Intro : : Treatment 1 : : Treatment 2 : : Treatment 3 : : Treatment 4 : : Treatment 5 : : Review
Several years ago I supervised a program at a pediatric hospital for children who were developmentally delayed, and in some instances seriously retarded and emotionally disturbed. A member of my staff was a brilliant young behaviorist who specialized in toilet training children. He became absolutely gleeful when a child came into our program who was enuretic or encropetic (lacking in bladder or bowel control). He was often heard to say, "I like nothing more than to get my hands into a dirty diaper." His enthusiasm for dirty diapers was certainly not shared by the parents of children with whom he worked. In fact, he is the only person I ever met who was enthusiastic about a dirty diaper.
In the developmental process, there are few milestones achieved by children that parents accept with more joy and enthusiasm than that of becoming toilet trained. In this chapter, I discuss some important facts about the development of children relative to achieving bladder and bowel control. I also describe several approaches to teaching children to control bladder and bowel movements. I emphasize "teaching" since 90% of bladder and bowel control is a matter of learning, as I will explain later.
Typically, once a child has reached about two and a half years old and has not learned bladder and bowel control, parents become concerned. This concern for the normal growth and development of the child is aggravated by the ever increasing burden of work that must be assumed by the parent. After all, as children increase in age and size, so does the volume of waste material being eliminated from those growing bodies. All things considered, it is certainly understandable that parents would want their children to become toilet trained as quickly as possible.
Although some children will learn to control their bladder and bowel very early in life-in some instances before the age of a year and a half-about 80-85% of children acquire this skill by the age of 5. Boys generally take a little longer, on the average, to learn complete bladder and bowel control, and are twice as likely as girls to wet the bed at night. So far as the child is concerned, parents shouldn't become concerned about bladder and bowel control until after the child has approached his or her third year and is still not toilet trained.
As I noted earlier, bladder and bowel control are learned behaviors; still, there are some precautionary measures parents should take if children find it inordinately difficult to learn this skill.
The single best precaution is to have the child examined by a physician to see if there is something physiologically or chemically the matter. Occasionally, children will have smaller than normal bladders. A study done by a team of Danish researchers concluded that chronic bed wetters don't produce enough of the hormone that regulates urine production while they sleep, a condition that can often be treated with the drug imipramine hydrochloride (Tofranil). Also, the drug desmopression (Stimate) which decreases bladder fullness, is frequently prescribed. But as is the case with virtually any behavior problem that is treated with drugs (for example, attention deficient disorder), behavioral therapy should also be a major component of treatment, if not the treatment of choice.
Regarding the treatment of bedwetting (nocturnal enuresis), this was recently borne out by research conducted at Boystown, under the direction of Patrick Friman, Mary Louise Kerwin, and Mary Osborne. They found that medication is effective in only about half the cases, and that for well over half the children, bedwetting reoccurred as before once drug treatment stopped. They concluded that behaviorally-based strategies (as described in this chapter), including urine alarm systems, pelvic muscle exercises, "dry bed training", and simple incentive/reinforcement techniques are ultimately the best since they teach children bladder control. (I am indebted to Dr. Joseph Wyatt, Editor of Behavior Analysis Digest, for bringing this study to my attention.)
Since infections and diseases of the urinary tract can also aggravate bed wetting, it's always a good idea, if a child is having an inordinately difficult time learning bladder and bowel control, for the child to be examined by a qualified physician.
Assuming that nothing is amiss physiologically or from a medical point of view, there are some very effective methods that have been well documented in research for teaching children to control their bladder and their bowels. In this chapter, I speak only about bladder control. Bowel control problems tend to be so rare in comparison to bladder control problems that I've chosen to focus on bladder control. If you have a problem with a child who is encropetic (lacks bowel control), your pediatrician, family physician, or a urologist will very likely have information that will be helpful.
As I have noted elsewhere in this book, when selecting methods for improving a child's behavior, we are well advised to begin with those methods that are the easiest to put into place and to manage. I will follow that same approach in treating bladder control.
