Elimination Disorders

Elimination Disorders
Elimination Disorders
Evidence-Based Treatment for
Enuresis and Encopresis
Thomas M. Reimers, PhD
Elimination Disorders: Evidence-Based Treatment for Enuresis and Encopresis

Copyright Momentum Press, LLC, 2017.
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First published in 2017 by
Momentum Press, LLC
222 East 46th Street, New York, NY 10017
www.momentumpress.net
ISBN-13: 978-1-60650-911-1 (print)
ISBN-13: 978-1-60650-912-8 (e-book)
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Dedication
This is dedicated to my family who brings joy, meaning, and value to
everything I do.
Abstract
Elimination disorders, specifically enuresis and encopresis, affect millions
of children worldwide. Management of this problem is often a source of
frustration for parents, especially as their children reach school age and
beyond. For clinicians, having a good understanding of both the physical
and behavioral factors that contribute to these problems is essential if they
are to be successfully treated. This volume will walk clinicians through the
physical, behavioral, and emotional factors that contribute to the development of these disorders and, most importantly, provide evidence-based
interventions that will result in the effective treatment and elimination of
these common clinical problems. Thus, this book will serve as a resource
for clinicians to not only explain the etiology of enuresis and encopresis,
but more importantly to provide clinically proven interventions that have
been demonstrated to treat these disorders successfully.
Keywords
enuresis, encopresis, elimination disorders, wetting, soiling
Contents
Acknowledgmentsxi
Preface.................................................................................................xiii
Introduction.......................................................................................... xv
Chapter 1 Nocturnal Enuresis.............................................................1
Chapter 2 Diurnal Enuresis..............................................................59
Chapter 3 Encopresis........................................................................91
References153
Index159
Acknowledgments
A few times in ones life, you encounter someone who is truly excellent and
a master at what they do. Julianne Furey is one of those individuals. Julianne demonstrates excellence with everything she does, without drawing
attention to herself and in a way that appears to be effortless, even though
it is absolutely not. This book simply would not have been produced without the expertise of Julianne Furey. Her assistance with all aspects of this
book was invaluable and I simply could not, and would not, have done it
without her. Everyone should have a Julianne Furey in their lives, as difficult as that may be to find. More importantly, everyone should be a little
more like Julianne, which is an even more difficult challenge.
I am very grateful to Dr. Patrick Friman for his mentorship, leadership, and friendship. Pat has provided me with countless opportunities over the years, some tangible, mostly not, for which I will always be
thankful. I have been beyond fortunate to have spent nearly a decade
observing a real master demonstrate how to be effective as a leader, psychologist, and most importantly a human being. I once heard Pat say, If
someone hands you the microphone, do something with it! Apparently,
Pat has had the microphone in his hand most of his life, because he is not
only perpetually doing something, but doing things that are impactful
and meaningful at every level of his being.
Preface
For those old enough to remember, Jim McKay introduced a sports show
called the Wide World of Sports through the phrase the thrill of victory
and the agony of defeat. I suspect that most parents who are toilet-training
their child can relate to this phrase. For parents, the thought of no longer
changing and, maybe more importantly, paying for diapers seems like a
dream that will never come true. Every occurrence of their child urinating or having a bowel movement in the toilet becomes a thrilling victory,
with the next wetting or soiling episode bringing about agony. For about
95% of children under the age of 5 years, they and their parents eventually hoist their gold medals on the champions platform for all to see. The
only question that remains is who is prouderthe parent or the child?
For the other 5%, the victory stand is nowhere in sight. Thoughts of
a thrilling victory have long faded, and a resignation of defeat has taken
over. The occasional successes in the toilet are more likely to be met with,
Why cant you do that every time? and wetting and soiling accidents
are likely accompanied by looks of disappointment, verbal reprimands,
and possibly other forms of punishment. What should have been another milestone in the life of their child has turned into a prolonged and
anguishing debacle that has no end in sight. And instead of being hard
on the wetting and soiling problem, parents, caretakers, siblings, and
peers are hard on the child who is wetting and soiling. Eventually, the
child joins in and becomes hard on himself or herself. What should be
an exercise in behavior and contingency management has turned into
name-calling, ridiculing, and pathologizing, thus further complicating
a problem that can be easily solved with the right combination of patience, perseverance, and know-how. My goal for this book is to walk you
through the art and science of understanding and managing enuresis and
encopresis. Most importantly, the strategies and techniques outlined in
this book not only have empirical support, but they have been applied to
hundreds of children with elimination disorders of every type. I have tried
xiv PREFACE
to combine science, empirical support, and evidence-based interventions

with my experience of treating hundreds of children over the past several
decades. The clinical approach and specific techniques that are outlined in
the texts that follow are those techniques that have proven to be successful
across a wide range of children with varied clinical histories. My hope is
that you will find this book to enhance and expand your clinical acumen
of a clinical problem that can be challenging but, almost always in the
end, is very rewarding. If you have not experienced this in your clinical
career, there are few problem resolutions that are met with a greater thrill
of victory than helping a child to stop wetting the bed or soiling himself
or herself. If you dont believe me, ask any child or parent who has been
down this path.
Introduction
Most of us give little thought to the wide range of physical activities that
we engage in on a daily basis. We sleep, eat, breathe, walk, and talk with
little thought about those activities. Expelling bodily waste also falls into
that category for most of us. We engage in these activities as part of our
daily routine, giving little thought to the amount of time taken or their
frequency, that is, until something goes wrong or we are not able to do
them as effortlessly as we had in the past. This is especially true for children. Three to five percent of all children experience difficulty urinating
and/or defecating in an effortless and expected manner. They either never
developed this skill to begin with, or developed successful skills but lost
them along the way. This creates a tremendous amount of distress, not
only for children but also, of course, for the parents who are caring for
them. In the pages that follow, we will explore the nature of the p
roblem,
the wide range of factors that contribute to elimination problems,
and the various treatment options that have been shown to be effective
for managing them.
Our society seems to spend a great deal of time discussing elimination problems. A myriad of books have been written on the topic, with
titles such as Everybody Poops and Time to Pee. It appears as though there
is a broad audience interested in learning how we can facilitate the process of peeing and pooping. This is probably never more evident than
for a frustrated parent who has been struggling for years with a toddler
or preschooler who refuses to sit on the toilet or finds creative places
around the house to urinate. We think nothing of animals marking their
territory out in the wild, but we dont seem to be as humored by a young
child who marks his or her territory inside or outside of the house. Also,
society tends to make broad assumptions about peoples elimination
habits. There is a tendency to pathologize those who are not successfully
voiding in the toilet, with that level of pathology seeming to increase
as one becomes older. Assumptions are made that there is some type of
xvi INTRODUCTION
characterological or psychological problem associated with one who is

not successfully voiding in the toilet. And although there are often clear
physical or functional reasons for this issue, it is often not viewed as such
by most members of society. One can find references going back to ancient times that describe the pathology associated with individuals who
failed to void successfully according to common practice in various parts
of the world. There are interesting descriptions of all types of interesting
forms of punishment that almost border on sacrificial-type activities, simply because one was not voiding as expected.
Within the past century, Sigmund Freud spent a fair amount of time
focusing on toileting habits as part of his description of psychosexual
stages of development. Freuds writings, including his psychodynamic
and psychosexual approach toward development and the function of a
wide range of behaviors, caused society to look at human behavior, including elimination problems, as being due to a mysterious, deeper, and
very complicated set of factors that required years of analysis by a trained
professional to resolve. We now look at this as being somewhat entertaining and attribute little value to these writings, other than their entertainment value. However, at the time, society assumed that Freud had truth
and that human behavior was a very complex and dynamic event that
required sophisticated and trained professionals to address. Fortunately,
the reality is much less dire and complicated than Freud described. That
does not mean that, in todays world, we have avoided attributing human
qualities and characteristics to elimination problems. For example, it is
not uncommon for someone to make comments such as, He seems a little constipated, Im somewhat anal-retentive, or He was really pissed
off. There are a multitude of examples of these types of references, but
all of these suggest that society continues to attribute the function and
success of daily defecation and urination as being related and attributed
to successful human behavior.
Parents of young children seem almost obsessed with getting their
children potty-trained. They become almost apoplectic if their child is
not fully trained by age 3 or 4 years, and clearly, the lobbies of the outpatient behavioral health clinics in the United States have their share of 4- or
5-year-olds who are struggling with potty-training. This is especially true
if they are about to head to kindergarten. By the reaction of some parents,
Introduction
xvii
you might think their child had just graduated from Harvard Law School
rather than from toilet-training school. It simply speaks to the frustration
that parents experience when their child is having difficulty successfully
voiding in the toilet.
Clearly, the elimination of bodily waste is a critical and important
function. Failure to do so causes a wide range of physical, behavioral,
and emotional complications for people of all ages. Children who do not
urinate or defecate in the toilet until an older age or in places that society does not find appropriate find themselves at times being ridiculed or
punished by some, while, at the same time, developing a certain sense of
insecurity and lack of confidence due to their failure to do what so many
of us simply take for granted. This book will explore a process that most
of us take for granted, but that a percentage of the world finds exceedingly frustrating and difficult to accomplish. It will explore the nature
of elimination disorders, the causes behind these disorders, and, most
importantly, the treatments that have been shown to be very effective
for the management of them. Most importantly, it will take the mystery
out of the process and provide useful and functional ways to manage this
problem.
CHAPTER 1
Nocturnal Enuresis
Description and Diagnosis
Numerous definitions of enuresis have been developed over several decades. However, the consensus for the definition of enuresis tends to be
repeated elimination of urine into inappropriate places. In the case of nocturnal enuresis, this includes the repeated elimination of urine during
sleeping hours. Initially, an age limit of 3 years or older was defined as the
criterion for a diagnosis of nocturnal enuresis. However, in recent years,
that criterion has been changed to a minimum age of 5 years. A chronological age of 5 years is typically used; however, developmental considerations need to be taken into account. Thus, children with developmental
disabilities and/or children who experience some type of cognitive delay
should be expected to have a developmental age of 5 years in order for
them to meet the criteria. Both the Diagnostic and Statistical Manual
of Mental Disorders (DSM-5; American Psychiatric Association [APA],
2013) and The ICD-10 Classification of Mental and Behavioural Disorders:
Clinical Descriptions and Diagnostic Guidelines (World Health Organization, 1992) include criteria for nocturnal enuresis. They are listed here.
Definitions
The definition for nocturnal enuresis tends to vary from agency to agency.
For example, the International Childrens Continence Society defines
nocturnal enuresis as a condition where involuntary loss of urine is a
social or hygienic problem and is objectively demonstrable (Neveus
et al., 2010). One issue here is that the term involuntary is difficult to
assess in children. For most children, continence develops during childhood. Also, the definition does not take into account the developmental
ELIMINATION DISORDERS
age of a child. With the ICD-10, nocturnal enuresis is defined as intermittent incontinence of urine while sleeping, regardless of whether
intermittent daytime urinary incontinence is also present or not and
involuntary discharge of urine during sleep at night after expected age
of completed development of urinary control. The ICD-10 does suggest a developmental age of 5 years as a baseline for making a diagnosis
of nocturnal enuresis. The DSM-5 has a similar definition, but tends to
define nocturnal enuresis as incontinence only during nighttime sleep.
This varies somewhat from the ICD-10 definition, in that the ICD-10
definition allows for intermittent daytime urinary incontinence being
present or not. Thus, the definition varies somewhat from agency to
agency, which will, in turn, have an impact on epidemiological statistics.
For the purposes of this book, the DSM-5 criteria will be used. Most definitions focus on the fact that nighttime incontinence is characterized by
complete bladder emptying during sleep without any symptoms pointing
to bladder dysfunction. This is important because diurnal enuresis (which
we will discuss later) includes, on occasion, children who wet during the
day and also, at times, at night. These children have bladder dysfunction
that can be either functional or organic in nature, with there being a great
deal of variety in regard to incontinence patterns. And although there can
be a functional component to nocturnal enuresis, it is much more likely
with the group of children who are classified as having diurnal enuresis.
Monosymptomatic Versus Polysymptomatic
The distinction between nighttime wetting and daytime wetting is sometimes subcategorized in regard to monosymptomatic versus polysymptomatic symptoms. Monosymptomatic means that a child has no daytime
symptoms. Children with polysymptomatic symptoms can have daytime
symptoms and also nighttime symptoms.
Primary Versus Secondary
A further distinction is often made between primary versus secondary
symptoms. Children with primary enuresis have never been fully continent. Conversely, children with secondary enuresis have had lengthy
Nocturnal Enuresis
periods of continence, followed by periods of incontinence. Secondary

enuresis is more typical with children who have diurnal enuresis versus
children who have nocturnal enuresis.
2016 ICD-10-CM Diagnosis Code N39.44:
Nocturnal enuresis
2015 Billable Code
Clinical Information
Intermittent incontinence of urine while sleeping, regardless
of whether intermittent daytime urinary incontinence is also
present or not.
Involuntary discharge of urine during sleep at night after
expected age of completed development of urinary control.
Many children wet the bed until they are 5 years or even
older. A childs bladder might be too small. Or the amount of
urine produced overnight can be more than the bladder can
hold. Some children sleep too deeply or take longer to learn
bladder control. Children should not be punished for wetting
the bed. They dont do it on purpose, and most outgrow
it. Until then, bed-wetting alarms, bladder training, and
medicines might help.
Description Synonyms
Nocturnal enuresis (bed-wetting)
The DSM-5 criteria for enuresis (code 307.6 [F98.0]) are as follows
(APA, 2013).
Repeated voiding of urine into bed or clothes (whether
involuntary or intentional).
Behavior must be clinically significant as manifested by either
a frequency of twice a week for at least 3 consecutive months
or the presence of clinically significant distress or impairment
in social, academic (occupational), or other important areas of
functioning.
Chronological age is at least 5 years of age (or equivalent

developmental level).
The behavior is not due exclusively to the direct physiological
effect of a substance (such as a diuretic, antipsychotic, or
Selective Serotonin Reuptake Inhibitor) or to incontinence
incurred as a result of polyuria or during loss of consciousness.
All of the DSM-5 criteria must be met in order to diagnose an
individual.
These symptoms must not be due to a general medical
condition.
Specify whether
nocturnal only: passage of urine only during nighttime sleep,
diurnal (daytime) only: passage of urine during waking hours, or
nocturnal and diurnal: a combination of the two subtypes
above.
Epidemiology
The definition used to define nocturnal enuresis has an impact on the
frequency reported in various epidemiological studies. Some studies combine primary and secondary enuresis or combine monosymptomatic and
polysymptomatic symptoms. Also, some studies report data from longitudinal studies, while others report data from cross-sectional studies.
Typically, longitudinal studies are preferred, but are much less common.
In general, most studies report the following findings: boys are two times
more likely to have nocturnal enuresis than girls; the incidence tends to
gradually decrease over time across all samples and different populations
around the world; and the spontaneous cure rate (the rate at which the
condition resolves on its own without intervention) tends to be higher
for children in the 3- to 4-year age range, approximately 30 percent, and
is around 15 percent for children over age 5 years. Although definitions
vary across the world in terms of how nocturnal enuresis is defined, the
incidence by age and gender tends to be fairly consistent.
Nocturnal Enuresis
There are many studies reporting the incidence of nocturnal enuresis.

