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).     

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.     

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.     

Intermittent reinforcement in behaviour therapy

It is suggested that intermittent reinforcement may be of value in retarding the tendency towards relapse in aversion therapy. An experiment with rats was conducted to examine the effects of intermittent shocks in approach-avoidance conflict learning. Intermittent reinforcement was shown to produce marked resistance to extinction in this type of avoidance learning. In a field-investigation of conditioning treatment of enuresis, intermittent reinforcement was found not to retard acquisition unduly and to give promise of reducing the relapse rate. A longer follow-up period is required to permit a final evaluation of the procedure.     

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.     

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.     

Avoidance of overlearning characterises the spacing effect

The spacing of a fixed amount of study time across multiple sessions usually increases subsequent test performance—a finding known as the spacing effect. In the spacing experiment reported here, subjects completed multiple learning trials, and each included a study phase and a test. Once a subject achieved a perfect test, the remaining learning trials within that session comprised what is known as overlearning. The number of these overlearning trials was reduced when learning trials were spaced across multiple sessions rather than massed in a single session. In addition, the degree to which spacing reduced overlearning predicted the size of the spacing effect, which is consistent with the possibility that spacing increases subsequent recall by reducing the occurrence of overlearning. By this account, overlearning is an inefficient use of study time, and the efficacy of spacing depends at least partly on the degree to which it reduces the occurrence of overlearning.     

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.     

The effect of overlearning on transfer of training

The effect of overlearning on transfer of training on the A-B:A-B_r paradigm was studied in paired-associate learning with meaningful material (adjective pairs). One group of subjects was trained to criterion on list A-B, and two additional groups were given 100 per cent and 200 per cent overlearning on list A-B. Rate of learning list A-B_r was found to be directly related to amount of overlearning. Negative transfer on list A-B_r was found for errors with the criterion group, while positive transfer was found for the 100 per cent and 200 per cent overlearning groups. The results were consistent with previous paired-associate experiments, and with results of some maze, reversal learning experiments with infrahuman subjects.

The notation “A-B:A-B_r” will be used for the transfer paradigm in which the same stimuli and responses are used in both the original acquisition phase of paired associate learning and in the subsequent transfer of training phase. In the transfer phase, however, the responses (i.e. B) are rearranged so that they are paired with different stimuli (i.e. A). The notation “A-B:A-C” will be used for the transfer paradigm in which a new set of responses (i.e. C) are paired with the old set of stimuli in the transfer of training phase.     

Amygdala and hippocampal activity during acquisition and extinction of human fear conditioning

Previous functional magnetic resonance imaging (fMRI) studies have characterized brain systems involved in conditional response acquisition during Pavlovian fear conditioning. However, the functional neuroanatomy underlying the extinction of human conditional fear remains largely undetermined. The present study used fMRI to examine brain activity during acquisition and extinction of fear conditioning. During the acquisition phase, participants were either exposed to light (CS) presentations that signaled a brief electrical stimulation (paired group) or received light presentations that did not serve as a warning signal (control group). During the extinction phase, half of the paired group subjects continued to receive the same treatment, whereas the remainder received light alone. Control subjects also received light alone during the extinction phase. Changes in metabolic activity within the amygdala and hippocampus support the involvement of these regions in each of the procedural phases of fear conditioning. Hippocampal activity developed during acquisition of the fear response. Amygdala activity increased whenever experimental contingencies were altered, suggesting that this region is involved in processing changes in environmental relationships. The present data show learning-related amygdala and hippocampal activity during human Pavlovian fear conditioning and suggest that the amygdala is particularly important for forming new associations as relationships between stimuli change.     

Cross-US reinstatement of human conditioned fear: Return of old fears or emergence of new ones?

Re-exposure to the unconditioned stimulus (US) following fear extinction in the laboratory produces reinstatement of fear. Similarly in clinical situations, anxiety patients may experience adverse events that reinstate fear following successful exposure therapy. The current study employed two USs, shock and loud noise, to examine whether a US that is qualitatively different but of the same valence as the original acquisition US can produce reinstatement in human fear conditioning. Both standard and cross-US reinstatement manipulations led to elevated fear as indexed by skin conductance. However, cross-US reinstatement was accompanied by elevated expectancy of the US that had been presented during the reinstatement manipulation, not the US that had been used to establish fear in acquisition. This result implies that reinstatement may involve the development of new fears. Context conditioning and cognitive processes were implicated as possible mechanisms. The current findings suggest that clinical relapse attributed to reinstatement may not always reflect the reactivation of old fears but may instead represent new fears worthy of clinical examination.     

Perceptions of Training-Related Factors and Personal Variables as Predictors of Transfer Implementation Intentions

A number of factors influence the outcomes of computer skills training and the likelihood of successful transfer. The first empirical test of a conceptual model of training transfer sought to explain how trainees' perceptions of various in-training transfer-enhancing activities such as overlearning, fidelity, stimulus variability, principles-meaningfulness, self-management activities, relapse prevention, and goal setting would predict the self-efficacy and implementation intentions (rather than actual transfer outcomes) of computer skills trainees. As expected, posttraining self-efficacy and transfer enhancing activities both predicted transfer implementation intentions. Pretraining self-efficacy also significantly predicted posttraining self-efficacy, trainees' level of learning during training and transfer enhancing activities, providing support for the conceptual model of training transfer.     

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.     

