Bedwetting, also called enuresis, is a much more common problem than you would expect. Prior to the age of 3 to 4 years, children cannot reasonably be expected to remain dry through the night. After that age, however, bedwetting becomes more of a problem. Bedwetting in the general population occurs until adulthood for some unfortunate people. For them, it certainly would have been a blessing if something had been done in childhood to stop the problem.

The pattern of bedwetting in general is highly variable. Some children wet the bed regularly several times each night, and others wet only infrequently or in sporadic bursts. The age at which children are expected to become dry at night varies between families, social classes and within communities. Regardless of when children are expected to become dry at night, surveys have found that at the age of 4 to 5 years, about 20 percent of children are still wetting the bed enough to be a significant problem for the parents.

By the age of 14 years only about 2 to 3 percent of children are still wetting the bed, so even if you don't do anything about it most children will grow out of it anyway. This doesn't help you live with the problems of soiled bedding and the psychological effects on the child and the parents, however.

There are several causes of this problem, but the most common is the child has learned the behavior and either doesn't want to stop it or doesn't know how to break the habit. There are also physical causes of bedwetting and these must be diagnosed and treated by a physician. Because of this, it is a good idea to have your child checked by your physician if bedwetting continues after the child should be waking up dry in the morning. Physical causes are relatively rare, however, and most cases of bedwetting are due to psychological factors. The psychological causes are the subject of this chapter.

Before I go into ways to use behavior modification techniques to help your child stop bedwetting, I think you should know about some of the more serious reasons for this problem. When a child is having severe stress or emotional distress related to something happening in his life, he will often regress to bedwetting after being dry for a period. In this case, bedwetting can be a symptom of emotional distress. Sometimes, the child will also regress to other more infantile types of behavior such as a return to thumb sucking or clinging behavior. By regress, I mean after a period of time without the symptom, a child returns to the behavior of an earlier age.

Regression in this case is a symptom of a much more serious problem with the child. This can happen during times of family disturbance, such as parents who are fighting or getting a divorce. It can happen as a result of problems the child is having at school or other places. Sometimes, when a child is being bullied at school or is being intimidated by a teacher a child will regress as a way of coping with an unbearable situation. Yes, some teachers do intimidate or humiliate a child. It is a good idea to be aware this kind of thing does happen and find ways to correct it if it does. This may be a good time to seek professional help with ways of dealing with the situation and helping the child.

In this situation, the bedwetting is a symptom of a greater disturbance and can be a child's defense against his own anguish. I never believe in attacking a person's defenses without first providing a better way of dealing with the problems. When a person has a better way, the defense is no longer needed. Merely, trying to remove the defense can cause another symptom to appear as a defense or possibly the child could have a nervous breakdown since there are no defenses left.

One of the worst things you can do if the bedwetting is a symptom of emotional distress is to berate and shame the child because he wets the bed. Unfortunately, this is a tactic many parents use when they come to the end of their rope. This is a way to insure the child will have emotional distress and damage to his self concept. Also, it won't work to get him to stop wetting the bed.

If there are family problems that are causing distress, consider doing something to change the situation before the child, and you, become much worse. I know divorces are necessary at times, but it would be a good idea to get guidance in ways of doing things that will help your child cope with something that is very upsetting to him.

Most of all, be aware bedwetting or other regressive behavior can be a sign of a much more serious problem and act accordingly until you know it is just lack of motivation or habit. Once you decide the problem is merely behavioral, behavior modification methods can be very effective.

Besides bedwetting being a symptom of emotional distress, it can also be a symptom of some physiological disorder. This is relatively rare, but since it can happen, it would be a good idea to consult with your physician about this possibility. There are medications physicians use to help prevent bedwetting, and only you and your doctor can decide whether to try that or not. Bedwetting in this case is a medical problem and I will leave that aspect up to the physician.

Now that I have warned you thoroughly, you should know usually bedwetting is due to habit or lack of motivation to stop. Often, lack of motivation is the beginning of the problem and this leads to forming a habit which continues after the child becomes motivated to stop. Shaming techniques often used by parents can actually increase the bedwetting problem because this causes emotional distress in the child. This is a much more serious condition when that happens.

It may seem strange to you, but a child can find comfort in sleeping in a wet bed. Your child may not have developed your sense of cleanliness and aversion to a wet bed. The warm, wet bed may feel very good in this case. Always keep in mind your motivations are not your child's motivations. Since this may well be the situation with which you are faced, your first job will be to work on the motivation aspect of bedwetting. If your child doesn't want to stop wetting the bed, you will have a much more difficult time getting it under control.

First, it will be a good idea to discuss the problem with your child in an accepting manner. It is important you not be judgmental and condemning of your child's behavior. Long, detailed explanations will not be of much help. As a matter of fact, they will probably make it more difficult to enlist your child's co-operation. The subject of the discussion needs to be something along the line of your perception of the bedwetting as being a problem--not that bedwetting is a shameful thing to do. Such things as causing more work because you keep having to change the bed each morning, the disagreeable odor it makes, the problems if your child wants to spend the night with someone else, etc. are good topics. The point is there are practical problems associated with the bedwetting.

Whether your child understands the discussion or not, you can then proceed with some behavior modification techniques. Although it is not necessary for your child to understand, it is very helpful. He will understand much better if you do not take a judgmental or critical approach. If at all possible you need to have your child interested in accomplishing the goal of dry nights.

Notice I am not including the habit component of bedwetting at this time. Unless you are sure your child is motivated to stop wetting the bed, it is best to deal with the motivation problem first. This needs to be a joint project for you and your child to succeed the best. I will describe methods of working with the habit component of bedwetting later.

