Nocturnal Enuresis

183 Pages·1987·3.897 MB·English

Nocturnal Enuresis:
Psychological Perspectives
Richard J. Butler BSc, MSc, ABPsS
Principal Clinical Psychologist,
High Royds Hospital,
Menston, Ilkley, West Yorkshire
WRIGHT
BRISTOL
1987
© IOP Publishing Limited. 1987
All Rights Reserved. No part of this publication may be reproduced, stored in a
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Published under the Wright imprint by
IOP Publishing Limited
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British Library Cataloguing in Publication Data
Butler, Richard J.
Nocturnal enuresis: psychological
perspectives
1. Enuresis
I. Title
618.92'63 RJ476.E6
ISBN 0-7236-0899-7
Typeset by
EJS Chemical Composition,
Midsomer Norton, Bath  A3 4BQ
Printed in Great Britain by
Butler & Tanner Ltd, Frome and London
Dedicated to the memory of
Don Bannister
Preface
The last thing one discovers in writing a book is what to put first.
Blaise Pascal 1623-1662
With the text complete, I am now challenged to make clear the
purpose, scope and orientation of this book. Let me immediately state
the focus is concerned with those children who have yet to achieve
bladder control during sleep, synonymously referred to as 'bed­
wetting' throughout this book. It has been estimated that 750000
children over the age of 7 years suffer from bedwetting in Britain at any
one time. The extent of suffering is therefore vast: the embarrassment
felt by children, the guilt of parents and the disruption experienced
within the family is immeasurable. Untreated, it can stretch into
adulthood. Little wonder bedwetting has been described as the most
chronic childhood problem.
I deliberated on a number of titles before deciding on Nocturnal
Enuresis: Psychological Perspectives which I hope captures the pre­
dominant themes. Briefly, the book is a comprehensive overview of
the field, a guide for clinicians; it is psychological rather than medical,
devoted to personal understanding rather than authoritarian advice
and offers an alternative view of the problem in addition to discussing
the more traditional stance.
The excellent collection of chapters in Bladder Control and
Enuresis, edited by Kolvin et al. (1973) is now a decade and a half old
and, despite many recent journal articles, nowhere is there a book
which pulls together the findings and presents an overall picture
exclusively of bedwetting. This book makes such an attempt, drawing
heavily on the literature. Where a number of papers report similar
findings, rather than list a number of articles, a limited number were
chosen with particular emphasis on the most recent.
The development of a guide to interviewing and therapeutic
involvement for clinicians, with detailed direction on method is
attempted. Issues are summarized at relevant points throughout the
chapter rather than at the end of each chapter. The guide is intended
vii
VÜi PREFACE
for all those who come into contact therapeutically with bedwetting
children: for example clinical medical officers, clinical psychologists,
general practitioners, health visitors, paediatricians, psychiatrists,
school nurses and social workers.
Presenting bedwetting within a psychological framework in contrast
to the more traditional medical emphasis is a dominant theme
throughout the book. The medical model attempts to define and
categorize, with little emphasis on the child who suffers with the bed­
wetting. It suggests diagnosis, as with the DSM HI definition
(American Psychatric Association, 1980), although as Verhulst et al.
(1985) have demonstrated the criteria for diagnosis are arbitrarily
chosen, classification (frequently into categories of primary or
secondary enuresis) which seemingly has no predictive value, and
treatment. Ironically, the most successful forms of intervention are not
those of a medical origin but, as will be reviewed, those fundamentally
of a psychological nature.
Many clinicians claim up to 90% of children are freed from
bedwetting when treatment based on psychological principles is used.
Although this indicates the enormous potential psychological
processes can have, it also invites us to understand why some families
(and it can be of the order of 30%) terminate appointments
prematurely, why as many children again return to wetting the bed
after a period of being dry, and why it is that 10% of children fail to
achieve regular dry nights. In many respects it is these children who
invite us to challenge our current assumptions, to offer fresh ideas and
ultimately to widen our knowledge of bedwetting.
Over the past few years I have been attempting to understand both
the child's and the mother's understanding of bedwetting from the
stance of the psychology of personal constructs (Kelly, 1955). This
book inevitably draws on this theory and in particular on the many
discussions I have had with my friend, encourager and mentor, Don
Bannister.
R.J.B.
Acknowledgements
I am indebted to the following people for their involvement,
encouragement and advice during my work with bedwetting children
and the creation of this book: Pam Benjamin, Shirley Bottrill, Chris
Brewin, Dorothy Fielding, Ian Forsythe, Amanda Pulían, Tom
Ravenette and Jackie Stainer.
I am also grateful to my wife Sue and to my sons, Joe and Gregory,
for bearing with me during the times I have been drawn to my study to
write, when perhaps I should have been otherwise occupied.
R.J.B.
ix
1. Introduction
Sometimes I feel at night, if I wet again I'll do something stupid like
jump out of the window or commit suicide.
The words of an 11-year-old boy, not representative perhaps of most
children who wet the bed, but an example of how it can evoke misery
and sadness in children who suffer an inability to control their bladder.
