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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Can children with Aspergers also get diagnosed with Bipolar Disorder?

Question

Could you tell me if some children with Asperger's also get diagnosed with Bipolar Disorder? Our daughter has always had mood issues but we can usually identify causes, such as sensory issues, anxiety or overstimulation. We have just had an IEE FBA done on my daughter at school. The school has not been implementing her BIP, and she has been running the show. She is in 7th grade. The school district is so out of compliance with IDEA 2004. None of the Teacher's or staff are trained.

This behavior specialist wants us to go to a Psychiatrist to get a "clean diagnosis." We have had numerous testing done on her over the years. She was diagnosed at 4 years with ADHD, then at 5 with PDD-NOS. We took her to University of Texas Health Science Center and they diagnosed "High Functioning Autism" at 6 years. The doctor told us that it was essentially the same as Asperger's.

Answer

A diagnosis of both Aspergers and Bipolar is especially problematic because there are fundamental differences between ‘Aspergers mood states’ versus ‘mood states of a child without Aspergers’. Four specific domains need to be considered in the process of diagnosis:

• ‘Psychosocial masking’ make some unusual behaviors seem like disorders when they are not.
• ‘Intellectual distortion’ involves confusion in communication; a person may say he is afraid instead of angry.
• ‘Cognitive disintegration’ may interfere with proper diagnosis since a child may exhibit odd behavior in response to seemingly insignificant occurrences.
• ‘Baseline exaggeration’ differences suggest that unusual base behaviors can interfere with proper diagnosis.

Bipolar Disorder (BD) can be misdiagnosed as Aspergers (AS) because BD can present itself via symptoms such as obsessive compulsive behavior, odd habits, and bouts of rage. Children with BD and AS both have symptoms that lead to lacking social development skills, educational issues, behavioral issues, and anger issues.

BD can also be present in conjunction with AS. Typically, this is the case. It is unknown, however, if the BD is a result of the AS, or if the same neurological issues that cause AS are related to the chemical imbalances in the brain thought to be the cause of BP. Answers to these questions will likely come to light as research in neurological, technological and psychiatric areas continue to progress.

Medication treatments for BD and AS are quite similar. There are no medications for AS; however, medications exist to treat the symptoms of AS. Since the symptoms of AS (e.g., depression, obsessive compulsive disorder, and anxiety) are the same symptoms often experienced with BD, the medications used in both instances are the same.

Counseling treatments are also commonly used for both BD and AS, used in conjunction with medication or alone. Most AS children do not need medication. Counseling is required, however, to help the child cope with her disability. Counseling treatments for BD are considered necessary, with or without medication. These treatments can help the child learn to recognize and correct irrational emotions or behavior.

My Aspergers Child: Preventing Meltdowns

Does Your Child Have Asperger Syndrome, ADHD, or Both?

"Is ADHD a result/symptom of Aspergers, or do the two disorders tend to coincide with one another?"

People often wonder if these two disorders are opposite, independent, or correlated. At first blush, ADHD seems to be short attention span and inability to focus, and Aspergers (high functioning autism) the opposite problem. But then, descriptions of ADHD also mention ‘hyper-focus’. If they do turn out to be correlated or similar, then what are the differences between the two?

Aspergers and ADHD share some similarities that can make diagnosis challenging. However, a close examination of their definitions reveals that the attention problems in Asperger are quite different from ADHD symptoms. The fact that a child can have both Aspergers and ADHD further adds to the confusion. Roughly 60-70 % of children with Aspergers have symptoms which are compatible with an ADHD diagnosis.

Here are some of the similarities between ADHD and Aspergers:

• Attention problems
• Irrationally energetic activity
• Learning problems
• Often appears to not be listening to someone during a conversation
• Problems following directions
• Says inappropriate things and has problems figuring out the appropriate response to some situations
• Talking at someone or talking nonstop
• Tantrums
• When younger, difficulty accepting soothing or holding

Both Aspergers children and ADHD children have serious sensory integration problems, can be uncoordinated and impulsive, and they both very much respond positively to structure and routine. Whenever there is a deficit in executive functions, it manifests itself in inattentiveness, distractability and impulsivity – three areas recognized on both the Aspergers and ADHD checklist of behaviors.

