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Enuresis
(bedwetting) and Attention Deficit Hyperactivity Disorder (AD/HD or ADD)
are both common conditions that can affect children and adolescents.
Although there is no evidence that either one causes the other, children
with AD/HD appear to have a higher incidence of enuresis. The child with
AD/HD may feel different and unaccepted. Enuresis might exacerbate these
feelings. There are several medically accepted treatments for enuresis.
Some of them require impulse control and cooperation. Might this be more
difficult for individuals with AD/HD? Individuals with AD/HD may be
taking medications for the condition. How might these medications affect
their enuresis?
We
all wet the bed at some point in our lives.
When a baby’s bladder fills to a certain point, the bladder
muscles contract, and the baby urinates. Over time, the young child’s
nervous system matures. The feedback circuits between the brain and the
bladder enable the child to realize when his or her bladder is full. The
child becomes physically able to delay urination until he or she decides
that it is the appropriate time and place to void. Different children
develop the neurological and emotional capacity to control their
bladders at different ages. In many cases, children learn to control
their bladders during the day before they master nighttime dryness.
Occasional episodes of daytime or nighttime bladder accidents after five
may be a normal part of growing up. . However, if a child continues to
have regular trouble controlling his bladder after age five, he meets
the criteria for enuresis. Bedwetting (nocturnal enuresis) usually does not occur while
the child is dreaming. It is more likely to happen during the deeper
phases of sleep.
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Primary
enuresis refers to wetting in a person who has never been dry for at
least 6 months.
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Secondary
enuresis refers to wetting that begins after at least 6 months of
dryness.
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Nocturnal
enuresis refers to wetting that usually occurs during sleep
(nighttime incontinence).
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Diurnal
enuresis refers to wetting when awake (daytime incontinence).
How common is
bedwetting? The reported incidence varies depending on the study.
Children do not like to admit to this problem. Thus the actual incidence
may actually be higher than some estimates.
At age five the incidence is between 5-20%. It is much more
frequent in boys than in girls. The incidence drops significantly with
age. A general rule of thumb is that about 15% of children achieve
nighttime dryness each year after age 5.
At age 5, enuresis affects 7% of boys and 3% of girls. By age 10,
it affects 3% of boys and 2% of girls. About 1% of adolescents still
experience enuresis. That
1% may not sound like much, but it translates into a large number of
adolescents and young adults with an
embarrassing—sometimes-humiliating—problem. What causes enuresis? We
do not know an exact cause of nighttime enuresis.
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Most
children with enuresis seem to be normal, physically, intellectually
and emotionally. Enuresis is probably associated with a combination
of factors including heredity, slower neurological maturation, small
bladder capacity, a tendency to produce too much urine at night, and
the inability to recognize a full bladder while asleep. The child
who is a deep sleeper may have more difficulty waking up when his
bladder is full.
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Sometimes
enuresis may be due to anxiety, a change in the home situation (such
as the birth of a sibling) or an emotional trauma. We particularly
look for emotional factors in children who were previously dry and
start to wet again. A child with shaky bladder control may be more
likely to revert to wetting when under stress.
-
A
small percentage of children have specific physical causes for their
enuresis. Depending on the type of physical difficulty, the child
might never have been dry (primary enuresis) or may have gone back
to enuresis after a period of dryness (secondary enuresis) Physical
problems include diabetes mellitus, lower spinal cord problems,
congenital malformations in the genitourinary tract and urinary
tract infections. Obstructive sleep apnea, sometimes caused when a
child has enlarged tonsils or adenoids, can also be associated with
enuresis.
Treatment of
enuresis: If the enuresis is related to a specific physical or emotional
issue, the causative factor must be addressed. For the majority of
children, there is not specific cause. It is often best to counsel the
families of young children to wait and see whether the child becomes dry
within the next year or two. Parents should not be harsh or judgmental.
Sometimes it is the emotional reaction of the parent that causes the
psychological hurt, more than the bedwetting itself. The child is often
the best one to determine whether the bedwetting is a problem. Does the
bedwetting bother him? Does it interfere with sleepovers or camping
trips? The incidence of enuresis declines by about 15% per year after
age five. Bladder capacity increases, an overactive bladder may
normalize, the child learns to recognize the signal that it is time to
void, and stressful events may fade.
However, some
children do require extra intervention for their bedwetting. Initial
interventions may include:
- Behavior
Modification: The child learns to take responsibility for his
bed-wetting. Encouraging and praising the child for staying dry
instead of punishing when the child wets. Reminding the child to
urinate before going to bed, if he or she feels the need. Limiting
liquid intake at least two hours before bedtime. When he wets the
bed, he is responsible for changing the sheets in the morning. He
learns to wake up regularly at night to void. Bedwetting alarms are
often useful. These devices are available for $50 -$100 in specialty
catalogs, some pharmacies and medical supply sources. A
moisture-sensing device is attached to the pajamas or is placed
under the sheet. When the child urinates at night, the sensor sets
off a buzzer and or a light alarm. Some children who wet the bed are
especially deep sleepers. In these cases, it may be necessary for
someone else to wake the child when the alarm sounds. Ideally the
child eventually becomes conditioned to wake up when his bladder is
full.
- Hypnosis:
Some practitioners have had success using hypnosis to help
children cooperate with behavior modification or even to become dry
by themselves.
