Parents' and young people's attitudes towards bedwetting and their influence on behaviour, including readiness to engage in and persist with treatment

The Importance of Understanding Parental Perception When Treating Primary Nocturnal Enuresis: A Topic Review and an Institutional Experience

Primary nocturnal enuresis (PNE) is a common childhood disorder that adversely affects a child’s mental well-being and social life. Our clinical experience showed parents and their child often have significantly different perspective of enuresis, and these differences can affect family dynamics, treatment approaches, and treatment success. Parents’ perception of PNE also influences the likelihood of seeking medical treatment, and we found parents of children with enuresis have markedly different beliefs regarding bedwetting than those of physicians. Because achieving remission for PNE requires parents and their child to actively participate in treatment, assessing their expectancy of success and their beliefs will allow clinicians to adjust treatment goals as necessary. When treating PNE, guidelines consistently recommend incorporating bed alarms as part of the therapy. However, through interviewing parents and treating their children, we found parents preferred medications or other behavioral strategies, such as limiting water intake, because of their convenience. Many parents would complain bed alarms woke them up instead of their child, and they would soon give up on bed alarms. Part of assessing their beliefs includes assessing their confidence in their child being able to wake up to alarms and to persist with treatment. Understanding how they manage and approach setbacks will also determine the treatment modality suited for their child. In this review paper, we detailed our experiences interviewing parents and treating their child with NE with urodynamics and medications at the Changhua Christian Hospital in Taiwan.

Parental perception and factors associated with treatment strategies for primary nocturnal enuresis

OBJECTIVE

The aim was to investigate the factors influencing parents seeking reasonable managements for their child and their overall outlook toward primary nocturnal enuresis (PNE).

STUDY DESIGN

We recruited 93 children with PNE from enuresis clinics and requested their parents to complete questionnaires regarding their child's medical history and behavior, their methods for coping with PNE, and their perception of enuresis. Logistic regression models were applied to investigate factors influencing the parents to adopt a positive approach toward enuresis and to subsequently seek a medical consultation.

RESULTS

One-third of the parents had an encouraging attitude toward children with PNE, whereas slightly less than half reacted with anger. The more educated the father or the younger the child with NE, the larger the possibility of the parents utilizing a positive approach, such as encouragement, for coping with NE. Factors that influenced parents to seek medical consultation for NE were socioeconomic status, maternal educational level, and the age and birth order of their child.

DISCUSSION

From our results, angry and frustrated parents (43.0%) were significantly more likely to punish their child for bedwetting than were parents who approached NE positively (comfort and encouragement; 33.3%). A lack of encouragement may negatively affect the self-esteem of children with NE. Moreover, an individual's self-esteem or confidence, both of which can help them eliminate NE, determines the person's behavioral response to bedwetting. In our study, approximately 50% of the parents who approached NE positively (comfort and encouragement) or inconsistently (ambivalence) reported that they comforted their child after bedwetting.

CONCLUSIONS

Nearly half the parents reacted angrily to children with NE, and some parents even punished their child. The parents' socioeconomic background, education, and the age and birth order of the child were the factors associated with their seeking active treatment for NE. A father's education and young age of the child were factors that influenced parents who preferred positive approaches, such as encouragement, for coping with NE.

Parents have different perceptions of bed-wetting than children from six to 15 years of age

AIM

Enuresis is a common childhood disorder that negatively affects children's social and psychological well-being. This study investigated the psychological and emotional problems of children in Taiwan who wet the bed between the ages of six and 15 by comparing feedback from the children, their parents and a control group.

METHODS

This case study featured 93 children with primary nocturnal enuresis from enuresis clinics, and their parents, and 98 nonenuretic controls and parents from the local community. All the parents completed the Behavioural and Emotional Rating Scale (BERS) and all the children completed the Teenage Self-Concept Scale (TSCS). T-scores were used for statistical comparisons and high scores related to higher self-concept.

RESULTS

The parents and their children displayed different perceptions of enuresis, with more behavioural and emotional problems in enuretic children. Older children and children with more severe enuresis reported more difficulties, and low maternal education was also a risk factor.

CONCLUSION

Parental attitudes and perceptions towards bed-wetting were different from their children's. The children's age, enuresis severity and their mothers' educational level were potential risk factors that affected well-being. Health practitioners need to facilitate communication between enuretic children and their parents in addition to monitoring their psychological well-being.

Nocturnal enuresis with spina bifida occulta: Does it interfere behavioral management success?

PURPOSE

We aimed to investigate the incidence of spina bifida occulta (SBO) in patients with nocturnal enuresis (NE) and its effect on the success of behavioral interventions. We also aimed to identify predictive factors related to success of behavioral interventions.

METHODS

A total of 163 patients with NE and 160 patients without NE were enrolled to study. Urinalysis, urine culture, biochemical evaluation, plain radiography and urinary system ultrasonography were performed before treatment. Patients with NE received behavioral interventions for 3 months. Response to behavioral interventions was analyzed according to the presence and absence of SBO. Possible predictive factors for treatment success were also evaluated.

RESULTS

Spina bifida occulta was detected in 47 (28.8 %) children at NE group and 24 (15.0 %) at control group (p = 0.138). Non-monosymptomatic NE was more prevalent in patients with SBO (p < 0.001), and response to the treatment was significantly lower (p = 0.037). Presence of SBO (OR 8.8, 95 % CI 3.1-25.6), NE severity (OR 7.2, 95 % CI 2.4-21.7) and NE frequency on 3-day voiding diary (OR 9.4, 95 % CI 3.7-24.3) were significantly related to the success.

CONCLUSIONS

The presence of SBO, severe NE and higher frequency of NE in voiding diary affect the response to behavioral interventions. Other treatment options such as medical treatment or enuresis alarm may be recommended for those patients.

Simple behavioural interventions for nocturnal enuresis in children

BACKGROUND

Nocturnal enuresis (bedwetting) is a socially disruptive and stressful condition which affects around 15% to 20% of five year olds and up to 2% of adults. Although there is a high rate of spontaneous remission, the social, emotional and psychological costs can be great. Behavioural interventions for treating bedwetting are defined as interventions that require a behaviour or action by the child which promotes night dryness and includes strategies which reward that behaviour. Behavioural interventions are further divided into:(a) simple behavioural interventions - behaviours or actions that can be achieved by the child without great effort; and(b) complex behavioural interventions - multiple behavioural interventions which require greater effort by the child and parents to achieve, including enuresis alarm therapy.This review focuses on simple behavioural interventions.Simple behavioural interventions are often used as a first attempt to improve nocturnal enuresis and include reward systems such as star charts given for dry nights, lifting or waking the children at night to urinate, retention control training to enlarge bladder capacity (bladder training) and fluid restriction. Other treatments such as medications, complementary and miscellaneous interventions such as acupuncture, complex behavioural interventions and enuresis alarm therapy are considered elsewhere.

OBJECTIVES

To determine the effects of simple behavioural interventions in children with nocturnal enuresis.The following comparisons were made:1. simple behavioural interventions versus no active treatment;2. any single type of simple behavioural intervention versus another behavioural method (another simple behavioural intervention, enuresis alarm therapy or complex behavioural interventions);3. simple behavioural interventions versus drug treatment alone (including placebo drugs) or drug treatment in combination with other interventions.

SEARCH METHODS

We searched the Cochrane Incontinence Group Specialised Trials Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE in process, and handsearching of journals and conference proceedings (searched 15 December 2011). The reference lists of relevant articles were also searched.

SELECTION CRITERIA

All randomised or quasi-randomised trials of simple behavioural interventions for treating nocturnal enuresis in children up to the age of 16. Studies which included children with daytime urinary incontinence or children with organic conditions were also included in this review if the focus of the study was on nocturnal enuresis. Trials focused solely on daytime wetting and trials of adults with nocturnal enuresis were excluded.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed the quality of the eligible trials and extracted data. Differences between reviewers were settled by discussion with a third reviewer.

MAIN RESULTS

Sixteen trials met the inclusion criteria, involving 1643 children of whom 865 received a simple behavioural intervention. Within each comparison, outcomes were mostly addressed by single trials, precluding meta-analysis. The only exception was bladder training versus enuresis alarm therapy which included two studies and demonstrated that alarm therapy was superior to bladder training.In single small trials, rewards, lifting and waking and bladder training were each associated with significantly fewer wet nights, higher full response rates and lower relapse rates compared to controls. Simple behavioural interventions appeared to be less effective when compared with other known effective interventions (such as enuresis alarm therapy and drug therapies with imipramine and amitriptyline). However, the effect was not sustained at follow-up after completion of treatment for the drug therapies. Based on one small trial, cognitive therapy also appeared to be more effective than rewards. When one simple behavioural therapy was compared with another, there did not appear to be one therapy that was more effective than another.

AUTHORS' CONCLUSIONS

Simple behavioural methods may be superior to no active treatment but appear to be inferior to enuresis alarm therapy and some drug therapy (such as imipramine and amitriptyline). Simple behavioural therapies could be tried as first line treatment before considering enuresis alarm therapy or drug therapy, which may be more demanding and have adverse effects, although evidence supporting their efficacy is lacking.

Problem behavior, parental stress and enuresis

PURPOSE

We determined maternal and paternal ratings of problem behavior in 5 to 13-year-old children with (non)monosymptomatic enuresis and investigated parental stress and the association between parental ratings of child behavior and parental stress.

MATERIALS AND METHODS

We compared problem behavior in 78 children with (non)monosymptomatic enuresis vs that in 110 without enuresis using the Child Behavior Checklist and the Disruptive Behavior Disorders Rating Scale. Parental stress was measured using the Parenting Stress Index.

RESULTS

Maternal results replicated previous findings of significantly higher Child Behavior Checklist scores for externalizing and total problems compared with those in the control group, whereas no significant differences were found for paternal ratings. Mothers and fathers of enuretic children reported significantly higher scores on the Disruptive Behavior Disorders Rating Scale inattention, hyperactivity/impulsivity and oppositional defiant disorder subscales than parents of children without enuresis. The Parenting Stress Index revealed significantly higher overall stress in mothers and fathers of children with (non)monosymptomatic enuresis compared with that in parents of controls. Especially parental stress related to child characteristics was associated with a greater report of child behavior problems.

CONCLUSIONS

Each parent but especially mothers reported more problem behavior in children with (non)monosymptomatic enuresis than in controls. They also reported more stress, which correlates highly with parental ratings of problem behavior in children with (non)monosymptomatic enuresis.

Relationship of sleep quality and quality of life in children with monosymptomatic enuresis

BACKGROUND

Health-related quality of life (QoL) in children with monosymptomatic nocturnal enuresis might be influenced by impaired quality of sleep. The aim of this study was to evaluate possible deteriorations in QoL and sleep quality and the association between these parameters in children with monosymptomatic nocturnal enuresis.

METHODS

The study consisted of 44 children with monosymptomatic nocturnal enuresis and 27 healthy controls aged 6-15 years. KINDL QoL and Pittsburgh Sleep Quality Index (PSQI) were applied to all children.

RESULTS

Mean total KINDL scores in enuresis and control groups were 65.1 +/- 11.0 vs. 67.4 +/- 13.7, respectively (P = 0.44). PSQI scores were not significantly different between the groups (P > 0.05l). In the enuresis group, age showed significant negative correlation with self-esteem domain of KINDL (r = -0.39, P = 0.01) and positive correlation with sleep duration sub-score of the PSQI (r = 0.37, P = 0.03). Duration of enuresis showed significantly negative correlation with total KINDL score and self-esteem domain (r = -0.32 and r = -0.39, P = 0.04 and P = 0.01, respectively). There was significant correlation between physical well-being sub-score of KINDL with daytime dysfunction and total scores of PSQI (r = -0.53, P = 0.001 and r = -0.41, P = 0.02, respectively). Daytime dysfunction sub-score of PSQI was significantly correlated with friends sub-score of KINDL (r = -0.33, P = 0.04).

CONCLUSIONS

As age of the child and duration of enuresis increase, self-esteem domain of QoL worsens. Moreover, there is a significant correlation of physical well-being and friends domains of QoL score and total and daytime dysfunction scores of PSQI. These findings necessitate global evaluation of QoL and sleep quality in children with monosymptomatic nocturnal enuresis to increase efficacy of health care.

Uma comparação entre crianças e adolescentes com enurese noturna primária: impacto e problemas de comportamento

Esse estudo teve como objetivo comparar crianças e adolescentes com enurese noturna primária quanto ao impacto da experiência da enurese e à presença de problemas de comportamento. A pesquisa foi conduzida com um grupo de crianças (n=76) e adolescentes (n=26) inscritos no Projeto Enurese do Instituto de Psicologia da Universidade de São Paulo. Solicitou-se às mães que preenchessem a Lista de Verificação Comportamental para Crianças e Adolescentes. As crianças e os adolescentes responderam a uma entrevista e a partir de suas respostas foram atribuídos graus de impacto da enurese. Tanto nos escores de problemas de comportamento quanto nos graus de impacto não foram encontradas diferenças significativas entre crianças e adolescentes. Os resultados indicaram apenas tendência de as crianças apresentarem uma maior freqüência de escores na faixa clínica e de serem atribuídos graus de impacto maiores às respostas fornecidas pelos adolescentes.

4. Bedwetting and toileting problems in children

Bedwetting (nocturnal enuresis) is common. It occurs in up to 20% of 5 year olds and 10% of 10 year olds, with a spontaneous remission rate of 14% per year. Weekly daytime wetting occurs in 5% of children, most of whom (80%) also wet the bed. Bedwetting can have a considerable impact on children and families, affecting a child's self-esteem and interpersonal relationships, and his or her performance at school. Primary nocturnal enuresis (never consistently dry at night) should be distinguished from secondary nocturnal enuresis (previously dry for at least 6 months). Important risk factors for primary nocturnal enuresis include family history, nocturnal polyuria, impaired sleep arousal and bladder dysfunction. Secondary nocturnal enuresis is more likely to be caused by factors such as urinary tract infections, diabetes mellitus and emotional stress. The treatment for monosymptomatic nocturnal enuresis (bedwetting with no daytime symptoms) is an alarm device, with desmopressin as second-line therapy. Treatment for non-monosymptomatic nocturnal enuresis (bedwetting with daytime symptoms--urgency and frequency, with or without incontinence) should initially focus on the daytime symptoms.Bedwetting without daytime symptoms, the most common toileting problem, can be effectively treated with an alarm device.

Children presenting at UK community enuresis clinics--comparison with hospital-based samples

OBJECTIVE

This study compares the clinical and psychosocial characteristics and the treatment outcomes of bedwetting UK children presenting at a community enuresis service with those from studies conducted in hospital-based settings.

MATERIAL AND METHODS

Cluster stratification by clinic was applied to ensure that the population attending the 15 enuresis clinics selected was representative. Parents completed the maternal tolerance scale and children completed the impact of bedwetting and Coopersmith self-esteem scales. The electronic databases MEDLINE and CINAHL were searched for the years 1966-2002 for UK-based empirical studies conducted in children aged 5-16 years with nocturnal enuresis.

RESULTS

Children in the community sample were younger and had more day-time wetting than the hospital-based population but did not have significantly lower self-esteem. The impact of bedwetting had the strongest relationship with the Coopersmith self-esteem score, followed by ethnicity and the maternal tolerance score (beta = -0.49, p < 0.001; beta = 2.83, p < 0.001; and beta = 0.45, p = 0.015; respectively).

CONCLUSION

Primary referrals to community enuresis services are younger and have more day-time wetting than those attending hospital-based clinics but the majority do not have low self-esteem. Ethnicity appears to be an important factor in evaluating the impact of wetting on the child.

Nocturnal enuresis in the adolescent: a neglected problem

OBJECTIVE

To assess the features of adolescent bedwetters, as few data are available on enuresis in this age group.

PATIENTS AND METHODS

A specific database for adolescents and young adults was created with the collaboration of various specialists (paediatricians, urologists, gynaecologists, psychiatrists). Questions focused on family and personal history, stressful events, age of attaining urinary and fecal control, characteristics of enuresis (primary vs secondary, monosymptomatic vs enuresis associated with daytime urinary symptoms), school performance, diagnostic examination and physical examinations, and treatment and its response.

RESULTS

Data were collected from 107 enuretic adolescents (mean age 15.3 years, median 14, range 13-23; 63 males and 44 females). A positive family history for enuresis was recorded in 82%. Enuresis was primary in 79 patients (74%), secondary in 28 (26%), monosymptomatic in 76 (71%) and associated with daytime urinary symptoms in 31 (29%). In males monosymptomatic enuresis was significantly more frequent than in females (P < 0.01). Urinary tract infections were reported by 13 patients, all females; eating disorders (anorexia, polyphagia) were present in six. In 85 patients (80%) enuresis was considered severe (> or = three nights/week). Of the 107 patients, 27 (20%) had never consulted a doctor about their problem and 43 (40%) had received no therapy; 66 received desmopressin monotherapy, with a good response (half the number of wet nights) in 44 (79%). There was no relation between response to desmopressin and gender, age, type and severity of enuresis or positive family history of enuresis. Eight patients were provided with a nocturnal alarm but this was not tolerated by two. Altogether, 25 patients refused any therapy or did not comply with the given therapy.

CONCLUSIONS

Enuresis can persist into adolescence and be a significant problem; 80% of these patients had severe enuresis and 31% also had associated daytime urinary symptoms, with 40% receiving no previous therapy. The treatment of enuresis can be particularly difficult at this age; 22% of patients did not respond to desmopressin and 23% had low compliance with the given therapy. Enuresis in adolescents requires further study; hopefully more enuretic children will receive adequate treatment before reaching adolescence.

Secondary nocturnal enuresis

Secondary nocturnal enuresis accounts for about one quarter of patients with bed-wetting. Although a psychological cause is responsible in some children, various other causes are possible and should be considered. This article reviews the epidemiology, psychological and social impact, causes, investigation, management, and prognosis of secondary nocturnal enuresis.

Living with a young person who wets the bed: the families' experience

After allergic disorders, bed-wetting is the most common chronic condition of childhood. It can seriously diminish the quality of life of young people and their families, having an impact on day-to-day activities, family holidays and the young person's willingness and ability to stay away from home with friends and wider family. In this ethnographic study, family members describe the practical and social consequences of bed-wetting, both for themselves and for the family, and the methods that they have employed to encourage the bed-wetting to stop. Most of these methods have little chance of success. Many families' feelings of helplessness and isolation are reinforced by lack of help from healthcare professionals, although the professional's intention to be helpful is rarely questioned. The nature of the families' experiences illustrates the urgent need for adopting a new professional approach to the support of these families, which is based on the principles of 'family nursing'.

'You feel helpless, that's exactly it': parents' and young people's control beliefs about bed-wetting and the implications for practice

'You feel helpless, that's exactly it': parents' and young people's control beliefs about bed-wetting and the implications for practice Young people wet the bed when they fail to wake up to a full bladder. The causes of bed-wetting are far from certain and this uncertainty is reflected in the diversity of treatments on offer and the lack of any guarantee that treatment will work in a particular case. Most young people are sad and ashamed about the bed-wetting and want it to stop, but they vary widely in their belief in their own capacity to influence the situation, and in their optimism about what the future holds. The problem can persist into adolescence or even adulthood, with far reaching social and emotional consequences, both for the young people and their families. In an ethnographic study involving 19 families 'perceived helplessness' emerged as a key issue permeating the whole system and often activating a downward spiral, leading to abdication of effort and responsibility by the young people themselves, by their parents and sometimes by health care professionals. Informed by the insights gained from this study and an extensive review of the literature on perceived control the Family Perspectives on Bed Wetting Questionnaire has been developed to explore family members' feelings, degree of concern and dimensions of perceived control relating to: effort, ability, luck, important others and the unknown. This questionnaire was used as a basis for structured interviews with family members in a longitudinal survey, involving 40 families attending one of nine community-based, nurse-led enuresis clinics in Greater Glasgow. It was found that only 38% of the young people were entering into treatment with the belief that they had the ability to be dry at night. This became self-fulfilling, with only 33% achieving initial success of 14 consecutive dry nights in a 16-week period (chi-squared test, P=0.029). Seventy per cent of young people felt that luck was important, while most parents felt that luck had little part to play. Implications for practice include the need to assess the families' readiness to engage in treatment, to create opportunities for effective control and to encourage realistic expectations.