A clinical trial of continuous, intermittent and overlearning 'bell and pad' treatments for nocturnal enuresis

Alarm interventions for nocturnal enuresis in children

BACKGROUND

Enuresis (bedwetting) affects up to 20% of five-year-olds and can have considerable social, emotional and psychological effects. Treatments include alarms (activated by urination), behavioural interventions and drugs.

OBJECTIVES

To assess the effects of enuresis alarms for treating enuresis in children.

SEARCH METHODS

We searched the Cochrane Incontinence Specialised Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE In-Process, MEDLINE Epub Ahead of Print, ClinicalTrials.gov, WHO ICTRP, and handsearching of journals and conference proceedings (searched 25 June 2018), and reference lists of relevant articles.

SELECTION CRITERIA

We included randomised or quasi-randomised trials of enuresis alarms or alarms combined with another intervention for treating nocturnal enuresis in children between 5 and 16 years old.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed risk of bias and extracted data.

MAIN RESULTS

We included 74 trials (5983 children). At treatment completion, alarms may reduce the number of wet nights a week compared to control or no treatment (mean difference (MD) -2.68, 95% confidence interval (CI) -4.59 to -0.78; 4 trials, 127 children; low-quality evidence). Low-quality evidence suggests more children may achieve complete response (14 consecutive dry nights) with alarms compared to control or no treatment (RR 7.23, 95% CI 1.40 to 37.33; 18 trials, 827 children) and that more children may remain dry post-treatment (RR 9.67, 95% CI 4.74 to 19.76; 10 trials, 366 children; low-quality evidence). At treatment completion, we are uncertain whether there is any difference between alarms and placebo drugs in the number of wet nights a week (MD -0.96, 95% CI -2.32 to 0.41; 1 trial, 47 children; very low-quality evidence). Alarms may result in more children achieving complete response than with placebo drugs (RR 1.59, 95% CI 1.16 to 2.17; 2 trials, 181 children; low-quality evidence). No trials comparing alarms to placebo reported the number of children remaining dry post-treatment. Compared with control alarms, code-word alarms probably slightly increase the number of children achieving complete response at treatment completion (RR 1.11, 95% CI 0.97 to 1.27; 1 trial, 353 children; moderate-quality evidence) but there is probably little to no difference in the number of children remaining dry post-treatment (RR 0.91, 95% CI 0.79 to 1.05; moderate-quality evidence). Very low-quality evidence means we are uncertain if there are any differences in effectiveness between the other different types of alarm. At treatment completion, alarms may reduce the number of wet nights a week compared with behavioural interventions (waking, bladder training, dry-bed training, and star chart plus rewards) (MD -0.81, 95% CI -2.01 to 0.38; low-quality evidence) and may increase the number of children achieving complete response (RR 1.77, 95% CI 0.98 to 3.19; low-quality evidence) and may slightly increase the number of children remaining dry post-treatment (RR 1.39, 95% CI 0.81 to 2.41; low-quality evidence). The evidence relating to alarms compared with desmopressin in the number of wet nights a week (MD -0.64, 95% CI -1.77 to 0.49; 4 trials, 285 children) and the number of children achieving complete response at treatment completion (RR 1.12, 95% CI 0.93 to 1.36; 12 trials, 1168 children) is low-quality, spanning possible harms and possible benefits. Alarms probably slightly increase the number of children remaining dry post-treatment compared with desmopressin (RR 1.30, 95% CI 0.92 to 1.84; 5 trials, 565 children; moderate-quality evidence). At treatment completion, we are uncertain if there is any difference between alarms and tricyclics in the number of wet nights a week, the number of children achieving complete response or the number of children remaining dry post-treatment, because the quality of evidence is very low. Due to very low-quality evidence we are uncertain about any differences in effectiveness between alarms and cognitive behavioural therapy, psychotherapy, hypnotherapy and restricted diet. Alarm plus desmopressin may reduce the number of wet nights a week compared with desmopressin monotherapy (MD -0.88, 95% CI -0.38 to -1.38; 2 trials, 156 children; low-quality evidence). Alarm plus desmopressin may increase the number of children achieving complete response (RR 1.32, 95% CI 1.08 to 1.62; 5 trials, 359 children; low-quality evidence) and the number of children remaining dry post-treatment (RR 2.33, 95% CI 1.26 to 4.29; 2 trials, 161 children; low-quality evidence) compared with desmopressin alone. Alarm plus dry-bed training may increase the number of children achieving a complete response compared to dry-bed training alone (RR 3.79, 95% CI 1.85 to 7.77; 1 trial, 80 children; low-quality evidence). It is unclear if there is any difference in the number of children remaining dry post-treatment because of the wide confidence interval (RR 0.56, 95% CI 0.15 to 2.12; low-quality evidence). Due to very low-quality evidence, we are uncertain about any differences in effectiveness between alarm plus bladder training versus bladder training alone. Of the 74 included trials, 17 reported one or more adverse events, nine reported no adverse events and 48 did not mention adverse events. Adverse events attributed to alarms included failure to wake the child, ringing without urination, waking others, causing discomfort, frightening the child and being too difficult to use. Adverse events of comparator interventions included nose bleeds, headaches and abdominal pain. There is probably a slight increase in adverse events between code-word alarm and standard alarm (RR 1.34, 95% CI 0.75 to 2.38; moderate-quality evidence), although we are uncertain because of the wide confidence interval. Alarms probably reduce the number of children experiencing adverse events compared with desmopressin (RR 0.38, 95% CI 0.20 to 0.71; 5 trials, 565 children; moderate-quality evidence). Very low-quality evidence means we cannot be certain whether the adverse event rate for alarms is lower than for other treatments.

