DESCRIPTION OF THE STRATEGY

Regular bed-wetting of several times a week is a problem for about 1 of every 10 children
from elementary school through high school. In first grade, about 15 of every 100 children
wet the bed most nights. In high school, only about 1 of every 100 children continue to have
the problem. Most bed-wetting will simply go away as a child matures physically in terms of
bladder capacity and nervous system development. Bed-wetting is not generally a sign of
psychological or emotional problems but is instead a problem of maturation and learning the
proper sequence of behaviors to control the bladder during sleep. Most children learn this
control without any special assistance by the time they are 4 years old. Some children fail to
acquire this night time control, and many of them have an unknown genetic basis for this
failure to acquire nighttime control. Those children who continue to have routine bed-wetting
past age 4 may need special assistance to overcome the problem. The reason for treating the
problem as opposed to just waiting for it to go away is that continued bed-wetting can
interfere with a child's normal development and association with peers. Children who
continue bed-wetting and do not get help may develop feelings of inferiority and
embarrassment due to the fact that they are restricted in social activities.
Full-spectrum home training (FSHT) is a behavior therapy procedure for teaching a child how
to overcome bed-wetting. The basic idea behind FSHT is that bed-wetting can continue due to
many factors. FSHT was designed to address several of these major factors, and each part of
the procedure was also selected for convenience of use by parents and children. The entire set
of procedures that make up FSHT have been written into a manual that parents and children
can follow under the guidance of a health care professional who understands basic principles
of conditioning and learning.
FSHT consists of four components: (1) basic urine alarm training, (2) cleanliness training, (3)
retention control training, and (4) overlearning. The components are presented in an
integrated manual for parents to follow, and a behavioral contract between parents and
children forms the basis for implementing the procedures.

Family Support Agreement

The behavioral contract between the child and parents is called a family support agreement.
Like most child problems, correcting bed-wetting requires cooperation from the entire family.
The most demanding part of FSHT is training a child to wake to the alarm. Many children
need their parents' help to wake up. Parents have to be committed to waking the child and
requiring the child to get out of bed to be fully awake. A family environment of cooperation
and firm resolve is necessary. Children have to be ready to do the hard work of getting up
whenever the alarm sounds and be mature enough to do so without having tantrums and
defeating the whole process. The family support agreement is a behavioral contract procedure
between parents and children designed to promote cooperation and to clarify family rules for
assisting the child. Siblings are included in the family contract so that they will know how to
help and what to avoid. In extended families and blended families, all are included in the
contracting process if the child spends the night with those people. Consistency and followthrough in each household are needed for success.
The family support agreement covers all parts of the FSHT approach. Parents and children
complete the family support agreement while a trainer illustrates what to do for each step.

