Overlearning in the conditioning treatment of enuresis: A long-term follow-up study

V studies have reported high rates of relapse following the otherwise highly successful conditioning treatment of childhood enuresis nocturna (Young, 1969). Relapse would seem to be a hazard inherent in this form of treatment, and to be independent of patient variables (Young and Morgan, 1972a). Use of the technique of intermittent reinforcement schedules (Lovibond, 1964; Turner, Young and Rachman, 1970) and of CNS stimulant drugs (Young and Turner, 1965; Turner and Young, 1966) to counteract the problem of relapse have failed to achieve satisfactory results.

Young and Morgan (1972b) have demonstrated the success of overlearning therapy in reducing the relapse rate. This regime requires the child to maintain or regain his learned nocturnal bladder control, to a success criterion of 14 consecutive dry nights, while drinking up to 2 pints of liquid in the hour before retiring. The present paper reports the experience gained in the counteraction of relapse by the use of overlearning therapy over approximately 4 yr at the Vale Drive Clinic, at which enuresis is treated by conditioning techniques (Young, 1965; Morgan and Young, 1972).     

Apparatus for conditioning treatment of enuresis

Recent experimental work is cited which has implications for basic equipment design. Some unsatisfactory earlier innovations are also briefly discussed.

The traditional pad and bell apparatus is not superseded but commonly exhibits defects and hazards for which the recessed electrode principle is introduced as a solution. New high-sensitivity requirements in circuitry to match the recessed electrode pad are met in an unusual and inexpensive way.     

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.     

Critique of Turner, Young and Rachman's conditioning treatment of enuresis

The abstract of the paper begins by asserting that “one hundred and fifteen children were assigned to five treatment groups (including two control treatments)”. The abstract continues “over a one month period there was no difference between conditioning and control procedures”. A further sentence to the effect that conditioning treatment brought about an initial arrest of bedwetting in 81.4 per cent of cases, does nothing to dispel the implication of the earlier sentences that a large scale study has failed to produce evidence that conditioning treatment is superior to “placebo” or “arousal” treatments.     

Effect of varying alarm schedules on acquisition and relapse parameters in the conditioning treatment of enuresis

Acquisition and relapse rates for 178 enuretic children were examined as a function of varying intermittent alarm schedules ranging from the standard (100%) bell-and-pad conditioning alarm treatment to a variable-ratio (VR) alarm schedule of 30–59%. Median follow-up time was 25 months. Children who experienced multiple wetting (MW) events beyond the third treatment week experienced twice as many wettings to reach dryness criterion as non-multiple wetting (NMW) children. Approximately one-third of the sample proved to be MW children. Optimal relapse results for NMW children were achieved with the 70–79% VR alarm schedule (10% relapse rate). MW children treated with the standard experienced a 100% relapse rate. For MW children the lowest relapse rates were attained with a 60–69% VR schedule (42% relapse). Older children experienced higher relapse rates than younger children, but age differences were eliminated with a 70–79%, VR alarm schedule. Collectively, the results demonstrate optimal VR intermittent alarm schedules for differen: categories of enuretic children.     

Treatment of nocturnal enuresis by conditioning techniques

One hundred and fifteen enuretic children were assigned to five treatment groups. Three groups received Mowrer-type continuous signal (C.S.), Twin-Signal (T.S.) or intermittent Twin Signal (T.S.-I.R.) conditioning treatment, and two groups were given “placebo” or “arousal” control treatments. Over a one-month period, there was no difference between conditioning and control procedures, and it was concluded that further research is needed to determine the basis of treatment response. There was no evidence in support of the escape training hypothesis, and the twin-signal modification to standard bell-and-pad treatment is not recommended. The investigation confirmed the success of conditioning treatment in bringing about the initial arrest of enuresis (i.e. in 81.4 per cent of the cases) but the relapse rate was high. The investigation provided tentative evidence that intermittent conditioning treatment offers one way of reducing the frequency of relapse. The problem of obtaining satisfactory parental co-operation in a badly housed working-class population was apparent, and ways of reducing the demands that treatment imposes on parents are indicated. The results are discussed with regard to theories of conditioning treatment of nocturnal enuresis, and possible improvements in this technique of treatment.     

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.     

Relapse and therapeutic response in the conditioning treatment of enuresis: A review of recent findings on intermittent reinforcement,overlearning and

Recent research concerning relapse and response to auditory alarm stimuli in the conditioning treatment of enuresis is reviewed. Both intermittent reinforcement and overlearning procedures have been found to be associated with reduced relapse rates—of 25% and 12.8% respectively, a consensus of published results to date favouring overlearning as the more effective procedure in countering relapse. Auditory stimulus intensity is identified as a critical factor affecting rate of acquisition of continence, but not relapse, and appears implicated in the improved acquisition obtained in past studies of variations upon basic conditioning treatment.     

The effect of continuous, intermittent, and "placebo" reinforcement on the effectiveness of the conditioning treatment for enuresis nocturna

It has been suggested that intermittent reinforcement may be of value in reducing the rate of relapse in bedwetting conditioning therapy. An experiment was conducted with 30 enuretic boys to examine acquisition and extinction parameters of continuous (100%), intermittent (70% variable ratio), and “placebo” (0%) reinforcement schedules. Reinforced trials were administered as in the typical Mowrer conditioning procedure. Non-reinforced trials were achieved by means of a time delay with the subsequent alarm being activated in the parent's room rather than in the child's room. These procedures required the development of a new conditioning device which could be programmed to automatically administer the desired schedule of reinforcement. The results of the field investigation revealed that continuous reinforcement (CR) and intermittent reinforcement (IR) groups attained acquisition in approximately the same number of trials and with essentially the same success rate. Relapse rate was significantly greater in the CR group than in the IR group. The placebo group showed no improvement over the 6 weeks of treatment. The results of this study may be interpreted as supporting the tenet that relapse can be viewed and treated as an extinction of the acquired response.     

Childhood nocturnal enuresis: The prediction of premature withdrawal from behavioral conditioning

Predictors of premature withdrawal from a 12-week program of behavioral conditioning for childhood nocturnal enuresis were examined for 47 children treated at a university outpatient clinic. All children were administered the Piers-Harris Children's Self-Concept Scale; parents completed the 55-item Behavior Problem Checklist and the Tolerance Scale for Enuresis. Parents also reported the methods (i.e., random awakening, restriction of fluids, rewards,punishment, medication, other) previously used to control their child's wetting. A stepwise discriminant function analysis revealed that the function containing number of previous techniques used, presence of child behavior problems, and parent tolerance of enuresis was a significant predictor of early termination of treatment.