A CONTROLLED COMPARISON OF TWO TREATMENTS FOR
NOCTURNAL ENURESIS: THE RELATIONSHIP BETWEEN
BEHAVIORAL CHANGE AND GENERAL ADJUSTMENT

BY

WILLIAM G. WAGNER

A DISSERTATION PRESENTED TO THE GRADUATE COUNCIL
OF THE UNIVERSITY OF FLORIDA IN
PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE
DEGREE OF DOCTOR OF PHILOSOPHY

UNIVERSITY OF FLORIDA

1981

Dedicated to my wife, Diane,
who supports my dreams and
helps them become reality.

ACKNOWLEDGMENTS

I sincerely wish to thank Dr. Suzanne Johnson for her

efforts in making this study possible. As a talented and

concerned teacher, Dr. Johnson has shaped my professional

development in ways far beyond the limits of this single

research project. She helped me find direction when I

was lost and confused. Her respect for my work and my

ideas helped me to develop a level of self-confidence that

made difficult periods of learning more bearable. And it

was through my interaction with her that I learned what it

really means to be a psychologist.

I also wish to thank Dr. Dixon Walker who provided

physical examinations and supervision of the medication

treatment program used in the study. Dr. Walker's enthusiasm

and active participation made possible the multi-disciplinary

nature of this study. I want to thank Drs. Michael Dennis

and Paul Sawyer, residents in urology, who assisted in the

provision of the medication treatment program. A special

thanks goes to Mrs. Janie Robinson who handled the

scheduling of clinic appointments for all children enrolled

in the study.

As chairperson of my doctoral committee, Dr. Joe

Wittmer provided counsel and support during rather tumultuous

times in my academic program. I truly appreciate these

efforts which eased the sometimes confusing journey through

the structure inherent in a large university.

I wish to thank Dr. Randy Carter for his help in the

statistical analysis of the data collected in this study.

Through his patience and guidance both in and out of the

classroom, Dr. Carter has helped me to develop a greater

appreciation for the use of statistics in the study of

human behavior.

I thank Dr. Ellen Amatea for her interest and support

during the last three years. Her willingness to sponsor

an individual reading project in the area of family therapy

helped expand my understanding of treatment approaches with

children.

I applaud the efforts of my student friends in the

Department of Clinical Psychology who volunteered their time

and energy to serve as therapists for the conditioning

treatment program. Thank you Stella Couchells, Gary Geffken,

Brenda Gilbert, Jill Harkavy, Miles Hohenegger, and Robin

Morris.

I wish to thank Mrs. Cecelia Young of the Florida

Department of Health and Rehabilitative Services for her

efforts that lead to state support of treatment fees for

children of indigent families enrolled in the study. A

thank-you also goes to Mrs. Gay Cellon, Children's Medical

Services, who coordinated the scheduling of appointments

for children who received state support. I thank the

Department of Child and Adolescent Psychiatry, J. Hillis

Miller Health Center, for its financial support of the study.

I also wish to acknowledge the efforts of clerical staff

for the Children's Mental Health Unit in the Department of

Child and Adolescent Psychiatry.

Finally, I wish to thank all individuals who assisted

in the recruitment of subjects for this study. Special

thanks go to the staff of the Town and Country Shopper, the

Alachua County Information and Referral Service, the J.

Hillis Miller Health Center Friday Evening Post, television

station WUFT, and the Levy and Alachua County Departments

of Public Health.

TABLE OF CONTENTS

Page

ACKNOWLEDGMENTS ..... . . . . . . . iii

ABSTRACT. . . . . . .. . . . ... .. ix

CHAPTER

I INTRODUCTION . . ... . . . . .. 1

Rationale for the Study . . ... .. 4
Purpose of the Study . . . . . 6
Definitions of Terms . . . . . 7

II REVIEW OF RELATED LITERATURE . . . .. 10

Overview . . . . . . . .. 10
Theoretical Formulations . . . ... 12
Genetic Interpretation . . . .. 12
Organic Formulations . . ... 13
Psychodynamic Interpretations . .. 17
Behavioral Formulations . . .. 18
Treatment Approaches . . . . ... 20
Counseling or Psychotherapy ... . 21
Pharmacotherapy . . . ... 23
Behavioral Treatment . . . .. 27
Self-Concept . . . ... . . . 38
Emotional and Behavioral Correlates . 44

III METHODOLOGY . . . . ... . . 53

Subjects . . . . .. . . .. 53
Hypotheses . . . . ... . . . 55
Instrumentation . . . . ... 56
Child Self-Report Measures . . .. 57
Piers-Harris Children's Self-
Concept Scale . . . .. 57
What I Think and Feel: A Revision
of the Children's Manifest
Anxiety Scale . . . ... 61
This Week . . . . .. . 63
Peabody Picture Vocabulary Test 64

CHAPTER Page

III METHODOLOGY (Continued)

Parent-Report Measures . . . .. 67
Tolerance Scale for Enuresis . 67
Nuisance Scale for Enuresis . 68
Personality Inventory for Children 69
Behavior Problem Checklist . .. 74
Procedures . . . . . . . . 77
Collection of Baseline Data . .. 77
Treatment Format . . . . .. 78
Collection of Posttest Data ... . 81
Analysis of the Data . . . . .. 82

IV RESULTS . . . . . . . ... 87

Statistical Description of the Sample . 87
Pre-treatment Assessment . . . .. 91
Results . . . . . . . .. 95

V SUMMARY, CONCLUSIONS AND RECOMMENDATIONS FOR
FURTHER RESEARCH .. .. . . . . .. 114

Summary . . . . . . . ... 114
Discussion . . . . . . ... 115
Limitations . . . . . . .. 124
Conclusions . . . . . . .. 126
Recommendations for Further Research . 127

APPENDICES

A INFORMED CONSENT FORM . . . . ... .130

B TOLERANCE SCALE FOR ENURESIS AND NUISANCE
SCALE FOR ENURESIS . . . . . .. .132

C WHAT I THINK AND FEEL . . . . . .. .133

D THIS WEEK . . . . . . . ... 134

E TREATMENT RECORDING CHART . . . ... .135

F THE NIGHTTIME TRAINING APPROACH . . .. .136

G RELAPSE DATA FOR SUBJECTS IN THE CONDITIONING
AND PHARMACOTHERAPY GROUPS . . . .. .139

H COMPARISON OF PRE- AND POST-TREATMENT SCORES
ACCORDING TO TREATMENT METHOD . . .. .140

APPENDICES Page

I COMPARISON OF PRE- AND POST-TREATMENT SCORES
ACCORDING TO ATTAINMENT OF CURE CRITERION 141

J COMPARISON OF PRE- AND POST-TREATMENT SCORES
ACCORDING TO WETTING FREQUENCY AT WEEK #14 142

K SIGNIFICANT WITHIN-SUBJECT SPEARMAN RANK
ORDER CORRELATIONS BETWEEN WEEKLY WETTING
FREQUENCY AND RESPONSES TO THIS WEEK . 143

REFERENCES . . . . . . . . ... . 144

BIOGRAPHICAL SKETCH . . . . . . . .. 155

viii

Abstract of Dissertation Presented to the Graduate
Council of the University of Florida in Partial
Fulfillment of the Requirements for the Degree
of Doctor of Philosophy

A CONTROLLED COMPARISON OF TWO TREATMENTS FOR
NOCTURNAL ENURESIS: THE RELATIONSHIP BETWEEN
BEHAVIORAL CHANGE AND GENERAL ADJUSTMENT

By

William G. Wagner

August, 1981

Chairperson: Dr. Joe Wittmer
Major Department: Counselor Education

The purpose of this study was to investigate the

difference in efficacy of the two most commonly used treat-

ment approaches for primary nocturnal enuresis, pharmaco-

therapy and behavioral conditioning. The study also

examined the relationship of primary nocturnal enuresis

and its methods of treatment with subjects' level of

emotional and behavioral adjustment. An attempt was made

to identify pre-treatment predictors of treatment outcome

and premature withdrawal from treatment.

Specifically, the project was designed 1) to assess

change in the frequency of nighttime wetting produced by

either conditioning treatment with a urine alarm or

pharmacotherapy with imipramine hydrochloride ('Tofranil');

2) to determine whether change in the frequency of

nighttime wetting influenced subjects' level of emotional

and behavioral adjustment; 3) to determine if the method

of treatment received affected a subject's level of

emotional and behavioral adjustment; 4) to determine if

pre-treatment variables existed which could predict outcome

from treatment; and, 5) to determine whether pre-treatment

variables existed which could predict premature withdrawal

from the treatment program.

Subjects involved in the study were male and female

children and adolescents, ages 6 through 16. A total of

49 subjects were formally enrolled in the project. From

this initial study sample, 36 subjects actually completed

all facets of the 15-week program.

Analyses of subjects' wetting frequency over the

course of treatment revealed a significantly more effective

outcome for the conditioning approach as compared with

either pharmacotherapy or assignment to a clinical waiting

list. Comparisons of pre- and post-treatment measures of

adjustment provided insufficient evidence to support the

hypotheses that either change in the frequency of nighttime

wetting or the method of treatment received would significantly

influence subjects' level of emotional and behavioral adjust-

ment. In addition, only one of 26 pre-treatment variables

was found to significantly predict treatment outcome. The

only pre-treatment predictor of premature withdrawal from

treatment was the Tolerance Scale for Enuresis which was

found to be a highly significant predictor of early

termination from conditioning treatment.

CHAPTER I
INTRODUCTION

The study and treatment of enuresis has an extensive

and picturesque history (Glicklich, 1951). Research in

the area has proceeded in many directions with attention

devoted to physiological, psychological, behavioral, and

social factors as they relate to etiology and treatment.

The basic focus of enuresis is behavioral, the micturition

response. The ultimate goal of treatment is the elimina-

tion of the inappropriate enuretic behavior.

Not all forms of urinary incontinence are included

under the label of enuresis. Uncontrolled wetting that

is a result of uropathology is not diagnosed as enuresis.

Likewise, various age minimums (e.g., three to five years

old) are used as a starting point at which lack of bladder

control is viewed as dysfunctional. Various minimum

criteria regarding wetting frequency (e.g., at least three

wet days/night per week) have also been proposed to differ-

entiate enuresis from occasional "accidents." Although

frequently considered synonymous with bedwetting, enuresis

is not limited to nighttime wetting (nocturnal enuresis)

but may occur during the daytime as well (diurnal enuresis).

Although it may occur in adulthood (Thorne, 1944),

enuresis is most commonly found in children, affecting

approximately 15% of all five-year-olds at any one point

in time (Young,1969). This high incidence has stimulated

a voluminous amount of research involving both the medical

and psychological professions. It is unfortunate that much

confusion and misunderstanding continue to surround the

disorder. Still, wealth of information is available from

which workable hypotheses can be developed that will hope-

fully lead to better evaluation and treatment.

One must guard against what Kolvin and Taunch (1973)

consider the simplistic approach of conceptualizing enuresis

as a distinct and unidimensional phenomenon. It is inviting

to identify a particular variable (e.g., urinary tract

infection or psychosexual dysfunction) and then develop a

theory around it. But enuresis does not appear to lend

itself to such interpretation (Davidson & Douglass, 1950).

The initial cause of the disorder may vary from individual

to individual and may be multifactorial in nature. Should

the problem continue to exist over a long period of time,

it may be maintained by factors unlike the initial cause

(MacKeith, 1973).

Johnson (1980) concurs with MacKeith (1973) and opts

for a multidimensional perspective. It is necessary to

consider physiological problems such as small bladder

capacity (Zaleski, Gerrard, & Schokier, 1973). It is

important to assess the existence of a sleep disorder

(Broughton, 1968; Ritvo, Ornitz, Gottlieb, Poussaint, Maron,

Ditman, & Blinn, 1969). But itsessential that such factors

be considered in relation to the child's intellectual and

psychological fucntioning, the family environment, and the

child's social relationship with peers. As Johnson (1980, p. 98)

states, "most of us would agree that human behavior is

multidetermined; enuretic behavior seems to be no exception."

In addition to studying the variables that contribute

to the existence of enuretic behavior, it is possible to

assess the extent to which enuresis influences other aspects

of a child's life. Of particular interest might be the

effect enuresis has on the child's relationship with parents.

As Baker (1969) has indicated, enuresis is an appropriate

behavior to use in such research as it provides concrete

evidence to indicate whether or not the disorder actually

exists. With the use of treatment modalities of proven

effectiveness, it is possible to isolate the enuresis and

evaluate secondary changes that might occur upon complete

elimination of the problem behavior. In this manner,

enuresis can be studied within the context of the total

life experience of the child.

Rationale for the Study

Theories of enuresis can be categorized under three

general headings: medical or organic, psychodynamic, and

behavioral or learning interpretations. Given the goal of

a more holistic approach, the present study utilized all

three of these viewpoints. Research questions which

relate to treatment efficacy focused on the medical and

learning theory explanations, while the aspect of secondary

effects dealt primarily with the learning theory and

psychodynamic formulations.

Numerous attempts have been made to study the effective-

ness of the urine alarm conditioning approach in eliminating

enuretic behavior (see reviews by Young, 1969; Morgan, 1978).

