| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Journal of Pediatric Psychology, Vol. 25, No. 4, 2000, pp. 215-218
© 2000 Society of Pediatric Psychology
Commentary: Empirically Supported Treatments in Pediatric Psychology: Nocturnal Enuresis
University of Oulu, Finland, and the Imperial College School of Medicine, UK
All correspondence should be sent to Marjo-Riitta Järvelin, Department of Epidemiology and Public Health, Imperial College School of Medicine, Norfolk Place, London W2 1PG, UK. E-mail: m.jarvelin{at}ic.ac.uk .
 |
Introduction |
|---|
 Top Introduction References |
|---|
The extensive and colorful history of enuresis shows that it has long posed an etiologic and therapeutic problem for physicians. The word "enuresis" is derived from the Greek "enourein," meaning to void urine. The first record of enuresis in the literature is in the Papyrus Ebers dated 1550 B.C., where the recommended remedy for incontinence was one juniper berry, one leaf of cyprus, and beer. Enuresis is mentioned in the first printed book on diseases in children published by Paul Bagellardus in 1472. He states that all treatments for urinary incontinence and bedwetting must be preceded by purging of the body, a probable remedy for relaxation of the vesicle muscles, because it was thought, in spite of magic cures, that enuresis resulted from weakness of the neck of the bladder (Glicklich, 1951
).
With the perfection of human anatomy studies, especially in the form of
nerve pathology, by the eighteenth century, anatomically oriented treatments
began to appear as the magic elements disappeared. The study of enuresis in
Europe, in England in particular, began in the nineteenth century, when upper
class schoolboys in boarding schools wet their beds. Social pressure forced
the medical community to form a task force to investigate enuresis. Similar
research started in the United States at almost the same time; traditionally
most studies have been conducted in these countries
(Järvelin,
1999).
A number of treatments arose, including limitation of fluids, regulation of
diet and exercise, application of cold poultices to the perineum and lower
spine, electric stimulation of the genital and perineal region, and
cauterization of urethra with silver nitrate. Various penile bandages were
used, until a case of gangrene was reported
(Glicklich, 1951). The most
important change in the study of enuresis, which also affected treatment
recommendations from the nineteenth to the twentieth centuries, was the
transfer of etiological emphasis from organic to psychological aspects.
Freud's research at the turn of the century led to the theory that enuresis
was a neurosis or a symptom of personality disorder. Over the next 30-40
years, this concept was widely accepted
(Gerard, 1939), until research
dealing with genetic disposition and other organic reasons for enuresis began
to appear (Hallgren, 1956). One
of the landmark findings for current treatment, in addition to the invention
of enuresis alarm, was made by Poulton and Hinden in the early 1950s
(Poulton & Hinden, 1953).
They showed that large amounts of nocturnal urine output occur in
nightwetters. The observation was replicated by a Danish research group and
led them to discover that nightwetters exhibit low arginine vasopressin levels
at night (Rittig, Knudsen, Norgaard,
Pedersen, & Djurhuus, 1989).
The influence of psychic factors on enuresis and the use of psychological
interventions have been highly debated, the latter partly due to a fear of
symptom substitution. Psychological and other types of treatments have been
systematically researched since the 1960s even though the urine alarm saw its
dawn in the nineteenth century. In 1904, it was accidentally discovered that
the alarm diminished night wetting and the first treatment series was reported
in the 1930s (Mowrer & Mowrer,
1938). To date, more than 300 papers have been published on the
effectiveness of interventions for nocturnal enuresis, but as Mellon and
McGrath write in this issue, only a small number of the studies of
psychological treatments are well controlled. Mellon and McGrath present an
excellent overview of the different psychological treatments for nocturnal
enuresis and the current knowledge of the scientific background of these
treatments and their efficacy.
Treatment preferences have varied in different parts of the world mainly because of different research traditions and etiological emphasis. It is universally agreed that enuresis is multifactorial in its origin, but beliefs about the relative importance of the different etiologies vary. In spite of increased research, particularly over the past 30 years, there has been no comprehensive global agreement on how to examine or treat enuretic children, in part because of the results of research on small and/or selected study groups, which are greatly affected by individual variation between children. Some children clearly have only a genetic disposition and/or low secretion of vasopressin, whereas some children show additional signs of distress. There are very few unselected population-based studies on the etiology or treatment of enuresis. As pointed out by Mellon and McGrath, another major difficulty in comparing the effectiveness of different treatment choices arises from the different definitions of enuresis and treatment response used.
