Detailed Assessment of Incontinence, Psychological Problems and Parental Stress in Children with Autism Spectrum Disorder

  • Justine NiemczykEmail author
  • Roman Fischer
  • Catharina Wagner
  • Alina Burau
  • Theresa Link
  • Alexander von Gontard


Incontinence, psychological symptoms, parental stress and psychopathology were examined in 51 children (43 boys, mean age = 9.7 years) presented in an outpatient clinic for autism spectrum disorders (ASD) and in 53 matched controls (43 boys, mean age = 10.2 years). All children were clinically assessed for ASD, incontinence and psychopathology according to current guidelines. ASD was confirmed in 37 children and excluded in 14. Enuresis (16.2%) and daytime urinary incontinence (16.2%), but not fecal incontinence (8.2%) were more common in ASD than in controls. Children with ASD showed significantly more comorbid psychiatric disorders. Parents of children with ASD experience more stress. Parental stress was predicted by parental psychopathology, role restriction and group (patient/control), but not by incontinence.


Autism spectrum disorder Incontinence Enuresis Parental stress Parental psychopathology 


Author Contributions

JN conceived the study, participated in the coordination, performed statistical analysis, interpreted the data and drafted the manuscript. RF participated in the design of the study coordinated data acquisition, performed the measurement, helped with statistical analysis and interpretation of the data. CW conceived the study and participated in the design and interpretation of the data and helped to draft the manuscript. AB participated in the design and coordination of the study and performed the measurement. TL participated in the design and coordination of the study and performed the measurement. AvG conceived the study and participated in the design and interpretation of the data and revised the manuscript. All authors read and approved the final manuscript.

Compliance with Ethical Standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent

Informed consent was obtained from all individual participants included in the study.


