Behavioral interventions for childhood nocturnal enuresis: the differential effect of bladder capacity on treatment progress and outcome

Study participants were fifty 5- to 13-year-old children (33 boys and 17 girls) with nocturnal enuresis of at least 3 months duration. All wet their beds at least twice per week, were of normal intelligence, and were without demonstrable organic cause for their enuresis. Each youngster's pretreatment maximum functional bladder capacity (MFBC) was used to classify the child as having small or large MFBC based on available norms. Youngsters were then randomly assigned to treatment with the urine alarm (UA) alone or with the urine alarm supplemented with retention control training (UA plus RCT). Of the 40 youngsters who completed treatment, 37 (92.5%) achieved the treatment goal of 14 consecutive dry nights. Two additional children became dry during follow-up, leaving only one child who failed to stop wetting. Sixteen children (41%) subsequently relapsed, but all who reentered treatment became dry. Because treatment outcome was uniformly excellent across all groups, treatment progress was evaluated by analyzing wetting frequency and arising at night to use the bathroom during treatment, as well as prechange and postchange in MFBC For both wetting frequency and arising at night, there was a significant interaction between bladder capacity and treatment. Small MFBC children treated with the UA plus RCT and large MFBC youngsters treated with the UA alone had the fewest wetting episodes and got up at night to use the bathroom less often; these youngsters took less time to be successfully treated. Prechanges and postchanges in MFBC indicated that RCT did not lead to consistent increases in bladder capacity in the sample studies. The 10 children who terminated treatment prematurely had lower self-esteem and more parent-reported conduct problems than the 40 children who completed treatment.     

The response of day and night wetting children and children who wet only at night to retention control training and the enuresis alarm

Forty-five children with night wetting only (NW) and 30 children with day and night wetting (DNW) were randomly assigned to 2 treatment groups: alarm only and alarm preceded by 4 weeks of retention control training (R.C.T.). Fewer children became dry at night in the DNW group than the NW group and DNW children relapsed earlier following treatment. The enuresis alarm was far superior to R.C.T. in reducing night wetting in both enuretic groups. It also reduced day wetting in some of the DNW children. Children who became dry in the NW group did not show significant changes in functional bladder capacity. Although changes in functional bladder capacity were seen in the DNW children who became dry, changes were only noticeable once dryness had been achieved.     

A controlled trial of the treatment of nocturnal enuresis in residential homes for children

The present study was undertaken to evaluate the practicability and efficacy of treating enuretic children in residential Children's Homes by means of the enuresis alarm. A control group design was employed with 19 and 20 subjects in the treatment and control groups respectively. Eighteen of the nineteen treatment group children achieved initial arrest of enuresis in a mean of 11.9 weeks of treatment (range 5–28 weeks). Over the initial 12-week period, the treatment group showed a statistically significant reduction in mean wetting frequency, both over time and in comparison with the control group. After a follow-up period of at least 20 months. 17 of the 19 children were known to be dry. The results of an independent evaluation are reported, and it is concluded that alarm treatment is as effective and practicable in Children's Homes as it is in family situations.     

Bladder training and enuresis: A controlled trial

This study was designed to test the effectiveness of a short bladder training procedure to increase bladder capacity and to improve enuresis. Eighteen enuretic children, aged 5–13 years, were randomly assigned to either an experimental or control group. Pre- and post-treatment measures of bladder capacity and frequency of bedwetting were obtained from subjects in both groups. The experimental group received 35 days of bladder training administered at first by the experimenter and then by the parents. The training consisted of required drinking, practice in holding and rewards for retaining progressively larger volumes of fluid before voiding. The control group received no training during the duration of the experiment. The results showed that the mean bladder capacity of the experimental subjects increased significantly with bladder training compared to controls. However, the frequency of bedwetting of the experimental subjects did not decrease significantly with training. Consequently, the efficacy of a bladder training procedure in the treatment of enuresis is questioned     

An analysis of the behaviour of day- and night-wetting children: Towards a model of micturition control

Recent research has suggested that features of daytime bladder control are of importance in predicting the treatment response of nocturnal enuretics to the enuresis alarm. This paper suggests that a detailed analysis of daytime toileting behaviour should be carried out. A study is described where 22 children with day and night wetting and 22 matched normal controls were observed after they had consumed a considerable amount of fluid. The limb movements and postures were reliably rated by two observers and wetting events and visits to the toilet were recorded. Various deficits in bladder control were shown by the enuretic children. A working model of daytime bladder control is described which draws attention to significant components which may be disturbed in abnormal bladder control. The models implies that treatment regimes should be based upon a behavioural analysis of the particular dysfunction shown by the enuretic child.     

