Journal of Pediatric Psychology Advance Access originally published online on October 27, 2006
Journal of Pediatric Psychology 2007 32(5):605-616; doi:10.1093/jpepsy/jsl039
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Psychological Problems in Children with Bedwetting and Combined (day and night) Wetting: A UK Population-Based Study
1Department of Social Medicine, University of Bristol, 2Department of Community Based Medicine, University of Bristol, and 3Clinical Psychology Department, Child & Adolescent Mental Health Services, East Leeds Primary Care Trust, UK
All Correspondence concerning this article should be addressed to Carol Joinson PhD, Avon Longitudinal Study of Parents and Children, Department of Social Medicine, 24 Tyndall Avenue, Bristol, BS8 1TQ , UK. E-mail: Carol.Joinson{at}bristol.ac.uk
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Abstract |
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 Top Abstract MethodsResultsDiscussionAppendix I.Appendix II.AcknowledgmentsReferences |
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Objective To investigate the psychological problems associated with bedwetting and combined (day and night) wetting in children aged around 7
years. Methods Participants were a cohort of over 8000 children enrolled in the population-based Avon Longitudinal Study of Parents and Children. Parents completed postal questionnaires assessing common childhood psychological problems, and children were asked about behavior, friendships, bullying, and self-esteem in clinical interviews. The rates of psychological problems were compared in children with bedwetting, combined wetting, and in children with no wetting problems. Results The study found a higher rate of parent-reported psychological problems in children with bedwetting and combined wetting compared with those with no wetting problems. Children with combined wetting were particularly at risk for externalizing problems. There was little difference with the child-reported measures. Conclusions Bedwetting and combined wetting are associated with parent-reported psychological problems and combined wetting confers an increased risk for externalizing problems. Key words: bedwetting; behavior; daytime wetting; enuresis; psychological problems.
Bedwetting is a prevalent and potentially distressing experience for children and their parents (Butler, 1994
; 1998). Around 15–22% of boys and 7–15% of girls wet the bed at 7 years of age, with almost 3% wetting more than twice a week (Butler, Golding, & Northstone, 2005). Combined (day and night) wetting has been reported in 3.3% of 7-year-olds (Butler et al., 2005) and 4% of children aged 5–12 years (Bower, Moore, Shepherd, & Adams, 1996). The Diagnostic and Statistical Manual for Mental Disorders (DSM-IV: American Psychiatric Association, 1995) uses the term enuresis for the repeated voiding of urine into clothing, occurring at least twice a week, for at least three consecutive months, in children over 5 years of age in the absence of congenital or acquired defects of the central nervous system.
There is a growing literature investigating whether children who wet the bed experience more psychological distress compared with children who are dry at night. Some studies find no increased rates of psychological problems in children who wet the bed (Hirasing, van Leerdam, Bolk-Bennink, & Bosch, 1997; Robinson, Butler, Holland, & Doherty-Williams, 2003; Wagner & Geffken, 1986; Wille & Anvenden 1995), or when higher behavior problem scores are found in children with bedwetting, they are still within normal limits and therefore of limited clinical significance (Couchells, Johnson, Carter, & Walker, 1981; Friman, Handwerk, Swearer, McGinnis, & Warzak, 1998). In another study, the association between bedwetting and psychological problems disappeared after adjusting for socioeconomic status (Van Hoecke, Baeyens, Vande Walle, Hoebeke, & Roeyers, 2003). However, an increasing number of studies are finding evidence for increased levels of psychological problems in children who wet the bed compared with those who do not wet the bed, with more internalizing and externalizing problems (Byrd, Weitzman, Lanphear, & Auinger, 1996; Chang, Ng, & Wong, 2002; Feehan, McGee, Stanton, & Silva, 1990; Fergusson & Horwood 1994; Liu, Sun, Uchiyama, Li, & Okawa, 2000; Moilanen et al., 1998; Rutter, Yule, & Graham, 1973; Van Hoecke, Hoebeke, Braet, & Walle, 2004; Van Hoecke, De Fruyt, De Clercq, Hoebeke, & Vande Walle, 2005; Von Gontard, Mauer-Mucke, Pluck, Berner, & Lehmkuhl, 1999), attention-deficit hyperactivity disorder (Baeyens et al., 2004; Robson, Jackson, Blackhurst, & Leung, 1997), and reduced self-esteem (Hagglof, Andren, Bergstrom, Marklund, & Wendelius, 1998; Theunis, Van Hoecke, Paesbrugge, Hoebeke, & Vande Walle, 2002). There is also growing evidence that children with combined wetting have a higher rate of psychological problems compared with children who suffer from isolated bedwetting (Berg, Fielding, & Meadow, 1977; Hallgren, 1957; Theunis et al., 2002; Van Hoecke et al., 2005). However, one study reported no difference in self-esteem levels between children with bedwetting compared with combined wetting (Collier, Butler, Redsell, & Evans, 2002).
