Punishment for bedwetting is associated with child depression and reduced quality of life

Study Design and Participants

We performed a cross-sectional, case–control study between September 2013 and April 2014 on a consecutive sample of 65 children (7–13 years) with PMNE who attended the psychiatric outpatient clinics of King Abdulaziz University Hospital. A control group of 40 age- and gender-matched healthy children were selected from the family members of the cases with enuresis. The diagnosis of PMNE was made according to the classification of the International Children's Continence Society ( Neveus et al., 2006 ). As defined by the Diagnostic and Statistical Manual for Mental Disorders (DSM IV) criteria ( American Psychiatric Association, 1995 ), at least twice weekly episodes of urine incontinence for three consecutive months were necessary for the diagnosis of nocturnal enuresis.

The children with PMNE were previously examined by pediatric nephrologists and pediatric neurologists, and clinical investigations (including complete blood counts, blood urea, serum creatinine, serum glucose levels, serum thyroid-stimulating hormone level, urine analysis and culture, measurement of residual urine, as well as renal and bladder ultrasonography) were conducted to rule out lower urinary tract symptoms, bladder dysfunction, and neurogenic bladder. The results of these investigations were normal in all cases. The children had received several treatment trials with imipramine and desmopressin; however, the condition was refractory to treatment.

We assessed whether parents used punitive methods in their children with urinary incontinence by asking close-ended questions such as “Did you punish your child for bedwetting?” If the response was “Yes”, further questions were asked as follows:

• 1. “What punishment method did you use?” This question had four response choices: (a) verbal only, for example, shouting or using aggressive words; (b) verbal and physical punishment without contact, for example, leaving the child wet for long, making the child stand up for long, locking up the child in his room for long periods, or forcing the child to take a cold shower after each incontinence episode; (c) verbal and punishment with physical harm, including spanking, beating, hitting the child's penis with the hand, or searing the child's hand or arm; and (d) a combination of (b) and (c).
• 2. “What was the frequency of punishment?” This question had two responses, “sometimes” and “frequent”.
• 3. “What was the duration of punishment?” Three responses were allowed: (a) less than six months; (b) six months to one year; and (c) more than one year.

Based on the parents’ response to the first question, the children with PMNE was further subdivided into two groups: Group I included children who received punishment and Group II included those who were not punished for enuresis ( Fig. 1 ).

Fig. 1 Schema of the survey methodology.

We assessed depression symptom severity and the health-related quality (HRQL) of in all three groups. The socio-demographic data of the participants were recorded. The severity of symptoms (assessed by the frequency of wet nights per week) was recorded for children with nocturnal enuresis. Poor academic performance was also assessed for all the children based on the grades obtained as follows: (1) A, excellent; (2) B, very good; (3) C, good; and (4) D, poor. These four categories were dichotomized into good (which included the first three categories) and poor (which included the last category). Socio-demographic characteristics, severity of enuresis, as well as the method, frequency and duration of punishment were used as independent predictors for depression and HRQL in children with nocturnal enuresis.

Exclusion criteria: We excluded all children with developmental delay, mental retardation, pervasive developmental disorders (such as autism and Asperger's disorder), attention-deficit hyperactivity disorder (ADHD), psychotic disorders, and concomitant serious medical disorders.

The participants were interviewed in the presence of their parents. Parental consent was obtained prior to inclusion in the study. Ethical approval was obtained from the local ethics committee of King Abdulaziz University Hospital.

Measures

The Children's Depression Inventory (CDI) ( Kovac, 1985 ) is a child self-report that assesses the symptoms of depression. It has a high internal consistency, test–retest reliability, and established validity ( Twenge & Nolen-Hoeksema, 2002 ), with an α coefficient of 0.86. It is appropriate for children and adolescents aged 7–17 years. The CDI yields scores for five subscales: negative mood, interpersonal problems, ineffectiveness, anhedonia and negative self-esteem. The CDI is a 27-item instrument that consists of three forced–choice answers, namely 0 = absence of symptoms, 1 = moderate symptoms 3 = severe symptoms. The CDI scores range from 0 to 54 with a higher score indicating increasing severity. In the clinical setting, 13 is recommended as a cut-off point for depressive states ( Friedberg & Sinderman, 2011 ). We used this cut-off point in our study.

We used the Pediatric Quality of Life Inventory, version 4.0 generic core scales (Peds-QL 4.0) to assess the HRQL of our sample. The 23-item Peds-QL 4.0 generic core scales encompasses four subscales that measure: (1) physical functioning (eight items); (2) emotional functioning (five items); (3) social functioning (five items), and (4) school functioning (five items) (Varni et al, 1999 and Varni et al, 2001). The physical health summary score (eight items) is the same as the physical functioning scale. To create the psychosocial health summary score (15 items), the mean is computed as the sum of the items divided by the number of items answered in the emotional, social and school functioning scales. The instrument takes approximately five minutes to complete ( Varni et al., 2001 ). The items of Peds-QL 4.0 were scored on a 5-point Likert response scale (0 = never a problem; 1 = almost never a problem; 2 = sometimes a problem; 3 = often a problem; 4 = almost always a problem). Items were reverse – scored and linearly transformed to a 0–100 scale (0 = 100, 1 = 75, 2 = 50, 3 = 25, and 4 = 0) so that higher scores indicated a better HRQL. Scale scores were computed as the sum of the items divided by the number of items answered.

To ensure that participants understood and answered all the questions in the CDI and Peds-QL 4.0, the psychiatric team, with the aid of parents, interviewed all the children.

Statistical Analysis

The data were analyzed using the Statistical Package for the Social Sciences (SPSS Inc., Chicago, IL, USA), version 20. Descriptive data were analyzed using means, standard deviation and percentages. ANOVA was used to compare quantitative parameters. The Chi square, Mann–Whitney and Kruskal–Wallis tests were used to compare categorical parameters. Regression methods were used to develop predictive models. A P value <.05 was considered to indicate statistical significance.

Limitations of the Study

The small sample size did not permit us make relevant comparisons (for example age- and gender-based comparisons). The cross-sectional design of this study prevents us from making causal conclusions. However, this is the first study that has attempted to assess the relationship between parental punishment and depression and HRQL in children with PMNE. We believe that our findings will as a basis for further investigation.

Conclusion

Taken together, our study demonstrates that parental punishment for urinary incontinence was associated with an increase in the severity of depressive symptoms severity and a poor psychosocial HRQL in children with PMNE. While parents might believe that a punitive approach will resolve nocturnal enuresis, they should be educated of the adverse effect of punishment on the child, which might include an increase in the frequency of incontinence episodes and consequently lead to increased depression and a poor psychosocial HRQL. Thus, parents should be advised to avoid punishing enuretic children.

