Michael A. Tompkins, Ph.D.
Co-Director of the San Francisco Bay Area Center for Cognitive Therapy
While most pediatricians favor pharmacologic treatments for nocturnal enuresis, there is growing interest in other treatment strategies, in part because of the limited effectiveness of medications (less than 50% increase in dry nights) and high relapse rates (most children return to their previous wetting frequency) after discontinuing the medication (Moffat, et al., 1993). A well-studied alternative to medications is urine alarm systems (such as the bell-and-pad) that train the child to awaken to the sensation of a full bladder. The overall efficacy of urine alarm systems alone is about 60% (decrease in frequency of wet nights) and, although relapse rates are still high, they are much lower than with medications (Houts, 1994). However, many problems can occur when parents are left to implement the urine alarm system alone, without regard to a number of factors that might influence the child’s compliance and success. I present several guidelines when implementing the bell-and-pad system to treat nocturnal enuresis.
Include incentives for dry nights and disincentives for wet nights. An incentive system can improve adherence with the bell-and-pad system while reinforcing appropriate toileting behavior. Incentive systems can be as simple as stickers on a calendar or plastic chips or tokens the child receives for dry nights. The child then cashes in the tokens for small rewards or privileges (small toys, selecting the movie for the family to watch, outings with a parent). I recommend the child be rewarded for even partial voiding prior to bedtime. In addition, incentives are useful for reinforcing other features of the program, such as positive practice. For example, before bed every night, the clinician directed his parents to prompt 7-year-old Josh to lie in bed and pretend to be asleep. He was to imagine that his bladder felt full and he felt pressure to void. He then imagined jumping out of bed and walking to the bathroom and sitting on the toilet. He practiced the “dry night” behavior three times every night and his parents praised and rewarded him each time with two chips. In addition, after every accident, I instructed the parents to ask Josh to help clean up and change the bedclothes. I asked the parents to deliver this disincentive in a neutral non-punitive manner with the rationale that Josh is learning to take control of his bladder, which includes taking responsibility for the dry nights, as well as the accidents.
Avoid reinforcing bed-wetting behavior. It is essential that clinicians uncover any factors that might reinforce bed-wetting behavior and develop a plan to handle them. For example, Amber is 6-years old and the youngest of three children in a busy household. She was not responding as quickly as I expected to the bell-and-pad system and I asked her parents to explain how they were helping Amber with accidents. I learned from the mother that when Amber wet the bed, she asked Amber to help clean up (as she had been instructed) but then she read a story to Amber to help her get back to sleep. I suggested the mother stop this as it reinforced we nights and instead read a story to Amber in the morning as an additional reward for a dry night. With this change, the treatment quickly was back on track. Similarly, 7-year-old Jack, who was an anxious child and often frightened to go to sleep, tended to have accidents in the first hour of going to bed, and sometimes several accidents during this first hour. I hypothesized that Jack, by wetting the bed, pulled his parents upstairs and delayed his bedtime and thereby avoided his fears. I suggested to Jack’s parents that we delay working on his enuresis and instead help Jack with his fearfulness. Once Jack’s fearfulness was treated, I was able to successfully treat his enuresis.
Avoid habituation to the alarm. Although many clinicians and parents believe that enuretic kids sleep more deeply than non-enuretic kids, there is no evidence to support this idea. However, many children (enuretic or not) can and will sleep through the bell-and-pad alarm if not aroused by a parent. Over time, the child then habituates (or desensitizes) to the alarm, rendering the system ineffective. I recommend clinicians carefully select the parent who will assist the child. Avoid the parent who is a deep sleeper or who is less troubled by the child’s enuresis, as he or she is less likely to follow through with the plan. Ask the parent to sleep near enough to the child’s bed to hear the alarm and to test the alarm system to make certain he or she can hear it. In addition, I ask the parent and child to practice, in my office, the desired “waking up” behavior. The child lies on the sofa in my office and pretends to be asleep. I pretend to be the alarm and when I begin to “ring,” the parent raises the child to a sitting position and says “Charles, time to get up.” The parent helps the child stand and then walks the child around the office to awaken the child fully. The parent and child then use a scripted response to test for alertness (“Charles, if you’re awake please sing the first two lines of the Twinkle-Twinkle Little Star song.”). Once the child has demonstrated that he or she is awake, then, and only then, is the child instructed to turn off the alarm (he taps the top of my head). If habituation to the alarm does occur, you can re-train with a different stimulus (an alarm that buzzes rather than rings, or vibrates) often available with other urine alarm systems.
Houts, A. C., Berman, J. S., & Abramson, H. (1994). Effectiveness of psychological and pharmacological treatments for nocturnal enuresis. Journal of Consulting and Clinical Psychology, 62, 737-745.
Moffat, M. E. K., Harlos, S., Kirshen, A. J., & Burd, L. (1993). Desmopressin acetate and nocturnal enuresis: How much do we know? Pediatrics, 92, 420-425.