Several limitations affect the generalizability of these studies. First of all, some of the bedwetting studies have failed to distinguish between children with isolated bedwetting and those with combined (day and night) wetting. Many are based on clinic samples making it difficult to generalize the findings to the total population of children with wetting problems. In addition, some of the studies have drawn the wetting and control groups from different populations making them difficult to compare, while some studies have failed to include a nonwetting comparison group. Another weakness is that the majority of studies are based on parental reports, with only a few including reports from children, none of which ask children about social problems associated with bedwetting such as teasing or bullying.
There is also a lot of variation between studies in the inclusion criteria for enuresis, with some including only the children whose wetting meets DSM-IV criteria for enuresis while others include children with less frequent wetting (e.g., once a week). In a population-based study Byrd et al. (1996) reported that bedwetting, even as infrequently as once every other month, is associated with increased rates of behavior problems. This has not yet been investigated in relation to combined wetting.
The present study, based on a UK population of over 8,000 children, is an investigation of the psychological problems associated with bedwetting and combined wetting in children aged around 7 years. Based on reports from parents and children, the study compares the rate of internalizing and externalizing problems and problems with bullying and friendships in children who wet the bed, those with combined wetting and in children with no wetting problems. It is hypothesized that there will be elevated rates of internalizing and externalizing problems in children with combined wetting compared with children with bedwetting alone. The study will also investigate whether children with less severe bedwetting or combined wetting that does meet DSM-IV criteria for enuresis are also at greater risk of internalizing and externalizing problems compared with children with no wetting problems.
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Methods |
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TopAbstractMethodsResultsDiscussionAppendix I.Appendix II.AcknowledgmentsReferences |
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Participants
The Avon Longitudinal Study of Parents and Children (ALSPAC: Golding, Pembrey, & Jones, 2001
) is an ongoing population-based study investigating a wide range of environmental and other influences on the health and development of children. Pregnant women residing in the former Avon Health Authority in south-west England, having an estimated date of delivery between April 1, 1991 and December 31, 1992 were invited to take part, resulting in a cohort of 14,541 pregnancies and 13,971 children alive at 12 months of age. The primary source of data collection was via self-completion questionnaires administered at four points during the prenatal period then at regular intervals following birth. The representative nature of the ALSPAC sample has been investigated by comparison with the 1991 National Census data of mothers with infants under 1 year of age who were residents in the county of Avon. The ALSPAC sample had a slightly greater proportion of mothers who were married or cohabiting, who were owner-occupiers (people who owned or had a mortgage on their house rather then living in rented accommodation) and who had a car in the household. All aspects of the study are reviewed and approved by the ALSPAC Law and Ethics Committee, which is registered as an Institutional Review Board. Approval was also obtained from the Local Research Ethics Committees, which are governed by the Department of Health. Written consent was not required by these committees for either postal questionnaires or interviews, as returning of questionnaires and attendance at the clinics was entirely voluntary. More detailed information on the ALSPAC study is available on the web site: http://www.alspac.bris.ac.uk.