Study Design and Participants

We performed a cross-sectional, case–control study between September 2013 and April 2014 on a consecutive sample of 65 children (7–13 years) with PMNE who attended the psychiatric outpatient clinics of King Abdulaziz University Hospital. A control group of 40 age- and gender-matched healthy children were selected from the family members of the cases with enuresis. The diagnosis of PMNE was made according to the classification of the International Children's Continence Society ( Neveus et al., 2006 ). As defined by the Diagnostic and Statistical Manual for Mental Disorders (DSM IV) criteria ( American Psychiatric Association, 1995 ), at least twice weekly episodes of urine incontinence for three consecutive months were necessary for the diagnosis of nocturnal enuresis.

The children with PMNE were previously examined by pediatric nephrologists and pediatric neurologists, and clinical investigations (including complete blood counts, blood urea, serum creatinine, serum glucose levels, serum thyroid-stimulating hormone level, urine analysis and culture, measurement of residual urine, as well as renal and bladder ultrasonography) were conducted to rule out lower urinary tract symptoms, bladder dysfunction, and neurogenic bladder. The results of these investigations were normal in all cases. The children had received several treatment trials with imipramine and desmopressin; however, the condition was refractory to treatment.

We assessed whether parents used punitive methods in their children with urinary incontinence by asking close-ended questions such as “Did you punish your child for bedwetting?” If the response was “Yes”, further questions were asked as follows:

• 1. “What punishment method did you use?” This question had four response choices: (a) verbal only, for example, shouting or using aggressive words; (b) verbal and physical punishment without contact, for example, leaving the child wet for long, making the child stand up for long, locking up the child in his room for long periods, or forcing the child to take a cold shower after each incontinence episode; (c) verbal and punishment with physical harm, including spanking, beating, hitting the child's penis with the hand, or searing the child's hand or arm; and (d) a combination of (b) and (c).
• 2. “What was the frequency of punishment?” This question had two responses, “sometimes” and “frequent”.
• 3. “What was the duration of punishment?” Three responses were allowed: (a) less than six months; (b) six months to one year; and (c) more than one year.

Based on the parents’ response to the first question, the children with PMNE was further subdivided into two groups: Group I included children who received punishment and Group II included those who were not punished for enuresis ( Fig. 1 ).

Fig. 1 Schema of the survey methodology.

We assessed depression symptom severity and the health-related quality (HRQL) of in all three groups. The socio-demographic data of the participants were recorded. The severity of symptoms (assessed by the frequency of wet nights per week) was recorded for children with nocturnal enuresis. Poor academic performance was also assessed for all the children based on the grades obtained as follows: (1) A, excellent; (2) B, very good; (3) C, good; and (4) D, poor. These four categories were dichotomized into good (which included the first three categories) and poor (which included the last category). Socio-demographic characteristics, severity of enuresis, as well as the method, frequency and duration of punishment were used as independent predictors for depression and HRQL in children with nocturnal enuresis.

Exclusion criteria: We excluded all children with developmental delay, mental retardation, pervasive developmental disorders (such as autism and Asperger's disorder), attention-deficit hyperactivity disorder (ADHD), psychotic disorders, and concomitant serious medical disorders.

The participants were interviewed in the presence of their parents. Parental consent was obtained prior to inclusion in the study. Ethical approval was obtained from the local ethics committee of King Abdulaziz University Hospital.

Measures

The Children's Depression Inventory (CDI) ( Kovac, 1985 ) is a child self-report that assesses the symptoms of depression. It has a high internal consistency, test–retest reliability, and established validity ( Twenge & Nolen-Hoeksema, 2002 ), with an α coefficient of 0.86. It is appropriate for children and adolescents aged 7–17 years. The CDI yields scores for five subscales: negative mood, interpersonal problems, ineffectiveness, anhedonia and negative self-esteem. The CDI is a 27-item instrument that consists of three forced–choice answers, namely 0 = absence of symptoms, 1 = moderate symptoms 3 = severe symptoms. The CDI scores range from 0 to 54 with a higher score indicating increasing severity. In the clinical setting, 13 is recommended as a cut-off point for depressive states ( Friedberg & Sinderman, 2011 ). We used this cut-off point in our study.

We used the Pediatric Quality of Life Inventory, version 4.0 generic core scales (Peds-QL 4.0) to assess the HRQL of our sample. The 23-item Peds-QL 4.0 generic core scales encompasses four subscales that measure: (1) physical functioning (eight items); (2) emotional functioning (five items); (3) social functioning (five items), and (4) school functioning (five items) (Varni et al, 1999 and Varni et al, 2001). The physical health summary score (eight items) is the same as the physical functioning scale. To create the psychosocial health summary score (15 items), the mean is computed as the sum of the items divided by the number of items answered in the emotional, social and school functioning scales. The instrument takes approximately five minutes to complete ( Varni et al., 2001 ). The items of Peds-QL 4.0 were scored on a 5-point Likert response scale (0 = never a problem; 1 = almost never a problem; 2 = sometimes a problem; 3 = often a problem; 4 = almost always a problem). Items were reverse – scored and linearly transformed to a 0–100 scale (0 = 100, 1 = 75, 2 = 50, 3 = 25, and 4 = 0) so that higher scores indicated a better HRQL. Scale scores were computed as the sum of the items divided by the number of items answered.

To ensure that participants understood and answered all the questions in the CDI and Peds-QL 4.0, the psychiatric team, with the aid of parents, interviewed all the children.

Statistical Analysis

The data were analyzed using the Statistical Package for the Social Sciences (SPSS Inc., Chicago, IL, USA), version 20. Descriptive data were analyzed using means, standard deviation and percentages. ANOVA was used to compare quantitative parameters. The Chi square, Mann–Whitney and Kruskal–Wallis tests were used to compare categorical parameters. Regression methods were used to develop predictive models. A P value <.05 was considered to indicate statistical significance.

Limitations of the Study

The small sample size did not permit us make relevant comparisons (for example age- and gender-based comparisons). The cross-sectional design of this study prevents us from making causal conclusions. However, this is the first study that has attempted to assess the relationship between parental punishment and depression and HRQL in children with PMNE. We believe that our findings will as a basis for further investigation.

