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Therapeutic Treatment Protocol for Enuresis Using an Enuresis Alarm

Enuresis, one of the most prevalent and chronic childhood disorders, imposes serious financial, physical, and emotional
burdens on the child and the family affected by it. This article provides counsellors with an overview of the complex
etiologies, diagnostic criteria, and current treatment options for the disorder, as well as assessment tools and
comprehensive treatment guidelines, including instructions on the use of an enuresis alarm. Supportive interventions and
advocacy related issues are discussed.

Journal of Counselling and Development : JCD


Author: Shapira, Bettina E
Date published:  April 1, 2010

Despite the high prevalence of enuresis (i.e., about 15% in children age 5 years; Cendran, 1999) and the financial, physical, and
emotional burdens it can place on the child and the family, clinicians are often uninformed about the clinical manifestations of
and effective interventions for the disorder. Many pediatricians and clinicians justify delaying or not providing treatment by
arguing that most children will eventually grow out of it (Houts, Berman, & Abramson, 1994), which only adds to the problems
related to this disorder. It is true that many children will eventually stop wetting their bed on their own; however, this process
can take many years, during which the child experiences embarrassment and other stresses related to the disorder. In addition,
research indicates that the longer a child has enuresis, the greater his or her chance for developing behavioral and emotional
problems (Fergusson & Horwood, 1994). Conversely, research has proven that successful enuresis treatment will improve the
child's self-esteem (Hägglöf, Andren, Bergström, Marklund, & Wendelius, 1998) and long-term emotional development
(Stromgren & Thomsen, 1990).

In this article, we provide counselors with guidelines for the effective treatment of enuresis with the use of an enuresis alarm.
First, we inform counselors about the complex etiologies, diagnostic criteria, and additional treatment options for this
condition.Next, we introduce clinical parameters for counselors treating children with enuresis, which include strategies for a
diagnostic interview, detailed treatment guidelines explaining the use of an enuresis alarm, family supportive interventions,
and advocacy related issues.

*Diagnostic Criteria of Enuresis

Enuresis is defined by the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; DSM-TV-TR; American
Psychiatric Association [APA], 2000) as repeated intentional or involuntary urination, with wetting episodes occurring at least
twice a week for a minimum of 3 consecutive months, or when the occurrence of the wetting episodes creates significant
distress or impairment in social, academic, or other vital functioning areas. To be diagnosed with enuresis, the child needs to
be at least 5 years old or have achieved a developmental level comparable to that of a 5-year-old (DSM-IV-TR; APA, 2000).
Excluded from the diagnosis of enuresis are wetting episodes that are due to a general medical condition or episodes that are
the direct physiological consequence of a substance (e.g., diuretic; DSM-IV-TR; APA 2000).

Enuresis presents in different types. Nocturnal enuresis refers to wetting episodes at night only (Thiedke, 2003). Diurnal
enuresis refers to daytime wetting episodes only (Skoog & Andriole, 2004), and mixed enuresis refers to both day and
nighttime wetting (Mikkelsen, 2001). Primary enuresis is a condition that occurs in children who never reached consistent
dryness (Goin, 1 998), while secondary enuresis is defined as a reoccurrence of enuretic symptoms in children who had
previously reached consistent dryness over a period of 6 months or longer (Gera, Seth, & Mathew, 2002).

*Etiology of Enuresis

The etiology of enuresis has been widely discussed in the literature (Cendran, 1999), and there seems to be no consensus on a
single explanation for the cause of the disorder (Thiedke, 2003). Recent research indicates that the etiology is complex (Boris &
Dalton, 2004) and multifactored (El-Radhi, 2005). To date, the primary etiological variables recognized in the literature are
genetic factors, lack of sleep arousal, delayed maturation, psychological factors, reduced functional bladder capacity, and low
level of the antidiuretic hormone (ADH) vasopressin.

Genetic Factors

A genetic predisposition for enuresis is the most commonly supported etiological variable for developing enuresis (Thiedke,
2003). Research indicates that children whose parents have a history of enuresis have a 77% chance to develop enuresis, while
children with one parent with a family history of enuresis have a 43% chance to become enuretic. In contrast, only 1 5% of
children who do not have a family history of the disorder will develop it (Norgaard, Djurhuus, Watanabe, Stenberg, & Lettgen,
1997).