Likewise, pharmacological treatment with imipramine hydro-

chloride ('Tofranil') has been evaluated (MacLean, 1960;

Treffert, 1964; Poussaint, & Ditman, 1965; Werry, Aman,

Dowrick, & Lampen, 1977). However, there has been a major

void in this research. Although the conditioning approach

and imipramine pharmacotherapy have frequently been evaluated

in isolation, there has been limited direct comparison of

the two methods (Kolvin, Taunch, Currah, Garside, Nolan, &

Shaw, 1972). This situation is particularly surprising

when one considers thatno other drug appears to be as effec-

tive in controlling enuresis as imipramine (Steward, 1975),

and that the urine alarm is a very successful means of

intervention for wetting disorders (Johnson, 1980; Perl-

mutter, 1978).

The topic of secondary effects has typically been

addressed from a somewhat negative perspective. Attempts

have been made to show that symptomatic treatment of enuresis

does not result in symptom substitution, the manifestation

of alternate forms of inappropriate affect or behavior

following elimination of the enuretic response. Such

research attempts were justifiable since most clinicians

in the field were reluctant to utilize the symptomatic

approach which they considered to be an incomplete method

of treatment (Werry, 1966). Although the results of

these investigations (Baker, 1969; Dische, 1971; Sacks,

DeLeon, & Blackman, 1974) provided no empirical support

for the psychodynamic hypothesis of symptom substitution,

there was only limited mention of positive secondary

effects that might result from successful treatment of

the disorder.

In order to assess secondary benefits, one must first

consider consequences that might be the direct result of

the enuresis. Although disagreement exists in regard to

the true dependent variable in the relationship, numerous

studies (Cust, 1952; Oppel, Harper, & Rider, 1968a; Stein

& Susser, 1965) have indicated that children who exhibit

enuretic behavior tend to be rated as more withdrawn,

submissive, or immature than their nonenuretic peers. It

is somewhat easier to identify the secondary factors or

consequences in other areas. For example, children who

wet the bed experience certain restrictions such as no

overnight visits with friends or no vacations at camp,

and the parents of bedwetters are faced with the inconven-

ience of each morning's new supply of wet bed linens.

Likewise, children who exhibit diurnal enuresis must carry

a change of dry clothes in case an accident occurs when

they are away from home.

One might expect that consequences such as these

affect a child's image of self and parents. Similarly,

parents' perceptions and expectations of their child plus

their own feelings of adequacy as a mother or father may

be directly influenced by their child's enuresis. The

present study investigated the extent to which such secondary

factors are related to the enuretic behavior.

Purpose of the Study

This study compared the effectiveness of two methods

commonly used in the treatment of childhood enuresis,

conditioning treatment with a urine alarm and pharmaco-

therapy with imipramine hydrochloride ('Tofanil'). The

study also investigated secondary effects that could be

attributed to the elimination of the enuretic behavior.

The study addressed the following questions:

1) What is the comparative effectiveness of

conditioning treatment using a urine alarm

vs. pharmacotherapy with imipramine hydro-

chloride in the treatment of primary

nocturnal enuresis in children?

2) What effect does treatment outcome have on

a child's emotional and behavioral adjust-

ment?

3) What effect does treatment method have on

a child's emotional and behavioral adjust-

ment?

4) Does a pre-treatment variable exist which

can predict the outcome of treatment?

5) Does a pre-treatment variable exist which

can predict premature withdrawal from treat-

ment?

Definitions of Terms

Considerable debate exists regarding the appropriate

criteria to be used for enuresis. Age, frequency, and

duration requirements vary considerably from study to

study (see Douglas, 1973; Forsythe, Merrett, & Redmond,

1972). Since enuresis does not appear to be a unified

phenomenon, researchers have developed various classifications

of the disorder. The individual categories are listed

below as part of the definition of the more general term

of enuresis. Since the present study focused on bed-

wetting only, the operational meanings for enuresis and

nocturnal enuresis become synonymous.

The following definitions were used in this study:

Enuresis --urinary incontinence occurring at
Yeast three days/nights per week in a person
over the age of four for whom there is no
evidence of neurological or genitourinary
abnormality.

Nocturnal Enuresis -- enuresis that is limited
to nighttime only.

Diurnal Enuresis -- enuresis that is limited
to daytime only.

Nocturnal/Diurnal Enuresis -- enuresis that
occurs both at night and during the day.

Primary Enuresis -- enuresis that has continued
at criterion level since birth without periods
of dryness of one year or more.

Secondary Enuresis --enuresis that is a
resumption of wetting at criterion level
after a dry period of at least one year
following the pre-trained incontinent stage.

Cure Criterion --the period of time (14 conse-
cutive nights in the present study) that a
child must be continent in order to be considered
non-enuretic.

Relapse Criterion -- the frequency of wetting
following the attainment of cure criterion that
will signal the reoccurrence of enuresis (at
least three nights during a period of 14 conse-
cutive nights in the present study).

Tricyclic Antidepressants -- a group of synthe-
tic drugs structurally related to the pheno-
thiazine tranquilizers that are used in the
treatment of childhood enuresis and all types
of depression.

9

Self-Concept-- the conscious image a person
has about self which includes awareness of
one's attitudes and values, mental and
physical abilities, and social relationships.

CHAPTER II
REVIEW OF RELATED LITERATURE

The review of literature for this study is divided

into the following sections: a) overview, b) theoreti-

cal formulations, c) treatment approaches, d) self-

concept, and e) emotional and behavioral correlates.

Since there is an extensive body of literature available

on enuresis (DeJonge, 1973; Perlmutter, 1978; Starfield,

1972; Yates, 1970), discussion is limited to those areas

directly applicable to the focus of the proposed investiga-

tion.

Overview

A comparison of the results from different studies is

often difficult because researchers have utilized different

client populations and have been inconsistent in their use

of operational definitions for enuresis (DeJonge, 1973).

The conclusions presented below provide a general descrip-

tion of the disorder, although all points may not apply to

each and every case.

The most consistent finding among the research has been

the decline in the prevalence of enuresis with increasing

age. The annual rate of spontaneous remission between the

ages of 5 and 19 is 14-16% (Forsythe & Redmond, 1974) which

partially accounts for the decrease in the overall incidence

rate from 15% at age 5, to 5% at age 10, and to 1% at age 15

(Young, 1969). Age then becomes an important variable to

consider when one evaluates treatment research since

symptom remission could be attributable to age as well as

the effect of an intervention program.

Enuresis is more commonly found with males than females,

and as a general rule, nocturnal enuresis is more prevalent

than diurnal enuresis. However, there appears to be an

interaction between sex and enuresis type since nocturnal

enuresis is more likely to occur with males and diurnal

enuresis with females (DeJonge, 1973). Although Blomfield

and Douglas (1956) reported a higher incidence of enuresis

with the children of manual workers, Oppel et al. (1968a)

found no such relationship between enuresis and socioeconomic

level. This conflicting evidence prompted Rutter, Yule,

and Graham (1973) to hypothesize that variations associated

with a social class gradient may be due to a secondary

factor, such as the rate of stressful events during child-

hood, rather than socioeconomic level in and of itself.

It is important to distinguish between primary and

secondary enuresis. The latter, sometimes referred to as

onset enuresis, occurs less frequently and is found in

about one-third of those children identified as nocturnally

enuretic (Starfield, 1972). Kolvin and Taunch (1973) have

suggested an etiological difference between primary and

secondary enuresis. However, Rutter et al. (1973) and

MacKeith (1973) concluded that there is a lack of empirical

evidence to justify such a position.

Theoretical Formulations

Tremendous effort has been devoted to the search for

causes of enuresis and many theories have been proposed to

explain the disorder. The position to which one adheres

depends to some extent on the field or perspective from

which the problem is addressed. Since micturition is a

physiological response, it is not surprising to find a

wealth of medical interpretations concerning the problem.

Likewise, the traditional formulation of enuresis as a

symptom of underlying psychopathology has stimulated the

development of hypotheses with more psychologically oriented

viewpoints. The following incorporates findings from the

genetic, organic, psychodynamic, and behavioral positions

as they apply to the proposed investigation.

Genetic Interpretation

A familial factor does appear to operate with enuresis.

Bakwin (1973) indicates that the rate of occurrence within a

family is directly related to the closeness of the genetic

relationship. Researchers have found a higher incidence of

enuresis with siblings of bedwetters (Blomfield & Douglas,

1956) and with children of parents who at one time had

this problem (Hallgren, 1957). Additional evidence indi-

cating that monozygotic twins are twice as likely as dizygotic

to be concordant for enuresis prompted Bakwin (1973) to

propose a genetic basis for bedwetting.

One must be cautious in this regard as these results

may also be attributable to common factors, such as child-

rearing practices, that operate within the family system

(Brazelton, 1962). It is possible that a genetic factor

exists, but it may only predispose for the disorder by

affecting the age at which a child develops the necessary

physical maturation for bladder control (MacKeith, 1973).

Therefore, a more appropriate formulation might be that

genetic influences are only one of the factors that may

contribute to the existence of enuretic-hehavior in a given

child.

Organic Formulations

Urinary incontinence can be caused by organic abnormal-

ities or illness. Scott (1973) describes various physical

problems associated with lack of bladder control (e.g.,

chronic renal failure and urinary tract .obstruction).

Urinary tract infection is also commonly found with enuretic

children, especially girls, but the infection may be a

result, rather than a cause of the enuresis (Stansfield,

1973). Although a very small percentage of bedwetting

cases can be attributed to uropathology (Forsythe & Redmond,

1974; Kendall & Karafin, 1973), it is important for the

clinician to rule out the possibility of organic abnormality

by first consulting with appropriate medical personnel.

Cases of urinary incontinence that are a result of

organic pathology are not considered examples of enuresis.

The dynamics surrounding these cases are different from

those found with the normal bedwetting pattern. However,

certain organic factors are related to what is typically

defined as enuresis. This review is limited to a discussion

of small bladder capacity, depth of sleep, and maturational

lag.

Children who exhibit enuretic behavior appear to have

smaller bladder capacities than their non-enuretic counter-

parts (Doleys, Ciminero, Tollison, Williams & Wells, 1977;

Starfield, 1967; Zaleski et al., 1973). This finding has

intuitive appeal since a small bladder capacity might prevent

the retention of the amount of urine necessary to last

through a normal night's sleep. Zaleski et al. (1973)

found no structural difference in bladder capacity between

a group of enuretic children and non-enuretic controls.

However, they did find a functional difference. Although

both groups of children passed equal amounts of urine

during a 24-hour period, the children with enuresis urinated

more frequently and passed smaller volumes at each voiding

than did their non-enuretic peers. Their results suggest

that small bladder capacity may be a result of poor habit

formation rather than a sign of uropathology.

A commonly held opinion of enuresis is that the problem

is a form of sleep disorder in which a child experiences

poor arousal to internal and external stimuli (Kolvin &

Taunch, 1973). Children who wet the bed are frequently

described by their parents as deep sleepers who are diffi-

cult to awaken (Braithwaite, 1955). More recent investiga-

tions have indicated that enuretic episodes may occur during

both light and deep stages of sleep (Broughton, 1968;

Ritvo et al., 1969).

Contrary to popular opinion, bedwetting incidents

rarely occur while a child is dreaming (Broughton, 1968;

Ritvo et al., 1969). Broughton (1968) reported that rapid-

eye-movement (REM) sleep, the pattern associated with dreaming,

always followed the enuretic episode, typically after 5-15

minutes of further non-REM sleep. This result may account

for the dreaming that children sometimes report to be asso-

ciated with bedwetting incidents. Rather than occurring

concomitantly with the enuretic episodes, the dreams are

more likely the result of later exterioceptive stimulation

from the wet bed.

The third organic position to be considered is that of

maturational lag, a concept frequently associated with

developmental delay (see reviews by Perlmutter, 1978;

MacKeith, 1972). As indicated by MacKeith, Meadow, and

Turner (1973), maturation is the term applied to the pre-

determined and orderly growth of structures and functions

inherent in the central nervous system (CNS). Maturational

lag then indicates a slow rate of growth relative to the

normative standards for a particular age group. On the

other hand, development relates to the behaviors that emerge

as the result of CNS maturation (MacKeith et al., 1973).

Since behavior is overt and CNS growth is relatively diffi-

cult to observe, developmental improvement is frequently

used as an indirect measure of maturation.

Maturational lag has been adopted by some as an explan-

ation for the wide variation in the age at which bladder

control develops (MacKeith, 1973; Perlmutter, 1978). A

child must possess certain neuromuscular mechanisms before

urinary control can develop, but it is assumed that young-

sters gain control of these mechanisms at different ages.

CNS maturation is genetically determined. It cannot be

hastened by training but its emergence can be delayed by

environmental assaults such as illness, injury, or anxiety.

The task facing researchers who study enuresis is the deter-

mination of the point at which adequate maturation exists

for normal bladder control. Brazelton (1962) indicated that

98 1/2 percent of his sample of 1170 children were dry at

night by age five. Although maturational lag may be a

possible cause of urinary incontinence in younger children,

MacKeith et al. (1973) concluded that it is probably

responsible for only a very small percentage of the enuresis

cases in individuals over five years of age.

Psychodynamic Interpretations

The various formulations described as intrapsychic,

psychodynamic, or psychoanalytic all have one common feature:

enuresis is viewed as an overt symptom of an underlying

emotional disturbance. Symptomatic treatment is frowned

upon since it avoids the true problem, the underlying

emotional problem, and because it can result in symptom

substitution, the re-emergence of the basic disturbance in

an alternate form. Although empirical research is limited,

the psychodynamic position has had a profound effect on

the theoretical interpretation of enuresis (Young, 1969).