Conclusion

Taken together, our study demonstrates that parental punishment for urinary incontinence was associated with an increase in the severity of depressive symptoms severity and a poor psychosocial HRQL in children with PMNE. While parents might believe that a punitive approach will resolve nocturnal enuresis, they should be educated of the adverse effect of punishment on the child, which might include an increase in the frequency of incontinence episodes and consequently lead to increased depression and a poor psychosocial HRQL. Thus, parents should be advised to avoid punishing enuretic children.

Study Design and Participants

We performed a cross-sectional, case–control study between September 2013 and April 2014 on a consecutive sample of 65 children (7–13 years) with PMNE who attended the psychiatric outpatient clinics of King Abdulaziz University Hospital. A control group of 40 age- and gender-matched healthy children were selected from the family members of the cases with enuresis. The diagnosis of PMNE was made according to the classification of the International Children's Continence Society ( Neveus et al., 2006 ). As defined by the Diagnostic and Statistical Manual for Mental Disorders (DSM IV) criteria ( American Psychiatric Association, 1995 ), at least twice weekly episodes of urine incontinence for three consecutive months were necessary for the diagnosis of nocturnal enuresis.

The children with PMNE were previously examined by pediatric nephrologists and pediatric neurologists, and clinical investigations (including complete blood counts, blood urea, serum creatinine, serum glucose levels, serum thyroid-stimulating hormone level, urine analysis and culture, measurement of residual urine, as well as renal and bladder ultrasonography) were conducted to rule out lower urinary tract symptoms, bladder dysfunction, and neurogenic bladder. The results of these investigations were normal in all cases. The children had received several treatment trials with imipramine and desmopressin; however, the condition was refractory to treatment.

We assessed whether parents used punitive methods in their children with urinary incontinence by asking close-ended questions such as “Did you punish your child for bedwetting?” If the response was “Yes”, further questions were asked as follows:

• 1. “What punishment method did you use?” This question had four response choices: (a) verbal only, for example, shouting or using aggressive words; (b) verbal and physical punishment without contact, for example, leaving the child wet for long, making the child stand up for long, locking up the child in his room for long periods, or forcing the child to take a cold shower after each incontinence episode; (c) verbal and punishment with physical harm, including spanking, beating, hitting the child's penis with the hand, or searing the child's hand or arm; and (d) a combination of (b) and (c).
• 2. “What was the frequency of punishment?” This question had two responses, “sometimes” and “frequent”.
• 3. “What was the duration of punishment?” Three responses were allowed: (a) less than six months; (b) six months to one year; and (c) more than one year.

Based on the parents’ response to the first question, the children with PMNE was further subdivided into two groups: Group I included children who received punishment and Group II included those who were not punished for enuresis ( Fig. 1 ).

Fig. 1 Schema of the survey methodology.

We assessed depression symptom severity and the health-related quality (HRQL) of in all three groups. The socio-demographic data of the participants were recorded. The severity of symptoms (assessed by the frequency of wet nights per week) was recorded for children with nocturnal enuresis. Poor academic performance was also assessed for all the children based on the grades obtained as follows: (1) A, excellent; (2) B, very good; (3) C, good; and (4) D, poor. These four categories were dichotomized into good (which included the first three categories) and poor (which included the last category). Socio-demographic characteristics, severity of enuresis, as well as the method, frequency and duration of punishment were used as independent predictors for depression and HRQL in children with nocturnal enuresis.

Exclusion criteria: We excluded all children with developmental delay, mental retardation, pervasive developmental disorders (such as autism and Asperger's disorder), attention-deficit hyperactivity disorder (ADHD), psychotic disorders, and concomitant serious medical disorders.

The participants were interviewed in the presence of their parents. Parental consent was obtained prior to inclusion in the study. Ethical approval was obtained from the local ethics committee of King Abdulaziz University Hospital.

Measures

The Children's Depression Inventory (CDI) ( Kovac, 1985 ) is a child self-report that assesses the symptoms of depression. It has a high internal consistency, test–retest reliability, and established validity ( Twenge & Nolen-Hoeksema, 2002 ), with an α coefficient of 0.86. It is appropriate for children and adolescents aged 7–17 years. The CDI yields scores for five subscales: negative mood, interpersonal problems, ineffectiveness, anhedonia and negative self-esteem. The CDI is a 27-item instrument that consists of three forced–choice answers, namely 0 = absence of symptoms, 1 = moderate symptoms 3 = severe symptoms. The CDI scores range from 0 to 54 with a higher score indicating increasing severity. In the clinical setting, 13 is recommended as a cut-off point for depressive states ( Friedberg & Sinderman, 2011 ). We used this cut-off point in our study.

We used the Pediatric Quality of Life Inventory, version 4.0 generic core scales (Peds-QL 4.0) to assess the HRQL of our sample. The 23-item Peds-QL 4.0 generic core scales encompasses four subscales that measure: (1) physical functioning (eight items); (2) emotional functioning (five items); (3) social functioning (five items), and (4) school functioning (five items) (Varni et al, 1999 and Varni et al, 2001). The physical health summary score (eight items) is the same as the physical functioning scale. To create the psychosocial health summary score (15 items), the mean is computed as the sum of the items divided by the number of items answered in the emotional, social and school functioning scales. The instrument takes approximately five minutes to complete ( Varni et al., 2001 ). The items of Peds-QL 4.0 were scored on a 5-point Likert response scale (0 = never a problem; 1 = almost never a problem; 2 = sometimes a problem; 3 = often a problem; 4 = almost always a problem). Items were reverse – scored and linearly transformed to a 0–100 scale (0 = 100, 1 = 75, 2 = 50, 3 = 25, and 4 = 0) so that higher scores indicated a better HRQL. Scale scores were computed as the sum of the items divided by the number of items answered.

To ensure that participants understood and answered all the questions in the CDI and Peds-QL 4.0, the psychiatric team, with the aid of parents, interviewed all the children.

Statistical Analysis

The data were analyzed using the Statistical Package for the Social Sciences (SPSS Inc., Chicago, IL, USA), version 20. Descriptive data were analyzed using means, standard deviation and percentages. ANOVA was used to compare quantitative parameters. The Chi square, Mann–Whitney and Kruskal–Wallis tests were used to compare categorical parameters. Regression methods were used to develop predictive models. A P value <.05 was considered to indicate statistical significance.

Limitations of the Study

The small sample size did not permit us make relevant comparisons (for example age- and gender-based comparisons). The cross-sectional design of this study prevents us from making causal conclusions. However, this is the first study that has attempted to assess the relationship between parental punishment and depression and HRQL in children with PMNE. We believe that our findings will as a basis for further investigation.

