PATTERN OF BEHAVIOURAL RESPONSES TO ENURESIS AMONG CHILDREN IN A SELECTED COMMUNITY, IBADAN, NIGERIA

In recent times, one of the most common distressful disorders among children is enuresis. It makes them highly vulnerable to the development of behavioural and mental health disorders, such as attention deficit disorder, conduct disorders, oppositional defiant disorders among others. This study aimed to determine the pattern of behavioural disorder in children with enuresis in a rural community in South -West, Nigeria.Descriptive research design using an interviewer-administered questionnaire to elicit information on the perceived pattern of behavioural disorder in children with enuresis. Mothers of children with enuresis (198) in a rural community were selected using accidental sampling method.Both descriptive and inferential statistical tests were employed in analyzing data collected for this study. One hundred and ninety-eight (198) questionnaires were retrieved and analyzed using tables, percentages and Pearson correlation. Ethical clearance was secured from the ethics committee of the University of Ibadan/University College Hospital community.The mean age of respondents was 7.00 ±1, with moremale children with enuresis than females. The findings from the study revealed that the majority bedwets at least twice a week in the past six months, with 83.3% bedwetting at night only. The result showed that parents punished their children on wet days, but only a few encouraged on dry days. The pattern of behavioural response revealed significant internalized and externalized behavioural problems among children with enuresis. It is recommended that comprehensive enuresis awareness and management options be included in family health programs.

In recent times, one of the most common distressful disorders among children is enuresis. It makes them highly vulnerable to the development of behavioural and mental health disorders, such as attention deficit disorder, conduct disorders, oppositional defiant disorders among others. This study aimed to determine the pattern of behavioural disorder in children with enuresis in a rural community in South -West, Nigeria.Descriptive research design using an intervieweradministered questionnaire to elicit information on the perceived pattern of behavioural disorder in children with enuresis. Mothers of children with enuresis (198) in a rural community were selected using accidental sampling method.Both descriptive and inferential statistical tests were employed in analyzing data collected for this study. One hundred and ninety-eight (198) questionnaires were retrieved and analyzed using tables, percentages and Pearson correlation. Ethical clearance was secured from the ethics committee of the University of Ibadan/University College Hospital community.The mean age of respondents was 7.00 ±1, with moremale children with enuresis than females. The findings from the study revealed that the majority bedwets at least twice a week in the past six months, with 83.3% bedwetting at night only. The result showed that parents punished their children on wet days, but only a few encouraged on dry days. The pattern of behavioural response revealed significant internalized and externalized behavioural problems among children with enuresis. It is recommended that comprehensive enuresis awareness and management options be included in family health programs. 490 beenruledoutwithaminimumwettingfrequencyofoncepermonth. Enuresis is a disease that many children and their families commonly confront. It is a worrying condition that involves repeated voiding of urine into clothes or bedclothes that persist beyond the normative age of maturation of urinary control. (Imoudu, Bugaje, and Aikhionbare, 2014). It is a source of concern for families because it leads to considerable emotional distress in affected children. Parents reported some psychological consequences of enuresis (Kiddoo, 2012), such as low selfesteem(Salem, El-Shazly and Hassan, 2016) behavioural problems and specifically low school success(IS and O, 2012), (Mahmoodzadeh et al., 2013). Behavioural disorders among children include various forms of anxiety(Salem, El-Shazly and Hassan, 2016), attention deficit hyperactive disorder (ADHD), obsessive-compulsive disorder (OCD), depression, disruptive (oppositional defiance disorder (ODD), conduct disorder (CD), developmental disorders, and pervasive disorders (Abrams et al., 2012), (Salem, El-Shazly and Hassan, 2016), (ELsayed, Hassan and Ibraheem, 2018). Behavioural problems appear as a result of emotional reactions to negative environmental influences linked with other children noticing, shyness, social isolation,being humiliated by peers, emotional and physical abuse from parents and guardian. (Niemczyk, Wagner and von Gontard, 2018), (Akyüz et al., 2016) The relationship between enuresis and behavioural problems has been studied for several decades due to its importance to the growth of children (Gaonkar et al., 2018) , (Alshahrani, Selim, and Abbas, 2018 (Niemczyk, Wagner, and von Gontard, 2018)carried out in Germany on the prevalence of incontinence among preschool children portrayed that attention-deficit/ hyperactivity disorder was common among enuretic children. Research assessing the prevalence of behavioural disorders among children that presented in a clinic documented a distinct pattern of the occurrence of internalizing and externalizing symptoms in this group of children. (Liu, 2004) The prevalence of the internalizing symptoms(Abou-Khadra, Amin and Ahmed, 2013) (depression and anxiety disorder) was 29% in the group. The prevalence of externalizing problems (Liu, 2004) (conduct disorder and attention deficit and hyperactivity disorder) was 35%. On the rates of psychiatric comorbidity in a group of 1001 children with bladder and bowel dysfunction.(Niemczyk et al., 2019)(Niemczyk, Wagner, and von Gontard, 2018). The study showed that psychiatric symptoms were up to six times higher in urinary incontinent children than the rates seen in the general population with externalizing and internalizing problems. A higher percentage of symptoms of the oppositional defiant disorder (ODD) in children was also seen in the study.
Few studies in Nigeria assessed the prevalence of enuresis in children ( In Nigeria,thereis a lack of information on enuresis in children and adolescents. (Osungbade and Oshiname, 2003)The formative period in children determines in no small extent personality and behaviours to be exhibited throughout their lives; the effect of enuresis during this period contribute to their chances of developing behavioural and personality disorder. This study assessed the pattern of behavioural problems among children living with enuresis.