Mellon and McGrath also stress that a symptom-oriented examination and
treatment approach is warranted. It is an essential first-stage tool in
excluding possible functional and structural abnormalities in a wetting child,
helps explain the etiology of a child's wetting, and may aid in the prediction
of response to a planned treatment
(Järvelin,
1989;
Järvelin,
Huttunen, J. Seppänen, U.
Seppänen, & Moilanen, 1990;
Järvelin et
al., 1991). However, I do not suggest any further clinical or
laboratory examinations, not even urine samples, if the child has pure primary
nightwetting and no dysuric symptoms
(Järvelin et
al., 1990). Mellon and McGrath's article is consistent with a
recent committee report on a suggested European treatment strategy of
nocturnal enuresis by Läckgren and co-authors
(1999). Mellon and McGrath
state that assessments are conducted more efficiently when a reliable
psychological and social screening questionnaire is combined with a careful
clinical interview with the child and the parents and with a clinical exam.
This procedure may help identify which children will do best with different
treatment regimens, which in turn may decrease the relapse rate. This also
helps with the interpretation of research results and may explain treatment
failure or relapse.
An abundance of ongoing research on treatment choices, their evaluation,
and their implementation in practice is being conducted in many parts of the
world. In Britain, Butler and co-workers have done important work on
implementing research results into practice
(Butler, 1994). Butler
(1998) stresses the importance
of careful delineation of the symptoms and signs when choosing treatment. The
importance of proper clinical assessment is further stressed in a recent
article by Devitt and co-workers
(1999). Using a small sample,
they demonstrated that the best predictors of desmopressin treatment success
were a past history of breast feeding, mean nocturnal vasopressin
concentration, and the height of the child. The response was adversely
affected by poor weight at birth and poor linear growth.
As shown in the current literature, the main treatment choices are general
counseling and non-medical interventions such as star charts, rewards,
lifting, fluid and food restrictions, enuresis alarm alone or combined with
other treatments, multidimensional behavioral treatment programs, and
medication. Although there are no controlled studies showing the benefits of
general counseling or other nonmedical interventions, there is some evidence
that avoiding certain foods, such as dairy products, chocolate, and citrus
fruit juices or diuretic beverages (coffee, tea, cocoa, and cola), has
benefited a small minority of wetting children particularly as an adjuvant
treatment (see Lister-Sharp, O'Meara,
Bradley, & Sheldon, 1997). The enuresis alarm is effective in
reducing wet nights even though there is considerable variation in the cure
rates between different studies. Initial response to the treatment is
relatively high, but on average one-third of those initially cured relapse. It
seems that those augmented by an overlearning therapy or by medication
(desmopressin; Bradbury & Meadow,
1995) have higher success and lower relapse rates. Research into
multidimentional behavioral treatment programs (e.g., dry bed training, Azrin,
Sneed, & Foxx, 1971; Houts, Peterson,
& Whelan, 1986) suggests that the essential part of the
treatment is enuresis alarm. Currently, the only recommended medication for
routine use is desmopressin. It is clearly superior to a placebo but, although
it is initially superior to an alarm, it has been shown to have higher relapse
rate.
The Mellon and McGrath review, the suggested European treatment strategy
for nocturnal enuresis by Läckgren and
co-workers (1999), and the UK
work on enuresis (Butler, 1998;
Lister-Sharp et al., 1997)
show agreement about the substantive parts of an examination and treatment
strategy. Current research (e.g., Devitt et
al., 1999) also suggests that future studies need to focus on
developing a more profound understanding of the etiology of enuresis, on why
some children who seem to have the same clinical pattern do or do not respond
to the treatment chosen, and on the mechanisms of action of a particular
treatment. This will help to identify an individually specific, etiologically
addressed treatment for an enuretic child.
I will summarize the stepwise strategy for treatment of night wetting
children originally presented by Läckgren and
co-workers (1999), but
modified here to also include suggestions for the preliminary examination
schedule. The principal steps for clinical practice are (1) perform an
"etiologic interview" to explore prenatal and perinatal risk
factors; the child's growth, development, and emotional status; family
distress; and to exclude daytime incontinence (performed by a standardized
screening tool as suggested by Mellon and McGrath); (2) consider the child's
and parental motivation for treatment; (3) explain the disorder to the family,
and emphasize it is not psychological in origin though it may have a current
psychological component; (4) if the family is motivated, and willing to follow
careful instructions, begin with enuresis alarm, particularly useful for those
with sleep arousal disturbance (Butler,
1998); (5) if the alarm treatment is ineffective, discontinue
after 6-8 weeks; (6) consider desmopressin 10-40 µg at bedtime for 3
months; (7) if desmopressin is effective, consider using it for 1 year;
alternatively, try a second course of alarm treatment; (8) do not use
tricyclic antidepressants; (9) be alert to the possibility of emerging daytime
or psychological symptoms; (10) remember that a combination of desmopressin
treatment with enuresis alarm is likely to be more effective than either
treatment alone.