- Psychotherapy:
This is used when the child is showing severe anxiety in relation to
his bedwetting and this anxiety is interfering with teaching him to
become dry. It is also useful if the enuresis is associates with
external stress or trauma.
- Evaluation
for allergies: In rare cases, food or other allergies may be
related to enuresis.
- Medication:
There are two main medication approaches. DDAVP (desmopressin
acetate) is a safe and effective long-term treatment for patients
with nocturnal enuresis. More than half of the children treated this
way show a positive response. DDAVP is a compound similar to the
hormone that regulates urine production. It is sprayed into the
child’s nose at night. It decreases the production of urine for
several hours. Children who do not respond to DDAVP may respond to a
tricyclic antidepressant, imipramine (Brand name Tofranil.) Some
clinicians have successfully used other, related tricyclics. These
medications are sometimes also used for treatment of depression,
AD/HD and narcolepsy (sleep attacks). Sometimes a parent is confused
when their doctor suggests imipramine, “My child is not
depressed!” For children, the FDA approves imipramine only for
enuresis. Tricyclics
can sometimes be associated with changes in heart rhythm. Ask your
doctor whether he or she feels that an EKG or other testing is
indicated. In my experience, children who are especially deep
sleepers, and who do not respond to other treatments, may respond
well to the tricyclics. Unfortunately, when the medication is
stopped, some children relapse. Some children take medication only
when they are in special situations when bedwetting would be
especially embarrassing—sleepovers or camping trips. Other
children take the medication every night.
Like
enuresis, AD/HD is also a common childhood condition. . Individuals with
inattentive ADHD have difficulty paying attention and staying organized.
Individuals with impulsive or combined ADHD have difficulty with
attention and organization but also are overly active and impulsive ADHD
affects 3-5% of school-aged children.
Although most children with enuresis experience remission of
their enuresis by age 18, a higher percentage of individuals with AD/HD
continue to experience inattention and impulsivity well into adulthood.
For years, clinicians have anecdotally noted an increased incidence of
enuresis in children with AD/HD. Others
have observed that their patients with enuresis have an increased
incidence of AD/HD. Because both conditions are fairly common, it would
be important to have more systematic studies that looked at the
relationship between enuresis and AD/HD.
An
article in the Southern Medical Journal published in 1997compared a
fairly large group of 6-year-old children with AD/HD to a non-AD/HD
control group selected from a pediatric clinic population.
They found that the 6-year-olds with AD/HD had 2.7 times higher
incidence of enuresis and a 4.5 times higher incidence of diurnal
(daytime) enuresis as compared to a control group Other authors have
cited higher rates of enuresis in children with ADHD. However, these
studies did not have control groups or were not selected randomly.
Sometimes
enuresis may be more upsetting for a child with AD/HD.
A non-AD/HD child, who is successful in most spheres, may be able
to accept his bedwetting more easily. Later, such a child may find it
easier to cooperate with behavioral interventions. However the child
with ADHD already feels different from his peers. His disorganization
and impulsivity may lead to peer rejection and shame. Such a child may
cover his shame with a false appearance of bravado. And although he may
be more ashamed of his bedwetting, his inattention and disorganization
may make it more difficult for him to cooperate with some behavioral
treatments. Individuals with AD/HD are more likely to have sleep
problems. Some of them sleep deeply and have difficulty waking up to go
to the bathroom when their bladder is full.
Treating
the child with both AD/HD and enuresis: This child should have a
complete physical exam. It is important to always ask an individual with
AD/HD about current and past bedwetting problems. Don’t neglect to ask
adolescents about this too. They will rarely volunteer this information
on their own. Ask what they and their parents have tried in the past.
Some children and teens with AD/HD are veterans of many types of
therapy. They may already expect the treatment to fail. The behavioral
techniques listed earlier in the article are still useful for these
children and teens. Since these children have often experienced teasing
and criticism, one should be especially careful to avoid punitive
behavioral techniques. One may have to modify behavioral interventions
to accommodate the child’s shorter attention span. You may need to
prioritize symptoms. If the child has a myriad of behavior difficulties,
the family cannot address all of them at once. Which ones are the most
important to the child and the parent? Some children and families opt to
wait a while longer before starting behavioral or medical interventions.
When the family
decides that this is the time to treat the enuresis, they may have to
back off with some of their other behavioral goals to avoid being
overwhelmed. The child and family should be made aware that there are
several ways to treat the enuresis. If one does not work, you are not a
failure. You still have plan B, plan C, etc.
Medication
for children with both AD/HD and enuresis. Some children with AD/HD
may also have other psychiatric disorders and may be on several
medications. A few of these medications might exacerbate the enuresis.
It is important to consider all medications and all medical
conditions before proceeding with treatment.
DDAVP help the enuresis of some children and teens with AD/HD..
In other cases, one may want to consider one of the tricyclic
antidepressants for the enuresis. This class of medication seems to work
well with some of the “deep sleeper” kids.. You may be able to treat
both the AD/HD and the enuresis with one medication. Several studies
have shown that the tricyclics by themselves are an effective medical
treatment for AD/HD in children and adults
In some cases, one can combine stimulants and tricyclics. Such
cases may require more frequent medical monitoring.
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