I will highlight a few of those as follows.
A longitudinal study conducted in Australia (Avon Longitudinal
Study of Parents and ChildrenALSPAC) surveyed 11,000
individuals, of whom over 8,000 responded. Of those who
responded, 15.5 percent of 7.5-year-olds wet the bed, with 83
percent doing so, at most, once per week. This study used DSM
criteria as a definition for nocturnal enuresis (Butler & Golding
1986).
In another study, 1,139 children in New Zealand were
followed over 9 years. They found that primary nocturnal
enuresis gradually decreased with age, which is consistent with
other studies. They found that approximately 15 percent of
children aged 5 years, 14 percent of children aged 7 years,
9 percent of children aged 9 years, 6 percent of children
aged 11 years, and 4 percent of children aged 13 years were
experiencing nocturnal enuresis. Consistent with other
studies, boys showed a higher incidence than girls across most
cohorts. However, in this study, boys did not show a 2:1 ratio,
as is typically found in Western cultures. This is true of many
international studies. In this study, as boys tend to always
show a higher incidence than girls, the reported incidence also
tends to be higher in Western countries. As time progresses,
the differences between males and females tend to diminish
(McGee et al., 1984).
Another study conducted in France looked at both the
severity and consequences of nocturnal enuresis in a sample
of 349 children who had reported enuresis. A subsample of
228 children was studied. In the subsample, 66 percent had
more than one wet night each month, 37 percent had more
than one wet night per week, and 22 percent wet the bed
every night. Perhaps most interesting, parents reported that
42 percent were bothered a lot, while 15 percent were not
bothered at all. Interestingly, 92 percent of the 228 mothers
declared that enuresis had no effect on family life and did
not impact the childs behavior at school. Fourteen percent

of mothers reported punishing their child, and 13 percent
intended to seek treatment for their child (Lottmann, 1999).
In another study, general rates of nocturnal incontinence were
reported. The study found that 12 to 25 percent of 4-year-old
children, 7 to 10 percent of 8-year-old children, and 2 to 3
percent of 12-year-old children had nocturnal enuresis (Speevan der Wekke et al., 1998). In teenagers, 1 to 3 percent
were also reporting nighttime wetting (Feehan et al., 1990).
This study also reported an incidence of 2:1 boys versus girls.
They also found that the incidence rate was higher for lower
socioeconomic groups and institutionalized children (Fritz
& Rockney, 2004). Also, some studies have looked at the
spontaneous cure rate of 30 to 40 percent for 2- to 4-yearolds versus approximately 15 percent for children over age
5years. The marked decrease in the spontaneous cure rate for
older children lends credence to the idea that enuresis should
be considered more of a clinical concern after age 5 years,
with nighttime wetting being a more natural developmental
variant, as opposed to being a clinical problem.
Koff (1996) found that, of the children diagnosed with
nocturnal enuresis at age 5 years, approximately 80 percent
are diagnosed with primary enuresis. Also, approximately
20 percent of children with nocturnal enuresis experience
daytime enuresis or lower urinary tract symptoms.
Additionally, approximately 50 percent of children with
nocturnal enuresis experience encopresis, or the passage of
feces in inappropriate places, which also shows a strong male
predominance (Joinson et al., 2007).
Finally, Yeung, and colleagues (2006) conducted an
epidemiological study in which they examined the prevalence
of nocturnal enuresis across children aged 519 years. Several
interesting trends were observed. First, as found in other
studies, the prevalence of nocturnal enuresis declined with
age. Approximately 15 percent of children aged
5 years experienced nocturnal enuresis, with that percentage
Nocturnal Enuresis
decreasing to around 2 to 3 percent by age 10 years. Most

interesting, however, was the trend that, by age 10 years,
the incidence of nocturnal enuresis was fairly static. The
mean percentage of children experiencing nocturnal enuresis
remained fairly steady at between 2 and 3 percent between age
10 and 19 years. Perhaps most noteworthy was that nocturnal
enuresis was fairly persistent and more severe with age. For
example, in this study, approximately 14 percent of children
aged 5 years wet the bed seven nights per week. However, of
those 19-year-olds who reported having nocturnal enuresis,
nearly 50 percent were wetting the bed seven nights per
week. Thus, for those individuals whose nocturnal enuresis
persists into early adulthood, the likelihood that it will be
severe is much greater than for their younger counterparts.
Thus, the overall prevalence of nocturnal enuresis decreases
with increasing age; however, the proportion of children
with severe enuretic symptoms progressively increases. One
implication from these data is that for those children with
severe symptoms, treatment should be started at as early an
age as possible to increase the probability that their nocturnal
enuresis does not persist into adulthood.
Conceptualization
Etiology and Risk Factors
Family History/Genetics
Nocturnal enuresis has a strong genetic connection, with the mode of
inheritance being autosomal dominant. Several studies have looked at
the degree to which genetics contributes to children with nocturnal enuresis. A study by Bakwin (1973) showed that monozygotic twins were
twice as likely as dizygotic twins to have nocturnal enuresis. This study
found that there was a 77 percent chance of a child having nocturnal enuresis if both parents were enuretic versus a 45 percent chance of having
monosymptomatic enuresis if one parent was enuretic. The study found
that there was a 15 percent chance if no parents had nocturnal enuresis.
The prevalence rate of 15 percent is consistent with what is seen in many

epidemiological studies. The ALSPAC (2001) conducted in Australia had
similar results. This study reported that the odds ratio for a child developing severe nocturnal enuresis (which was defined as two or more
episodes per week) were 3.63 times higher if there was a maternal history
of enuresis, and 1.85 times higher with a paternal history. Similar to the
Bakwin study, when both parents had a history of nocturnal enuresis,
there was a 77 percent chance of the offspring developing enuresis. Also,
there have been recent studies (Loeys et al., 2002) that have shown a linkage to specific chromosomes in nocturnal enuresis. Finally, in a Finnish
population-based study, the results showed that the concordance rate

for enuresis among monozygotic twins was 46 percent, compared to
19 percent for dizygotic twins. Thus, even though the contributions to
enuresis are multifactorial, it certainly shows that at least with nocturnal
enuresis, there is a strong genetic connection.
Behavioral and Psychosocial Factors
In general, there appears to be little association between primary nocturnal enuresis and behavioral problems and/or psychopathology, either
during the time that the child is experiencing nocturnal enuresis or later
in life. A number of studies have looked at the relationship between nocturnal enuresis and behavioral problems and/or other types of psychosocial disturbance. A study by Feehan and colleagues (1990) showed a low
correlation between nocturnal enuresis and later behavioral problems.
A longitudinal study conducted by Fergusson, Horwood, and Shannon
(1986) indicated that there was not a strong connection between primary nocturnal enuresis and behavior problems. On the contrary, it is
much more likely that nocturnal enuresis causes behavior problems, as
opposed to behavior problems or other psychosocial factors contributing
to or causing nocturnal enuresis (Friman et al., 1998). This is perhaps
not surprising when we think about the chronic nature of nocturnal enuresis for most children as well as the lack of understanding by parents.
This is especially true when combined with the frustration experienced
by caretakers and children as they struggle with and manage the complications related to nocturnal enuresis. It is not uncommon for parents
Nocturnal Enuresis
to become punitive or to lose control of their emotions in regard to a

child who is chronically waking up wet each morning. Due to a lack of
understanding, some parents attribute intention to childrens history of
wetting the bed and/or perhaps assign blame or punish their children
as a means of managing the nocturnal enuresis. For some children, this
may lead to an increase in disruptive behavior, anxiety, or a number of
other psychosocial or behavior-related concerns. In fact, there is support
for the fact that children with nocturnal enuresis are much more likely to
be at risk for physical and emotional abuse than other children (Warzak,
1993). On the other hand, children with secondary enuresis are more
likely to experience an association with various behavioral disorders and/
or have comorbidity with behavioral and psychosocial factors, compared
to children with primary nocturnal enuresis. We will discuss this further
in a later section.
Although primary nocturnal enuresis has little association with behavioral problems and/or psychosocial contributions, there is some
suggestion that children with secondary nocturnal enuresis may have experienced some type of trauma or abuse, parental divorce, hospitalization,
and so on, which contributed to their regression in toileting skills, leading
to a polysymptomatic course of enuresis. Even so, this comprises a relative
minority of children with nocturnal enuresis.
There has also been some study of the relationship between attentiondeficit/hyperactivity disorder (ADHD) and children with nocturnal enuresis. Children with ADHD are 2.5 times more likely to have enuresis
(Robson et al., 1997). The contribution of ADHD symptoms to secondary enuresis, especially diurnal enuresis, is easier to understand. However,
the relationship between ADHD and nocturnal enuresis is a little more
difficult to understand in regard to its contribution to enuresis. Most
studies show that as nocturnal enuresis improves, so do the related behavioral disturbances that children are experiencing. This would not be
likely with children with ADHD. Given the central nervous system and
biological contribution of ADHD, one would not expect ADHD symptoms to abate or disappear as symptoms of enuresis decrease. Regardless,
there appears to be some support for the fact that there is a much stronger
relationship between nocturnal enuresis and children with ADHD. In
a more recent study, Baeyens and colleagues (2005) conducted a 2-year
10
follow-up of a cohort of children whom they studied previously. The followup study showed that the odds that a child with ADHD will have voiding problems are 3.17 times more likely than non-ADHD children. It
further seems plausible that children with ADHD may present a greater
management challenge for parents, especially in regard to the treatment
packages that are employed for children with nocturnal enuresis. This
could contribute further to some of the frustration that parents experience, as well as lead to additional frustration and/or anxiety for children
who are experiencing both ADHD and nocturnal enuresis. Overall, it
should be remembered that at least for children with primary nocturnal
enuresis, behavioral problems and psychosocial contributors are a minor
factor. Rather, the experience of nocturnal enuresis, especially as it persists
chronically, is more likely to cause or contribute to emotional or behavioral challenges.
Nocturnal Polyuria
The kidney is responsible for maintaining fluid homeostasis, filtering
waste, and excreting excessive fluid. Most individuals produce more urine
during the day than during the night. Additionally, the average individual
goes anywhere from 2.5 to 4 hours between voids during the day and
up to 8 hours at night. Thus, there is a ratio of approximately 2:1 day to
night voids for the average individual. Research has found that this ratio is
significantly decreased for individuals with nocturnal enuresis and that the
ratio is much closer to 1:1. That is, individuals with nocturnal enuresis are
voiding as often at night as they are during the day. Research in the mid1980s (Rittig et al., 1989) and early 1990s found a relationship between
antidiuretic hormone (ADH) and vasopressin in regard to their impact
and influence on urine production during the day and night. Vasopressin
was found to be responsible for contributing to urine volume. Individuals
with nocturnal enuresis had decreased levels of vasopressin, especially at
night. Individuals with nocturnal enuresis were found to have what was
referred to as nocturnal polyuria, which refers to increased urine production during sleep. It is hypothesized that either reduced production of or
reduced response to ADH or vasopressin increases urine production for
individuals with nocturnal enuresis. It has also been surmised that reduced
Nocturnal Enuresis
11
production of ADH may affect the distention of the bladder, thus creating
less capacity for holding urine. In any respect, nocturnal polyuria is often
documented in the history of individuals with nocturnal enuresis.
Sleep Arousal
The contribution of nocturnal polyuria and diminished functional bladder capacity to nocturnal enuresis has been well supported in the research.
However, this does not explain why children do not wake up to urinate in
the middle of the night. There has been much discussion and some controversy in regard to whether nocturnal enuresis is due, in part, to some
type of sleep disorder (Yeung, Chiu, & Sit, 1999). When surveyed, most
parents will insist that their enuretic children are deep sleepers and cannot be aroused, compared to siblings who do not have nocturnal enuresis.
Some studies have also suggested that children with nocturnal enuresis
experience confused awakenings, such as sleep terrors and sleepwalking
(Neveus et al., 1999).
An examination of the research will show studies that support deep
sleep (Koff, 1996), light sleep (Yeung et al., 2008), and no effect (Bader
et al., 2002). However, there tends to be more support for children with
nocturnal enuresis being deep sleepers than not (Neveus et al., 1999).
Also, parents rarely try to awaken nonenuretic children compared to their
enuretic children. It is not known whether nonenuretic children would be
just as difficult to awaken. It appears as though there is a need for greater
understanding as to how the arousal system may possibly be dysfunctional in nocturnal enuretic children. Although there are strong anecdotal
reports from parents with nocturnal enuretic children that they are deep
sleepers, combined with a number of research supports that suggest that
there is some type of sleep disturbance for nocturnal enuretic children,
there, at this point, does not appear to be sufficient evidence to define
sleep disturbance as a major etiological factor for nocturnal enuresis.
Bladder Dysfunction
For infants, urine production is spontaneous. Urine volume gradually
increases to a critical point, which causes the bladder to contract. The
12
bladder pressure overcomes the detrusor muscle in the bladder neck, leading to emptying. As a child ages, the reflex dampens over time. By age 6
years, most children have volitional control over their bladder and the
likelihood of spontaneous contractions is eliminated. Thus, daytime continence gradually increases from around age 2 or 3 years as children have
greater awareness of their bladder being full and demonstrate the ability
to both hold and void their urine with intention.
Several studies have looked at differences in true bladder capacity
between children with nocturnal enuresis and those without nocturnal
enuresis. Most studies show no difference in the true bladder capacities
between these two groups (Djurhuus, 1999). However, a number of studies have shown that children with nocturnal enuresis have a lower functional bladder capacity compared to their counterparts who do not have
nocturnal enuresis. Children with nocturnal enuresis tend to void more
frequently and produce smaller volumes of urine. This is a routine that
is more consistent with younger children, thus lending additional support to the possibility that maturational delay contributes to nocturnal
enuresis.
Global/Maturational Delay
There have been a number of studies that have looked at the correlation
between maturational or central nervous system delay in children with
nocturnal enuresis versus those without nocturnal enuresis. Epidemiological studies show that boys exhibit nocturnal enuresis at a rate twice
as high as girls. There is plenty of evidence to indicate that boys in general develop more slowly than girls. Thus, it may not be surprising that
maturational factors contribute to the incidence of nocturnal enuresis in
boys more frequently than girls. In fact, there have been some who have
suggested that the cutoff age for boys should be higher than that for girls
due to maturational differences. Some studies have looked at electroencephalogram (EEG) outcome with children who have nocturnal enuresis. The results suggest that progressive maturation of bladder stability
occurs in conjunction with EEG findings that suggest increased central
nervous system recognition of bladder fullness and the ability to suppress
the onset of bladder contraction (Van Hoeck et al., 2007). Other studies
Nocturnal Enuresis
13
have demonstrated a positive correlation between average height and