Conclusion

Taken together, our study demonstrates that parental punishment for urinary incontinence was associated with an increase in the severity of depressive symptoms severity and a poor psychosocial HRQL in children with PMNE. While parents might believe that a punitive approach will resolve nocturnal enuresis, they should be educated of the adverse effect of punishment on the child, which might include an increase in the frequency of incontinence episodes and consequently lead to increased depression and a poor psychosocial HRQL. Thus, parents should be advised to avoid punishing enuretic children.

Study Design and Participants

We performed a cross-sectional, case–control study between September 2013 and April 2014 on a consecutive sample of 65 children (7–13 years) with PMNE who attended the psychiatric outpatient clinics of King Abdulaziz University Hospital. A control group of 40 age- and gender-matched healthy children were selected from the family members of the cases with enuresis. The diagnosis of PMNE was made according to the classification of the International Children's Continence Society ( Neveus et al., 2006 ). As defined by the Diagnostic and Statistical Manual for Mental Disorders (DSM IV) criteria ( American Psychiatric Association, 1995 ), at least twice weekly episodes of urine incontinence for three consecutive months were necessary for the diagnosis of nocturnal enuresis.

The children with PMNE were previously examined by pediatric nephrologists and pediatric neurologists, and clinical investigations (including complete blood counts, blood urea, serum creatinine, serum glucose levels, serum thyroid-stimulating hormone level, urine analysis and culture, measurement of residual urine, as well as renal and bladder ultrasonography) were conducted to rule out lower urinary tract symptoms, bladder dysfunction, and neurogenic bladder. The results of these investigations were normal in all cases. The children had received several treatment trials with imipramine and desmopressin; however, the condition was refractory to treatment.

We assessed whether parents used punitive methods in their children with urinary incontinence by asking close-ended questions such as “Did you punish your child for bedwetting?” If the response was “Yes”, further questions were asked as follows:

• 1. “What punishment method did you use?” This question had four response choices: (a) verbal only, for example, shouting or using aggressive words; (b) verbal and physical punishment without contact, for example, leaving the child wet for long, making the child stand up for long, locking up the child in his room for long periods, or forcing the child to take a cold shower after each incontinence episode; (c) verbal and punishment with physical harm, including spanking, beating, hitting the child's penis with the hand, or searing the child's hand or arm; and (d) a combination of (b) and (c).
• 2. “What was the frequency of punishment?” This question had two responses, “sometimes” and “frequent”.
• 3. “What was the duration of punishment?” Three responses were allowed: (a) less than six months; (b) six months to one year; and (c) more than one year.

Based on the parents’ response to the first question, the children with PMNE was further subdivided into two groups: Group I included children who received punishment and Group II included those who were not punished for enuresis ( Fig. 1 ).

Fig. 1 Schema of the survey methodology.

We assessed depression symptom severity and the health-related quality (HRQL) of in all three groups. The socio-demographic data of the participants were recorded. The severity of symptoms (assessed by the frequency of wet nights per week) was recorded for children with nocturnal enuresis. Poor academic performance was also assessed for all the children based on the grades obtained as follows: (1) A, excellent; (2) B, very good; (3) C, good; and (4) D, poor. These four categories were dichotomized into good (which included the first three categories) and poor (which included the last category). Socio-demographic characteristics, severity of enuresis, as well as the method, frequency and duration of punishment were used as independent predictors for depression and HRQL in children with nocturnal enuresis.

Exclusion criteria: We excluded all children with developmental delay, mental retardation, pervasive developmental disorders (such as autism and Asperger's disorder), attention-deficit hyperactivity disorder (ADHD), psychotic disorders, and concomitant serious medical disorders.

The participants were interviewed in the presence of their parents. Parental consent was obtained prior to inclusion in the study. Ethical approval was obtained from the local ethics committee of King Abdulaziz University Hospital.

Measures

The Children's Depression Inventory (CDI) ( Kovac, 1985 ) is a child self-report that assesses the symptoms of depression. It has a high internal consistency, test–retest reliability, and established validity ( Twenge & Nolen-Hoeksema, 2002 ), with an α coefficient of 0.86. It is appropriate for children and adolescents aged 7–17 years. The CDI yields scores for five subscales: negative mood, interpersonal problems, ineffectiveness, anhedonia and negative self-esteem. The CDI is a 27-item instrument that consists of three forced–choice answers, namely 0 = absence of symptoms, 1 = moderate symptoms 3 = severe symptoms. The CDI scores range from 0 to 54 with a higher score indicating increasing severity. In the clinical setting, 13 is recommended as a cut-off point for depressive states ( Friedberg & Sinderman, 2011 ). We used this cut-off point in our study.

We used the Pediatric Quality of Life Inventory, version 4.0 generic core scales (Peds-QL 4.0) to assess the HRQL of our sample. The 23-item Peds-QL 4.0 generic core scales encompasses four subscales that measure: (1) physical functioning (eight items); (2) emotional functioning (five items); (3) social functioning (five items), and (4) school functioning (five items) (Varni et al, 1999 and Varni et al, 2001). The physical health summary score (eight items) is the same as the physical functioning scale. To create the psychosocial health summary score (15 items), the mean is computed as the sum of the items divided by the number of items answered in the emotional, social and school functioning scales. The instrument takes approximately five minutes to complete ( Varni et al., 2001 ). The items of Peds-QL 4.0 were scored on a 5-point Likert response scale (0 = never a problem; 1 = almost never a problem; 2 = sometimes a problem; 3 = often a problem; 4 = almost always a problem). Items were reverse – scored and linearly transformed to a 0–100 scale (0 = 100, 1 = 75, 2 = 50, 3 = 25, and 4 = 0) so that higher scores indicated a better HRQL. Scale scores were computed as the sum of the items divided by the number of items answered.

To ensure that participants understood and answered all the questions in the CDI and Peds-QL 4.0, the psychiatric team, with the aid of parents, interviewed all the children.

Statistical Analysis

The data were analyzed using the Statistical Package for the Social Sciences (SPSS Inc., Chicago, IL, USA), version 20. Descriptive data were analyzed using means, standard deviation and percentages. ANOVA was used to compare quantitative parameters. The Chi square, Mann–Whitney and Kruskal–Wallis tests were used to compare categorical parameters. Regression methods were used to develop predictive models. A P value <.05 was considered to indicate statistical significance.

Limitations of the Study

The small sample size did not permit us make relevant comparisons (for example age- and gender-based comparisons). The cross-sectional design of this study prevents us from making causal conclusions. However, this is the first study that has attempted to assess the relationship between parental punishment and depression and HRQL in children with PMNE. We believe that our findings will as a basis for further investigation.