The modification of a child's enuresis: some response-response relationships

The present study attempted to evaluate experimentally the relationship between two response classes, enuresis and oppositional behavior. One child who had a long history of bed-wetting was observed in his home setting. Parents' reports and initial observations confirmed that the child was oppositional much of the time. When a timeout operation and differential attention were presented, removed, and presented again, the frequency of oppositional behavior decreased, increased, and decreased accordingly. Fluctuations in enuretic activity also correlated with the presence and absence of the timeout and differential attention operations. The suppression of oppositional behavior and enuretic activity persisted over an 18-month treatment period. It was suggested that the parental operations performed on oppositional behavior may have led to an increase in the parents' social reward value. Cessation of enuretic activity was explained in terms of a shift in parental reinforcer effectiveness.     

Parent‐administered modified dry‐bed training for childhood nocturnal enuresis: evidence for superiority over urine‐alarm conditioning when delivery factors are controlled

We compared the relative efficacy of modified dry‐bed training and standard urine‐alarm conditioning for treating functional nocturnal enuresis in 36 children aged 7–12 years attending health centres in Glasgow, Scotland. A minimal intervention, self‐help approach was adopted. Parents and children received standardized instruction, which, for each method, consisted of one clinic interview and a manual and videotape for home viewing. Outcomes were contrasted with those from untreated controls. Twelve children were randomly assigned to each condition. All groups were matched for age, gender, social class (deprivation category), and baseline wetting frequency. In the two treated groups, an intake interview was followed by two review appointments, otherwise families carried out the programmes independently at home with fortnightly telephone support either until the success criterion of 14 consecutive dry nights was met or the 16 week maximum treatment period expired. Of the 12 children treated by dry‐bed training, eight achieved initial success compared with only three of the 12 treated by the conventional urine‐alarm method. One waiting‐list control child remitted spontaneously. ANOVA showed highly significant differences in wet nights per week immediately after intervention for both treatment and time factors (p < 0.001) and their interaction (p < 0.01). The dry‐bed group averaged 0.8 nights per week wet on treatment cessation, a frequency which was significantly superior to the average of 3.25 for the urine‐alarm group and 5.00 for the controls. Six months after attaining initial success, one child in each treated group had relapsed. Our results show an outcome of 58% long‐term remission (67% initial arrest, 13% relapse) for dry‐bed training when delivered by minimal intervention methods and indicate dry‐bed training as being more effective than orthodox urine‐alarm conditioning for the same input of clinic time and instruction. Copyright © 2002 John Wiley & Sons, Ltd.     

A delivery system for the treatment of primary enuresis

To illustrate how to deliver underutilized psychological treatments, a comprehensive, low-cost treatment for primary enuresis was developed consisting of bell-and-pad training, cleanliness training, retention control, and overlearning. Sixty primary enuretic children and their parents attended 1-hour group training sessions and implemented treatment in the home. Each case required 15 minutes of professional time, and net cost to each family was $50. Forty-eight (81%) achieved initial arrest of bedwetting and only 11 (24%) relapsed at 1-year follow-up. Significant association between relapse and prior treatment failure with imipramine was noted. The outcome was found to compare favorably with previous treatments that required more professional time.     

Dry-bed training for childhood bedwetting: A comparison of group with individually administered parent instruction

Thirty nocturnally enuretic children and their parents took part in this study which examined the effectiveness of Dry-Bed Training (DBT) with and without the adjunct of a urine-alarm device. Parents administered all treatment, following initial instruction in small group settings and supported by regular group meetings with a professional therapist. Ten children were treated by DBT without an alarm. Results showed this method to be effective in significantly reducing bedwetting frequency but not in effecting complete arrest of bedwetting symptoms. Ultimately all 30 children were treated by DBT with an alarm and this method led to 29 children reaching the success criterion of 14 consecutive dry nights. The average time taken to the last wet night was 30 days. There were 10 relapses at a 3-month follow-up. These results were virtually the same as those from a previous study involving 60 subjects who were treated by DBT with an alarm, either under the direction of a professional therapist, or of the child's parents who had been previously trained in the procedure on an individual basis (Bollard and Nettelbeck, 1981). Instructing parents in a group to administer DBT with an alarm is therefore an economical large-scale method of treating nocturnal enuresis because of savings in therapist time and effort in administering the demanding procedure.     

