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
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