Evaluating Evidence Based Practice for Enuresis—Full Spectrum Home Training

Nocturnal enuresis—commonly known as bed wetting—refers to involuntary urination that occurs overnight. This phenomenon is reported in the literature and reported by pediatricians as an unexceptional occurrence experienced by many children (Houts, 2010). However, in spite of the common nature of the condition, enuresis is very troubling and results in a considerable level of stress for children as well as parents (Steele, Elkin & Roberts, 2008). Therefore, rather than simply letting enuresis run its course, or waiting for a child to outgrow the problem, the medical and psychological communities have developed a number of interventions designed to address and manage the condition. Parents are therefore willing, in many cases, to participate in an intervention recommended by medical professionals or psychologists.

Nocturnal enuresis (NE) is considered a normal part of child development and there is no specific time period established regarding when a child should attain full bladder control. This condition may also be caused by medical problems or symptomatic of a psychological disorder (Houts, 2010). In any event, regardless of the reason for NE, it should be treated with patience and understanding by parents and, if necessary, professionals. This paper will evaluate an evidence based practice (EBP) for NE, specifically Full Spectrum Home Training (FSHT). In fact, the purpose of this paper is to recommend FSHT as the EBP of choice especially if the child does not suffer from additional medical or psychological complications.

Initial Assessment

Prior to recommending any intervention, a licensed clinical social worker (LCSW) should make sure that the parents have taken their child to a medical doctor to rule out any underlying medical condition as the cause of NE. Possible medical conditions include: “neurogenic bladder and associated spinal cord abnormalities, urinary tract infections, and the presence of posterior urethral valves in boys or an ectopic ureter in girls” (Cendron, 1999, p. 1206). If medical causes are eliminated, it is them incumbent upon a LCSW to advise the parents on conditioning and CBT treatment intervention (Mellon & Houts, 2006). Early intervention is advisable since complications related to NE may result in a child with lower self-esteem that will be much more difficult to treat by licensed clinicians at a later time. Based on the needs of the family, a LCSW can offer a variety of interventions or EBPs, including cognitive-based therapies that address NE.

Part of the psychological assessment of a child with NE undertaken by a LCSW must include a determination of the level of commitment on the part of the parents and the child to make sure that implementation of any recommended intervention will be followed closely (Mellon & Houts, 2006; Steele et al., 2008). In most cases, it is apparent that the desire to overcome the problem is sufficient motivation for everyone involved to follow through with the steps included in an intervention. Conversely, parents occasionally are uncomfortable with the fact that their child is experiencing NE as well as the process that is involved with addressing it through an intervention. When that is the case, their negative attitude may inhibit the treatment options suggested by a LCSW (Mellon & Houts, 2006). This reality requires a comprehensive assessment by the LCSW to ensure that whatever intervention is recommended will not only be followed but, perhaps more importantly, will be fully supported. Potentially, this may require that parents adjust their behavior toward their child’s NE to remove any tendency toward punitive reactions directed at the child (Steele, Elkin & Roberts, 2008).

Interventions

A variety of interventions for NE are currently available and utilized by LCSWs with very good results. Interventions may be behavioral, pharmacological, or based on other elements that have proven successful in previous studies (Glazener, Evans & Peto, 2004). The goal of any intervention, however, and the point at which it is considered successful is the child with NE achieving two full weeks without nocturnal urination. Once that threshold has been met, the intervention may be discontinued since there is little chance of recurrence of NE. While studies indicate that NE will subside on its own in the majority of cases, this typically takes a period of years. Consequently, most parents (and children) prefer to participate in an EBP that will likely resolve the NE within a much shorter period of time (Houts, 2010). The focus of this paper is on FSHT, which is one of many EBPs that are used successfully and recommended by many LCSWs nationwide.

Full Spectrum Home Training

Full spectrum home training (FSHT) is the name used for an intervention which combines four specific techniques for managing the treatment of NE. All four techniques have proven to be effective and the process of merging them into one overall intervention improves the chances of success dramatically. The four components of FSHT are: overlearning; urine alarm; retention control; and cleanliness training (Glazner et al., 2004). Use of the urine alarm is a consistent element in most NE interventions, but the other elements simply increase its effectiveness as well as incorporate other critical cognitive activities into the EBP.

The first component discussed is overlearning, which is simply providing the child with specific amounts of water prior to bedtime (measured in ounces and which are increased in nightly intervals). This is done to cause the child to feel the urge to urinate due to increasing the level of stress on the detrusor muscle of the bladder (Glazener et al., 2004). According to Houts (2010), this intervention is designed to increase the bladder capacity and hopefully enable the child to make it through the night without wetting the bed. Houts also reported, however, that this component alone is unproven to improve NE and additional research is warranted.

The second component of FSHT—the urine alarm—involves a device that responds to the presence of liquid and triggers an alarm sufficient enough to wake the child from sleep (Mellon & Houts, 2006). This alarm may be in the form of sounds (e.g., a bell or buzzer) or a vibration that would startle the child. Whatever method is used for the alarm, all are triggered by the presence of urine which results from NE (Houts, 2010). Ideally, upon the triggering of the alarm, the child awakens and ceases urination, deactivates the alarm, and goes to the bathroom to finish urinating. This intervention is identified in research as the most effective single method and is also the most widely studied tool for treating NE (Brown, Pope, & Brown, 2011). There are cases where the child does not wake to the alarm, which is another reason why the FSHT is recommended since it adds other elements to the intervention.

