Although wetting the bed or having accidents during the day isn’t uncommon for young children, it can still cause a lot of shame and frustration, particularly when kids don’t seem to be growing out of it, or are regressing back into the behavior. When the problem persists after their fifth birthday, it can be a sign of a disorder called enuresis.
Enuresis is characterized by voluntary or involuntary urination at inappropriate times and places. Children have to be at least five years old to be diagnosed with the disorder, and the wetting incidents must occur at least twice a week for three months or longer.
Dr. Laura Kirmayer, a clinical psychologist who has worked with many children who have enuresis, says that the disorder is very treatable, although she warns that it is important to rule out any possible medical condition before diagnosing a child with enuresis. Bedwetting could also be caused by diabetes, sleep apnea, urinary tract infection, hormone imbalance, chronic constipation or some other issue.
Types of enuresis
Kids with enuresis may wet the bed while they’re asleep (called night-time enuresis), or their clothes while they’re awake during the day (daytime enuresis), or both.
The psychology community also discriminates between what’s called primary and secondary enuresis. In the case of the former, the child never learned to control her bladder and has been wetting the bed since she was a baby. Children with secondary enuresis did learn to use the toilet correctly and stay dry over night, but develop the condition at least six months after learning to control their bladders.
Primary nocturnal enuresis is the most common form of the disorder.
When it comes to treatment, the most important distinction to make is whether the wetting is voluntary or involuntary. If it is voluntary, treatment should resemble that of any other oppositional behavior treatment plan: parents should focus on positive reinforcement for desired behaviors, and limit setting and appropriate consequences for undesired behaviors. For involuntary enuresis, treatment needs to begin with skill building because the child is still learning how to control her bladder. Using disciplinary methods – or shaming – for children with involuntary enuresis would be unfair and could potentially have negative consequences.
Be on the lookout for things that could be causing accidents, like anxiety that might make a child not want to go to the bathroom at school or feel like she can’t ask for permission. Other kids who struggle with distractibility or impulsivity might even forget that they need to use the bathroom because they’re doing something very fun or interesting. Kids going through significant stress at home or school might also begin having accidents again. Paying attention to potential underlining causes can let parents know if their child might require some targeted help besides regular enuresis interventions.
The bell and pad technique
The most common treatment for nighttime enuresis is the bell and pad technique, also known as a bedwetting alarm. This method consists of a device kids wear at night that has a sensor, making a noise when it becomes wet and ideally waking up the child in time for him to stop the stream and go to the bathroom.
Dr. Kirmayer says that for a small percentage of children, the bell and pad method can have a kind of positive placebo effect. Just using the bell and pad means that they will start to be more aware of their bladder and have fewer accidents as a result. However the alarm doesn’t teach children how to prevent themselves from wetting the bed, since the alarm only goes off once the bed is already wet, often after the child has already emptied his bladder. It can also sometimes take several months before the bell and pad method starts having an effect.
If it has been determined that the child has involuntary enuresis, Dr. Kirmayer suggests a more proactive approach that families can try either by itself or combined with the bell and pad.
Learning about the bladder
Dr. Kirmayer likes to begin treatment by explaining how the bladder works. In a session with parents and child, she frames the bladder as a muscle that can be controlled, and explains that the brain and muscle can work together. The session is informative, but she also tries to make it fun, using a balloon filled with water to demonstrate how the bladder can expand and contract.
Families coming for help with enuresis are often feeling frustrated, so it can be a relief to parents and children alike to shift the focus away from what the child is failing to do to more neutral, proactive grounds: learning about how the bladder works and how, with time and practice, the child can learn to control it.
After the child understands how the bladder works, it’s time to start practicing. Dr. Kirmayer recommends that the family first spend a week tracking the child’s pattern of urinating, diet and fluids, setting aside the weekend for the whole family to practice what she calls bladder training: “Filling the bladder, rating the level of urge, being mindful of what it feels like when the bladder is really, really full versus only a little bit full.”
Making it an activity for the whole family takes some of the pressure off and creates a fun way for families to positively reinforce the child’s growing ability to pay attention to what he’s feeling. Dr. Kirmayer notes that this might be a good time for parents to also help kids start paying attention to other sensory experiences they are having, since children who struggle with bedwetting sometimes also are not aware of when they’re feeling full or tired.
Also, if parents notice that their child tends to have more accidents when he is deeply engaged in an activity, they can flag that tendency for him and give regular reminders to check in with how he’s feeling.
This daytime practice actually helps kids who struggle primarily with nighttime enuresis, too. “The skills training exposure and practice really has to happen in the daytime to see it generalize into the nighttime,” says Dr. Kirmayer. “If they’re deep sleepers then they need to have already started increasing their attention and awareness when they’re conscious and not fatigued in the daytime for it to able to map onto the time when they’re most at risk.”
Besides helping the child learn to start being more mindful of the sensations he is having in his body, another goal should be for the child to start feeling like he has some control over his body’s functions, and for him to take some pride and excitement in the skill he is developing. Parents can help by periodically reminding kids to check in with how their bladder is feeling and offering lots of positive reinforcement to keep kids motivated and engaged.
There is a pill for enuresis, and parents often employ it for events like sleep-away camp or a sleepover. But it won’t solve the problem in the long-run. Dr. Kirmayer likens it to taking a Xanax before a plane ride — “It’s not going to cure your fear of flying if you don’t eventually fly without the Xanax,” she says. Still, she thinks taking the medication does make sense for certain situations, like a sleepover the child is desperate to go on.
It can take time for kids to learn to control their bladder, so it is important for families to stay positive. Dr. Kirmayer says that kids should be encouraged to keep practicing body awareness and stay engaged. “Even if they end up wetting the bed, maybe they could still get up in the morning and change the sheets or put them in the laundry basket — whatever the routine is that has been agreed upon — without them having to be prompted,” Dr. Kirmayer suggests. That way the child is staying invested in the process and playing an active role. It also gives parents something positive to reinforce.
“I think the biggest challenge is that unfortunately with nighttime wetting either parents are getting woken up and they’re tired and they’re frustrated or they wake up in the morning it’s not what they want to be dealing with first thing,” says Dr. Kirmayer. It’s hard for parents to contain what they might be feeling internally, but it’s important to stay neutral and focus on the positive. Inadvertently shaming and blaming the child won’t help and may even cause her to start having “accidents” on purpose out of defiance.
Modeling distress tolerance in the face of disappointment will help everyone in the family stay feeling positive. After an accident the lesson should be: It’s no big deal. We’re still working on it, you’re going to get it, but we’re just not there yet.