Basic Urine Alarm Training and Cleanliness Training

The idea behind urine alarm training is to provide the child with a new opportunity to learn
the active response needed to avoid wetting the bed. Most children learn this response without
any assistance. We suspect they do this because they find the wet bed is noxious and it wakes
them from a sound sleep. Children who get past 4 years old and who have not learned this
response may get accustomed to the wet bed and sleep right through it without feeling
anything. The urine alarm provides a new way to learn this response of stopping and then
preventing altogether wetting during sleep. Eventually, children who use the urine alarm go
from wetting to sleeping through the night without wetting and without even awakening.
However, they have to go through the training to get to that final goal. Going through the
training is difficult and means that the child will have to be awakened at first. This means
work for the parents who must assist.
FSHT can be implemented with any urine alarm device. In the past 15 years, body-worn
alarms have replaced the older bed pad alarms. Body-worn alarms use small alarm boxes that
operate on hearing aid batteries, and the urine detection unit is typically placed in the child's
underwear rather than on the bed. When even a very small amount of urine reaches the
detection unit, a circuit is closed like a switch and the alarm sounds. The alarm is turned off
when the detection unit is removed from the underwear and wiped dry.
These alarms are generally reliable and very convenient to use. However, they can lead
parents to over-look the importance of full cleanliness training, which requires that the child
remake the bed after each wetting episode. As children become more and more skilled at
preventing bed-wetting, the amount they wet on the bed gets smaller and smaller. This is due
to interrupting the stream sooner and sooner after wetting starts. As a result, some children
can set off the alarm and never actually wet the sheets. Full cleanliness training requires that
the bed be remade not only to provide appropriate consequences for bed-wetting but also to
ensure that the child is fully awake after the alarm sounds.
Children follow the rule to get out of bed and stand up before turning off the alarm.
Obviously, the entire process can be defeated if the child merely turns off the alarm and goes
back to sleep. Parents follow the rule to never turn off the alarm for the child. The steps
involved in remaking the bed are displayed on a wall chart (Daily Steps to a Dry Bed) placed
in the child's room. The chart shows a record of progress, and the child colors the chart wet or
dry for each day. Parents support a rule for the child to go through with the full procedure of
remaking the bed even if the sheets are not wet. Some children are very deep sleepers and
hard to train to awaken to the alarm. The child has to be awakened so that the child turns off
the alarm. This may require having a parent share the room with the child for a short time.
Training the child to awaken to the alarm is imperative. Giving parents an easy way to
determine if their child is truly awake can help. Shortterm memory checks such as choosing a
password each night before bedtime or asking the child to spell a familiar word backwards
will work.
The rationale for having the child take care of the wet bedclothes and bed linens is to have the
child take responsibility for maintaining his or her own bed. This also relieves parents of the
burden of doing this for the child. By taking active responsibility for keeping the bed made
and cared for, the children learn a sense of pride in being grown up and solving problems for
themselves with parent assistance rather than parent imposition. The aforementioned rules set

forth in the family support agreement are there to ensure that the child and parent keep
focused on the goals and the procedures.
In FSHT, the first goal of urine alarm training is for the child to achieve 14 consecutive dry
nights. The professional assisting the child and parents needs to focus on reinforcing
accomplishments during the urine alarm training. Children who wet multiple times each night
get easily discouraged. These families need to understand that it will take 12 to 16 weeks as
opposed to the average of 8 to 12 weeks for the child to get the first 14 consecutive dry nights.
Also, multiple wettings mean multiple awakenings with all of the added work. For these
children, their first goal is to get from multiple wettings to a single wetting each night.
Progress can be measured by the decreasing size of wet spots. This helps parents and children
focus on the positive accomplishment of the child who is responding more readily to the
alarm. As the size of the wet spot gets smaller and smaller, the child is learning to make the
active avoidance response sooner and sooner. Dry nights are sure to follow. In focusing on the
goal of attaining 14 consecutive dry nights, parents and children often need to be reminded of
the overall picture. Even though a child may not have reached the 14-night goal, the child
may have been 90% dry for the past 6 weeks. This can give the family a more positive
perspective.
Many children enjoy the challenge of overcoming bed-wetting, and it is easy to engage their
competitive spirit. Some bring their wall charts to each follow up visit to show off their
progress. Others set goals of beating the 42-day record for completing FSHT. So long as their
goals are not outlandish and beyond reach, this energetic approach to getting rid of the
problem is useful.
Parents often want to add other incentives to the FSHT program, and this is not a good idea.
What can be helpful is to redirect this urge to teach the parents to use contingent praise for
completion of various tasks. Praising children for their hard work of waking to the alarm,
remaking the bed, and taking the soiled linens to the laundry is directly beneficial. Outcomerelated rewards such as a new mattress or new bed upon completion of the program can be
helpful.

Retention Control Training

This procedure is included in FSHT to increase the amount of fluid the child's bladder can
hold before it reflexively contracts and produces the sensation of having to urinate. Due to
hereditary factors and even habit, some children have low bladder capacities. This functional
capacity can be altered by practicing holding larger and larger amounts of urine before giving
in to the initial sensation to urinate. This can be practiced during the day and can help a child
get to the 14 consecutive dry nights goal faster when using the urine alarm.
Retention control training is done once a day with a parent or older sibling assisting. Parents
and children agree on a practice time spanning a 2-hour period when the child and the
assistant can be together in the event the child has to urinate. The procedure begins by having
the child drink a large quantity of water (1216 oz.). The child finds the assistant when the
child feels the urge to urinate, and the assistant starts timing the holding time. The child is
given money for postponing urination for increasing amounts of time in a step-by-step fashion
up to a 45-minute holding time. The total amount of money the child receives for reaching all
15 of the 3-minute incremented goals is $6.25. Children are encouraged to save the money in

a prominent place to remind them of their success. Retention control training ends when the
child attains the 45-minute goal, typically within 3 weeks.