There is little agreement regarding the basic nature

of the disorder and the specific factors that cause enuresis.

Psychoanalytic theorists have interpreted enuresis as a

form of sexual discharge or as a masturbation equivalent

(Fenichel, 1945); it has also been considered a form of

conversion hysteria (Deutsch, 1953). Conflicts arising within

the mother-child relationship have been cited as contributory

factors to the existence of urinary incontinence (Sperling,

1965). Sweet (1946) hypothesized that enuresis is a

regressive urge in which the child subconsciously wishes

to remain in or return to the protected, irresponsible

state of infancy. In contrast, urinary incontinence may

also represent a subconscious resentment against the parents

and provide a means of retaliation (Sweet, 1946).

The emotional problems that may cause and maintain

enuresis are personal in nature and are therefore different

from individual to individual. This accounts for the

large number of causal factors attributed to the disorder.

No clear explanation is provided for the reason enuresis

becomes the overt symptom of the underlying problem, but

it is assumed that physiological predisposition somehow

interacts with the psychological disturbance and enuretic

behavior results.

Behavioral Formulations

According to the behavioral position, enuresis is a

result of deficient learning. This interpretation directs

attention to the enuretic response, with minimal concern

devoted to underlying emotional problems. The major emphases

are training the child to associate the sensation of dis-

tended bladder with the need to micturate and to have the

youngster develop discriminative ability in regard to appro-

private sites for micturition.

Behavioral formulations have been confronted with alter-

native explanations that minimize the role of training in

the development of urinary control. Muellner (1960) opted

for a maturational hypothesis when he stated that bladder

control is a self-learned skill involving a complex inter-

action of muscular functions. He contends that it is not

possible for parents to train their children in the mastery

of the voluntary mechanisms involved with normal micturition

(Muellner, 1960). Bladder control appears spontaneously

with no need for external intervention. Others have

echoed this position by stating that nocturnal urinary

control is a result of maturation and not learning

(Klackenberg, 1955; MacKeith et al., 1973).

Yates (1970) agrees that maturation is an important

factor, but he contends that it is only one of three major

variables associated with the normal development of bladder

control. Before a child can attain voluntary control of

micturition, it is necessary for adequate physiological

growth to have occurred, particularly in terms of the

muscular structure in the bladder. In addition to this

maturational factor, Yates (1970) identifies two other

requirements which are more an outgrowth of learning. One

such skill is that of high-level cortical control. The

child must have acquired a level of neurological maturation

that allows for inhibition of involuntary urination and

also permits development of voluntary control of the complex

response pattern involved in normal micturition. The

youngster must also develop the ability to discriminate

environmental cues that determine whether voiding is done in

a socially appropriate manner. This learned awareness

encourages the child to urinate in an acceptable site when

the bladder may be much less than full, rather than waiting

to void in an improper place once urgency develops. An

example of this would be the youngster who has a partially

filled bladder but who micturates at a public restroom

prior to going on a two-hour sailboat ride.

Both classical and operant conditioning interpretations

have been proposed to explain the development of urinary

continence. At the present time it is difficult to choose

the more appropriate formulation due to a lack of sufficient

information (Turner, Young, & Rachman, 1970). Nevertheless,

one can summarize the behavioral approach as one that is

concerned with discriminative cues, both internal and external,

and with the antecedent and consequent events associated

with the micturition response.

Treatment Approaches

Treatment approaches for enuresis are as numerous and

varied as the etiological formulations designed to account

for the disorder. Limited attempts have been made to develop

programs involving diet restriction, hypno-therapy, punish-

ment, and bladder training methods, but the most popular

procedures have been counseling, behavioral conditioning,

and pharmacological treatment. The present review is

limited to a discussion of the most popular approaches.

Empirical evidence is available on these methods, especially

the pharmacological and behavioral programs.

Counseling or Psychotherapy

The basic rationale for the psychotherapeutic approaches

is the psychodynamic formulation. According to this view-

point, proper treatment of enuresis must go beyond the

enuretic behavior to the underlying emotional disturbance

which is thought to be the cause of the problem. Although

this approach has considerable appeal, there is limited

empirical support for its claims of therapeutic effective-

ness.

Werry and Cohrssen (1965) were unable to find a signifi-

cant difference between no treatment and supportive psycho-

therapy. DeLeon and Mandell (1966) were able to cure only

18.2% of their clients with a form of psychotherapy as

compared with a success rate of 11.1% for a waiting-list

control group. Similar results were obtained by Sacks et

al. (1974) who achieved success rates of only 20% for psycho-

therapy and 22.2% for a no-treatment control group. An

uncontrolled factor in all of these studies was the type

of psychotherapy provided. Both DeLeon and Mandell (1966)

and Sacks et al. (1974) used 12 weekly sessions which con-

sisted of 40 minutes with the child and 20 minutes with the

mother. However, the actual format for therapy was unspeci-

fied but was left to the discretion of the individual

therapist.

Steward (1975) identified advice and encouragement as

a common method of treatment. This technique, discussed

here since it bears some resemblance to other counseling

approaches, typically elicits the child's participation

by having the youngster keep a record of wet and dry nights

on a calendar. The therapist then provides encouragement

for the child and attempts to alter the emotional climate

in the family. Dische (1971) found that 37% of her sample

attained bladder control with the use of this method alone.

Control of treatment format is also a problem with

advice and encouragement. One can identify two major treat-

ment variables: record keeping by the child and encourage-

ment from the therapist. An important question to consider

is the extent to which each of these factors contributes

to successful outcome. Dische (1971) felt that charting

alone had a therapeutic function. One would also expect

therapist involvement to be an important variable, but Baker

(1969) cast some doubt on this assumption.

Since most intervention programs involve clinician/

client interaction, it is difficult to abruptly dismiss the

role that psychotherapeutic techniques play in treatment.

Such methods inadvertently become part of most interven-

tion packages as advice, social reinforcement, and reflection

of client or parent feelings may be utilized in the treat-

ment setting. Given the disruption that appears to exist

within enuretic families (Nilsson, Almgren, Kohler, &

Kohler, 1973; Oppel et al., 1968a; Umphress, Murphy,

Nickols, & Hammar, 1970; Wolkind, 1976), psychotherapeutic

techniques might serve to uncover feelings and behaviors of

parents or siblings that help to maintain the enuretic

behavior. In this sense, psychotherpay may be considered

a valuable adjuvant to other modes of treatment as was

recommended by Shader (1968) and Starfield (1972).

Pharmacotherapy

The use of medicinal remedies for the treatment of

enuresis has been dated as far back as 1500 B.C. (Glicklich,

1951). The herbal concoctions of ancient times have given

way to the synthetic drug compounds of modern medicine.

Although research has been conducted with a variety of

drugs such as stimulants, sedatives, and antidiuretics, the

most effective pharmacological agent has been the family

of tricyclic antidepressants (Meadow, 1973).

The most commonly prescribed antidepressant has been

imipramine hydrochloride, 'Tofranil' (manufactured by Geigy).

MacLean (1960) was the first to investigate the use of this

drug in the treatment of childhood enuresis. Since that

time numerous studies have been conducted but researchers

are still unable to describe the mechanism by which imipra-

mine reduces the frequency of enuretic behavior. Some

believe the drug has a relaxing effect on bladder muscles

(Poussaint & Ditman, 1965); others cite a differential

effect on the stages of sleep (see Perlmutter, 1978;

Steward, 1975).

The typical criterion for dosage level has been age,

although body weight has also been used (Werry et al., 1977).

Children under the age of 8 are administered 25 mg. of

medication, while older children receive 50 mg. At one

point in time imipramine was not approved for use with

children under the age of 12 (Starfield, 1972), but recent

changes now allow prescription of the drug to children as

young as 6 years old (Medical Economics Company, 1981).

Cure rates with imipramine vary depending upon client

population, sex, age, and treatment duration. Perlmutter

(1978) cites an overall average of 40-50% of the children

cured, with an additional 10-20% greatly improved. These

figures appear to be somewhat high given the evidence

presented by Johnson (1980) in her review of imipramine

treatment literature which indicated cure rates ranging

from 9% to 47%, with only two studies reporting rates above

25%.

Children treated with imipramine are highly susceptible

to relapse once the medication is withdrawn. MacLean (1960),

Margolis (1962), Mariuz and Walters (1963), Treffert

(1964), and Thomsen, Reid, and Hebeler (1967), all report

relapse as an invariable result of drug termination. There

is evidence to suggest that the manner in which the drug

is withdrawn somehow determines whether relapse will occur.

Poussaint and Ditman (1965) reported no reoccurrence of

symptoms with children who received gradual withdrawal

from imipramine, but the results were not replicated by

McConaghy (1969).

Side effects from imipramine occur infrequently but

they need to be taken into consideration when a child is

placed on the drug. The most frequent adverse effects

have been sleep disorders, nervousness, tiredness, and mild

gastrointestinal disturbances (Medical Economics Company,

1981). Since poisonings and death have been reported, it

is necessary for parents to supervise drug administration

with younger children and to guarantee proper storage of

the medication in a location that is inaccessible to younger

siblings. Mofenson, Greensher, and Horowitz (1972) report

possible severe symptoms with an overdose of 10 mg. per kg.

of body weight, definite occurrence of such symptoms at

20 mg., and possible death at 40 mg.

A nonorganic side effect of imipramine may be long-term

use of the drug by some parents as a means of controlling

their child's behavior (Werry, Dowrick, Lampen, & Vamos,

1975). Mothers of subjects who were administered imipramine

reported considerable improvement in their child's behavior,

almost to a super-normal level. Werry et al. (1975)

raised the ethical question of whether children were being

continued on imipramine as a means of behavior management

rather than for treatment of their enuresis. The authors

recommended that use of antidepressants be limited to brief

periods of two or three months with ongoing evaluation of

psychotropic effects and the manner in which these effects

alter the emotional climate of the family system.

Given the high rate of relapse with imipramine, the

treatment may be viewed as a "simple method of temporarily

suppressing a troublesome type of behavior" (Kolvin et al.,

1972, p. 721). Miller, Champelli, and Dinello (1968)

supported this notion with their hypothesis that imipramine

is successful in curing enuresis in certain children simply

because the drug controls wetting until spontaneous

remission of symptoms occurs with normal maturation. The

pharmacological approach may be carried out with relative

ease, especially when compared with behavioral techniques,

but low initial cure rates, high relapse rates, and

possible side effects detract from the drug's appeal and

invite consideration of other forms of treatment (Perlmutter,

1978).

Behavioral Treatment

Numerous behavioral techniques have been used with

youngsters who exhibit urinary incontinence. Two common

features of these methods have been the identification and

description of the problem behavior relative to antecedent

and consequent events plus quantification of that behavior

coupled with recording of response frequency over time.

The problem behavior in enuresis is the enuretic response

which is usually measured in terms of the frequency of wet

nights, although number of bedwetting incidents is also

used. Treatment effectiveness is then determined by moni-

toring the rate of enuretic episodes over the course of the

intervention program.

When considered on a more specific level, each behavioral

treatment package exhibits a uniqueness that differentiates

it from other approaches. Ross (1974) developed a success-

ful contingency management program in which material and

social rewards were used to positively reinforce "dry"

nights. A contingency management approach was also

utilized by Nordquist (1971) but the enuresis was ignored

and attention was directed at a secondary response class,

oppositional behavior. The results from this single-subject

reversal design indicated that enuresis was eliminated when

parents positively reinforced cooperative behavior and

applied a time-out procedure to suppress the oppositional

behavior. Tough, Hawkins, McArthur, and Ravenswaay (1971)

made punishment contingent upon the enuretic response.

The results from their multiple-baseline-across-two-subjects

design indicated that only one child was cured of his

enuresis when the mother followed wetting with immersion

in a bathtub of cold water. Although the problem behavior

was eliminated in the one case, the use of such a procedure

is highly questionable given the emotional correlates

sometimes reported with enuresis.

Kimmel and Kimmel (1970) developed a diurnal instru-

mental conditioning procedure, later referred to as Reten-

tion Control Training (Miller, 1973). This approach attempts

to train a child to sleep through the night without exper-

iencing a need to micturate. This goal is theoretically

accomplished by increasing the child's functional bladder

capacity through the consumption and prolonged retention of

liquids during the daytime. Although Kimmel and Kimmel

(1970) reported complete remission of symptoms in their

three subjects, a follow-up investigation by Paschalis,

Kimmel, and Kimmel (1972) was able to cure less than half

of the children treated (19/31) with an additional 25% (8/31)

listed as significantly improved. Likewise, Rocklin and

Tilker (1973), utilizing a bladder training program, were

unable to replicate the Kimmels' original findings. Later

studies have indicated that Retention Control Training

does increase functional bladder capacity but this may not

translate into a significant reduction in the frequency of

enuretic incidents (Doleys & Wells, 1975; Doleys et al.,

1977; Harris & Purohit, 1977).

By far the most intricate program designed for the

treatment of childhood enuresis is the operant conditioning

procedure outlined by Azrin, Sneed, and Foxx (1973, 1974).

These authors conceptualized enuresis as "a socially

unacceptable response that persists because the social

reinforcement and social inhibitory influences are not

acting at an optimal level" (Azrin et al., 1973, p. 428).

Known as Dry Bed Training, this intensive program is designed

to eliminate enuresis with one day of training administered

in the child's home by a trained professional.

Dry Bed Training involves the use of numerous components.

