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Journal of Pediatric Urology (2015) 11, 75.e1e75.

e7

Screening for depression and anxiety in


childhood neurogenic bladder
dysfunction

Aashish T. Kabra a, Paul J. Feustel b, Barry A. Kogan c


a
Department of Urology, The
University of Texas Health
Summary Anxiety and depression among caregivers: Of the
Science Center at San Antonio, 47 caregivers who completed the HADS and CES-D,
San Antonio, TX, USA Introduction the median HADS score was 7 (IQR: 4e11) for anxiety
Patients with chronic illnesses are known to have and 4 (IQR: 1e7) for depression; both scores were
b
Albany Medical Center, anxiety disorders and are likely to be depressed. within the normal range. Individual abnormal HADS
Albany, NY, USA Anxiety and depression (A/D) has been studied in scores were seen in 23/47 (49%) for anxiety and 10/
adults with spina bifida (SB), however, no study has 47 (21%) for depression. Abnormal CES-D scores
c
Urological Institute of directly screened for A/D in pediatric patients with (>15) were seen in 15/47 (32%). The median CES-D
Northeastern New York neurogenic bladder (NB) and their caregivers. scores were 8 (IQR: 3e19).
Community Care Physicians,
Albany, NY, USA Objective
The aims of our study were to determine the prev- Discussion
Correspondence to: alence of A/D in caregivers of all children with SB In this preliminary screening study, we found
A.T. Kabra, Department of and other NB dysfunction and in adolescents with considerable anxiety in adolescents with NB and
Urology, The University of validated screening measures. both A/D in caregivers. When screening by two
Texas Health Science Center at validated surveys, adolescents with NB had median
San Antonio 7703 Floyd Curl Study design & patients scores for A/D that were normal; yet 27% of these
Drive Mail Code 7845 San
This was a preliminary cross-sectional screening patients exhibited scores for anxiety that outwit the
Antonio, Texas, 78229-3900,
Tel.: þ1 832 457 8766; fax: þ1
investigation for A/D in pediatric patients with NB normal range. For the caregivers, the median scores
210 567 6868 and their caregivers and adolescents with NB. Pedi- were also normal; yet 49% and 32% had scores for A/
atric patients were defined as ages birth to 19 years D, respectively, that were abnormal. SB among pe-
kabra@uthscsa.edu and adolescents as ages 10 yearse19 years. A care- diatric patients has been shown to result in alter-
(A.T. Kabra) giver was self-defined as a primary parent/guardian ations in daily functioning and to increase the
who took care of the pediatric patient for a majority dependency on adult care, factors that are associ-
Keywords of their time on a daily basis. ated with altered self-concept, psychological
Screening; Depression; Anxiety; distress, including A/D. Our findings underscore such
Spina bifida; Children; Materials and methods results from previous studies. In caregivers, we
Caregivers
We contacted 75 families by mail, of which 15 observed a higher prevalence of anxiety than ado-
returned the consent and completed the question- lescents; similar findings have been reported for
Received 25 April 2014 naires. Subsequently, 25 consecutive families whose caregivers of other chronic conditions. Surprisingly,
Accepted 10 November 2014
children were seen for routine office appointments in caregivers, a lower percentage of scores for
Available online 26 February
2015
by the pediatric urology service at the Albany Med- depression was observed. Although we have no data
ical Center in New York participated in person. 22 on the cause of this finding this may be related to a
adolescents completed the Hospital Anxiety and caregiver’s ability to adapt to the demands of the
Depression Scale (HADS). 47 caregivers completed situation in chronic illness or perhaps, lower ex-
both the HADS and the Center for Epidemiologic pectations. The cross-sectional nature of our study
Studies Depression Scale (CES-D). limited us to draw any causal relationships for anx-
iety or depression between neurogenic patients and
Results their caregivers.
Depression among adolescents: Of the 22 adoles-
cents who completed the HADS, the median HADS
score was 5.5 (Inter-quartile range (IQR): 1.75e8.75) Conclusion
for anxiety and 1.5 (IQR: 0e4.25) for depression; Despite our study limitations, the prevalence of
both scores were within the normal range (<8/21). anxiety in adolescents and in the caregivers is
Individual abnormal HADS scores (8/21) were seen striking. Our data highlight that clinicians should
in 6/22 (27%) for anxiety and 1/22 (5%) for screen for A/D more aggressively in pediatric pa-
depression. tients with NB dysfunction and in their caregivers.