Conclusion

Taken together, our study demonstrates that parental punishment for urinary incontinence was associated with an increase in the severity of depressive symptoms severity and a poor psychosocial HRQL in children with PMNE. While parents might believe that a punitive approach will resolve nocturnal enuresis, they should be educated of the adverse effect of punishment on the child, which might include an increase in the frequency of incontinence episodes and consequently lead to increased depression and a poor psychosocial HRQL. Thus, parents should be advised to avoid punishing enuretic children.

Study Design and Participants

We performed a cross-sectional, case–control study between September 2013 and April 2014 on a consecutive sample of 65 children (7–13 years) with PMNE who attended the psychiatric outpatient clinics of King Abdulaziz University Hospital. A control group of 40 age- and gender-matched healthy children were selected from the family members of the cases with enuresis. The diagnosis of PMNE was made according to the classification of the International Children's Continence Society ( Neveus et al., 2006 ). As defined by the Diagnostic and Statistical Manual for Mental Disorders (DSM IV) criteria ( American Psychiatric Association, 1995 ), at least twice weekly episodes of urine incontinence for three consecutive months were necessary for the diagnosis of nocturnal enuresis.

The children with PMNE were previously examined by pediatric nephrologists and pediatric neurologists, and clinical investigations (including complete blood counts, blood urea, serum creatinine, serum glucose levels, serum thyroid-stimulating hormone level, urine analysis and culture, measurement of residual urine, as well as renal and bladder ultrasonography) were conducted to rule out lower urinary tract symptoms, bladder dysfunction, and neurogenic bladder. The results of these investigations were normal in all cases. The children had received several treatment trials with imipramine and desmopressin; however, the condition was refractory to treatment.

We assessed whether parents used punitive methods in their children with urinary incontinence by asking close-ended questions such as “Did you punish your child for bedwetting?” If the response was “Yes”, further questions were asked as follows:

• 1. “What punishment method did you use?” This question had four response choices: (a) verbal only, for example, shouting or using aggressive words; (b) verbal and physical punishment without contact, for example, leaving the child wet for long, making the child stand up for long, locking up the child in his room for long periods, or forcing the child to take a cold shower after each incontinence episode; (c) verbal and punishment with physical harm, including spanking, beating, hitting the child's penis with the hand, or searing the child's hand or arm; and (d) a combination of (b) and (c).
• 2. “What was the frequency of punishment?” This question had two responses, “sometimes” and “frequent”.
• 3. “What was the duration of punishment?” Three responses were allowed: (a) less than six months; (b) six months to one year; and (c) more than one year.

Based on the parents’ response to the first question, the children with PMNE was further subdivided into two groups: Group I included children who received punishment and Group II included those who were not punished for enuresis ( Fig. 1 ).

Fig. 1 Schema of the survey methodology.

We assessed depression symptom severity and the health-related quality (HRQL) of in all three groups. The socio-demographic data of the participants were recorded. The severity of symptoms (assessed by the frequency of wet nights per week) was recorded for children with nocturnal enuresis. Poor academic performance was also assessed for all the children based on the grades obtained as follows: (1) A, excellent; (2) B, very good; (3) C, good; and (4) D, poor. These four categories were dichotomized into good (which included the first three categories) and poor (which included the last category). Socio-demographic characteristics, severity of enuresis, as well as the method, frequency and duration of punishment were used as independent predictors for depression and HRQL in children with nocturnal enuresis.

Exclusion criteria: We excluded all children with developmental delay, mental retardation, pervasive developmental disorders (such as autism and Asperger's disorder), attention-deficit hyperactivity disorder (ADHD), psychotic disorders, and concomitant serious medical disorders.

The participants were interviewed in the presence of their parents. Parental consent was obtained prior to inclusion in the study. Ethical approval was obtained from the local ethics committee of King Abdulaziz University Hospital.

Measures

The Children's Depression Inventory (CDI) ( Kovac, 1985 ) is a child self-report that assesses the symptoms of depression. It has a high internal consistency, test–retest reliability, and established validity ( Twenge & Nolen-Hoeksema, 2002 ), with an α coefficient of 0.86. It is appropriate for children and adolescents aged 7–17 years. The CDI yields scores for five subscales: negative mood, interpersonal problems, ineffectiveness, anhedonia and negative self-esteem. The CDI is a 27-item instrument that consists of three forced–choice answers, namely 0 = absence of symptoms, 1 = moderate symptoms 3 = severe symptoms. The CDI scores range from 0 to 54 with a higher score indicating increasing severity. In the clinical setting, 13 is recommended as a cut-off point for depressive states ( Friedberg & Sinderman, 2011 ). We used this cut-off point in our study.

We used the Pediatric Quality of Life Inventory, version 4.0 generic core scales (Peds-QL 4.0) to assess the HRQL of our sample. The 23-item Peds-QL 4.0 generic core scales encompasses four subscales that measure: (1) physical functioning (eight items); (2) emotional functioning (five items); (3) social functioning (five items), and (4) school functioning (five items) (Varni et al, 1999 and Varni et al, 2001). The physical health summary score (eight items) is the same as the physical functioning scale. To create the psychosocial health summary score (15 items), the mean is computed as the sum of the items divided by the number of items answered in the emotional, social and school functioning scales. The instrument takes approximately five minutes to complete ( Varni et al., 2001 ). The items of Peds-QL 4.0 were scored on a 5-point Likert response scale (0 = never a problem; 1 = almost never a problem; 2 = sometimes a problem; 3 = often a problem; 4 = almost always a problem). Items were reverse – scored and linearly transformed to a 0–100 scale (0 = 100, 1 = 75, 2 = 50, 3 = 25, and 4 = 0) so that higher scores indicated a better HRQL. Scale scores were computed as the sum of the items divided by the number of items answered.

To ensure that participants understood and answered all the questions in the CDI and Peds-QL 4.0, the psychiatric team, with the aid of parents, interviewed all the children.

Statistical Analysis

The data were analyzed using the Statistical Package for the Social Sciences (SPSS Inc., Chicago, IL, USA), version 20. Descriptive data were analyzed using means, standard deviation and percentages. ANOVA was used to compare quantitative parameters. The Chi square, Mann–Whitney and Kruskal–Wallis tests were used to compare categorical parameters. Regression methods were used to develop predictive models. A P value <.05 was considered to indicate statistical significance.

Limitations of the Study

The small sample size did not permit us make relevant comparisons (for example age- and gender-based comparisons). The cross-sectional design of this study prevents us from making causal conclusions. However, this is the first study that has attempted to assess the relationship between parental punishment and depression and HRQL in children with PMNE. We believe that our findings will as a basis for further investigation.