Danish (Eiberg, Berendt, & Mohr, 1 995) and German (Von Gontard, Eiberg, Hollmann, Rittig, & Lehmkuhl, 1998, 1999) studies
in pedigree analysis and molecular biology found several chromosomes linked to the etiology of nocturnal enuresis (Oshlag,
1999). However, the understanding of the molecular genetics of nocturnal enuresis is only in the beginning stage, and it is
expected that further advances in molecular genetic research (Von Gontard et al., 1998) and pedigree analysis will provide a
more profound knowledge of the link between microsatellite markers on various chromosomes and the etiology of nocturnal
enuresis.

Lack of Sleep Arousal

Research indicates that children with nocturnal enuresis are more difficult to awaken from sleep (Neveus, 2003; Wolfish,
1999), which suggests a possible correlation between sleep arousal and nocturnal enuresis. For example, Wolfish researched
the sleep arousal function in 1 5 boys with enuresis who ranged in age from 7 to 1 2 years. He compared the results with those
from a control group of 1 8 age-matched boys who did not have enuresis. His findings indicated that boys with enuresis were
more difficult to arouse from sleep than were the boys in the control group.

Delay in Maturation

In the pediatric community, the belief that enuresis derives from a developmental delay in the attainment of bladder control is
commonly accepted (Fritz et al., 2004). This theory is supported by findings from a longitudinal cohort study in New Zealand,
which found that the child's developmental level between the ages of 1 to 3 years is a reliable predictor for the failure to
achieve bladder control (Fergusson, Hons, Horwood, & Shannon, 1986). Järvelin (1989) pointed to several neurological delays
observed in children with enuresis, such as signs of clumsiness and a delay in fine motor coordination. The correlation between
a delay in maturation and enuresis is not yet well researched; however, the available literature indicates that delayed
maturation plays a relevant role in the etiology of enuresis for some children (Fritz et al., 2004).

Psychological Factors

For the majority of children, primary enuresis is not caused by psychological factors (Fritz et al., 2004). Instead, the literature
indicates that children with enuresis are generally well adjusted (Friman, Handwerk, Swearer, McGinnis, & Warzak, 1 998).
However, in a minority of enuretic children, especially those who have diurnal or secondary enuresis, the disorder can be
triggered by parental divorce, neglect, abuse, or other stressors (Fritz et al., 2004).

On the other hand, prolonged or untreated enuresis can cause emotional problems in children ages 10 years and older
(Fergusson & Horwood, 1994). It can lead to negative self-image (Theunis, Van Hoecke, Paesbrugge, Hoebeke, & Vande Walle,
2002) and low self-esteem (Hägglöf et al., 1998). Often, emotional problems are mislabeled as the cause rather than the result
of enuresis.

Reduced Functional Bladder Capacity

The notion of a possible relationship between bladder capacity and bladder dysfunction has been researched in various studies
and reviews (Kawauchi et al., 2003; Neveus et al., 2000) and has long been implicated in etiology of enuresis. The study by
Kawauchi et al. indicated that children with enuresis show a significantly smaller nocturnal bladder capacity compared with
their diurnal bladder capacity, whereas in children without enuresis, the diurnal and nocturnal bladder capacities are similar.
Other research indicates that uninhibited detrusor contractions may lead to enuresis in some children (Neveus et al., 2000).

Low Level of ADH

The circadian rhythm, responsible for regulating a child's urine production is established between the ages of 2 and 5 years
(Lundgren, 2003). In healthy children, nocturnal urine production is two to three times lower compared with the diurnal urine
production (Lundgren, 2003). This decrease in the nocturnal urine production is caused by an increase of arginine vasopressin,
an ADH. Arginine vasopressin is produced in the hypothalamus and is stored in the posterior pituitary gland for nocturnal
release. The hormone functions in a way that reduces the overall nocturnal urine volume (Butler & Holland, 2000).

*Treatment of Enuresis

Current enuresis treatment options include pharmacology, alternative therapies, and behavioral interventions with the use of
an enuresis alarm.

Pharmacological Treatment Approaches

Today two types of medications are typically indicated in the treatment of enuresis: tricyclic antidepressants (Imipramine) and
synthetic analog vasopressin (desmopressin). In the past 40 years, Imipramine, a tricyclic antidepressant, was frequently used
in treating enuresis. Several hypotheses on the pharmacological process of Imipramine in the treatment of enuresis (Gimpel &
Warzak, 1998) have been discussed in the literature; however, the mechanism of action of Imipramine in this treatment has
yet to be fully understood (Fritz et al., 2004). The overall effectiveness of Imipramine has been established at about 50%
(Ullom-Minnich, 1996), with a relapse rate as high as 60% to 95% (Gimpel & Warzak, 1998) after the discontinuation of the
drug.