http://dx.doi.org/10.1016/j.jpurol.2014.11.017
1477-5131/ª 2015 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.
75.e2 A.T. Kabra et al.

Table Summary table of anxiety and depression scores.

Anxiety and depression in adolescents (10e19 years in age)


No. HADS-A HADS-D
Median (IQR) # Abnormal (%) Median (IQR) # Abnormal (%)
All 22 5.5 (1.75e8.75) 6 (27) 1.5 (0e4.25) 1 (5)

Anxiety and depression in primary caregivers of patients (0e19 years in age)


No. HADS-A HADS-D CES-D
Median (IQR) # Abnormal (%) Median (IQR) # Abnormal (%) Median (IQR) # Abnormal (%)
All 47 7 (4e11) 23 (49) 4 (1e7) 10 (21) 8 (3e19) 15 (32)
Abnormal HADS scores, (8/21).
Abnormal CES-D scores, (>15/60).

Introduction Seventy-five families were contacted by mail based on a


mailing list from a previous study. No families refused to
Patients with chronic illnesses are known to have anxiety participate. Fifteen returned the consent and completed
disorders and are likely to be depressed [1,2]. These pa- the questionnaires. Subsequently, 25 consecutive families
tients have shown less compliance to medical treatments whose children were seen for routine office appointments
and adherence to self-care than patients without depres- were asked to participate in person. All but one agreed to
sion and/or report a diminished quality of life (QoL) [3]. take part; 23 out of 24 families completed the question-
Spina bifida (SB), a chronic disorder, is a major congen- naires. When two caregivers responded for a single pedi-
ital neural tube defect. The urologic manifestations of SB atric patient, their responses were assumed to be
require considerable care, management [4], and treatment independent.
adherence by children and their families [5]. With inter-
vention, many children gain continence through intermit-
tent catheterization and medications. Over half of
Procedures
pediatric patients suffer from substantial upper urinary
tract damage due to failure to care for the lower urinary After completion of informed consent, measures were
tract [4,6]. Like patients with other chronic diseases, anx- administered during an office visit or by mail according to
iety and depression (A/D) among children with neurogenic the family preference. Adolescent patients themselves or
bladder (NB) could contribute to non-adherence in treat- the primary caregivers completed the questionnaires
ment regimens, with severe consequences [4,6]. independently, with research staff available to assist with
The burden placed on caregivers of children with chronic questions. Caregiver was self-defined as a primary parent/
disabling disease is apparent. Previous studies demonstrate guardian who took care of the pediatric NB patient for the
that caregivers of children with chronic illnesses are at majority of their time on a routine basis.
greater risk for stress, depression [7e9] and chronic sorrow This was a cross-sectional study. We evaluated symp-
[10]. QoL for children with SB seems related to family func- toms of A/D once for adolescents and for their caregiver.
tioning and parental hope [11,12]. Since the responsibility for Characteristics, such as history of urinary tract infections
the care of children with NB is placed on the caregiver, A/D in (UTIs), renal scarring/abnormal kidney, continence, pres-
the caregivers is likely to have significant consequences. ence of ventriculoperitoneal (VP) shunt, and Medicaid in-
A/D has been studied in adults with SB [2]. No study has surance were assessed for all pediatric patients.
directly screened for A/D in pediatric patients and their Adolescents, aged 10e19 years with SB or other NB ab-
caregivers. We hypothesized that children with SB and their normalities completed the Hospital Anxiety and Depression
caregivers would have high rates of A/D. The objective of Scale (HADS): HADS-A, designed to assess anxiety, and HADS-
our study was to investigate the prevalence of A/D in D, designed to assess depression. HADS is a brief, reliable,
caregivers of children with NB and in adolescents and valid screening measure for A/D. It is a 14-item scale
(those > 10 years of age) with validated screening tools. with seven items each for A/D; each item can be scored
between 0 and 3. HADS scores can range from 0 to 21 for
either anxiety or depression with a well-established clinical
Materials and methods cut-off point of 8 out of 21 for an abnormal score and is
specifically developed for patients with chronic medical
Our study was approved by the Institutional Review Board conditions [13,14]. HADS does not include symptoms of
at Albany Medical Center. depression that can confound an actual illness (e.g., fa-
tigue). The psychometric properties of HADS are validated in
Patients adolescents [15,16]. We administered HADS only to children
age >10 years. Caregivers of pediatric patients (ages birth to
Caregivers of all pediatric patients with NB and adolescents 19 years) completed the HADS-A, HADS-D, and the Center for
aged 10e19 years with NB seen by the pediatric urology Epidemiologic Studies Depression Scale (CES-D). CES-D is
service were offered the opportunity to participate. designed to assess depression in community samples, and
Screening for mood disorder in childhood neurogenic bladder 75.e3