Here are some of the differences between ADHD and Aspergers:

1. Aspergers focuses more on attention problems related to (a) a need for strict routines, (b) language difficulties, (c) obsessive rituals, and (d) self-stimulating behaviors. Conversely, ADHD focuses more on attention problems related to (a) impulsivity and (b) hyperactivity.

2. A child with Aspergers has the ability to focus on an activity of interest. A child with ADHD does not.

3. An Aspergers child tends to focus on only one activity with a level of intensity that excludes everything else in his environment (e.g., he may spin an object for hours and refuse to engage in any other activity). On the other hand, an ADHD child tends to be interested in multiple activities, but is easily distracted by the environment and jumps from one activity to the next.

4. A child with Aspergers may get angry if his routine or favorite activity is interrupted, but he does not generally show a wide range of emotions in public. A child with ADHD may be prone to express emotions directly and clearly.

5. An Aspergers child can stick with one activity for long periods of time. The child with ADHD may not be able to focus on any activity or subject for more than a few minutes.

6. Children with Aspergers and children with ADHD usually want to have friends. Both groups have poor “rite-of-entry” skills and both groups play badly. Yet both groups usually fail socially for different reasons. With Aspergers, the behavior is so unusual and idiosyncratic that the child is viewed as a “nerd” or a “weirdo”. With ADHD, the behavior is so loud and chaotic that the child is viewed as annoying or disruptive.

7. Children with Aspergers like rules, but break the ones they don’t understand. Children with ADHD frequently break rules they understand, but defy and dislike.

8. Children with Aspergers are often oppositional in the service of avoiding something that makes them anxious. Children with ADHD are often oppositional in the service of seeking attention.

9. Children with Aspergers crave order, hate discrepancy, and explode (or withdraw) in the face of violation of expectations. Thus, they are very brittle and fragile. Children with Aspergers are much more tyrannized by details – they accumulate them, but cannot prioritize them. Children with ADHD also have poor organizational skills, but can be much more fluid in their thinking, more inferential in their comprehension, and less rigid in their treatment of facts that they are able to organize.

10. An Aspergers child can talk or play quietly. An ADHD child finds talking or playing quietly very difficult.

11. An Aspergers child has difficulty waiting for his turn in games or activities due to a lack of social intelligence. An ADHD child has difficulty waiting for his turn due to impulsivity.

12. Both groups seem not to listen when spoken to directly, but for different reasons. It appears that the Aspergers child is not paying attention because he avoids direct eye-contact. It appears that the ADHD child is not listening because he is focused on other things at the time.

The main differences between Aspergers and ADHD deal with focused attention ability as well as whether or not obsessive behaviors and sensory issues are present.

It is possible for a child to have a cormorbidity of ADHD and Aspergers (i.e., both conditions are present). A child with both conditions will have more ADHD symptoms (e.g., impulsivity and hyperactivity) than common in Aspergers.

The problem with the Aspergers - ADHD overlap is that, at the more severe margins of the ADHD spectrum and the less extreme margins of the Aspergers spectrum, clinicians can legitimately argue for one over the other diagnosis. It is common for a child with Aspergers to first be diagnosed with ADHD due to attention and behavioral issues. As further tests are done and more specialists get involved, a more specific diagnosis of Aspergers is often made.

Most of the processes to get these labels placed are not an exact science, and the frustrating process for parents, teachers, and medical professionals is finding the right label to make sure that the right approaches are taken to help the child progress in the best manner possible.

More resources for parents of children and teens with High-Functioning Autism and Asperger's:

==> How To Prevent Meltdowns and Tantrums In Children With High-Functioning Autism and Asperger's

==> Parenting System that Significantly Reduces Defiant Behavior in Teens with Aspergers and High-Functioning Autism

==> Launching Adult Children with Asperger's and High-Functioning Autism: Guide for Parents Who Want to Promote Self-Reliance

==> Teaching Social Skills and Emotion Management to Children and Teens with Asperger's and High-Functioning Autism

==> Parenting Children and Teens with High-Functioning Autism: Comprehensive Handbook

==> Unraveling The Mystery Behind Asperger's and High-Functioning Autism: Audio Book


==> Parenting System that Reduces Problematic Behavior in Children with Asperger's and High-Functioning Autism