AUTHORS' CONCLUSIONS

Alarm therapy may be more effective than no treatment in reducing enuresis in children. We are uncertain if alarm therapy is more effective than desmopressin but there is probably a lower risk of adverse events with alarms than with desmopressin. Despite the large number of trials included in this review, further adequately-powered trials with robust randomisation are still needed to determine the full effect of alarm therapy.

An interprofessional approach to managing children with treatment-resistant enuresis: an educational review

Enuresis (intermittent urinary incontinence during sleep in a child aged ≥ 5 years) is commonly seen in paediatric practice. Despite the availability of effective interventions, treatment resistance is encountered in up to 50% of children. In this educational review we attempt to provide insight into the causes of treatment resistance, and offer practical suggestions for addressing this condition using an interprofessional approach. We explore the pathophysiology of and standard treatments for enuresis and discuss why standard treatments may fail. An interprofessional approach to treatment resistance is proposed which utilises the expertise of professionals from different disciplines to address the problems and barriers to treatment. The two interprofessional approaches include a multidisciplinary approach that involves the patient being sent to experts in different disciplines at different times to address their treatment resistance utilising the skills of the respective experts, and an interdisciplinary approach that involves a patient being managed by members of interdisciplinary team who integrate their separate discipline perspectives into a single treatment plan. Although an interdisciplinary approach is ideal, interdisciplinary teams may not be available in all circumstances. Understanding the roles of other disciplines and engaging clinicians from other disciplines when appropriate can still be helpful when treatment resistance is encountered.

Night diuresis stimulation increases efficiency of alarm intervention

INTRODUCTION

The prevalence of primary monosymptomatic nocturnal enuresis (PMNE) varies from 1.6% to 15%. Although treatment with enuretic alarms has been used for a long period of time, there are many disadvantages, including the necessity for long-term use and the high percentage of children who are resistant to such therapy. We hypothesized that more intense use of the alarm system would accelerate the process of forming the conditioned response to awakening, caused by the desire to urinate and, probably, increase the percentage of patients with positive results. Increased fluid intake will cause more frequent awakenings, so the use of alarm system will be more intense (Figure).

OBJECTIVE

To study the effect of increased fluid intake, prior to going to bed, on the efficacy of alarm therapy.

STUDY DESIGN

The treatment group consisted of 294 children (178 boys) average age: 11.3 (9.1-11.9) years. All participants completed an overactive bladder questionnaire (OAB-q) and a bladder diary, and underwent uroflowmetry, blood and urine testing. Group A (n = 141, mean age 10.9 (9.1-11.6) years), used the alarm system traditionally (Wet Stop/BYE-WET, USA). Group В (n = 153, mean age 11.5 (9.3-11.9) years) drank either water or any other transparent non-colored fluid (any table mineral water with mineralization of less than 1 g per dm³) once immediately prior to sleep at a volume of 4-5 ml/kg of body weight. The effectiveness of therapy was assessed by the change in frequency of urination episodes during sleep per week, episodes of spontaneous awakenings, caused by the desire to urinate per week. Data were analyzed using JMP SAS Statistical Discovery 8.0.2. Wilcoxon criterion was used for comparison of results between groups; correlation of changes in groups was analyzed using the Spearman coefficient.

