BEHAVIORAL
ALARM TREATMENT FOR NOCTURNAL ENURESIS
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doi: 10.1590/S1677-55382010000300010
RODRIGO F. PEREIRA, EDWIGES F. M. SILVARES, PAULA F. BRAGA
Behavior Therapy Laboratory, Institute of Psychology, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
ABSTRACT
Purposes:
To investigate the efficacy of alarm treatment in a sample of Brazilian
children and adolescents with nocturnal enuresis and relate treatment
success to age and type of clinical support.
Materials and Methods: During 32 weeks,
84 children and adolescents received alarm treatment together with weekly
psychological support sessions for individual families or groups of 5
to 10 families.
Results: 71% of the participants achieved
success, defined as 14 consecutive dry nights. The result was similar
for children and adolescents and for individual or group support. The
time until success was shorter for participants missing fewer support
sessions.
Conclusions: Alarm treatment was effective
for the present sample, regardless of age or type of support. Missing
a higher number of support sessions, which may reflect low motivation
for treatment, increased the risk of failure.
Key
words: enuresis; behavior therapy; child; adolescent; group therapy
Int Braz J Urol. 2010; 36: 332-8
INTRODUCTION
According
to the International Children Continence Society, nocturnal enuresis is
defined as discrete incontinence episodes while an individual is asleep
(1). Children must be at least five years old to be diagnosed with enuresis.
In addition to that, the DSM-IV criteria states that the involuntary voiding
must occur at least twice a week for at least three months (2). Nocturnal
enuresis is one of the most frequent problems of childhood, affecting
up to 15% of children from 5 to 7 years of age and 1 to 2% of young adults
(3-6). However, if DSM-IV criteria are employed, the prevalence of enuresis
is around 2.6% (3). The variation in the criteria employed by different
investigators to define enuresis makes it difficult to establish a precise
prevalence rate (5).
The etiology and underlying physiological mechanisms of nocturnal enuresis
are heterogeneous (7). Nevertheless, there is consensus concerning the
notion that nocturnal enuresis arises from a combination of lack of vasopressin
release during sleep or bladder hyperactivity and the inability to be
aroused from sleep by bladder sensations (8). There clearly is a genetic
basis at the origin of these phenomena (9), and the difficulty in waking
up when the bladder is full is a sign of problems in the maturation of
the central nervous system (10).
Both pharmacological and behavioral treatments are currently available
for nocturnal enuresis. Desmopressin acetate, the most effective drug
treatment, reduces the production of urine during the night, significantly
decreasing wetting (11). The preferred behavioral treatment is alarm conditioning
(12), associated with a success rate of 65% and 42% of relapse (13). Desmopressin
acetate is no better than alarm or alarm plus desmopressin acetate in
the long term (14).
Some factors may affect the response to alarm treatment, especially those
of a psychological nature, such as marital conflict, lack of motivation
and parental punishment (13). The physiological aspects associated with
a poor response to alarm treatment include the difficulty to wake up with
the sound of the device (15). The literature concerning the impact of
enuresis severity on the outcome of alarm treatment is contradictory,
with both positive (13) and negative (16) impacts being reported.
There is a dearth of studies on the prevalence and severity of enuresis
in the Brazilian population. A study carried out with a probabilistic
sample in an urban center in southern Brazil (17) has revealed a 20.1%
prevalence of nocturnal enuresis in boys and 15.1% in girls based on the
criterion of one wetting episode per night. This lack of studies may lead
to a low level of information about enuresis and other lower urinary tract
diseases among professionals that deal with children, such as caregivers
and school teachers (18).
The main objective of the present study was to determine the success rate
of alarm treatment in a population of Brazilian children and adolescents
with nocturnal enuresis. We also aimed at identifying the relationship
between age, type of psychological support and rate of success.
MATERIALS AND METHODS
The study
sample included 84 children and adolescents from a university psychology
clinic. Between 2002 and 2006, this group received care from four psychologists
(graduate students at the university’s Clinical Psychology graduate
program). The participants were classified as children (6 to 10 years
of age, n = 52) or adolescents (11 to 17 years of age, n = 32). Inclusion
criteria were: age between 6 and 17 years, having wetting episodes at
least twice a week for three consecutive months and absence of other disorders
that could have caused the wetting episodes, such as diabetes or spina
bifida. The sample included 19 adolescents that participated in the study
conducted by Rocha, Costa and Silvares in the same research center (19).