Both wetting data and parent-reported psychological outcomes were taken from a questionnaire administered to the parents when the children were around 7 years of age. This questionnaire was sent to 11,021 families and 8,242 questionnaires were returned (in 98% of the cases the respondent was the mother of the study child; age range of children = 90–111 months, median = 91 months, 95% of assessments completed by 95 months). Reports of bedwetting in a previous questionnaire given at 78 months were not related to the rate of response to the current questionnaire (of those bedwetting at 78 months, 87.4% returned the 91-month questionnaire compared with 86% of those who were not wetting the bed).
Child-reported psychological measures were taken from a clinic attended by 7,171 children (age range = 97–125 months, median = 102 months, 95% of assessments completed by 110 months). The proportion of children attending the clinic was higher for those who wet the bed (79.4% attended) compared with those who were not wetting the bed at 91 months (74.6% attended) (
2 = 12.5, p < .001).
Among the children for whom wetting data was available, those with a WISC-III IQ (Wechsler, 1991) <70 and/or who had received a statement of special educational needs (n = 278) and those whose parents had failed to provide information on bedwetting (n = 29) were excluded leaving a study sample of 7,935 (51% males, 49% females). Of the 7,935 children, 6,386 had no wetting problems, 951 had bedwetting alone, 241 had combined (day and night) wetting. An additional group (n = 357) with daytime wetting alone were not included in the analyses because this was not the main topic of the article (see Table I for a breakdown of wetting groups by gender and DSM-IV status).
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Measures
The self-report questionnaire, given to parents when children were
7 years of age, contained questions concerning how often the child wets the bed at night or during the day, with the following options: (a) never, (b) occasional accidents but less than once a week, (c) about once a week, (d) 2–5 times a week, (e) nearly every day, and (f) more than once a day. Also included in this questionnaire was "The Development and Well-Being Assessment" (DAWBA: Goodman, Ford, Richards, Gatward, & Meltzer, 2000), comprising questions relating to a number of common internalizing and externalizing disorders in children occurring in the present and recent past.
Children were invited to attend a clinic in which they were interviewed using the following schedules: (a) A modified version of the Bullying and Friendship Interview Schedule (BFIS: Woods & Wolke, 2003); (b) 11 items from the Self-Reported Antisocial Behavior for Young Children Questionnaire (Loeber, Stouthamer-Loeber, Van Kammen, & Farrington, 1989); (c) a reduced (12 item) version of Harter's Self-Perception Profile for Children (SPPC: Harter, 1985); and (d) five questions from the Cambridge Hormones and Moods Project Friendship Questionnaire (Goodyer, Wright, & Altham, 1990) (see Appendix I for a description of these measures and prevalence of the child-reported problems). Due to the sensitive nature of some of the questions, children were required to post their response in either an YES or a NO box. The interviewer could not see which box was chosen and stressed that all answers would be confidential.
Analysis
The small numbers of children meeting DSM-IV criteria for psychiatric disorders in the ALSPAC study population [range = 0.2% (social phobia) to 1.9% (oppositional-defiant disorder)] precluded a multivariable regression analysis. Consequently, a set of dichotomous outcome variables was derived from the lists of symptoms in the DAWBA relating to each psychiatric disorder. This permitted a more rigorous multivariable analysis of the association of bedwetting and combined wetting with emotional and behavior problems with adjustments for confounding variables. In deriving the dichotomous outcome variables based on reported symptoms of psychiatric disorders, only the children who were reported to have suffered from the symptoms the most often, or a lot more than others of the same age were included in the group with internalizing or externalizing problems. For instance, in determining whether a child had any separation anxiety symptoms (e.g., has he/she worried about sleeping alone?), only the children whose parents reported in the DAWBA that they had symptoms "a lot more than others" of the same age were placed in the symptom group and children who had the symptoms "no more than others" or "a little more than others" were not counted as having symptoms. (Appendix II for prevalence in the study population of DSM-IV disorders, prevalence of psychological problems derived from the DAWBA and a description of how they were derived).