Let's see how behavior modification principles can be applied to this problem. First, we need to define the behavior to be modified and then the probable rewards coming from the behavior. We do have a problem concerning the time interval between the actual wetting and the reward or punishment to be used. It will be very trying for you to stay up all night sitting beside your child's bed and feeling for the first sign of wetting. I think we can accomplish the desired result by helping the child to make the connection with the wet bed and the trouble it causes.

The first thing to do is to let your child have the consequences of the problems associated with the wet bed rather than you having them. For example, you can make it the child's responsibility to get up and change the bed when it is wet. Depending on the child's age, you might even make it his responsibility to put the bedding in the washer and take care of cleaning the soiled bedding himself. You see, this is giving the consequences to the child.

It is important you not get concerned with how good a job the child does when changing the bed. Let the quality of the job also be his responsibility along with the results of poor quality in making the bed. He can sleep on wrinkled and misaligned sheets and it won't hurt him. Also, if he washes his own bedding, it is good to remember the important thing is for your child to learn something--not to do a good job of washing. Quality of work can be the subject of later behavior modification projects.

With this in mind, see how many of the problems associated with bedwetting you can give to your child. After all, he is the one who did the wetting. In all cases, it is important you not fuss at him or belittle him for wetting the bed or doing a poor job of changing the bed. You do need to be insistent that he always change his own bed every time it is wet. This may be more than once a night. Any time his bed is wet he is required to get up and change it. You might even give yourself the project of checking during the night occasionally to see if the bed is wet and he is asleep. When you find this happening, you can wake him up and insist he change the bed right then. See, this is giving the consequences of the wet bed to the child where it belongs.

This process needs to be done consistently even if it makes more work for you. In the long run, it will be less work because your child should stop the wetting and there will be no more work for either of you. This process also needs to be done lovingly because this should be a joint project between two people who like each other and want to keep on liking each other.

Many people may fail at this project because they insist on things being done right, and they forget what the real project is over the long run. A properly made bed is not as important as your child's self image or embarrassment later in life if he still wets the bed occasionally. You may think going through the hassle of making your child get up from a sound sleep is asking too much, but overall it will be a lot less of a hassle later in life if you teach your child to be responsible for himself and his bedwetting.

To summarize behavior modification of the motivation aspect of bedwetting: Give your child responsibility for the wetting and the consequences of the wet bed. Do this with the attitude that this is a practical matter and be consistent. Do not try to shame or embarrass your child in the process. Be willing to work hard at this yourself, because you will find yourself weakening and tempted to skip doing what is needed "just this once."

Now for the matter of the habit component of bedwetting. Often, when a child desperately wants to stop wetting the bed, he just can't accomplish it. That is most likely due to his having developed an unconscious bit of behavior that occurs automatically even though he doesn't want it to occur. That is what I call a habit. When something occurs automatically, it is still something a person is doing. He is just not doing it consciously. If you are wanting to do something that is not a habit, you will do it consciously as well as unconsciously.

In the chapter on nail biting and other bad habits, I said the way to break a habit is to monitor the habit. That means catching yourself doing your habit and mentally saying the equivalent of "Whoops!" whenever you do it. Each time you catch yourself doing your habit and bring it into consciousness, you will weaken the habit tendency to do it automatically. As it gets weaker, it will be easier to catch yourself doing it and bring it into consciousness. This creates a circle which soon results in eliminating the habit.

The main problem in applying this to bedwetting is in finding a way of bringing it into consciousness at the time it happens. This is because it usually happens when the child is asleep. It is going to be pretty hard for him to monitor his habit when he is asleep. This can make a particularly difficult situation without some specialized help. A device is available, however, which is designed to solve this exact problem. Normally, I don't care for the use of gadgets to help people, but there are times when they are extremely helpful.

The thing that is needed to help break the habit is something that will stay awake all night and constantly monitor the condition of the bed. The instant the child first wets, the device needs to wake the child immediately and inform him that he has just wet the bed. That is also a good time for the child to get up and change his bed. You, as parent, could do this, but I will bet you won't be willing to stay up all night with your hand under your child's bottom.

This is where an electrical monitoring device comes in handy. Such a device is available, and it will monitor the dryness or wetness of the bedding. The instant the child urinates, the device sounds an alarm which can be set to wake you as well as your child. This device consists of a pad that contains electrodes separated by fabric or some other non-conductor. As soon as urine touches the pad, contact is made through the electrodes and they trigger the alarm. This is a simple, rather ingenious device and it works very well.

Now, for a word of warning. If the device allows a small electrical current to come in contact with your child's skin, it can burn an ulcer into the skin. Most devices are designed to eliminate or minimize this problem, but you should be aware it can occur if you plan to try this approach. What happens is a small amount of urine could make contact between your child's skin and the electrodes and a weak electrical current can pass through your child's skin causing ulcers. This current is too weak for the child to feel or to set off the alarm, but it is strong enough to burn a lesion in the skin. Actually, when this happens, ions from the electrodes are deposited in the skin and there is a discoloration in the ulcer which is related to the material of the electrodes. These ulcers heal poorly and can leave a permanent discoloration.

Therefore, it is very important the alarm be set loud enough to wake the child and probably yourself. This helps prevent the possibility of the child remaining on the wet pad and increasing the chance of causing the lesions. It is also important the bed be changed every time the alarm goes off. It is also very important you check your child regularly for any signs of an ulcer forming if you use one of these devices.

I consider these devices a last resort to be used only when the habit component cannot be changed any other way. I think if you apply the procedures discussed earlier you will not need to take these extreme measures.