In addition to experiencing a high rate of relapse, children taking Imipramine are at some risk for developing severe side
effects, such as DNA damage to the lymphocytes (Dündaröz et al., 2002), or cardiac arrhythmia (Fritz et al., 2004), which leads
to the conclusion that Imipramine treatment for enuresis should only be considered with great caution.

Desmopressin is the synthetic analog of the natural ADH arginine vasopressin. Similar to the natural hormone, desmopressin
regulates the reabsorbing of water in the kidney ducts (Van Kerrebroeck, 2002), thus reducing nocturnal urine production. The
effectiveness of desmopressin in the treatment of enuresis is well established, with success rates ranging from 40% to 80%.
However, once desmopressin is discontinued, 80% or more children relapse (Thiedke, 2003). Harari and Moulden (2000)
suggested using desmopressin either as a short-term intervention for such occasions as a sleepover or a school trip or as a
medium-term intervention for children who are resistant to behavioral treatment that incorporates the use of an enuresis
alarm system.

Recent research on combination treatment using an enuresis alarm in combination with medication, particularly combining
enuresis alarm treatment with desmopressin, has shown promising results, especially for children with severe wetting
(Bradbury & Meadow, 1995). However, more research is needed to verify the initial success.

Alternative Treatment Approaches

Alternative treatment approaches for enuresis range among hypnotherapy (Diseth «feVandvik, 2004), acupuncture (Honjo et
al., 2002), family therapy (Selig, 1982), and psychotherapy (Mishne, 1993). Research on the effectiveness of alternative
treatment approaches for enuresis is limited and often relies on single-case studies. Limited case evidence suggests that family
therapy can be beneficial for some children (Selig, 1982); however, family therapy and psychotherapy treatment for enuresis
have yet to be proven effective in controlled clinical studies. On the other hand recent research using hypnotherapy (Diseth
&Vandvik, 2004) and acupuncture (Honjo et al., 2002) as a treatment protocol for enuresis produced encouraging preliminary
empirical results, especially in children who have otherwise been treatment resistant.
Behavioral Treatments

Enuresis alarm treatment is the most frequently adopted behavioral intervention for enuresis. In addition to the enuresis alarm
intervention, several other behavioral interventions for treating enuresis are available. Generally, behavioral interventions are
reviewed within three treatment modalities: monobehavioral treatments (without an enuresis alarm), enuresis alarm
treatment (without additional behavioral interventions), and combination treatments with the use of an enuresis alarm. The
monobehavioral treatments without the use of an enuresis alarm include interventions such as bladder stretching exercises,
positive practice, waking the child at night to go to the bathroom, keeping a chart of dry and wet nights, and fluid restriction
before bedtime. The available literature and controlled studies on the different monosymptomatic behavioral treatments
without the use of an enuresis alarm are limited and present little evidence of effectiveness. On the other hand, enuresis alarm
interventions for children have been thoroughly researched and documented. The enuresis alarm is therapeutic in that it
wakes the child up as soon as the first drop of urine is detected. A more detailed description of the enuresis alarm system and
its use in the context of behavioral treatment is provided later in this article.

Treatment outcome literature on enuresis and scholarly publications, such as the Nelson Textbook of Pediatrics (Behrman,
Kleigman, & Jenson, 2004), rate the enuresis alarm treatment superior to all other treatment modalities, with success rates
ranging from 65% to 75% (Butler & Gasson, 2005). Relapse after initial treatment success is a valid concern in enuresis alarm
treatment (Butler & Gasson, 2005). However, in most cases, retreatment with the enuresis alarm will lead to complete dryness
(Gustafson, 1993).

*Conducting a Diagnostic Interview Using DSM-IV-TR Criteria

In most cases, a child will attend counseling or therapy treatment accompanied by one or both parents. This sets the stage for
the assessment process and the following intervention. During the initial phase of the diagnostic interview, it is important for
the counselor to focus on building rapport with the child and the accompanying adult(s). Addressing questions related to
enuresis often triggers embarrassment and discomfort on the part of the individuals affected. Focusing on the involuntary
nature of enuresis (Harari & Moulden, 2000) and explaining the high frequency of the disorder can help the child and the
parents to overcome this initial embarrassment. To ensure that the child can relate to the information, it is important for the
counselor to provide age-appropriate examples. For example, to help the child understand the rate of occurrence of this
disorder, it is helpful to provide the example of how many children in the child's classroom are likely to have enuresis (Harari &
Moulden, 2000).