Typically, parents don't become concerned about the behavior of their children until something is the matter. Our tendency as parents, unfortunately, is to leave well enough alone and hope nothing goes wrong. The toilet training of children provides an excellent opportunity for me to illustrate and emphasize the importance of not waiting until something goes wrong before something is done. My recommendation, therefore, is that parents take a proactive, before-the-fact, approach to teaching children to control their bladder (and their bowel, for that matter).Intro : : Treatment 1 : : Treatment 2 : : Treatment 3 : : Treatment 4 : : Treatment 5 : : Review
Treatment #1: Initial Daytime Bladder Control
To begin, when the child has reached about a year and a half (unless he/she has exhibited an interest earlier in remaining dry or using the potty), the parents should look for opportunities during the day to find the child dry and to comment on that by saying something like, "Good for you, you're doing a really good job staying dry." You might also say, "When you need to wet, tell me and we will go to the potty." If, through observations of the child's wetting behavior, you can predict fairly accurately when the child is likely to wet his diapers, before "it" happens take the child to the potty and say, "Thank you for sitting on your potty chair." You might even give the child a small edible, like a piece of animal cracker, to emphasize your appreciation and as a reinforcer for sitting on the potty. While the child is sitting on the potty, the parent should then say something like, "Try hard to wet in the potty." To help facilitate wetting, it is frequently useful to turn the faucet on or even place the child's hand in warm water.
If the child urinates while on the potty, be sure to acknowledge this enthusiastically by smiling, opening your eyes wide with excitement, and saying something like, "That's wonderful! You wet in the potty. What a big-boy thing to do!" You might even give the child another small piece of animal cracker. I hasten to note that edibles should be used very, very sparingly. Small pieces of animal cracker (no more than about a quarter of an inch square), a fourth of a jelly bean, and so on are sufficient. In fact, if you can get by without using edibles at all, so much the better since the use of edibles has to be faded out as quickly as possible.
If after sitting on the potty chair for 2 or 3 minutes the child still hasn't voided, even after encouragement, take the child off the potty chair, put his diaper and clothes back on, and say, "When you need to wet, come get me and we will come to the potty chair together." If you have found edibles to be effective, put one in a tightly sealed jar and set it by the potty, and say, "When you wet in the potty chair, you may have this." Then send the child on his way to play. If the child asks for the edible right then (which he will very likely do), say, "When you wet in the potty chair you may have this cookie (or a piece of candy, or whatever)." Later, if the child comes to you dry and wants to use the potty chair, receive this warmly and enthusiastically, and, as the child is sitting on the potty chair urinating, enthusiastically show your delight. You might even call attention to the sound the urine makes as it hits the potty chair. Being reinforced for making that sound happen will increase the probability that the child will want to make it happen again in the near future.
If, however, the child continues to play and eventually wets his diaper, whether you discover the diaper is wet or the child comes to you complaining that the diaper is wet, do not say a word. I repeat, do NOT say a word. Don't scold the child for wetting his diapers. Don't ask the child why he didn't come to you when he needed to wet. Don't even look at the child as though you are angry or upset. In fact don't even make eye-to-eye contact. Simply change the diaper without saying a word as though you were preoccupied with many other important things. Don't tickle the child's tummy, don't hold the child close in a warm embrace, don't kiss the child, just change the diaper with efficiency and without emotion. When the diaper is changed and the child is ready to go back to his play, say, "When you feel like wetting, tell me so we can go to the potty chair together." Again, you will want to check the child occasionally to try and find him dry so you can take him to the potty chair, and to practice what it is you want him to do. It's during those times, when the child is either actually urinating or at least sitting on the potty chair that he should get a lot of enthusiastic, positive parental attention and praise. Any other time, the child should be responded to caringly, but not with enthusiasm, exuberance, or affection. Using this simple teaching strategy, all (and by that I mean every one) of the parents I have worked with have successfully taught their children bladder control. With some children, the skill was learned rapidly, sometimes within a day or so. Others took longer, even up to a week or two. But in every instance, this simple pro-active approach proved to be effective. Nothing more involved or complicated was necessary.Intro : : Treatment 1 : : Treatment 2 : : Treatment 3 : : Treatment 4 : : Treatment 5 : : Review
Treatment #2: Daytime Bladder Control for Older Children
When teaching bladder control to older children, follow exactly the same procedures outlined above except for one added step: role playing. With older children (i.e., children who are two and a half to three years old and older), I have parents role play their expectations with their children. It goes like this:
"Billy, when you need to wet, I want you to come and tell me. What do I want you to do when you need to wet?"