Retention Control Training is incorporated into the method

as is the Mowrer and Mowrer (1938) conditioning apparatus

(described below). Another aspect of the program is Positive

Practice, a procedure in which the child lies in bed for

approximately 30 seconds, arises and walks to the bathroom,

assumes the micturition stance and attempts to urinate

before returning to bed. Twenty repetitions of Positive

Practice are performed prior to bedtime and immediately

following every enuretic incident. Nightly accidents also

require that the youngster engage in Cleanliness Training

during which the alarm apparatus and wet sheets are removed

from the bed, linens are disposed of in an appropriate place,

and the bed is then remade and the alarm reassembled.

This approach has been successfully used with institu-

tionalized retardates and normal children, but it is unclear

which components contribute significantly to treatment

outcome. Available empirical evidence suggests that the

alarm apparatus is important (Bollard & Woodroffe, 1977;

Nettlebeck & Langeluddecke, 1979) and that professional

trainers can be replaced with parents who administer the

treatment program (Bollard & Woodroffe, 1977). Doleys

et al. (1977) found Dry Bed Training clearly superior to

a bladder training program which would suggest that Retention

Control Training may not be an essential part of the treat-

ment package. Sadler and Merkert (1976) indicated that the

approach is hampered by the considerable amount of time

and effort needed to administer the program. More research

is necessary to identify crucial aspects and to refine the

procedure.

The most popular behavioral approach, and the most

effective form of intervention for bedwetting, has proven

to be the enuresis alarm recommended by Mowrer and Mowrer

(1938). Although cure rates vary from study to study (see

review by Johnson, 1980), an average of 80% of the children

treated with this approach develop bladder control (Perl-

mutter, 1978). Outcome studies have indicated that this

approach is more effective than supportive therapy (DeLeon &

Mandell, 1966; Sacks et al., 1974; Werry & Cohrssen, 1965)

and evidence has suggested that treatment with a urine

alarm is more successful in reducing the frequency of enuretic

incidents than pharmacotherapy with imipramine (Kolvin et

al., 1972).

The urine alarm represents an application of learning

theory to the treatment of bedwetting. Enuresis is inter-

preted as a learning deficit in which the child fails to

associate the feeling of a distended bladder with the need

to awaken and micturate. Mowrer and Mowrer (1938) believed

that the alarm represented a classical conditioning approach

in which an unconditioned stimulus (the sound of the alarm)

was paired with a conditioned stimulus (the feeling of a

distended bladder) resulting in a conditioned response

(arousal to bladder cues alone). The problem with this

explanation is that classically learned responses tend to

extinguish once the unconditioned/conditioned stimulus

pairing is eliminated.

This observation has lead Azrin et al. (1974) and

Lovibund (1964) to conclude that the Mowrer apparatus could

be more adequately explained with an avoidance conditioning

model. Rather than a classical pairing of two stimuli,

success with the conditioning apparatus may result from the

anticipation of an aversive consequence (the sound of the

alarm coupled with the cleanliness tasks required of the

child). With repeated trials learning occurs as the young-

sters awakens to the internal cue of a distended bladder

and then arises to urinate in an appropriate site.

Various models of the alarm are commercially available

(see Dische, 1973) but all operate according to the same

basic principle. The apparatus consists of two layers of

perforated foil or wire mesh that are separated by a thin

layer of absorbent cotton sheet. Electrodes connect the

two metal layers with a bedside power unit in which a

battery and a bell or buzzer alarm are housed. When the

cotton insulating sheet is dry, the electrical circuit is

incomplete between the battery and the alarm. Once liquid

is absorbed by the sheet, the circuit is closed and the

alarm sounds. A power switch located on the bedside unit

can then be used to terminate the sound of the alarm.

Dische (1973) provides an excellent review of the

procedure one should follow when treating an enuretic child

with the urine alarm. Conditioning treatment typically

involves an ongoing assessment of the enuretic behavior,

training parents and the child in the use of the alarm,

plus proper and consistent application of treatment proce-

dures by the family.

At the outset of treatment the therapist evaluates the

severity of the child's enuresis by having the parents keep

a pretreatment record of their youngster's bedwetting

pattern (Dische, 1971). A calendar can be used for this

purpose with "wet" and "dry" nights registered accordingly.

This form of assessment continues after the intervention

program is initiated since it serves as an indicator of

treatment effectiveness. A functional analysis of the

problem behavior is also made to identify possible antece-

dent and consequent events that influence the enuretic

response. A pretreatment assessment of functional bladder

capacity can be done by asking the parents to have their

child refrain from voiding as long as possible, directing

the youngster to urinate in a graduated container, and then

recording the volume of liquid that is passed (Starfield,

1972). Parents must also have their child examined by

appropriate medical personnel to eliminate the possibility

of organic pathology.

Once sufficient baseline data have been collected in

regard to the enuretic behavior, the therapist can train

the parents and the child in the proper use of the apparatus.

This can be done in the clinician's office or in the home

of the client. In addition to the demonstration, the therapist

needs to provide the parents and the child with a written

explanation of the alarm apparatus and a detailed descrip-

tion of the treatment procedure to be followed. It is also

important for the therapist to collect information regarding

the number of children (or parents and children) sleeping

in one room or in one bed, the distance from the child's

bed to the bathroom, the level of illumination available

in the bedroom at night, etc.

The ideal intervention program is one in which the

child assumes responsibility for treatment, although it is

always necessary for the parents to insure that all

aspects of the training program are performed successfully.

Prior to retiring each evening the child inspects the

apparatus, makes certain that it is properly assembled,

and then activates the alarm by turning on the power

switch. If an accident occurs during the evening and the

alarm sounds, the child must first arise and then turn

off the buzzer before going to the bathroom and emptying

the bladder. At this point Cleanliness Training (Azrin

et al., 1973, 1974) is performed. After splashing the face

with water to guarantee alertness, the child returns to the

bedroom, removes any wet bed linens, and places them in

a paper bag located nearby. The child then removes the

insulating sheet from the apparatus and installs a dry

replacement. Dry linens are placed on the bed, the apparatus

is reactivated, and the child returns to sleep.

Consistent use of the treatment procedure is a must.

Collins (1973) found a definite relationship between the

rate of cure and consistent use of the intervention program.

For those youngsters who made appropriate use of the alarm

apparatus, the cure rate was 84%, but that figure dropped

to 33% for the children who used the apparatus in an

inconsistent manner. The conditioning approach requires

more time and effort from parents than is needed with certain

other methods (e.g., pharmacotherapy). Lack of parent

cooperation frequently results in early termination and

treatment failure (Forsythe & Redmond, 1970; Geppert, 1953;

Turner et al. 1970; Young, 1965). Although empirical

evidence is lacking to support the hypothesis, it would

appear that therapist attention needs to be directed

toward parental concerns and attitudes, particularly

toward their child's enuresis (Morgan & Young, 1975), as

well as the behaviors and feelings of the enuretic child.

Various components of the conditioning approach have

been examined in regard to their impact on treatment out-

come. Collins (1973) indicated the importance of temporal

contiguity between the enuretic response and the consequent

sound of the alarm apparatus. A five minute delay in the

activation of the alarm resulted in significantly fewer

youngsters attaining cure criterion than was the case

with the continuous alarm approach. Finley and Wansley

(1977) investigated two levels of auditory intensity and

found a superior treatment effect with the louder alarm

(105dB vs. 80dB). The rate of the reinforcement schedule

has also been studied by comparing continuous application

of the buzzer consequence with intermittent reinforcement.

No significant difference has been found between the contin-

uous approach and intermittent schedules of 50% (Taylor &

Turner, 1975; Turner et al., 1970) and 79% (Finley, Besserman,

Bennett, Clapp & Finley, 1973).

Although the urine alarm is quite successful in producing

initial remission of symptoms, later reoccurrence of the

wetting behavior remains a problem. Johnson (1980) cited

relapse rates that range for 13% to 56%. Morgan (1978)

indicated that an average of 35% of the children originally

cured of enuresis resume wetting within one year following

the termination of treatment. Although many of the children

who relapse become permanently dry after retreatment with

the urine alarm (Forsythe & Redmond, 1970; Geppert, 1953),

attempts have been made to develop intervention strategies

that initially result in permanent cure.

Intermittent reinforcement schedules were originally

developed as a means of reducing high relapse rates. Of

the numerous studies conducted, only Finley et al. (1973)

found a rate significantly lower than that obtained with

a continuous schedule. Another technique designed to

reduce relapse is a procedure known as overlearning. This

method is incorporated into the traditional conditioning

treatment after the child has attained cure criterion.

The youngster abruptly increases pre-bedtime fluid intake,

usually by 1 1 1/2 pints, and continues to use the

alarm apparatus until cure criterion is once again achieved.

Young and Morgan (1972) compared overlearning with the

traditional conditioning approach and found that over-

learning resulted in a significantly lower rate of relapse.

Although their results were not significant, Taylor and

Turner (1975) obtained a lower rate of relapse with over-

learning than they did with a continuous or intermittent

reinforcement procedure. Young and Morgan (1972) recommended

that overlearning be included as a routine element in

the conditioning treatment of enuresis. However, some

adjustments need to be considered. Young and Morgan

(1972) reported that certain children relapsed badly when

overlearning was initiated. This problem may be due to

the abrupt increase in fluid intake, a point that has

stimulated Johnson (1980) to recommend a more gradual

approach.

Brief attention must be directed to side effects

associated with the conditioning apparatus. "Buzzer

ulcers" occur when a child wets the bed, does not awaken,

and remains in contact with the electrical current passing

through the apparatus. Dische (1973) indicated that such

ulcers are a potentially serious problem but are fortunately

uncommon. Parents can guard against the possibility of

buzzer ulcers by insuring that the apparatus is functioning

properly and that their child is aroused by the sound of

the alarm. Although psychodynamic theorists predict problems

with symptom substitution, empirical data are lacking to

support such a claim (Baker, 1969; Sacks et al., 1974).

Given the existing evidence, one can conclude that treatment

with a urine alarm is a safe and relatively successful

method of eliminating enuretic behavior.

Self-Concept

Investigations into the meaning of self have been

wrought with definitional shortcomings and inconsistencies.

Although the label, "self-concept," has been a popular

descriptor for one's awareness and opinion of self, there

have been numerous terms used for this purpose. Wells and

Marwell (1976) listed a number of these phrases, such as

self-confidence, self-esteem, self-respect, ego, self-

acceptance, and self-satisfaction. An important task facing

contemporary researchers is the selection and definition

of the terms) considered most appropriate for the topic

under discussion.

Regardless of the label selected, it is necessary to

consider the psychic nature of the phenomenon under invest-

igation. Theorists have frequently viewed their focus of

study in a way that has lead to its reification which treats

it as a physical object. This outlook becomes an obstacle

if one's goal is that of conducting empirical research of

the self. According to Gergen (1971) it is more productive

to consider self as a hypothetical construct which may be

helpful in predicting behavior although it has no externally

observable referent. In this way, self is like a "fiction"

which is treated "as if it refers to a fact" (Gergen, 1971,

p. 14).

An important point of deliberation is the origin and

maintenance of the self-concept. Gergen (1971) stated that

one's concept of self is formed through the sensation of

external data which are then organized through a process of

cognition. Taken together, sensation and cognition are

insufficient to explain the development of self. What is

needed is a third factor of reinforcement dependence which

accounts for the effects of an individual's interaction with

the social environment (Gergen, 1971). In other words,

one's self-concept is influenced by each behavior exhibited

and every situation experienced,but there is an important

function played by social reinforcement which serves to

develop a concept of self that reflects "the way a person

wishes to be seen and known by others" (Jourard, 1974, p.

151).

It is necessary to consider whether self should be

viewed as a single, unified entity or as a multi-dimensional

phenomenon. Wells and Marwell (1976) suggested that common

usage of the term favors a unitary interpretation but they

indicated that variations do exist in the way an individual

approaches and responds to different situations. Gergen

(1971) focused on this situational perspective and opted for

a multidimensional approach which he felt would be more

productive in terms of research outcomes. Although the

present study defines self-concept as that relatively stable

image of "I," or "me," it is recognized that an individual

can assume different identities and levels of self-esteem

as environmental stimuli merit. By focusing on these two

variable aspects of self-concept, the current investigation

has adopted the multi-dimensional interpretation and has

attempted to operationalize somewhat the abstract term of

self-concept.

As stated above, identity and self-esteem are considered

as two aspects of self-concept. Identity is formed through

a process of self-definition. By answering the question,

"Who am I?", identity provides that connection between the

individual's past and future. Of greater significance to

the present study is the phenomenon of self-esteem which

represents an individual's personal appraisal of self.

Self-esteem has been defined as "a more or less phenomenal

process in which the person perceives characteristics of

herself and reacts to those characteristics emotionally

or behaviorally" (Wells & Marwell, 1976, p. 164). Gergen

(1971, p. 11) provided a more concise and directional meaning,

"the extent to which the person feels positive about himself."

Self-esteem can be conceptualized as the self-evaluatory

behavior which attempts to answer the question, "What am

I like?"

The particular identity and level of self-esteem func-

tioning at any point in time are affected by two factors,

salience and differentiation (Gergen, 1971). Differentia-

tion is essentially a reflection of the person's complexity

of self. The greater the number of identities an individual

possesses, the greater the degree of differentiation. A

person with a high level of differentiation may function

as a father, husband, son, friend, golfer, teacher, and

gardener. The more complex the degree of differentiation,

the greater the individual's capacity to withstand the

negative effects of conflict or failure.

