Bed-Wetting (Enuresis)

Enuresis, known as bed-wetting, is very common childhood complaint encountered by pediatricians. Nocturnal enuresis (NE) is defined as involuntary passage of urine during sleep beyond the age of expected continence which is 5 years of age. There are two types of NE. Primary is when a child never stopped wetting for any period, whereas secondary is acquired after being dry for at least 6 months. Primary enuresis affects the majority of children with enuresis.

NE is 2-3 times more frequent in boys. Since most NE is due to maturational delay, there is a significant improvement or resolution as the child gets older. Approximately 15% resolve each year. Interestingly, family studies show a strong genetic predisposition for bed-wetting.

Organic causes of enuresis account for less than 5% of all cases; with most being urinary tract infections. Other organic problems include: diabetes, diabetes insipidus, nocturnal seizures, urinary anomalies, nocturnal ADH deficiency, hyposthenuria (constant secretion of urine) associated with sickle cell disease, medications, or emotional stress. Those children need to be identified and treated. Children with severe constipation may compress the bladder and present with bed-wetting. Other theories suggest sleep disturbance or reduced bladder capacity.

The evaluation of NE must exclude any organic causes. A careful history is taken which should include pattern of wetting, fevers, increasing fluid intake due to the sensation of having a dry mouth , excessive or abnormally large production or passage of urine, and prior urinary infections. Questioning about food allergy, sickle cell disease, and constipation is occasionally helpful. Attention should also be paid to stresses and family dynamics that may uncover psychological factors.

There is no treatment modality that is 100% successful so far. Parents should be reminded that a majority of bed-wetting is caused by maturational delay and not under conscious control. Therefore, the important aspects of treatment are reassurance and protection of the child's self esteem. It is important that bed-wetting not be perceived as a bad behavior. because punishment not only lowers the child self esteem, but also does not improve the symptoms. Early education of the caregivers in regards to maturational delay, role of genetics and the importance of a supportive toilet training may ease the difficult period. Remember that there is a 15% spontaneous decrease or disappearance every year so many recommend an approach of watchful waiting and reassurance. Some simple life changes such as improving access to the toilet, avoiding excessive fluid before bed time and emptying the bladder at bed time may be tried initially.

To some families, this conservative approach that requires patience can lead to frustration and suffering. Instead, a  wide-ranging method of treatment that includes pharmacologic therapy, bladder training and behavior modification with an alarm system may be implemented.

Treatment can begin with positive reinforcement like keeping a calendar and rewarding dry nights. Another treatment is bladder training composed of different methods such as holding urine as long as possible, then when the child urinates, he/she is suppose to stop and start the urine flow frequently. Another manner is going to the bathroom several times during the night, or having the parents wake the child several times during the night and subsequently increasing the time interval between waking. The goal is to increase the muscle strength of the urethra and give the child confidence that he or she can control urine flow and connect the feeling of a full bladder with the need to go to the bathroom.

Pharmacologic therapy consists of imipramine (tricyclic antidepressants) or desmopressin acetate (DDAVP). Each one has advantages and disadvantages. 10-60% respond to imipramine treatment, but more than 90% relapse. Imipramine is potentially lethal with acute overdose (especially cardiac toxicity). DDAVP is available in two forms, nasal spray and tablets. The oral form is used in children with nasal congestion such as colds and allergies. The drawback is the cost and rare mild side effects of DDAVP. DDAVP is helpful in certain situations such as going to overnight camp. There is a 25-50% success rate with DDAVP, but a relapse rate of 94%.

Enuresis alarms have been shown recently to be the most effective treatment for bed-wetting. Urination acts as a stimulus for the alarm and wakes the child from sleep. The cure rate is 60-80% and the relapse rate is 10-40%. The only drawback is that the child and family must be highly motivated to stay committed to these conditioning methods.

Common Behavioral Problems in Toddlers and Young Children

Some children seem to get through childhood without many problems at all and others seem to have an unusual amount of difficulty. Parents are often puzzled as to why their children do not behave or listen while their friend's children seem to be perfect angels. Some of the most common behavioral problems in children include temper tantrums, not following directions, whining, fighting with siblings or other children, breaking rules and talking back. Fortunately there is hope in dealing with everyday discipline problems using methods that are effective and easy to learn.

Parents have the ability to shape their children's behavior towards both good and bad results. All behaviors are shaped by rewards that are given to them. A common mistake that parents make is to accidentally reward their children's bad behavior. Four year old Jack gets to eat ice cream before dinner. He has been whining and begging for the ice cream long enough that his mother gives it to him so she can finish preparing dinner. Unfortunately, by rewarding bad behavior it is often strengthened. On the other hand behavior that is not rewarded, but instead punished, will often weaken and therefore decrease.

Developmentally, it is expected that young children will have a difficult time controlling their emotions, particularly if tired, hungry or stressed. Toddlers and preschoolers often lack the self-control necessary to express anger and other unpleasant emotions peacefully. When this happens it is important for the child's caregiver to be able to provide him or her with the support to deal with these difficult and uncomfortable feelings. Children learn a lot through their parents' modeling of behaviors and this is the main reason for parents needing to be most in control when their children are feeling out of control. If a father or mother joins the child in an uncontrollable emotional state, the situation will likely worsen because the child will feel less safe and more out of control.

