Bedwetting, behaviour and self-esteem: a review of the literature

AIM: The aim of this review was to examine the empirical evidence on the impact of bedwetting and its treatment on a child's self-esteem and behaviour. INCLUSION CRITERIA: The inclusion criteria for this review were empirical studies conducted on children, aged 5-16 years old, with primary nocturnal enuresis using measures of self-esteem or behaviour. Studies utilizing psychological measurement scales completed by children were the main focus although those that used scales completed by parents were also included. SEARCH STRATEGIES: The electronic databases from 1981 to 1999 were searched, and hand searching of the literature dating back to 1973 was conducted using the reference lists of key papers. RESEARCH FINDINGS: Fifteen empirical studies matched the inclusion criteria. There was only one randomised-controlled trial and the rest of the studies were cohort, case-control or cross-sectional design. Evidence of sample bias predominantly due to the use hospital-based and/or 'volunteer' subjects was found in five studies. A further five studies used birth cohort data, which excludes important variables such as the impact of treatment. Four studies used single parent-reported measures, which may under or over-estimate the problem. No large cohort studies were available which compare the self-esteem of bedwetting children with matched controls. The most interesting line of enquiry is pursued by studies looking at whether self-esteem improves with successful treatment. However, the use of self-selected subject groups does not make the current evidence convincing and more work is required to determine outcomes for all children. There is empirical evidence for increased behavioural problems in bedwetting children. Studies conducted on younger children report less behavioural problems with more reported in studies conducted on older children with complex wetting disorders. This may point towards wetting being the primary problem, but more work is needed, as causation in any direction is difficult to ascertain from the literature.