Aspergers and Enuresis

"We have experienced unusual urination issues with our 'aspie' daughter. She wears pull-ups at night and has never had a dry night, but she will also urinate in containers, bags, purses and even in her play tea set. It doesn't happen as often any more, but has happened as recently as a month ago. She doesn't do it out of anger - it's more like a compulsion and she can't explain why she does it. (She also has a wide variety of other compulsive behaviors we're trying to work though.)"

Enuresis is diagnosed when kids repeatedly urinate in inappropriate places, such as clothing (during the day) or the bed (during the night). In most cases, the youngster's urination problem is involuntary in nature, and is perceived by the youngster as an unavoidable loss of urinary control.

There are three subtypes of Enuresis:

• Nocturnal (night-time) Only

• Diurnal (day-time) Only

• Nocturnal and Diurnal

The DSM criteria for diagnosis state that the urination problem (whether involuntary or intentional) must occur with regularity, at least twice a week, for three consecutive months before the diagnosis applies. The diagnosis cannot be made unless there is evidence that the urination problem causes distress or impairment in the youngster's social or academic functioning.

In Nocturnal Only Enuresis, the most common form of enuresis, kids wet themselves during nighttime sleep. Typically, wetting occurs during the first third of the night, but it is not uncommon for wetting to occur later, during REM sleep. In this latter case, kids may recall having a dream that they were urinating.

Diurnal Only Enuresis, where kids wet themselves only during waking hours, is less common than nighttime bedwetting. This type of enuresis is more common in females than in males, and is uncommon altogether after age 9. Kids who are affected by this type of disorder will typically either have urge incontinence (i.e., they feel a sudden overwhelming urge to urinate) or voiding postponement (i.e., they know they need to urinate, but put off actually going to the bathroom until it is too late).

As the name suggests, kids with Nocturnal and Diurnal Enuresis suffer from a combination of the two scenarios described above.

Predisposing factors that contribute to increased risk of developing enuresis include:

• abnormal urinary functioning
• delayed or lax toilet training
• psycho-social issues (e.g., social anxiety)
• reduced bladder capacity
• unstable bladder syndrome (i.e., a condition wherein the youngster's bladder contracts involuntarily, resulting in sudden urine leakage)

Enuresis is most frequent in younger kids, and becomes less common as kids mature. According to the DSM, while as many as 10% of five year olds qualify for the diagnosis, by age fifteen, only 1% of kids have enuresis.

Enuresis is typically experienced as an embarrassing and shameful condition, particularly if the affected youngster is older. Kids with enuresis may be ostracized, teased and bullied by peers. In addition, they may face caregivers' anger, rejection and punishment for not meeting developmental expectations. Prompt treatment for enuresis can help to head off potential self-esteem problems associated with the condition.

Treatment involves a range of strategies including:

• cleanliness training (kids help thoroughly clean the bedding and mattress when accidents occur)
• family encouragement of good toilet habits and successful progress.
• mild punishment (primarily disapproval when accidents occur)
• nighttime waking (kids learn to wake themselves in the night to use the restroom)
• positive practice (parents help their youngster to develop the habit of going to the bathroom at regular intervals during the day, just before sleep, and during the nighttime in order to avoid accidents)
• positive reinforcement (rewards or praise) for urinating appropriately
• urine retention control training (strategies to promote better bladder control)

Success rates associated with this Enuresis treatment appear to be around 85%, with relapse rates falling between 7%-29%.

Some physicians may suggest a pharmacological treatment for Enuresis. The most commonly prescribed drug is imipramine (Tofranil) which is an old-style tricyclic antidepressant. Imipramine treatment is often a successful treatment in the short term, with between 40 and 50 % of kids showing improvement. However, when the drug is discontinued, about 2/3 of kids show a relapse and begin enuresis behavior again.

Alternatives to antidepressant therapy for enuresis exist. Desmopressin (DDAVP) is a synthetic form of a natural pituitary antidiuretic hormone which reduces urinary production by instructing the kidneys to retain water inside the body rather than excreting it. Administering Desmopressin to kids reduces their urine output dramatically, making it easier for them to maintain continence. Between 10 and 60 % of kids with enuresis taking DDAVP show improvements. However, as is the case with Imipramine, relapses back into enuresis are common when the drug is discontinued.

Due to their better side effect profiles and longer lasting effects, behavioral treatments for enuresis are usually recommended over medical ones with rare exception.  

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