BEHAVIOR:
ASK THE EXPERTS

NOCTURNAL ENURESIS, REVISITED

Q I have a 9-year-old female patient with recurrent primary nocturnal enuresis. She toilet trained easily at 3 years of age with no subsequent daytime wetting or stooling problems. She has no medical or emotional problems, and her parents are very supportive. Her functional bladder capacity, however, is smaller than average.

When the girl was 7 years old, she responded well to the urine alarm and became dry within six weeks. Interestingly, once dry, she did not sleep through the night like most children but usually woke up once every night to void. She relapsed after being dry for several months. Over the past two years, I have twice retrained her using the alarm, but she relapsed within two weeks to two months after becoming dry. The last time, I continued the alarm for 30 consecutive dry nights before we stopped.

Two other factors besides her small bladder might contribute to the relapses: a vasopressin deficit and a sleep-arousal disorder. I addressed these possibilities with a course of desmopressin and hypnosis/biofeedback, neither of which helped. I have even considered a course of oxybutynin, but I suspect this is unlikely to provide the needed long-term response. At this point, the patient is understandably frustrated, and I've run out of ideas. What should I do next?

Howard J. Bennett, MD
Bethesda, Md.

A You mention that this girl, whose nocturnal enuresis has returned three times after she became dry with the aid of enuresis alarms, has a smaller than average bladder capacity. A normal bladder capacity for a 9-year-old is 10 to 11 ounces. Most children who wet nightly have a bladder that is half the normal size for their age. If your patient's undersized bladder has been documented, you need not search further for a cause of her persistent enuresis.

The first step in treatment is to clarify with the patient that every wet night is a night when she forgot to get up and that self-awakening is the key. Stated more strongly, to become completely dry, she must awaken to the sensation of a full bladder and use the toilet during the night every night for the rest of her life. The need to awaken when the bladder is full should be the last message a bed wetter leaves on the vigilant part of the brain before falling asleep.

The second step in treatment is to make the child an active participant in the process. Bed wetters need to be told that only you can solve this. Have the child start using the enuresis alarm again, and this time emphasize that she must take complete responsibility for turning it on and responding to it. She also should be in charge of requesting new batteries when they are needed. I am confident she can again learn to awaken to the signal of a full bladder because she responded well to the alarm in the past.

An extra step in treatment, called "overlearning while still wearing the alarm," can greatly reduce relapses. By this I mean: Teach the child to awaken earlier each night. As you recall, the first three or four hours of sleep are spent in deep sleep. Learning how to awaken from deep sleep is a valuable skill for bed wetters. Overlearning can be activated by drinking extra water at bedtime. I suggest 1 oz for each year of age. The extra fluid can be added gradually over the course of one or two weeks, which will allow the child to adjust slowly. Have the girl use the alarm until she has achieved 30 consecutive dry nights, as you did before.

Some children who learn to awaken at night to the signal of a full bladder relapse when their lives become very busy (when school starts, for example). Children who experience a physically or emotionally exhausting day sleep more deeply and are less likely to wake up. Going to bed earlier on such days may preserve the ability to awaken. Staying up later than usual can trigger a wet night. (For an in-depth discussion, see Schmitt BD: Nocturnal enuresis. Pediatr Rev 1997;18:183.)

Barton D. Schmitt, MD

DR. SCHMITT is professor of pediatrics, University of Colorado School of Medicine, and Director of General Consultative Services, The Children's Hospital of Denver. He is also a member of the Contemporary Pediatrics editorial board.

MORE THAN STUBBORNNESS—MUCH MORE

Q I saw a 6-year-old boy recently whose mother reported that he strongly resists getting his hair cut and his toenails clipped. She asked for suggestions about how to get him to cooperate. Since 1 year of age, she explained, the boy has been overly sensitive to physical touch. From an early age he hated food on his face, insisted on wearing socks with his sandals, and didn't even enjoy physical affection.

As a child, he had mild hypotonia, which required physical therapy for strengthening, and he now shows mild fine motor delay. According to his mother, the child has no significant emotional problems, and there is no history of abuse.

The parents have tried cutting their son's hair as he watches TV and trimming his nails at night while he sleeps—all with minimal success. Even bribing and star charts have not worked. Any suggestions?