The concept of self operating at any given moment is

dependent upon the salience of the identity. Salience

represents a situationally dependent factor in which certain

stimulus cues are necessary for the emergence of the particu-

lar identity and related self-esteem level. The individual's

"golfer" identity is likely to become salient when the person

is in close proximity to the local country club. The

level of self-esteem associated with this identity is

influenced by the individual's past experiences on the golf

course and the expectations for future performance.

Jourard (1974, p. 155) stated that, "people act in

ways that confirm their self-concepts." As mentioned

above, the repertoire of actions available to an individual

depends upon the extent to which the self-concept possesses

differentiation. The child who has adopted one identity

of "failure" and has accepted its inherently low level of

self-esteem will react in a more limited but consistent

manner than the youngster who can draw upon a variety of

identities, such as "brilliant student," "immature bedwetter,"

and "adequate baseball player."

In a similar manner, the salience of a particular

concept of self will be affected by the level of differen-

tiation. The enuretic youngster who possesses one identity,

"immature bedwetter," will be expected to experience low

self-esteem across a variety of situations. In contrast,

the youngster who also possesses an identity of "brilliant

student" may have a less generalized outlook toward life.

The second youngster's "immature bedwetter" identity may

become salient at home around bedtime and during the early

morning hours, but when the child is in the successful

atmosphere of the classroom, the youngster's identity and

self-esteem level would change as "brilliant student" came

to the fore. An empirical question worthy of investigation

is the extent to which one identity and its related

self-esteem level generalize across situations.

Research in the area of self is dependent upon data

of a secondary nature. Although a person's identity and

level of self-esteem are knowable to that individual,

others must rely upon inference through the use of self-

reports, behavioral observations and ratings, or projective

techniques. Such information is subject to error since

individuals can respond in what they feel is a socially

desirable manner (Wylie, 1961). As a result, one must

always reserve some level of doubt in regard to the validity

of such data.

Combs and Snygg (1959) considered self as both a

consequence of prior experience and a guide for the future.

The question facing those involved in the helping professions

is the appropriate point of intervention for individuals who

are seeking change. This is of particular significance

when one is discussing the effectiveness of symptomatic

treatment programs. If a client enters therapy with a

problem for which successful symptomatic approaches exist,

is it more appropriate to treat the target problem and

anticipate generalized improvement or is it better to deal

with the person's general outlook toward self and expect

remission of the particular symptom?

Wylie (1961) cited research indicating change in self-

evaluations following situations in which success and

failure were experimentally induced. The author reported

that changes in a subject's self-ratings were generally

restricted to the experimental task itself rather than

global evaluations of self (Wylie, 1961). These results

are of significance to the present study since primary

nocturnal enuresis has responded successfully to sympto-

matic treatment. An initial question would be the extent

to which enuresis, a socially inappropriate behavior,

influences a child's appraisal of self. Since primary

nocturnal enuresis has responded positively to symptomatic

treatment, an additional focus of investigation could be

the change that might occur in a youngster's self-concept

following elimination of the target behavior. Both of

these questions could be studied in terms of the level of

change and the specific/global nature of that change.

Through an objective assessment of emotional and behavioral

factors frequently associated with enuresis, inferences

could be drawn in regard to the role played by enuresis

in the development of self-concept.

Emotional and Behavioral Correlates

The association of enuresis and emotional/behavioral

problems has had a longstanding history as documented in

theprofessional literature (see review by Glicklich, 1951).

Early research attempts were hampered by poor methodological

procedures that cast doubt upon the findings (Werry, 1967).

In addition, a self-fulfilling prophecy evolved as many

clinicians presumed enuresis to be a form of psychopathology.

Cust (1952) found a similar attitude on the part of mothers

of enuretic children; the most frequently cited cause of a

child's bedwetting was "nerves and emotional stress" (Cust,

1952, p. 1169). This attitude along with strict adherence

to particular theoretical orientations provided enuresis

with limited descriptive data which hampered the empirical

search for causal explanations.

Although an association may exist between enuresis

and emotional/behavioral problems, the nature of that

relationship remains unclear. Werry (1967) posited five

different forms which the association could take:

psychogenic, psycho-additive, somatopsychic, vicious

circle effects, and coincidental. The psychogenic type

represents the traditional belief that enuresis is a result

of emotional stress of psychological disturbance. The

reverse of this relationship is the somatopsychic condition

in which the enuresis is caused by organic factors and the

psychopathology is a result of the shame and anxiety

produced by the somatic symptom. Psycho-additive cases

can be attributed to somatic etiology but the condition is

aggravated by the existence of concomitant emotional problems.

This form is similar to the vicious circle effects that

result when psychogenic factors bring about somatic compli-

cations which in turn cause further emotional problems.

Consideration of these four relationships suggests the

deep and involved interpretations that can be made regarding

enuresis. Clinicians typically search for evidence that

might provide a causal link between enuresis and emotional/

behavioral disturbance. However, they tend to overlook the

possibility that the manifestation of both phenomena may

be no more than coincidental. Werry (1967) cautions that

this lack of relationship may be the case in more instances

than is commonly believed.

Investigations into the possible association between

enuresis and emotional/behavioral problems have considered

the extent to which bedwetting represents a form of psychi-

atric disorder. It appears that less than a third of the

children who exhibit enuretic behavior actually show signs

of psychiatric disturbance (see review by Shaffer, 1973).

Although this rate is higher than the 10-15% figure found

in the general population (Hallgren, 1957), it does not

account for a majority of enuretic cases. Approaching the

question from a different perspective, Rutter, Tizard, and

Whitmore (1970) found a higher rate of enuresis among

psychiatrically disturbed youngsters (24-30%) than with normal

children (4-7%). In those cases where a relationship has

been found, there is once again a lack of evidence to

indicate whether bedwetting brings about a psychiatric

distrubance or if the disturbance can be considered the

driving force behind the enuresis.

Although most enuretic children do not exhibit overt

signs of psychiatric disorder, more subtle emotional and

behavioral problems may exist. Tapia, Jekel, and Domke

(1960) found no significant difference in the emotional

adjustment of enuretic and nonenuretic youngsters, but later

studies have reported an association between enuresis and

certain emotional characteristics. Oppel et al. (1968a)

compared a group of 7-year-olds who exhibited primary enuresis

with a group of nonenuretic controls of the same age. They

found that the enuretic youngsters were more sensitive and

withdrawn, were more likely to suppress feelings, had less

ambition, and were less likely to exhibit a fear of failure.

Wolkind (1976) indicated that enuretic 4-year-olds were more

likely to exhibit dependency problems, temper tantrums,

and management problems than was a comparison group of

nonenuretic youngsters at age 4. However, no history of

bladder control was collected in this study so there was

no differentiation made between primary and secondary

enuresis. The need for such a distinction was indicated

by Kolvin et al. (1972) who found that secondary enuretics

were significantly more solitary, fearful, and obsessive

than primary enuretics. Although there was no significant

difference between the two groups in regard to sensitivity,

thepercentage of children exhibiting this characteristic

was very high (62% with primary enuresis and 81% with secon-

dary enuresis).

These results lend some support to the notion given

by Shaffer (1973) that children who exhibit enuretic behavior

are probably distressed by their problem. But Kolvin et al.

(1972) indicated "the picture that emerged (from parent

reports) was of a cheerful and easygoing group of children"

(p. 717). They described the children as "quite unexcep-

tionally average" (Kolvin et al., 1972, p. 718), an observa-

tion reiterated by Sacks et al. (1974) whose entire sample

of enuretic children was within the normal range of

adjustment. For this reason, measurement of emotional/behav-

ioral problems will require instruments sensitive to the

subtle changes that might occur and assessment procedures

that attempt to minimize error.

Parent ratings of the child's behavior and emotional

adjustment are commonly used in enuresis research (Baker,

1969; Kolvin et al., 1972; Rutter et al., 1973; Sacks et

al., 1974; Tapia et al., 1960; Wolkind, 1976). Some studies

have collected additional information from the child's

teacher for those youngsters of school age (Baker, 1969;

Rutter et al., 1973; Sacks et al., 1974; Tapia et al., 1960).

The data obtained from parents and teachers may sometimes

be contradictory (Rutter et al., 1973). One possible explan-

ation for this disparity is that behaviors are situation

specificto either home or school. The child who is with-

drawn and sensitive around classmates may be talkative and

relatively confident when at home in the family setting.

It is also possible that evaluations are affected by expec-

tation bias or halo effects. This applies particularly

to parent ratings which are done with full knowledge of the

child's bedwetting history, the data of admission to

treatment, and the child's response to the intervention

program. Such factors are less likely to affect ratings

done by teachers, who are typically unaware of a child's

bedwetting problem.

Parents and teachers have not been the only sources of

information utilized in enuresis research. Data have also

been collected from the children with the use of a variety

of assessment tools. The Stanford-Binet and the Wechsler

Intelligence Scale for Children have been used as IQ

measures (Oppel et al., 1968a; Scallon & Herron, 1969).

Personality characteristics have been investigated with the

Rorschach, the Cattell Personality Questionnaire, the

Children's Personality Questionnaire, the Children's

Embedded-Figures Test, the Draw-A-Person and Draw-Your-Family

Tests, to name a few (Baker, 1969; Campbell, Weissman &

Lupp, 1970; DeLuca, 1968; Kolvin et al., 1972; Sacks et al.,

1974).

An individual assessment at a particular point in time

provides important information about an enuretic child.

It gives the clinician an idea of how the child compares with

normative standards computed from the population at-large.

However, this approach provides no within-subject comparative

data that can be used to assess change over time, something

which is of interest to those who study the efficacy of

treatment techniques. To achieve this purpose, it is

necessary to administer multiple assessments, typically

before and after treatment intervention.

Controlled research in regard to changes in emotional/

behavioral correlates over time is limited. Baker (1969)

utilized such a design when he studied the relationship

between symptomatic treatment of enuresis and the phenomenon

of symptom substitution. The results of his investigation

indicated that children who were cured of their enuresis

were happier, less anxious, and more mature following

treatment. In addition, there was an improvement in self-

image and there appeared to be a positive change in regard

to parent-child relationships. It is true that all children

in this study showed evidence of change in a positive

direction, but those youngsters who exhibited an improve-

ment in enuresis demonstrated a significantly greater change

in emotional/behavioral correlates than did controls and

children for whom enuretic symptoms remained unchanged.

Baker (1969) not only found support for his primary hypo-

thesis that symptomatic treatment would not result in symptom

substitution, he also found that the changes which did

occur with symptomatic treatment were in a positive direc-

tion and were at a statistically significant level.

A later study by Sacks et al. (1974) addressed the

same question studied by Baker (1969). Sacks et al. (1974)

found that children assigned to three treatment groups

(conditioning, psychotherpay, and control) all demonstrated

significant declines in psychological symptoms across time

as measured by parent responses to the Staten Island Behavior

Scale. These results occurred irrespective of treatment

outcome: those who were not cured exhibited a drop in

psychological symptoms similar to the youngsters who had

attained bladder control. Although they found no evidence

for symptom substitution, Sacks et al. (1974) were unable

to correlate successful treatment outcome with positive

psychological and behavioral change. As a result, the

controlled research available at the present time contains

conflicting evidence.

Since pharmacological treatment is commonly used with

enuresis, it is important to consider possible psychotropic

effects when assessing emotional/behavioral correlates of

treatment intervention. Using a double-blind, placebo-

controlled, crossover design, Werry et al. (1975) conducted

a three-week study to investigate possible side effects of

imipramine treatment for enuresis. The authors found a

post-treatment reduction in conduct problems, an increase

in sedation or slowing, plus a greater degree of cooperative-

ness and happiness. There was a significant correlation

between behavioral improvement and decrease in wetting

frequency. Although this might be interpreted as a causal

relationship between control of bedwetting and behavioral

improvement, Werry et al. (1975) opted for a psychopharma-

cological explanation.

The present investigation built upon the findings of

Baker (1969), Sacks et al. (1974), and Werry et al. (1975).

The study represents the first direct comparison of imi-

pramine pharmacotherapy and conditioning treatment using

the clinically significant dependent variable of cured vs.

not cured. In addition, the investigation focused on positive

secondary effects. This was done in two ways. First,

change in emotional and behavioral adjustment was related

to treatment outcome. Second, an investigation of possible

psychotropic effects from pharmacotherapy was conducted by

studying the relationship of treatment modality to emotional

52

and behavioral correlates. In this way, the present study

examined the efficacy of the two most commonly used inter-

vention strategies for enuresis, and it also studied treat-

ment modality and outcome relative to the total life

experience of the child.

CHAPTER III
METHODOLOGY

The purpose of this study was to investigate the differ-

ence in efficacy of the two most commonly used treatment

approaches for primary nocturnal enuresis, pharmacotherapy

with imipramine hydrochloride and behavioral conditioning

using a urine alarm. The study also examined the relation-

ship of primary nocturnal enuresis and its methods of treat-

ment with subjects' level of emotional and behavioral adjust-

ment. An attempt was made to identify pre-treatment

predictors of treatment outcome and premature withdrawal

from treatment. The investigation utilized a pretest-

posttest control group design (Campbell & Stanley, 1973).

Subjects

The subjects involved in the present study were male

and female children and adolescents, ages 6 through 16.