Note: Wait a moment for the child to answer. If he doesn't answer, simply restate what you expect him to do.
|Billy:||"You want me to come and get you."|
|Parent:||"That's right, Billy. Thank you for that good answer. I want you to come and tell me. I want you to come and tell me before you wet. When do I want you to come tell me, Billy?"|
|Billy:||"Before I wet my pants."|
|Parent:||"That's right, Billy! I want you to come tell me before you wet your pants. Let's pretend, Billy, that you have not wet your pants and you need to go to the toilet. Show me right now what you are going to do. Tell me what you are going to say to me."|
|Billy:||"I'm going to tell you that I need to go to the toilet."|
"Thank you, Billy. I appreciate your listening so carefully. Now go into the living room and let's pretend that you need to go to the toilet. I want you to show me what you are going to do and tell me what you are going to say."
Note: The parent then sends Billy into the living room. The parent might even prompt the child about what to do next by saying, "Okay, Billy, show me what you are going to do and say."
|Billy:||(Comes to the mother) "I need to go to the toilet."|
(Checks his diaper/pants to be sure he is dry) "Great job, Billy, you are dry and you came and told me that you need to go to the toilet. That's wonderful. Now, let's walk together into the toilet and I will show you what I expect you to do next."
Note: It is important for the parent to check the boy to make sure he is dry. This emphasizes an important precondition, and it also gives the parent a chance to praise the boy for being dry.
The parent and child then go together into the lavatory.
|Parent:||"When we get to the toilet, Billy, I want you to sit on the toilet/potty chair until you are finished wetting. What do I expect you to do, Billy, after we get into the lavatory?"|
|Billy:||"I'm supposed to sit on the toilet/potty chair."|
|Parent:||"That's right, Billy. Thank you for listening so carefully. I want you to sit on the toilet/potty chair. How long do I want you to sit on the potty chair?"|
"Until I am through wetting."
Note: It is important that the boy say back to the parent all the conditions that are to be met.
"That's exactly what I expect of you, Billy. Now, show me what you are going to do after we have gotten to the toilet."
Note: At this point, let Billy show you how well he understands your expectations. If he has any trouble along the way, simply restate your expectations and have those repeated back to you. Once he demonstrates to you exactly what you expect, acknowledge that enthusiastically by saying something like, "That is exactly correct, Billy. You have listened so well and you were able to do exactly what I want you to do. That is so wonderful." Then give the boy a hug, a kiss, a back rub, or whatever it is the child enjoys in terms of verbal and physical contact.
Once you are completely satisfied that the child understands perfectly what it is you expect, move on to the statement of consequences, which in this case, will only be of a positive nature.
|Parent:||"Billy, when you come and tell me when you need to wet and then wet in the potty chair, I'm going to put a smiley face on this chart." (Figure 18.1)|
Figure 18.1 - Toilet Training Record
A clever technique suggested by Friman and his associates at Boystown is dot-to-dot pictures of things the child wants (a book, toy, or whatever). With each dry night, the child is allowed to advance to one more dot. Once the picture is completed, the child is given (has earned!) the item drawn in the picture.
Note: Show the child a chart which will be fixed to the wall near the potty chair. To heighten the effect of the chart, I have parents take a picture of their child sitting on the potty chair smiling, and affix it to the top of the chart.
To illustrate the chart's use, say, "Billy, sit on the potty chair the way you showed me."
When the child does, draw a smiley face on the chart, and say, "You see, Billy, when you sit on the potty chair I will draw a smiley face. When you wet in the potty I will draw two smiley faces. When you have six smiley faces, then we will read a story from your favorite book." I have used a story only as an example. If something else is more desirable to the child, use it. It might be the privilege of playing with a favorite toy that is available only upon urinating in the potty chair. It might be going to the grocery store during family shopping. It could be any number of things. Some privileges might be earned by simply sitting on the potty chair whereas others might be available only if the child actually urinates. I leave it up to the parents to decide how to set up this part of the program and have found their judgment to be very good. The key is that an important target behavior must be met before a reinforcer is granted. Remember: No free lunch. No noncontingent reinforcers.
