ADHD WITH NON-ORGANIC ENURESIS AND BORDERLINE INTELLIGENT QUOTIENT

Symptoms of Attention Deficit Hyperacitivity Disorder (ADHD) can be associated with nocturnal enuresis. Nocturnal enuresis cases are common occur in children with Mental Retardation. There are several hypotheses underlying this comorbidity, such as genetic, neurophysiological, environmental and psychosocial factors. We report the case of a 7 year old boy with symptoms such as inability to concentrate, active movement, talk a lot, unable to wait his turn, unable to delay desires, easy fighting and behaving and speaking harshly. Patients still wet the bed at night at least 3-4 times a week The Abbreviated Conners Score rating scale assessed by the mother at the start of treatment was 21. The IQ test score was 71 and the Strength and Difficulty Questionnaire (SDQ) score was 35. The patient's symptoms were reduced after 4-month therapy with 2x5mg of methylphenidate administration, psychoeducation of parents to implement toilet training and behavior therapy for patients, apply reward and punishment with the principle of token economy. In the development process of children and adolescents, parenting is an important factor. Many studies shows that parenting can impact the resilience and vulnerability of a child to behavioral disorders. In children with ADHD with borderline IQ and enuresis, parenting with a high parental control component can cause psychological symptoms to worsen without being balanced with the attitude of parents who are responsive to the psychological needs of the child.


INTRODUCTION
Enuresis co-morbidities with mental disorders such as Attention Deficit Hyperactivity Disorder (ADHD) and Mental Retardation (RM) are quite common. From a study conducted by Yang and colleagues, 28.3% of 53 children aged 6-10 years who were diagnosed with ADHD had comorbid nocturnal enuresis. There are several hypotheses underlying this comorbidity, among others, from a genetic, neurophysiological, environmental and psychosocial perspective. 1 Genetic factors play an important role in the etiology of enuresis and ADHD, the heritability rate is quite high, which is around 0.7. Molecular genetic studies conducted by Elia and colleagues found that the genetic basis of these two disorders does not have the same gene base. 1,2 In terms of functional deficits, it is hypothesized that the complex neuron network between the cortex, subcortex, and brainstem plays an important role in comorbidity between enuresis and cases of developmental delays. 1 The tricyclic antidepressant group is one of the psychopharmaceutical management in the earliest cases of enuresis. At least 58 clinical studies have shown that imipramine and other tricyclic antidepressants are effective in reducing the frequency of enuresis to one day per week compared to placebo. 3 Behavioral therapy is the first choice in enuresis management. This type of therapy ranges from simple behavioral intervention such as fluid restrictions, lifting, scheduled waking, alarms, and reward / reward systems to complex types such as dry-bed training and full spectrum home training. Evidence regarding the effectiveness of these types of therapy is inconclusive due to the limitations of the research conducted. 4

CASE
A boy, aged 7 years, was diagnosed with ADHD with symptoms such as inability to concentrate, active movement, talk a lot, unable to wait his turn, unable to delay desires, easy fighting and behaving and speaking harshly. There is a permissive and inconsistent parenting style. Parents are more

Journal of Psychiatry Psychology and Behavioral Research
likely to follow the patient's wishes because they are unable to control the patient's emotions and behavior. The Abbreviated Conners Score rating scale assessed by the mother at the start of treatment was 21.

DISCUSS AND CONCLUSION
Parenting is an important factor in the development process of children and adolescents. Several studies suggest that parenting can affect a child's resilience and vulnerability to behavioral disorders. 5 One form is the parenting style of parents who fall into the authoritarian category when parents are too controlling or intrusive which can interfere with the development of self-esteem, self-efficacy, and the ability of a child to solve problems and make decisions. 6 Parenting patterns that are at the other extreme, namely permissive parenting (overindulgence) are also closely associated with narcissism later in life. Parenting in children with special needs can also exacerbate or accommodate the onset of symptoms or other psychiatric disorders. 7 Parents can apply reward and punishment. By using the token economy principle, the patient is taught that to ask for something he must say it politely and not force his will. The patient will get a star if the patient performs the desired behavior. When he manages to collect the agreed number of stars, he will get the reward desired by the patient and agreed upon by the parents.
The examiner provides parents with psychoeducation about the goals, how to implement, and the importance of following a schedule of toilet training & behavior therapy by drinking the last time at 7 pm (1 hour before bed). Wake up at 9-10 at night (the time when the patient usually wet the bed) to urinate then can go back to sleep. One free day of bed-wetting gets one star.
If the patient can get 3 stars in seven days (3 days free to wet the bed a week), then the patient will be given a toy car.
In the case of children with Attention Deficit Hyperactivity Disorder (ADHD) with borderline intelligent quotient (IQ) and enuresis, parenting with a high parental control component without being balanced with the attitude of parents who are responsive to the child's psychological needs can cause exacerbation of psychological symptoms. there is. This is in line with the study conducted by Çöp and Givertz that there is a relationship between parenting styles of parents who use inconsistent and over-controlling punishment with comorbid oppositional defiant disorder (ODD) and externalizing behavior in ADHD. 8 In another study conducted by Schuiringa and colleagues, children with borderline IQ with comorbid externalizing behavior have parents with more disciplined parenting, less involved with children's needs, and tend to choose methods with punishment compared to parenting of children with borderline IQ without the comorbid externalizing behavior. 9 In Kessel's research, he also stated that authoritarian parenting at 3 years of age can be a predictor of enuresis in the future. 10