  1. Achenbach, T. M., & Rescorla, L. (2003). ASEBA adult forms & profiles: For Ages 18–59: Adult self-report and adult behavior checklist: ASEBA.Google Scholar
  2. American Psychiatric Association (APA). (2013). Diagnostic and statistical manual of mental disorders (DSM-5 ® ). ‎Philadelphia, PA: American Psychiatric Publishing Inc.CrossRefGoogle Scholar
  3. Austin, P. F., Bauer, S. B., Bower, W., Chase, J., Franco, I., Hoebeke, P.,.. . Wright, A. (2016). The standardization of terminology of lower urinary tract function in children and adolescents: Update report from the standardization committee of the International Children’s Continence Society. Neurourology and Urodynamics, 35(4), 471–481.CrossRefGoogle Scholar
  4. Bishop, D. V., Maybery, M., Maley, A., Wong, D., Hill, W., & Hallmayer, J. (2004). Using self-report to identify the broad phenotype in parents of children with autistic spectrum disorders: A study using the Autism-Spectrum Quotient. Journal of Child Psychology and Psychiatry, 45(8), 1431–1436.CrossRefGoogle Scholar
  5. Bölte, S., & Poustka, F. (2006). Fragebogen zur sozialen Kommunikation. FSK; German version of the social communication questionnaire (SCQ) by Michael Rutter, Anthony Bailey and Catherine Lord; Manual. Bern: Huber.Google Scholar
  6. Bolton, P., Macdonald, H., Pickles, A., Rios, P. a., Goode, S., Crowson, M.,.. . Rutter, M. (1994). A case-control family history study of autism. Journal of Child Psychology and Psychiatry, 35(5), 877–900.CrossRefGoogle Scholar
  7. Caamaño, M., Boada, L., Merchán-Naranjo, J., Moreno, C., Llorente, C., Moreno, D.,.. . Parellada, M. (2013). Psychopathology in children and adolescents with ASD without mental retardation. Journal of Autism and Developmental Disorders, 43(10), 2442–2449.CrossRefGoogle Scholar
  8. Chaidez, V., Hansen, R. L., & Hertz-Picciotto, I. (2014). Gastrointestinal problems in children with autism, developmental delays or typical development. Journal of Autism and Developmental Disorders, 44(5), 1117–1127.CrossRefGoogle Scholar
  9. Dabrowska, A., & Pisula, E. (2010). Parenting stress and coping styles in mothers and fathers of pre-school children with autism and down syndrome. Journal of Intellectual Disability Research, 54(3), 266–280.CrossRefGoogle Scholar
  10. De Bruyne, E., Van Hoecke, E., Van Gompel, K., Verbeken, S., Baeyens, D., Hoebeke, P., & Walle, J. V. (2009). Problem behavior, parental stress and enuresis. The Journal of Urology, 182(4), 2015–2021.CrossRefGoogle Scholar
  11. Ding, H. T., Taur, Y., & Walkup, J. T. (2017). Gut microbiota and autism: key concepts and findings. Journal of Autism and Developmental Disorders, 47(2), 480–489. Scholar
  12. Domsch, H., & Lohaus, A. (2010). Elternstressfragebogen: ESF: Hogrefe.Google Scholar
  13. Döpfner, M., Plück, J., & Kinnen, C. (2014). Manual deutsche Schulalter-Formen der Child Behavior Checklist von Thomas M. Achenbach. Elternfragebogen über das Verhalten von Kindern und Jugendlichen (CBCL/6-18R), Lehrerfragebogen über das Verhalten von Kindern und Jugendlichen (TRF/6-18R), Fragebogen für Jugendliche (YSR/11-18R). Göttingen: Hogrefe.Google Scholar
  14. El-Baz, F., Ismael, N. A., & El-Din, S. M. N. (2011). Risk factors for autism: An Egyptian study. Egyptian Journal of Medical Human Genetics, 12(1), 31–38.CrossRefGoogle Scholar
  15. Equit, M., Becker, A., El Khatib, D., Rubly, M., Becker, N., & von Gontard, A. (2014). Central nervous system processing of emotions in children with nocturnal enuresis and attention-deficit/hyperactivity disorder. Acta Paediatrica, 103(8), 868–878.CrossRefGoogle Scholar
  16. Fowler, C. J., & Griffiths, D. J. (2010). A decade of functional brain imaging applied to bladder control. Neurourology and Urodynamics, 29(1), 49–55.Google Scholar
  17. Franco, I. (2015). Neuropsychiatric disorders and genetic aspects of bowel or bladder dysfunction. In I. Franco, P. F. Austin, S. B. Bauer, A. von Gontard & Y. Homsy (Eds.), Pediatric incontinence. Evaluation and clinical management (pp. 73–88). Hoboken: Wiley.CrossRefGoogle Scholar
  18. Gor, R. A., Fuhrer, J., & Schober, J. M. (2012). A retrospective observational study of enuresis, daytime voiding symptoms, and response to medical therapy in children with attention deficit hyperactivity disorder and autism spectrum disorder. Journal of Pediatric Urology, 8(3), 314–317.CrossRefGoogle Scholar
  19. Harris, S. R. (2017). Early motor delays as diagnostic clues in autism spectrum disorder. European Journal of Pediatrics, 176(9), 1259–1262. Scholar
  20. Hyams, J. S., Di Lorenzo, C., Saps, M., Shulman, R. J., Staiano, A., & van Tilburg, M. (2016). Childhood functional gastrointestinal disorders: child/adolescent. Gastroenterology, 150(6), 1456–1468.CrossRefGoogle Scholar
  21. Jansson, U.-B., Hanson, M., Hanson, E., Hellström, A.-L., & Sillen, U. (2000). Voiding pattern in healthy children 0 to 3 years old: A longitudinal study. The Journal of Urology, 164(6), 2050–2054.CrossRefGoogle Scholar
  22. Järvelin, M. R., Moilanen, I., Vikeväinen-Tervonen, L., & Huttunen, N. P. (1990). Life changes and protective capacities in enuretic and non-enuretic children. Journal of Child Psychology and Psychiatry, 31(5), 763–774.CrossRefGoogle Scholar
  23. Lord, C., Risi, S., Lambrecht, L., Cook, E. H., Leventhal, B. L., DiLavore, P. C.,.. . Rutter, M. (2000). The autism diagnostic observation schedule—generic: A standard measure of social and communication deficits associated with the spectrum of autism. Journal of Autism and Developmental Disorders, 30(3), 205–223.CrossRefGoogle Scholar
  24. Lord, C., Rutter, M., DiLavore, P. C., Risi, S., Gotham, K., & Bishop, S. (2012). Autism diagnostic observation schedule: ADOS-2. Los Angeles, CA: Western Psychological Services.Google Scholar