similar to HADS has been confirmed to have good psycho- 5.5 (interquartile range [IQR]: 1.75e8.75) for anxiety and
metric properties [16]. The estimated completion time for 1.5 (IQR: 0e4.25) for depression (Table 1), both within the
the HADS or the CES-D questionnaire was 5 min [16,17]. normal range (<8/21). Individual abnormal HADS scores
(8/21) were seen in six out of 22 (27%) for anxiety and one
out of 22 (5%) for depression. The prevalence of abnormal
Results scores for A/D was not different between SB versus other
causes of NB, nor were any other factors investigated
Baseline characteristics associated with abnormal scores. (p Z 1.0).

We had 38 pediatric patients with NB: 26 had SB and 12 had Anxiety and depression among caregivers
NB of other etiologies, specifically, lipomyelomeningocele
(4), VATER (2), spinal ischemia, caudal regression, neuro-
Forty-seven caregivers completed HADS and CES-D. They
blastoma, viral paraplegia, and undiagnosed neurological
had a median HADS score of 7 (IQR: 4e11) for anxiety and 4
abnormalities (2). Twenty-two out of 38 patients were
(IQR: 1e7) for depression (Table 2), again within the normal
considered adolescents (10e19 years of age) and eligible
range. Individual abnormal HADS scores were seen in 23 out
for HADS. The remaining 16 patients were younger than 10
of 47 (49%) for anxiety and 10 out of 47 (21%) for depres-
years of age and not eligible to take HADS. They were
sion. Abnormal CES-D scores (>15) were seen in 15 out of 47
therefore excluded from A/D evaluation. Regardless of a
(32%). The median CES-D scores were 8 (IQR: 3e19).
patient’s age, all caregivers (n Z 47) were eligible to take
Nine of the 38 patients had two caregivers who completed
both CES-D and HADS.
HADS and CES-D. They were included in the patient clinical
characteristic data twice (n Z 47) and were assumed to be
Depression among adolescents independent responses. The percentage of abnormal scores
for HADS or CES-D for caregivers of patient’s with SB versus
Twenty-two adolescents completed HADS (7 males, 15 fe- those with other causes of NB was not different (HADS-A,
males, 1 missing data). They had a median HADS score of p Z 0.53, HADS-D, p Z 1.0, CES-D, p Z 1.0). The percentage

Table 1 Anxiety and depression in adolescent patients (10e19 years of age).