I mentioned earlier that a smiley face would be drawn on the chart. Again, that was only for illustration purposes. Parents have used smiley-face rubber stamps, smiley-face pressure sensitive stickers, and sometimes things other than smiley faces such as stars, pictures of butterflies or animals, or whatever. Frequently, children find it very reinforcing when they can draw or affix something on the chart.
Continue the role playing by having the child get off the potty chair, get redressed, then, using the example of reading a favorite story, take the child into the living room, have him pick a story from one of his favorite books, then sit down together and read the book. When that is done, say something like, "Billy, that was so much fun reading the story with you. Tell me what I can expect you to do so that we can have another fun time together reading a story." Then wait for a correct response, prompting the child as necessary until the correct response is forthcoming.
Most toilet training programs produce the desired results within a week or two when used as prescribed.
As soon as the child has demonstrated that he understands perfectly what your expectations are, put the program into effect. Recalling Treatment #1, above, it's a good idea to check the child once in a while to see if he is dry and acknowledge that enthusiastically as I described earlier. Also, as I described earlier, if the child is wet or complains of being wet and wants to be changed, take care of that efficiently and objectively and with as little interpersonal interaction as possible. Following these procedures, the probability is very good that you will have the success you want within a week or so.Intro : : Treatment 1 : : Treatment 2 : : Treatment 3 : : Treatment 4 : : Treatment 5 : : Review
Treatment #3: Nighttime Bladder Control
Bladder control during the day is almost always achieved ahead of bladder control at night. With most children, once they have learned to control their bladder during the day, it is only a short while before they learn to control their bladder at night, especially when they receive a lot of verbal praise as they begin waking up dry. However, it is not unusual for nighttime bladder control to be a persisting problem. In fact, up to 2% of the adult population has nighttime bladder control problems! One study found that 3% of servicemen still wet their beds.
If your child continues to have a problem with nighttime bladder control, I suggest the following treatment developed by a group of Israeli scientists lead by Dr. Ahmos Rolider of the University of Haifa in Isreal. This treatment requires a heavy commitment on the part of parents, but its effectiveness is well worth the effort parents put into it.
The treatment begins with giving the child as much of his or her favorite beverage as the child can drink. This is done during the afternoon, and is done for two reasons. First, it helps to enlarge the bladder. Occasionally, children have difficulty with nighttime bladder control because their bladders are smaller than ordinary and are unable to hold much liquid. Filling the bladder to capacity helps stretch it to its desired size. The second reason for filling the bladder is to increase the child's ability to restrain the flow of liquid using what is called a "strain and hold procedure." This involves having the child lay on his bed in a darkened room, concentrating on full-bladder sensations produced by straining and holding back the flow of urine, and then hurrying to the toilet to urinate. Most parents I work with who are having problems teaching their children bladder control skills typically tell me they keep liquids away from their children as much as possible. Conventional wisdom would suggest this to be an appropriate thing to do if the child has a problem wetting the bed at night. However, research in the area of bladder control has taught us that, contrary to conventional wisdom, children who are having bladder control problems should consume a lot of liquid and then learn to hold it, thus, increasing the size of the bladder and learning bladder control skills.
The strain and hold procedure should be practiced for 15 minutes during which time the child is given as much of his or her favorite beverage as he can drink. Practicing the strain and hold procedure should be done several times (six to eight times during the afternoon). Appropriate practice can be reinforced using a wall chart (much like the one shown in Figure 18.1) posted conspicuously in the child's room on which is recorded the trial successes using smiley faces or whatever other symbol would communicate success to the child.
An hour before bedtime, the parents should practice with the child what is called a "cleanliness and positive practice procedure." The cleanliness procedure involves practicing with the child what would be done to clean up after an accident, including remaking the bed with clean linen and blankets, etc. The positive practice procedure involves having the child lie in bed while counting to fifty then getting up, going to the toilet and attempting to urinate. Remember, the child has been drinking lots of liquids.
At bedtime the child describes the cleanliness and positive practice procedures and is asked to feel the sheets and describe how good they feel being dry. Before actually going to bed to sleep, the child should try to urinate following a strain and hold procedure.