All patients received full-spectrum home training (12), which consisted
in the use of a bell-and-pad alarm during the night. Children and families
were told to use the alarm daily in combination with cleanliness training
and retention training as described by Houts (12). In addition, the families
and patients were instructed to restrict fluid intake before going to
bed, to keep regular sleep hours and to keep a record of night wetting
episodes. Treatments lasted up to 32 weeks.
Each family participated in a weekly follow-up/support session lasting
about one hour at the clinic. They were first screened for diagnosis and
when there were about 20 families waiting for treatment, they were randomly
assigned to participate in individual sessions (n = 51) or group sessions
including five to ten families (n = 33). This procedure was undertaken
about once or twice a year, and at each time a new randomization was made
with the families previously screened. During the support sessions, the
therapist reviewed the wetting record and made sure the procedures were
being correctly followed. The children were accompanied by their parents
or by caregivers in charge of monitoring the treatment at home.
Data were collected from the record filled out by the family, in which
they informed whether the child was wet or dry on waking up. In the presence
of bed wetting, the time when the alarm had rung and the approximate amount
of urine, based on the size of wet patches (small, medium or large), were
recorded. The treatment was considered to be successful if the child/adolescent
remained dry for 14 consecutive nights during the treatment period. Treatment
failure was defined as 13 or fewer consecutive dry nights or the family
discontinuing the treatment (dropout). After success was achieved, a procedure
(overlearning) to prevent relapse was performed. Overlearning involves
drinking a small amount of water before going to sleep. The amount was
determined according to the maximum voided volume expected for the child’s
age (age x 30 + 30 mL) and was increased every two consecutive dry nights,
until the child was able to remain dry another 14 nights after reaching
initial success. The alarm treatment was interrupted when overlearning
was complete or when it was attempted two times unsuccessfully. In these
cases, after the second attempt, more 14 dry nights were required for
finishing the program.
Unpaired t-test was used to compare the frequency of enuresis episodes
before treatment. Fisher’s exact test was used to verify the relationship
between success and the study variables (age and type of psychological
support), and variance analysis was used to determine the time required
to obtain success taking into consideration the study variables. ANOVA
was used to analyze the variation in the time required to achieve success.
Significance was established at p < 0.05.
RESULTS
To characterize the sample, the frequency of wetting episodes (severity of enuresis) in the sample was determined before the start of treatment. This information was not available for 10 participants, and thus 74 children and adolescents were considered (N = 74). Table-1 shows the distribution of the sample according to the frequency of night wetting episodes.
Table-1 shows that more than half of the overall sample experienced bedwetting
every night. This proportion was slightly larger in the group of adolescents,
but the difference was not significant. Similarly, the mean number of
weekly episodes for the overall sample (5.2) was similar to that for the
two separate age groups.
The rate of severe enuresis in the sample is larger than that reported
in prevalence studies (3). This is possibly due to the inclusion criteria
used in this study and to the fact that the search for treatment may be
more frequent when enuresis is more severe.
Table-2 shows the distribution of the two age groups and types of support
in terms of treatment success and failure. Dropouts were included in the
failure criteria.
Success was achieved in 71% of the sample. The success rate among children
(6 to 10 years of age) and adolescents (11 to 17 years of age) was not
statistically significant. Similarly, there was no statistical difference
between the two types of support, although the failure rate was lower
to participants receiving individual support (14% vs. 41% for group support)
(Table-2). An analysis was also carried out to investigate if the onset
of success differed in terms of age and session format. Figures 1 and
2 show the chance of obtaining success during treatment for these two
variables.
Figure-1 shows that although success was achieved earlier in the group
receiving individual support, the difference was not statistically significant.
There was also no significant difference in time to achieve success according
to age (Figure-2).
An analysis of time to achieve success related to session attendance is
shown in Table-3.
The number of missed follow-up/support visits had a significant association
with success: participants who missed less than 10% of sessions became
dry faster than those who missed more than 10% of the sessions. It was
also observed that the number of missed sessions was higher among those
receiving group support: 62.5% of the participants missed more than 10%
of the sessions vs. 37.5% of the participants receiving individual support
(p = 0.03).