lower mean bone age in conjunction with children with nocturnal enuresis (Shaffer, Gardner, & Hedge, 1984). Also, children who have delays in
their attainment of motor and language milestones tend to show a higher
incidence of nocturnal enuresis (Gross & Dornbusch, 1983). Thus, there
does appear to be a correlation between various maturational and central
nervous system delays and the incidence of nocturnal enuresis. However,
these are associative and not causative.
Other Risk Factors for Nocturnal Enuresis
There have been a number of other characteristics that have been associated with nocturnal enuresis. Some children with upper airway obstruction and/or sleep apnea have been shown to have higher rates of nocturnal
enuresis. In fact, some studies have shown improvements in the incidence
of nocturnal enuresis after tonsillectomies (Weider et al., 1991). Children with constipation have also been shown to have a higher incidence
of nocturnal enuresis (Loening-Baucke, 1997). The same is true for the
polyuria associated with children who have diabetes mellitus. Finally,
there have been cases in which severe sexual abuse has also been associated with episodes of nocturnal enuresis; however, these tend to be more
a secondary type (Forbes, 1998).
Comorbidity
There are relatively few psychological conditions that are comorbid with
nocturnal enuresis. Some have suggested that the parasomnias are comorbid with nocturnal enuresis (Neveus et al., 1999). A number of studies
have looked at how problems with sleep arousal may be contributing to
nocturnal enuresis as well as the presence of various parasomnias, which
also may be related to sleep arousal issues that may be contributing to
nocturnal enuresis. Nocturnal enuresis typically occurs during non-REM
sleep. Additionally, there is a sufficient amount of anecdotal reports from
parents of children with nocturnal enuresis to suggest that arousal is very
difficult. Overall, however, the comorbid relationship between parasomnias and nocturnal enuresis is relatively weak.
14
Perhaps, the strongest comorbid condition with nocturnal enuresis is

ADHD. There is sufficient evidence that suggests that there is a fairly high
co-occurrence between children with nocturnal enuresis and ADHD. Most
studies have shown that children with nocturnal enuresis are two to three
times more likely to have ADHD than those without nocturnal enuresis.
Additionally, Friman and colleagues (1998) showed a slight elevation in
various psychological conditions as being associated with nocturnal enuresis. A well-conducted study by Shreeram and colleagues (2009) documented the co-occurrence of ADHD in children with nocturnal enuresis.
In this study, 1,136 children were surveyed using the DISC (Diagnostic
Interview Schedule for Children). The overall findings from the study
were fairly consistent with previous research studies showing that boys
had a somewhat higher than 2:1 ratio of nocturnal enuresis over girls,
younger children were more likely to have nocturnal enuresis than older
children, and black children were more likely to have nocturnal enuresis
compared to white children, after controlling for Socioeconomic Status
(SES). Interestingly, only one-third of children diagnosed with nocturnal
enuresis sought treatment. Only 7 percent of those children identified
received medication for the treatment of their nocturnal enuresis. Also,
those children who had been diagnosed with nocturnal enuresis and were
comorbid with ADHD were less likely to obtain treatment. Finally, children with nocturnal enuresis were 2.88 times more likely to have been
diagnosed with ADHD. The author suggested that perhaps a delay in
central nervous system maturation could be responsible for children who
are diagnosed with ADHD as well as those diagnosed with nocturnal enuresis. In all likelihood, the etiological pathways are different for ADHD
and nocturnal enuresis. This perhaps lends continued support for maturational delays being one contributing factor to nocturnal enuresis. It also
raises the question as to whether children diagnosed with ADHD may
have greater difficulty complying with or following the treatment regimen
associated with nocturnal enuresis. Thus, it may be the case that the sequelae and complications associated with ADHD behaviors and the management of those behavioral constellations may complicate the treatment
of nocturnal enuresis. The results from this study as well as other studies
that have documented the comorbidity between ADHD and nocturnal
enuresis suggest that clinicians would be wise to explore the possibility of
Nocturnal Enuresis
15
nocturnal enuresis in children with ADHD and vice versa. It also speaks
to the need to increase efforts to address treatment regimen issues with
children who are comorbid with ADHD and nocturnal enuresis.
Differential Diagnosis
There are a number of medical conditions and factors that can cause or
exacerbate nocturnal enuresis. As one can see from the list that follows,
these are primarily medical or physical in nature. These medical conditions do not have a psychological or behavioral component to them in
general. Thus, as we will discuss in the assessment section later, it is critical that a child have a full medical workup by a physician before behavioral interventions are initiated. Following is a list of some of the more
common medical conditions that can contribute to or cause nocturnal
enuresis.

Urinary tract infection

Diabetes mellitus or diabetes insipidus
Chronic constipation
Bladder instability
Congenital abnormality of urinary tract
Neurological disorder such as spina bifida
Genetic disorder such as Gitelman syndrome
Urethral stricture
Epilepsy
ADHD/parasomnias
Model
Toward a Biobehavioral Model
To appreciate how far we have come in the assessment and treatment of
enuresis, it is helpful to look at a historical account of the treatment for
enuresis (Figure 1.1). Historical accounts of the treatment of enuresis date
back to 1550 BC as documented in the Papyrus Ebbers. In 77 AD, Pliny
the Elder wrote in his Natural History that the incontinence of urine in
infants is checked by giving boiled mice in their food. Also included in
16
the treatment recommended by Pliny the Elder was the consumption

of woodlice and urine of spayed swine. The Byzantine historian Paul of
Aegina wrote, Burn the crop of a cock, and give to the patient to drink in
tepid water when fasting, or the flowers of the white oxeye in like manner;
or shave down the testicle of a hare into fragrant wine and give to drink
(Salmon, 1975). Other treatments dating back to 1550 BC suggest that
a remedy for incontinence included juniper berry, one leaf of cypress,
and beer (Jrvelin, 1999). One of the first accountings of the evidence of
enuresis as a medical condition was cited in 1472 by Paulus Bagellardus
of Padua, who published a book on diseases of children. A chapter was
included called On Incontinence of Urine and Bedwetting. In this book, he
referenced children beyond the age of 3 years who were continually passing urine in the bed, sometimes daily, but also continually every night,
and not only up to the age of 5 or 6 years, but sometimes beyond the time
of puberty (Salmon, 1975). This was one of the first indications that what
is now known as enuresis was being studied and evaluated by the medical
community.
Beginning in the 1700s, the use of magical elements and the doctrine
of humors began to disappear from the literature. However, treatments
for enuresis continued to take on less than desirable elements. For example, Dickson in 1762 applied vitriol to the sacral area to raise a blister
and provide counterirritation, while a mechanical device was described
by Sharp (see Salmon, 1975). He made an apparatus of iron, stating:
For use, it must be covered with velvet. It must be accommodated to
the size of the penis and taken off whenever the patient feels an inclination to pass water. This instrument is exceedingly useful because it always
answers the purpose and seldom galls the part after a few days of wearing (Salmon, 1975). During the 1800s, a wider range of treatments was
used, including fluid restriction, use of alarm clocks, both cold and warm
baths, and douches to the lower spine. A wide number of drugs were
used to treat encopresis. Jacobi (1891) mixed strychnine and sheep fat
into a suppository the size of a bean, which he inserted into the rectum
several times daily to strengthen a presumed weakness of the bladder. He
said that in desperate cases, this treatment could be continued for some
time, augmented by injections of strychnine into the perineum (Salmon,
1975). Ruddock (1878) suggested cauterization of the urinary meatus
Nocturnal Enuresis
17
with silver nitrate so as to render it more tender to the passage of urine.

There are also descriptions of the prosthetic part of the urethra being
cauterized with silver nitrate to allow the passage of a catheter. This was
done every few days for 2 to 4 minutes at a time. Some authors went on
to describe inserting a few drops of cocaine into the urethra to render
anesthesia superfluous. By the late 1800s, a variety of mechanical devices
were used to treat enuresis. Trousseau (1870) provided this account of
his apparatus: An apparatus consisting of a sort of metallic bung of the
form of a very elongated olive, varying in size between a pigeons egg and
a small hens egg. This bung diminishes downwards, taking the form of
a neck so that once introduced into the rectum, it is retained there by
the natural constriction of the sphincter of the anus. Size varies with the
patients tolerance (Salmon, 1975). Electrical stimulation was also used
as a form of treatment. Electrodes were placed on the sacrum and pubis
or even against the urethral orifice. This form of treatment was carried out
for several minutes each day until a result was achieved (Salmon, 1975).
In what may be a precursor to what became the bell-and-pad, Nye in
1881 described the first electrical apparatus to be used at night: Attach
one pole of an electric battery to a moist sponge fastened between the
shoulders of the patient and the other to a dry sponge placed over the urinary meatus. The sound of the battery will soon lull the patient to sleep.
While the sponge is dry, no electricity passes through the body of the patient and his slumber is not disturbed. The moment the sponge is moistened by urination, it becomes a conductor of electricity. The circuit is
completed through the body of the patient, and he is aroused and caught
in the very act. A repetition of a like experience for a sufficient number of
times, I am inclined to think, ought to cure the patient (Salmon, 1975).
There are also several accounts of unique treatments in other parts of
the world. Herskovits (1938) wrote that in Dahomey, if a child does not
respond to training and manifests enuresis at the age of 4 or 5, soiling the
mattress on which it sleeps, then at first it is beaten. If this does not correct the habit, ashes are put on water and the mixture is poured onto the
head of the offending boy or girl, who is driven into the street, where all
the other children clap their hands and run after the child singing adidi
ga ga ga ga (urine everywhere) (Salmon, 1975). Torrey (1972) describes
the practice in western Nigeria of tying a toad to the penis of small boys
18
who wet their beds. When the child wets, the toad croaks and the child
is awakened. This method represented an interesting antecedent to the
electric bell-and-pad. There are multiple examples of similar treatments in
various civilizations throughout the world (see Salmon, 1975 for further
descriptions). Various treatments with little efficacy were implemented
well into the early 1900s. As one can see, children with enuresis were
subjected to a wide range of at times magical and, at best, ineffective
treatments. It certainly highlights the concern that has existed throughout
time in regard to the treatment of enuresis. Fortunately, more effective
treatments based on a better understanding of human physiology and
human behavior allowed for not only more effective, but more humane
treatment of enuresis.
During the early 20th century, the etiological focus of enuresis started
to shift from organic causes to psychological causes. The focus on the
psychological aspects of enuresis was influenced somewhat by the work
of Freud. Freud asserted that enuresis was a neurosis or a symptom of a
personality disorder. This position was held for the next several decades
until evidence started to show that there was a genetic disposition associated with enuresis and that there were other organic explanations for
the condition (Jrvelin, 2000). The work of Freud and psychodynamic
theory in general was highly accepted as an effective treatment in the early
1900s for a wide range of conditions. The acceptance of psychodynamic
theory resulted in enuresis being viewed as some type of deep psychological problem that required an understanding of complex psychological
processes. Rather than looking at enuresis as a skill deficit, the focus was
placed on some type of underlying psychosexual conflict or mechanism
that was contributing to the childs bed-wetting. The tendency to pathologize children with nocturnal enuresis did little to advance the treatment of
nocturnal enuresis and likely subjected many children and their parents
to much unnecessary frustration and guilt. Despite the preponderance
of psychodynamic thinking, some scientific studies were advancing the
treatment of nocturnal enuresis. One of the first treatment series was reported in the 1930s showing the efficacy of the bell-and-pad (Mowrer &
Mowrer, 1938). This led to a series of hundreds of studies looking at the
efficacy of what was then the bell-and-pad. By the mid-20th century, the
advent of applied behavior analysis and behavioral interventions through
Nocturnal Enuresis
Figure 1.1 Bed-wetting treatments through the ages
19
20
the work of Skinner and others started to provide objective behavioralbased interventions for the treatment of enuresis. This, in combination
with what was known within the medical community and the work of
pioneers such as Mowrer and Mowrer, helped to direct treatment of nocturnal enuresis in a more scientific and evidence-based arena. In 1974,
Azrin and Foxx published Toilet Training in Less Than a Day, which has
sold over 2 million copies to date. This provides further documentation
of the acceptance of behavioral interventions to address toileting issues in
general. Fortunately, scientific advances have allowed for a much better
understanding of the physical dynamics associated with enuresis. This,
in combination with further advances in the use of wet alarms and other
behavioral techniques, has provided a body of scientific knowledge and
evidence that allows us to use a biobehavioral model in our understanding
of enuresis. Next, I will highlight the aspects of the biobehavioral model
that allow us to move forward in our treatment and understanding of
nocturnal enuresis.
In 2000, Butler and Holland proposed The Three Systems Model to
facilitate our understanding of the pathogenesis of enuresis and to encourage more directed and focused therapeutic interventions. They proposed that enuresis was the end result of dysfunction in one or more of
the following three systems: (i) the normal diurnal variation in vasopressin release during sleep, (ii) detrusor overactivity, and (iii) normal sleep/
arousal mechanisms. This model continues to have strong validity today,
although on reading the literature it is evident that individual subspecialties place greater emphasis on the different elements. Over time, our
improved understanding of the three systems has evolved the following:
(i) relative nocturnal polyuria, (ii) nocturnal bladder dysfunction, and
(iii) neurological developmental delay.
Recent research has helped us increase our understanding of the biologic factors that are causing or impacting nocturnal enuresis. As described earlier, there are a number of factors, many of which are biologic,
that contribute to the occurrence of nocturnal enuresis. To date, a model
has not been developed that completely and comprehensively describes
and identifies those factors that are responsible for nocturnal enuresis.
However, recent research has allowed for the development of some basic
models. For example, Butler and Holland proposed a three-system model
Nocturnal Enuresis
Nocturnal
Polyuria
21
Bladder
Dysfunction
Sleep/Arousal
Disturbance
ENURESIS
Figure 1.2 Three systems model
that identified the relationship between nocturnal polyuria, bladder dysfunction, and arousal dysfunction (Figure 1.2). There is much scientific
evidence to support the influence of these three factors in regard to nocturnal enuresis. More recent research has also outlined the impact of neurological and/or maturational delays on nocturnal enuresis. Furthermore,
it is likely that maturational or neurological delays impact or are interrelated with nocturnal polyuria, bladder dysfunction, and arousal dysfunction. Having a good basic understanding of the biologic factors that are
responsible for nocturnal enuresis is necessary, but not completely sufficient in regard to understanding which treatment options will be most
effective for nocturnal enuresis. Clearly, the behavioral interventions have
been developed to impact, to some degree, those biologic factors that are
contributing to nocturnal enuresis.
A number of behavioral strategies have been developed and have
evolved along with our biologic understanding of nocturnal enuresis. A
wide range of behavioral interventions have been developed in an e ffort
to counteract the effects of nocturnal polyuria, bladder dysfunction,
and arousal dysfunction. It could be argued that a behavioral treatment
22
package will lead to increased arousal, improved responsibility, and improved bladder control all of which help contribute to improved nighttime continence (see Figure 1.3). Additionally, maturational factors also
interplay in regard to the impact of the effectiveness of behavioral interventions. Regardless, several behavioral interventions have been shown to
be very effective and, to some degree, critical in regard to the behavioral
management of nocturnal enuresis. Nearly, all well-conducted and controlled studies have shown that the use of a wet alarm is a critical treatment component when managing nocturnal enuresis. It is possible that
the use of the wet alarm helps to manage the effect of nocturnal polyuria
and also helps to increase arousal and bladder awareness and, to some
degree, bladder dysfunction issues. Further discussion of the mechanism
of action through the use of wet alarms will be discussed later. Finally, a
number of other behavioral interventions, which will be further described
later, have been developed to augment and support the use of the wet
alarm, all of which tend to work together to impact and affect those biologic factors that are contributing to or exacerbating nocturnal enuresis.
Improved
Sleep/Arousal
Increased
Responsibility
Improved
Bladder
Control
NIGHTTIME
CONTINENCE
Figure 1.3 Nighttime continence model
Nocturnal Enuresis
23
Evaluation and Assessment