Number HADS-A p-Valuea HADS-D p-Valuea
b c b c
Median (IQR) Number abnormal Median (IQR) Number abnormal
(%) (%)
All 22 5.5 (1.75e8.75) 6 (27%) 1.5 (0e4.25) 1 (5%)
Gender
Female 15 4 (1e11) 5 (33%) 1 (0e5) 1 (7%)
Male 7 7 (4e7) 1 (14%) 0.61 2 (1e3) 0 (0%) 1.0
Type of neurogenic
Spina bifida 15 4 (1e8) 4 (27%) 2 (0e5) 1 (7%)
Other 7 7 (4e11) 2 (29%) 1.0 1 (0e2) 0 (0%) 1.0
Medicaidd
No 15 5 (2e7) 3 (20%) 1 (0e3) 0 (0%)
Yes 7 7 (1e11) 3 (43%) 0.33 2 (0e6) 1 (14%) 0.32
UTI
No 11 7 (4e8) 3 (27%) 2 (1e5) 0 (0%)
Yes 11 2 (1e11) 3 (27%) 1.0 0 (0e3) 1 (9%) 1.0
Renal scarring/abnormal kidney
No 16 7 (4e10.25) 5 (31%) 2 (1e5) 1 (6%)
Yes 6 2 (0.75e5) 1 (17%) 0.63 0 (0e1) 0 (0%) 1.0
Continent
No 9 5 (1.5e7.5) 2 (22%) 1 (0.3e5) 0 (0%)
Yes 13 7 (1.5e11.5) 4 (31%) 1.0 2 (0e5.5) 1 (8%) 1.0
VP shunt
No 17 6 (2.5e9.5) 5 (29%) 2 (0e4.5) 1 (6%)
Yes 5 1 (0e9) 1 (20%) 1.0 1 (0e3.5) 0 (0%) 1.0
Abbreviations:HADS Z Hospital Anxiety and Depression Scale (Anxiety subscale, HADS-A, Depression subscale, HADS-D); UTI Z urinary
tract infections; VP Z ventriculoperitoneal.
a
p-Value was computed using the Fisher exact test, p  0.05 was considered significant.
b
Interquartile range (IQR) is the 25th to 75th percentile, encompassing the central 50% of observations.
c
Abnormal scores, HADS 8.
d
Medicaid program in the United States is a national government funded health insurance welfare program for children, adults, and
families with low income and those with disabilities.
75.e4
Table 2 Depression and anxiety in primary caregivers and association with patient’s (birth to 19 years of age) characteristics.
n CES-D p-Valued HADS-A p-Valued HADS-D p-Valued
Median (IQR)a Number Median (IQR)a Number Median Number
abnormalb (%) abnormal (%) (IQR)a abnormalc (%)
All (caregivers) 47 8 (3e19) 15 (32%) 7 (4e11) 23 (49%) 4 (1e7) 10 (21%)
Patient age
< 10 21 14 (5e23.5) 9 (43%) 7 (4.5e11) 10 (48%) 4 (2e9) 6 (29%)
> 10 26 5 (5e29) 6 (23%) 0.21 7.5 (3.75e9.75) 13 (50%) 1.0 3 (1e5.25) 4 (15%) 0.31
Patient gender
Female 29 4 (1.5e15) 6 (21%) 6 (3e9) 12 (41%) 4 (1e5.5) 4 (14%)
Male 18 15.5 (5.75e24) 9 (50%) 0.06 9 (5.75e11.25) 11 (61%) 0.24 4.5 (1e10.25) 6 (33%) 0.15
Type of Neurogenic
Spina bifida 33 8 (3.5e20.5) 11 (33%) 7 (4.5e11) 15 (46%) 4 (1e7) 7 (21%)
Other 14 4 (1.75e17.5) 4 (29%) 1.0 8 (3.75e10.5) 8 (57%) 0.53 4 (1e7.5) 3 (21%) 1.0
Medicaide
No 36 6 (2.25e15) 8 (22%) 6 (4e9) 13 (36%) 2.5 (1e5.75) 7 (19%)
Yes 11 17 (6e19) 7 (64%) 0.02 12 (8e12) 10 (91%) 0.002 6 (4e12) 3 (27%) 0.68
UTI
No 28 6.5 (3e16.5) 7 (25%) 7 (4e9) 11 (39%) 3 (1e6) 5 (18%)
Yes 19 14 (1e19) 8 (42%) 0.33 9 (5e12) 12 (63%) 0.14 5 (1e11) 5 (26%) 0.50
Renal scarring abnormal kidney
No 39 8 (3e19) 11 (28%) 7 (5e10) 19 (49%) 4 (1e6) 8 (21%)
Yes 8 9.5 (0e18.75) 4 (50%) 0.24 7 (1e12) 4 (50%) 1.0 5 (1e10.75) 2 (25%) 1.0
Continent
No 28 5.5 (3e13.75) 5 (18%) 6.5 (3.25e8) 10 (36%) 3 (1e5) 4 (14%)
Yes 17 15 (2e23) 8 (47%) 0.05 9 (5e5.12) 12 (71%) 0.03 5 (1e11) 6 (35%) 0.14
VP shunt
No 38 9.5 (3.75e19.75) 14 (37%) 8 (4e11) 20 (53%) 4 (1e7.25) 9 (24%)
Yes 9 3 (1e10) 1 (11%) 0.23 5 (3e9.5) 3 (33%) 0.46 1 (0e5.5) 1 (11%) 0.66
CES-D Z Center for Epidemiologic Studies Depression (CES-D) Scale; HADS, Hospital Anxiety and Depression Scale (Anxiety subscale, HADS-A, Depression subscale, HADS-D); UTI Z urinary
tract infections; VP, ventriculoperitoneal.
a
Interquartile range (IQR) is the 25th to 75th percentile, encompassing the central 50% of observations.
b
Abnormal scores, CES-D > 15.
c
Abnormal scores, HADS 8.
d
p-Value was computed using Fisher’s exact test, p  0.05 was considered significant.

