Treatment of primary nocturnal enuresis: A randomized clinical trial comparing hypnotherapy and alarm therapy

Primary nocturnal enuresis (PNE) is a relatively common condition of childhood (1). According to The ICD-10 Classification of Mental and Behavioural Disorders: Diagnostic Criteria for Research (2), a child is diagnosed with PNE if there is at least one wetting event per month for children seven years of age and older, and the bedwetting is not due to neurological disorders, abnormalities of the urinary tract or epileptic attacks. The present study compares the effectiveness of alarm therapy and hypnotherapy in achieving dryness, as suggested by Milling and Costantino (3). We also examined the effects of PNE on children's self-esteem and behaviour problems. Children aged seven to 12 years who presented to the Enuresis Clinic at the Children's Hospital of Western Ontario (London, Ontario) between September 2000 and December 2002, and who fulfilled PNE criteria, were eligible to participate in the study (n=96). Exclusion criteria were attention-deficit hyperactivity disorder, conditions associated with large urine volumes, abnormal neurological control, abnormalities of bladder and outflow tracts, daytime wetting and previous use of prescription medications for enuresis. Approval was obtained from The University of Western Ontario Research Ethics Board for Health Sciences Research Involving Human Subjects. At the first clinic, participants were asked to bring in charts of their dry and wet nights over the previous two weeks. Following a clinical history, a physical examination was performed by a paediatrician (FG). The children completed a measure of self-esteem (the Culture-Free Self-Esteem Inventory, Second Edition [CFSEI-2]) (4), while parents completed the Parenting Stress Index, Third Edition (PSI-III) (5), and the Child Behavior Checklist (CBCL) (6). The latter two measures assess parenting stress levels and parents' perception of their child's behaviour problems, respectively. Subjects were then randomly assigned to hypnotherapy or alarm therapy. Randomly assigned blocks of 10 subjects minimized any temporal effects. The anatomy and physiology of bladder control was explained to subjects using Figure 8.1 from Olness and Kohen's Hypnosis and Hypnotherapy with Children, 3rd edition (7). The hypnotherapy protocol in the present study was modelled after the protocol described by Olness and Kohen (7). Hypnotherapy subjects were provided an audiotape, which they were to listen to nightly until they achieved dryness. Alarm therapy patients received instruction about use of the alarm. Participants were asked to document dryness and wetness each night in a diary for the duration of treatment and to bring the diaries to each clinic visit. Two of the authors (SF and FG) were involved in the care of the children. The psychologist (SF) followed the hypnotherapy subjects. Outcomes were defined as success (14 consecutive dry nights within three months), failure (not meeting success criteria) or relapse (more than two wet nights in two consecutive weeks) (8). Data were entered into the Statistical Package for the Social Sciences, version 11.0 (SPSS Inc, USA). Student's t tests were used for continuous variables. For the CBCL, total behavioural problem T-scores, internalizing T-scores and externalizing T-scores were compared between the groups. Total stress and life stress scores were compared for the PSI-III. Total self-esteem scores were compared for the CFSEI-2. χ2 tests or the Fisher's exact test were used for categorical variables, where appropriate. A statistically significant difference was noted at P≤0.05. Thirty-eight subjects from the alarm therapy group and 36 subjects from the hypnotherapy group, along with their parents, completed the study. Fifteen participants did not finish the trial (six subjects from the alarm therapy group and nine subjects from the hypnotherapy group, 60% male, mean age ± SD 9.1±1.4 years), four subjects refused participation and three subjects were excluded due to concurrent medical conditions that interfered with treatment. The mean age of the children in both groups was 8.8 years. Most participants were male (68.4% versus 77.8% in the alarm therapy and hypnotherapy groups, respectively, P=0.37). Alarm therapy subjects were more likely than hypnotherapy subjects to achieve dryness (55.3% versus 19.4%, P=0.001). No significant pretreatment differences occurred in mean CBCL, PSI-III or CFSEI-2 scores. Self-esteem and problem behaviour scores of both groups fell within the average range, suggesting that this sample of children did not suffer from low self-esteem or behaviour problems. Hypnotherapy was stopped for 16 subjects after their second or third clinic because the treatment was not working, and those subjects were categorized as treatment failures. Seven of those subjects continued to have wet nights after switching to the alarm therapy. Those seven subjects were then started on medication (desmopressin acetate). Compliance – defined as adherence to the procedures for hypnotherapy or alarm therapy, returning to follow-up clinic visits and completion of diary entries – was not significantly different between the alarm therapy and hypnotherapy groups (92.1% versus 86.1%, respectively, P=0.41). Six subjects in the alarm therapy group experienced a relapse, compared with two subjects in the hypnotherapy group (P=0.26). Alarm therapy was more effective than hypnotherapy in achieving dryness in children with PNE. Possible explanations for the poor success of hypnotherapy were ineffectiveness of the audiotape, commencement of treatment before establishing therapeutic rapport and individual differences in hypnotic susceptibility. There were no pretreatment differences in self-esteem or behaviour problems between the two groups or in comparison with normative groups. This result is contrary to some previous research (1,9–20). Low self-esteem and/or behaviour problems are not an inevitable finding in children with PNE. The authors thank Betty Freedman for all of her work with data entry, and for assisting the parents and children in completing the questionnaires. They also thank Rene Silberman for her editorial assistance.

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