When conducting an assessment to either make an initial diagnosis of
nocturnal enuresis or provide assessment and treatment of a child with
nocturnal enuresis, there are two primary components that should be
considered. The first is to make sure that a medical evaluation has been
conducted to rule out potential physical causes of the childs nocturnal
enuresis. Once a medical evaluation has been conducted, a thorough initial behavioral assessment should be conducted. Both of these evaluations
will be described here.
Medical Evaluation
As discussed earlier, there are a wide range of medical and physical factors
that contribute to nocturnal enuresis. Although it is important to question parents and children about their past medical history, it is even more
important that the child is seen by his or her primary care physician or a
specialist to identify any physical factors that are causing or exacerbating
a childs nocturnal enuresis. If this has not occurred, it is important that
the child returns to see the primary care physician before any behavioral
recommendation is offered. Also, it is important to maintain good communication with the primary care physician and/or urologist involved
with the child. Keeping physicians informed of your assessment and interventions that are in place, as well as the outcome of those assessments,
is an important part of the team approach that is needed to effectively
treat nocturnal enuresis. Also, if there is some type of atypical response to
treatment or if there are physical symptoms that are difficult to explain, it
is important to return the child to the primary care physician for ongoing
assessment and evaluation.
Behavioral Evaluation
An initial clinical interview (ICI) contains a wide range of categories in
which a clinician is obtaining critical information to help provide appropriate assessment of nocturnal enuresis. This includes not only the
presenting concern but also the childs social history, medical history,
psychiatric history, educational history, and mental status. All sections
24
of a typical ICI will not be covered in detail here. Rather, the focus will
be directed toward those questions and information-gathering that will
be important to consider throughout the ICI and which will be helpful
toward providing adequate information to allow the clinician to make an
appropriate diagnosis and, more importantly, to conduct assessment that
will lead to an effective treatment program. A checklist of key interview
items is provided in Table 1.1.
Initial Clinical Interview: Key Considerations
Presenting problem: When discussing with parents the
clinical concern, it is important to develop an understanding
as to whether the parents are concerned about nocturnal
enuresis, diurnal enuresis, encopresis, and any related
comorbid conditions, such as ADHD and sleep disorders.
Also, obtaining an understanding of any other behavioral or
compliance-related issues will be important, as those issues
may impact compliance with treatment strategies that are
developed in the future. Thus, it is important to identify the
primary concern that brings the child in for evaluation as well
as related issues that may affect assessment and treatment.
Assessment methods: It is important to have a brief
conversation with both the parents and the child (together)
in regard to the presenting problem. This allows for the child
and parents to have an open and clear understanding of the
presenting problem and the importance of working together
to address the issue. Following this, and depending on the age
of the child, it is usually most effective to conduct separate
interviews with the parents and child. This allows parents
to talk candidly about concerns that they may have about
their child, thus preventing the child from misinterpreting
information as being critical or condemning of the child.
Also, obtaining separate interviews allows for the clinician
to develop an understanding of the level of information
and understanding that both the child and the parents have
nocturnal enuresis. When children are present during an
Nocturnal Enuresis
25
Table 1.1 Interview checklist for nocturnal enuresis

Interview
Were parent and child interviewed together, separately?
Family Constellation
Intact family, single parent, blended family, divorced, separated?
Medical
Family history of nocturnal enuresis?
Medication or health conditions (past and present) that affect nocturnal enuresis?
History of taking DDAVP or Imipramine?
Has child been evaluated by a pediatrician or specialist?
Behavioral Health History

Past treatments for nocturnal enuresis?
Current and past interventions that have been used to treat nocturnal enuresis?
History of oppositional defiant disorder or ADHD?
Development
Does child have the behavioral and developmental skills necessary to treat nocturnal
enuresis?
Barriers to Treatment
Are time, cost, and/or motivation potential barriers to treatment?
Onset and Frequency

When did nocturnal enuresis first present in childs life?
Is nocturnal enuresis primary or secondary?
What is the frequency of nighttime wetting episodic, daily?
Sleep Hygiene
Is child a heavy sleeper?
Number of hours child sleeps at night?
Is child difficult to awaken?
Will child hear an alarm?
Bedtime Attire
Does child wear pajamas, underwear, pull-ups, or diapers?
Morning Routine
Does child remove and replace wet clothing and bedding?
Does parent provide assistance?
Does parent take full responsibility for helping child with removing clothing and
bedding?
Sleepovers/Vacations
What is the frequency of nighttime wetting when child is away from home?
26
ICI, they will often defer to parents or look at them for

acceptance when responding to the clinician. Some children
with nocturnal enuresis experience a certain amount of guilt
or shame, and conducting an interview in the presence of
others sometimes affects the validity and honesty of responses
provided.
Social history: It is important to obtain a good social history
in regard to who lives in the family, whether the parents
are divorced or separated, and the number of members in
the household. If the child is spending time between two
households, having an understanding of the household
members, and dynamics, in each home will be important.
This is important, in part, because treatments for nocturnal
enuresis often involve the use of devices such as wet alarms
and can cause disruption to sleep patterns for other family
members. Also, parental involvement is often critical when
providing treatment to children with nocturnal enuresis.
Having commitment from all caretakers in each respective
home will be important for success. It is also important to
obtain information from the parents in regard to their history
with nocturnal enuresis as well as related sleep issues or
ADHD for themselves as children. There is often a familial
or genetic contribution to nocturnal enuresis. Thus, it will be
important for the clinician to note if there is a strong family
history of nocturnal enuresis. Also, if a parent does have a
history of nocturnal enuresis, be sure to obtain their treatment
history as well as the success of past treatments.
Medical history: This is especially important for a child
with nocturnal enuresis. It will be important to obtain a
brief medical history, including outcomes of assessments
and evaluations by a primary care physician and/or an
urologist. As mentioned earlier, it is critical that the primary
care physician and/or the urologist have evaluated the child
for medical factors that are causing or contributing to the
nocturnal enuresis. Additionally, be sure to question the
parent in regard to the childs medical history, including
Nocturnal Enuresis
treatments for any medical conditions. This will include

obtaining history of other medical conditions, such as
allergies, asthma, diabetes, handicapping conditions, chronic
pain, and so forth, that may impact the childs treatment.
Clinicians should also obtain a history of any emergency
room visits or surgeries that have occurred, especially in
regard to the bladder or kidneys. Obtaining a history of the
childs current and past medications is also important. It is
not uncommon for children with nocturnal enuresis to have
been treated with or to be currently taking medications, such
as DDAVP, imipramine, or other medications used to treat
nighttime wetting. Also, there are some medications that do
in fact contribute to bladder and/or kidney problems. Again,
coordination and communication with the PCP will help to
address any questions that a clinician may have in regard to
relevant medical facts and history that could be contributing
to the childs nocturnal enuresis.
Psychiatric history: Obtaining a history of the childs past
behavioral health services is critical. Clinicians should
obtain a history of treatment for any past concerns or issues,
especially in regard to treatment for nocturnal enuresis.
Obtaining a thorough history of the interventions that have
been put in place at home or in a clinical setting will be
important. This should include an understanding of the types
of interventions that were put in place as well as the response
to treatment. Also, it will be important at this time to obtain
from the parents their assessment of not only successes and
failures of treatment but also barriers and obstacles that may
have prevented treatment success. Additionally, developing
some understanding of the acceptability or social validity of
those interventions can be quite helpful (Reimers & Wacker,
1988). Treatments for nocturnal enuresis can often be very
time-consuming and, at times, disruptive to families. Effective
treatments may have been recommended in the past, but
parents may have stopped the treatment or not implemented
the treatment due to the lack of acceptability or the
27
28
disruptiveness that was present in regard to implementation of

the treatment. Also, it is necessary to obtain an understanding
of the childs developmental status. If children are presenting
as having developmental delays, then it will be important to
understand the degree and severity of those delays and how
that may be impacting treatment. Some children who present
with significant developmental delays may not be ready for
treatment if they are presenting as having a developmental age
that is below 5 years.
Clinical presentation: As mentioned earlier, the clinical
history should be obtained with interviews conducted with
the child and parents. Initially, a conversation should be had
with the child and parents together to discuss the general
goals and purpose of treatment. It is also helpful to conclude
the clinical interview by meeting together with the child and
parents to review the history in general, discuss treatment
goals, and clarify any differences or misunderstandings that
might exist between the childs report and the parents report.
Parent interview: The following are several factors to consider
during the parent interview.
Onset: With nocturnal enuresis, it is typically assumed
that the child has never been dry. However, some children,
especially those with secondary enuresis, may have had a
period of dryness during the night followed by the onset
of wet nights. Thus, it is important to determine whether
a child has a history of always having been wet at least
several nights each week or whether there was a period of
time in which the child did experience periods of dryness
(e.g., for 3 months or longer).
Frequency: The frequency of wetting episodes should be
obtained. This includes determining, on average, how
many nights per week the child is wet. For some children,
they will report waking up wet every morning. Other
children may report episodic wetting ranging from one
or two nights per week to multiple nights per week. If
the child is experiencing episodic wetness, it is helpful to
Nocturnal Enuresis
know whether there is a trend toward the child becoming

increasingly dry or if this has been a steady pattern. As
children typically develop dryness over time, without
intervention, it is important to know whether the child is
heading toward resolution of his or her symptoms, thus
perhaps negating the need for treatment.
Sleep hygiene: Given that many parents report that their
children are heavy sleepers, obtaining a history of the
childs bedtime routine, sleep schedule, and number of
hours of sleep obtained each night is important. Also,
parents should be questioned in regard to the ease of
awakening their child in the middle of the night if
necessary. It may be helpful to have families complete a
sleep diary for a period of 1 week or so to document the
childs sleep habits and hygiene.
Bedtime attire: Some parents continue to have children
wear diapers or pull-ups, even into later years, as a means
of managing wetness. Thus, some children are wearing
pajamas or underwear to bed, while others are wearing
pull-ups. Wearing pull-ups and diapers to bed may delay
treatment success due to the convenience and efficiency of
these products. Although it is certainly understandable why
parents would have children wear pull-ups to bed, it may
be necessary to have pull-ups and diapers discontinued,
in part to determine whether the child will have greater
awareness of being wet if these items are removed. The
agitation or distress that a child may experience in regard
to not being allowed to wear a pull-up may actually benefit
him or her, from a treatment standpoint, if it increases his
or her bladder awareness throughout the night.
Morning routine: The routine in which parents and
children engage in the morning to manage wet bedding
and clothing ranges quite widely. Some parents take on the
responsibility as a means of getting the wet bedding and
clothing changed and cleaned as quickly as possible, while
others will enlist the assistance of their children. For some
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30
families, the child is completely responsible for removing