RESULTS

Complete resolution of NE, 2 weeks after the end of alarm therapy, was found in 34 patients (24%) in Group A and 59 (39%) in Group B. This difference was statistically significant with a confidence level of 95%.

DISCUSSION

Having searched the publication databases, including PubMed and Scopus, we failed to find any publication presenting evidence or recommendations on the ideal management of fluid intake in patients with PMNE. Although a limitation of fluid intake is commonly recommended, there is no evidence showing an increase in dry night frequency when such fluid restriction is used as monotherapy. In contrast, our study has shown an improvement in outcome when an increased fluid intake is used in combination with enuretic alarm therapy.

CONCLUSION

We were able to prove that increased fluid intake improved the efficiency of alarm therapy intervention during the treatment of PMNE in children.

Treatment of Primary Nocturnal Enuresis in a Boy with Down's Syndrome

Primary nocturnal enuresis in a nine-year-old boy with Down's Syndrome was treated successfully with an enuresis alarm. A criterion of four consecutive dry weeks was reached after fourteen weeks and the child remained dry at six-month and twelve-month follow-up. Treatment included a gradual withdrawal phase. The study replicates others showing that a simple ‘bell and pad’ procedure can suffice. Client, family and procedural variables associated with success and failure of alarm treatments are discussed.

Effectiveness of an alarm intervention with overlearning for primary nocturnal enuresis

OBJECTIVE

To explore the effectiveness of the enuresis alarm with overlearning for treatment of primary nocturnal enuresis (PNE). A key objective was to explore the effect of overlearning on treatment gains, and its impact on relapse.

PATIENTS AND METHODS

The RMIT University Psychology Clinic has been treating PNE in the community for more than 20 years following a standardized treatment protocol. The study analysed archival data of 126 participants, aged ≥ 5 years, presenting with PNE. A mean wetting frequency of 5.13 wet nights per week was observed at baseline.

RESULTS

Treatment significantly reduced mean wetting from baseline levels during both treatment and overlearning phases, F(1.41, 176.10) = 588.54, p < 0.001, r(2) = 0.77, 95% CI (0.74-0.81). Wet nights per week reduced from a mean of 5.13 (SD = 1.77) during baseline to 1.88 (SD = 0.85) during treatment, and 0.64 (SD = 0.60) during overlearning. Alarm treatment with overlearning produced a treatment response of 87%, compared with 59% for alarm treatment only.

CONCLUSIONS

Evidence of improved treatment response with the addition of overlearning suggests overlearning should be considered as a potentially useful adjunct to alarm treatment for PNE. Overlearning was not unreasonably onerous for participants. Further research is required to explore the impact overlearning has on reducing relapse rates.

Factors Associated with Drop-Out, Relapse and Failure in the Conditioning Treatment of Nocturnal Enuresis

The enuresis alarm is a very successful method of treating nocturnal enuresis. Nevertheless many children drop-out of treatment and many relapse once dryness has been achieved. This paper examines the relationship between 30 variables, measured during the pre-treatment assessment of 75 enuretic children, and treatment outcome (success, failure, drop-out and relapse). Treatment was either by the enuresis alarm alone or the enuresis alarm preceded by four weeks of retention control training. Two features of diurnal bladder control (frequency and urgency) were related to failure in treatment and two factors reflecting parental intolerance to wetting (early toilet training and parental urging to use the toilet) were related to treatment drop-out.

Evaluation of a cure process during alarm treatment for nocturnal enuresis

Using a treatment package featuring the urine alarm, this study evaluated a treatment process for nocturnal enuresis. Children who received the training were classified into treatment successes (N = 38) and nonsuccesses (N = 19) according to a criterion (3-week continence). Their daily results were analyzed with four categories: dry with sleep (DS), dry with spontaneous awakening (DA), wet with spontaneous or alarm-forced awakening (WA), and wet with sleep (WS). In a trend analysis, an increase of DA over the treatment process was prominent for successes compared to nonsuccesses. Entering WA to a discriminant analysis, 86% of children were correctly classified into the two groups. The findings that awakening categories well distinguished successes from nonsuccesses provide support for an active avoidance model explaining the efficacy of urine-alarm treatment for nocturnal enuresis.

Alarm interventions for nocturnal enuresis in children

BACKGROUND

Enuresis (bedwetting) is a socially disruptive and stressful condition which affects around 15 to 20% of five year olds, and up to 2% of young adults.

OBJECTIVES

To assess the effects of alarm interventions on nocturnal enuresis in children, and to compare alarms with other interventions.