A.T. Kabra et al.


e
Medicaid program in the United States is a national government funded health insurance welfare program for children, adults, and
families with low income and those with disabilities.
Screening for mood disorder in childhood neurogenic bladder 75.e5

of abnormal scores for HADS and CES-D was higher when caregivers had anxiety, and the prevalence was even higher
patients had Medicaid (HADS-A, 36% no vs. 91% yes, among caregivers than the adolescents themselves. This is
p Z 0.002; CES-D, 22% no vs. 64% yes, p Z 0.02). Continence similar to that seen in caregivers of asthmatic children [8].
was associated with a higher percentage of abnormal scores We also found that nearly a third of the caregivers in our
for A/D among caregivers (HADS-A, 71% no vs. 36% yes, study had depression, much higher than the adolescents.
p Z 0.03; CES-D, 47% no vs. 18% yes, p Z 0.05). This is consistent with the rates of A/D among caregivers of
pediatric patients with other chronic illnesses [8e10,25].
For example, among caregivers of children with other
Discussion chronic diseases, depressive symptoms were found in 39%
of male and 33% of female caregivers of asthmatic children
In this preliminary screening study, we found considerable and 14% of male and 50% of female caregivers of children
anxiety in adolescents with NB and both A and D in care- with chronic renal disease [9]. Previous literature in chil-
givers. When screening using two validated surveys, ado- dren with neurological problems is conflicting. In 132 par-
lescents with NB had median scores for A/D that were ents of pediatric patients with neural tube defects, a
normal; yet 27% of these patients exhibited scores for relationship between depression and chronic sorrow was
anxiety that are outwith the normal range. For the care- demonstrated [10]. In another study, family functioning and
givers, the median scores were also normal; yet 49% and psychological status of parents did not seem to be affected
32% had scores for A/D, respectively, that were abnormal. by the disability level of SB in children [11]. In contrast, life
SB among pediatric patients has been shown to result in stress scores were found to be similar among caregivers of
alterations in daily functioning and to increase dependency patients with SB and matched controls [8]. Parental hope
on adult care, factors that are associated with altered self- was associated with better QoL in SB [12], and depression
concept, psychological distress, including A/D [1,18e20]. was shown to negatively affect medical care and patient
Our findings underscore such results from previous studies. outcomes, further suggesting that our findings warrant
Although previous studies have reported the prevalence attention by healthcare providers [3].
of depression in SB and urinary incontinence [2,21], we In addition, a child or adolescent’s disability will
report the median and individual scores for depression in certainly affect family dynamics and will have a significant
adolescents with NB as normal (only 1 case had depression). impact on family functioning [11,27,28]. This underscores
This is in contrast to a study of adolescents with SB where that A/D in parents can deleteriously impact children and
self-reported A/D symptom scores above the clinical cut-off vice versa [25,29]. Maternal A/D investigated at various
values were reported in 41% and 31% of the study popula- intervals postpartum demonstrated that the ability to fulfill
tion, with 53% of youths reporting symptoms of both A and D the roles of parenting are impaired due to impaired in-
[2]. Pain was found to be a risk factor for both A and D. We teractions, decreased gratification, and lower feelings of
rarely perceive pain to be an issue for children with NB [22]. self-efficacy [28] can put children at higher risk for devel-
Among incontinent adults, the odds of depression were opmental delay, social difficulties, and internalizing and
twofold higher than continent controls, and depression was externalizing problems [7,25]. Pediatric patients of
attributed to altered serotonin function [23]. Our results depressed parents can show more impaired functioning in
are also quite different from other chronic conditions. For work and family environments than those of non-depressed
example, depression has been reported to be more parents [29]. The implications of these findings are impor-
commonly present in adolescent patients with asthma, tant; one can imagine how challenging it would be for an
epilepsy, diabetes, end-stage renal disease, cystic fibrosis, anxious parent to help an anxious child. Since these pedi-
and sickle cell disease [1,24]. Possible explanations for the atric patients will likely undergo numerous interventions,
lack of depression in SB/NB adolescents may relate to the mental health professionals should look for ways to assist
limited effects the condition has on self-image [25], the high-risk families. Psychosocial interventions in these
support provided by the local SB association, or the small families may well be of benefit.
sample size of the pilot study. In our study, we surprisingly found caregivers to have a
In our study, the percentage of adolescent patients with lower percentage of depression in patients with inconti-
abnormal anxiety was 27%. This finding is similar to the high nence. Although we have no data on the cause of this
prevalence that has been reported for adults, 18e25 years of finding in this preliminary study, this may be related to a
age with SB (23e31%) [2]. In comparison, in a nationally caregiver’s ability to adapt to the demands of the situation
representative survey of the US general population, the 12- in chronic illness or, perhaps, lower expectations. Care-
month prevalence rate of mood disorders was reported to be givers of pediatric patients with Medicaid had higher per-
3.7% in youth [24] and 6.6% in adults [26]. The presence of centages of A/D by HADS-A and CES-D. Medicaid in the
anxiety in our study sample is striking and suggests physicians United States is a government funded health insurance
should have a heightened awareness of the potential for program for children, adults, low-income families, and
excessive anxiety in these patients, as physicians generally those with disabilities. Higher percentages of A/D are not
perform many medical procedures in these patients. In the surprising in this population as they are likely to have many
urology setting, these children undergo many ultrasounds other poverty-related stresses (e.g., housing and food) and
and urodynamic studies. Child-life services and other support are consistent with previous studies. For example, higher
systems may be valuable to help prevent/reduce anxiety, dysfunction was found in the family functioning of SB pa-
even for these seemingly innocuous procedures. tients of lower socioeconomic status [11]. Similarly, in a
Similar to adolescents, caregivers also had issues. study of pediatric patients with sickle-cell disease and
Although median scores were normal, nearly half of the Medicaid, socio-demographic strata, family’s poverty level,
75.e6 A.T. Kabra et al.