and changing any wet bedding or clothing. The routine
that children and parents have in place should be well
documented, both from the childs perspective as well as
that of the parents.
Current and past treatment efforts: Most families have
undergone a wide range of interventions by the time
they are seeking clinical help. Obtaining information in
regard to not only the interventions that have been put
in place but also the integrity with which they have been
implemented is important. The range of interventions
that parents have employed likely includes things such
as eliminating fluids, awakening their child to urinate
during the late evening or early morning, various
rewards and reinforcement programs, and the use of
punishment. If punishment has been used as a treatment
component, then obtaining additional information in
regard to the type and range of punishment is essential.
Depending on the type of punishment used, it can
sometimes inhibit future treatment success or can lead
to children not being honest with parents in regard
to wet bedding and clothing. It is not uncommon for
children to hide their clothing or bedding if there is the
likelihood of some form of punishment being imposed
for a wetting episode. If parents have used a wet alarm
in the past, obtain a history of how the wet alarm was
used and whether it was implemented along with a
treatment package. It is not uncommon for parents to
start and stop treatments fairly quickly due to the lack
of treatment success or frustration on the part of the
child or parents. Thus, obtaining a sense of the level of
treatment integrity that was in place with any of these
treatments will be helpful.
Sleepovers and vacations: The frequency of childrens
wetting episodes will sometimes vary during sleepovers
or family vacations away from home. Obtaining a history
Nocturnal Enuresis
as to whether the childs wetting habits change during

these occasions may provide some leads in regard to
the probability for success as well as possible treatment
interventions.
Barriers to treatment: Both parents and children often
need to be actively involved in the treatment of nocturnal
enuresis. There are barriers to treatment that likely affect
both of them. One factor is cost. Some families may balk
at certain treatment interventions, especially if they are
costly. The cost of wet alarms, bedding, pajamas, and so
forth may cause some parents to be reluctant to implement
these types of interventions. However, when compared
against the long-term cost of pull-ups, diapers, and so
forth, most parents realize that cost is not a critical factor,
especially if use of a wet alarm leads to success. Other
barriers that sometimes impact treatment include the time
commitment needed, the disruption to nighttime and
bedtime routines, motivation on the part of parents and
child, fatigue from past treatment efforts, and also the
overall concern on the part of the parents. Some parents
are content with allowing their child to grow out of the
problem, thus limiting his or her level of motivation in
regard to employing considerable time and effort to resolve
the problem.
Child interview: When interviewing children, it is
necessary to take into account their age and developmental
level. Make sure to use terminology and language that is
understandable to them. It is often necessary to clarify with
either the childs parents or the child himself or herself in
regard to any terms or special wording that he or she uses
in regard to toileting habits or wetting episodes and bodily
functions.
History: It is important to obtain from the childs
perspective how long nighttime wetting has been a
concern. Although the parents will likely provide an
accurate and valid history, obtaining the childs perspective
31
32
can be informative. Asking the child how often they

awaken dry or wet each week as well as how long they can
remember having the difficulty will provide some sense of
the childs awareness.
Frequency: In addition to identifying how often the child is
awakening in the morning with wet bedding and clothing,
it is important to determine his or her awareness of his or
her bladder being full either first thing in the morning or
on occasion in the middle of the night. Some children will
admit that they are aware that they have a full bladder,
but are too tired or fatigued to leave their bed to use the
bathroom. For some children, the frequency of nighttime
wetting has become so routine that it does not seem
out of the ordinary for them to wet, even though they
may have the ability to leave their bed. This is atypical,
but does occur on occasion. Still other children will on
occasion indicate that they feel their bladders fullness in
the morning, yet do not make the effort to get out of bed.
Again, compared to most children with nocturnal enuresis,
these are atypical scenarios, but they do occur from time
to time. Thus, it is important to get a sense of the childs
awareness of his or her bladder.
Morning routine: Question the child about what is done
with his or her wet bedding and clothing. While the
parents will have provided you with their information, it is
helpful to learn from the child what he or she perceives as
the morning routine and what is expected of him or her on
the part of his or her parents.
Motivational level: Obtain from the child his or her level of
motivation for resolving this problem. Some children have
a fairly nonchalant and devil-may-care attitude in regard
to resolving the nighttime wetting. For some children, it
has become so routine that resolving the problem is not a
top priority. For other children, they are highly motivated,
especially older children who are not only tired of waking
up wet in the morning, but who are being inconvenienced
Nocturnal Enuresis
because they are not able to participate in sleepovers with

friends or perhaps spend nights visiting family or friends.
Barriers to treatment: An interview with the child will also
allow you to obtain a mental status and determine whether
there are any cognitive or developmental factors that might
be a barrier to treatment.
Follow-up plan: Once you have conducted the remainder
of your initial intake, which would likely include the childs
educational history, mental status, and clinical impressions, it
will be important to develop a follow-up plan with the child
and parents. At the initial interview, this typically includes
asking the parents and child to collect data on the frequency
of nighttime wettings. It is important to have the parents and
child record the date and time of each wetting episode in a
journal. Knowing the time of the wetting can be important
in regard to developing interventions. For example, it may
be helpful to arrange for a scheduled awakening for those
children who wet during the first sleep cycle. For other
children who may be wetting at a later point in the evening,
that becomes less practical. If necessary, the child could wear a
wet alarm for a period of a week to determine whether there is
a consistent time that they are wetting during the night.
Wet versus dry nights: It is helpful to have parents record
the childs reaction and routine in response to both wet
nights and dry nights. If the parents have established some
type of positive reinforcement for dry nights, recording
the reward or special activity that has been arranged will
help to provide documentation and also allow for further
discussion as to its effectiveness as far as motivating the
child and impacting his or her frequency of wet nights in
the future. Also record parents reaction and response to
the child awakening wet.
Nighttime bathroom visits: If a child is occasionally getting
out of bed and using the bathroom to urinate, then it will
be important to record this. This would certainly suggest
that the child is having some awareness and increases the
33
34
probability for success with treatment package. In general,

collecting data over a 1- or 2-week period should be
sufficient. Obtaining a record of the number of wet nights
versus dry nights and the parental and child response to
those should help to set the stage for the development of
an effective treatment package.
Treatment
For children and their families, the treatment of nocturnal enuresis can
be time-consuming, embarrassing, and frustrating on one hand, and extremely rewarding on the other. There are a number of issues that should
be considered when initiating treatment of nocturnal enuresis. Because
of the complexity and time-consuming nature of treating nocturnal enuresis, education should be the first step in the treatment process. There
are several issues that should be discussed with parents and children when
initiating treatment of nocturnal enuresis. They are as follows:
1. Are parents sure that they want to initiate treatment? Once parents
have been educated about the genetic factors that are associated with
nocturnal enuresis, the spontaneous cure rate that occurs if no treatment is initiated, as well as the nonvolitional aspects of nocturnal
enuresis, some parents decide that they would prefer to hold off on
treatment. This is especially true if the child is fairly young, say 5
or 6 years of age. Sometimes educating parents about the nature
of nocturnal enuresis, along with some general guidelines and tips
for day-to-day management of the enuresis, allows parents to give
the child more time before they initiate a treatment package. This is
not to suggest that you should discourage parents from putting in
place a treatment protocol; however, providing them with appropriate information and education gives them an opportunity to decide
whether they want to commit themselves to treatment.
2. Parents are sometimes more comfortable not initiating treatment if
a child is under the age of 7 years old. This is due, in part, to the
relatively high frequency of 7-year-olds, especially males, who have
nocturnal enuresis. Also, the spontaneous cure rate allows parents
Nocturnal Enuresis
35
to give it more time with children this age. However, children over
10 years of age should probably be given more priority in regard to
initiating treatment. In fact, parents should be encouraged to initiate
treatment for children over the age of 10 years. This is due to the relatively lower frequency of children experiencing nocturnal enuresis
beyond the age of 10 or 11 years, as well as some of the socio-behavioral sequelae that tend to occur with children who are experiencing
nocturnal enuresis at an older age. Additionally, research has shown
that children over the age of 10 years, who are wetting the bed seven
nights per week, should likely receive more intensive treatment. This
is based on studies that have shown that of those individuals who are
wetting at night by age 19 years, 50 percent are wetting seven nights
per week (Yeung et al., 2006). Thus, once children are over the age
of 10 years and are wetting on a nightly basis, it is possible that they
are at greater risk for this to be a prolonged problem if effective treatment is not initiated. Also, intensive treatment is not likely indicated
with children under the age of 5 years.
3. Explain the time and energy demands of implementing the treatment protocol for nocturnal enuresis to both children and parents.
There is a fairly significant expectation for time and effort in regard
to the initiation of a treatment package that includes not only the
wet alarm but also other treatment components (which will be discussed later). The child and parents should have a full understanding
of their role in the treatment process and should be willing to commit the time and energy needed to help the protocol result in success.
4. Determine the motivation level of both the child and the parent.
The parents motivation level is especially important, primarily for
younger children. Parents often need to play a very active role. Having a highly motivated child is, of course, always helpful, but it is
not critical or necessary if parents are willing to put in place the
treatment protocol and follow the therapists/psychologists direction. However, if the child is highly resistant and there is a clear lack
of motivation, one might want to consider holding off on treatment
until the motivation level has increased; developing incentives for the
child often increases motivation. Regardless, if there is a disparity in
regard to motivation levels, it certainly warrants further discussion.
36
5. Keep treatment symptom-focused. Parents sometimes have a tendency

to pathologize a child with nocturnal enuresis. Accordingly, children
themselves sometimes assume that there is something wrong with
them or that there is something highly unusual about their nocturnal enuresis. Providing some education and reassurance and keeping treatment focused on symptoms, as opposed to other emotional
or behavioral issues, is important in regard to achieving treatment
success.
6. During the initial intake, identify those factors that might work
against treatment success. Some of those that are most salient include marital problems, differences in parenting approaches between
each caretaker, significant externalizing behaviors, and intolerance
on the part of the parent in regard to their childs nighttime wetting.
Hopefully, these issues can be resolved or addressed before treatment
begins. If not, it may suggest that attempting to treat nocturnal enuresis should perhaps be delayed if these factors will cause treatment
to be either unsuccessful or sabotaged.
Treatment Techniques
Wet Alarm
The McGrath, Mellon, and Murphy study (2000) suggested that a biobehavioral approach toward treatment for nocturnal enuresis results in the
greatest treatment success. They indicated that the use of a wet alarm is a
critical component in regard to the behavioral strategies that are implemented. In fact, most well-controlled studies demonstrate the efficacy of
using a wet alarm as part of a treatment protocol (Friman, Reimers, &
Legerski, 2012). Next, I will review several factors to consider when using
a wet alarm, including the pros and cons of using one as part of your
treatment package.
History
The history of the wet alarm dates back to the early 20th century. A German pediatrician, Pfaundler, developed a device that notified nurses when
a child had wet the bed and needed to be changed. Pfaundler discovered
Nocturnal Enuresis
37
by accident that the device not only worked to notify nurses but also had
a therapeutic effect. Many of the children who had the device placed on
their bed showed recovery within 2 months time. The use of the device was somewhat limited until two psychologists, Mowrer and Mowrer
(1938), systematically studied the effects of a modified device to treat
children aged 313 years who presented with nocturnal enuresis. The research and work by Mowrer and Mowrer led to continued investigation
as well as the development of a number of different devices that remain in
use today (see next section).
Description of Device
A number of devices have been developed over the years to alert (sound
and vibration) both children and parents that the child has urinated in
the middle of the night.
Pad-type alarm: The bell and pad has continued to be a useful
device over the past four or five decades. This is essentially a
pad that is placed on the bed. The child is expected to sleep
on top of the pad. Once moisture is detected, an alarm is
sounded for the child and/or for the parents. It is possible
to extend a lead to the parents bedroom in order to alert
them that the child has urinated. The placement of the alarm
depends on whether the clinician is using a child-directed
protocol or a parent-directed protocol. In some cases, the
child is alerted and is expected to awaken and follow the
protocol that has been designed. In other cases, when more
intensive parental involvement is needed, the parents are
alerted via the alarm and then the protocol is initiated with
the child. In some cases, both the child and the parent
are alerted. We will discuss later in more detail different
components that are often incorporated into the protocol
along with use of the wet alarm. In general, the child is
expected to have full arousal, is escorted to or independently
goes to the bathroom to finish urinating, and then replaces
bedding before returning to bed and resetting the alarm.
38
Pajama devices: One of the disadvantages of the pad-type

alarm is that it sometimes requires a greater amount of
moisture to set off the sensor and/or the child may sleep
off the pad, thus rendering it useless. A modified device has
been developed in which the child wears the alarm. A sensor
is attached to the childs underwear or pajamas. A wire lead
alerts the child once he or she starts to urinate. The alarms
vary, producing either auditory signals or, in some cases,
vibrating signals, which are especially helpful for children who
are deep sleepers.
Wireless alarms: Most recently, wireless alarms have been
developed. They work in the same way as the pajama device;
however, the alarm sounds via a wireless transmission. This
has several advantages. The device can be set up so that both
the caregiver and the child are alerted. Also, the alarm can
be physically placed away from the childs reach, making it
difficult for him or her to turn off the alarm and go back to
bed. If the alarm is set on the other side of the room, the child
will need to get out of bed to turn it off. The wireless alarms
also have the option of alerting both the parent and the child
or just the parent alone if a parent-directed protocol has been
put in place.
Thus, there are a variety of devices at various price points that have
been shown to be effective in regard to waking and alerting children and
parents that the child has urinated during the middle of the night.
Mechanism of Action
There are a number of learning principles that are in play with the use
of the wet alarm. There has been some debate as to whether classical
conditioning versus operant conditioning principles are responsible for
the success of wet alarms. In all likelihood, both learning principles are
contributing to the change in behavior. In regard to classical conditioning, the buzzer/alarm serves as an unconditioned stimulus (US), which
results in the child awakening and experiencing sphincter contraction
Nocturnal Enuresis
39
(unconditioned response, UR). After enough pairings of the alarm with

