Running Head: ENURESIS - Weebly



Running Head: ENURESIS

Practical Paper: Enuresis

Sarah Brick

Child and Adolescent Therapy

Professor Katy Araujo

Enuresis

According to the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text revision, American Psychiatric Association, 2000), enuresis is repeated voiding of urine into clothing or bed. Involuntary or intentional urination must occur at least two times a week for three consecutive months or cause significant distress in social, academic or other important areas of functioning. The child must have reached an age at which continence is expected, which is five unless developmental delays are present. When the child is developmentally delayed, continence is expected at a mental age of at least five years old. In addition, repeated voiding of urine can not be due to a general medical condition or the direct physiological effects of a substance (e.g. diuretics).

The DSM IV TR distinguished between three types of subtypes. These include, nocturnal only, diurnal only, and nocturnal and diurnal. The nocturnal only subtype is most common subtype, and voiding of urine occurs only during nighttime sleep. Voiding takes place typically during rapid eye movement (REM) stage of sleep. Interestingly enough, children sometimes wake remembering a dream in which they urinated. The diurnal only subtype is more common in girls than boys, and involves the passage of urine only during waking hours. After the age of nine, it is uncommon for this problem to persist. The diurnal only subtype can be divided into two classifications, which are urge incontinence and voiding postponement. Sudden urges of wanting to urinate describe the urge incontinence type. Voiding postponement is likely due to the influence of social anxiety, or a preoccupation with playing in engaging school activities. Typically, children who fall under this category have significant behavioral disruptions. Lastly, the nocturnal and diurnal subtype is a combination of the nocturnal only and diurnal only subtypes.

According to the DSM IV TR cormorbidy of enuresis and mental disorders are low. However, the prevalence of coexisting behavioral symptoms increases in children with enuresis than in children with out enuresis. Delays in development, including speech language, learning, motor skills are present in some children with enuresis. Some disorders that coexist with enuresis include, encopresis, sleepwalking disorder, and sleep terror disorder. Other associated features of enuresis include limited social interaction, lower self esteem, rejection by peers, underachievement in school, and conduct problems in school (Walker, 1995).

Initial evaluations of enuresis should include urinary tract infection and sleep histories, psychosocial history, and family history; a physical examination; and a urinalysis and urine culture (Rushton, 1993). These tests are important to rule out possible general medical condition. The results of these and other test will determine the type of treatment needed. For the purpose of this paper, enuresis not due to a general medical condition is discussed.

Assessment and treatment is a collaborative approach which may include family practitioner, pediatricians, physician assistants, nurse practioners, school nurses, counselors, clinical social worker and psychologists (Geroski, A. M. & Rodergs, K. A., 1998). With so many people involved communication between professional is important for successful and effective treatment.

The treatment of enuresis can take be approached in multiple ways. Treatment typically involves counseling and psychotherapy, behavioral interventions, and pharmacotherapy (Walker, 1995).

The biopsychosocial model and family systems model has had a significant influence of the treatment of enuresis (bishchoff & Benson, 2004). The biopsychosocial model integrates biology, psychology and social aspects into treatment. It provides a larger framework for understanding the disorder (Bischoff, & Benson, 2004). In addition, the family systems approach seeks to understand what how family member are influencing and maintaining a problem (Fletcher, 2000). These two approaches depathologize the child, and make therapy a collaborative approach involving the family.

There are several behavioral interventions for the treatment of enuresis. The enuresis alarm or, bell-and-pad, and dry-bed operant conditioning techniques are reported to have had the highest rates of success for the treatment of enuresis (Azrin, Sneed, & Fox, 1974). Additionally, Rice and Palmer (2004) studied the effectiveness of behavioral conditioning with urine alarm for the treatment of nocturnal enuresis. They found that alarm-based behavioral conditioning reduced the number of wet nights by 61% to 75% when compared to baseline data. Other behavioral interventions include restriction of fluid before bedtime, scheduled toileting prior to bedtime, positive reinforcement for appropriate toileting and dry underwear, bladder stretching by drinking large quantities of fluid then reinforcing the ability to withhold urination for increasing amounts of time (Geroski & Rodgers, 1998).

According to Arajarvi, Kivalo and Nyberg (1977), drug treatment remains the most prescribed therapy for enuretic children. More recently, however Vogel, Young, and Primack (1996) reports that behavioral treatment approaches have more long-term effectiveness than pharmacologic treatment. Vogel et al. (1996) states that pharmacologic treatment remains the preferred treatment approach, none the less. The reported success rates of the anti-depressant Imipramine (for example) are approximately 50%, with relapse rates about 30% (Ullom-Minnich, 1996).