The third component of the FSHT is daytime retention control training (Houts, 2010) which is similar to the process involved in overlearning, with the exception that it is carried out during the daytime. However, the purpose of the practice is also to increase the child’s bladder capacity (Houts, 2010). During the day—at a specific time each day—the child drinks liquid and is then expected to inform a parent when the urge to urinate occurs. When the child feels the need to urinate, he or she is asked to wait for several minutes before urination. The interval for waiting is gradually increased over time. Whenever the child is successful in this activity, a reward is given to reinforce the behavior. The goal of this component of FSHT is to eventually allow the child to reach a point where he or she is able to delay urination for up to 45 minutes, which should contribute to overcoming NE (Houts, 2010). The benefit of this element of the intervention is its location during the daytime when the child has a greater sense of being in control of his or her actions.

The final component of FSHT—cleanliness training—simply implies that the child is expected to make their bed each day and take care of whatever issues that includes, even if the bed is wet as a result of NE (Houts, 2008). Of course, a child that is too young to accomplish this will be assisted by a parent, but the child needs to realize the importance of the activity. Specifically, the child is responsible for taking the wet sheets off the bed whenever necessary, not as a form of punishment, but to emphasize the importance of having a bed that is clean every day. This activity, as well as all components of the FSHT, is included in a written policy statement (the Family Support Agreement) that is agreed to by the parents and child prior to starting the intervention. It is recommended that the child and parents practice these procedures before the FSHT is actually implements in order to familiarize everyone with what is expected and make the child comfortable with the process. A LCSW will also stress the importance of parental reinforcement of all behaviors completed successfully.

Family Involvement

The full involvement and cooperation of the parents, or other caregivers, is a necessary element of the successful completion of the FSHT. Indeed, NE is a childhood problem and, as in the case of other childhood behavioral issues, a supportive environment is probably the most critical factor leading to positive results (Houts, 2010). Parents may initially be responsible for waking the child when the urine alarm is triggered and this may last for weeks. In all cases, the parents will need to make sure that the child actually gets out of bed a goes to the bathroom. Without a full commitment from parents, there is little chance that any intervention will succeed.

In the majority of cases, children suffering from NE come from families that are willing to provide the necessary support and also have the resources required for completing the FSHT. While family dysfunction may occasionally be identified by the consultation with a LCSW, NE is not typically an indicator of family discord (Houts, 2010). However, when it is determined that family issues are contributing to the ongoing nature of NE, it is the responsibility of the LCSW to attempt to resolve those primary issues before continuing with a FSHT. This can be accomplished by means of standard screening tools and will save a considerable amount of time and effort on the part of the child and parents since NE is rarely overcome while significant family issues are unresolved.

Conclusion

This paper evaluated an EBP for effectiveness in treatment of enuresis, specifically FSHT. Based on the preponderance of current research related to its success as an intervention for NE, this paper recommended FSHT as the EBP of choice, especially if the child does not suffer from additional medical or psychological complications. While NE will eventually resolve in due course without intervention, that process may take many years and result in long-term emotional issues for the child. In the absence of medical causes, the use of FSHT, which includes four successfully tested components, should be considered a primary option by LCSWs. The initial assessment should also include assurances from the family (parents and child) of full commitment to the process, which may take many weeks to complete.

Interventions designed to eliminate NE should be based on concern for the child and always carried out in a kind and respectful manner. Occasionally, the LCSW may need to advise the parents to adjust their behavior toward the child, especially if they were using punitive measures to deal with the child’s NE. Throughout the process of the FSHT, parents or caregivers must consistently reinforce positive behavior and reward completion of components of the therapy. In the vast majority of cases, FSHT accomplishes its goal and the child is freed from the embarrassment and stress caused by NE and this part of childhood is left behind and soon forgotten.

References

Brown, M.L., Pope, A.W., & Brown, E.J. (2011). Treatment of primary nocturnal enuresis in children: A review. Child: Care, Health and Development 37(2), 153-160.

Cendron, M. (1999). Primary nocturnal enuresis: Current concepts. American Family Physician. 59(5), 1205-1214.

Glazener, C.M.A., Evans, J.H.C., & Peto, R.E. (2004). Complex behavioural and educational interventionsfor nocturnal enuresis in children. Cochrane Database of Systematic Reviews. (1): CD004668. doi: 10.1002/14651858.CD004668.

Houts, A.C. (2010). Behavioral Treatment for Enuresis. In Weisz, J., & Kazdin, A. E. (eds.) Evidence-Based Psychotherapies for Children and Adolescents (pp. 359-374). New York: Oxford University Press.

Houts, A.C. (2008). Parent Guide to Enuresis Treatment, 6th ed. Retrieved from http://drhouts.com/pdfs/100_PARENT_GUIDE_6th_Ed_2008.pdf.

Mellon, M.W., & Houts, A.C. (2006). Nocturnal enuresis: Evidenced-based perspectives in etiology, assessment and treatment. In J. E. Fisher & W. T. O’Donohue (Eds.), Practitioner’s guide to evidence-based psychotherapy (pp. 432-441). New York: Springer.

Steele, R.G., Elkin, T.D., & Roberts, M.C. (2008). Handbook of evidence-based therapies for childrenand adolescents: Bridging science and practice. New York: Springer.