Glen Rosenbaum, MD
Jerusalem, Israel

A The complex of symptoms you describe is not often encountered in general pediatric practice. The boy's symptoms suggest diffuse neurologic dysfunction in motor and sensory systems but are not specific to any single disorder. Depending on what professional sees the child, the severity of the symptoms, the context in which the symptoms occur, and other associated dysfunctions, any of a number of diagnoses is possible. They include:

• "Sensory overload," which is seen in autistic spectrum disorders (autism, pervasive developmental disorder, or Asperger syndrome)

• Anxiety disorders (separation anxiety, generalized anxiety disorder, or obsessive-compulsive disorder)

• Attention deficit hyperactivity disorder, which can cause sensory dysfunction

• Affective disorders or oppositional defiant disorders, which can manifest as excessive irritability

• Speech and language disorders that cause children to be excessively anxious or irritable.

Your patient's tactile defensiveness may reflect an abnormality in the way the central nervous system processes sensory input, leading to sensory integrative dysfunction. In sensory integrative dysfunction, touch may be perceived as extreme or uncomfortable. Other areas of sensory defensiveness include hypersensitivity to auditory, visual, or gustatory stimuli. Sensory integrative dysfunction does not appear in the medical literature, but a recent Internet search revealed almost 4,000 hits. It is not clear whether sensory integrative dysfunction is a unique syndrome or is a set of symptoms associated with other brain dysfunctions.

The key to the diagnosis is an in-depth history that focuses on the child's trajectory of development. Take note of regressions, loss of skills, or conditions resulting from brain injury. Pay special attention to language abilities. Delays in reaching developmental milestones can be quantified by a parent's report, baby books, or video. Compare the child's abilities with connected language—such as multistaged commands, story telling, and summarizing abilities—to rote skills such as naming and pointing. Ask about prolonged echolalia and programmed or routine speech. Assess the child's ability to understand humor, inference, and nonverbal language. Evaluate speech for clarity and dysprosody (the disturbance of stress, pitch, and rhythm that conveys meaning).

Assess the child's play skills. Does he play well with children of similar age? Can he separate from his parents? Is he invited to other children's houses? How well does he do in new situations? Is he a loner? What makes him shut down? Does he have a good imagination? What kind of games does he like to play? Does he obey the rules, and is he a good winner or loser? Does he perseverate or carry things beyond their normal limits? Does he show evidence of islands of knowledge? Also note special skills or weaknesses.

Assess adaptive behaviors related to sleeping, eating, and dressing skills. Note unusual behaviors such as poor settling for sleep, inability to sleep alone, strong food preferences, avoiding touch, excessive fear of the dark, and special routines. Raise questions that focus on attention, distractibility, impulsivity, and hyperactivity. Assess excessive behaviors such as aggression, poor modulation of anger or joy, stereotypic movements, tics, or self-injury.

Observe speech, language, and psychological skills, which often yield useful information about the diagnosis.

Note the diagnostic and clinical picture, which may suggest laboratory tests to determine abnormalities of growth, dysmorphisms, or major organ dysfunction. Also, medical evaluation of the cause of the child's hypotonia may be helpful.

Therapy is symptomatic. Maturation plays an important role in diminishing the target behaviors. Caution the parents against excessive discussions with the child, or between themselves, about hair and nail clipping because undue parental focus reinforces the recalcitrant behaviors.

A behavioral approach involving desensitization (exposure and response prevention) and relaxation techniques may help more severe behaviors. Therapists should be experienced in working with children who have similar problems, and they should be willing to initiate therapy at a very fundamental level (having the child sit in a chair at the barber shop, for example) without exceeding the child's tolerance level. Referring the child to an occupational therapist for sensory integrative therapy is another option.

Some children benefit from stimulants, others from selective serotonin reuptake inhibitors (SSRIs). Medication should be used only after establishing a proper diagnosis, however. The child should also be monitored periodically for the appearance of tics, poor school performance, and any escalation of his behavioral symptoms.

Bruce Shapiro, MD

DR. SHAPIRO is vice president, training, and associate professor of pediatrics, Johns Hopkins University School of Medicine, Baltimore.

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Behavior: Ask the experts. Contemporary Pediatrics October 2002;19:33.