Enuresis (Wetting): Tactics and Tips
Parenting concerns are pretty universal when it comes to the basics, but few things are quite as universally troublesome as potty training when it does not go as scheduled. In a decade of helping families with child emotional and behavior issues, I have frequently witnessed the frustration of parents facing this problem with their children, as well as the intense relief they feel when potty habits improve.
Interestingly, elimination, or potty incidents are considered pretty normal even as children get beyond what most consider "potty training days". The American Psychiatric Association indicates that as many as 5-10% of all 5-year-olds and up to 5% of all 10-year-olds experience diagnosable enuresis (APA, 2013).
As I continue, I will write in generalities to address the majority of factors in play related to wetting accidents, but keep in mind that in some pretty rare (but not unusual) cases, enuresis can be a sign of a larger problem. Thankfully, this has usually not been the case in my practice or that of my colleagues as we have worked with kids and this specific issue. Based on the significant reduction in the APA's prevalence stats toward adulthood, I can conclusively say that, in most cases, the problems related to childhood enuresis are almost always either partially, or completely, solved.
Physical/Developmental- the first step
The first step is generally to know if a medical or other physical condition exists that might contribute to your child's wetting. In my experience, medical doctors usually explain that children vary significantly in what their bodies are capable of, so when trying to determine what is "normal" for our little guys, we have to first determine what could possibly be going on physically. Things such as hydration schedule, sleep schedule, relative fatigue, medication, and bladder development could play a physical role in potty accidents. Keep it simple, right?
Another factor when determining normalcy is the child's age and relative developmental level. Except when other serious issues are evident, most therapists and doctors really don't tend to give much attention to enuresis issues until after 5 years of age. That is when the diagnostic label can be assigned, should other criteria be met. Again, even after age 5, the question should not be so much about whether the child can be labeled, as it should be about how far outside the norm the wetting is compared to other kids around the same age. Without saying labeling is completely horrible, I think it is important to note that the labeling here should always be left to the experts. So, as a parent, keep in mind that even if it can be called something, enuresis is still highly treatable.
In other words, wetting behavior can usually be stopped, but it might take time. In the case of physical or developmental limitations, "treatment" might be something your doctor prescribes, but it also might be a number of reasonable or creative accommodations that your family make in order to work with your child's physical limitations. After all, the best scenario regardless of your child's abilities is that they feel some level of mastery. Take care to give little guys and gals the time they need to develop physically and to avoid shaming about elimination challenges. Shame or fear could definitely make potty time complicated for the little one...And that will only make matters worse for you.
Playing Your Cards Right- Behavior Interventions
While it took me a while to get to this point in the post, it is important that we all take our time in getting to the point where we assume that wetting accidents are purely behavioral and therefore move to train them away. Let's assume that junior or little miss check out just fine at the doc. Suppose that the doc refers you to a therapist, or maybe just sends you away telling you that it will just take time to improve. This is where behavior interventions might be able to help you make some, if not all the progress you were hoping for.
Many times, I get kids in my office who were "already potty trained" and seem to have experienced a little (or bigger) setback. At other times, frustrated parents come in saying that it just, "seems like it should be time (already)." I completely empathize, so let's talk about some ways we can start to narrow down potty issues when they return for some reason.
Unlike when we go to the physical doctor, it may not be too helpful to examine or speculate about why it is happening. Simple observation and intervention usually works best.
Step 1- Observe: Depending on how often accidents happen with your child, you might start with a simple hourly schedule to identify as accurately as possible when accidents occur. If you have a reliable memory of the times wetting has happened, you might be able to simply reflect on specific things around the events, such as how long your child had gone between potty breaks. Or, how much liquid your child had in the hour or two prior to the accident.
If you memory is not that great about the specifics, that is okay. Make a calendar with hour-by-hour spaces for recording and begin to carefully observe your child's behavior the next few days. You may only be able to capture chunks of time, which can work, and if you are busy like my wife and I, this might only be possible on weekends. It can still work, but the idea is simple: Capture good examples of an "accident" (or two) and definitely some time when accidents did not happen. Do not intervene at this point, which is to say, don't do anything you haven't been doing already. Think of yourself like a nature photographer. The idea is to get as natural of a record as possible about contributing factors, conditions, and how your child responds.