Conclusion

Taken together, our study demonstrates that parental punishment for urinary incontinence was associated with an increase in the severity of depressive symptoms severity and a poor psychosocial HRQL in children with PMNE. While parents might believe that a punitive approach will resolve nocturnal enuresis, they should be educated of the adverse effect of punishment on the child, which might include an increase in the frequency of incontinence episodes and consequently lead to increased depression and a poor psychosocial HRQL. Thus, parents should be advised to avoid punishing enuretic children.

Study Design and Participants

We performed a cross-sectional, case–control study between September 2013 and April 2014 on a consecutive sample of 65 children (7–13 years) with PMNE who attended the psychiatric outpatient clinics of King Abdulaziz University Hospital. A control group of 40 age- and gender-matched healthy children were selected from the family members of the cases with enuresis. The diagnosis of PMNE was made according to the classification of the International Children's Continence Society ( Neveus et al., 2006 ). As defined by the Diagnostic and Statistical Manual for Mental Disorders (DSM IV) criteria ( American Psychiatric Association, 1995 ), at least twice weekly episodes of urine incontinence for three consecutive months were necessary for the diagnosis of nocturnal enuresis.

The children with PMNE were previously examined by pediatric nephrologists and pediatric neurologists, and clinical investigations (including complete blood counts, blood urea, serum creatinine, serum glucose levels, serum thyroid-stimulating hormone level, urine analysis and culture, measurement of residual urine, as well as renal and bladder ultrasonography) were conducted to rule out lower urinary tract symptoms, bladder dysfunction, and neurogenic bladder. The results of these investigations were normal in all cases. The children had received several treatment trials with imipramine and desmopressin; however, the condition was refractory to treatment.

We assessed whether parents used punitive methods in their children with urinary incontinence by asking close-ended questions such as “Did you punish your child for bedwetting?” If the response was “Yes”, further questions were asked as follows:

• 1. “What punishment method did you use?” This question had four response choices: (a) verbal only, for example, shouting or using aggressive words; (b) verbal and physical punishment without contact, for example, leaving the child wet for long, making the child stand up for long, locking up the child in his room for long periods, or forcing the child to take a cold shower after each incontinence episode; (c) verbal and punishment with physical harm, including spanking, beating, hitting the child's penis with the hand, or searing the child's hand or arm; and (d) a combination of (b) and (c).
• 2. “What was the frequency of punishment?” This question had two responses, “sometimes” and “frequent”.
• 3. “What was the duration of punishment?” Three responses were allowed: (a) less than six months; (b) six months to one year; and (c) more than one year.

Based on the parents’ response to the first question, the children with PMNE was further subdivided into two groups: Group I included children who received punishment and Group II included those who were not punished for enuresis ( Fig. 1 ).

Fig. 1 Schema of the survey methodology.

We assessed depression symptom severity and the health-related quality (HRQL) of in all three groups. The socio-demographic data of the participants were recorded. The severity of symptoms (assessed by the frequency of wet nights per week) was recorded for children with nocturnal enuresis. Poor academic performance was also assessed for all the children based on the grades obtained as follows: (1) A, excellent; (2) B, very good; (3) C, good; and (4) D, poor. These four categories were dichotomized into good (which included the first three categories) and poor (which included the last category). Socio-demographic characteristics, severity of enuresis, as well as the method, frequency and duration of punishment were used as independent predictors for depression and HRQL in children with nocturnal enuresis.

Exclusion criteria: We excluded all children with developmental delay, mental retardation, pervasive developmental disorders (such as autism and Asperger's disorder), attention-deficit hyperactivity disorder (ADHD), psychotic disorders, and concomitant serious medical disorders.

The participants were interviewed in the presence of their parents. Parental consent was obtained prior to inclusion in the study. Ethical approval was obtained from the local ethics committee of King Abdulaziz University Hospital.

Measures

The Children's Depression Inventory (CDI) ( Kovac, 1985 ) is a child self-report that assesses the symptoms of depression. It has a high internal consistency, test–retest reliability, and established validity ( Twenge & Nolen-Hoeksema, 2002 ), with an α coefficient of 0.86. It is appropriate for children and adolescents aged 7–17 years. The CDI yields scores for five subscales: negative mood, interpersonal problems, ineffectiveness, anhedonia and negative self-esteem. The CDI is a 27-item instrument that consists of three forced–choice answers, namely 0 = absence of symptoms, 1 = moderate symptoms 3 = severe symptoms. The CDI scores range from 0 to 54 with a higher score indicating increasing severity. In the clinical setting, 13 is recommended as a cut-off point for depressive states ( Friedberg & Sinderman, 2011 ). We used this cut-off point in our study.

We used the Pediatric Quality of Life Inventory, version 4.0 generic core scales (Peds-QL 4.0) to assess the HRQL of our sample. The 23-item Peds-QL 4.0 generic core scales encompasses four subscales that measure: (1) physical functioning (eight items); (2) emotional functioning (five items); (3) social functioning (five items), and (4) school functioning (five items) (Varni et al, 1999 and Varni et al, 2001). The physical health summary score (eight items) is the same as the physical functioning scale. To create the psychosocial health summary score (15 items), the mean is computed as the sum of the items divided by the number of items answered in the emotional, social and school functioning scales. The instrument takes approximately five minutes to complete ( Varni et al., 2001 ). The items of Peds-QL 4.0 were scored on a 5-point Likert response scale (0 = never a problem; 1 = almost never a problem; 2 = sometimes a problem; 3 = often a problem; 4 = almost always a problem). Items were reverse – scored and linearly transformed to a 0–100 scale (0 = 100, 1 = 75, 2 = 50, 3 = 25, and 4 = 0) so that higher scores indicated a better HRQL. Scale scores were computed as the sum of the items divided by the number of items answered.

To ensure that participants understood and answered all the questions in the CDI and Peds-QL 4.0, the psychiatric team, with the aid of parents, interviewed all the children.

Statistical Analysis

The data were analyzed using the Statistical Package for the Social Sciences (SPSS Inc., Chicago, IL, USA), version 20. Descriptive data were analyzed using means, standard deviation and percentages. ANOVA was used to compare quantitative parameters. The Chi square, Mann–Whitney and Kruskal–Wallis tests were used to compare categorical parameters. Regression methods were used to develop predictive models. A P value <.05 was considered to indicate statistical significance.

Limitations of the Study

The small sample size did not permit us make relevant comparisons (for example age- and gender-based comparisons). The cross-sectional design of this study prevents us from making causal conclusions. However, this is the first study that has attempted to assess the relationship between parental punishment and depression and HRQL in children with PMNE. We believe that our findings will as a basis for further investigation.

