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.     

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.     

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 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.     

Short-term effects of behaviour therapy and hospital treatment of chronic alcoholics

Conditioning therapies, including electro-aversion treatment, of advanced states of alcoholism have not yielded an impressive record. There are probably several reasons for this state of affairs. Many studies have neglected the concurrent training of socially acceptable behaviour in the place of heavy drinking (Sobell and Sobell, 1972), and few studies have taught patients' relaxation or other anxiety-relieving methods (Blake, 1965). It may also be that treatment attempts have focused on conditioning fear or disgust to drinking stimuli themselves rather than covert, cognitive associations to various drinking situations (Claesson and Malm, 1973). The elements of electro-aversion therapy of alcoholism are little known and a number of problems remain to be investigated (Rachman and Teasdale, 1969; Hallam and Rachman, 1972). Among these problems are: how do we account for the different effects of electro-aversion therapy for different clients? How long-lasting are the effects of electro-aversion therapy?     

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.     

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.     

Training the disturbed enuretic

Twenty-two disturbed enuretic children were treated for their bedwetting with training procedures. Eighteen of 22 (81.8%) reached the initial success criterion in an average of 57.5 days. Ten of the 18 (55.6%) met the retraining criteria of relapse, and 9 of the relapses were successfully retrained, while I stopped wetting spontaneously. As compared to non-relapsed children, relapsed children had a significantly higher number of initial symptoms checked. The results indicate that a training approach is effective for the treatment of enuresis in disturbed children, but the more disturbed have a greater likelihood of relapse.     

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.     

Further investigation of the relationship between expressed social fear and assertiveness

Recently, Morgan (1974) investigated the relationship between expressed social fear and assertiveness. As hypothesized, Morgan found a statistically significant relationship between social fear as measured by ten items from the Fear Survey Schedule-III (FSS-III) (Wolpe and Lang, 1964) and assertiveness as measured by the Rathus Assertiveness Schedule (RAS) (Rathus, 1973b). The observed relationship, however, was of little predictive importance, as noted by Morgan, in that the Pearson product-moment correlation coefficients accounted at most for less than 6 per cent of the variance. This finding raises questions concerning traditional views of assertiveness (e.g. Salter, 1949; Wolpe 1958; Wolpe and Lazarus, 1966) which have hypothesized that an individual is “inhibited from the performance of ‘normal’ behavior because of neurotic fear” (Wolpe, 1973, p. 81).The literature concerning the relationship between assertive behavior and social fear is meager. Goldstein, Serber and Piaget (1970) have reported two illustrative case studies in which anger expressiveness induced through assertiveness training resulted in the clinically assessed reduction of social fear. Rathus (1973a) has reported the results of an empirical investigation of assertiveness training which might, as suggested by Morgan, lend indirect support for the hypothesized relationship. Using undergraduate female subjects, Rathus found that an assertive training group not only scored higher on a measure of assertiveness—the RAS—at post-testing than either the placebo or the no-treatment groups, but the training group also reported a nonsignificant tendency of being less fearful than the other two groups of social criticism and social incompetence, as measured by the Temple Fear Survey (Braun and Reynolds, 1969).Weinman et at. (1972) administered the Fear Survey Schedule-II (FSS-II) (Geer, 1965) to a sample of hospitalized patients diagnosed as schizophrenic. The FSS-II consists of 51 fear items, 13 or 25.9% of which can be considered to be interpersonal in nature. All three treatment conditions—socioenvironmental, desensitization, and relaxation therapy—resulted in a significant decrease in reported fear (p < 0.001).Bates and Zimmennan (1971) during the initial stages of constructing their Constriction Scale (CS) administered the CS and the FSS-II. The term ‘constriction’, incidentally, was used by the authors to “denote non-assertion” (p. 100). Unlike the RAS, a high score on the CS denotes low assertiveness. Correlation coefficients for the CS with the FSS-II of 0.32 for the male sample and 0.13 for the female sample were obtained. The male coefficient was significant at the 0.05 level. These findings may be confounded, as in the case of Weinman et al. (1972), by the inclusion of fear items on the FSS-II unrelated to interpersonal behavior, such as Thunderstorms' and ‘Hypodermic needles’.Morgan (1974) attacked the problem more directly. Drawing on several factor analytic studies of various fear schedules, Morgan constructed a 10-item Social Fear Scale (SFS) from the FSS-III. Using a large, undergraduate sample (n = 261), Morgan reported correlation coefficients for the RAS with SFS of-0.17 for the male sample, ?0.20 for the female sample, and ?0.24 for the sample as a whole.Whereas the magnitude of the correlation coefficients reported by Bates and Zimmerman (1971) may have been attenuated by the inclusion of items unrelated to social situations, Morgan's results may have been attenuated by the tapping of only limited aspects of social fear. Morgan reported that in the construction of the SFS, “The items selected were those which most consistently loaded heavily on ‘social fear’ factors and did not load heavily on other factors” (1974, p. 255). Inspection of FSS-III items not included in the SFS, however, indicated that several had been excluded which may be conceptualized as relevant to assertive behavior, such as ‘Speaking in public’, ‘Feeling angry’, and ‘People in authority’.It is suggested that an expanded SFS which would include all items from the FSS-III conceptually compatible with assertiveness might result in findings of greater predictive value. One purpose of this study is the replication of the Morgan (1974) study. In addition, however, a more comprehensive SFS and another measure of assertiveness will be used to further investigate the relationship between assertiveness and social fear. It is hypothesized that the expanded SFS will correlate inversely with both self-report measures of assertiveness to a degree significantly greater than the correlations of the two measures with the original SFS.     