During the assessment, the counselor must rule out medical conditions as a cause of enuresis. Enuresis can be caused by
several bladder dysfunctions and other medical conditions (Boris & Dalton, 2004). A counselor should ask questions about
possible previous medical assessments and interventions. Prior to the referral to a counselor, it is often the case that the child
has undergone several clinical tests to exclude those medical conditions or dysfunctions of the bladder (Morrison & Anders,
1999). Therefore, the counselor should first inquire whether medical issues have been addressed by a physician. If there is
evidence of medical issues, the clinician should address them as possible diagnostic criteria with the parents and suggest
appropriate medical referrals.

The diagnostic interview continues with taking a detailed personal history (Mikkelsen, 2001), a history of the symptoms of
enuresis (Fritz et al., 2004), and a family history of enuresis (Mikkelsen, 2001). The history of the symptoms includes onset,
frequency, severity of the wetting episodes, wetting times (i.e., day, night, or mixed), and recurring enuresis, as well as
questions about changes in the family system, stressors for the child family stressors, and modifications to the child's living or
social environment prior to the onset of enuresis. This interview section provides the counselor with necessary information on
the nature of the disorder by providing the essential data that will enable the appropriate assessment for primary, secondary,
nocturnal, diurnal, or mixed enuresis and the severity of the problem. It also provides valuable information on possible
personal, family, or environmental stressors. The interview concludes with questions about prior enuresis treatments and
behavioral interventions for managing the symptoms. This data pool provides the counselor with vital information about
previous treatment efforts, and it presents valuable data on behavioral intervention, such as fluid restriction, that could later
interfere with the success of the enuresis alarm intervention. Last, parents are asked questions about the occurrence of
enuresis in the family history, thus assessing the hereditary aspect of the disorder.

After establishing the personal, symptomatic, and family history of the disorder, the focus of the diagnostic interview shifts to
the readiness of the child to participate in the treatment. One predictor for negative treatment outcome is the child's lack of
motivation for or distress about the problem (Butler & Robinson, 2002); therefore, it is beneficial to assess the degree of the
child's concern about the problem and evaluate the child's level of motivation for treatment. There are two ways to evaluate
the child's lack of motivation or distress about the problem.The counselor can ask the older child directly about his or her
readiness and motivation for treatment, whereas with younger children, it is more appropriate and beneficial to rely on the
parents' assessment of their child's readiness for treatment.

Because enuresis can be a symptom of or reaction to sexual abuse, especially in children with secondary enuresis, counselors
"must be alert to the possibility of previous or ongoing inappropriate sexual contact" (Fritz et al., 2004, p. 1546) and, when
appropriate, investigate this issue more thoroughly. It is beyond the scope of this article to address the in-depth issues of
sexual abuse. Counselors need to be able to assess and address the ethics of sexual abuse and provide appropriate treatment
of the emotional, mental, and physical effects of child sexual abuse.

*Enuresis Alarm Treatment

As we have noted one of the most effective treatments of enuresis is the use of an enuresis alarm. This alarm system is
implemented to detect bedwetting episodes. Its use was first documented in the beginning of the 20th century, when a
German physician used a urine alarm system to alert the clinical staff in a hospital to patients' bedwetting episodes (Butler,
1994).

At the start of the treatment, the child and parents are informed that the enuresis alarm treatment is only effective if
implemented consistently each night and that it usually takes about 2 to 4 months for the treatment to be successful (Gimpel
& Warzak, 1 998). Next, the child and the parents are introduced to the enuresis alarm device. The functioning and correct
positioning of the alarm is demonstrated with a sample alarm device. It is important to include the child in the demonstration
of the alarm system and to address any questions or concerns of the child about the system. Two components, a sensor that
detects moisture (i.e., urine) and an alarm that is activated when moisture is detected are the fundamental parts of any
contemporary enuresis alarm device. Different alarm systems are available in pharmacies, through wholesalers, on the
Internet, and in specialty stores, and they generally come with a detailed description on how to use the apparatus. These
manufacturer-provided instructions (e.g., where to place the different system components and how to operate the system)
need to be followed carefully to ensure the proper function of the system. Furthermore, some alarm systems rely on sound
only, while other systems combine sound light, and vibration. Generally, enuresis alarm systems are available either as a
wireless system or a system wherein wires connect the moisture sensor to the alarm ringer. In both systems, the moisture
sensor is triggered by the first drop of urine, which activates the alarm and causes two simultaneous responses. The child
wakes up to the noise of the alarm and concurrently contracts the pelvic floor muscle, which automatically inhibits an enuretic
episode (Butler, 1994). With time, the child wakes up earlier and earlier to the noise of the alarm. At first, this results in the
wetting episode being less and less severe, but eventually, the child learns to wake up to the sensation of a full bladder (Fritz et
al., 2004).