and rural/urban environment were factors that contributed [2] Bellin MH, Zabel TA, Dicianno BE, Levey E, Garver K, Linroth R,
to higher rates of depression [30]. et al. Correlates of depressive and anxiety symptoms in young
There are several limitations to our study. First and adults with spina bifida. J Pediatr Psychol 2010;35:778e89.
foremost, even though our study was designed as a pre- [3] Woltmann E, Grogan-Kaylor A, Perron B, Georges H,
Kilbourne AM, Bauer MS. Comparative effectiveness of
liminary screening investigation, our numbers are small.
collaborative chronic care models for mental health condi-
Second, the cross-sectional nature of the study can only tions across primary, specialty, and behavioral health care
provide associations, and causal relationship for A/D be- settings: systematic review and meta-analysis. Am J Psychia-
tween NB patients and their caregivers cannot be inferred. try 2012;169(8):790e804.
Third, we had no measures of intelligence quotient (IQ) and [4] Joseph DB. Current approaches to the urologic care of chil-
could not study the impact of IQ on A/D. Fourth, we are dren with spina bifida. Curr Urol Rep 2008;9:151e7.
aware that only a small proportion of families initially [5] DiMatteo MR, Lepper HS, Croghan TW. Depression is a risk
invited by post returned the completed consent. The factor for noncompliance with medical treatment: meta-
remaining families included were subsequently asked at analysis of the effects of anxiety and depression on patient
outpatient clinic visits to complete the consent form. As a adherence. Arch Intern Med 2000;160:2101e7.
[6] Bauer SB, Joseph DB. Management of the obstructed urinary
result, this may select only those families coming for care.
tract associated with neurogenic bladder dysfunction. Urol
It is conceivable that those having even worse A/D may not Clin North Am 1990;17:395e406.
even attend outpatient clinics or respond to mail. We [7] Downey G, Coyne JC. Children of depressed parents: an
cannot test this possibility in our study but would point out, integrative review. Psychol Bull 1990;108:50e76.
if so, this would make our findings even stronger. Fifth, our [8] Ong LC, Norshireen NA, Chandran V. A comparison of
study does not provide qualitative analysis of the families parenting stress between mothers of children with spina bifida
studied. Although specific factors that cause A/D in care- and able-bodied controls. Dev Neurorehabil 2011;14:22e8.
givers would be clinically important to identify, they were [9] Szabo A, Mezei G, Kovari E, Cserhati E. Depressive symptoms
outside the scope of this study. Despite these limitations, amongst asthmatic children’s caregivers. Pediatr Allergy
the prevalence of anxiety in adolescents and in the care- Immunol 2010;21(Pt 2):e667e773.
[10] Hobdell E. Chronic sorrow and depression in parents of children
givers is striking. Certainly our data highlight that clinicians
with neural tube defects. J Neurosci Nurs 2004;36:82e8. 94.
should look for A/D more aggressively in pediatric patients [11] Holmbeck GN, Westhoven VC, Phillips WS, Bowers R, Gruse C,
