possible explanation for the low prevalence in this ru- vious study in Ethiopia, where, during a validation study
ral community could be the difficulties rural parents may of the RQC, it was found that, of the 10 screening items,
face in detecting nocturnal enuresis in children, for exam- the presence of wetting or soiling in the child had the
ple, due to the lack of bedding for children in most rural highest discriminating power in differentiating cases from
homes and the common practice of sleeping on a pile of hay non-cases (10). In spite of the ongoing argument about the
in children beyond toddler age. The problem of detection of relationship of enuresis and psychopathology, unambigu-
enuresis could also have been aggravated by the fact that, in ous evidence supporting either position is not yet available.
many rural homes in Ethiopia, due to the prevailing poverty, Redsell and Collier reviewed 15 empirical studies on noc-
domestic animals and humans spend the night in the same turnal enuresis spanning a number of years. They concluded
room for security and also for thermo-regulatory purposes. that although there were increased behavioural problems in
In such situations, the more pungent smell of the more pro- children with bedwetting, determination of causation in any
fuse animal excreta could have disguised the child’s enuresis direction was difficult (28).
from detection by parents. As our study was a cross-sectional one, a cause-effect re-
In our study, the prevalence of enuresis was higher in boys lationship between enuresis and psychopathology could not
compared to girls, in agreement with the majority of reports be inferred. All the same, our data raise the concern that in
from around the world. However, while some papers report traditional societies such as Ethiopia, neglecting the mental
higher prevalence of enuresis in girls than in boys (17) some health component in the medical management of enuresis
find no difference between the two sexes (18). may lead practitioners to overlook possible underlying psy-
The prevalence of enuresis showed a decreasing trend with chological distress. The societies in Ethiopia are still predom-
increasing age of children. This trend is also similar to most inantly traditional. Many years of clinical experience of the
reports in the literature. However, no significant decrease first, third and fourth authors, indicate that somatoform dis-
in the rate of enuresis was found with increasing age in a orders including conversion disorders are still common man-
sample of 6–16 year olds in China (19) and 8–12 year olds ifestations of distress in Ethiopia. We speculate, therefore,
in India (18). that it is possible that enuresis, like other somato-sensory
We did not find any association between ethnicity and manifestations of psychopathology, can be used as an outlet
enuresis in our population of children. Previous studies in of stress in a traditional society. The finding of enuresis as
different countries have reported ethnic differences in the the commonest disorder in Indian children was also associ-
prevalence of enuresis (20–22). ated with lower prevalence of other psychiatric problems in
Although not significant, the adjusted odds ratio for enure- Indian children compared to Western populations (16).
sis showed a 30% decline in children who came from house- Such similar findings in studies of psychopathology
holds with size greater than 10. Household size had been amongst traditional societies probably strengthens the hy-
reported as not associated with enuresis by some studies pre- pothesis that enuresis, as a bodily dysfunction, may play
viously (23) whereas others have found enuresis to be more a role in the manifestation of distress. On the other hand,
frequent in children from large families (24,25). One study we acknowledge the possibility that the higher rate of psy-
from Sudan found that the presence of fewer children in the chopathology in children with enuresis may be secondary
family was associated with increased prevalence of noctur- to the stress of living with enuresis and the environmental

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Desta et al. Enuresis and psychopathology

reactions to the problem. Either way, given the repeated 8. Desta M, Kebede D, Hagglof B, Alem A. Psychiatric disorders
findings of concurrent existence of enuresis and psy- in urban children in Ethiopia: a population-based cross-
chopathology, it will be necessary to manage emotional sectional survey. Soc Psychiatry Psychiatr Epidemiol
(submitted).
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