Following the demonstration and explanation of the enuresis alarm, the counselor introduces behavioral interventions vital to
the success of the overall treatment. After waking up to the alarm, the child must get up to use the bathroom (Harari &
Moulden, 2000). This is an important part of the intervention. Parents consistently need to monitor the child make sure the
child wears the alarm, wakes up to the alarm, goes to the bathroom, and puts the alarm back before returning to sleep. It is
vital that the child is awake during this process, otherwise the habit of wetting during sleep is reinforced and the treatment will
fail (Fritz et al., 2004). During this part of the intervention, parents supervise the child closely and if necessary, help the child to
wake up and go to the bathroom. Parents are discouraged from carrying the child to the bathroom. A better practice for
ensuring that the child is awake is to make the child walk to the bathroom, while providing praise and positive feedback. In
individual cases, it is necessary to change living or sleeping arrangements that ensure that the child has easy access to the
bathroom at night and the parents can be most effective in monitoring the process (Fritz et al., 2004). Parents are instructed to
keep a daily progress chart or journal to monitor treatment progress. Each morning, they should document the frequency of
the wetting episodes, the severity of the episodes, and if and when the child awoke to the alarm. Consistency of the data
collection is ensured by setting the standards for documentation prior to the enuresis alarm intervention.

During the final part of this enuresis alarm treatment session, the counselor invites parents to talk about their current practices
to control nightly bedwetting episodes. Some practices, such as fluid restrictions, restriction of caffeinated soft drinks, the
nightly carrying of the child to the bathroom, punishment of the child for a wet night or rewards for a dry night are methods
often used by parents to control bedwetting episodes. But such practices need to be discouraged to ensure the success of the
enuresis alarm treatment. For example, fluid restriction for children with enuresis, especially before bedtime, is a practice
frequently used by parents (El-Radhi, 2005) to control enuresis. There is no sound empirical evidence that supports this
practice. To the contrary, children should have a small glass of fluid (avoid caffeinated soft drinks, tea, or coffee before
bedtime) before bedtime to ensure the proper response to the enuresis alarm (Butler, 1994). A similar practice is to restrict the
intake of caffeinated soft drinks (El-Radhi, 2005) during the day. This practice is also not supported by empirical research and
can be discontinued with the start of the enuresis alarm treatment. Another intervention often suggested by health care
practitioners and frequently used by parents is lifting (Butler, 1998), which entails nightly prescheduled awakenings of the child
to use the bathroom (Morrison & Anders, 1999). Studies indicate that this intervention only maintains enuretic episodes
(Butler, 1998) and is therefore not encouraged and should be discontinued with the start of the enuresis alarm treatment.
Finally, counselors should strongly discourage parents from either punishing the child for a wetting episode (Boris & Dalton,
2004) or rewarding a child for a dry night because this suggests to the child that he or she has conscious control over the
wetting episodes. However, it is appropriate to reward a child for compliance with the enuresis alarm treatment.

The second treatment session is scheduled approximately 2 weeks after the initial treatment session. Progress is assessed by
evaluating the information documented in the daily progress chart and journal and through feedback from the child and the
parents. Pending the review of the data as well as the remarks of the family about their satisfaction with the treatment
progress, treatment is continued with or without introducing supportive interventions. The counselor needs to assess levels of
family stress with the new intervention. In some cases, a lack of motivation hinders the progress of the treatment. In those
cases, the issue of motivation is addressed and, if necessary, additional supportive interventions are suggested. In other cases,
issues related to living and sleeping arrangements need to be revisited and new solutions need to be implemented. For follow-
up, subsequent sessions are scheduled in 1- to 3-week intervals, depending on the motivation and compliance with the
treatment regimen. During the follow-up sessions, treatment success is evaluated using the daily progress chart, and further
treatment options (e.g., continuing the alarm treatment, using supportive exercises, or changing living arrangements) are
discussed.

