It's Nobody's Fault (26 page)

G
len was a terrific kid—smart, confident, personable, a good athlete. He was about to go into the sixth grade. When I met him, his parents had just brought him home from summer camp, and he was desperately unhappy. His fellow campers had come up with a new nickname for him there: “Diapers.” At 12 years of age Glen still wet his bed almost every night, and despite his best efforts and those of the camp counselors to keep his bedwetting a secret all summer, the other boys had found out. The last week of camp had been sheer torture.

Six-year-old Victor was having a lot of difficulties in school, academically and socially. His speech hadn’t developed according to the normal guidelines, and he was inattentive, occasionally disruptive, in class. His social skills were similarly undeveloped, and the other kids in school often made fun of him. His parents suspected that Victor had a learning disability, and one of the teachers told them it might be attention deficit hyperactivity disorder; this is what finally brought them to my office. It was only after I had seen Victor a couple of times that I found out that he regularly wet his bed at night and sometimes wet himself during the day. The parents were well and truly disgusted with their son and made no effort to hide their negative feelings. When he came to see me, Victor was so downhearted that he spoke barely above a whisper.

Most children stop wetting their beds at night by the age of three, or five at the latest, but some—estimates put it at five to seven million kids—have trouble with this task. Those children suffer from enuresis, often referred to as bedwetting. According to the textbook, enuresis is the involuntary passage of urine at least twice a week for a period of three months in children over the age of five. It may occur at night or during the day.

The disorder affects twice as many boys as girls. At age five the breakdown is 7 percent male versus 3 percent female. At age 10 it drops to 3 percent boys and 2 percent girls. Enuresis is rare in people older than 18: only 1 percent of all males and about half as many females continue to be bedwetters after age 18.

There are two basic categories of enuresis: primary and secondary. A child who has never been fully trained—that is, a child who has never achieved a six-month period of dryness at night—falls into the primary enuresis group, the more common of the two. A diagnosis of secondary enuresis applies to kids who have been dry for up to a year and then start wetting again. Secondary enuresis usually occurs between the ages of five and eight. (A sub-category of secondary enuresis is transient, or temporary, enuresis. This condition is brought on by trauma or stress, such as a divorce in the family, and may last anywhere from a couple of weeks to several months.)

There’s a high spontaneous recovery rate with enuresis; that is, the problem goes away all by itself. Some sources put it as high as 15 percent, lower with boys than with girls. It’s not difficult to understand, then, why many pediatricians send concerned parents who seek their advice about a child with enuresis away with a cavalier, “Oh, he’ll outgrow it.” There’s a good chance the child
will
outgrow his problem, but there’s also the distinct possibility that he won’t.

Experts, by whom I mean pediatricians, urologists, psychiatrists, and psychologists, disagree about the age at which a child should be diagnosed with enuresis. The
Diagnostic and Statistical Manual of Mental Disorders
declares that five years old is the cutoff point, but some pediatricians feel that it’s better to wait until a child is seven or eight before
diagnosing enuresis. Why spend time and money, they ask, treating a child who’s going to get better all by himself? There’s a major flaw in that argument, however: a large percentage of the children who are wet at age five will still be wet at age seven, two years later, and
the longer a child has this symptom, the more likely he is to experience negative social consequences
, including serious family conflict. Furthermore, a child is entitled not to be uncomfortable.

Controversy or no, if a child is five years old and enuresis persists for three months or more, I believe that something should be done about it. Parents should consult as many health professionals as it takes to satisfy themselves that their child is all right. If they don’t, that child could end up with a nickname that will haunt him for a long long time.

Most younger children with enuresis, age five and six, aren’t especially bothered by their condition. True, they probably don’t enjoy waking up in wet sheets or seeing their parents get annoyed at them every morning, but the level of distress and dysfunction in these kids is generally quite low. As children get older and become more interested in having an active social life, enuresis begins to interfere more seriously in their lifestyles. Sleepover dates, summer camp, slumber parties—all these things are huge obstacles for the child with enuresis. (I treated a 13-year-old girl who used to stay up all night at pajama parties, even when everyone else was sound asleep. She was terrified that she’d have an accident in front of all her friends. Once, unable to keep her eyes open a moment longer, she spent a few hours dozing in the bathtub behind a locked door.) If a kid has a problem with wetting during the day, even going to school can be a trial. I’ve comforted more than one child who has been brought to tears when his classmates made fun of him because of the telltale odor of his wet pants.

It is estimated that two thirds of all bedwetters never even make it into a pediatrician’s office. Of those who do get to a pediatrician a sizable
percentage are sent home with instructions to watch and wait. The kids who are referred to psychologists and psychiatrists are nearly always sent there because they have other behavioral problems, such as ADHD, learning disabilities, or aggression. Kids who have enuresis generally will show signs of other maturational delays, including speech lags and learning difficulties. Enuresis may also be a symptom of a power struggle between a parent and child.

Diane was a 10-year-old girl who was referred to me because of attention deficit disorder (see
Chapter 7
). There was no hyperactivity associated with Diane’s disorder. In fact, Diane had a kind of dreamy, otherworldly quality, as if she were in some kind of trance. The little girl was an incredibly heavy sleeper, and she wet her bed nearly every night without even waking up.

Her patents told me that some nights Diane would be watching television, and, sitting on the sofa with the rest of the family, she would just urinate. To hear Diane tell it, she knew she needed to go, but she didn’t want to get up. Other times she’d just sort of forget about it until it was too late. Everyone in her family was furious with her, naturally, but Diane really didn’t understand why they were making such a big deal out of it.

