Enuresis 155Behavioural measures
Rewards
It is important that parents do not inadvertently reward and thereby
reinforce enuresis, for example, by letting their child sleep in the parents’
bed once the child’s own bed is wet. The emphasis should be on praise,
attention and other rewards for dry nights rather than on criticism and
punishment for wet nights. Keeping a wall chart of wet and dry nights for
a month (with the child marking each dry night with a star) is quite often
all that is needed to cure the enuresis.
Enuresis alarm
If enuresis persists and the family are sufficiently motivated, the most
successful behavioural technique for bringing about a lasting cure is an
enuresis alarm. Urination activates an alarm that wakes the child. Modern
devices use a small pad in the child’s pyjamas or underpants, with the
alarm being carried in a pocket or on a wristband. When the alarm goes
off, the child is expected to get up, go to the toilet, and change pyjamas and
sheets as necessary (with parental help if needed). Cure rates of 60–80%
are often reported, with children typically achieving 14 consecutive dry
nights in the second month of treatment (though children with intellectual
disability may take up to six months). The likelihood of cure is unaffected
by whether or not the enuresis is primary or secondary, or by the presence
or absence of a family history. The cure rate is lower when there is a
high level of family stress, when the child wets several times a night,
also wets by day, has a psychiatric disorder, or is unconcerned about the
enuresis. Roughly a third of those who become dry while using the alarm
subsequently resume wetting the bed again in the year after treatment is
stopped. There is some evidence that the relapse rate can be significantly
reduced by an ‘over-learning’ technique: once the child has learned to be
dry at night, he or she is encouraged to drink a large quantity of fluids
before bedtime, and the enuresis alarm is continued until the child is dry
despite the fluid loading. However, there are also concerns that a process
that initially worsens wetting may be demoralising.
Why, in behavioural terms, does the enuresis alarm work? There are
elements of classical conditioning: the sound of the buzzer (the uncon-
ditioned stimulus) leads to waking, and eventually the sensation of a full
bladder (the conditioned stimulus) leads to waking too. There are elements
of operant conditioning too: the sound of the buzzer is a somewhat
aversive stimulus and the child learns to avoid it by not wetting the bed.
Finally, social learning theorists might add that the use of the bell and pad
helps the family to notice dry nights and to make more of a fuss of the
child after dry nights.
If the enuresis alarm does not work, it may be sensible to try the
combination of enuresis alarm and desmopressin (see below); or to switch
to medication alone, aiming for symptomatic relief rather than for a
cure; or to give up for a year or so before trying again. Another option