Once the child is asleep, the parents should allow him to sleep to within 5 or 6 hours of his usual time of awakening in the morning. For example, if the child usually wakes around seven o'clock, he would be awakened by the parents at about two o'clock in the morning. The key is to wake the child shortly before he/she would otherwise urinate. Research has demonstrated that children who have bed wetting problems can usually control their bladder for about 5 hours. Since most children go to bed about nine o'clock, 5 hours of sleep would take the child to two a.m. which is about 5 hours before the child would ordinarily be getting up. Since all children's sleeping habits are different, parents must take individual sleeping habits into consideration when preparing this treatment.
Upon waking the child, it is very important that he is fully awake before proceeding with treatment. This can be accomplished by asking the child several questions, for example, what day of the week is it, what his/her name is, how old he/she is, names of brothers and sisters, and so on. Once fully awake, the child is required to urinate as much as he can in the toilet. If the child is dry for 6 consecutive mornings, the time for waking should be set back for 1 hour. In other words, rather than waking the child at two o'clock he should be awakened at one o'clock in the morning. This procedure should be continued until the child is sleeping at least 8 full hours (after having been awakened and taken to the toilet) and waking up dry in the morning.
If, when awakened, the child has already wet the bed, the child should clean himself with as little help from the parent as possible, including changing any bedding as necessary. While this is being done, the parent must say nothing about the child having wet the bed. Once everything is all cleaned up and it is time for the child to go back to bed, the parents should have the child feel the bed and make comments about how nice it is to be able to sleep in a clean, dry bed, then have the child go to sleep. Adjustments should be made in what time the child is awakened to assure the child is dry. It is very important that the treatment go forward in an atmosphere of success. The child should be given lots of verbal praise for succeeding, and if necessary, to earn points that can later be used to acquire desirable things.Intro : : Treatment 1 : : Treatment 2 : : Treatment 3 : : Treatment 4 : : Treatment 5 : : Review
Treatment #4: Dry Bed Training
This treatment was first described by a team of three researchers (Azrin, N.H., Sneed, T.J., and Foxx, R.M., in 1974) and is known as "dry bed training" (DBT). This procedure employs a urine alarm device that is activated the instant moisture makes contact with the urine alarm pad. The pad is placed in the child's diaper/training pants so that it is immediately in contact with the urine. I've had parents use such a device with many children and have enjoyed 100% success with it. These devices have taken several creative forms. My friend and colleague at Utah State University, Dr. Carl Cheney, developed his "electric potty chair." It could be programmed so that when urine flowed into it, music would play, bells would sound, the TV would go on, and/or any number of other delightful things would happen.
Before using such a system, it should be explained and demonstrated to the child. The following description of how the treatment is applied draws heavily from the work of Eugene Walker, Mary Kenning, and Jan Faust-Campanile of the University of Oklahoma Health Sciences Center, published in Childhood Disorders, edited by E. Marsh and R. Barkley, Guilford Press, New York, 1989. The treatment is described as follows:
On the first night of the intensive training portion of the program, parents and child review all aspects of the procedure. About an hour before bedtime, the child is given a glass of his or her favorite drink, and the urine alarm is placed in the child's diaper/training pants. The child then performs 20 trials of positive practice (a form of the strain and hold procedure). This entails the child's lying on the bed, counting to 50 (less for younger children), going to the bathroom, attempting to urinate, and returning to bed. The child is also encouraged to note the dry bed and feel how comfortable it is. Just before retiring, the child consumes more fluids and repeats the training instructions to the parents.
Every hour during the night, the parents gently awaken the child and prompt him or her to go to the bathroom. At the bathroom door, the child is asked whether he or she can retain urine for another hour. If so, the child is praised for his or her control and returned to bed without voiding. If not, the child urinates in the toilet, is praised for the correct toileting, and returns to bed. In the bedroom, parents call the child's attention to the dry sheets and praise him for a dry bed. The child is given more fluids to drink and then goes back to sleep for another hour.
If a wetting accident occurs, parents shut off the alarm, wake the child, express mild displeasure, and rush the child to the bathroom to complete urination. The child then performs cleanliness training by changing pajamas, removing wet sheets, cleaning the mattress, getting clean sheets, remaking the bed, and appropriately disposing of the soiled linens. The child then performs 20 trials of positive practice as described above.