the feeling of a full bladder, the full bladder eventually becomes a conditioned stimulus (CS) that elicits a conditioned response of awakening and
urinating before the child wets the bed. It is also likely that the negative
consequences associated with being awakened in the middle of the night,
along with going to the bathroom and possibly replacing bed sheets and
clothing, is experienced as negative by the child, thus having a punishing effect. The child may then make an effort to avoid having the alarm
sound, thus reducing the need to change the bedclothes and deal with
the aversive consequences associated with wetting the bed. Additionally,
parents, in all likelihood, are providing praise and reinforcement in some
fashion for remaining dry. Thus, the avoidance of the noxious or aversive
stimuli associated with wetting the bed, in combination with the positive reinforcement of remaining dry, also likely contributes to changes in
behavior. Thus, both classically conditioned and operantly conditioned
factors are likely in play.
Procedure
The procedure for using a wet alarm is described, along with treatment
considerations, as follows. In many cases, other treatment components
are incorporated into the protocol. Those will be described here.
1. The rationale for using a wet alarm as well as all other treatment
components in general should be thoroughly explained to the child
and parents. Additionally, they should understand that they should
commit 1 to 2 months to increase the probability for success. Thus,
it is important that they understand not only the components of
treatment but also the length of treatment that is required. In most
cases, treatment should not be initiated if there are likely to be significant disruptions or interruptions to the treatment protocol. This
might include holidays, vacations, and so forth. Ideally, one would
select a period of time in which the family anticipates few, if any,
disruptions.
2. Collect baseline data prior to treatment. Have the parent and child
keep a journal of the date, frequency of wettings each day, and time
40
of each wetting (if known). Two to three weeks of baseline data

should be sufficient.
3. Establish a criterion for success. Parents will sometimes discontinue
the use of the alarm if the child starts to demonstrate being dry after
only a few nights. This will likely result in treatment failure. Rather,
establish a fairly stringent expectation for discontinuing the use of
the wet alarm. One wet night over a 30-day period is a reasonable
expectation to help ensure consistency and prolonged success.
4. Select a wet alarm. There are a wide range of choices available to parents and children. Review with parents the pros and cons of using a
pad-type device versus a wearable and/or wireless device.
5. Demonstrate the device. It is simple to demonstrate how moisture
will set off the alarm. Have the parents hold the alarm to see that
there is no danger in the device itself. Also, demonstrate for the child
how the device is placed on his or her pajamas and/or how the wireless device works if that is what was selected by the family. It is important for the child to understand that this is simply a tool to help
him or her be successful and is not necessarily to be feared. However,
the device may take on negative qualities fairly quickly.
6. Review with parents the protocol that is used when the alarm goes
off. Discuss with the parent and child what procedures will be followed each night. This should include having the child get up, go
quickly to the bathroom to finish urinating, and remove any wet
bedding or pajamas if necessary. The parents will discuss with the
child their role and the assistance that they will offer to the child. It
is important to clearly spell out the expectations for both the child
and the parent. In general, and at a minimum, the protocol should
include the child awakening at the sound of the alarm, the parents
assisting the child if he or she is having a difficult time awakening,
the child going to the bathroom and finishing emptying his or her
bladder, removing any wet clothing or bedding, and resetting the
alarm.
7. Discuss the use of any rewards or incentive programs that have been
established. Discuss with the child the criteria for earning access to
rewards and/or special activities, and describe in detail the behavioral
protocol that is in place.
Nocturnal Enuresis
41
8. Practice during the day the protocol that will be put in place at night.
It will be helpful to have the parents and child practice several times
the procedures that they will follow when the alarm sounds at night.
This can be done a few times over a 2-day period, which should be
sufficient. It may be necessary to rehearse this periodically to remind
and reinforce with the child the protocol that is in place.
9. Remind the parents of the importance of keeping data on the childs
success. Ask them to keep a daily log of the childs wetting events and
documentation of the protocol being followed.
10. The childs fluid intake should not be altered. There has been some
suggestion on the part of various professionals that fluid intake be
restricted. Research has shown this to be ineffective. In fact, it is
probably more effective if the child increases fluid intake to increase
the frequency of the child wetting and/or experiencing the contingencies of the protocol.
11. Establish a follow-up schedule. Closely monitoring the child and his
or her progress is important early on. Having weekly sessions for the
first month of treatment is likely very helpful. Once the protocol is
in place and the child is having some success, sessions can be spread
out until eventually they are reaching a maintenance-type level of
perhaps monthly or every other month visits.
Efficacy
The urine alarm has been shown to be very effective across a number
of research studies. The form and variation of the wet alarm does not
seem to be a distinguishing variable. Thus, all devices appear to be effective when compared to each other. McGrath et al. (2000) provide a
nice discussion and description of the studies that have demonstrated
the effectiveness of the urine alarm. They report a 77.9 percent cure rate
using a basic urine alarm. The efficacy of the urine alarm has been studied extensively, dating back to 1938 (Mowrer & Mowrer, 1938), with
multiple studies documenting the effectiveness of the urine alarm alone,
and also in combination with a number of other procedures. There are a
number of studies that have shown that the basic urine alarm, when used
in combination with other interventions, has also been shown to provide
42
good effectiveness. One particular multicomponent treatment approach

is called full-spectrum home training (Houts & Liebert 1984). Multicomponent interventions such as full-spectrum home training appear to
have good efficacy and have been designed to be easy to use. One advantage of these types of approaches is that they include components that are
designed to reduce relapse and increase the success with treatment. Multicomponent interventions have not been studied as extensively as urinealarm-only studies, but those studies that have been conducted appear to
suggest not only good effectiveness but also a high level of social validity.
Clinicians can likely increase their level of effectiveness by not only clearly
describing the aspects of the use of the urine alarm, but also discussing
with families various components that could be used in conjunction with
the wet alarm and the procedures associated with them. Allowing families
to discuss openly their interest in and concerns with adding each of these
components will help to reduce relapse and increase effectiveness. Paying
attention to treatment acceptability when designing an intervention to
treat nocturnal enuresis will be especially important.
Relapse
Relapse is fairly common in the treatment of nocturnal enuresis. Studies generally suggest that around 3040 percent of children will relapse
after becoming dry. However, the severity of relapse is relatively low, and
retraining is fairly quick. Most children return to successive dry nights
fairly quickly. One thing that will help to reduce relapse is overlearning.
Having children follow the protocol for an extended period of time and
setting the criteria for success at a fairly high rate will increase the probability for success and reduce relapse. Many research studies suggest an
initial expectation of 14 dry nights, with full success being defined as
28 days, or 4 weeks, of successive dry nights. Another variable that is
often included to increase success and reduce relapse is to increase fluid
intake once treatment success has initially been acquired. Thus, having
children drink larger volumes of fluid before they go to bed will help,
from the standpoint that it allows for increased bladder distention and
allows for a demonstration of whether the child is able to hold his or her
urine through the night or appropriately use the toilet during the night.
Nocturnal Enuresis
43
Another variable that may be helpful in regard to reducing relapse and

increasing efficacy is to use an intermittent schedule with the alarm once
treatment success has been attained. This will allow for the urine alarm
to be faded over time and provide a demonstration as to the dependency
that the child may have using a continuous schedule with the wet alarm.
Barriers to Success
1. Parental cooperation: Lack of parental cooperation is probably the
single biggest factor in regard to relapse or poor treatment success.
It is helpful for parents to have a full understanding of how the wet
alarm works, as well as all of the procedures that are being recommended in conjunction with the use of the wet alarm. Allowing parents to see a demonstration of the device, along with a discussion of
procedures that will increase success as well as possible pitfalls, will
hopefully help parents follow the protocol for a length of time to
allow for success. Parents also need to understand that the treatment
will take a minimum of 1 to 2 months and that they need to commit
themselves to an extended treatment period if their child is to have
success with the wet alarm. It will be important for the clinician to
provide ongoing instruction and supervision throughout the initial
treatment period. If parents are hesitant or reluctant to initiate treatment, it is better to wait until they are fully committed, as opposed
to trying treatment and hoping for success.
2. Child does not hear alarm: Many children have a difficult time hearing the alarm. Parents will often report that the alarm goes off, but
that the child does not awaken. Unfortunately, the rest of the house
is usually awake and hears the alarm quite well. There are several
things that can be done to increase the likelihood of the child hearing the alarm. One is to try a vibrating alarm. Some children awaken
more readily to the use of a vibrating device versus an audio alarm.
Some wet alarms allow for both a vibrating device and an audio
alarm. Another option is to set a regular clock alarm for a time when
the child usually wets. The alarm can be set to determine whether
the child awakens. There may be value in having the parents and
child work on awakening during the night when they hear the clock
44
alarm before they implement the use of the wet alarm. Once the
child is awakening regularly, the wet alarm can be put in place. It
may also be necessary for parents to spend some time helping their
child awaken once the alarm has gone off. Placing a washcloth on
the childs forehead or jostling the child to help him or her awaken
in conjunction with the alarm usually helps children learn to wake
up once they hear the alarm. Again, parents will need to know that
they may need to spend some time helping their child with this, and,
again, there is a necessary commitment on the part of the parents for
this to happen.
3. Low urine output: Some children do not urinate a significant amount
during the night. Thus, it limits their opportunity to have their bladder distend or to have greater awareness of their bladder during the
night. Increasing the amount of fluid that the child consumes before
going to bed may help with this.
4. Oppositional behavior: Some children demonstrate moderate to high
levels of defiant or noncompliant behavior that is independent of
the concern with nocturnal enuresis. If, during your initial clinical history, there is clear evidence or demonstration of a history of
noncompliant or defiant behavior, it may be necessary to treat that
behavior and demonstrate improvement with compliance and/or a
reduction in defiance before implementing the use of a wet alarm. A
child with a history of a high level of oppositional behavior or defiance is not likely to become suddenly compliant when awakened at
1:00 a.m. Thus, some parent training and instruction on managing
oppositional and defiant behavior during the day may be helpful in
regard to increasing success with the wet alarm.
5. Poor treatment success: The wet alarm is not 100 percent effective. In
some case, the parents and child implement the protocol with great
integrity and exactly according to plan, and despite this, the wet
alarm is not effective. If the family has put the protocol in place for
3 to 4 weeks but has not had success, it may be necessary to take a
2- or 3-month break before discussing whether to reinitiate treatment. Extending treatment beyond 3 or 4 weeks if there has been no
success, and in which there has been no obvious barrier to success,
will likely only increase frustration and reduce the likelihood that
Nocturnal Enuresis
45
the family will be willing to implement it in the future. Discussing

this with the family on the front end will be helpful. Thus, the criteria for success as well as the criteria that will result in treatment being
put on hold should be discussed with the family.
Augmentative Treatment Components
There are a number of treatment options that should be considered to be
used either independently or in combination with a wet alarm. Research
has shown that using a multicomponent treatment intervention is often
more effective than using a wet alarm alone. The components described
next can be used selectively, based on the clients history and presentation.
Retention Control Training
There is some evidence to suggest that retention control training can be
helpful in the overall treatment of nocturnal enuresis. Research suggests
that enuretics tend to urinate frequently during the day, with the tendency to urinate at low bladder pressures and volumes. With retention
control training, the assumption is that enuretic children who learn to
retain their urine for longer periods during the day will also be able to do
so at night, thus reducing the opportunity for nighttime wetting. There
are multiple studies dating back to the 1960s (e.g., Muellner, 1960) that
demonstrate the benefits of retention control training. In general, children are asked to increase their fluid intake and to delay urination as long
as possible. The goal is to increase the volume of diurnal urinations and
expand the interval between urges at night. One approach that is used to
motivate children to hold their urine for longer periods of time is to have
them urinate into a measuring cup or receptacle. Goals and some type of
external reward can usually be established to help gradually increase the
volume of urine that is produced. It is assumed that bladder distention is
a stimulus for urination and that nocturnal enuretics tend to urinate at
the first sign of distention. Expanding and extending bladder distention
and a childs ability to hold urine will hopefully help to decrease the need
for urinating at the first stimulus of bladder distention. When using this
procedure, it is important to have children increase their fluid intake and
46
practice the retention control earlier in the day and at least 34 hours before bedtime. Retention control training is also often used in conjunction
with helping children to practice Kegel exercises.
Kegel Exercises
Kegel exercises generally involve manipulating muscles that are necessary
to prematurely terminate urination (Kegel, 1951). These exercises were
originally developed for women who were experiencing stress urination.
In general, children are taught to use Kegel exercises by having them stop
and start their urine flow during active urination. Once children have
mastered this technique, they can be encouraged to do dry training. This
is essentially having them engage in the exercise of these muscles using
the Kegel exercises when they are not urinating. Children should then
be encouraged to hold the contractions for 510 seconds, followed by a
5-second rest. The ability of children to engage in stream interruption will
hopefully help to reduce output in the middle of the night when they are
starting to urinate or will give them better control in regard to retaining
their urine during the day.
Scheduled Awakening
This treatment component essentially includes awakening children in the
night and escorting them to the bathroom. The goal of these scheduled
awakenings is, in part, to increase the arousal of the child, provide the
natural reinforcing benefits that come with being dry in the night should
the awakening and urination result in a dry bed, and help children learn
to urinate in the early stages of sleep. It also increases the opportunity for
success and access to rewards for being dry throughout the night. The
success of scheduled awakenings by itself is somewhat limited. Typically,
scheduled awakening is used in combination with one of the treatment
packages, most of which include the use of a wet alarm. Scheduled awakenings have been used with both dry bed training and full home training
programs. Friman (2008) suggests having parents awaken children and
escort them to the bathroom prior to the parent themselves going to bed.
Also, it appears as though scheduled awakening is most effective when
Nocturnal Enuresis
47
combined with the use of a wet alarm. There is questionable benefit of