SEARCH STRATEGY

We searched the Cochrane Incontinence Group specialised trials register (searched 22 November 2004) and the reference lists of relevant articles.

SELECTION CRITERIA

All randomised or quasi-randomised trials of alarm interventions for nocturnal enuresis in children were included, except those focused solely on daytime wetting. Comparison interventions included no treatment, simple and complex behavioural methods, desmopressin, tricyclics, and miscellaneous other methods.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed the quality of the eligible trials, and extracted data.

MAIN RESULTS

Fifty five trials met the inclusion criteria, involving 3152 children of whom 2345 used an alarm. The quality of many trials was poor, and evidence for many comparisons was inadequate. Most alarms used audio methods. Compared to no treatment, about two thirds of children became dry during alarm use (RR for failure 0.38, 95% CI 0.33 to 0.45). Nearly half who persisted with alarm use remained dry after treatment finished, compared to almost none after no treatment (RR of failure or relapse 45/81 (55%) vs 80/81 (99%), RR 0.56, 95% CI 0.46 to 0.68). There was insufficient evidence to draw conclusions about different types of alarm, or about how alarms compare to other behavioural interventions. Relapse rates were lower when overlearning was added to alarm treatment (RR 1.92, 95% CI 1.27 to 2.92) or if dry bed training was used as well (RR 2.0, 95% CI 1.25 to 3.20). Penalties for wet beds appeared to be counter-productive. Alarms using electric shocks were unacceptable to children or their parents. Although desmopressin may have a more immediate effect, alarms appear more effective by the end of a course of treatment (RR 0.71, 95% CI 0.50 to 0.99) and there was limited evidence of greater long-term success (4/22 (18%) vs 16/24 (67%), RR 0.27, 95% CI 0.11 to 0.69). Evidence about the benefit of supplementing alarm treatment with desmopressin was conflicting. Alarms were better than tricyclics during treatment (RR 0.73, 95% CI 0.61 to 0.88) and afterwards (7/12 (58%) vs 12/12 (100%), RR 0.58, 95% CI 0.36 to 0.94).

AUTHORS' CONCLUSIONS

Alarm interventions are an effective treatment for nocturnal bedwetting in children. Alarms appear more effective than desmopressin or tricyclics by the end of treatment, and subsequently. Overlearning (giving extra fluids at bedtime after successfully becoming dry using an alarm), dry bed training and avoiding penalties may further reduce the relapse rate. Better quality research comparing alarms with other treatments is needed, including follow-up to determine relapse rates.

Treating Nocturnal Enuresis in Children

BACKGROUND

Childhood nocturnal enuresis (bedwetting) affects many families. Although it has a high rate of spontaneous remission, bedwetting may bring social and emotional stigma, stress, and inconvenience to both the child with enuresis and his or her family.

DESIGN

Summary of systematic reviews of treatment for nocturnal enuresis in children, published in the Cochrane Library, using evidence only from randomized and quasi-randomized trials to compare interventions. Interventions included behavioral, alarm, and pharmacologic treatments.

SETTING AND METHODS

Six Cochrane Reviews contributed evidence to this review: simple behavioral interventions, alarms, complex behavioral or educational interventions, desmopressin, tricyclics and related drugs, and other drugs.

SUBJECTS

The participants were children (usually up to the age of 16).

RESULTS

Much of the available evidence was of poor quality, and there were few direct comparisons between different types of intervention. Simple behavioral Interventions, such as reward systems, are widely used as standard first-line treatment, but they require a high level of parental involvement. There is currently little evidence to show that these interventions work, but they may be worth trying because they have only a few adverse effects. The use of an alarm intervention reduced nighttime bed wetting in a majority of children both during and after treatment. Overlearning or dry-bed training may reduce the relapse rate. Before embarking on alarm treatment, families need to be made aware of both the time and the high level of parental involvement necessary to attain success. Drug therapy, such as desmopressin and tricyclics, reduced the number of wet nights per week compared with placebo but only while the drug was used. Patients and their families need to be warned about possible side effects of some of the drugs.

CONCLUSIONS

Alarms are the most effective treatment for nocturnal enuresis in children, but desmopressin may be considered for temporary relief.

Alarm interventions for nocturnal enuresis in children

BACKGROUND

Enuresis (bedwetting) is a socially disruptive and stressful condition which affects around 15-20% of five year olds, and up to 2% of young adults.

OBJECTIVES

To assess the effects of alarm interventions on nocturnal enuresis in children, and to compare alarms with other interventions.

