TOILET TRAINING AND ENURESIS: REVIEW AND UPDATE

TOILET TRAINING AND ENURESIS
Parentally Ranked Behavior Problems
in 3 Year Old Children
GIRLS
1. Night wetting
2. Poor appetite
3. Fears
4. Night waking
5. Sleep with parents
6. Day wetting
7. Picky eating
8. Sibling rivalry
9. Overactive
10. Bedtime struggles
11. Attention seeking
BOYS
1. Night wetting
2. Day wetting
3. Soiling
4. Poor appetite
5. Overactive
6. Bedtime resistance
7. Night waking
8. Non compliance
9. Picky eating
10. Sleep with parents
11. Sibling rivalry
Richman, Stevenson, & Graham
Earls
1
RANKED BEHAVIOR PROBLEMS: 3
YEAR OLD CHILDREN
GIRLS
1. Night wetting
2. Poor appetite
3. Fears
4. Night waking
5. Sleep with parents
6. Day wetting
BOYS
1. Night wetting
2. Day wetting
3. Soiling
Richman, Stevenson, & Graham
TOILETING READINESS
Physical readiness




Raise and lower own
garments
Pincer grasp
Fully ambulatory
Sit independently
Bladder readiness

Dry for several hours
Language readiness

Toileting words
Instructional readiness

Follow simple instructions
Emotional-psychological
readiness

Assess for clinical
significance
Proprioceptive readiness

Awareness of urge
2
DAYTIME CONTINENCE
PROLONGED DIAPERING
Big Boy Pampers
Reduced discomfort
Reduced detection
Reduced effort
Delayed continence
3
REMOVING DIAPER
Tarbox, Williams, & Friman, 2004
Steps to Effective Toilet Training
Moratorium
Modeling
Drink up
Naked
Tell don’t ask
Play
Pay
$60
Sit down on the job
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Nocturnal Enuresis
1. Supportive health
education
2. Prescriptive
treatment
DSM IV Definition: Enuresis
Repeated voiding of urine during the day
or night into the bed or clothes whether
involuntary or intentional.
At least twice a week for three consecutive
months
At least five years of age
Not due to a medical condition
5
NOCTURNAL ENURESIS: ETIOLOGY
Psychopathology
Family history
Functional bladder
capacity
Developmental
immaturity
Deep sleep
Limited social
resources
6
Sample Psychopathological
Interpretations
Children wet their beds due to a hysterical
identification with an incontinent parent

Ginot & Harms
Enuresis is the disavowal of female
genitalia

Calef; also see Brown
Sample Tests of
Psychopathological Interpretation
Small minority exhibit an increase in
psychiatric disorders

Shaffer, 1978; Shaffer & Lucas, 1999
Not clinically significant on ECBI

Friman et al, 1998
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Enuresis Comparisons
Enuresis, clinical, and nonclinical samples
N = 97 in each sample
Boys = 68
Girls = 29
Mean age 8.7 years
Range 5 – 13 years
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FAMILY HISTORY
DEVELOPMENTAL IMMATURITY
Decreased height and
lower mean bone age
Late secondary
sexual characteristics
15% spontaneous
cure rate
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FUNCTIONAL BLADDER
CAPACITY
True bladder capacity
Functional bladder
capacity
Incomplete urinations
Frequent urinations

Troup & Hodgson
(1971)
DEEP SLEEP
No EEG differences
between enuretics
and non enuretics
(Kales & Kales, 1977)
Enuretic episodes
occur on a random
basis throughout the
night (Mikkelson &
Rapoport, 1980)
Parent reports
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SOCIAL RESOURCES
Child training needs
versus survival
(Gross & Dornbusch,
1983)
NOCTURNAL ENURESIS: ASSESSMENT
Go no further until a
physician has
evaluated the child
Typical medical
assessment
procedures



Urinalysis
General health exam
Rarely needed—
Voiding Cysto
Urethrogram
Behavioral
assessment


Toilet training history
Urinary elimination
history
Daytime
Frequency
Parental response


Behavior problems
Instructional control
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NOCTURNAL ENURESIS:
TREATMENT
Ancient treatments
Various treatments
Drug treatments
Behavioral treatments
ANCIENT TREATMENTS
Ground hedgehog
testicles
Cauterizing the
urethra
Burning the sacrum
Penile bandages

Glicklich (1951)
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RESULTS OF VARIOUS
TREATMENTS
Spontaneous cure
Counseling
Bladder exercises
Alarm treatment
Multi-behavioral
Medication
15%
25%
35%
70%
>70%
25%
MEDICATION
Tricyclics




Imipramine
M=25%
Very high relapse
Serious Side effects
Desmopressin



(DDAVP)
M=25%
Currently disallowed
by FDE due to side
effects
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BEHAVIORAL TREATMENTS
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BEHAVIORAL TREATMENT OF
ENURESIS
Self monitoring


Reactivity
Valence
Reward system
Clean up
Sleep in own bed
Kegel exercises
Urine retention
training
Waking schedule
Fluid restriction
Visual sequencing
Urine alarm


Noise
Vibrating
Alarm based practice
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VIBRATING ALARM: PRELIMINARY
EVALUATION
Vibrating Alarm
Expected Outcome
WET
DRY
10
9
17.1
1.9
Compared data to expected outcome
Chi-square with a Yates Adjustment

Critical value = 2.711-tailed
2 (1, N= 19)= 4.79, p < .05.
“Size of Spot” Dependent
Measure
3’ X 2.5’ sheet to
record dispersion of
urine
Count number of 1”
grids
More sensitive
measure of wetting
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Weekly Mean Size of Spot
(inches)
Fast Responders
(Dry < 5 Weeks of Tx.)
900
750
600
S4
S19
450
S30
300
S32
150
0
1
3
5
7
9
11 13
15
Week
Slow Responders
(Dry > 6 Weeks of Tx.)
Weekly Mean Size of Spot
(inches)
S3
750
S6
S18
600
S23
S24
450
300
150
0
1
3
5
7
9
11
13
15
Week
17
Partial/Initial-Responders
Weekly Mean Size of Spot
(inches)
1200
1000
S8
800
S14
600
S27
400
S29
200
0
1
3
5
7
9
11
13
15
Week
Weekly Mean Size of Spot (inches)
Non-Responders
900
750
S5
600
S7
S13
450
S20
300
S21
S28
150
0
1
3
5
7
9
11
13
15
Week
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DIURNAL ENURESIS
Very little research
Alarm based
intervention


Halliday & Meadow,
1987
Friman & Vollmer,
1995
ALARM BASED BIOFEEDBACK
Friman & Vollmer, 1995
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NEW ENURESIS RESEARCH
NEEDED
Determination of behavior process

Respondent? Operant? Combination?
Effects of vibrating alarm
Role of sleep
Alarm based practice
Treatment for diurnal enuresis
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