Luckily for their parents, most children want to please their parents. Parents can therefore use this to their advantage when deciding how to discipline children. When a parent shows joy for a behavior that is good, the child will be positively reinforced for doing this behavior. On the other hand if a parent shows disapproval for a behavior, the child is less likely to repeat this behavior given the basic principle that children want to please their parents.

Discipline is the system in which parents guide and teach their children. This word is often confused with the term punishment. The purpose of discipline is to teach children the difference between right and wrong, to tolerate delayed gratification and to incorporate a sense of limits and appropriate behavior. Teaching discipline is a challenging task for parents and caregivers and not one that is taught overnight. It takes many years for most children to be able to achieve self-control. Also, as children grow and develop, so do the types of things that they must be taught. The method of discipline must grow and change with the child. Caregivers need to be flexible because of changes in children and their environment as children mature and grow.

Do's and Don'ts: Three Good Child-Rearing Rules to Keep in Mind

1) Reward good behavior and do it quickly and often. A child's good behavior will be positively reinforced and therefore strengthened when they receive a reward from a caregiver. Social rewards are the most effective rewards and include smiles, hugs, kisses, words or praise, eye contact and attention. Other rewards include activity rewards such as going to the park or helping to bake cookies and material rewards like ice cream, money or a compact disc. Social rewards are the most powerful, easiest to give and least expensive. The other types of rewards should be used less often. It is important for parents to remember that they are the most important reward for their children. It is very important to keep in mind that especially in younger children rewards need to immediately follow the behavior.

2) Avoid accidentally rewarding bad behavior. This will strengthen the bad behavior and is a very easy trap for parents to fall into. One example is when a child whines to get their parents attention. If a parent gives the child attention while they are whining, even if this attention is to yell at their child, it will act to reward the bad behavior of whining. Parents are very prone to making this mistake, especially if preoccupied with another activity like making dinner, talking on the phone or having a long day.

3) Punish some bad behavior by using mild punishment. Examples of mild punishment include time-out, scolding, natural consequences and logical consequences.

Time out is a very effective form of mild punishment. Time-out literally means time-out from all the things the child enjoys, for example - rewards, parent's attention, reinforcement, toys, music and all other interesting activities. Time-out has two major goals. The immediate goal is the stop the problem behavior as quickly as possible and the long-term goal is to help the child learn self-discipline. The good thing about time-out is that it does not emotionally harm the child and it models calm and good behavior on the parent's part. Time-out works best with children age two to twelve. This method should be considered with certain types of behaviors including impulsive, aggressive, hostile and emotional behaviors. Time-out does not work to get a child to begin doing a behavior, but it is very effective in stopping bad behaviors.

Time-out can be used initially with one or two target behaviors and once the parent and child get used to the technique it can be expanded to more problem behaviors. Getting started with time-out should occur after caregivers agree on this as a form of mild punishment. It should then be explained to the child before it is initially used so the child can understand what to expect the first time it is used. The child should immediately be placed in a very boring and safe predetermined location using up to ten words in less than ten seconds from the time the target behavior occurred. The child should be placed in time-out for one minute for every year of life (for example a five year old would sit in time out for five minutes) up to a maximum of about 10 minutes. A small portable timer should always be used to remind the child when the time-out is over. Once the timer rings the child will be asked why they went to time-out. Once they produce the answer the parent drops the issue and goes about their daily activities as usual. Time-out is not designed to make a child feel bad or humiliated.

Scolding is a common form of mild punishment used by parents. When scolding a child for bad behavior it is important to move close to the child, maintaining good eye contact, being stern, and expressing your feelings while naming the undesirable behavior. It is important to be brief and calm, showing disapproval for the behavior not the child. Another type of mild punishment is natural consequences. This is an event that would naturally occur after a child does a bad behavior. Some examples include not wearing an appropriate outfit to school and getting sent to the principal's office or being careless in not packing a lunch and being hungry at lunchtime. Logical consequences occur for behaviors that do not have natural consequences. Some examples include not eating all of your dinner and then not having any dessert; or riding the bicycle in the street and having the bike taken away for three days.

There are several ways in which parents can accidentally increase bad behaviors or decrease good behaviors. Once parents become aware of these common mistakes, avoiding them will be easier and promote a healthier parenting style. These errors include failing to reward good behavior, accidentally punishing good behavior, accidentally rewarding bad behavior and failing to punish bad behavior. A parent can fail to reward good behavior by not praising or recognizing that their child cleaned their room or brought home a great report card. Parents accidentally punish good behaviors by not being satisfied with a job well done and commenting that they could have done more or better. Some parents accidentally reward bad behavior by giving in to child who is whining and making unreasonable demands. Finally, parents can fail to punish bad behavior by ignoring it and saying something like "Oh well, boys will be boys".

Common behavioral problems are challenges that all parents and caregivers face. Some caregivers have more difficulty than others in managing their children. Parents will often come to the pediatrician with questions about behavioral problems. It is important to listen to these parents, take them seriously and offer suggestions as to how some of these problems can be remedied. It is essential to praise the parents for the things that they are doing correctly and gently try to shape some of the less helpful things that they are doing in a positive way. Most children will show great improvements if the strategies in this chapter are followed. For those children with more serious behavioral problems, these strategies may not be enough and this is when the pediatrician may consider referral to a psychiatrist, psychologist or other behaviorally astute professional.