Consistent with outcome measures of various enuresis alarm studies, initial success is recognized after the child reaches a goal
of 14 consecutive dry nights (Butler & Robinson, 2002). However, after the initial treatment success, there is a considerable risk
for relapse (El-Radhi, 2005). In this case, the child returns to using the alarm and is monitored for an additional 1 6-week period
(Butler & Robinson, 2002) to ensure continued dryness. When relapse occurs, the enuresis alarm treatment is reinstated under
the supervision of the counselor. Finally, approximately 4 months after successful treatment completion has been determined
the counselor initiates a last follow-up call to ensure that no relapse has occurred and that the child is now completely dry.

*Supportive Interventions

In some cases, motivational exercises are helpful and appropriate to introduce with a child who is not complying with the
enuresis alarm treatment. Two commonly used motivational interventions are cleanliness exercises and reward interventions.
Cleanliness exercises are designed to increase the child's awareness of the inconvenience of the wetting problem (Butler,
1994), thus motivating the child to comply with treatment. After waking up to the enuresis alarm and using the bathroom, the
child assists the parents with removing wet nightclothes and bedsheets, carries the wet articles to the laundry room, and helps
to put clean sheets on the bed. This intervention works best with older children, while younger children should only be asked
to take part in some age-appropriate components of the intervention.

Reward interventions are used to foster motivation in the child (Butler, 1994). The child is rewarded for the participation in the
enuresis alarm treatment and is never punished for a wetting incident. For example, a child earns 1 point for each night he or
she complies with the treatment regimen. The earned points can be exchanged for rewards, and the greater the number of
points the bigger the reward. A variation of this intervention is to deduct 1 point for each night the child has refused to
participate in the treatment. The reward intervention can be used with children as young as 5 years.

*Counselor Advocacy for Enuresis Treatment

Counselors need to advocate for more widespread use of enuresis treatment. Despite the high prevalence of enuresis, only a
small number of pediatricians and mental health clinicians offer effective and safe interventions for this disorder. Pediatricians
mostly look for physical dysfunctions or underlying medical conditions as the reasons for the enuretic episodes. Once medical
conditions are excluded, most pediatricians refrain from providing further treatment, reasoning that the child will eventually
grow out of the problem, while some other clinical health care professionals suggest behavioral interventions that only
maintain bedwetting (Butler, 1998) instead of ending it. In their desperation, parents often seek help on the Internet, where
they find offers for home-based enuresis alarm treatments. Because enuresis alarm treatment is usually demanding for the
child and the family, it is best implemented under the supervision of a trained clinician. Without encouraging and
knowledgeable instructions and supervision from a clinician, families often prematurely discontinue the treatment, which only
adds to the overall frustration with the problem.

Counselors can demonstrate the advantages of treating an enuretic child to the community, including the medical community,
by pointing to the advantages of treating the child, such as increased self-esteem (Hägglöf et al., 1998). To this end, they can
explain the success and safety record of enuresis alarm treatment, especially as compared with the current pharmacological
options.

*Conclusion

Enuresis, one of the most prevalent and chronic childhood disorders (Butler, 1998), places serious financial, physical, and
emotional burdens on the child and the family system affected by it. For reasons not yet fully understood, enuresis is
undertreated in the United States. In most cases, pediatricians are the first clinicians alerted to the problem. They assess the
child with enuresis for physical dysfunctions or underlying medical conditions as a cause of the symptoms. Ordinarily, after
ruling out medical conditions, no further interventions are provided. The decision not to provide treatment for enuresis seems
questionable. Effective and noninvasive treatment is available, and research clearly indicates that successful treatment
increases the child's self-esteem (Hägglöf et al., 1998), whereas the postponement of dryness can lead to the child's behavioral
and emotional problems (Fergusson & Horwood, 1994).

This article provides information on the essential aspects of successful enuresis alarm treatment: knowledge-based treatment
instruction, skilled guidance and motivational interventions throughout the treatment regimen, ongoing clinical supervision,
and reliable relapse interventions by a trained counselor. Moreover, information on the etiology, diagnostic criteria, and other
treatment options for enuresis adds to the knowledge-based content of the article. More education is needed for clinicians on
the effectiveness and the advantages of early enuresis treatment. Counselors have the opportunity to learn more about
effective enuresis treatment, educate their local communities about the problem, and advocate for treatment. We also
encourage further research on the outcomes of counselor-supervised enuresis alarm treatment.

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