Overlearning
Overlearning is the final component of FSHT and only begins once the child has attained 14
consecutive dry nights with the urine alarm. Overlearning is done to prevent relapse once the
child has succeeded with the urine alarm. The chance of a relapse without over-learning is 4
out of 10. In contrast, the chance of relapse is less than 1 out of 10 if the child does overlearning. The benefit of doing overlearning far out-weighs the time and effort to complete it.
Overlearning begins by determining a maximum amount of water. The maximum is 1 ounce
for each year of age plus 2 ounces. For example, the maximum amount for an 8-year-old child
is 10 ounces. Children then begin by drinking 4 ounces of water 15 minutes before bedtime. If
they remain dry for two nights while drinking 4 ounces, the amount increases to6 ounces. If
they remain dry for two nights at 6 ounces, the water is increased to 8 ounces. The water
increases continue in this fashion, 2 ounces more for every 2 consecutive dry nights, until the
child's maximum is reached. The child continues to drink this maximum until 14 more
consecutive dry nights are attained. In the event a child wets, and most do at least once, a
simple rule is followed. The child goes back to whatever amount was consumed on the last
dry night and continues with that amount until there are 5 dry nights in a row. If the child is
not already at the maximum, the procedure continues as before, increasing by 2 ounces for
every 2 dry nights. The goal remains 14 dry nights in a row during overlearning. Some
children end up having all 14 of those dry nights at the maximum amount, but this is not
required for the relapse prevention effect.

Research Basis
Based on five randomized outcome trials, about three out of every four children treated with
FSHT can be expected to stop bed-wetting by the end of the average of 12 weeks needed to
complete the treatment. These outcomes were obtained under research protocol conditions
where flexibility of procedures was highly constrained. These samples excluded children with
clinically significant behavioral problems such as conduct disorder and ADHD. Single-parent
house-holds were represented in these data as were lowincome families. However, the
samples did not include families with marked marital discord or clinically significant family
dysfunction. Although these sample characteristics limit the generalizability of findings, it
also should be remembered that these samples are quite representative of bed-wetting
children, most of whom do not have such additional problems.
At the 1-year follow-up, 6 out of every 10 children are permanently dry. In some studies, we
obtained lower relapse rates in the range of 85% to 90% remaining permanently dry. These
better long-term outcomes were from children who did the overlearning, where they increased
nighttime drinking in 2-ounce increments adjusted for their age. That over-learning was
described above. In other studies, over-learning was done in the original fashion of having
children consume 16 ounces of water regardless of age. Recent evidence supports a consistent
finding that slightly less than 10% of children relapse using the gradual overlearning
procedure.

RELEVANT TARGET POPULATIONS AND

EXCEPTIONS
The research evidence for saying that FSHT is an effective treatment has been based on
monosymptomatic primary nocturnal enuresis (MPE) or simple bed-wetting. Almost all bedwetting is of this type, with 85% being MPE. These children have no other physical
symptoms or medical complications; they simply continued bed-wetting from birth and never
had a period of 6 months or more of sustained night-time continence. Furthermore, they also
did not display other major behavior problems such as conduct disorder or ADHD.

