EFFECTS ON FAMILY LIFE AND THE NEED FOR HELP

by Penny Dobson

The Enuresis Resource and Information Centre (ERIC) is a national charity based in Bristol that provides advice and information to children, parents, young adults, and professionals suffering from nocturnal enuresis. It also provides advice on daytime wetting and has a weekday helpline service. It has strong links with the Institute of Child Health at the University of Bristol. This article focuses on:

• how parents respond to nocturnal enuresis;
• the stresses that contribute to an intolerant response and its effect upon treatment outcome;
• What can be done to improve the situation.

How parents respond to nocturnal enuresis

Parents often feel anxious, helpless, and guilty about their children's enuresis and sometimes this leads to loss of confidence in their parenting skills. These feelings can be exacerbated by pressures from within the family, from members of the extended family and from neighbours and friends. They feel under pressure that their child should be 'normal'. This can contribute to conflicts within the family and thereby difficulties in the relationship between parents and child.

ERIC has approximately 5000 enquiries per annum from parents or carers, by telephone or letter. These are, it is true, likely to be from a selective group of the more articulate and confident parents. However, the same responses to bed wetting crop up again and again. Some typical parental responses are shown in Figure 1. The last example is an instance of the treatment not helping the situation. Research confirms that bed wetting can cause adverse reactions from parents. Margaret White reported in 1971 that 30 per cent of mothers in her sample of 1000 cases of enuresis admitted to scolding or beating their child. Gerard Tisiard, in 1983, found in a review of 13 000 children, aged 5 years, in a national child health and education survey, that nonaccidental injury was associated with increased rates of bed wetting. Benjamin, in 1971, in a study of 90 parents in Madison, USA, who brought their children for a routine paediatric visit, found that night training was retarded by the use of negative reinforcers, such as shaming, spanking, rejecting and name calling.

Most mothers perceive their children's bed wetting to be a result of heavy sleeping, worrying, being easily upset, or a family history of the condition. There is a minority, however, who believe that bed wetting is controllable by the child. This group associates bed wetting with negative characteristics, such as laziness and 'getting back at' mother; older children are also perceived as having more control over their bed wetting than younger children. This group of mothers is more likely to be intolerant and angry towards their children. A study by Woolnough, in 1991, included fathers' responses to bed wetting, showing that mothers and fathers have similar beliefs about the causes of nocturnal enuresis.

Stresses contributing to an intolerant response and affecting treatment outcome

The highest scores on the parental intolerance scale, devised by Morgan and Young, were associated with:

• increased likelihood of drop-out from treatment
• older children
• families from lower socioeconomic classes

The area with which ERIC can offer most help is the third group, the lower socioeconomic class. This group is more likely to be associated with poor housing, poverty, poor drying conditions, and also with a greater incidence of nocturnal enuresis. This constitutes a vicious circle that needs to be broken.

The extra cost incurred by one child who wets three times a week is not inconsiderable. It involves an extra three washes, extra washing powder, extra drying costs and the cost of replacement bedding. The cost is still higher, of course, for parents who have to go to the launderette.

What can be done to improve the situation?

Intolerance can be addressed by suggesting that the burden of extra washing is shared among the family members, by using medication, and by emphasising to the parents that wetting is not under the child's control. All these measures help parents to change their attitudes and approaches.

It is also important to give adequate supervision. Enuresis advisers should ensure that the families concerned are receiving the maximum state benefits or earnings entitlement, linking with social services where necessary.

Finally, advisers can work with the child to reduce any medication gradually - Desmotabs or Desmospray are the appropriate medication, not tri-cyclic antidepressants (TCAS) and then to introduce treatment methods such as the enuresis alarm. Thus, gradually, a more active form of treatment is introduced that requires more work from both child and parent.

Parents seeking advice and support are very often relieved that there is somewhere that they can telephone or write to for information and advice. ERIC is a charity that fulfils a need, particularly for families who feel that their GP is not interested in the problem of enuresis or in giving practical advice and guidance.