with NB dysfunction and in their caregivers. Nikolopoulos T, et al. A multimethod, multi-informant, and
multidimensional perspective on psychosocial adjustment in
preadolescents with spina bifida. J Consult Clin Psychol 2003;
Conclusion 71:782e96.
[12] Kirpalani HM, Parkin PC, Willan AR, Fehlings DL,
Our study found preliminary evidence for a high risk of Rosenbaum PL, King D, et al. Quality of life in spina bifida:
anxiety in adolescents with NB dysfunction and for A/D in Importance of parental hope. Arch Dis Child 2000;83:293e7.
the caregivers of pediatric patients with NB. These results [13] Bjelland I, Dahl AA, Haug TT, Neckelmann D. The validity of
suggest routine screening for A/D in pediatric patients with the Hospital Anxiety and Depression Scale. An updated liter-
SB and NB and in their families will most likely yield high ature review. J Psychosom Res 2002;52:69e77.
[14] Brennan C, Worrall-Davies A, McMillan D, Gilbody S, House A.
rates of abnormality. Psychosocial therapeutic in-
The Hospital Anxiety and Depression Scale: a diagnostic meta-
terventions may be beneficial for such families. Future analysis of case-finding ability. J Psychosom Res 2010;69:
studies investigating reasons for A/D in families would be 371e8.
beneficial. [15] White D, Leach C, Sims R, Atkinson M, Cottrell D. Validation of
the Hospital Anxiety and Depression Scale for use with ado-
lescents. Br J Psychiatry 1999;175:452e4.
Conflict of interest [16] Berard R, Ahmed N. Hospital Anxiety and Depression Scale
(HADS) as a screening instrument in a depressed adolescent
None. and young adult population. Int J Adolesc Med Health 1995;8:
157e66.
[17] McCauley SR, Pedroza C, Brown SA, Boake C, Levin HS,
Funding Goodman HS, et al. Confirmatory factor structure of the Cen-
ter for Epidemiologic Studies-Depression scale (CES-D) in mild-
None. to-moderate traumatic brain injury. Brain Inj 2006;20:519e27.
[18] Landry SH, Robinson SS, Copeland D, Garner PW. Goal-
directed behavior and perception of self-competence in
Acknowledgments children with spina bifida. J Pediatr Psychol 1993;18:389e96.
[19] Orth U, Robins RW, Trzesniewski KH, Maes J, Schmitt M. Low
self-esteem is a risk factor for depressive symptoms from young
We thank Preeti Zanwar, PhD, MPH, MS, for her assistance adulthood to old age. J Abnorm Psychol 2009;118:472e8.
with revising and proofreading the manuscript. [20] Moore C, Kogan BA, Parekh A. Impact of urinary incontinence
on self-concept in children with spina bifida. J Urol 2004;171:
1659e62.
References [21] Zorn BH, Montgomery H, Pieper K, Gray M, Steers WD. Urinary
incontinence and depression. J Urol 1999;162:82e4.
[1] Rao C, Ramu SA, Maiya PP. Depression in adolescents with [22] Oddson BE, Clancy CA, McGrath PJ. The role of pain in
chronic medical illness. Int J Adolesc Med Health 2011;23: reduced quality of life and depressive symptomology in chil-
205e8. dren with spina bifida. Clin J Pain 2006;22:784e9.
Screening for mood disorder in childhood neurogenic bladder 75.e7