Conditioning treatment of enuresis using a 70% intermittent reinforcement schedule

A 70% intermittent variable ratio reinforcement schedule was administered by automated equipment to 80 enuretic children of both sexes. Dryness criterion (14 consecutive dry nights) was reached by 94% of the sample. Mean treatment duration was less than seven weeks. Approximately 80% of the sample recorded at least one multiple wetting night during the early stages of conditioning treatment. Relapse rates varied as a function of age ranging from 5.25% in 7–8 year olds to 50% in 9–10 year olds. For all ages combined, the observed relapse rate of 25% was found to be significantly lower than reported in the enuresis literature over the past 10 years.     

Work conditions, social status and sex differences in primary and secondary enuresis

From previous investigations on the enuresis problem a distinction between primary and secondary enuresis is established. The first type concerns children who have never been dry and the second those with acquired enuresis. The theory is advanced that primary enuresis is a development problem mainly due to delayed cortical development or insufficient bladder capacity, whereas secondary enuresis is regarded as caused by an increased anxiety level. Some social and psychological factors in this theory, i.e., the mother's working conditions, the social status of the family, and the sex of the child, are empirically examined in an investigation of 82 children 7–15 years old. The results support the view that the main factors in the enuresis problem are related to the child's daily practice and in the socialization form of the family.     

Auditory intensity as a variable in the conditioning treatment of enuresis nocturna

Auditory intensity in the conditioning treatment of enuresis nocturna was examined in a study by Young and Morgan (1973a). In their study of three alarm intensities, no significant differences either in terms of treatment efficacy or of subsequent relapse were found. For both theoretical and practical reasons, the finding of no differences in treatment parameters as a function of varying alarm intensities is puzzling. In learning theory terms, a very intense UCS (bell or buzzer) would be expected to lead to more rapid acquisition of dryness (conditioned response) than a less intense UCS. Learning theory notwithstanding, the depth of somnolence of the enuretic child is legend. Not only are testimonials from parents regarding difficulty in arousal of their bedwetting child commonly elicited, but the literature on causes and treatment of bedwetting is replete with evidence of a deep-sleep enuresis syndrome (Bostock, 1962). It has been demonstrated by Finley (1971) and Di Perri and Meduri (1972) that the arousal threshold of enuretic children is abnormally high compared to nonenuretic children. The failure of the enuretic to awaken to the presentation of a bell (UCS) is frequently cited as responsible for unsuccessful bell-and-pad conditioning (Browning, 1967). Young and Morgan (1973b) in their study on rapidity of response to the conditioning treatment for enuresis found that one treatment problem most significantly related to slow responders was failure of the alarm stimulus to awaken the child. For those unfamiliar with the literature, the Young and Morgan (1973b) finding appears particularly surprising when one considers that they employed as their alarm UCS “...a powerful auditory stimulus...” (p. 490).Because of these important theoretical as well as practical concerns, an attempt was made to examine the effect of two auditory intensities on treatment and relapse parameters in the conditioning of enuresis nocturna.     

Overt and fantasized aggression toward parents by enuretic and nonenuretic children

This study compared the amount and direction of overt and fantasized aggression of enuretic and nonenuretic children. Following the dynamic approach, it was hypothesized that enuretic children would differ from nonenuretics in having more difficulty in expressing overt aggression toward their mothers than toward a neutral figure. In fantasy, enuretic children were expected to express more aggression feelings toward their parents than control subjects. Twenty-eight enuretic subjects and a matched group of control subjects were induced to aggress toward their mothers and toward a neutral figure. The experimental situation was a variation of the Buss (1961) technique for eliciting and measuring aggression. Aggressive fantasies were assessed, using Bene and Anthony's Family Relation Test (1957). A significant interaction was obtained between enuresis/nonenuresis and target figures. Enuretic subjects expressed more aggression toward a neutral figure than toward the mother (p=.05) and differed from the control group in expressing less aggression toward the mother (p=.10). On the fantasy level, a significantly opposite trend to the predicted one emerged: Enuretic subjects showed less aggression toward both parents. The results were discussed with respect to the dynamic and the behavioristic approach to enuresis, and further research directions were suggested.This study is based in part on an M.A. thesis submitted by the second author to the Department of Psychology, Tel-Aviv University,     