Bedwetting may seem a fairly minor or trivial complaint compared
to other childhood problems and illnesses. However, when we begin to
consider the effects it has on those involved, a picture of conflict, fear
and intolerance frequently emerges. Children, as we shall see in later
chapters, adopt many attitudes to their bedwetting, yet tend to be
faced with consequences of a similar nature: the secrecy, smell, a sense
of isolation from peers through fear of staying at a friend's house
overnight and avoidance of school organized holidays. Parents, living
with a problem which can extend for many years, are confronted by
both the practicalities of excessive washing loads and the emotional
consequences such as fear for the child's emotional development and
adjustment, a sense of failure and a helplessness to do anything about
it, often coupled with a confusion over how they should react and deal
with the problem. Collins (1980) suggests bedwetting may be regarded
as the most chronic and prevalent of all childhood disorders.
Bladder control during sleep is typically the final achievement in a
usually consistent developmental sequence. Stein and Süsser (1967a)
report that control of the bowel during sleep marks the beginning of
this sequence which is followed by bowel control during waking hours.
Bladder control during the day soon follows and finally, after a
variable interval, night-time control of the bladder is accomplished.
Figures 1.1 and 1.2 illustrate how this sequence is inferred from the
proportions of children achieving control of these functions at each
age.
These graphs also illustrate how most children become dry by the
end of the third year which, as Campbell (1970) has suggested, is
consistent with normal physiological maturation which has developed
1
2 NOCTURNAL ENURESIS
/
/
/
/ { Control of
bowels .
/
Control of
/
bladder...
Γ Control of
Awake
J bowels
by day ] Control of
Control of
bladder
—ι— —ι—
18 24 30 36 42 48 54 60
Age in months
Fig. 1.1 Percentage of boys with control of bowel and bladder, awake and
asleep, at different ages {n = 356). (Reproduced from Stein and Süsser
(1967a) with permission.)
sufficiently to allow night-time urinary control by this age. However,
as Figs. 1.1 and 1.2 again show, many children do not achieve such
control, so by school age frequent bedwetting is still a relatively
common and distressing problem. Although many children will
become dry during middle childhood years, a small proportion (about
1%) will still fail to be dry at night when they reach the late teens.
There appears to be general agreement over the incidence of bed-
wetting. Most surveys report at least 15% of 5-year-olds continue to
wet the bed regularly (Young, 1969; Lovibond and Coote, 1970;
Pierce, 1980). This percentage decreases to about 5% of 10-year-olds,
2% of 12-14-year olds and 1% of 15-year-olds (Oppel et al., 1968a).
Although absolute figures inevitably differ, prevalence curves for
bedwetting show a characteristic sharp fall between the ages of 1 and
4 years and as Quay and Werry (1979) suggest, apart from a slight
INTRODUCTION 3
/
Control of
Asleep bowels „.
by night Control of
I bladder...
Control of
Awake bowels
by day Control of
bladder
18 24 30 36 42 48 54 60
Age in months
Fig. 1.2 Percentage of girls with control of bowel and bladder, awake and
asleep, at different ages (n = 315). (Reproduced from Stein and Süsser
(1967a) with permission.)
rise between 5 and 7 years, the curve indicates a slowly declining
rate of spontaneous resolution throughout middle childhood and
adolescence. Werry (1967b) has noted that there is no credence to the
popular belief of puberty being a particularly advantageous time for
spontaneous resolution. Forsythe and Redmond (1974) found the
average annual spontaneous cure rate between 5 years and 19 years was
of the order of 14 to 16%. They found 3% were still wetting at 20 years
of age. Doleys (1977) has pointed out that there are no valid predictors
of which children will become dry spontaneously during these years.
However, it does seem girls are likely to become dry more quickly,
although prolonged bedwetting is at least as common in girls as boys.
Verhulst et al. (1985) found agreement with the prospective study of
Oppel et al. (1968a) where in girls the decline in prevalence was
discovered to occur earlier in their development (see Fig. 1.3). Weir
4 NOCTURNAL ENURESIS
20 • boys
• girls
c
Φ.
o
O)
c
•i
4 5 6 7 8 9 10 11 12 13 14 15 16
Age (years)
Fig. 1.3 The prevalence of bedwetting by age and sex with a minimum of one
accident a month. (Reproduced from Verhulst et al. (1985) with permission.)
(1982) in an epidemiological study of the development of 3-year-old
English children found that more boys (55%) than girls (40%) wet at
night.
Verhulst et al. (1985) point out that not until the eighth year are
almost as many boys dry as girls in the fifth year. On average therefore
bedwetting occurs more frequently in boys than girls. Tissier (1983)
reports boys are 30% more likely to be bedwetting than girls. Verhulst
et al. (1985) chose two criteria of frequency to measure the incidence
of bedwetting: at least once a month, and at least twice a month. This
raises an issue of what frequency of wetting episodes constitutes a
problem. More generally, it reflects a problem of definition — at what
point is failure of bladder control during sleep considered problematic
and worthy of intervention? This, of course, depends on the per­
spective of those involved. Clinicians generally determine the
presence of nocturnal enuresis by:
1. The absence of urologic and neurologic pathology.
2. The age of the child.
3. The frequency of bedwetting episodes.
Parents on the other hand become concerned over bedwetting when: