Memoirs of a Psychologist: How to Deal with Bedwetting in Children
The following is a piece on pre-teen parenting tips, co-authored with psychologist Robert Erdei. We partnered with Dr. Erdei to create a series of blog posts geared specifically toward the difficult parenting challenges we were experiencing ourselves. We call this series, "Memoirs of a Psychologist". We hope you enjoy this piece and please don't hesitate to leave a comment below with your thoughts.
Bedwetting, or enuresis, is a behavioral disorder common in childhood and, in some cases, adolescence. The bedwetting has nothing to do with general health and has no organic causes. Children usually learn to control their urination around the age of two during daytime and approximately 80% can fulfill the requirement of sphincter control during the night as well.
Nocturnal continence is established without problems by the majority of children, but considering the variety of skills required to have it, certain problems can arise. For example, the child must be aware of the urgency, he must be able to start initiating urination and inhibiting the impeding urination while awake and even when asleep. The mastery of these skills needs an awful lot of practice, especially for children, who actually have difficulties learning them.
What Does It Take to Diagnose Bedwetting (Enuresis)?
We talk about enuresis as a condition when the child reaches the age of five and they repeatedly urinate into the bed or into their clothing. To have a diagnosis which requires treatment, the occurrence of the problem must have a frequency of at least two cases per week for at least three months and it cannot be explained by developmental delays, substance effects or other conditions.
Bedwetting refers to the form when enuresis that happens during the night hours, usually during sleep (nocturnal enuresis). It is important to know however that enuresis can happen during daytime as well (called diurnal enuresis) and can occur as a mixed form of the two.
The prevalence of the disorder is hard to estimate. About half of the children who suffer from enuresis during childhood, spontaneously recover into adolescence. This is called primary enuresis and is optimally solved by the reaching of eventual voluntary control. In other words, the child typically just grows out of the behavior.
We have to take the opposite into consideration as well; there are several children who reach the ability to fully control urination, but due to some reason (usually a traumatic event), start bedwetting at a later age. This type is called secondary enuresis. The exact prevalence is hard to tell over and above because many children (and families) are ashamed and the cases and causes go un-reported.
How Prevalent is Bedwetting and What Are Possible Causes?
According to British data, 1 in 40 children regularly wet the bed at the age of seven and half years, 1 in every 65 at nine and half years and 1 in 100 children continue to suffer from this parasomnia deeper into adulthood. (NHS Choice, 2013) Other estimates paint a less rosy picture, according to Christophersen & Friman (2004). 25% of boys and 15% of girls are enuretic at the age of six and 8% of boys and 4% of girls still wet the bed at the age of 12. The disorder is more common among boys than girls.
Psychologists can never forget that enuresis can have organic causes; therefore the child must be thoroughly examined medically to find out if there are any problems that require medical treatment. Such conditions can be type 1 diabetes, infections or abnormalities of the urinary tract, damages of the nerves that control the bladder or constipation (which can put pressure on the bladder.) The bladder itself can be a source of the problem as well. The bladder capacity of enuretic children might be lower than the capacity of their peers. This means that, although they urinate the same amount everyday, they feel the urge to urinate more frequently, as the bladder is filled sooner. Another cause is when the kidneys produce too much urine for the bladder to handle. Some children are very deep sleepers and do not detect the signals during night, they wake up in the morning and only realize then what happened at night.
Enuresis has a genetic background as well, if one or both parents were enuretic, it dramatically increases the chance for their child to be enuretic. The assumed inheritance in the background is also supported by twin studies, if one of a monozygotic twin is enuretic, there is a 68% chance that the other twin will wet the bed as well. In non-identical twins the chance is just 36%.
Also, we cannot forget that certain emotional disturbances, like being upset or worried because of a new school, the arrival of a new sibling, the conflict between the parents or the death of a relative, just to name a few examples can also lead to bedwetting. (NHS Choice, 2013, Christophersen & Friman, 2004)
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Bedwetting Solutions & Treatments
Psychotherapy as a Treatment
Classical psychotherapy is rarely successful in itself to treat enuresis. Although emotional problems can lead to occasional bedwetting, it is more common that the opposite happens. A child, who is enuretic will almost certainly face emotional difficulties based on this fact.
Classical psychotherapy can help children to battle enuresis, when the cause is emotional trauma. The role of the parents is especially important in the avoidance of associated emotional stress. The child is not doing it on purpose, therefore it makes no sense to punish or humiliate him or her. Enuresis can be annoying and unpleasant, but in most cases it can be treated effectively.
Medications as a Treatment
Modern treatment methods do not focus solely on the reaching of continence during nights, but consider the well-being of children most important. Effective treatment methods take into consideration a variety of factors, such as the characteristics of the child and the family, their available resources and their willingness. Enuresis can be treated with medication, like hormones that regulate urine production in the kidneys or antichoolinergics, which are relaxing the muscles of the bladder, increasing its capacity.
If you do not want to medicate your child, there is an option of behavioral methods as well (which can be used as a supplement of medication too.) behavioral treatment focuses on the development of certain skills necessary for continence. Children can use urine alarms, which are small devices that sense the first drops of urine and wake up the child. Retention control training can be useful to increase the bladder capacity of the child. This method indirectly affects nocturnal continence, as it focuses on the increased urination during the day.
Kegel Muscle Exercises
The exercise of Kegel muscles is a great way to deal with enuresis as well. It is relatively easy as the child simply tries to interrupt the stream of urine as an exercise. The contraction of the right muscles helps to eliminate all types of enuresis. Parents can apply a waking schedule to prevent bedwetting as well, although, some would argue this is treating the symptoms and not the real issue.
Controlling Fluid Intake
The controlling of fluid intake might help also. Not only too much, but too little fluid intake can contribute to bedwetting. Children should avoid certain types of drinks, for example the ones that contain caffeine and the timing of fluid intake is essential as well, only one fifth is optimal during the evening, the rest should be consumed during the day.
Parents can use motivation schemes, such as rewards for managing bedwetting. These should promote positive behavior and not punish negative behavior. Rewards do not focus on the exact result. They are given because the child sticks to the plan, e.g. controls fluid intake or goes to the toilet before going to sleep. Enuresis is out of his control, it is not making too much sense to reward him for such things.
Improving the Environment
Parents can take measures to deal with bedwetting. You can make sure to have access to the toilet. Bedwetting can happen for the simple reason that the child is afraid to go out, but he cannot hold back his urine. Leave the light on or let him sleep on the bottom of the bunk bed. You can use waterproof covers on the mattress. Try to avoid carrying your child to the toilet, as this will not help him in the long term. Allow the child to change bedding and pajamas during the night. Prepare a clean set and make it available for him. This, alone, can save a lot of embarrassment and help the child cope with his or her issue. (NHS Choice, 2013)
Do not expect that bedwetting solutions will be presented in a short amount of time. As mentioned earlier, the establishment of continence requires extensive training and practice. It can be achieved, however. Effective treatment will allow your child to leave the burden of the secret, which prevents him to go on school trips or sleep by a friend. You must be aware and make your child aware that he is not the only one suffer from the problem.
Your parental love, care and acceptance is most certainly the best way to deal with it.
- Christophersen, E. R., Friman, P. C. (2004): Elimination Disorders, IN: Brown, R. T. (Ed,): Handbook of Pediatric Psychology in School Setting, Lawrence Erlbaum Associates, Publishers, Mahwah, New Jersey, London
- NHS Choices (2013): Bedwetting, http://www.nhs.uk/Conditions/Bedwetting/Pages/Introduction.aspx
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