Most of the clinic measures were already categorical, but scores on the SPPC and the Friendship Questionnaire are continuous. To aid comparison with the rest of the analyses these were dichotomized so that children with the lowest scores on the SPPC (lowest self-esteem) and those with the highest scores on the Friendship Questionnaire (least happy with friendships) were in the top quartile (Appendix 1).
Preliminary analyses consisted of 2 tests to compare the rate of parent-reported internalizing and externalizing problems derived from the DAWBA and child-reported problems in children who wet the bed, those with combined wetting and children with no wetting problems. Main analyses comprised multivariable logistic regression models examining the association of the psychological problems in the three groups. Analyses adjusted for the effect of confounding variables including gender (51.5% male) and stressful life events (assessed using the question ‘has anything exceptionally stressful happened to him/her that would really upset almost anyone?’ 12.2% of parents responded positively to this question). Stressful life events are thought to be a risk factor for both enuresis and psychological problems (Kalo & Bella, 1996; Mesman & Koot, 2001).
Analyses also adjusted for family socio-demographic background derived from variables in questionnaires administered during the prenatal period including home ownership status (82% mortgaged/owned their house, 18% living in rented accommodation), car ownership (5.9% did not own a car), crowding (persons per room in house—4.3% had a crowding ratio of at least 0.75, 47.9% had an ratio of <0.5 i.e., more than two rooms per person), mother's education (22.9% with limited educational qualifications, 41.7% with college education or higher), mother's age (2.2% < 20 years, 13.8% 20–24 years, 39.8% 25–29 years, 32.5% 30–34 years, 11.6% > 34 years), birth order (46.2% first born, 18.4% third child or higher) and marital status (14.1% never married, 4.9% widowed/separated/divorced, 6.8% in second marriage). Low socioeconomic status has been found to be a risk factor for the development of wetting problems (Mark & Frank, 1995; Steinhausen & Gobel, 1989) and behavior problems (Campbell, 1995) and has been described as a common factor underlying the two conditions (Van Hoeke et al., 2003).
The logistic regression analyses were repeated after removing children who attained DSM-IV levels of enuresis (bedwetting or daytime wetting occurring at least twice a week) in order to address whether any observed group differences could be explained by children who had the most severe wetting problems. In the multivariable models, missing data on confounding variables resulted in a loss of almost 10% of the sample when the fully adjusted models were derived. To avoid any potential bias that might result from performing a complete-case model on these variables, a missing data imputation technique was employed (MICE—Missing Imputation for Chained Equations: van Buuren, Boshuizen, & Knook, 1999) using the procedure in STATA known as ice (Royston, 2005). Imputation was restricted to confounding variables (no imputation of the outcome or the wetting variables was performed).
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Results |
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TopAbstractMethodsResultsDiscussionAppendix I.Appendix II.AcknowledgmentsReferences |
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Table II shows the rate of internalizing and externalizing problems reported by parents (from the symptom-based dichotomous outcome variables derived from the DAWBA) and the rate of child-reported problems (from the clinic-based assessments) in children with no wetting problems (controls), in children with bedwetting, and in those with combined wetting. It also shows the prevalence of each variable in the study population (the rate of relational bullying was too rare for any further analysis).
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The results show strong evidence for group differences in the rate of all the parent-reported psychological problems and two of the child-reported measures (victim of overt bullying and antisocial activities). Post hoc comparisons showed that this was generally due to differences in risk of adverse outcomes between children with no wetting problems and those with bedwetting or combined wetting. However, differences were found between the children with bedwetting and combined wetting in oppositional behavior (p = .05) and conduct problems (p = .04).