Interviews with children who have enuresis are not usually very fruitful. Most children find it hard to explain their behavior.

“I don’t know why I do it,” one child might say. “It just slips out while I’m sleeping. I don’t even know it’s happening.”

“I don’t want to wet my bed. Sometimes I try to stay awake all night just to keep from doing it,” says another.

“I think I was dreaming about going to the bathroom,” says a third kid.

“Sometimes I’m too tired to get up and go to the toilet. I’d rather sleep,” says a fourth.

The same few themes run through all the experiences of these children: I was playing with my friends and didn’t notice that I had to go to the bathroom until it was too late; I was sleeping so hard I didn’t even realize I had to go; I knew I had to go, but I couldn’t wake up in time. Each one is a clear indication of enuresis.

There are many theories about what causes enuresis. The most widely held is that the primary cause of enuresis is a maturational lag. Some of the systems in these kids, including the bladder and the brain, are not maturing as quickly as is to be expected in normal development.

There are experts who put all the blame on a child’s bladder. Many kids with enuresis do, in fact, have a lower functional bladder volume than children without enuresis; this means that a child with enuresis will urinate as much as a normal child over a 24-hour period in terms of volume, but he will need to urinate more frequently in order to put out that same volume. The problem with this theory is that there are many people in the general population who have low functional bladder volume but do
not
have enuresis.

Obviously, bladder function is not the only cause of enuresis. Regardless of the size of his bladder, the reason a child is wetting his bed is, ultimately, in his brain. His brain is not adequately reading the signal that his bladder is sending. His bladder tells his brain that it’s full, but the brain just doesn’t get the message, at least not in time.

A possible cause of enuresis is an abnormal regulation of a brain hormone called ADH (antidiuretic hormone), which determines the way that water is retained in the body. In some children with enuresis too little ADH is released at night, so that their bodies produce more urine than the bladder can handle. Another commonly held theory is that children with enuresis simply sleep more deeply than those who stay dry at night. Treatment with medications that lighten sleep have been effective in some cases.

Primary enuresis is genetic; what’s more, a recent study has located the general site of a gene linked to primary enuresis. The gene is believed to be
dominant
, which means that if one parent has enuresis, the child is likely to have the disorder too. Studies show that 75 percent of all children with enuresis have a primary relative—a mother or, more probably, a father—who also had the disorder. (As one of my colleagues said to me, only half-joking, “It’s almost always the parent who
doesn’t come
to the appointment.”) If one identical twin has enuresis, 68 percent of the time the other twin will have it—an extraordinarily high rate. If one
fraternal twin has enuresis, the other twin will have it only 36 percent of the time. I nearly always discuss the genetic influences in the cause of enuresis with both parents and children, and I usually get a mixed reaction. Parents are embarrassed, and kids are relieved and surprised. Many children don’t realize until then that anybody else in the world has this problem, let alone someone in the family.

Virtually every child diagnosed with enuresis, either primary or secondary, receives behavioral treatment. Depending on the severity of the case and the effectiveness of the treatment, a child may benefit from medication as well. The goal in any treatment for enuresis is, of course, to change the child’s behavior.

By the time a child comes to see me about this problem, there’s a good chance his parents have already tried a few home remedies—not letting a child have any liquids after supper, for example, or restricting caffeine and sugar. Many routinely wake the child and escort him to the bathroom several times during the night, starting with the time the parents themselves turn in. I’ve known parents who set an alarm for every few hours all night so that they can wake their child. (“It takes me back to our two o’clock feeding days,” one mother said.) Still others set alarm clocks for their kids.

All of these efforts can pay off sometimes. If a child is caught at exactly the right time and he empties his bladder, he may well wake up in a dry bed the next morning. (A lot of kids with enuresis tend to wet during the first two or three hours of sleep.) Of course, none of these remedies teaches a child new behavior—he doesn’t learn to respond to an internal signal—so any improvements are likely to be temporary. What’s more, these activities don’t usually do much to improve family harmony. Parents don’t take any pleasure in getting up several times a night to wake their kids, and kids positively hate having their sleep interrupted and being dragged to the bathroom. In some instances children become downright defiant, and the problem gets even worse.

The more formal treatment for enuresis isn’t exactly fun either, but it does get excellent results—about an 85 percent success rate after six months. The first thing I ask parents who consult me to do is to keep a
dry-wet calendar. Over a period of a month parents keep track of how many nights a child was wet and how many nights he remained dry. Then we have our baseline, and we can measure how serious the problem really is. For very small children, keeping the calendar may be sufficient to solve the problem. Simply being made aware of the problem can be enough to motivate some children to fix it, especially if those dry nights are rewarded with a small token.

At the heart of nearly all enuresis treatment is a device called the
bell and pad.
There are several versions of the bell and pad, but the principle is always the same: somewhere in the bed—under the sheet or perhaps even attached to a child’s pajamas—there is a pad with a sensor that detects wetness. At the very first sign of wetness that sensor causes a bell to ring, waking the child. The child then gets up, runs to the bathroom, and urinates in the toilet. There are different kinds of pads and sensors and variations on the theme of a bell too. Some alarms are worn on the wrist. Others get attached to the collar of a child’s pajamas right near his ear. Still others are made to go under a pillow or sit on a night table. Since children with enuresis are notoriously heavy sleepers, these alarms sometimes fall on deaf ears, especially if the kids become experts at hiding them. The rest of the family wakes up to the alarm, but the child in treatment sleeps right through it. One mother solved this problem by keeping the bell in a coffee can, so that the ringing sound reverberated.
Nobody
could sleep through that.