Six-year-old Jonathan wet his bed frequently when he first entered
a foster home. He felt both humiliation and shame as he watched his
new foster mother change his sheets and air his mattress every morning.
He also experienced frustration because he knew he could not control
"It is wrong to assume that every foster child who wets the bed
does so because of the trauma he or she has suffered," says Brian
F. Greer, Director of the Center for Preventative Psychiatry in Coconut
Creek, Florida. "Perhaps the first assumption should be that this
is happening because the child is adjusting to the placement. If the
bedwetting continues for more than three weeks, this child should be
evaluated first for physical causes and then emotional."
Five to seven million American children over the age of six have a
condition called Primary Nocturnal Enuresis (PNE), more commonly known
as bedwetting. Clinically, PNE is defined as a condition in a child
over the age of six who has never achieved dryness at night.
Doctors are divided in their opinions as to its cause, but a genetic
predisposition to PNE and bladder size are considered contributing factors.
Recent research indicates that the absence of the hormone, ADH, which
acts as an anti-diuretic, limiting the body's urine output at night,
may cause PNE. Children without ADH produce four times the amount of
urine as those who have the hormone.
"Bedwetting can also be an indicator of an emotional disorder,"
says Dr. Greer. "But physical causes should be ruled out first
before a psychiatric evaluation is sought."
Secondary enuresis occurs in children who are enduring trauma or stress.
Often these kids have already overcome enuresis once; however, an event
they perceive as stressful triggers the bedwetting once again. "Enuresis
is not a willful act. A sleeping child has no control over this,"
explains Clinical Pediatric Psychologist, Blair Barone. "Anything
from a trivial situation such as school ending for the summer to abuse
and trauma in the home can trigger secondary enuresis."
No matter what the cause, quick, effective treatment of enuresis
will bring positive results. "To help a child achieve more positive
self-esteem, stopping the bedwetting behavior is most important,"
stresses Dr. Greer. "However we cannot just take care of the symptoms
without looking for the cause."
Dr. Greer suggest three steps. First, allow the child ample time to
comfortably adjust to the foster home. If bedwetting has not stopped
by the fourth week of placement, schedule a physical with a pediatrician
or a pediatric urologist to rule out any physiological problems.
The factors which are evaluated at an enuresis consultation include:
diabetes, urinary tract infection, small bladder capacity, lack of ADH,
neurological problems, and serious medical concerns, such as a misplaced
ureter or problems with ureter reflex.
The National Kidney Foundation's Physician Referral Network (1-800-622-9010)
can put you in touch with a doctor experienced in treating Enuresis.
Finally, if the condition cannot be traced to a physical cause, consult
a pediatric psychologist or psychiatrist.
Many children are not treated for enuresis because they are too embarrassed
to tell a doctor. Foster parents should stress to the child the importance
of being open about bedwetting in the hopes of correcting the condition.
Including the child's social worker in a discussion about the problem
is also important, Dr. Greer points out. "Most children will not
volunteer this information to their social workers, but thought a private
interview with the foster parents and the child, the worker should be
informed so that he or she can help make referrals for follow-up care."
Help is available
While primary nocturnal enuresis cannot be cured, it can be controlled
through behavior modification, rewards, and for some, medication. Those
children with secondary enuresis will benefit from psychological counseling.
But for any treatment to work, the child has to be willing to face the
problem and, with the foster parent, treat it.
"It helps a child so much if we can stop the bedwetting quickly
as we treat its underlying causes," says Dr. Greer.
For some children, an alarm system, available from a pharmacy or department
store, may be the first step. Ask your social worker if this is a reimbursable
Used as a motivational tool, the alarm is attached to the child's
shoulder and the front of the underwear. At the first sign of wetness
the alarm buzzes, awakens the child, and reminds him to complete urination
in the toilet. Continued use of the alarm conditions the child to get
up sooner until just the urge to use the bathroom gets him or her out
While the alarm can be successful if used properly, it may not be
appropriate for all households. It may take as long as six months to
work, and some experts thing the alarm motivates the adults in the home
more than the child.
Behavior modification--including limiting drinks in the evening, escorting
the child to the bathroom during the night, and acknowledging dry nights
with rewards--can be effective, but this, too, requires an intense commitment
for all involved.
Medication is often prescribed as an adjunct to behavior management.
Imiprimine as an antidepressant may provide some relief, but doctors
caution that the side effects can be severe if it is not taken properly.
Another drug called DDAVP Nasal Spray (desmopressin acetate) has been
proven to provide quick, effective relief for enuresis. DDAVP is a synthetic
form of the urine-limiting hormone, ADH. Prescribed as a nasal spray,
it is used once a day at bedtime. Improvement usually comes within one
to three days. Many medical experts believe DDAVP is the most appropriate
choice for foster children, especially those in temporary placement.
Medicines prescribed to treat enuresis are usually covered by Medicaid.
Alleviating a foster child of the distress of bedwetting will yield
positive results. Not only will the child's shame and embarrassment
be reduced, but the foster parent will no longer have the daily burden
of laundry and housekeeping associated with the condition.