The focus of this calendar/schedule/diary needs to be: accidents, behaviors and responses of others before during and after the accident, foods and drinks taken in (everything), sleep and wake times, activities when accidents happen and when they don't. Oh yeah, don't forget to put in every single bathroom trip.
Step 2- Implementing Changes
Sometimes, after a day or two of observations, the answer might just jump out at you, and you might find yourself naturally making adjustments. If that does not happen, try to make your focus relatively narrow and simple. Can you implement one or two more bathroom breaks to increase the likelihood of success? What if you noticed that accidents seem to happen only at playtime (which is frequently the case)? What about more bathroom breaks at specific times? If your child is not that interested in potty time, try to make it as quick and maybe offer a small reward after it is done.
While this is not the long-term solution, it is a strategy to stop accidents, get your child to experience some mastery again, and allow you to think of the next step. Remember that no matter what you do, encourage your child as much as possible and focus on working within your child's limitations for now. Depending on how long your child has been having accidents, this could very well be the first time or at least first time in a while that he or she has not had an accident or as many accidents. Either way, this would be a sign of progress that should be celebrated.
Once accidents have begun to slow or stop, you can start to develop a plan of rewards related to appropriate toileting behavior. There are a variety of different ideas that parents have used over the years, but in general, make it small, make it affordable (preferably free), and make it something that will put a smile on your child's face. If you need some help choosing rewards, I will be posting some information about how to select the best behavioral rewards in a future post.
As a last step, gradually increase the requirements for rewards over time. If your child has previously been required to go for 3 hours without an accident, make it 5, and so on. If you are trying to increase spontaneous potty breaks that your child takes on his or her own (which is a great idea to enhance independence and mastery), you might simply start rewarding times when your child is "caught being good" (see post on 12/26/17 with the same name) by going potty. Remember to pick easy to identify and specific target behaviors to encourage. Stay with the behavior, as long as it will help your child be successful.
Once you have begun to develop momentum toward independent toileting you might find that a few different periods of "tuning up" or observation might be required. Most of the time this is normal for most kids, and it is true that we all need a little reminder or encouragement sometimes. Depending on your child's age, you will likely find a point where you have reached the highest possible level of "potty performance" before you reach perfection. While it would be nice for our kids to have perfect scores in this area, it is not necessarily realistic for all kids nor of all ages. Keep this in mind, remember to have fun, and "potty on", friends!
This article is, by no means, an exhaustive training resource, but here is a basic summary of points that might help.
1. Acknowledge physical limitations
2. Get a checkup to address physical questions
3. Manage your frustrations if limitations or setbacks occur
4. Observe behavior and make a schedule of liquid intake, sleep patterns, potty time, and accidents.
5. Identify specific target behaviors such as spontaneous potty breaks or specific
benchmarks, such as longer accident-free time periods.
6. With this and other behaviors, focus on positive progress rather than negative
behaviors. Encourage and reward preferred behaviors as much as possible.
7. Talk to a therapist if you have any questions, need helpful ideas, or remain frustrated about the issue. Give me a call if you are in Kansas, as I'd love to help you conquer this
issue or any other you may be facing. Call my office at (785)551-2304.
Brock Caffee, LCMFT is a Marriage and Family Therapist, licensed in California and Kansas. He has over a decade of practice experience. He has a private practice in Lawrence, KS. At home he has three children, three dogs, and a very patient wife.
Parenting Disclaimer: As I mentioned earlier, parenting can be complicated and difficult. Please understand that not all families are prepared to change tactics, and not all children will demonstrate the same preparedness for behavior change. If you feel that additional guidance may be necessary, please contact a family therapist in your area. If you are in the Lawrence, Kansas City, or Topeka area, you may contact me (firstname.lastname@example.org) for a free telephone consultation.
The views expressed in this blog are meant to help foster perspective, to entertain, and to be fun when possible. Any intent to regard the blog as counseling or therapy constitutes misuse. Advice offered in the blog should be considered only if consistent with your family values and with advice given by your own mental health professionals. Please seek consultation with a mental health professional in your area if you experience distress or feel you are in crisis. The National Suicide Prevention Lifeline is 1-800-273-8255.