There are several things that one can do to assist the enuretic child. For example, parent can become educated. Dunlop (2005) conducted a study in which results indicated that most parents and guardians of enuretic children did not know that enuresis is a physical problem. Educating parents and children about the disorder may assist in therapy. In addition to education, parents and guardians can ensure easy access to the toilet at night, and encourage small steps, such as going to the toilet before bed without prompting.

Control over bladder and bowels is an important developmental milestone in all cultures (Hackett, Hackett, Bhakta and Gowers, 1999). The prevalence of enuresis varies from culture to culture. Developing countries have generally lower rates of enuresis. For example, children in India, have a prevalence of 2.5%, whereas Westerners have a much higher prevalence rate of about 15.2% (Hackett, et al., 1999).

McDonald and Trepper (1977) examined a historical cultural and contemporary account of etiology and treatment of enuresis. They suggest the cultural relativism of enuresis in that it may not be always be considered pathology. McDonald and Trepper suggest that bed wetting is merely a problem associated with social expectations and developmental delays. Interestingly, however the DSM IV TR considers developmental delays in the diagnosis of enuresis.

The amount of impairment associated with enuresis may be influenced by culture. According to the DSM IV TR, impairment is associated with the amount of social involvement or activity. For example, a child who maintains an active schedule and peer interactions may experience more distress than the child who stays home all day with little to no friendships.

Lunsing, hadders-Algra, Touwen, and Huisjes (1991) conducted a study in which results indicated that 80% of their enuretic subjects had a family history of nocturnal enuresis. It seems fair to assume that genetics as well as culture play an important role in the development of enuresis.

There is an abundant amount of literature on treatments for enuresis. However, studies focusing on a single subject are somewhat rare when compared with the numbers of studies involving multiple subjects. Additionally, in dealing with the topic of enuresis, it may be more helpful and easier to learn from an individual detailed account (Goin, 1998). Therefore, the academic and scientific communities may benefit from directing more attention to studies involving case studies.

Reference

American Psychiatric Association (2000). Diagnostic and Statistical Manual of Mental Disorder, (4th ed.), Text Revision. Washington, DC: Author.

Arajarvi, T., Kivalo, A., & Nyberg, P. (1977). Effect of antidepressants on enuretic school children. Psychiatria Fennica, 83-87.

Azrin, N. H., Sneed, T. J., & Fox, R. M. (1974). Dry-bed training: Rapid elimination of childhood enuresis. Behavioral Research Therapy, 12, 147-156.

Bischoff, G. H. & Benson, B. M. (2004). Childhood enuresis: A biopsychosocial systems approach. Journal of Family Psychotherapy, 15,1-17.

Fletcher, T. B. (2000). Primary nocturnal enuresis: A structural and strategis family systems approach. Journal of Mental Health Counseling, 22, 32-44

Geroksi, A. M. & Rodgers, K. A. (1998). Collaborative assessment and treatment of children with enuresis and encopresis. Professional School Counseling, 2, 128.

Goin, R. P. (1998). Nocturnal enuresis in children. Child: Care, Health and Development, 24, 277-288.

Hackett, R., Hackett, L., Bhakta, P., & Growers, S. (1999). Enuresis and encopresis in South indian population of children. Child: Care, Health and Development, 27, 35-46.

Lunsing, R., Hadders-Algra, M., Touwen, B. & Huisjes, H. (1991). Nocturnal enuresis and minor neurological dysfunction at 12 year: A follow- up study. Developmental Medicine and Child Neurology, 33, 439-455.

McDonald, J. E. & Trepper, T. (1977). Enuresis: An historical, cultural, and contemporary account of etiology and treatment. Psychology in the Schools, 14, 308-314.

Rice, L. M. & Palmer, S. U. (2004). The effectiveness of behavioral conditioning with the urine alarm for the treatment of nocturnal enuresis in emotionally and/or behaviorally disordered children receiving services in a local community mental health care system. Dissertation Abstracts International: Section B: The Sciences and Engineering, 65, 450.

Rushton, H. G. (1993). Evaluation of the enuretic child. Clinical Pediatrics, 93, 14-18.

Ullom-Minnich, M. R. (1996). Diagnosis and management of nocturnal enuresis. American Family Physician, 54, 2259-2266.

Vogel, W., Young, M., & Primack, W. (1996). A survey of physician use of treatment methods for functional enuresis. Developmental and Behavioral Pediatrics, 17, 90-93.

Walker, C. E. (1995). Elimination disorder: Enuresis and encopresis. Pediatric Psychoogy, 18, 814.

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