Secondary enuresis in institutionalized conduct-disordered children

The incidence of secondary enuresis in 16 institutionalized conduct-disordered children was examined. In contrast to a control group of 16 noninstitutionalized conduct-disordered children, the former showed significantly more enuretic behaviour. Also, enuresis began within 6 mo. of the children's separation from their families, suggesting this problem is very likely related to the emotional trauma surrounding the change in living conditions. However, the small number of subjects limits further interpretation of the findings.     

SUCCESSFUL USE OF THE NOCTURNAL URINE ALARM FOR DIURNAL ENURESIS

We report the effects of using a urine alarm, typically employed for nocturnal enuresis, to treat chronic diurnal enuresis in a 15-year-old female resident at Boys' Town. The results of an ABAB reversal design indicate that the alarm eliminated wetting in both treatment phases and that continence was maintained at 3- and 6-month follow-up.     

Dry-bed training: rapid elimination of childhood enuresis

Enuresis has been treated with moderate effectiveness by the urine-alarm method which requires many weeks of training. The present procedure used a urine-alarm apparatus but added such features as training in inhibiting urination, positive reinforcement for correct urinations, training in rapid awakening, increased fluid intake, increased social motivation to be nonenuretic, self-correction of accidents, and practice in toileting. After one all-night training session, the 24 enuretic children averaged only two bedwettings before achieving fourteen consecutive dry nights and had no major relapses. Little or no reduction in bedwetting occurred within the first two weeks for matched-control enuretics who were given the standard urine-alarm training. The results of a control-procedure showed that the new procedure did not involve Pavlovian conditioning. The new method appears to be a more rapid, effective and different type of treatment for enuresis.     

A clinical trial of continuous, intermittent and overlearning ‘bell and pad’ treatments for nocturnal enuresis

Sixty-one enuretic children were allocated sequentially to ‘standard’, ‘intermittent’ or ‘overlearning’ bell and pad treatment. The results suggest that the ‘overlearning’ modification of standard treatment was successful in bringing about a reduction in the relapse rate. The present status and implications of research into nocturnal enuresis were discussed in the light of the results of the investigation.     

The effects of extending the CS-UCS interval on the effectiveness of the conditioning treatment for nocturnal enuresis

Previous studies of the “conditioning method” of enuresis treatment have confounded the effects of conditioning with those of nonspecific psychotherapeutic aspects of the procedure. The present study compared three groups of enuretic children: (1) under the conventional bell-light conditioning procedure; (2) under a similar procedure, but which involved a three-minute delay between wetting and alarm, and (3) under no-treatment conditions. Double-blind precautions were used. Results suggested that conditioning effects improvement over and above that effected by nonspecific influences. The findings are qualified by large variances in improvement, and by premature termination of the experiment.     

A 2-year follow-up of bedwetters treated by dry-bed training and standard conditioning

Sixty nocturnally-enuretic children treated by Dry-Bed Training (DBT) and 35 children treated by standard conditioning were followed-up over a 2-yr period. Results showed that after achieving the initial success criterion of 14 consecutive dry nights, 39% of the DBT group and 41% of the standard-conditioning group relapsed during the follow-up period. Renewed bedwetting was arrested in 14 out of 15 cases re-treated by DBT and in all 10 cases re-treated by standard conditioning. Children who relapsed following initial treatment were compared with those who remained dry in respect of the child's age and sex, bedwetting frequency prior to treatment, the number of bedwets (and consequent conditioning trials) during treatments, a history of primary or secondary enuresis and a history of diurnal micturitional difficulty. Children who had a history of day-time wetting accidents beyond the age of 4 were found to be more likely to suffer a relapse in bedwetting following either DBT or standard conditioning. None of the other variables examined was found to be significantly associated with proneness to relapse.