SEARCH STRATEGY

We searched the Cochrane Incontinence Group trials register (December 2002) and the reference lists of relevant articles. Date of the most recent searches: December 2002.

SELECTION CRITERIA

All randomised or quasi-randomised trials of alarm interventions for nocturnal enuresis in children were included, except those focused solely on daytime wetting. Comparison interventions included no treatment, simple and complex behavioural methods, desmopressin, tricyclics, and miscellaneous other methods.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed the quality of the eligible trials, and extracted data.

MAIN RESULTS

Fifty three trials met the inclusion criteria, involving 2862 children. The quality of many trials was poor, and evidence for many comparisons was inadequate. Most alarms used audio methods. Compared to no treatment, about two thirds of children became dry during alarm use (RR for failure 0.36, 95% CI 0.31 to 0.43). Nearly half who persisted with alarm use remained dry after treatment finished, compared to almost none after no treatment (RR of failure or relapse 45/81 (55%) vs 80/81 (99%), RR 0.56, 95% CI 0.46 to 0.68). There was insufficient evidence to draw conclusions about different types of alarm, or about how alarms compare to other behavioural interventions. Relapse rates were lower when overlearning was added to alarm treatment (RR 1.92, 95% CI 1.27 to 2.92). Penalties for wet beds appeared to be counter-productive. Alarms using electric shocks were unacceptable to children or their parents. Although desmopressin may have a more immediate effect, alarms appear more effective by the end of a course of treatment (RR 0.71, 95% CI 0.50 to 0.99) and there was limited evidence of greater long-term success (RR 4/22 (18%) vs 16/24 (67%),RR 0.27, 95% CI 0.11 to 0.69). Alarms were better than tricyclics during treatment (RR 0.73, 95% CI 0.61 to 0.88) and afterwards (7/12 (58%) vs 12/12 (100%), RR 0.58, 95% CI 0.36 to 0.94).

REVIEWER'S CONCLUSIONS

Alarm interventions are an effective treatment for nocturnal bedwetting in children. Alarms appear more effective than desmopressin or tricyclics by the end of treatment, and subsequently. Overlearning (giving extra fluids at bedtime after successfully becoming dry using an alarm) and avoiding penalties may further reduce the relapse rate. Better quality research comparing alarms with other treatments is needed, including follow-up to determine relapse rates.

The effectiveness of desmopressin in the treatment of childhood nocturnal enuresis: predicting response using pretreatment variables

OBJECTIVE

To determine the factors that predict the effectiveness of desmopressin in the treatment of childhood nocturnal enuresis.

PATIENTS AND METHOD

Sixty-six children with monosymptomatic nocturnal enuresis were treated with intranasal or oral desmopressin for a 4-week period. starting with a standard dose of 20 microg (0.2 mg oral) and increasing after 2 weeks where no progress was apparent to 40 microg (0.4 mg oral). Before treatment a range of variables (demographic, situational, enuretic history, physiological, parental attitude and child) were recorded. Three parameters of success acted as dependent variables, with stepwise linear regression models used to determine pretreatment predictors of success with desmopressin.

RESULT

Each outcome variable produced a very similar model of predictors. Success, as assessed by the most dry nights over a 14-night period, was associated with less severe enuresis before treatment, a parental belief that the child's enuresis was unstable and higher birthweight.

CONCLUSION

From the analysis, a model of arginine vasopressin release is proposed and the clinical implications of the findings addressed.

Retention control training in the treatment of younger versus older enuretic children

This study compared the efficacy of retention control training (RCT) in two groups of children suffering from nocturnal enuresis: a younger group of 15 children aged 4 to 5 years and an older group of 15 children aged 7 to 8 years. To control for family history, frequency, and type of enuresis, only children with primary nocturnal enuresis who had a family history of enuresis and who wet the bed 4 to 7 nights per week were included. RCT was found to be an effective treatment for young children who were closer to the final stage of bladder development, but not for older children. RCT may be used for older children as a preliminary treatment to increase functional bladder capacity, after which treatment of enuresis should be continued by other methods, such as bell-and-pad reinforcement programs.