COMMENTS
In the present
study, the 71% success rate obtained by the participants is in accordance
with previous results described in the literature - 65% on average (13).
Considering more than half of our study participants had severe enuresis,
the hypothesis that severity affects the results of treatment, either
negatively or positively, may not be supported.
Age range has also been described as a predictor of failure, since adolescent
enuresis is usually more difficult to treat (20). We did not observe a
significant difference between children and adolescents, with both presenting
similar success rates. However, with a broader sample, the slight difference
in time to obtain success could appear as a significant factor.
The type of psychological support provided was not related to treatment
success, as previously reported (13). Participants from families receiving
individual support had similar success rates than those receiving group
support; however, those receiving group support missed more sessions,
an aspect associated with greater difficulty in achieving success. The
percentage of group format participants that missed more than 20% of the
sessions was 39.6%, against 17.5% of the participants of individual format.
It is possible that the individual support leads to a greater commitment
by the families, expressed in a better attendance to the sessions. Participants
that missed more than 10% of the sessions, regardless of session format,
took, on average, 5 more weeks to achieve success than those who missed
less than 10% of the sessions. There seems to be a relationship between
session attendance and success (13). The number of missed support sessions
may be interpreted as a reflection of low adherence. It is likely that
missing sessions in itself does not affect treatment, but rather, that
it reflects a difficulty in following the prescribed steps, leading to
a higher failure rate or to a longer interval until success achievement.
A limitation of this study was the absence of a control group and also
of an analysis to determine the variability between therapists in terms
of the support provided. In addition, a larger sample might have been
able to confirm the observed trend towards a better performance in participants
receiving individual support, and to clarify the relationship between
failure and missing support sessions. Therefore, it is not possible to
determine which of these two juxtaposed variables determines treatment
failure. A further limitation was the fact that treatment time was longer
than that routinely practiced. This may have exaggerated the success rate,
since the cases of success may have resulted from spontaneous remission
of enuresis.
CONCLUSIONS
Treatment of nocturnal enuresis with an alarm technique was satisfactory in this Brazilian sample. The success rate was in accordance with that described in the literature. The results of treatment were similar for children and adolescents and for individual and group support. Failure to participate in support sessions was associated with a delay in success achievement. We believe that treatment with the alarm technique may be used in other Brazilian patient populations and that additional studies should be carried out to identify predictors of success and failure that are characteristic of this population.
ACKNOWLEDGEMENTS
This work received financial support from Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP) and Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq).
CONFLICT OF INTEREST
None declared.
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____________________
Accepted
after revision:
January 18, 2010
_______________________
Correspondence
address:
Dr. Rodrigo Fernando Pereira
Av. Prof. Mello Moraes, 1721 / Bloco F / Sala 30
Cidade Universitária
São Paulo, SP, 05508-030, Brazil
E-mail: rpereira@usp.br
EDITORIAL COMMENT
The authors should be congratulated for performing a study evaluating the results with alarm for enuresis in Brazilian children and adolescents. The authors’ good results with this treatment demonstrate their high level of expertise in this field and that Brazilian patients can be successfully treated by this method. However, a significant drawback of the alarm treatment is the high dropout rate (reference 13 and 14 in the article). An intention to treat analyses is the most accurate way to evaluate the final success rate and it was not the case in this study. For instance, the alarm was indicated for 100 children and 30 discontinued the treatment (dropouts) even before patients could be entered into the study protocol. Suppose 45 (65%) out of those 70 had success with alarm. The rate of failure should be 55% (25 + 30 patients failed) not 35%. Unfortunately, the overall dropout rate was not stated. How many patients were not included in the protocol because they or the family was not adapted to the method? Since we do not have this information, the results of this study can be interpreted as overestimated. Also, the lack of a control group, the limited number of patients and the absence of clear randomization criteria does not permit to draw any conclusions regarding the value of a psychological support for these types of patients. It is interesting to note that children have the same success rate as the adolescents showing that this treatment is successful even in younger age.
Dr.
Ubirajara Barroso Jr.
Rua Alameda dos Antúrios, 212 / 602
Salvador, BA, 40280-620, Brazil
E-mail: ubarroso@uol.com.br