awakening children multiple times throughout the night or in the middle
of the night. Additionally, parents are much less likely to be compliant
with frequent awakenings or with awakenings that occur in the middle
of the night.
Overlearning
Overlearning is essentially the nighttime version of retention control
training. It is usually used to supplement and augment treatment effects
that are achieved with a wet alarm and/or a treatment package. Essentially, with overlearning, children are asked to increase the volume of
fluid that they consume just before bedtime. The idea here is to increase
the opportunity for accidents and, thus, overlearning of the treatment
contingencies. It also creates an opportunity to demonstrate success with
the treatment package. Once children have been dry for anywhere from
7 to 14 consecutive nights, the quantity of fluid (1216 oz) should be
increased. This will create an opportunity for children to experience the
treatment effects due to accidents or will demonstrate their ability to
besuccessful through either urinating appropriately in the middle of the
night or remaining dry throughout the night.
Cleanliness Training
This essentially requires the child to be responsible for changing his or
her wet bedding and clothing. Another name for this technique might
simply be overcorrection. There have not been well-controlled studies
to demonstrate the effectiveness of cleanliness training or overcorrection
in combination with other treatment components. However, it seems to
make inherent sense that the child should take responsibility for his or
her wet clothing and bedding, albeit on occasion with parental support
and assistance, to add some motivation to remain dry within his or her
volitional ability. Typically, treatment components that involve some type
of a hassle factor or inconvenience may lend themselves toward motivating the child to increase his or her bladder awareness, or may benefit the
treatment protocol through the negative properties associated with the
48
cleanliness training. One might argue that the use of the wet alarm plays a
similar role in regard to motivating the child via avoidance of this routine.
Reward Systems
Reward systems can play multiple roles in regard to the overall treatment
package. I would encourage the use of a reward system right from the
beginning. In fact, some children will have success with a reward system
alone, even before a wet alarm has been put in place. The likelihood of
this is small, but in regard to my own clinical practice, I have found that
anywhere from 5 to 10 percent of children will benefit from the use of
a reward system only. The type of reward system is only limited by ones
imagination. Ideally, parents will identify access to some preferred item
or activity that is highly desirable to the child. Providing access to that
item or activity upon arising in the morning can be used as a reward
for remaining dry throughout the night. For some children, this might
simply be having access to a special cereal or breakfast food item. For
other children, it might be money, and for others, access to some video
game or other activity that they might not normally be able to access. The
younger the child is, the more immediate the reward should be provided.
All children will benefit from immediate access to some activity or item
if they are dry in the morning. Older children may also benefit from the
inclusion of a longer-range reward system. An example of one system
includes providing the child with a token (e.g., marble and poker chip)
each night they are dry. The child will receive an additional token for each
successive night of being dry. For example, for a child who had four successive nights of being dry, he or she would receive one token on night 1,
two tokens on night 2, and so forth until he or she has reached the end
of his or her dry nights. If a child has a wet night, they start the sequence
over again. The tokens are placed into a reward jar, and a masking tape is
placed along the side of the jar, with rewards written on each of the pieces
of masking tape. Once they reach each level of the tape, they earn that
particular reward. The value of each reward will increase as the child earns
more tokens. Once they have reached the top of the jar, they can start over
and earn the same or a new set of rewards. For most children, once they
have filled the jar, they typically are experiencing mostly dry nights. Thus,
Nocturnal Enuresis
49
having both an immediate reward and access to longer-term rewards will

certainly enhance the childs cooperation and overall treatment success.
At the initial stages of the treatment program, it may be helpful to provide
tokens and/or rewards simply for participating in the treatment process.
Many children are reluctant to participate in everything from cleanliness
training to scheduled awakenings. Incorporating some type of token reward for childrens participation early on may help to reduce some of the
reluctance and resistance that parents encounter. As the child experiences
success, rewards can be gradually faded.
Fluid Restriction
Fluid restriction is probably the most commonly prescribed recommendation by physicians and psychologists. Unfortunately, there is little
to no research that provides evidence that this practice should be recommended. Limiting fluids will not result in the child remaining dry
throughout the night. Nearly all children will continue to wet, but just at
a lower volume. Additionally, parents will often report that children are
highly defiant and oppositional due to their fluids being restricted, usually after dinnertime. The amount of behavioral resistance and pushback
that parents get from restricting fluids often results in a more significant
problem than the one that they were trying to prevent. Again, restricting or limiting fluids does not prevent children from wetting the bed. It
just simply limits the amount of urine that is produced. Thus, clinicians
would be wise to avoid recommending fluid restriction as part of their
overall treatment protocol.
Medical Treatment
As discussed previously, it is essential that children are seen for a full medical evaluation before behavioral interventions are started. As such, it is
quite common for physicians to prescribe medication to treat nocturnal
enuresis. In all likelihood, children either will have tried a course of one of
the more common medications to treat enuresis or may come to you on
a prescribed treatment. There are two commonly prescribed treatments,
one is a tricyclic antidepressant and the other an antidiuretic.
50
Imipramine
Imipramine (Tofranil) is a tricyclic antidepressant that has been prescribed since the 1960s. Imipramine was prescribed for the treatment of
enuresis after psychiatrists in Melbourne, Australia, observed that adults
treated for depressive illness were having difficulty urinating. This resulted
in different tricyclic antidepressants being prescribed to treat children
with nocturnal enuresis. Imipramine was the most commonly prescribed
tricyclic antidepressant. The tricyclic antidepressants have been shown
to have anticholinergic properties; however, their exact mechanism of
action is not well understood. Once the tricyclic antidepressant has been
stopped, symptoms often recur. The long-term cure rate has been shown
to be somewhere between 20 and 25 percent (Christophersen & Friman,
2010). Also, tricyclic antidepressants have some overdose risk and, thus,
require careful monitoring and administration.
Desmopressin
Desmopressin (DDAVP) is an antidiuretic that is a synthetic analog of
vasopressin. Desmopressin works by concentrating urine, thus increasing the likelihood for incontinence to be reduced. Desmopressin works
as quickly as imipramine, and it is believed to have fewer side effects.
Thus, desmopressin is typically preferred by physicians over imipramine
and is prescribed much more commonly. The effects appear to be similar.
Desmopressin seems to cause long-term benefits in about 2025 percent
of children. Typically, desmopressin is prescribed to be used episodically
for overnight stays or short vacations. Most physicians do not prescribe
it for long-term use. As with imipramine, wetting often returns once the
medication has been stopped. Also, there have been recent concerns with
desmopressin. The Food and Drug Administration issued a warning in
which potential serious side effects could occur, especially with the inhaled version of desmopressin. Thus, restrictions have been placed on
the form of desmopressin that is prescribed, and recommendations have
been offered in regard to children not using the inhaled version of desmopressin. Most recently, desmopressin has come out in a melt version
that is reported to be more effective than the oral version. These decisions,
of course, are left to physicians who are prescribing the medication, but
Nocturnal Enuresis
51
awareness of the potential side effects, especially of the nasal form, should
be made clear to clinicians and families.
There is some evidence to suggest that the use of desmopressin in
combination with urine alarm therapy can increase the success rate for
children being treated for nocturnal enuresis. McGrath et al. (2000) suggested that the use of both desmopressin and alarm therapy may have
improved long-term benefits. There have not been a significant number
of studies to support this, but the combined effect of the two certainly
makes logical inherent sense. Further investigation is certainly needed.
Case Study
Here is a case study that is representative of children being seen for nocturnal enuresis.
Reason for Referral: John, a 10-year-old male, was referred by his parents
for treatment of nighttime bed-wetting. John has experienced almost
nightly bed-wetting since birth, and his parents are seeking further assessment and treatment to address this concern.
Medical History: John was born full term and met all developmental milestones. He had tubes placed in his ears at 1 year of age. He had his adenoids and tonsils removed at 18 months. He has also been prescribed
medication for the treatment of seasonal allergies. John has not experienced any other major illnesses, hospitalizations, injuries, or surgeries.
John has seen his pediatrician on a regular basis and, for the most part,
has been healthy. At around age 5 years, Johns parents expressed concern regarding his nightly bed-wetting. The pediatrician indicated that
John would likely outgrow this concern. Desmopressin (DDAVP) was
prescribed for episodic use during overnight stays or when the family was
on vacation. John responded well to the DDAVP, but the parents chose
not to use the medication other than for special occasions.
Social History: John is a 10-year-old male who lives at home with his
natural mother and father and two siblings. He has an older sister, age
15 years, and an older brother, age 18 years. Johns parents work on a
full-time basis away from home. Both Johns father and his older brother
have a history of nighttime bed-wetting. His brothers nighttime wetting
52
resolved at age 9 years. Behavioral health history within the family is otherwise unremarkable.
Psychiatric History: John experienced sleep onset problems around the age
of 3 or 4 years. The parents sought further consultation through a child
psychologist at the recommendation of their pediatrician. John and his
parents had a total of five visits with the child psychologist. A number
of interventions were recommended, and Johns sleep onset problems resolved. He has not received any other behavioral healthcare services. The
parents stated that although John had sleep onset problems around the
age of 3 or 4 years, he has never had a difficult time sleeping through the
night. In fact, they describe John as a very heavy sleeper. They often have
difficulty awakening John in the morning. Previous attempts to awaken
him in the middle of the night to escort him to the bathroom have met
with limited to no success.
Description of Reported Concern: An interview with Johns parents indicated that he has wet the bed nearly every night since birth. The parents
stated that there have been rare occasions when he has awakened dry.
They toilet-trained him at around age 3 years with little difficulty. John
had no difficulty urinating or having bowel movements in the toilet during the day. However, he has consistently awakened with wet bedding
and/or clothing nearly every morning. John has worn a pull-up to bed
almost nightly due to the frequent wetting. For a period of time, his parents placed him in regular underwear, hoping that the wetness and lack
of absorbency with regular pajamas and underwear would result in John
having greater awareness and increase his opportunity to go to the bathroom. This did not occur, and John has continued to wet at night, regardless of whether he wears a pull-up to bed or is in pajamas. The parents
consulted with his pediatrician at around age 5 years. The pediatrician
prescribed desmopressin for episodic use. The pediatrician also indicated
to the parents and John that he would likely outgrow this concern.
The parents have implemented several interventions in an effort to
help John. They limited fluids for a period of time, which had no effect on the frequency of Johns nighttime wettings. They also attempted
to awaken him at night, typically when they were going to bed. On
some occasions, this was helpful to John. The parents stated that they
Nocturnal Enuresis
53
escorted John to the bathroom. If they were successful with getting John
to urinate, he would often awaken in the morning dry. John had no
recollection of his parents escorting him to the bathroom, and when
the parents discontinued this practice, the nighttime wettings returned.
The parents also put in place several positive reward systems in which
John earned access to special activities or items for remaining dry in the
morning. John expressed excitement and interest in the reward system,
but was unsuccessful in remaining dry. As John has gotten older, he has
expressed increased frustration to his parents over the nighttime wetting.
Due to Johns frustration and the chronicity of the issue, they decided
to seek further consultation. The parents contacted Johns pediatrician,
who referred them to a child psychologist for further assessment and the
development of treatment efforts.
During the conversation with John, he expressed understanding
that he will likely outgrow the nighttime wetting. He also understands
that there is likely a genetic connection to his nighttime wetting due
to his fathers and brothers history of nighttime wetting. Despite this,
John stated that he is becoming frustrated. He stated that he is avoiding nighttime sleepovers with his friends and staying with grandparents
due to the nighttime wetting. He stated that the medication that he
takes has been helpful, but he is concerned that on some occasion, it
may not be helpful, and he is worried about being embarrassed should
he have a nighttime wetting episode away from home. He also stated
that it is very frustrating for him to awaken with a wet pull-up or wet
bedding and pajamas each morning. John appeared highly motivated
to implement interventions that may help him to resolve the nighttime
wetting.
At the end of the initial visit, homework assignments were discussed
with John and his parents. The parents were asked to keep a journal
of Johns wetting episodes. They were also asked to check him prior to
them going to bed at night to determine whether his bed was wet. This
was in an attempt to determine whether John was wetting during the
first one or two cycles of sleep. John and his parents were asked to bring
the information back with them to the first follow-up visit. A total of
seven return visits were scheduled. Details of those visits are discussed
as follows.
54
Follow-up Visit #1
At the first visit, the data collected by John and his parents were reviewed.
It showed that John was dry each night when his parents went to bed
around midnight. This suggested that his wetting episodes were occurring
later in the evening. A wide range of treatment options were discussed
with John and his parents. They included the use of a wet alarm, retention
control training, Kegel exercises, cleanliness training, a reward system,
and scheduled awakenings. After some discussion, it was decided that
the parents would purchase a wet alarm. Additionally, the use of retention control training, Kegel exercises, cleanliness training, and a reward
system would be used. The therapist recommended that the parents avoid
using the wet alarm until John had had sufficient time to make use of the
retention control training and Kegel exercises. Once John had demonstrated good success with retention control training and the use of Kegel
exercises, the wet alarm and cleanliness training would be added. The potential components of a reward program were also discussed. It was agreed
that John would engage in the retention control and Kegel exercises on a
daily basis. John was motivated to see how much urine he could produce
into a receptacle that had measurements along the side. Johns parents
agreed to reward him for increasing his urine output to a total of 6 oz.
The therapist also discussed how John could use Kegel exercises both during live stream interruption when he was urinating and also through dry
training. This was described, and all related questions were answered by
the therapist. Additionally, John and his parents were asked to continue
to keep data on his nighttime wettings. A follow-up visit was scheduled
for 2 weeks.
Follow-up Visit #2
At the second return visit, John and his parents reviewed the data with the
therapist. John experienced one dry night each of the past 2 weeks. He
was also able, through retention control training, to increase his bladder
output from 4 oz at baseline to 6 oz by the end of the training. He also
reported that he had been practicing the Kegel exercises both through
live stream interruption and through dry training. Further treatment
Nocturnal Enuresis
55
components were then discussed. The therapist reviewed with the parents
and John several available wet alarm devices. The family selected one, and
it was demonstrated for the parents by the therapist. The leads (that are
attached to the childs pajamas) were placed in a glass of water to demonstrate how the alarm goes off once the leads come into contact with
wetness. The therapist also showed John how the leads would be attached
to his pajamas and placement of the alarm itself. The family decided to
use a wireless alarm. One speaker was placed by Johns bedside and the
other in the parents room. Additionally, John was asked to remove any
wet clothing or bedding should he experience a wetting episode. John
was asked to continue with retention control training and Kegel exercises.
Also, the therapist discussed with John and his parents a reward system.
It was agreed that John would earn 50 cents for every morning that he
awakened dry. John would be allowed to keep whatever money that he
had earned by the end of each week. Additionally, it was agreed that John
would place a poker chip in a jar for every night that he was dry. Once the
jar was full, John would be allowed to take a friend to a movie and have a
pizza party. A follow-up visit was scheduled for 2 weeks.
Follow-up Visit #3
At this visit, John and his parents reported that John experienced a total
of four dry nights over the past 2 weeks. John appeared more motivated
and seemed excited about the fact that he was dry during four nights. The
parents reported that on three of those nights, John woke up dry without
awakening during the night. During one of those nights, he did awaken
during the middle of the night and used the bathroom appropriately.
John also had earned the agreed upon rewards, and although they were
relatively small, he appeared motivated to continue to earn access to both
money and eventually a movie with a friend. The therapist decided to
discontinue the retention control training and Kegel exercises and continue with the use of the wet alarm, cleanliness training, and the reward
system. The parents did report that John was exhibiting some resistance
with the cleanliness training. John stated that he was too tired to change
his pajamas or bedding. The therapist explained the rationale behind John
56
changing his clothes and bedding and recommended that John continue
with this expectation. A follow-up visit was scheduled for 2 weeks.
Follow-up Visit #4
At this visit, John and his parents reported a total of six dry nights. Johns
motivation continued to be relatively high. Resistance toward cleanliness
training continued, but not to the degree that was demonstrated at the
previous visit. This was perhaps due to him having two additional dry
nights. The reward system was also in place, and John appeared motivated
by the reward system. A follow-up visit was scheduled for 1 month.
Follow-up Visit #5
At this visit, John experienced only two wet nights during the past
1month. Given Johns success, the therapist left all components in place
but added an overlearning component. John was asked to consume 16oz
of fluid before bed each night. The rationale for the overlearning procedure was provided, and the therapist explained why it was important
for John to drink the increased fluids. John was exhibiting less resistance
with the cleanliness training, and the reward system was taking on greater
importance due to Johns success. A follow-up visit was scheduled for 1
month.
Follow-up Visit #6
At this visit, John was experiencing dry nights nearly every night. He
had experienced only one wet night during the past 1 month. John was
doing very well with the money he earned for dry nights and was excited
to discuss the reward that he had earned in which he and a friend went
to a movie and had a pizza party. The parents had added a new reward
that John was working toward. The therapist recommended that John
continue with the cleanliness training, even though it was rare for John to
wet during the night and the impact of the cleanliness training was likely
minimal. Regardless, the therapist felt as though it was important for
John to be responsible for replacing any wet clothing or bedding should
Nocturnal Enuresis
57
it occur. The efforts put forth by John and his parents were acknowledged
by the therapist, and a final visit was scheduled for 2 months.
Follow-up Visit #7
This was Johns final visit. John had experienced dry nights every night
for the past 2 months. The parents had discontinued on their own the use
of the wet alarm several weeks before. John was awakening on occasion
in the middle of the night to use the bathroom, but, on other nights, was
sleeping through the night. John was excited that he had been dry every
night for the past 2 months. The therapist had a discussion with John and
his parents in regard to how to fade out the reward system. The therapist discussed with John and his parents strategies that would help John
maintain his progress. The therapist asked Johns parents to contact him
in 2 months to provide a phone update on Johns progress. Recommendations were also offered in regard to situations or conditions in which it
would be important for John to return for a follow-up visit. Given Johns
progress, it was agreed that treatment would be discontinued.
Index
Access to special activities/items,
139140
Antidiuretic hormone (ADH), 10
production of, 1011
Anus, sphincter of, 17
Anxiety, 9
Arousal dysfunction, 21
Attention-deficit/hyperactivity
disorder (ADHD), 9, 14,
9899, 105
comorbid with, 14
co-occurrence of, 14
symptoms, 9, 127
Augmentative treatment
components, 45
Avon Longitudinal Study of Parents
and Children (ALSPAC), 5, 8
Awakening, scheduled, 4647
Awareness of physical cues, 117
Bakwin study, 8
Bed-wetting treatments, 19
Behavior modification techniques,
7879
awareness, 79
baseline data, 79
caretaker response, 8283
dry pants check, 7980
regular bathroom breaks, 81
responsibility training, 82
rewards and positive feedback,
8182
use of wet alarms, 8081
Biobehavioral approach, 36
Biobehavioral model, 1522
Bladder distention, stimulus of,
4546
Bladder dysfunction, 1112, 21
Bowel motility, 97, 108
Bowel movements, 97
Caregivers, 34, 87
outside, 126127
Case study
diurnal enuresis, 8489
encopresis, 144151
nocturnal enuresis, 5157
Chronic constipation, 97, 109,
124125
characteristics of, 97
Cleanliness training, 4749, 5456
effectiveness of, 47
Clean pants check, 140141
Cleanup process, 118
Comorbidity, 1315, 6465, 9799
Compliance, 121
Conceptualization
diurnal enuresis
comorbidity, 6465
etiology, 61
functional causes, 6163
organic causes, 6364
encopresis
comorbidity, 9799
differential diagnosis, 100
etiology and risk factors, 9597
models, 101103
nocturnal enuresis
behavioral and psychosocial
factors, 810
biobehavioral model, 1522
bladder dysfunction, 1112
comorbidity, 1315
differential diagnosis, 15
etiology and risk factors, 78
global/maturational delay, 1213
nocturnal polyuria, 1011
risk factors for, 13
sleep arousal, 11
Congenital aganglionic
megacolon, 100
Congenital megacolon, 100
Constipation, 6263, 95, 99, 102
chronic, 97, 109, 124125
encopresis without, 92
functional, 94
160 INDEX
Constipation, 6263, 95, 99,