Subjects were recruited for the program in a variety of

ways: referrals from local clinics and private physicians,

advertisements in newspapers and on television, plus contact

with school personnel in Alachua County, Florida. The

parents of 148 children and adolescents inquired about the

treatment program. From this total, 49 subjects, 40 males

and 9 females, were formally enrolled in the study; 36

subjects actually completed all facets of the 15-week

program.

All subjects received an initial screening performed

by a licensed physician in the Department of Pediatrics at

Shands Teaching Hospital, Gainesville, Florida. This exam-

ination was designed to assess the extent to which a child's

enuresis was the result of physical or neurological

abnormalities. Subjects found to exhibit such signs were

not included in the study. Only those children referred for

primary nocturnal enuresis were considered for the study

sample. This information was obtained by questioning the

parents) regarding the child's wetting history. Each

child was also to have a minimum baseline wetting frequency

of three wet nights per week. Data for this criterion

were collected by parents for a period of at least seven

days prior to the child's initial clinic visit. All but

one of the subjects in the study sample met the frequency

criterion. The one child who did not meet the criterion

had wet only twice during baseline although his parents

reported that he typically wet more frequently, an observa-

tion that was confirmed after the child was randomly assigned

to the waiting list condition.

During the screening process the child and parents)

were informed of the nature and purpose of the investigation.

All parents were informed of the necessity for weekly visits

to Shands Teaching Hospital should conditioning be allotted

to their child. They were also told that pharmacotherapy

would require bimonthly appointments at Shands. Parents who

decided to enroll their youngster in the study were asked

to sign a consent form (see Appendix A). The child and

parents) were then administered the assessment instruments

described in the section below.

Following the clinic examination, subjects were randomly

assigned to one of the three treatment conditions. Parents

were then informed of the intervention program assigned to

their child. Appropriate appointments were scheduled for

those children enrolled in the conditioning and pharmacotherapy

groups. The parents of children allotted to the control

group were informed that a waiting period would be necessary

due to the large number of children seeking treatment.

These individuals were guaranteed access to treatment following

their period of time on the waiting list.

Hypotheses

The following null hypotheses were developed from the

questions stated in Chapter I.

HO1 There is no significant difference in treatment

outcome for subjects given conditioning treat-

ment, pharmacotherapy with imipramine hydro-

chloride, or assignment to a clinical waiting list.

HO2 There is no significant difference in emotional

and behavioral adjustment for children cured of

primary nocturnal enuresis as compared with

children for whom enuretic symptoms remain.

HO3 There is no significant difference in the emotional

and behavioral adjustment of children as a result

of the method of treatment received for primary

nocturnal enuresis.

HO4 There is no pre-treatment variable which can

significantly predict the outcome of treatment

for primary nocturnal enuresis.

HO5 There is no pre-treatment variable which can

significantly predict premature withdrawal from

treatment for primary nocturnal enuresis.

Instrumentation

The majority of assessment measures chosen for this

study were selected to provide data relevant to subjects'

emotional and behavioral adjustment. Data were also collected

regarding parent attitudes toward bedwetting. Children

provided a self-report of their emotional and behavioral

adjustment using the Piers-Harris Children's Self-Concept

Scale and What I Think and Feel, a revised version of the

Children's Manifest Anxiety Scale. An additional inventory,

titled This Week, was developed for use in this study as

a weekly measure of subjects' emotional and behavioral

adjustment. The Peabody Picture Vocabulary Test was also

included in the child's test battery as a measure of verbal

intelligence. Parent attitudes toward bedwetting were

assessed using the Tolerance and Nuisance Scales for

Enuresis. Parents rated their child's emotional and behavioral

adjustment using the Personality Inventory for Children and

the Behavior Problem Checklist.

Child Self-Report Measures

Piers-Harris Children's Self-Concept Scale

The Piers-Harris Children's Self-Concept Scale, sub-

titled The Way I Feel About Myself, is a paper-and-pencil,

self-report inventory. It was originally published in 1969

by Ellen V. Piers and Dale B. Harris and is currently

distributed by Counselor Recordings and Tests of Nashville,

Tennessee. The instrument was designed to investigate the

development of self attitudes in children. It has been

used successfully with groups of children in grades 3 through

12. The inventory can be administered to youngsters below

that level if done on an individual basis and if the

examiner reads the statementsto the child.

The Piers-Harris contains eighty declarative statements

that describe various personal characteristics (e.g., "I

am cheerful"). All items are presented in a forced-choice

format. The examine is asked to respond "Yes" to those

items that generally apply to him and "No" to the items

that are inappropriate. In order to minimize error due to

acquiescence, at least half of the statements on the inven-

tory are negative in content (e.g., "I am unpopular").

Instructions for administration and scoring are provided

in the manual that accompanies the instrument (Piers &

Harris, 1969). In order to reduce the effects of social

desirability it is important that the examiner instruct

youngsters to describe themselves as they are and not as they

think they should be. Scoring is relatively easy with the

use of a special key that identifies "positive" responses.

High scores indicate high, or a more adequate self-concept.

Piers and Harris (1969) provided normative data,

including the mean (51.84), median (53.43), and standard

deviation (13.87) for their original sample of 1183 school

children. The authors caution against indiscriminate use

of these standards since they were obtained from a single

school district in Pennsylvania which would limit the

generalizability of the results. This suggestion is

supported by data collected from other samples in which the

mean varied from 50.4 to 60.50 and the standard deviation

ranged from 9.15 to 15.19 (Piers & Harris, 1969).

Scores on the Piers-Harris appear to be negatively

skewed. The authors believe this tendency toward positive

results is influenced by the effects of social desirability.

Although very high scores, as well as low scores, could be

attributed to "faking" response sets, Piers and Harris

(1969) believe that children are less likely than adults to

make such deliberate attempts at distortion. Given the

error inherent in high scores, serious attention is typically

reserved for low results which are interpreted as indications

of low self-concept. As Piers and Harris (1969, p. 15)

state, "while we cannot assume that all high scores (par-

ticularly the very high) reflect truly positive self-

attitudes, we probably can assume that low scores reflect

truly negative self-attitudes.

Most of the reliability data presented in the manual

was computed with an earlier form of the Piers-Harris that

contained 95 items. Piers and Harris (1964) reported that

coefficients of internal consistency for different grade

levels varied from .78 to .93 using the Kudor-Richardson

formula 21. A reanalysis of sixth and tenth grade results

using the Spearman-Browm-odd-even formula revealed coeffi-

cients of .90 and .87 (Piers & Harris, 1964). Test-retest

reliability for the same sample was computed over a four-

month period with resulting correlations of approximately

.72. Wing (1966) utilized the current eighty-item format

and obtained test-retest coefficients of .77 for both two-

month and four-month periods. Smith and Rogers (1977)

reported more impressive stability data with a correlation

of .62 for a test-retest interval of approximately seven

months. Piers and Harris (1969) caution that scores do

tend to improve upon retest and they recommend that score

changes of less than ten points be ignored.

Mayer (1965) compared results from the Piers-Harris

with those obtained from Lipsitt's Children's Self-Concept

Scale and obtained a concurrent validity coefficient of .80.

Cox (1966) compared Piers-Harris scores with big problems

endorsed on the SRA Junior Inventory and obtained a corre-

lation of -.64. Comparisons have also been made with other

variables, but the Piers-Harris correlations with IQ

(-.04 to .48) and achievement (.06 to .43) have not approached

the results cited above. The inventory appears to be more

highly correlated with self-concept than with other pertinent

variables. No data are presented in the manual in regard

to the predictive validity of the Piers-Harris.

The Piers-Harris was selected for use in the present

study because of its intended focus and its suitability

for the age group under investigation. In addition, the

instrument is shorter than certain others (e.g., Children's

Personality Questionnaire). It was also assumed that the

respectable test-retest reliability data would make it a

desirable pre- and post-treatment measure for use in the

current 15-week study.

What I Think and Feel: A Revision of the Children's
Manifest Anxiety Scale

Castaneda, McCandless, and Palermo (1956) developed

a children's version of Taylor's Manifest Anxiety Scale

(Taylor, 1951). Titled the Children's Manifest Anxiety

Scale (CMAS), the inventory has been a popular instrument

in child research and is cited in over 100 articles (Reynolds

& Richmond, 1978). The CMAS has been used in enuresis

research by Morgan and Young (1975) and found to correlate

significantly with mothers' results on the authors' Nuisance

Scale for Enuresis.

Despite the instrument's popularity, Reynolds and

Richmond (1978) felt that the CMAS was in need of revision

for a variety of reasons. By decreasing the number of items

on the inventory and by adjusting the reading level so the

instrument was more appropriate for primary school children,

Reynolds and Richmond (1978) believed that a better self-report

scale for anxiety in children could be developed.

Reynolds and Richmond (1978) called their CMAS revision

"What I Think and Feel" (see Appendix C). The 37-item

scale includes 28 statements related to anxiety plus a 9-item

Lie scale. The 37 statements were selected from a pool of

73 items that were administered to a group of 329 school

age children in grades 1 through 12.

An estimate of reliability was computed using the

finalized inventory with the original sample and a cross-

validation group of 107 children from grades 2, 5, 9,

10, and 11. Anxiety scale items yielded a KR-20 reliability

estimate of .83 in the original sample with an estimate of

.85 for the cross-validation group. Lie-scale items that

did not correlate with other Lie statements were eliminated

as were any Lie items that correlated above .30 with the

Anxiety scale. Of the original eleven statements on the

Lie scale, nine were included in the final version of the

test.

Test items can be read to youngsters in grades 1 and 2,

but children above this level should have little difficulty

reading and understanding the inventory. The child responds

to test items by endorsing "Yes" or "No" on the test blank.

The instrument is scored by tallying the number of "Yes"

responses to items on the Anxiety and Lie scales. Individual

results are then compared with normative data provided by

Reynolds and Richmond (1978).

"What I Think and Feel" was included in the present

study because it provides an efficient means of assessing

a child's level of anxiety. Lie-scale items on the inventory

also give some indication of a child's response set. This

was an important consideration since the present study also

had subjects complete the Piers-Harris Children's Self-

Concept Scale, an inventory whose results are susceptible

to the effects of social desirability.

This Week

This Week is a four-item questionnaire (see Appendix D)

designed for use in the present study. This self-report

inventory was completed every Friday by all children in the

pharmacotherapy and waiting list groups. Children who

received conditioning treatment completed the inventory

during their weekly visit to Shands. When treatment was

terminated for these children, they also completed the

questionnaire on Friday. The measure utilizes a Likert-type

scale in which individual items contain a continuum of

happy-sad faces that correlate with "strongly agree" -

"strongly disagree" responses. Subjects are instructed to

read each statement and circle the picture that best describes

their evaluation of the item. All items are stated in a

positive manner with words such as "happy" and "good"

represented by happy faces.

All parents were asked to collect data regarding their

child's nightly wetting behavior. It was hypothesized that

a decrease or elimination of bedwetting would produce an

improvement in a child's evaluation of self. This Week

was designedas an ongoing measure of self-evaluation that

could be easily completed by every child. Subjects were

administered the inventory during the initial clinic session

and once each week for the remainder of the study period.

It was anticipated that the nonspecific nature of the items

would provide some indication of the extent to which

improvement in enuresis generalizes to other aspects of a

child's life.

Peabody Picture Vocabulary Test

The Peabody Picture Vocabulary Test (PPVT) was published

in 1959 by Lloyd M. Dunn. Distributed by American Guidance

Service, Inc., this instrument was designed to provide an

estimate of an individual's verbal intelligence. The

PPVT has been used with retardates, emotionally and physi-

cally handicapped youngsters, deaf children, schizophrenics,

and normal youngsters. Dunn (1965) indicated that the test

can be used with "any English speaking resident of the

United States between 2 years 6 months and 18 years who is

able to hear words, see the drawings, and has the facility

to indicate 'yes' and 'no' in a manner which communicates"

(p. 25).

The PPVT consists of pictorial representations of 600

stimulus words contained on 150 plates, with four equally

sized pictures assigned to each plate. Two word lists,

Forms A and B, are used with the same pictorial plates

and allow for repeated testing within a relatively brief

period of time. Alternate-form reliability coefficients

for the PPVT range from .67 at the 6-year level to .84 at

the 17- and 18-year levels. On both forms the stimulus

words are arranged in order of increasing difficulty with

the subject responding only to those items between his

basal level (eight consecutive correct answers) and ceiling

level (six failures out of eight consecutive responses).

The PPVT is not a timed test although it typically

requires about 10-15 minutes to administer. Scoring is

objective and is easily accomplished within a few minutes.

An individual's raw score can be converted to a percentile

rank, a mental age, or a standard score deviation IQ with

a mean of 100 and a standard deviation of 15.

Standardization of the PPVT was done with a group of

4,012 white children and youth living in and around Nashville,

Tennessee. Limited data is available on test-retest relia-

bility. While Budoff and Purseglove (1963) found a corre-

lation of .87 over an inter-test interval of one month,

Moed, Wight, and James (1963) reported a reliability

coefficient of .88 over a one-year interval.

Dunn (1965) reported that investigations of the statis-

tical validity of the PPVT outnumber reliability studies by

a three-to-one margin. The congruent validity of the instru-

ment, when correlated with other intellectual measures, is

best when comparisons are made with scores from the verbal

scales of these measures. PPVT deviation IQ scores and

verbal scale results from the Wechsler Intelligence Scale

for Children (WISC) correlate over a range of .41 to .74

with a median of .67. Correlations with WISC full-scale

scores range from .30 to .84 with a median of .61 and with

WISC performance scale scores over a range of .19 to .82

with a median of .39.

