Behavioural Difficulties and Interventions – Miscellany 40
The summaries here begin with a review of the nature of, and the efficacy of
various interventions for, nocturnal enuresis among children. Differences
between psychological and medical approaches and goals are highlighted,
and the conclusion points to the use of an alarm system ( which may be
combined with antidiuretic medication ) as the most effective means of
reducing the problem.
There follows an individual perspective upon the nature of Seasonal Affective
Disorder on the part of a physician with experience of this issue and of
working with patents from different parts of the USA with varying climatic
The third summary describes recent work relating to increased activation in
certain regions of the teenage brain in response to stimuli reflecting different
emotions, which appear to be correlated with developing resistance to peer
pressure to engage in risky or otherwise inappropriate behaviours.
Behavioural Difficulties and Interventions – Miscellany 40
In the introduction to their review, Brown et al (2011) define the core element
of nocturnal enuresis as the repeated passing of urine during night-time sleep.
To be classed as a true disorder, the nocturnal bed-wetting has to occur on at
least two occasions during the week and to have a negative impact upon
other aspects of the child’s day-to-day routines and functioning. Further, the
child in question has to be aged 5 years or more ( or to have a mental age of
at least 5 years in the case of anyone identified with a developmental delay ).
According to information available in the most recent edition of the Diagnostic
and Statistical Manual of the American Psychiatric Association, the
prevalence of nocturnal enuresis in the USA is between 5 and 10% among 5
year-olds, between 1 and 5% among 9 and 10 year-olds, and around1%
among those aged 15 years or above. Prevalence is higher among males
than females in any age group.
Two types of enuresis can be identified.
In primary enuresis, the child has never achieved complete dryness ; while
secondary enuresis applies to cases where the problem arises after the child
has established a period of at least 6 months of dryness. The advice is that
children who have this secondary type of enuresis are in need of a more
formal medical and psychological assessment because of the greater
likelihood that some particular event or circumstance will have triggered the
Another distinction is between mono-symptomatic or poly-symptomatic
enuresis, where the difference is a matter of the absence or presence of
bladder over-activity reflected in frequent and urgent need to pass urine
during the day and/or frequent daytime wetting.
The goal of the review by Brown et al was to provide a review and critique of
current information interventions and outcomes, and to highlight implications (
including scope for continuing research ).
Their method involved a search through various databases for any
publications concerned enuresis, and a scanning of the references attached
to these papers to identify any further material of salience for the review.
In respect of evidence-based interventions, the first approach under
examination involved alarm systems. These involve a moisture-sensitive
switching system where a small-voltage electrical circuits is closed when urine
is passed, thus setting off a bell or buzzer which wakes the child.
The alarm may be regarded as an aversive stimulus leading to a conditioned
avoidance response ( muscle contraction and an interruption in the flow of
urine alongside waking the child ). This physiological reaction becomes the
conditioned response to sensations of a full bladder, with the likelihood that
the child will wake up before any urine is passed, thus avoiding being startled
by the bell or buzzer.
Alternatively, it could be argued that the alarm signal acts as an operant
where the waking is an avoidance response maintained by the negative
reinforcement of not having to be wakened and not having the experience of
being in a wet bed.
In some variants, the alarm system can be geared to wake the parents who
then wake the child … although existing evidence indicates that the system
which works directly upon the child is more effective than the system which
operates through the parents.
The current authors describe the agreement among a number of meta-
analyses or well-controlled investigations ( eg Glazener et al 2004 ) that the
alarm procedure is an effective intervention for nocturnal enuresis, either
alone or as part of a package of strategies.
Meanwhile, comparative studies have indicated the superior value of an alarm
system over other forms of therapy, including “talking therapies” and
However, this is not to say that an alarm will work effectively for all children
who present with nocturnal enuresis. Factors which are predictive of poor
results with an alarm system include day-time wetting, multiple incidents of
wetting during the night, a family history of enuresis, a history of prior failures
of intervention, parental intolerance of bed-wetting, stressed or adverse home
circumstances, the presence of developmental delay or behavioural problems
such as oppositional defiance, and the lack of any motivation to change.
The authors then turn to “over-learning” which may be adopted after success
in the initial intervention. This involves training the children to a higher level
still with a view to minimising the risk of a relapse.