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.     

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.     

A selected review of the literature and an empirical analysis of drug treatment compliance by schizophrenic patients

One of the significant issues in the treatment of schizophrenic patients is their nonadherence to medication. While maintenance without medication may be possible for a minority of this group (Gardos and Cole, 1976; Cheung, 1981), most authorities believe that drug therapy should be continued indefinitely, particularly in view of the substantial risk of relapse when medication is discontinued (Prien and Klett, 1972). Davis (1975) reported that the evidence for the efficacy of neuroleptics in preventing relapse was substantial.     

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.     

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.     

Transswitching and contextual conditioning

An empirical evaluation of temporal aspects of contextual conditioning was conducted in relation to Asratyan’s (1965) theory of transswitching and to an alternative explanation that was partly stimulated by the Rescorla-Wagner model (Rescorla and Wagner 1972). On the basis of a human electrodermal conditioning preparation suggested by Kimmel and Ray (1978), five groups with 12 subjects each were run. The results indicated that the basic phenomena of transswitching are robust and therefore could be replicated; but the Asratyan theory was rejected. All the results supported an alternative explanation: in contextual conditioning, duration of contextual stimuli is less important than order. Phasic switching is due to simultaneous occurrence of stimuli (differential compound conditioning) and is therefore compatible with the Rescorla-Wagner model. Tonic switching is due to signals that occur before a marked sequence of conditioning trials, in part a challenge to the Rescorla-Wagner model. Long delays between critical events can perhaps be compensated for by mediating memory processes.     

Play desensitization of fear of darkness in preschool children.

Systematic desensitization therapy (SDT) is considered to be a technique of established effectiveness in reducing monosymptomatic fears (Paul, 1969a, 1969b), yet little systematic research has been done to investigate the merit of desensitization procedures in modifying children's behavior. The few available controlled studies (Miller et al., 1972; Obler and Terwilliger, 1970; Oliver, 1971) on desensitization with children have produced equivocal results. Although imagery and relaxation have been reported of benefit when used separately (Graziano and Kean, 1971; Lazarus and Abramovitz, 1962), evidence suggests that the usual combination of imagery and relaxation is not effective in reducing children's fears (Miller et al., 1972). Investigators in this area have often modified traditional SDT to include alternatives to imagery such as pictures, drawings, play (Cassell, 1965; Lazarus, 1960; Obler and Terwilliger, 1970; Patterson, 1965), or in vivo exposure to the feared stimulus (Obler and Terwilliger, 1970). Relaxation has often been replaced with other responses thought to be incompatible with anxiety such as eating (Jones, 1924). Another deviation from traditional SDT has been the delivery of positive reinforcement (food, praise, or toys) contingent upon the child's approaching the feared object (Obler and Terwilliger, 1970; Patterson, 1965). On the basis of such varied techniques, it is impossible to determine which of these procedures constitutes an effective treatment method for children. In the following study, three desensitization procedures involving graded exposure to the feared stimulus (darkness) through symbolic play, were compared to no-treatment and placebo control groups under differing instructional sets. Treatments were designed to determine the therapeutic efficacy of play as a method of stimulus presentation with children, and to determine whether reciprocal inhibition, extinction, operant reinforcement, or instructional set contribute to fear reduction in desensitization with children.     

Effects of massed practice and meprobamate on spasmodic torticollis: an experimental analysis

In recent years a variety of behavioral techniques have been used in the treatment of spasmodic torticollis including negative practice (Agras and Marshall, 1965). faradic aversion (Brierly, 1967). instructions and negative feedback (Bernhardt et al., 1972). and systematic desensitization (Meares. 1973). However, in most of the aforementioned reports the controlling effects of the particular technique over dependent measures (voluntary and/or involuntary evocations of the tic) have not been demonstrated experimentally (see Hersen and Eisler, 1973 for review). In the present single case experimental analysis (Barlow and Hersen. 1973; Hersen and Barlow, 1974). the effects of massed practice (see Yates. 1958) and meprobamate on a subject exhibiting spasmodic torticollis were systematically examined. Following Bernhardt. Hersen and Barlow (1972). treatment efficacy was evaluated by monitoring rate of involuntary torticollis movements per 10-min videotaped recording sessions.     

The Behavioral Treatment of Childhood Nocturnal Enuresis

Nocturnal enuresis is a relatively common childhood disorder. Although many treatments have been attempted, the most popular methods have been pharmacotherapy, individual psychotherapy, and behavioral conditioning. Of these, the most effective is behavioral conditioning with a urine alarm. The author reviews the enuresis literature and provides recommendations for use of the urine alarm approach.