Conclusion

Taken together, our study demonstrates that parental punishment for urinary incontinence was associated with an increase in the severity of depressive symptoms severity and a poor psychosocial HRQL in children with PMNE. While parents might believe that a punitive approach will resolve nocturnal enuresis, they should be educated of the adverse effect of punishment on the child, which might include an increase in the frequency of incontinence episodes and consequently lead to increased depression and a poor psychosocial HRQL. Thus, parents should be advised to avoid punishing enuretic children.

Study Design and Participants

We performed a cross-sectional, case–control study between September 2013 and April 2014 on a consecutive sample of 65 children (7–13 years) with PMNE who attended the psychiatric outpatient clinics of King Abdulaziz University Hospital. A control group of 40 age- and gender-matched healthy children were selected from the family members of the cases with enuresis. The diagnosis of PMNE was made according to the classification of the International Children's Continence Society ( Neveus et al., 2006 ). As defined by the Diagnostic and Statistical Manual for Mental Disorders (DSM IV) criteria ( American Psychiatric Association, 1995 ), at least twice weekly episodes of urine incontinence for three consecutive months were necessary for the diagnosis of nocturnal enuresis.

The children with PMNE were previously examined by pediatric nephrologists and pediatric neurologists, and clinical investigations (including complete blood counts, blood urea, serum creatinine, serum glucose levels, serum thyroid-stimulating hormone level, urine analysis and culture, measurement of residual urine, as well as renal and bladder ultrasonography) were conducted to rule out lower urinary tract symptoms, bladder dysfunction, and neurogenic bladder. The results of these investigations were normal in all cases. The children had received several treatment trials with imipramine and desmopressin; however, the condition was refractory to treatment.

We assessed whether parents used punitive methods in their children with urinary incontinence by asking close-ended questions such as “Did you punish your child for bedwetting?” If the response was “Yes”, further questions were asked as follows:

• 1. “What punishment method did you use?” This question had four response choices: (a) verbal only, for example, shouting or using aggressive words; (b) verbal and physical punishment without contact, for example, leaving the child wet for long, making the child stand up for long, locking up the child in his room for long periods, or forcing the child to take a cold shower after each incontinence episode; (c) verbal and punishment with physical harm, including spanking, beating, hitting the child's penis with the hand, or searing the child's hand or arm; and (d) a combination of (b) and (c).
• 2. “What was the frequency of punishment?” This question had two responses, “sometimes” and “frequent”.
• 3. “What was the duration of punishment?” Three responses were allowed: (a) less than six months; (b) six months to one year; and (c) more than one year.

Based on the parents’ response to the first question, the children with PMNE was further subdivided into two groups: Group I included children who received punishment and Group II included those who were not punished for enuresis ( Fig. 1 ).

Fig. 1 Schema of the survey methodology.

We assessed depression symptom severity and the health-related quality (HRQL) of in all three groups. The socio-demographic data of the participants were recorded. The severity of symptoms (assessed by the frequency of wet nights per week) was recorded for children with nocturnal enuresis. Poor academic performance was also assessed for all the children based on the grades obtained as follows: (1) A, excellent; (2) B, very good; (3) C, good; and (4) D, poor. These four categories were dichotomized into good (which included the first three categories) and poor (which included the last category). Socio-demographic characteristics, severity of enuresis, as well as the method, frequency and duration of punishment were used as independent predictors for depression and HRQL in children with nocturnal enuresis.

Exclusion criteria: We excluded all children with developmental delay, mental retardation, pervasive developmental disorders (such as autism and Asperger's disorder), attention-deficit hyperactivity disorder (ADHD), psychotic disorders, and concomitant serious medical disorders.

The participants were interviewed in the presence of their parents. Parental consent was obtained prior to inclusion in the study. Ethical approval was obtained from the local ethics committee of King Abdulaziz University Hospital.

Measures

The Children's Depression Inventory (CDI) ( Kovac, 1985 ) is a child self-report that assesses the symptoms of depression. It has a high internal consistency, test–retest reliability, and established validity ( Twenge & Nolen-Hoeksema, 2002 ), with an α coefficient of 0.86. It is appropriate for children and adolescents aged 7–17 years. The CDI yields scores for five subscales: negative mood, interpersonal problems, ineffectiveness, anhedonia and negative self-esteem. The CDI is a 27-item instrument that consists of three forced–choice answers, namely 0 = absence of symptoms, 1 = moderate symptoms 3 = severe symptoms. The CDI scores range from 0 to 54 with a higher score indicating increasing severity. In the clinical setting, 13 is recommended as a cut-off point for depressive states ( Friedberg & Sinderman, 2011 ). We used this cut-off point in our study.

We used the Pediatric Quality of Life Inventory, version 4.0 generic core scales (Peds-QL 4.0) to assess the HRQL of our sample. The 23-item Peds-QL 4.0 generic core scales encompasses four subscales that measure: (1) physical functioning (eight items); (2) emotional functioning (five items); (3) social functioning (five items), and (4) school functioning (five items) (Varni et al, 1999 and Varni et al, 2001). The physical health summary score (eight items) is the same as the physical functioning scale. To create the psychosocial health summary score (15 items), the mean is computed as the sum of the items divided by the number of items answered in the emotional, social and school functioning scales. The instrument takes approximately five minutes to complete ( Varni et al., 2001 ). The items of Peds-QL 4.0 were scored on a 5-point Likert response scale (0 = never a problem; 1 = almost never a problem; 2 = sometimes a problem; 3 = often a problem; 4 = almost always a problem). Items were reverse – scored and linearly transformed to a 0–100 scale (0 = 100, 1 = 75, 2 = 50, 3 = 25, and 4 = 0) so that higher scores indicated a better HRQL. Scale scores were computed as the sum of the items divided by the number of items answered.

To ensure that participants understood and answered all the questions in the CDI and Peds-QL 4.0, the psychiatric team, with the aid of parents, interviewed all the children.

Statistical Analysis

The data were analyzed using the Statistical Package for the Social Sciences (SPSS Inc., Chicago, IL, USA), version 20. Descriptive data were analyzed using means, standard deviation and percentages. ANOVA was used to compare quantitative parameters. The Chi square, Mann–Whitney and Kruskal–Wallis tests were used to compare categorical parameters. Regression methods were used to develop predictive models. A P value <.05 was considered to indicate statistical significance.