Table III shows the odds ratios (OR; both unadjusted and adjusted) and 95% confidence intervals (CI) for the analyses with the parent-reported measures derived from the DAWBA and Table IV shows the results from the clinic-based assessment of the children. The first set of models (columns 1 and 2) include children with any bedwetting or combined wetting and the second set of models (columns 3 and 4) exclude the children whose bedwetting or daytime wetting was severe enough to meet DSM-IV criteria.
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The results in Table III show that for most of the parent-report measures, the risk of psychological problems is higher for children with bedwetting and combined wetting compared with those with no wetting problems. The effect of adjusting for confounders varied from negligible (e.g., separation anxiety) to moderate (e.g., oppositional behavior) and in some cases, such as particular fears, regression estimates were raised mainly due to slight gender differences between bedwetting/combined wetting, and some of the psychological measures. Adjustment did not alter any of the conclusions for these analyses, that is, those children with bedwetting/combined wetting are at increased risk of most outcomes (particularly attention/activity problems, oppositional behavior, and conduct problems), with the exception of social fears and sadness/depression where the combined group are at no greater risk than the controls but rates of these problems were elevated in children who suffered from bedwetting alone. Furthermore, with these two exceptions, ORs for children with combined wetting were higher than for children with bedwetting and post hoc analyses showed that in some cases the difference between these two groups was considerable [separation anxiety: OR = 1.62 (1.01, 2.60), p = .045; attention/activity problems: OR = 1.56 (1.09, 2.22), p = .014; conduct problems: OR = 1.63 (1.03, 2.56), p = .035]. As one might expect, exclusion of the children with DSM-IV nocturnal and diurnal enuresis led to an attenuation of the majority of the estimates; however, the substantive conclusions remain.
For the child-reported outcomes in Table IV there is much less evidence to suggest differences between the three groups. The apparent increased risk of antisocial activities for children with combined wetting should be taken lightly given the number of tests performed, the amount of attenuation following adjustment and also the size of the p-value for the adjusted estimates. It is notable that the effect of adjusting for confounders (particularly gender) was considerably greater for the child-reported compared with the parent-reported outcomes (many estimates were reduced by 50% or more). It is not surprising that the removal of the children with DSM-IV enuresis had little effect on the conclusions for this set of outcomes.
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Discussion |
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TopAbstractMethodsResultsDiscussionAppendix I.Appendix II.AcknowledgmentsReferences |
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This is the first population-based study to investigate whether children with combined wetting have a higher rate of psychological problems compared with children with bedwetting alone. The study found a higher rate of parent-reported externalizing and internalizing problems in children with combined wetting than for children with bedwetting alone (with the exception of social fears and sadness/depression where the rate was higher in bedwetting children). The biggest differences were found for externalizing problems with the rates of attention, oppositional, and conduct problems in children with combined wetting well over twice those found in children with no wetting problems. This agrees with findings of previous studies reporting more psychiatric disturbance in children with combined wetting compared with those who only wet the bed (Hallgren, 1957
; Berg et al., 1977; Van Hoecke et al. 2005; Theunis et al., 2002). However, one study found no difference in the rate of attention and activity problems in children with combined wetting compared with those with bedwetting alone (Baeyens et al., 2004). Future investigations of children with bedwetting should take into account those with combined wetting because, due to its public nature, it likely to be associated with social humiliation, teasing from peers, and intolerance from parents and might make this group of children particularly vulnerable to psychological distress (Butler, 1998). Adjusting for confounding variables (gender, socio-demographic background, stressful life events) did not alter any of the main conclusions suggesting that these variables do not represent underlying risk factors for psychological problems in the study population.
