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.     

Training severely and profoundly mentally handicapped nocturnal enuretics

The problem of nocturnal enuresis in the institutionalized mentally handicapped is a major one which reduces independence in many handicapped adults and has major implications for hospital resources. Much work, which has looked at initial success rates, relapse rates, and factors involved in these, has been carried out with non-handicapped populations. However, there have been remarkably few such studies with the mentally handicapped. A study is reported in which five severely and profoundly mentally handicapped adolescents or young adults were successfully trained over periods ranging from 18 to 92 weeks. Several interesting features of the data are discussed.     

The effect of parent-administered dry-bed training on nocturnal enuresis in children

In this study, two substantial modifications were made to the Dry-Bed training procedure described by Azrin, Sneed and Foxx (Behav. Res. and Therapy, 12, 147–156 (1974). The first modification was to have parents administer the intensive all-night training programme rather than an outside trainer. With fourteen children treated in this manner, nocturnal enuresis was eliminated in all cases. The median time taken to the last night of wetting was only 12 days. There were two relapses in a 6-month follow-up. The second modification involved administering the Dry-Bed procedure without the adjunct of an enuresis machine. This resulted in significantly reduced frequency of bedwetting, although nocturnal enuresis was not completely arrested in any of the ten children treated. The implications of these findings are discussed.     

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.     

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.     

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.     

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.     

Effects of a waking schedule on primary enuretic children treated with full-spectrum home training

Examined the effects of adding a waking schedule to full-spectrum home training (FSHT) for primary enuresis. Twenty children received FSHT, and 17 children received FSHT plus a waking schedule. The groups did not reliably differ in average bedwettings per week in treatment and length of treatment. Also, the groups did not reliably differ with respect to proportion of treatment successes and proportion of relapses at 1-year follow-up. Further, across both treatment groups, 76% achieved a dry bed, and only 16% experienced a relapse by 1-year follow-up. Although results support the efficacy of FSHT, the beneficial effects of a waking schedule reported previously were not replicated. The findings suggest the need for closer examination of individual differences among children with primary nocturnal enuresis.     

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.     

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).     

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.     

A concussion by any other name: Differences in willingness to risk brain injury by label and level of participation in high‐school and college sports

One factor in reducing the likelihood of sports‐related brain injuries is the recognition of risks. However, using colloquial terms may deemphasize the severity of these risks. We hypothesized that using colloquial language to describe sports‐related brain injuries will lead to greater willingness to take on the risk. We conducted two experiments, varying the label describing an injury (getting your bell rung, concussion, or brain injury) and assessing willingness of current athletes, former athletes, and nonathletes to accept this risk as part of sports participation. High‐school and college athletes were willing to expose themselves to a high probability of risk, compared with nonathletes, when described colloquially. However, risk thresholds were low and indistinguishable across groups when using the term “brain injury.” Findings remained significant when controlling for knowledge, age, and sensation seeking. These differences indicate that the term “getting your bell rung” should not be used to describe a brain injury.     

Reducing cigarette smoking in a retarded adult: An application of self-management procedures

An attempt was made to reduce the overall number of cigarettes smoked per day with a mildly retarded adult. Self-monitoring was compared to self-monitoring plus self-graphing and goal setting procedures in reducing the number of cigarettes smoked. Self-monitoring plus self-graphing and goal setting was superior to self-monitoring alone when the goal was set at 15 cigarettes per day, but the actual number of cigarettes smoked increased when the goal was set at 12. The number of cigarettes smoked during all treatment conditions was lower than either baseline conditions. The therapist also reduced the patient's caffeine intake and switched the client's brand of cigarettes to a low “tar”/nicotine brand. The reduction in caffeine and “tar”/nicotine was related to a small and transient increase in somatic complaints and verbal abuse, as well as the complete elimination of nocturnal enuresis. Brand switching to low “tar”/nicotine cigarettes did not result in an increase in the number of cigarettes smoked per day.     