COMPLICATIONS
As a general procedure, FSHT should not be started without first having a child examined by
a medical doctor to rule out complicating factors. Most children will not have complicating
factors, but it is a mistake to start FSHT if a child has a urinary tract infection. The infection
should be treated first. If a child has daytime wetting in addition to nighttime wetting, the
child needs a thorough medical evaluation. Daytime wetting needs to be corrected first and
may require medical attention.
Children who have onset enuresis or secondary enuresis have a history of having been dry at
night for 6 months or more. Sometimes they started wetting again at night when a stressful
event occurred in their lives. These children need behavioral evaluation by a competent
mental health professional. If they are not displaying behavior problems and problems of
anxiety and if they have a cooperative family, they can be treated with FSHT. Otherwise, such
additional problems need to be resolved before starting FSHT for the bed-wetting problem.
Given these limitations, there are still MPE children who do not respond to FSHT with
success. Leaving aside cases where a child defeats the alarm device or where parents fail
follow-through, there are still some 10% to 15% who do not respond even after 20 weeks.
Information on such treatment failures is sorely lacking. Some may have problems with
arousal and might benefit from behavioral or drug interventions to alter sleep patterns. Those
who wet multiple times per night and never get to wetting once a night may have problems
with concentrating urine and could benefit from taking antidiuretic hormone
medications.Some may have undiagnosed food and airborne allergies that complicate sleep
and urination functions. Much more research is needed on those children who fail to respond.
Fortunately, they are only a small proportion of MPE children.

CASE ILLUSTRATION
Matthew was an 8-year-old boy who was referred by his pediatrician, who had
unsuccessfully treated him with antidiuretic hormone (DDAVP) and then with imipramine
(Tofranil). Physical exam showed no medical complications, and developmental milestones
were within normal limits. Matthew lived with both parents and his 14-year-old sister,
Maggie. Both parents completed the child behavior checklist and indicated there were no
additional problems for Matthew, who was described as an A and B student in third grade.
Parents also indicated normal marital adjustment on the Locke Wallace Marital Adjustment
Test.

Matthew wet the bed since birth, and the parents believed that he wet more than once per
night. The family was seen in two 1-hour visits with all attending. Maggie agreed to supervise
retention control training (RCT) in the afternoons, as both parents worked. The family
completed the family support agreement, and RCT began after the first visit. At the second
visit, the alarm procedures were demonstrated.
Matthew and Dad attended the third visit for half an hour. The RCT went well, with Matthew
having completed the 33-minute goal. Review of the wetting record kept by parents showed
that Matthew wet two times a night in the first week. The first wet typically occurred about 2
hours after bedtime (9 p.m.), with the second between 2 and 3 a.m. Matthew was reminded to
drink fluid throughout the day with no restrictions, even at bedtime. Parents were told to make
sure that at the first wetting episode, Matthew took the time to fully empty his bladder. This
might prevent a second wetting.
Matthew and either Mom or Dad returned for a total of five more half-hour visits spaced from
2 to 4 weeks apart. By Week 4 of the alarm, Matthew was wetting only once a night between
2 and 3 a.m., and the size of that wet spot was decreasing. In Week 6 of the alarm, he had two
consecutive dry nights. By Week 10 of the alarm, Matthew attained 14 dry nights in a row.
Matthew and his family were very enthusi-astic but also a bit afraid to start overlearning.
Matthew started overlearning by consuming 4 ounces of water just before bedtime. His
maximum amount was 10 ounces. By Week 15 of the alarm, Matthew completed 14 dry
nights in a row during overlearning. He was encouraged to accept sleepover invitations. The
family was instructed that if wetting happened again, this would be typical. The only cause for
alarm was if wetting happened twice within a 7-day period. In that case, they were instructed
to call the clinic to review the circumstances. If wetting persisted twice within another 7-day
period, the alarm would be introduced again until Matthew attained 14 consecutive dry nights
on the second application of the alarm.
At 3-month follow-up, Matthew had wet once when the family was on vacation. He was
otherwise dry and had spent the night away from home six times. At 6-month and 1-year
follow-ups, Matthew remained completely dry at night. His parents reported that he had
attended a 3-week Boy Scout camp without any problems and that he seemed to be more
confident in himself.
Arthur C. Houts
Further Reading

Entry Citation:
Houts, Arthur C. "Full-Spectrum Home Training for Simple Bed-Wetting." Encyclopedia of
Behavior Modification and Cognitive Behavior Therapy. 2007. SAGE Publications. 15 Apr.
2008. <http://sage-ereference.com/cbt/Article_n2055.html>.