Limitations of the Study

The small sample size did not permit us make relevant comparisons (for example age- and gender-based comparisons). The cross-sectional design of this study prevents us from making causal conclusions. However, this is the first study that has attempted to assess the relationship between parental punishment and depression and HRQL in children with PMNE. We believe that our findings will as a basis for further investigation.

Conclusion

Taken together, our study demonstrates that parental punishment for urinary incontinence was associated with an increase in the severity of depressive symptoms severity and a poor psychosocial HRQL in children with PMNE. While parents might believe that a punitive approach will resolve nocturnal enuresis, they should be educated of the adverse effect of punishment on the child, which might include an increase in the frequency of incontinence episodes and consequently lead to increased depression and a poor psychosocial HRQL. Thus, parents should be advised to avoid punishing enuretic children.

Study Design and Participants

We performed a cross-sectional, case–control study between September 2013 and April 2014 on a consecutive sample of 65 children (7–13 years) with PMNE who attended the psychiatric outpatient clinics of King Abdulaziz University Hospital. A control group of 40 age- and gender-matched healthy children were selected from the family members of the cases with enuresis. The diagnosis of PMNE was made according to the classification of the International Children's Continence Society ( Neveus et al., 2006 ). As defined by the Diagnostic and Statistical Manual for Mental Disorders (DSM IV) criteria ( American Psychiatric Association, 1995 ), at least twice weekly episodes of urine incontinence for three consecutive months were necessary for the diagnosis of nocturnal enuresis.

The children with PMNE were previously examined by pediatric nephrologists and pediatric neurologists, and clinical investigations (including complete blood counts, blood urea, serum creatinine, serum glucose levels, serum thyroid-stimulating hormone level, urine analysis and culture, measurement of residual urine, as well as renal and bladder ultrasonography) were conducted to rule out lower urinary tract symptoms, bladder dysfunction, and neurogenic bladder. The results of these investigations were normal in all cases. The children had received several treatment trials with imipramine and desmopressin; however, the condition was refractory to treatment.

We assessed whether parents used punitive methods in their children with urinary incontinence by asking close-ended questions such as “Did you punish your child for bedwetting?” If the response was “Yes”, further questions were asked as follows:

• 1. “What punishment method did you use?” This question had four response choices: (a) verbal only, for example, shouting or using aggressive words; (b) verbal and physical punishment without contact, for example, leaving the child wet for long, making the child stand up for long, locking up the child in his room for long periods, or forcing the child to take a cold shower after each incontinence episode; (c) verbal and punishment with physical harm, including spanking, beating, hitting the child's penis with the hand, or searing the child's hand or arm; and (d) a combination of (b) and (c).
• 2. “What was the frequency of punishment?” This question had two responses, “sometimes” and “frequent”.
• 3. “What was the duration of punishment?” Three responses were allowed: (a) less than six months; (b) six months to one year; and (c) more than one year.

Based on the parents’ response to the first question, the children with PMNE was further subdivided into two groups: Group I included children who received punishment and Group II included those who were not punished for enuresis ( Fig. 1 ).

Fig. 1 Schema of the survey methodology.

We assessed depression symptom severity and the health-related quality (HRQL) of in all three groups. The socio-demographic data of the participants were recorded. The severity of symptoms (assessed by the frequency of wet nights per week) was recorded for children with nocturnal enuresis. Poor academic performance was also assessed for all the children based on the grades obtained as follows: (1) A, excellent; (2) B, very good; (3) C, good; and (4) D, poor. These four categories were dichotomized into good (which included the first three categories) and poor (which included the last category). Socio-demographic characteristics, severity of enuresis, as well as the method, frequency and duration of punishment were used as independent predictors for depression and HRQL in children with nocturnal enuresis.

Exclusion criteria: We excluded all children with developmental delay, mental retardation, pervasive developmental disorders (such as autism and Asperger's disorder), attention-deficit hyperactivity disorder (ADHD), psychotic disorders, and concomitant serious medical disorders.

The participants were interviewed in the presence of their parents. Parental consent was obtained prior to inclusion in the study. Ethical approval was obtained from the local ethics committee of King Abdulaziz University Hospital.

Measures

The Children's Depression Inventory (CDI) ( Kovac, 1985 ) is a child self-report that assesses the symptoms of depression. It has a high internal consistency, test–retest reliability, and established validity ( Twenge & Nolen-Hoeksema, 2002 ), with an α coefficient of 0.86. It is appropriate for children and adolescents aged 7–17 years. The CDI yields scores for five subscales: negative mood, interpersonal problems, ineffectiveness, anhedonia and negative self-esteem. The CDI is a 27-item instrument that consists of three forced–choice answers, namely 0 = absence of symptoms, 1 = moderate symptoms 3 = severe symptoms. The CDI scores range from 0 to 54 with a higher score indicating increasing severity. In the clinical setting, 13 is recommended as a cut-off point for depressive states ( Friedberg & Sinderman, 2011 ). We used this cut-off point in our study.

We used the Pediatric Quality of Life Inventory, version 4.0 generic core scales (Peds-QL 4.0) to assess the HRQL of our sample. The 23-item Peds-QL 4.0 generic core scales encompasses four subscales that measure: (1) physical functioning (eight items); (2) emotional functioning (five items); (3) social functioning (five items), and (4) school functioning (five items) (Varni et al, 1999 and Varni et al, 2001). The physical health summary score (eight items) is the same as the physical functioning scale. To create the psychosocial health summary score (15 items), the mean is computed as the sum of the items divided by the number of items answered in the emotional, social and school functioning scales. The instrument takes approximately five minutes to complete ( Varni et al., 2001 ). The items of Peds-QL 4.0 were scored on a 5-point Likert response scale (0 = never a problem; 1 = almost never a problem; 2 = sometimes a problem; 3 = often a problem; 4 = almost always a problem). Items were reverse – scored and linearly transformed to a 0–100 scale (0 = 100, 1 = 75, 2 = 50, 3 = 25, and 4 = 0) so that higher scores indicated a better HRQL. Scale scores were computed as the sum of the items divided by the number of items answered.

To ensure that participants understood and answered all the questions in the CDI and Peds-QL 4.0, the psychiatric team, with the aid of parents, interviewed all the children.

Statistical Analysis

The data were analyzed using the Statistical Package for the Social Sciences (SPSS Inc., Chicago, IL, USA), version 20. Descriptive data were analyzed using means, standard deviation and percentages. ANOVA was used to compare quantitative parameters. The Chi square, Mann–Whitney and Kruskal–Wallis tests were used to compare categorical parameters. Regression methods were used to develop predictive models. A P value <.05 was considered to indicate statistical significance.