Behavioral Treatment of Enuresis

Arthur C. Houts

The University of Memphis

Reprinted from:
Houts, A.C. (1996). Behavioral treatment of enuresis. The Clinical Psychologist, 49(1), 5-6.

I. Description of Treatment

Our best evidence from controlled studies shows that for monosymptomatic bedwetting, the treatment of choice is some type of behavior therapy that includes using a urine alarm device (Houts, Berman, & Abramson, 1994). One of these alarm based behavior therapies is called Full Spectrum Treatment. This treatment package was designed to be taught to families in a 90 minute professional consultation and then implemented in the home by parents.

All aspects of the treatment are spelled out in a manual given to parents, and the parents and child complete an explicit behavioral contract that specifies what each is to do to implement the treatment at home. For example, all procedures including the necessity to wake the child are specified in the contract section for using a body worn urine alarm. The protocol also incorporates Retention Control Training where the child practices holding back from the urge to urinate for longer and longer intervals until the child can successfully withhold for 45 minutes. Once a child attains 14 consecutive dry nights during treatment, a modified form of over learning is implemented until the child attains 14 additional consecutive dry nights. Over learning consists of having the child continue to use the alarm device while deliberately drinking larger and larger quantities of fluid immediately before going to bed.

II. Summary of Studies Supporting Treatment Efficacy

Table 1 summarizes one year follow-up results from 6 observations of Full Spectrum Treatment, 4 of which are from published studies (Houts, Liebert, & Padawer, 1983; Houts, Peterson, & Whelan, 1986; Houts, Whelan, & Peterson, 1987; Whelan & Houts, 1990). The 48 cases labeled 1988 were accumulated in a private enuresis clinic over a period of 2 years and are not from a randomized study. The 1991 sample shows outcomes from our randomized trial that compared Full Spectrum Treatment to imipramine and oxybutynin. About 3 out of every 4 children treated with this approach can be expected to stop bed-wetting at the end of the average of 12 weeks needed to complete the treatment.

At the one year follow-up, 6 out of every 10 children are permanently dry. The lower relapse rates observed in the 1988 and 1991 samples were from children who did our modified overlearning where they gradually increased nighttime drinking in 2 ounce increments adjusted for their age. In the other samples, overlearning was done in the original fashion of having children consume 16 ounces of water regardless of age. We now consistently find that only about 10% of children relapse. This may be compared to 40% without overlearning and 20% with the original type of overlearning. We have not completely solved the problem of relapse, but we have come some distance in preventing relapse after successful treatment with the urine alarm.

Table 1
Percentage of Children Ceased Bed-wetting at 1 Year Follow-up with
Full Spectrum Treatment for Six Samples

Year of SampleN"Cured" of Original SampleRelapsed from Initial Arrest

III. References

Houts, A.C., Berman, J.S., & Abramson, H. (1994). The effectiveness of psychological and pharmacological treatments for nocturnal enuresis. Journal of Consulting and Clinical Psychology, 62, 737-745.

Houts, A.C., Liehert, R.M., & Padawer, W. (1983). A delivery system for the treatment of primary enuresis. Journal of Abnormal Child Psychology, 11, 513-519.

Houts, A.C., Peterson, J.K., & Whelan, J.P. (1986). Prevention of relapse in Full Spectrum home training for primary enuresis: A components analysis. Behavior Therapy, 17, 462-469.

Houts, A.C., Whelan, J.P., & Peterson, J.K. (1987). Filmed vs. live delivery of full-spectrum home training for primary enuresis: Presenting the information is not enough. Journal of Consulting and Clinical Psychology, 55, 902-906.

Whelan, J.P., & Houts, A. C. (1990) Effects of a waking schedule on primary enuretic children treated with Full-Spectrum Home Training. Health Psychology, 9, 164-176.

IV. Resources for Training

The manual for parents and children is available on request from

Arthur C. Houts
Department of Psychology
The University of Memphis
Memphis, TN 38152
Telephone (901) 678-4685

A treatment guidebook for professionals that incorporates the parent manual will be published in December 1996.

A body worn urine alarm, Wet Stop, is available from

Palco Laboratories
9030 Sequel Avenue
Santa Cruz, CA 95062
Telephone (800) 346-4488

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