In order to investigate whether children with the most frequent wetting were driving the observed group differences in the rate of psychological problems in the present study, analyses were repeated after removing children with enuresis that met DSM-IV criteria. This resulted in an attenuation of the majority of the estimates; however, the substantive conclusions remained. These findings provide evidence for an association of psychological problems with bedwetting and combined wetting even in children whose wetting does not meet DSM-IV criteria. This is in agreement with a previous study that found an increased risk of behavior problems in children with infrequent bedwetting compared with controls (Byrd et al., 1996). Furthermore, this supports the view that whilst the DSM-IV criteria for enuresis may prove clinically useful in terms of treatment, it represents an arbitrary cut-off with respect to psychological consequences.
Most previous studies of the psychological problems associated with bedwetting are based on parental reports; however, it is possible that parents of children who wet the bed might overestimate psychological issues relating to their child. Evidence for this is provided by the results of a study reporting no difference in the rate of children's self-reports relating to social anxiety or depression, whereas parents rated children who wet the bed as more withdrawn and anxious/depressed (Van Hoecke et al., 2004). In the present study, parents reported a higher rate of internalizing and externalizing problems in wetting compared with nonwetting children, but there was little evidence from children's self-reports to suggest that children with bedwetting or combined wetting have more problems than those with no wetting. The discrepancy between parent and child ratings of psychological problems is well-documented in the literature with consistent reports that externalizing and internalizing problems are more readily identified by parents than by children (Kemper, Gerhardstein, Repper, & Kistner, 2003; Sawyer, Baghurst, & Mathias, 1992; Stanger & Lewis, 1993). It is possible that the current findings were compounded by a bias in parental rating, with parents of children with bedwetting or combined wetting viewing them more negatively than those with no wetting problems. It is also possible that young children might fail to perceive a problem or underestimate its severity in self-reports; however, the way in which children in this study were asked sensitive questions in the interview (by posting their responses in either an YES or a NO box that the interviewer could not see) should have helped to minimize any such problems. Another possible explanation for parent/child differences in this study is that parents were asked about different issues (internalizing and externalizing problems) compared with children (bullying, friendships, and self-esteem), which may imply that children with bedwetting/combined wetting have distinct psychological problems.
In the current study, children with bedwetting or combined wetting did not have reduced self-esteem compared with those with no wetting problems. This is in agreement with previous studies reporting no evidence to suggest that children with bedwetting or combined wetting construe themselves more negatively than children with no wetting problems (Robinson et al., 2003; Van Hoecke et al., 2004; Wagner & Geffken, 1986; Wille & Anvenden, 1995). However, other studies have reported reduced self-esteem in children with bedwetting compared with children who are dry at night (Hagglof et al., 1998; Theunis et al., 2002). Furthermore, one study reported lower self-esteem scores (relating to scholastic competence) in children with combined wetting compared with those with bedwetting alone (Theunis et al., 2002), while another reported no difference in self-esteem levels between these groups (Collier et al., 2002). Such a discrepancy of findings might be a result of the different scales employed to measure self-esteem.
A weakness of the study is that the small numbers of children who met DSM-IV criteria for psychiatric disorders prevented an adequate multivariable statistical analysis using the proper diagnoses derived from the DAWBA. Instead, the study compared children on the rate of symptoms of internalizing and externalizing disorders. Although this had the advantage of permitting a more rigorous multivariable statistical analysis, the impact of the symptoms in terms of resultant distress and interference with family life, learning, friendships, and leisure activities was not considered. The fact that children can have symptoms of disorders but are not necessarily significantly impaired by them means that the rate of parent-reported psychological problems might have been overestimated in the present study. However, in deriving the dichotomous outcome variables based on reported symptoms of psychiatric disorders, only the children with the most ‘severe’ symptoms (children who were reported to have suffered from the symptoms the most often, or a lot more than others of the same age) were included in the group with emotional or behavioral problems.
It is also possible that in the present study, symptom categories may not be independent and that the psychological problems identified in children with wetting problems are indicators of comorbid psychiatric disorders. For example, attention and activity problems and oppositional behavior often occur together, as do anxiety and depression. There was some overlap between domains in the DAWBA, but of the children who were reported to have internalizing or externalizing problems many (around 70%) had symptoms in only one domain.
