What makes a child that was already dry to relapse?
“My son stopped wetting the bed at age 3. At age 6 he relapsed; at the beginning he had only few accidents but gradually the bedwetting frequency has increased and now it is every night. I can’t think of any reason that explains this relapse and I don’t know how to help him to stop having accidents at night.”
This is a very common situation called “Secondary Enuresis”. There is a distinction in the literature between “Primary Enuresis”: a child who has never stopped bedwetting or was dry for only a short period of time, and “Secondary Enuresis”: a child that was dry for at least six months and relapsed.
The conventional train of thought relates secondary enuresis to psychological causes. This is only partially true. The sub-conscious restraint mechanism in the brain is very sensitive and can easily lose control. The cause for relapse, in most cases, is a change in the child’s life or exposure to an event which can be on the scale from marginal to traumatic. Seldom the cause for relapse is medical. The change or the event requires an adjustment process to the new situation; as a result, some children will manifest undesired reaction or behavior; it can be aggression, stuttering, introversion, encopresis, fears, social problems etc. One of the most common ways of regression is relapsing to bedwetting.
The change or the event in the child’s life can vary, for example – birth of a sibling, geographical change, new school, new nanny, change of weather, domestic problems, child’s physical and/or emotional and/or sexual abuse, hospitalization, severe illness, involvement in a car accident… the list is endless. The severity of the change or the event/s will have an impact on the child’s response and it is obviously different from one child to another.
I recently treated a girl, age 6. She outgrew bedwetting at age 3; when she was 5, she played in a sandbox, where a friend threw sand in her face and into her eyes. She started to cry; from that night she started to wet the bed continuously until she came for treatment. This case strongly demonstrates how fragile is the restraint mechanism, especially with young children, and how easy it can get out of control.
The number one cause for bedwetting relapse is the birth of a sibling. The newborn, naturally, causes substantial changes in the family structure. The parents’ attention is divided among all the children, the baby draws more attention from the entire family and other siblings might feel neglected. It is particularly noticeable with a single child since the longer the age gap between the child and the new born, the more difficult the adjustment. Most children will adjust themselves to the new situation with no difficulties (although it strongly depends on the parents’ behavior and understanding the possible impact on the siblings); however, some children who managed to become dry naturally in an earlier age might react to the new situation by relapsing to bedwetting. For most of them, the relapse period will be short; the child will learn to adjust to the new situation and will stop wetting the bed naturally. However, for some children the adjustment’s process is longer and although they become fully adjusted to the new baby, they continue to wet their bed. The reason is that the learning of the sub-conscious restraint mechanism that they have acquired naturally in an early age is gone; it is exactly like a language that we are not actively using and as time passes, we simply forget it.
So, is the cause for bedwetting relapse psychological? The answer is Yes and No; Yes, because the initial cause had a psychological nature (change in the child’s life – birth of a new born). No, because it is a learning issue once the psychological issue no longer exists. It is very important to understand this distinction when diagnosing a child with secondary enuresis. Unfortunately, many professionals wrongly diagnose secondary enuresis as solely a psychological issue and consequently offer psychological treatment when the treatment of choice should be a process of learning.
In simple words; we need to reactivate the restraint mechanism by a learning process which will recondition the reflex system.
I must state, however, that in some severe cases such as child abuse, use of learning process will be like using a band aid for infection and psychological approach is the right choice of treatment. In those cases, the treatment will focus on the abuse rather on the bedwetting which in those cases is a symptom to a severe problem.
To sum up – In most cases there is no difference between children with primary enuresis to those with secondary enuresis in terms of treatment; the fact that children with secondary enuresis have previously acquired the skills which enable them to be dry at night, doesn’t give them any advantage on those that have never been dry; both groups are unable to activate the restraint mechanism during sleep.
When we diagnose a child with secondary enuresis we must be very careful; wrong assessment might lead to wrong treatment approach which might make the child’s condition even worse. The therapist must ask himself if the initial cause that led to the bedwetting relapse is still relevant or now it is merely became a pure learning issue.
Time plays an important role; it is important to seek professional help as soon as possible since the early learning is gradually diminished until it completely disappears. At early stage of the relapse we can still use and rely on learning remnants that will make the treatment easier and shorter. However, if the parents see that the child managed to recover by himself and the bedwetting frequency is reduced, it is advised to wait and see. When the child wets every night for more than a month, treatment is recommended.
The treatment must include a learning process – therefore – medication, pull-ups, fluid restriction and waking the child at night are not advised since they suppress any learning and will not lead for recovery.
The recommended treatment is the multi-modality method which is based on Cognitive-Behavioral Treatment combined with a and different learning techniques tailor to the patient. The patient goes through a process of learning which will eventually reactivate the restraint mechanism. The process normally takes about 3-5 months with an over 90% success rate.
This treatment is now available worldwide through TheraPee, the only online bedwetting treatment.
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