The child is encouraged to drink some water before bedtime ( which may
initially result in renewed incidents of bedwetting ) but the process is
continued until the set criterion is reached ( ie a given number of dry nights ),
and the amount of a water to be drunk increases in small increments over
time until the individual maximum is reached ( determined by reference to the
child’s age ).
Evidence is cited ( albeit not from randomised clinical trials ) that when
conditioning is not followed by over-learning, the relapse rate is typically
between 20 and 40% ; but with the over-learning, the relapse rate is around
In respect of medication, the general picture seems to be that this can be an
effective treatment for the short-term management of enuresis ; but is
regarded by researchers as more appropriate as a second line of action when
the alarm system has not been successful ( or if it is impractical ).
The medication used for enuresis has included antidepressants ( based upon
findings that these can reduce the problems of incontinence among adults
being treated for depression ). It is not clear how these drugs achieve any
observed effectiveness, but the most prevalent view is that they act as a
stimulant thus lightening sleep levels and allowing children to wake more
readily when they need to urinate.
Relapse rates after the use of medication have been found to be high so that
outcomes at follow-up commonly show no greater gains from baseline than
those associated with a placebo.
Further, there is concern that antidepressant medication used with children
carries a risk of quite serious side-effects such as cardiovascular problems,
rashes, altered mood states, and sleep disorders ( and there is always the
possibility of over-dose ).
Antidiuretic medication ( eg Desmopressin) has been proposed as another
possible intervention. Desmopressin is a synthetic form of vasopressin which
is a naturally- produced anti-diuretic hormone.
The theoretical underpinning of the use of this medication is that children with
nocturnal enuresis may not have the same increase in vasopressin during the
night as their non-affected peers so that there needs to be some additional
means of reducing urine production.
It appears that this intervention can be effective in reducing the number of wet
nights by up to 50%. However, this is a matter of reducing the symptoms
rather than the actual problem so that the enuresis reappears when the
medication is discontinued.
The authors then turn to interventions which they classify as having an
inconclusive evidence base.
The first of these interventions is Retention Control Training (RCT) which
seeks to extend bladder capacity by encouraging children to drink a high
amount of fluids and to delay urination for as long as they can.
RCT has been claimed to have success rates of up to 50% ; but recent
evidence suggests that these holding exercises do not have any useful effect
upon enuresis nor upon later response to intervention using an alarm system.
Most clinicians are reported as no longer regarding RCT as an empirically-
valid form of intervention.
Arousal Therapy is a combination of alarm training and positive reinforcement
for waking. The theory is that the child needs to be fully awake to gain from
When the alarm sounds, the parents ensure that the child gets up and goes to
the lavatory to urinate, and returns to bed following a re-setting of the alarm.
Some kind of token system is used for successful completion of this routine.
While high success rates have been claimed for this approach, there have
been no randomised control trials.
( Reinforcement may accompany successful outcomes following any
intervention, and may increase the child’s willingness to continue efforts, while
attention is switched from wet to dry beds. However, reinforcement alone
appears not to be successful in reducing enuresis, and seems useful only as
an adjunct to a specific strategy … such as the use of an alarm system. )
Cleanliness-training involves the child in changing pyjamas and bed linen
following an incident of enuresis, thus giving the child the responsibility for
maintaining dryness. This usually follows the activation of the alarm.
The scheme may be popular, but there is no record of any meaningful
20 years ago, work with children with enuresis was largely influenced by
psychodynamic theory such that the symptoms were typically perceived as an
expression of some underlying emotional disturbance or unconscious conflict.
Psychodynamic therapy was, accordingly, the common means of intervention,
but this has not proven any more effective for the majority of children with
enuresis than no intervention.
Dry-bed training seems little more than an extension of previously described
intervention in that it involves the use of an alarm to wake the child, with
parents involved in setting and supervising a routine for the child of visiting the
lavatory and changing pyjamas and sheets. There may be additional
components such as imaging having a full bladder and getting up to visit the
lavatory ; and the use of a token economy for dry nights.
There may be benefits from such a procedure but the pressure upon the
children and the parents is seen as considerable so that it is not commonly
recommended by clinicians.
A combination of an alarm system, cleanliness-training, RCT, and over-
learning has been found to achieve positive outcomes in a significant number
of cases ( albeit with a relatively high relapse rate ). However, only the
treatment developers have evaluated the scheme, and independent
assessments are required. Meanwhile, it appears that the alarm component
is crucial in this intervention.