According to DSM-IV criteria, enuresis should be present for at least 3 months, however, in our study parents were not asked about the duration of wetting. When rates of wetting were measured at a previous time point in the ALSPAC data it was found that of the 7,935 with information on bedwetting and daytime wetting at 91 months, 7,061 also responded to a previous questionnaire given at 78 months. Among the group reported to be bedwetting at least twice a week at 91 months, 77.5% were also bedwetting to this degree at 78 months. This suggests that bedwetting at DSM-IV levels is a long-term problem for these children. Another weakness relating to the wetting measures is that they were taken around 6–12 months after the parent measures and this could potentially confound the interpretation of the results, especially if the wetting problem had resolved within this period.
Differential attrition is a problem with all longitudinal cohort studies. In the present study, this could mean that the sub-sample responding to the questionnaire or attending the clinic are more socially advantaged than those who defaulted. However, there does not appear to be a relationship between dropout and bedwetting and controlling for socio-demographic variables had only a negligible effect on the regression estimates. As socio-demographic variables are good predictors of attrition, this would lead us to infer that there is not a great deal of bias present in our final adjusted models and that the results can be generalized to the ALSPAC population as a whole.
As with all cross-sectional studies, it is unclear whether the psychological problems found in the present study are a cause or a consequence of bedwetting. It could be argued that the distress caused to the child as a result of bedwetting and parental intolerance of the problem may contribute to the development of psychological problems (Butler, 1998). The fact that some studies have demonstrated improvements in psychological functioning following successful treatment for bedwetting provides support for this argument (Hagglof et al., 1998; Hirasing, van Leerdam, Bolk-Bennink, & Koot, 2002; Longstaffe, Moffatt, & Whalen, 2000; Moffatt, Kato, & Pless, 1987; Theunis et al., 2002). The presence of psychological problems, particularly the increased vulnerability to behavior problems, in children with bedwetting and combined wetting has important implications for treatment. For example, early withdrawal from treatment or treatment failure with the enuresis alarm is more likely when children are perceived to have behavior problems (Geffken, Johnson, & Walker, 1986; Moffatt & Cheang, 1995). Further analysis of the ALSPAC data longitudinally will look at the association between bedwetting and the development of psychological problems, particularly in association with the age at which toilet training commenced, parental child-rearing practices, child's temperament, and early stresses.
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Appendix I. |
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TopAbstractMethodsResultsDiscussionAppendix I.Appendix II.AcknowledgmentsReferences |
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Prevalence of child-reported problems and a description of the clinic-based measures used to derive them
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14 = low score. Cronbach's 
for the 12 items = .749.
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Appendix II. |
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TopAbstractMethodsResultsDiscussionAppendix I.Appendix II.AcknowledgmentsReferences |
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Prevalence in the study population of DSM-IV disorders, parent-reported psychological problems derived from the DAWBA (and a description of how they were derived)
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Acknowledgments |
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TopAbstractMethodsResultsDiscussionAppendix I.Appendix II.AcknowledgmentsReferences |
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We are extremely grateful to all the families who took part in this study, the midwives for their help in recruiting them, and the whole ALSPAC team, which includes interviewers, computer, and laboratory technicians, clerical workers, research scientists, volunteers, managers, receptionists, and nurses. The UK Medical Research Council, the Wellcome Trust and the University of Bristol provide core support for ALSPAC. This publication is the work of the authors who also serve as guarantors for the contents of this article. This research was specifically funded by a grant from the Big Lottery Fund and has been carried out in collaboration with the charity ERIC (Education and Resources for Improving Childhood Continence).
Conflict of interest: None declared.
Received January 5, 2006; revision received April 28, 2006; revision received October 2, 2006; accepted October 3, 2006
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References |
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