Saturday, May 8, 2010

Psychology: Battle bed-wetting with knowledge, patience

Psychology: Battle bed-wetting with knowledge, patience

Psychology: Battle bed-wetting with knowledge, patience

Posted: 08 May 2010 12:35 AM PDT

Unknown to even his closest friends, Jimmy suffered from nocturnal enuresis, more commonly known as bed-wetting. Sadly, his hidden problem created significant stress at home and also prevented him from enjoying a normal social life with his friends. "I'm sorry," Jimmy quietly told his friend. "I can come to the party, but I won't be able to stay over."

Urinating in the bed while sleeping is a common problem that affects approximately 20 percent of 5-year-olds, 10 percent of 10-year-olds and 1 percent of 15-year-olds. Before age 5, the numbers are even higher. But usually, by around age 6, children are able to exert greater control over their bladder even when sleeping, and they are either able to hold their urine until morning or get up during the night to relieve themselves.

For those unfortunate children who suffer from bed-wetting, the negative impact on their lives can be significant. Starting each morning with soaking wet sheets can be a trying event for a family. Then there's the ritual of changing clothes, showering and cleaning up the bedding, all before starting on the normal demands of the day.

There is also an effect on social events, including reluctance to attend overnight parties, retreats, camp-outs and even family vacations where there are new surroundings or other people present. Enuresis stresses both children and parents, and can result in feelings of anxiety, depression and poor self-esteem.

Enuresis - a Greek word that means "to make water" - is considered to be either primary or secondary in origin. Primary origin refers to bed-wetting that has been present and ongoing since early childhood without any break or indication of dry toilet habits. A child diagnosed with primary enuresis has never been dry at night for any significant amount of time and is more likely to have physiological or neurological causes for the problem.

Secondary enuresis is bed-wetting that starts up after a child has been dry at night for a significant period of time (more than six months) earlier in life. There is a greater chance that secondary enuresis has underlying emotional or environmental causes.

The actual causes of bed-wetting are somewhat mysterious and speculative. The exact origin of enuresis is not known, and it appears that there may be multiple contributors to the problem.

There is evidence that the origins fall into one of three categories: structural, neurological or emotional. Structural problems refer to abnormalities in the organs, tissues or nerves related to urination, while neurological problems imply that there is an issue in the brain that interferes with the delicate "signaling" process for urination.

An emotional cause is usually based in a response to major stressors, including conflict, loss and change. Major life challenges for children such as starting a new school, having a new baby in the family, moving, death or injury of a loved one, or physical or sexual abuse can sometimes trigger bed-wetting in previously dry children. There are also indications that, in some cases, nocturnal enuresis may be caused by excessively deep sleep patterns or a lack of antidiuretic hormone that slows the production of urine at night.

The good news about enuresis is that it can be treated, even if the exact cause is unknown. In fact, according to the National Enuresis Society, most cases of nighttime bed-wetting will resolve within six months of beginning treatment.

Treatment strategies usually involve some combination of using an alarm system to alert the child when he is wetting the bed, behavioral strategies that reward dry nights, psychological support, altered parenting responses and sometimes the use of medication.

Psychological support includes raising self-esteem, stress management, anxiety reduction, and efforts to make sure the family and parents don't "blame the victim" and thereby increase the child's distress.

Cognitive-behavioral programs work to reinforce "dry" behavior while encouraging positive responses to dry nights rather than punishing bed-wetting episodes. Counseling also can work to reinforce the connection between the brain and the signals that the bladder puts out to initiate bathroom behavior.

It is important that parents not fall sway to the myth about enuresis being something a child does "on purpose" to anger parents, and instead see the problem as a treatable health issue. Children don't wet the bed on purpose, and there is usually a rational cause that is initially out of the child's control.

It is also important to make sure there are no emotional problems, abuse or trauma occurring in the child's life that may be contributing to the problem. To only consider the physical causes of the problem without looking at the emotional contributors and consequences is shortsighted.

As for Jimmy, his parents finally sought counseling and the family was rewarded with rapid progress. Jimmy's treatment combined the use of a medication that limited the flow of urine while engaging him with a behavioral system that rewarded dry nights and encouraged him to "reconnect" his brain to the signals coming from his bladder.

Before long, he successfully went on his first sleepover, which further built his confidence in his ability to listen to his body, even when sleeping. With a renewed sense of self-mastery, Jimmy is confident again in approaching the challenges in his life.

Dr. Scott E. Smith is a licensed clinical psychologist with Spectrum Behavioral Health in Annapolis and Arnold. For services or ideas regarding this column, call 410-757-2077 or write to 1509 Ritchie Highway, Suite F, Arnold, MD 21012.

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