  25. Lord, C., Rutter, M., & Le Couteur, A. (1994). Autism diagnostic interview-revised: A revised version of a diagnostic interview for caregivers of individuals with possible pervasive developmental disorders. Journal of Autism and Developmental Disorders, 24(5), 659–685.CrossRefGoogle Scholar
  26. Mattila, M.-L., Hurtig, T., Haapsamo, H., Jussila, K., Kuusikko-Gauffin, S., Kielinen, M.,. .. Joskitt, L. (2010). Comorbid psychiatric disorders associated with Asperger syndrome/high-functioning autism: a community-and clinic-based study. Journal of Autism and Developmental Disorders, 40(9), 1080–1093.CrossRefGoogle Scholar
  27. Misri, S., Reebye, P., Kendrick, K., Carter, D., Ryan, D., Grunau, R. E., & Oberlander, T. F. (2006). Internalizing behaviors in 4-year-old children exposed in utero to psychotropic medications. American Journal of Psychiatry, 163(6), 1026–1032.CrossRefGoogle Scholar
  28. Morgan, J., Robinson, D., & Aldridge, J. (2002). Parenting stress and externalizing child behaviour. Child & Family Social Work, 7(3), 219–225.CrossRefGoogle Scholar
  29. Niemczyk, J., Wagner, C., & von Gontard, A. (2017). Incontinence in autism spectrum disorder: A systematic review. European Child & Adolescent Psychiatry. Scholar
  30. Rane, P., Cochran, D., Hodge, S. M., Haselgrove, C., Kennedy, D., & Frazier, J. A. (2015). Connectivity in autism: a review of MRI connectivity studies. Harvard Review of Psychiatry, 23(4), 223.CrossRefGoogle Scholar
  31. Rao, P. A., & Beidel, D. C. (2009). The impact of children with high-functioning autism on parental stress, sibling adjustment, and family functioning. Behavior Modification, 33(4), 437–451.CrossRefGoogle Scholar
  32. Rasquin, A., Di Lorenzo, C., Forbes, D., Guiraldes, E., Hyams, J. S., Staiano, A., & Walker, L. S. (2006). Childhood functional gastrointestinal disorders: Child/adolescent. Gastroenterology, 130(5), 1527–1537. Scholar
  33. Raven, J. (2002). Coloured progressive matrices-CPM. Dt. Bearbeitung von S. Bulheller & H. Häcker ((3). neu normierte Aufl.). Frankfurt: Harcourt Test Services.Google Scholar
  34. Raven, J. C., Raven, J. C., & Court, J. (1996). Standard progressive matrices: Sets A, B, C, D & E. Oxford: Oxford Psychologists Press.Google Scholar
  35. Rivard, M., Terroux, A., Parent-Boursier, C., & Mercier, C. (2014). Determinants of stress in parents of children with autism spectrum disorders. Journal of Autism and Developmental Disorders, 44(7), 1609–1620.CrossRefGoogle Scholar
  36. Robson, W., Jackson, H. P., Blackhurst, D., & Leung, A. (1997). Enuresis in children with attention-deficit hyperactivity disorder. Southern Medical Journal, 90(5), 503–505.CrossRefGoogle Scholar
  37. Sillen, U., Sölsnes, E., Hellström, A., & Sandberg, K. (2000). The voiding pattern of healthy preterm neonates. The Journal of Urology, 163(1), 278–281.CrossRefGoogle Scholar
  38. Simonoff, E., Pickles, A., Charman, T., Chandler, S., Loucas, T., & Baird, G. (2008). Psychiatric disorders in children with autism spectrum disorders: prevalence, comorbidity, and associated factors in a population-derived sample. Journal of the American Academy of Child & Adolescent Psychiatry, 47(8), 921–929.CrossRefGoogle Scholar
  39. Son, J. S., Zheng, L. J., Rowehl, L. M., Tian, X., Zhang, Y., Zhu, W.,. .. Robertson, C. E. (2015). Comparison of fecal microbiota in children with autism spectrum disorders and neurotypical siblings in the simons simplex collection. PLoS ONE, 10(10), e0137725.CrossRefGoogle Scholar
  40. Unnewehr, S., Schneider, S., & Margraf, J. (2013). Kinder-DIPS: diagnostisches Interview bei psychischen Störungen im Kindes-und Jugendalter. New York: Springer.Google Scholar
  41. von Gontard, A. (2010). Leitfaden enkopresis. Göttingen: Hogrefe.Google Scholar
  42. von Gontard, A. (2013). Urinary incontinence in children with special needs. Nature Reviews Urology, 10(11), 667.CrossRefGoogle Scholar
  43. von Gontard, A., & Equit, M. (2015). Comorbidity of ADHD and incontinence in children. European Child & Adolescent Psychiatry, 24(2), 127–140.CrossRefGoogle Scholar
  44. von Gontard, A., & Lehmkuhl, G. (2009). Leitfaden Enuresis. Aufl. Göttingen: Hogrefe.Google Scholar
  45. von Gontard, A., Pirrung, M., Niemczyk, J., & Equit, M. (2015). Incontinence in children with autism spectrum disorder. Journal of Pediatric Urology, 11(5), e261–e264.Google Scholar
  46. Wilcox, J. A., Tsuang, M. T., Schnurr, T., & Baida-Fragoso, N. (2003). Case-control family study of lesser variant traits in autism. Neuropsychobiology, 47(4), 171–177.CrossRefGoogle Scholar
  47. Williford, A. P., Calkins, S. D., & Keane, S. P. (2007). Predicting change in parenting stress across early childhood: Child and maternal factors. Journal of Abnormal Child Psychology, 35(2), 251–263.CrossRefGoogle Scholar
  48. Wolfe-Christensen, C., Manolis, A., Guy, W. C., Kovacevic, N., Zoubi, N., El-Baba, M.,.. . Lakshmanan, Y. (2013). Bladder and bowel dysfunction: evidence for multidisciplinary care. The Journal of Urology, 190(5), 1864–1868.CrossRefGoogle Scholar
  49. World Health Organization. (1992). The ICD-10 classification of mental and behavioural disorders: clinical descriptions and diagnostic guidelines (Vol. 1). Geneva: World Health Organization.Google Scholar
  50. Wright, A. J. (2015). The epidemiology of childhood incontinence. Pediatric Incontinence: Evaluation and Clinical Management, 37.Google Scholar
  51. Yang, T.-K., Huang, K.-H., Chen, S.-C., Chang, H.-C., Yang, H.-J., & Guo, Y.-J. (2013). Correlation between clinical manifestations of nocturnal enuresis and attentional performance in children with attention deficit hyperactivity disorder (ADHD). Journal of the Formosan Medical Association, 112(1), 41–47.CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Department of Child and Adolescent PsychiatrySaarland University HospitalHomburgGermany

Personalised recommendations