Methods:-
This is a descriptive cross-sectional study that aims at determining the pattern of behavioural problems among children living with enuresis in Ibadan. The study setting is a populated residential neighborhood in Ibadan, with most houses closely located within short distances within proximity to a famous market.
The study population was 198 mothers of children with enuresis within the ages of 5-12 years, living in a rural community in Ibadan, accidental sampling technique was used to select available participants who met the eligibility criteria. An interviewer-administered structured questionnaire was utilized to collect relevant information from the respondents. The instrument for data collection was pretested with a Cronbach alpha of 0.78.
Ethical approval was obtained fromthe University of Ibadan Ethics Review Committee, Ibadan. Consent was obtained after they had been briefed about the objective of the research. Data collected were cleaned for errors, and analysis was done using IBM-SPSS version 21. Descriptive statistics of simple percentage frequency counts, bar chart, pie chart, mean and standard deviation were used to summarize and present the result. Chi-square test was used to investigate whether the association between enuresis and patterns of behavioural disorder among enuretic children is statistically significant at a 5% level of significance.

Results:-
Of the total children, 58.1% were male, and 41.9% were female. By implication, more mothers with male children living with enuresis participated in this study. The children were between 6-12years with a mean of 7 and SD of [+ or -] 1. About 62% of the respondents are between the ages of 6-7years, 31% between the age of 8-9 years, ages 9-10 years, and 1.0% of the respondents were 12yrs and above. Most of the children were living with parents (80.8%), 17.8% living with single parents, 1.5% of and stays with widowed parents.
The mothers reported that the majority of the children bed-wets at least twice a week in the past six months, with 83.3% bedwetting at night only. By implication, most of the children bed-wets only at night and do not meet DSM IV criteria for the diagnosis of enuresis. Almost half the respondents agreed that other children know their children bed wet (49%), out of which 40% agreed that other children make jest of the child when he/she bed-wets. Most of the parents punish their child on wet days (55.1%), but only a few encourage their child on dry days (14.6 %), by implication majority of the mothers utilize negative reinforcement compared to positive reinforcement ( Table 1)

Discussion:-
This study examines the pattern of behavioural response to enuresis in children ofa community in Ibadan. A total of 198 respondents participated in the study. The findings revealed that there were males than female children with enuresis. Our study confirmed the prevalence of enuresis among children. This study further revealed that the majority of theparents punished their children on wet days, but only a few encouraged on dry days.This implies that the majority of the parents utilize negative reinforcement and not positive reinforcement. This is in line with ahospital-based,cross-sectionaldescriptivestudyinAbakaliki, Ebonyistate. (Anyanwu, Ibekwe and Orji, 2015)The study reported that attemptsatstoppingenuresiswerebasedonfrequent nightwaking,denialoffluids,andpunishments.In the same vein, most of the respondents claimed they never sought any form of treatment but relied on herbs.
The result is in line witha study in Ebonyi, Nigeria, that reported that the majorityofcaregiverswereunconcerned, so only a few sought help. But, on the contrary with Igbo ora study where respondents rely on herbs (Osungbade and Oshiname, 2003) , (Sarici et al., 2016)This study confirmed that enuresis at after the culturally acceptable age exposes a child to ridicule among peers as other children make jest of a child that bed-wet which inadvertently affect the children interaction. This is reinforced by other studies where children s self-esteemwas altered as a result of shame by peers. implies a need for adolescent psychiatric and mental health nurses to create more awareness of internalized and externalized behavioural problems among children with enuresis for early detection and management.

The implication of the Study to Nursing:
The inclusion of a comprehensive enuresis awareness education into family health will assist nurses in their health education delivery and guide parents in on the recognition and early management of enuresis. From the perspective of mental health nursing, early detection and understanding of behavioural deviations in childhood will prevent later life juvenile delinquency, thus, promoting healthy growth and development among these children.

Summary and Conclusion:-
This study described the behavioural responses of 198 children of a rural community in Ibadan, Nigeria. The reviewed literature confirms the comorbidity of behavioural problems with enuresis. The authors concluded by confirming the prevalence of childhoodexternalizing and internalizingbehaviours in children with enuresis, which constitute a risk for the development of juvenile delinquencies.It is noteworthy, to document that the majority of parents of children reported externalizing and internalizingbehaviours but did not associate these behaviours to enuresis. Furthermore, the parents did not seek help as they did not relate enuresis as a medical problem requiring hospital visitation and treatment of the children.
This study followed a rigorous data collection and analysis process. However, there are some limitations. The data collected was purely quantitative, and we relied on the perceived responses of the mothers to the questions on enuresis. This might have provided room for the mothers' inaccurate reporting through overestimation or underestimation. A future survey might add qualitative methods for the triangulation of data. Furthermore, the questionnaire used was only pretested but not a standardized tool; thus, it may be subject to measurement error. Lastly, the result of this study is not generalizable as representing the general behavioural responses of Nigerian children to enuresis. Further research is needed to broaden the scope of understanding enuresis in Nigeria. It is believed that improved awareness of the comorbidity of behavioural disorders with enuresis might promote early diagnosis and consequently prevent later life adolescent delinquencies.