In their summary and conclusion, Brown et al emphasise the point that
nocturnal enuresis can seriously impair a child’s psycho-social adjustment
and predict psychopathology so that it is very important to find the most
effective means of dealing with the problem.
Without effective intervention, self-esteem, attitudes, and behaviour are likely
to remain fragile and to deteriorate over time.
Accordingly, they highlight the pattern of findings which demonstrate the value
of an alarm system used either alone or as part of multi-component
There appears to be a division between the medical and the psychological
literature in that the former concentrates on managing symptoms ( usually by
means of medication or by dealing with physical issues which are seen as
related to the symptoms ) ; while the latter has a focus upon behavioural
intervention and the psycho-social needs and characteristics of the children,
and upon eliminating the condition by use of specific resources and support.
They comment that a promising step towards integrating the two approaches
is the use of a combination of an alarm system with certain types of
medication so that the symptoms are reduced quickly by means of the
medication while the alarm system provides the means of long-term
In respect of ongoing research, their advice is for larger scale projects thus to
avoid the typical criticism about reliance upon very small numbers of
participants. Larger sample sizes would also enable the use of randomised
clinical trials to gain more valid data while also providing the opportunity for
examining the moderating effects of child characteristics and circumstances.
It is also suggested that the research should extend to adults who continue to
experience nocturnal enuresis, particularly at times of stress or distress ; and
to daytime enuresis whose aetiology may differ from that of nocturnal enuresis
but has similarly harmful psycho-social impacts.
Their final point ( relevant to observed experience in the USA at least )
concerns the disparity between the finding of the relative efficacy of alarm
systems compared to other interventions and the limited use of this approach
by physicians who concentrate upon medication.
They speculate that this situation may reflect the corporate backing which is
applied to the use of certain medications, and which is not available for
behavioural approaches. The implication is for wider dissemination of
research data to ensure that actions are guided by the best available
Seasonal Affective Disorder
The following notes reflect the views of one individual, but with much
experience as a physician in this domain, and are included to provide informal
access to an issue which is interesting but not much represented in the
Ghaemi (2011) begins by describing how, to many people, seasonal affective
disorder (SAD ) is the same as Winter depression. However, he argues that
depression is only half of the issue, and that the significant other half
concerns the opposite end of this emotional spectrum, namely more manic-
like behaviour in Spring and Summer.
It is argued that, during the Winter, depressive-type behaviour reflects a kind
of hibernation with a slowing-down of performance. Commonly, Ghaemi
continues, people sleep more, eat more, and show a reduction in their usual
activity. There is no real sadness of mood, and there may not even be a
conscious awareness of the slowing of performance or of the reduced
enthusiasms which are similar to some of the symptoms of depression.
It is argued that various misconceptions exist about the nature of Winter
depression or SAD.
One is that it is related to the coldness of the Winter weather. This is not the
case. The issue is the decreased light not the lowered temperature. It makes
no difference whether it is 20ºF or 80ºF outside if there are only 9 or 10 hours
of light instead of 14. Given the limited light, seasonal depression is a real
Ghaemi commented that a number of patents who consulted him about
possible SAD were those who had moved from one part of the USA to
another … notably people who used to live in Florida but who had moved to
Georgia which has fewer daylight hours than Florida even if the general
temperature is much the same in both states.
Further, light per se is not the sole issue, but the variable of hours of daylight
has been found to interact with individual characteristics, such as a
susceptibility to depression. Some people who are prone to conditions such
as bipolar disorder are particularly sensitive to changes in light and may
experience Winter depression even in areas where the extent of daylight
hours and its intensity are not seen as particularly low and would not impact
upon most people.
Other people are much less light-sensitive and, therefore, are largely immune
to low light levels ( as experienced in New England, or in Scandinavian
countries, for example ).
Ghaemi goes on to describe how SAD should not be used as a diagnostic
category for people who are known to have bipolar disorder or recurrent uni-
polar depressive disorders.
The episodes of changed mood that are characteristic of these conditions
may occur at any time, but depressive states are more common in the Winter
and manic states more common in the Summer.
SAD is specific to depressive-type states in Winter only, and the individuals
affected rarely experience any such symptoms at other times of the year. It is
a relatively uncommon condition, impacting upon no more than between 1
and 2% of the USA population.