Postcriterion overlearning reduces the effectiveness of the method of adjusted learning

One goal of the method of adjusted learning (“dropout procedure”) is to equate the strength of different Items for subsequent retention. Some studies have yielded results in accord with this goal while others have not, with no known reason for the discrepancy. We manipulated the number of postcriterion overlearning trials and found that the adjusted learning procedure was effective in equating items for subsequent retention when learning terminated after one correct response per item but ineffective when postcriterion overlearning trials occurred. This finding is especially important for those versions of the adjusted learning procedure, such as the frequently utilized variant developed by Battig (1965), that incorporate overlearning of the to-be-equated items.     

The effects of overlearning and distributed practise on the retention of mathematics knowledge

In two experiments, 216 college students learned to solve one kind of mathematics problem before completing one of various practise schedules. In Experiment 1, students either massed 10 problems in a single session or distributed these 10 problems across two sessions separated by 1 week. The benefit of distributed practise was nil among students who were tested 1 week later but extremely large among students tested 4 weeks later. In Experiment 2, students completed three or nine practise problems in one session. The additional six problems constituted a strategy known as overlearning, but this extra effort had no effect on test scores 1 or 4 weeks later. Thus, long‐term retention was boosted by distributed practise and unaffected by overlearning. Unfortunately, most mathematics textbooks rely on a format that emphasises overlearning and minimises distributed practise. An easily adopted alternative format is advocated. Copyright © 2006 John Wiley & Sons, Ltd.     

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.     

Cross-modal transfer of conditioned suppression in rats: Effects of US intensity and extinction of the initial conditioning task

In conditioned suppression of water licking behavior by rats, we obtained data indicating general transfer of fear conditioning. A series of experiments resulted in two major findings. First, pairing of a neutral stimulus with a shock in the initial conditioning task facilitated acquisition of subsequent fear conditioning to another neutral stimulus, if the conditioned fear of the initial task was extinguished prior to the second task and if equally strong shocks were employed in both conditioning tasks. Second, omission of the extinction treatment or employment of weaker shocks in the initial task resulted in retardation, rather than facilitation, of the second conditioning task. An application to human clinical settings is discussed.     

Differential effects of progesterone and medroxyprogesterone on delay eyeblink conditioning in ovariectomized rats

Ovarian hormones modulate acquisition processes involved in classical conditioning. Although progesterone has been indirectly implicated, its role in classical conditioning of the eyeblink response has not been directly investigated. We assessed the effects of daily dosing of progesterone or medroxyprogesterone (MPA), a non-metabolized synthetic progestin, upon the acquisition of a classically conditioned eyeblink response in ovariectomized (OVX) female rats. Rats were dosed 4h prior to each training session with 0.1 or 1.5 mg/kg of either of these hormones or sesame oil. A delay conditioning paradigm was employed using a 500 ms conditioned stimulus coterminating with a 10 ms 10 V unconditioned stimulus. At the low dose, progesterone and MPA rats did differ from each other, with MPA-treated rats learning slower, but neither group differed from OVX-oil or Sham-oil controls. No group differences in acquisition were observed at the higher dose. During extinction trials, high-dose MPA-treatment and OVX-oil groups extinguished quicker than the high-dose progesterone-treated group. In addition, unconditional response (UR) amplitudes were lower in all OVX groups, regardless of hormone or oil treatment, compared to the sham-oil group. Since MPA did not affect extinction, it is likely the slower extinction in the progesterone-treated rats is due to a metabolite of progesterone. Corticosterone is discussed as a likely candidate for such a role. In addition, we found chronic absence of ovarian hormones decreased UR amplitudes, although differences in UR amplitudes were not associated with changes in the acquisition process. These results are discussed with respect to differences in the hormonal effects upon acquisition versus extinction processes and how these data may explain reports of learning differences in women based on oral contraceptive usage.     

Prevention education and substance abuse treatment

Relapse prevention is influenced by a number of variables including stress and negative mood states, motivation and commitment to abstinence, social support, physiological factors, withdrawal symptoms, and a repertoire of cognitive and behavioral strategies utilized in responding to the relapse process. Diverse theoretical approaches have emphasized conditioning models as well as information processing, cognitive and affective components of treatment, cognitive and behavioral coping responses, and a variety of other procedures. Outcome studies related to treatment have failed to consistently support the effectiveness of several of these components. To overcomes this, the authors advocate a single subject design in the study of these approaches. This article emphasizes the role of relapse prevention, and training and education in facilitating long-term abstinence, particularly with those intervention methods that are based on social learning theory and cognitive-behavioral models.     

Purkinje cell loss by OX7-saporin impairs acquisition and extinction of eyeblink conditioning

The current study examined the effects of globally depleting Purkinje cells in the cerebellar cortex with the immunotoxin OX7-saporin on acquisition and extinction of delay eyeblink conditioning in rats. Rats were given OX7-saporin or saline 2 wk before the start of eyeblink conditioning. The rats that reached a performance criterion of two consecutive days with 80% or greater conditioned responses were given 5 d of extinction training followed by 2 d of reacquisition training. Rats that received infusions of OX7-saporin had 77.2%-97.9% Purkinje cell loss and exhibited impaired acquisition and extinction. The amount of Purkinje cell loss was correlated with the magnitude of the acquisition and extinction impairments. The highest correlations between Purkinje cell number and the rate of acquisition were in lobule HVI and the anterior lobe. The highest negative correlation between Purkinje cell number and the percentage of conditioned responses during extinction was in the anterior lobe. The results indicate that cerebellar Purkinje cells, particularly in the anterior lobe and lobule HVI, play significant roles in acquisition and extinction of eyeblink conditioning.