Concurrent validity results have been obtained by

correlating the PPVT with measures of scholastic achieve-

ment. Comparisons were made with the Sequential Tests of

Educational Progress, the California Achievement Tests, the

Wide Range Achievement Test, the Stanford Achievement

Tests, the Metropolitan Achievement Tests, the Gray-Votaw-

Rogers Achievement Tests, and teacher ratings of school

achievement. Dunn (1965) provided a summary of correlation

coefficients for the above: two were in the .30's, seven

in the 40's, seven in the .50's, seven in the .60's, one

in the .70's, two in the .80's, and two in the .90's.

An intellectual evaluation was included in the present

student to assess the role of cognitive functioning in

treatment outcome. The PPVT was selected as the measurement

instrument because it provides a quick and objective means

of evaluating verbal intelligence and because it is appro-

priate for the age group under consideration. The PPVT

was used as a pre-treatment measure only since little fluctua-

tion in verbal intelligence would be anticipated over the

course of the study period. The PPVT also provided a means

of controlling for IQ differences among the treatment groups.

Parent-Report Measures

Tolerance Scale for Enuresis

The Tolerance Scale for Enuresis was developed by

Morgan and Young (1975) as a means of assessing maternal

attitudes toward enuresis. The instrument consists of

twenty declarative statements which reflect a tolerance/

intolerance dimension (see Appendix B). Each item is

assigned a weighted scale score with higher values repre-

senting greater degrees of intolerance toward bedwetting.

A person's total score is the median scale value of all

items to which the individual responds affirmatively.

Morgan and Young (1975) first obtained tolerance

scores from a clinical sample of 134 mothers who brought

their children to an outpatient clinic for treatment of

nocturnal enuresis. Scores for these subjects ranged from

1.25 to 3.425 with a median and modal score of 1.45. Split-

half reliability was 0.43; no test-retest reliability data

were reported.

The scale does appear to have some degree of predictive

validity since mothers who prematurely withdrew their children

from treatment had significantly higher intolerance scores

than mothers who completed treatment. However, intolerance

scores were not related to the rate of therapeutic outcome.

In addition, there was no significant relationship found

between mothers' scores and parent or child expectation of

treatment outcome.

The results of the Morgan and Young (1975) study indi-

cated that mothers' primary concern was that their children

exhibited enuretic behavior. There was no apparent signifi-

cance accorded to the severity of the problem, the age of

the child, or the nature of the bedwetting problem (primary

vs. secondary). Given the available evidence on parent

attitudes (Nilsson et al., 1973; Oppel et al., 1968a;

Umphress et al., 1970; Wolkind, 1976), the Tolerance Scale

would appear to be a valuable component of research in child-

hood enuresis.

The instrument was utilized as both a pre- and post-

treatment measure in the present study. Pre-treatment

results from the Tolerance Scale were used to study the

relationship between treatment outcome and initial parent

attitudes toward enuresis and to assess the measure's

predictive validity regarding premature withdrawal from

treatment. Pre- and post-treatment results were also

analyzed to assess parent attitude change relative to treat-

ment outcome.

Nuisance Scale for Enuresis

The Nuisance Scale was devised by Morgan and Young

(1975) and administered to the same sample of mothers who

completed the Tolerance Scale for Enuresis in the study

described above. The Nuisance Scale consists of 25 commonly

reported childhood problems (see Appendix B). Parents are

asked to check the items which they consider to be worse

than their child's bedwetting, regardless of whether their

youngster actually exhibits the behavior in question.

The authors reported frequency data for the various

problem behaviors. The items most often checked by mothers

were "stealing" (100), "often spiteful and cruel" (92),

and "running away" (91). No results were reported for the

instrument's reliability or predictive validity. However,

evidence exists for concurrent validity since the mother's

nuisance value score was significantly correlated with the

child's result on the Children's Manifest Anxiety Scale

(Castaneda et al., 1956). This suggests that the level of

a child's anxiety is somehow related to a mother's assess-

ment of the nuisance value of the youngster's bedwetting.

In the current study, the Nuisance Scale was used as

a pretest and posttest measure. As was described for the

Tolerance Scale, pre-treatment results from the Nuisance

Scale were used to study the relationship of initial parent

attitudes with treatment outcome and premature withdrawal

from treatment. Changes in parent attitudes were examined

by comparing pre- and post-treatment results relative to

treatment outcome.

Personality Inventory for Children

The Personality Inventory for Children (PIC) was

originally published in 1958 by R. D. Wirt and W. E. Broen.

Utilizing the methodological approach outlined by Hathaway

and McKinley (1951), the authors sought to develop an

empirically and rationally constructed personality assess-

ment tool for children that would resemble the Minnesota

Multiphasic Personality Inventory (MMPI) which is commonly

used with adults. Since its initial publication in 1958,

the PIC has been normed and data have been collected in

regard to scale construction, reliability, and validity.

Published by Western Psychological Services, the PIC

is primarily designed for use with children from the ages

of 6 through 16. The 600-item questionnaire is different

from the MMPI in the sense that relevant data regarding

the subject are collected from a secondary respondent,

usually the child's mother. True/false answers are obtained

which reflect the respondent's opinion of the child's

behavior and personality characteristics plus information

pertaining to family relationships. Responses are recorded

on an answer sheet which can then be hand corrected with the

use of special templates.

Like its MMPI model, the PIC contains both validity

and clinical scales. The validity scales (Lie, F, Defensive-

ness) assess the extent to which the respondent presents

a distorted representation of the child. Twelve clinical

scales measure achievement, development, somatic concern,

depression, family relations, delinquency, withdrawal,

anxiety, psychosis, hyperactivity, and social skills. A

gross intellectual screening is provided along with a

measure of the child's overall psychological adjustment.

Scores for the individual scales are displayed on a

profile sheet similar to that used with the MMPI. Three

methods of profile interpretation are provided in the PIC

manual (Wirt, Lachar, Klinedinst, & Seat, 1977). Linear

and configural approaches to evaluation are supplemented

in the manual with a variety of "typical" profiles which

allow for direct comparison of individual results with

configurations representative of particular childhood problems

(e.g., over-inhibition, sexual deviation).

Wirt et al. (1977) cited test-retest reliability coef-

ficients of .86 and .71. The first results were obtained

from a sample of child psychiatry outpatients in which

inter-test interval was randomized between 4 and 72 days,

with an average of 15.2 days (SD = 12.99). Latter results

were collected from a sample of 46 mothers of normal

children. Test-retest interval in this study varied from

13 to 102 days, with a mean of 50.96 (SD = 27.13).

Wirt et al. (1977) reported inter-parent reliability.

Father-mother correlations were computed for the 13 substan-

tive scales (Adjustment through Social Skills). A coeffi-

cient of .69 was obtained when data were collected from a

clinic sample of 184 parents. When results were computed

for 146 parents of normal children, the correlation dropped

to .59. Wirt et al. (1977) point out that these data may

not accurately describe the relative degree of inter-parent

agreement since the variability of scores was very restricted

in the normal sample.

Construct validity data for the PIC were obtained by

correlating each scale with the other 15 scales on the

instrument. In the PIC manual, Wirt et al. (1977) devoted

extensive discussion to the interpretation of these results.

Additional information is provided regarding criterion-

related validity for one validity and five clinical scales.

Seventy-three mothers of boys evaluated at child guidance

clinics were asked to complete the MMPI and the PIC Defen-

siveness Scale. Significant correlations were found between

the Defensiveness Scale and the following MMPI scales:

Paranoia (.46), Hypomania (.29), Psychasthenia (.24),

Social Introversion (.23), and the K Scale (.28). High

defensive mothers also presented high scores on the L Scale.

On the other hand, low defensive mothers scored less favorably

on Psychopathic Deviate, Hypomania, and Social Introversion.

The Achievement Scale on the PIC was designed to identify

underachievers in school. Dunn and Markwardt (1970)

correlated the Achievement Scale scores for 72 youngsters

with their results from the Peabody Individual Achievement

Test (PIAT). Coefficients indicated a -.61 correlation

with PIAT reading comprehension, -.42 with math, and -.59

with total achievement on the PIAT. The PIC Intellectual

Screening Scale was developed to locate those children for

whom poor academic performance was a result of intellectual

impairment. Wirt et al. (1977) presented data for a sample

of 75 clinic children in which Intellectual Screening scores

correlated -.40 with the Peabody Picture Vocabulary Test

and -.31 with the Porteus Maze Test Quotient. An additional

coefficient of -.55 was cited but the criterion measure

varied--"usually WISC-R, occasionally Stanford-Binet or

WPPSI" (Wirt et al., 1977, p. 19).

The Delinquency Scale contains 47 items that were

designed to measure delinquent tendencies. Lachar, Abato,

and Wirt (1975) cited a criterion validity coefficient of

.90 when scale scores were compared with group placement

of 70 delinquents vs. 210 normal controls. The 36-item

Hyperactivity Scale was designed to identify those children

who exhibited those behaviors commonly associated with this

disorder. A scale score to criterion validity coefficient

of .78 was obtained by administering the Hyperactivity

Scale to 80 hyperactive and 50 maladjusted non-hyperactive

children selected from child guidance clinics.

The Psychotic Scale was organized as a device to dis-

criminate normal youngsters from those with psychotic symp-

tomatology. Lachar (1971) used the 40-item scale to

differentiate psychotic and normal samples. The scale score

to criterion validity coefficient was .88 for a construction

group of 30 youngsters diagnosed as psychotic as compared

with a sample of 300 normal children. A cross-validation

coefficient of .84 was obtained by comparing an additional

30 psychotic youngsters with the original normative sample.

The PIC was incorporated into the present study because

ofits overall scope and its ability to identify deviant

response sets. The instrument provides information on

items important to the study of enuresis: development,

family relations, somatic concern, anxiety, withdrawal,

social skills, and depression. Since it is completed by

the parentss, the PIC provides data regarding the child

which can then be compared with results obtained directly

from the child. The complete instrument was used as a pre-

treatment measure in the present study. Due to the extreme

length of the inventory, post-treatment data were collected

for only those subscales where it was anticipated that partici-

pation in treatment might have influenced the scores. The

original 600-item measure was shortened to 281 questions which

provided post-treatment data for the following subscales:

Lie, F, Defensiveness, Adjustment, Depression, Family

Relations, Delinquency, Withdrawal, Anxiety, Hyperactivity,

and Social Skills.

Behavior Problem Checklist

The Behavior Problem Checklist (BPC) is a 55-item

questionnaire developed by Peterson (1961) to assess problem

behaviors that occur during childhood and adolescence. A

variety of behavior problems are covered by inventory

items (e.g., "temper tantrums," "social withdrawal," "short

attention span," or "truancy from school"). Individuals

who are familiar with the youngster in question complete

the checklist by rating each item on a three-point scale

("2" = a severe problem, "1" = a mild problem, "0 = not

a problem).

Factor analytic studies have identified three primary

subscales (Conduct Problem, Personality Problem, and Inade-

quacy-Immaturity) and one secondary subscale (Socialized

Delinquency). The BPC also contains four items which serve

as an alert mechanism for autism and childhood psychosis.

Although the four primary and secondary dimensions are

orthogonal, correlations do exist between subscale scores

since these values are only estimates of the true factor

scores for the four dimensions. The Conduct Problem (CP),

Personality Problem (PP), and Socialized Delinquency (SD)

subscales are independent but Inadequacy-Immaturity (II)

relates to the Conduct Problem and Personality Problem

subscales in varying degrees with correlations reported from

.21 to .72 (Quay & Peterson, 1975).

The BPC utilizes an objective scoring approach which

requires no more than five minutes to complete. Although

the instrument was designed to use weighted scores (adding

"ones" and "twos"), unweighted scores (tallying both

"ones" and "twos" as "ones") correlate so highly with weighted

scores (.98 to .99) that Quay and Peterson (1975) recommend

the use of the unweighted method. In this manner the score

for a particular subscale is the total number of items

checked either "1" or "2".

Once an individual's scores are completed for the four

subscales, a comparison is made with appropriate normative

data. The authors recommend the development of local norms

when large scale use is made of the BPC. This is necessary

since the frequency of deviant behavior varies according to

age, race, sex, observational setting, and type of rater

used. For the purpose of individual comparisons, the Manual

for the Behavior Problem Checklist (Quay & Peterson, 1975)

provides normative data on a variety of populations (e.g.,

rural black children, inner-city elementary school children

and hospitalized adolescents).

Since items for the BPC were originally selected from

a large number of case reports, the authors believe the

instrument does possess content validity in regard to the

variety of deviant behaviors exhibited by children and

adolescents. Speer (1971) reported data on the concurrent

validity of the BPC obtained from a comparison of clinic

children with their siblings and a group of nonclinic

youngsters. The BPC reliably and significantly differen-

tiated the clinic group from their siblings and the non-

clinic sample on the three primary subscales. Zold and

Speer (1971) were able to replicate these results with the

additional finding that the BPC was able to reflect changes

occurring between admission to and termination from

treatment.

Quay and Peterson (1975) reported that the BPC sub-

scales possess split-half reliabilities of .92 (CP),

.81 (PP), and .26 (II) and Kudor-Richardson Formula 20

reliabilities of .89 (C), .83 (PP), and .68 (II). No

data were presented for the Socialized Delinquency subscale.