102(continuous)
pathophysiology for, 97
and stool impaction, 102
Cooperation level of child, 113
Data collection, 128
Daytime frequency syndrome, 62
Daytime wetting, 2, 59, 6166,
6973, 7784
cause of, 62
Delay urination, 45
Desmopressin (DDAVP), 5051
inhaled version of, 50
melt version of, 50
side effects, 5051
use of, 51
Diabetes, 6364
Diet, 122123, 125126
DISC (Diagnostic Interview Schedule
for Children)., 14
Disruptive behavior, 9
Diurnal enuresis
case study, 8489
conceptualization (See under
Conceptualization)
description and diagnosis, 59
DSM/ICD definitions, 5960
epidemiology, 6061
evaluation and assessment, 6566
initial clinical interview (ICI)
(Seeunder Initial clinical
interview (ICI))
prevalence of females, 61
subtypes, 60
treatment (See under Treatment)
Diurnal urinary incontinence, 60
Dry bed training, 46
DSM-5 criteria
encopresis, 93
for encopresis, 93
for enuresis, 34
DSM/ICD definitions, diurnal
enuresis, 5960
Edible rewards, 135136
Electrodes, 17
Emotional stress, 63
Encopresis, 99
case study, 144151

clean pants check, 140141
overcorrection, 141143
Conceptualization)
with constipation, 95
data record, 119
description and diagnosis, 9192
DSM-5 criteria, 93
evaluation and assessment, 104
behavioral evaluation, 104105
medical evaluation, 104
functional constipation, 94
ICD-10 criteria, 93
initial clinical interview (ICI) (See
under Initial clinical interview
(ICI))
nonretentive fecal incontinence,
94, 95
physical and behavioral factors, 101
responding to soiling episodes, 140
treatment (See under Treatment)
without constipation, 92
Exercise, 122123, 125126
Fecal cleanout, 98, 120121
Fecal impaction, 98
Fecal incontinence, 92
Fiber, 125126
intake, 122123
Finnish population-based study, 8
Fluid homeostasis, 10
Fluid restriction, 16, 49
Frequency, 72
Full home training programs, 46
Functional patterns, 72
Gastrointestinal (GI) tract, 92
Genetics, 7
Giggle incontinence, 62
Global/maturational delay, 1213
Hirschsprungs disease, 100
ICD-10 criteria, encopresis, 93
Imipramine (Tofranil), 50
Initial clinical interview (ICI), 2324
diurnal enuresis
assessment methods, 68
INDEX
161
checklist for diurnal enuresis,

6768
child interview, 7476
clinical presentation, 71
follow-up plan, 7677
medical history, 6970
parent interview, 7174
presenting problem, 66
psychiatric history, 7071
social history, 6869
encopresis, 105116
behavioral health history, 110
social history, 107108
nocturnal enuresis
checklist for nocturnal enuresis, 25
presenting problem, 24
psychiatric history, 2728
social history, 26
Intentional stool-holding, 96
children with, 12
clinical information, 3
complications related to, 89
Conceptualization)
definition, 12
description, 1, 34
diagnosis, 1
epidemiology, 47
etiological focus of, 18
evaluation and assessment
behavioral, 2324
initial clinical interview, 2434
medical, 23
history of individuals with, 11
initial clinical interview (ICI) (See
under Initial clinical interview
(ICI))
maturational delays on, 21
monosymptomatic vs.
polysymptomatic
symptoms, 2
physical causes of, 23
primary, 9
vs. secondary symptoms, 23
studies reporting incidence of,
57
treatment (See under treatment)
Nocturnal polyuria, 1011, 21
Nonretentive fecal incontinence, 92,
9495
Kegel exercises, 46, 5455, 78
Oppositional behavior, 44
Outside caregivers, 126127
Overcorrection, 141143
Mechanics, 125
Megacolon, 122
Micturition deferral, 6162
Monosymptomatic symptoms, 2
Monozygotic twins, 7, 8
Motivational level, 118
Neurogenic bladder, 63
Nighttime continence model, 22
Nighttime wetting, 45
Nocturnal enuresis, 10
behavioral management of, 22
biologic understanding of, 21
case study, 5157
causing, 8, 15
Pad-type alarm, 37
Pajama devices, 38
Parental cooperation, 43
Parental demeanor, 126
Physical cues
awareness of, 117
responding to, 128129
Physiotherapy, 78
use of, 77
Polysymptomatic symptoms, 2
Primary diurnal enuresis, 59
Primary nocturnal enuresis, 9
162 INDEX
Psychodynamic theory, acceptance

of, 18
Punishments, rewards and, 118
Resistant child, 130134
Responsibility training, 83
Retention control training, 4547
Retention training, use of, 7778
Rewards
edible, 135136
jar, 137138
longer-range, 48
and punishments, 118
systems, 4849, 114115
Rome III classification, 92
Rome III criteria, 9293
Scheduled awakening,
4647
Secondary diurnal enuresis, 59
Secondary enuresis, 9
Sit times, 117
Sleep arousal, 11, 13, 2022
Sleep, stages of, 46
Sleep terrors, 11
Sleepwalking, 11
Soiling accidents, 114
Soiling episodes, 115
Stool consistency, 111112
Stool pattern, 112
Stool softeners, daily treatment with,
121122
Strychnine, 16
Suppositories, 121
Symptom-focused treatment, 36
Three systems model, 2021
The Three Systems Model (Butler and
Holland), 20
Toilet
bowel movements in, 134140
habits, 74, 87
sitting on, 129130
urinating in, 81
Toileting routine, 112113
Toilet Training in Less Than a Day

(Azrin and Foxx), 20
Token rewards, 136137
Treatment
behavioral contingencies, 7883
physiotherapy, 78
special considerations, 8384
encopresis
behavioral treatment, 123140
medical treatment, 120123
nocturnal enuresis, 3436
barriers to success, 4351
description of device, 3738
efficacy, 4142
history, 3637
mechanism of action, 3839
procedure, 3941
relapse, 4243
techniques, 36
Tricyclic antidepressants, 50
Urethral obstruction, 63
Urge syndrome, 63
Urinary meatus, cauterization of,
1617
Urinary tract infection (UTI),
6162
Urination, stimulus for, 45
Urine alarm therapy, 51
Vaginal reflux, 62
Vasopressin, 10, 50
Wet alarm, 36
barriers to success, 4345
description of device, 3738
efficacy, 4142
history of, 3637
mechanism of action, 3839
procedure, 3941
relapse, 4243
Wetting pants in class, 77
Wireless alarms, 38
Wrapped rewards, 139
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Elimination Disorders

Thomas M. Reimers, PhD

Elimination Disorders: Evidence-Based Treatment for Enuresis and Encopresis

to combine science, empirical support, and evidence-based interventions

characterological or psychological problem associated with one who is

periods of continence, followed by periods of incontinence. Secondary

Chronological age is at least 5 years of age (or equivalent

There are many studies reporting the incidence of nocturnal enuresis.

not impact the childs behavior at school. Fourteen percent

decreasing to around 2 to 3 percent by age 10 years. Most

The prevalence rate of 15 percent is consistent with what is seen in many

population-based study, the results showed that the concordance rate

to become punitive or to lose control of their emotions in regard to a

have demonstrated a positive correlation between average height and

Perhaps, the strongest comorbid condition with nocturnal enuresis is

Urinary tract infection

the treatment recommended by Pliny the Elder was the consumption

with silver nitrate so as to render it more tender to the passage of urine.

Figure 1.1 Bed-wetting treatments through the ages

Figure 1.2 Three systems model

Figure 1.3 Nighttime continence model

Evaluation and Assessment

Table 1.1 Interview checklist for nocturnal enuresis

Behavioral Health History

Onset and Frequency

ICI, they will often defer to parents or look at them for

treatments for any medical conditions. This will include

disruptiveness that was present in regard to implementation of

know whether there is a trend toward the child becoming

families, the child is completely responsible for removing

as to whether the childs wetting habits change during

can be informative. Asking the child how often they

because they are not able to participate in sleepovers with

probability for success with treatment package. In general,

5. Keep treatment symptom-focused. Parents sometimes have a tendency

Pajama devices: One of the disadvantages of the pad-type

(unconditioned response, UR). After enough pairings of the alarm with

of each wetting (if known). Two to three weeks of baseline data

good effectiveness. One particular multicomponent treatment approach

Another variable that may be helpful in regard to reducing relapse and

the family will be willing to implement it in the future. Discussing

combined with the use of a wet alarm. There is questionable benefit of

having both an immediate reward and access to longer-term rewards will

Constipation, 6263, 95, 99,

case study, 144151

checklist for diurnal enuresis,

Kegel exercises, 46, 5455, 78

Psychodynamic theory, acceptance

Toilet Training in Less Than a Day

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Learning Disabilities by Charles J. Golden and Lisa K. Lashley

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