[23] Merikangas KR, He JP, Brody D, Fisher PW, Bourdon K, [27] Ulus Y, Tander B, Akyol Y, Ulus A, Bilgici A, Kuru O, et al.
Koretz DS. Prevalence and treatment of mental disorders Functional disability of children with spina bifida: its impact
among US children in the 2001e2004 NHANES. Pediatrics 2010; on parents’ psychological status and family functioning. Dev
125:75e81. Neurorehabil 2012;15:322e8.
[24] Jerrell JM, Tripathi A, McIntyre RS. Prevalence and treatment [28] Silver EJ, Westbrook LE, Stein RE. Relationship of parental
of depression in children and adolescents with sickle cell psychological distress to consequences of chronic health
disease: a retrospective cohort study. Prim Care Companion conditions in children. J Pediatr Psychol 1998;23:5e15.
CNS Disord 2011;13(2). pii. [29] Myers JK, Weissman MM, Tischler GL, Holzer 3rd CE, Leaf PJ,
[25] Weissman MM, Wickramaratne P, Nomura Y, Warner V, Orvaschel H, et al. Six-month prevalence of psychiatric dis-
Pilowsky D, Verdeli H. Offspring of depressed parents: 20 orders in three communities 1980 to 1982. Arch Gen Psychi-
years later. Am J Psychiatry 2006;163:1001e8. atry 1984;41:959e67.
[26] Kessler RC, Berglund P, Demler O, Jin R, Koretz D, [30] Nguyen HT, Kitner-Triolo M, Evans MK, Zonderman AB.
Merikangas KR, et al. The epidemiology of major depressive Factorial invariance of the CES-D in low socioeconomic status
disorder: results from the National Comorbidity Survey African Americans compared with a nationally representative
Replication (NCS-R). JAMA 2003;289:3095e105. sample. Psychiatry Res 2004;126:177e87.

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