Measures of inter-rater reliability depend upon the extent

to which the rater knows the child being observed, the amount

of time the individual spends with the child, and the

similarity of the observation setting.

The BPC was incorporated into the current study because

of its proven ability as a behavior rating device. Since

the present study focused on changes in behavioral correlates

of enuresis, the BPC was administered as both a pre- and

post-treatment measure. Data were collected from the parents)

accompanying the child to the initial clinic visit.

Procedures

Collection of Baseline Data

Prior to the administration of pre-treatment measures,

all parents were instructed to collect at least seven nights

of baseline data on their child's wetting frequency. Parents

were provided with copies of the wetting frequency record

(see Appendix E) on which they were to record a "D" for

each dry night and a "W" for each night their child

wet the bed.

Treatment Format

As stated previously, subjects were randomly assigned

to treatment groups during the initial clinic visit.

Individuals assigned to the pharmacotherapy program were

provided with a prescription for imipramine hydrochloride

which could be filled at a local pharmacy. Children in the

conditioning group were given an initial treatment appoint-

ment which typically occurred within seven days of the clinic

visit.

Parents of children assigned to the waiting list

group were provided with a two week supply of This Week

inventories and wetting frequency records. Parents were also

given stamped envelopes addressed to the experimenter's

attention which they were instructed to use to return infor-

mation to the experimenter on a weekly basis. During the

remainder of the 14-week period, additional supplies of This

Week inventories, wetting frequency records, and stamped

envelopes were mailed to parents by the experimenter on a

bi-weekly basis.

Children in the pharmacotherapy program received a

dosage level of imipramine hydrochloride appropriate for

their age and body weight. The decisions regarding dosage

level were made by licensed physicians in the Department of

Pediatrics at Shands. Typically, younger and smaller

children received a dosage level of 25 mg. of imipramine

per day while older and larger children received 50 mg.

Consistent with normal clinic procedure, children in the

pharmacotherapy group returned to clinic six weeks after

their initial visit in order to have their enuresis condition

re-evaluated and to receive adjustments, if necessary, in

the dosage level of the medication. One subject, who was

wetting profusely upon return to clinic for the six-week

visit, was maintained on imipramine hydrochloride and started

on oxybutynin chloride ('Ditropan'), another medication used

in the treatment of nocturnal enuresis. The child was

continued in the study because his wetting frequency did

not change and because such changes in medication are

standard policy for treatment received through the Depart-

ment of Pediatrics at Shands.

All other experimental conditions for the pharmaco-

therapy group were the same as those outlined above for

waiting list subjects. This Week inventories, wetting

frequency records, and stamped envelopes were mailed to

parents on a biweekly basis. Parents were asked to forward

information by return mail to the experimenter on a weekly

basis.

During their second meeting in the clinic, the parents

and children assigned to the conditioning method received

instructions in the use of the alarm apparatus. The specific

procedures to be followed were discussed and an explanation

of the alarm mechanism was provided. The parents and the

child were given a written summary of this information which

they were to take home as reference material (see Appendix F).

Parents were provided with an alarm apparatus which they

were required to return upon termination of treatment.

All subjects assigned to the conditioning program

were given weekly appointments with either the experimenter

or a graduate student volunteer from the Department of

Clinical Psychology at Shands. The parents) and the child

were typically seen together during the weekly sessions.

The focus of discussion was the child's wetting frequency

during the previous week. Interaction with the child

involved discussion of significant life events that occurred

during the week, relationships with family and peers, and

the child's experience with the urine alarm. Parents were

encouraged to discuss problems they were having with their

child, events they considered to be important to their

youngster's treatment, and problems they may have encountered

in the use of the alarm. Parents were given wetting frequency

records during the treatment sessions and were asked to

return them on a weekly basis. This Week inventories were

administered to conditioning subjects during the weekly

sessions.

All participants in the study were charged a minimal

fee of $7.50 for the initial urological examination provided

by the Department of Pediatrics. Subjects assigned to

pharmacotherapy were provided treatment at a reduced rate of

$7.50 per visit through the Department of Pediatrics.

Subjects who received conditioning treatment were charged

for sessions according to a sliding-scale, ability-to-pay

arrangement. The total fee for all sessions ranged from a

minimum of $15.00 to a maximum of $150.00.

Collection of Posttest Data

Posttest data were collected immediately following the

point at which a child attained cure criterion of 14 conse-

cutive dry nights or at the end of the 14-week treatment

period, whichever came first. Parents completed the Enuresis

Nuisance and Tolerance Scales, the Personality Inventory for

Children, and the Behavior Problem Checklist. Post-treatmnet

results on the Piers-Harris and What I Think and Feel scale

were obtained from every youngster. Regardless of when a

child attained cure criterion, wetting frequency data and

This Week results were collected for the entire study period.

Successful conditioning subjects provided post-treatment

data during the weekly session immediately following the

attainment of cure criterion. Parents assigned to the

waiting-list control and pharmacotherapy conditions were

instructed to contact the experimenter when their child

reached cure criterion. Arrangements were then made for the

family to return to the clinic and provide posttest data.

Subjects from all treatment conditions who did not reach

cure criterion by the end of the study period were brought

to the clinic and administered posttest measures. For those

control subjects who continued to exhibit enuretic behavior,

arrangements were then made to initiate conditioning treat-

ment, if the parents so desired. Parents of children who

received pharmacotherapy were also given the opportunity

to begin conditioning treatment, although the option of

no treatment or continued use of the medication was available.

Analysis of the Data

Wetting frequency data collected in the present study

did not meet the assumption of normality required for para-

metric analysis. This was particularly true for data obtained

from subjects in the conditioning group where approximately

half of the children were no longer wetting after the eighth

week of treatment. As a result, data were tested for

significance using two nonparametric procedures, the Kruskal-

Wallis one-way analysis of variance by ranks and the

Wilcoxon rank-sum test, an equivalent of the Mann Whitney

U-Test (Siegel, 1956).

All comparisons of wetting frequency data were made

across treatment groups by week of treatment (3 X 15).

Fifteen separate Kruskal-Wallis tests were run to locate

overall significant differences among treatment groups for

each of the 14 weeks of treatment and the week of baseline.

For each week in which overall significance was found, three

separate Wilcoxon rank-sum tests were run to locate the

source of the difference: conditioning vs. waiting list,

pharmacotherapy vs. waiting list, and conditioning vs.

pharmacotherapy.

A pretest-posttest control group design with two

between subject factors (Treatment = Conditioning vs.

Pharmacotherapy vs. Waiting List; Outcome = Cured vs. Not

Cured) and one within subject factor (Time = Pretest vs.

Posttest) was used to study the effect of treatment method

and treatment outcome on subjects' emotional and behavioral

adjustment. Due to the possible interaction of factors,

a repeated measures multivariate analysis was used. Variables

related to emotional and behavioral adjustment were organized

into three conceptually coherent groups and three spearate

MANOVA procedures were conducted.

The first group of variables included child self-report

data (Piers-Harris Children's Self-Concept Scale and the

anxiety subscale of What I Think and Feel). The second and

third groups were parent ratings of each subject. These

data were analyzed by instrument because of the internal

consistency and cohesiveness of each questionnaire. The

second group involved parent responses to eight Personality

Inventory for Children subscales (Adjustment, Depression,

Family Relations, Delinquency, Withdrawal, Anxiety, Hyper-

activity, and Social Skills). The last group included five

scores obtained from the Behavior Problem Checklist (total

score plus subscale scores for Conduct Problem, Personality

Problem, Inadequacy-Immaturity, and Socialized Delinquency).

The two level definition of the factor Outcome (Cured

vs. Not Cured) assessed the effect that elimination of night-

time wetting had on subjects' emotional and behavioral

adjustment. However, it was hypothesized that changes in

adjustment may also occur as a result of a clinically signifi-

cant reduction in wetting behavior. This effect was studied

by redefining Outcome as the child's wetting frequency

during week #14, the final week of treatment. For this

analysis children were categorized as (1) 0% wetting at

week #14, (2) wetting < 50% of baseline wetting frequency,

(3) wetting > 50% of baseline frequency. Subjects' adjust-

ment data were re-analyzed using the new definition for

Outcome. The analysis utilized a multivariate procedure

identical to that used for the two-level classification of

Outcome: two between subject factors (Treatment = Condi-

tioning vs. Pharmacotherapy vs. Waiting List; Outcome = 0%

Wetting vs. < 50% of Baseline vs. > 50% of Baseline) and one

within subject factor (Time = Pretest vs. Posttest).

Weekly fluctuation in subjects' emotional adjustment

relative to their wetting frequency was assessed using This

Week. Data from this measure were analyzed in five different

ways: This Week total score (4-20) plus the score (1-5)

obtained for each of the four statements on the inventory.

Each score was correlated individually with the child's

wetting frequency during the seven nights prior to completion

of the instrument. Correlations were computed by subject

since the focus of the analysis was the relationship between

each individual's wetting frequency and the response pattern

to This Week items. Since the data collected with this

inventory were ordinal in nature, a Spearman's rank order

coefficient was used in the analysis.

Parent attitudes toward bedwetting, as measured by the

Tolerance and Nuisance Scales for Enuresis, were analyzed

using two between subject factors (Treatment = Conditioning

vs. Pharmacotherapy vs. Waiting List; Outcome Cured vs.

Not Cured) and one within subject factor (Time = Pretest

vs. Posttest). A repeated measures multivariate analysis

was used. After the data were analyzed to study the effect

of the elimination of wetting behavior, attention was

focused on possible changes in parent attitudes resulting

from a clinically significant reduction in wetting. This

multivariate analysis involved the use of two between

subject factors (Treatment = Conditioning vs. Pharmacotherapy

vs. Waiting List; Outcome = 0% Wetting vs. < 50% of Baseline

vs. > 50% of Baseline) and one within subject factor

(Time = Pretest vs. Posttest).

When predictors of treatment outcome were examined,

only pretest scores were used in the analysis. A multivariate

procedure was conducted using one between subject factor

(Outcome = Cured vs. Not Cured). A separate MANOVA procedure

was run for each of four conceptually coherent groups of

data: child self-report, parent responses to the Personality

Inventory for Children, parent report on the Behavior Problem

Checklist, and parent attitudes toward nocturnal enuresis.

Data were also analyzed to locate predictors of a clinically

significant reduction in wetting during the final week of

treatment. The multivariate procedure involved the use of

one between subject factor (Outcome = % Wetting vs. <

50% of Baseline vs. > 50% of Baseline).

A new between subject factor, Group, was defined when

analysis focused on predictors of premature withdrawal from

treatment. Group was a two level factor, people who com-

pleted all aspects of their assigned treatment program vs.

those who did not. Again, a MANOVA procedure was conducted

on pretreatment data for each of the four conceptually

coherent groups mentioned above. Since Morgan and Young

(1975) had presented evidence supporting the predictive

validity of their Tolerance Scale for Enuresis, individual

t-tests were computed to assess this inventory's ability to

differentiate subjects who did and did not complete each of

the three treatment programs.

CHAPTER IV
RESULTS

The purpose of this study was to examine the effective-

ness of the two most commonly used methods of treating

primary nocturnal enuresis in children and adolescents.

Specifically, the study was designed to assess change in

the frequency of nighttime wetting produced by either con-

ditioning treatment with a urine alarm or pharmacotherapy

with imipramine hydrocholoride. The project also exmained

the effect of treatment method and outcome on subjects'

level of emotional and behavioral adjustment. An attempt

was made to identify pre-treatment predictors of treatment

outcome and premature withdrawal from treatment.

Statistical Description of the Sample

A total of 49 boys and girls, ages 6 through 16, were

enrolled in the treatment program. Subjects were selected

from a pool of 148 children of parents who inquired about

the program. A breakdown by age, race, and sex of all

inquiries and subjects formally admitted to the study

appears in Table 1.

Table 1. Demographic data for inquiry pool and study
sample.

Inquiry Pool Study Sample
Number % of Total Number % of Total

AGE

S5
6
7
8
9
10
11
12
13
14
15
16
> 17
Total

RACE
Black
White
Hispanic

SEX
Male
Female

16t
20
16
18
20
15
15
5
9
6
3
3
2$
148

30
114
4

96
52

tAge 2 1/2 = 1; Age 3 =
TAge 17 = 1; Age 25 = 1.

1; Age 4 = 3; Age 5 = 11.

The age data reported for the inquiry pool concur with

data presented by Oppel, Harper, and Rider (1968b) which

indicate that the incidence of enuresis decreases with

increasing age. There is a noticeable lack of children

under six years of age in the inquiry pool. This is due

to the fact that no attempt was made to recruit children

in this age group since the minimum age for participation

in the study was six. However, certain advertising sources

were unable to provide sufficient space in which admission

criteria could be explained. Parents of children under six

years of age did inquire about the program and were then

informed that their child did not meet the age criterion.

The study sample includes individuals recruited from

both clinic and non-clinic sources. Clinic subjects were

referred to the study through the Department of Pediatrics

at Shands Teaching Hospital in Gainesville, Florida,

private physicians in the Gainesville area, and the public

health departments of Alachua and Levy Counties in North

Central Florida. Non-clinic children were recruited using

a variety of means, such as advertisements in newspapers,

notices on local television stations, and contacts with

school personnel. Table 2 provides a detailed breakdown

for sources of referral on all inquiries and subjects formally

enrolled in the program.

From the pool of 148 inquiries, 99 children did not

participate in the program for one reason or another.

There were ten children who were scheduled for an initial