Recent research by Devitt and co-workers
(1999) suggests that children
both with very low or very high arginine vasopressin levels respond poorly to
desmopressin. It seems that desmopressin should be recommended for those
children with low arginine vasopressin levels, urine alarm for those with lack
of arousal from sleep, and a bladder training program coupled with
anticholinergic medication for those who exhibit bladder instability. However,
in clinical practice the measurement of hormone level is troublesome and often
impossible; therefore, it is important to consider other clinical predictors.
The presented strategy is easy to follow and to modify individually and can be
implemented all over the world.
Received August 10, 1999; accepted August 14, 1999
|
References |
|---|
|
TopIntroductionReferences |
|---|
Azrin, N. H., Sneed, T. J., & Foxx, R. M. (1974). Dry-bed training: Rapid elimination of childhood enuresis. Behavior Research and Therapy, 12, 147-156.
Bradbury, M. G., & Meadow, S. R. (1995). Combined treatment with enuresis alarm and desmopressin for nocturnal enuresis. Acta Paediatrica Scandinavia, 84, 1014-1018.
Butler, R. J. (1994). Nocturnal enuresis. The child's experience. Oxford: Butterworth-Heinemann.
Butler, R. J. (1998). Annotation: Night wetting in
children: Psychological aspects. Journal of Child Psychology &
Psychiatry, 39,
453-463.
Devitt, H., Holland, P., Butler, R., Redfern, E., Hiley, E., & Roberts, G. (1999). Plasma vasopressin and response to treatment in primary nocturnal enuresis. Archives of Disease in Childhood, 80, 448-451.
Gerard, M. W. (1939). Enuresis. A study in etiology.
American Journal of Orthopsychiatry,
9, 48-58.
Glicklich, L. B. (1951). An historical account of enuresis. Pediatrics, 8, 859-876.
Hallgren, B. (1956). Enuresis I. A study with reference to the morbidity risk and symptomatology. Acta Psychiatrica et Neurologica Scandinavia, 31, 379-403.
Houts, A. C., Peterson, J. K., & Whelan, J. P. (1986). Prevention of relapse in full-spectrum home training for primary enuresis: A components analysis. Behavior Therapy, 17, 462-469.[ISI][Medline]
Järvelin, M-R. (1989). Developmental history and neurological findings in enuretic children. Developmental Medicine and Child Neurology, 31, 728-736.
Järvelin, M-R. (1999). Nocturnal enuresis. Acta Paediatrica Scandinavia, 88, 589-591.[ISI][Medline]
Järvelin, M-R., Huttunen, N-P., Seppänen, J., Seppänen, U., & Moilanen, I. (1990). Screening of urinary tract abnormalities among day and nightwetting children. Scandinavian Journal of Urology and Nephrology, 24, 181-189.[ISI][Medline]
Järvelin, M-R., Moilanen, I., Kangas, P., Moring, K., Vikeväinen-Tervonen, L., Huttunen, N-P., & Seppänen, J. (1991). Aetiological and precipitating factors for childhood enuresis. Acta Paediatrica Scandinavia, 80, 361-369.
Läckgren, G.,
Hjälm
ss, K., van
Gool, J., von Gontard, A., de Gennaro, M., Lottman, H., & Terho, P.
(1999). Nocturnal enuresius: A suggestion for a European
treatment strategy. Acta Paediatrica Scandinavia,
88, 679-690.
Lister-Sharp, D., O'Meara, S., Bradley, M., & Sheldon, T. A. (1997). A systematic review of the effectiveness of interventions for managing childhood nocturnal enuresis (CRD report 11). York, England: The University of York, NHS Centre for Reviews & Dissemination.
Mowrer, O.H., & Mowrer, W. M. (1938). Enuresis: A method for its study and treatment. American Journal of Orthopsychiatry, 8, 436-459.
Poulton, E. M., & Hinden, E. (1953). The classification of enuresis. Archives of Disease in Childhood, 28, 392-397.
Rittig, S., Knudsen, U. B., Norgaard, J. P., Pedersen, E. B., & Djurhuus, J. C. (1989). Abnormal diurnal rhythm of plasma vasopressin and urinary output in patients with enuresis. American Journal of Physiology, 256, 664-671.
CiteULike 
Connotea 
Del.icio.us What's this?
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||