The Effects of Bladder Training with Differential Contingencies on Nocturnal Enuresis

The first aim of this study was to provide further evidence regarding the effects of short retention training (RCT) on the treatment of enuresis. A second aim was to examine the effectiveness of adding specific and differential contingencies for wet and dry beds (DCDWB) when children's bladder size had acquired the capacity of normals. Two enuretic boys, aged 11-12 years, participated in this study. An ABC design with 4 months follow-up was used. The RCT consisted of required drinking, practice in urine retention and exercises to increase control over actual urine flow. The DCDWB involved the addition of either a unique period of over correction or reinforcing consequences when having a wet or dry bed in the morning. Results with RCT alone replicated previous studies. RCT is an effective method for normalizing enuretic bladder capacity, but not sufficient for eliminating enuresis, entirely. However, enuresis was totally eliminated when specific and explicit contingencies were implemented. All the components were faded out. Three months after the last intervention, follow-up data were collected for a period of 1 month. No subject relapsed. The implications of these findings are discussed.     

Factor Analysis of the Pediatric Symptom Checklist in a Population of Children with Voiding Dysfunction and/or Nocturnal Enuresis

The research objective was to identify the factor structure of the pediatric symptom checklist (PSC) in children with voiding dysfunction and/or nocturnal enuresis who were seen in a pediatric urology clinic. Retrospective chart reviews were conducted for 498 consecutive patients, ages 6–16, who were seen over a 13-month period. The PSC, a 35-item measure used to screen for psychosocial difficulties, was completed by the patient’s caregiver. Confirmatory factor analyses using three previous models were conducted. A four factor model comprised of internalizing, externalizing, attention problems, and chronic illness factors represented the best fit to the data. Within this population, the PSC appears to capture internalizing and externalizing problems, difficulties with attention, and possible side effects of a medical condition. This information could aid clinicians in assessing adjustment difficulties within this population and concurrently allow researchers to examine whether these specific factors are related to other relevant outcomes.     

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.     

Perceptual processing at adjacent location son a single finger: Masking and response competition

When target patterns and nontarget patterns are presented either to the same or to adjacent locations on the distal pad of the index finger, the amount of interference in identifying targets depends on both the shape and the location of the nontarget (Horner, 1997). In the present study, the question of whether such interference is caused by masking (the masker in some way distorts the initial representation of the target) or by response competition (the observer mistakenly responds with the masker, rather than with the target) was investigated. A 4-to-2 paradigm was used (Craig, 1995), in which four stimuli were mapped to only two responses. Targets and nontargets were randomly selected from the set of four stimuli and presented to the same or adjacent locations on the same fingerpad. Both the distal pad and the medial pad of the index finger were tested, because innervation density varies proximodistally on the distal pad, but not on the medial pad. The results indicated that response competition was an important factor limiting perception. Furthermore, perception was affected by varying location on the distal pad, but not on the medial pad. Finally, varying location on the distal pad affected perception only when responses were based on pattern shape, not when responses were based on direction of motion. The results are discussed in terms of differences in innervation density between adjacent locations and possible resultant differences in the spatial filtering properties of the skin.     

Perceptual processing at adjacent locations on a single finger: masking and response competition

When target patterns and nontarget patterns are presented either to the same or to adjacent locations on the distal pad of the index finger, the amount of interference in identifying targets depends on both the shape and the location of the nontarget (Horner, 1997). In the present study, the question of whether such interference is caused by masking (the masker in some way distorts the initial representation of the target) or by response competition (the observer mistakenly responds with the masker, rather than with the target) was investigated. A 4-to-2 paradigm was used (Craig, 1995), in which four stimuli were mapped to only two responses. Targets and nontargets were randomly selected from the set of four stimuli and presented to the same or adjacent locations on the same fingerpad. Both the distal pad and the medial pad of the index finger were tested, because innervation density varies proximodistally on the distal pad, but not on the medial pad. The results indicated that response competition was an important factor limiting perception. Furthermore, perception was affected by varying location on the distal pad, but not on the medial pad. Finally, varying location on the distal pad affected perception only when responses were based on pattern shape, not when responses were based on direction of motion. The results are discussed in terms of differences in innervation density between adjacent locations and possible resultant differences in the spatial filtering properties of the skin.