Behavioural treatment of somatic disorders in children and adolescents

During the past decade the field of behavioural medicine has developed rapidly and several somatic disorders in adults have been successfully treated. By contrast, the effects of behavioural interventions of somatic disorders in paediatric populations have been examined less extensively in controlled outcome research. The present review concerns the promising development and application of behavioural methods in the treatment of various somatic disorders in children and adolescents. The studies reviewed were required to be conducted on an individual or group basis and, in addition, to employ quasi-experimental or experimental designs. It is concluded that of psychological treatments, primarily behavioural approaches have proven to be effective for childhood disorders such as obesity, nocturnal enuresis and recurrent headaches. Further, in the treatment of recurrent abdominal pain and asthma in children, behavioural approaches have shown promising outcomes. This progress should alert the clinician and personnel in health care facilities to the contributions of behavioural paediatrics so that behavioural treatment methods may be utilized where appropriate.

A comparison of two approaches to the treatment of nocturnal enuresis and the prediction of effectiveness using pre-treatment variables

This study compared the effectiveness of the enuresis alarm alone with a brief version of Dry Bed Training in treating 74 enuretic children. Both procedures were equally effective, and in the total sample a better response to treatment was predicted by the child's report of being teased by siblings. Maternal anger was associated with a greater drop-out rate.

Epidemiology of nocturnal enuresis in a part of Khartoum, Sudan. II. The intensive study

An intensive study of enuresis nocturna was made on 245 children selected through stratified sampling from a population of 8,462 children. Subjects were 3-15 years and living in a suburban part of Khartoum, Sudan. The prevalence of enuresis nocturna had been found to be high up to the age of ten in the previous extensive study. Few somatic, developmental or behavioural factors, and no family socio-economic or emotional states or child rearing methods including bladder-training, co-varied with enuresis. Climatic conditions and their interaction with possible developmental lags are discussed.

Dry bed training without a urine alarm: lack of effect of setting and therapist contact with child

Three variations in the mode of delivery of Dry Bed Training as a treatment for nocturnal enuresis were investigated. Twenty-three children, ranging in age from 4 to 14, received dry bed training without the additional use of a urine alarm. Treatment variations included: (a) in-home training of parents and child, (b) office based training of parents and child, and (c) office based training of parents only. An additional 7 children served as a waiting list control during the first 8 weeks of the study. A wide variety of outcome measures showed improvement for the entire sample regardless of specific mode of delivery. Implications for the treatment of enuresis using dry bed training and a number of critical methodological issues are discussed.

Childhood nocturnal enuresis: factors associated with outcome of treatment with an enuresis alarm

A study was carried out to assess the factors that may affect the outcome of a single course of treatment for childhood nocturnal enuresis by use of an enuresis alarm. 113 children were treated and followed up; those showing failure of initial arrest of wetting, relapse and longterm successful outcome were analysed separately. Emphasis is placed on the need for the adoption of clear criteria regarding the definition of these three groups, and for an adequate follow-up of treated cases. Unsatisfactory housing conditions and circumstances giving rise to family difficulties were significantly associated with a less favourable rate of initial arrest. In the long term, family difficulties again were found to be significantly related to poor outcome. Behavioural deviance, as revealed by a teacher's behavioural questionnaire also adversely affected long-term success, although less significantly so. Family difficulties emerged as the most important predictor for outcome of treatment and adversely influenced the rate of initial arrest of wetting, the relapse rate and the long-term success rate.

Factors related to the efficacy of treatment of enuresis

The variables of sex, frequency of wetting, a family history of enuresis, and use of positive reinforcement were examined to determine if they were significantly related to response to the bell-and-pad procedure. Dependent measures were number of days required to achieve dryness and frequency of wetting in a 1-yr. follow-up. Among the findings was that girls achieved the dryness criterion more quickly than boys. Frequency of enuresis was inversely related to number of days required to achieve dryness. Evidence was obtained suggesting a genetic basis for resistance to reduction in enuretic behavior. Children who were tangibly reinforced for dryness did not wet less frequently in the follow-up nor did they achieve the dryness criterion more quickly.

After the dance is over: some issues and suggestions for follow-up assessment in behavior therapy

Behavioral intervention programs have thus far failed to provide sufficient follow-up information for the evaluation of long-term effects. This omission is believed to be related to an inadequate conceptualization of follow-up assessment, as well as to the methodological and practical difficulties inherent in assessing behavior over long time periods. A framework for follow-up assessment that is consistent with current behavioral efforts to program generalization is described and is contrasted with traditional views of follow-up that look for effects following the termination of treatment. Several methodological features of follow-up assessment are discussed, along with research recommendations, including the determination of length of appropriate follow-up intervals, the frequency of follow-up assessments, the need for standardization of measures both within and between studies, reactivity of follow-up assessment, the selection of follow-up measures and attrition of subjects.