Following the evening of intensive training, the posttraining phase begins. In this second phase, the urine alarm is again utilized, but encouraging fluid intake is discontinued. If the child has a dry night, he or she is praised throughout the next day for this success. Significant others are encouraged to praise the child as well (e.g., grandparents, a favorite aunt or uncle, etc.). If an accident occurs during the night, 20 positive practice trials are performed prior to bedtime the next night. Just before the parents retire (11:00 p.m. to 12:00 mid-night), they awaken the child and encourage him/her to urinate. After each dry night, the child is awakened a half hour earlier on the following evening. When the waking time follows bedtime by no more than an hour, it is discontinued. This phase ends when the child achieves dryness for seven consecutive nights.
In the final phase of training, the urine alarm and periodic awakening are discontinued. The child's bed should be inspected each morning by the parents. If a wetting accident has occurred during the night, the child is to change and remake the bed immediately. That evening, 20 trials of positive practice are performed. If two accidents occur in the same week, the second phase of training should be reinstituted until seven consecutive dry nights are again achieved.
It is worth noting that a general toilet training program based on DBT procedures has been described in nontechnical language in a book written by N. Azrin & R. Foxx, Toilet Training in Less Than A Day, Pocket Books, 1976. The use of this book should not be expected to replace contact with a clinician, as research has shown that parents are better able to manage this program if they are receiving professional supervision.Intro : : Treatment 1 : : Treatment 2 : : Treatment 3 : : Treatment 4 : : Treatment 5 : : Review
Treatment #5: Urine Retention and Sphincter Control Exercises
Children who have bed wetting problems are frequently aided by exercises that teach them to control the flow of urine and to control the opening and closing of the sphincter of the bladder, which in turn controls the flow of urine. Again, I defer to the writings of Walker, Kenning, and Faust-Campanile as cited in the discussion of Treatment #4 above.
Urine retention and sphincter control exercises were developed to assist children in gaining control over the urination reflex as well as increasing functional bladder capacity, which, as noted earlier, is deficient in many enuretic children. In the retention control procedure, children are instructed to go to the bathroom when they feel the urge to urinate, but are told to refrain from urinating for as long as possible. Initially, most children can inhibit the urgency for only a few seconds. However, with practice they can eventually refrain for several minutes or hours. Fluid intake may be increased to provide additional training opportunities as well as over learning. During their 15 to 20-day training period, each child is expected to increase the time of urine retention 2-3 minutes daily. He or she is rewarded for increases in retention time, urination in the toilet, and dry nights.
Sphincter control training has also been used in combination with retention control training. To accomplish this, the child is instructed to practice starting and stopping the stream of urine when voiding. Rewards may be offered to encourage the process.
When using these methods, care should be taken not to force the intake of excessive amounts of fluid or to require the child to retain urine for unusually long periods of time. A cup or two of fluid per hour with retention encouraged for up to 1-2 hours is well within safe limits. However, if the child shows signs of distress, these requirements should be lowered.
This method is a less intensive alternative that can be used with young children, especially those who exhibit excessive frequency and urgency in urination or who are known to have low functional bladder capacity. This method may also be employed with adolescents since they are generally resistant to methods requiring extensive supervision or control by parents.
The treatments described here will solve nearly any bladder control problem. If additional helps are needed with your child, I urge you to purchase the book written by Azrin and Foxx, Toilet Training In Less Than A Day. Also, there are two documents available at a nominal cost from the Division of Outreach and Development, Center for Persons with Disabilities, Utah State University, Logan, Utah 84322-6845. The one document is entitled Toilet Training: Short Term and the other is entitled Toilet Training: Long Term. These are both excellent guides to teaching children bladder control skills and are very inexpensive.Intro : : Treatment 1 : : Treatment 2 : : Treatment 3 : : Treatment 4 : : Treatment 5 : : Review
NOW TO REVIEW
When toilet training children:
- be certain there are no medical problems complicating a child's bladder or bowel control,
- begin initial bladder control using the basic behavioral strategies of extinction and selective reinforcement of appropriate behaviors,
- teach enuretic children "strain and hold" procedures,
- for more difficult causes, employ the "dry bed training" using a urine alarm device, and
- particularly for older children, teach urine retention and sphincter control exercises.