It is argued that most people who think they have SAD probably do not. In the
case of true depressive illness, the Winter episodes are part of that major
In the case of other putative cases of SAD, it may be a matter of depressive-
like symptoms in the Winter but the symptoms are mild and not like those of
In other words, some people do feel somewhat “down” in the dark days of
Winter, and this kind of “Winter blues” is more common. Estimates of
incidence are 1% for Florida, 5% for mid-Atlantic states, and 10% for New
The mechanism by which light impacts upon mood is thought to involve
impacts upon circadian rhythms which help to maintain regular sleep/waking
When sleep is reduced, there may actually be an antidepressant effect ; and,
in individuals with a particular sensitivity, there may be signs of manic-like
mood shifts with the implication that a change to lighter days in the Spring and
into Summer with longer hours of daylight can be a problem for these
One should not underestimate the potential hazards for some people of the
increasing light as Winter ends and Spring proceeds ( as reflected, possibly,
in the statistic that, over the last 100 years, the highest suicide rates in the
USA have always been in the sunny West despite the social and cultural
changes over this period ).
For most people, these seasonal changes, and the resulting shifts in circadian
rhythms, have no impact upon mood.
The advice offered by Ghaemi for warding off seasonal depression is to
maximise exposure to light during the Winter by sleeping with the blinds up
and by making a point of going out during the middle part of the day as often
as possible ; and, during the Summer, by sleeping with the blinds down, and
by wearing sunglasses during the brighter parts of the Spring and Summer
Where there is a susceptibility to SAD, the use of a light box for around 30
minutes a day ( with care taken not to look directly into the light ) can be
effective to compensate for the missing light during the darker months ( say,
from the end of October to the beginning of April ). The actual duration of
exposure can be modified by modest amounts according to the observed anti-
Neurological Development and Teen Behaviour ( Resistance to Peer
The study by Pfeifer et al (2011) is introduced by a reference to the increasing
time spent with peers, and the growing influence of those peers, during the
transition from childhood into and through adolescence. There is typically a
diverging of family values and peer values, a greater belief in the importance
of conformity with peer norms, and a heightened tendency towards sensation-
seeking and reward sensitivity.
The general view is that teenagers are typically less resistant to peer-pressure
than either children or adults.
The current authors acknowledge the existence of various social hypotheses
by which to account for this susceptibility, but they focus upon biological
factors which may influence teenage reactivity and emotion regulation during
These factors include hormonal changes that occur with puberty and specific
developments in certain brain structures … and the authors cite the
converging findings indicating the significance of sub-cortical neural systems
which are known to be involved in emotional reactivity ( including the
amygdala ) and which appear to mature earlier than those systems involved in
the regulation of emotional responses
( such as the pre-frontal cortex ).
The implication is that the emotional signals ( including facial expressions )
provided by peers can exert a powerful influence upon teenagers’ behaviour ;
and it becomes important to assess whether changes in response to
emotional signals are significantly associated with changes in susceptibility to
peer pressure ( to engage in dubious or risky behaviour ) ; and the extent to
which these neural responses to emotional displays can be regulated in order
to counter that pressure.
During early adolescence, modulation of emotional responses via pre-frontal
systems is still lacking in efficiency, but may be aided by sub-cortical
involvement, notably activation in the ventral striatum ( a brain region known
to be involved in reward-related processing and in responding to aversive
In the study by these current authors, a sample of typically-developing
participants underwent two brain scans using magnetic resonance imaging
while they looked at examples of 5 different expressions of emotion ( angry,
fearful, happy, sad, and neutral ). The first set of trials took place when the
participants were 10 years old ; and the second when they were aged 13.
They also completed, on both occasions, self-report measures of resistance
to peer influence and indicators of any involvement in risky or anti-social
Responses to the displayed emotions involved a combination of general and
emotion-specific changes in the ventral striatum, ventro-medial pre-frontal
cortex, amygdala, and temporal pole. Increases in ventral striatum activity
correlated with decreases in susceptibility to peer influence and engagement
in risky behaviour.
The view that the ventral striatum may play regulatory role in reactivity to
displays of emotion was supported.
In other words, specific brain regions ( linked to reward processing and also to
resistance to peer pressure ) become increasingly active during early
adolescence. The increases in such activity correlate with increases in the
children’s self-reported resistance to peer influence.
This pattern was regarded as important given that better regulation of
responses to emotional expressions appears to be related to improved ability
to resist peer pressure
( and displays of emotion are one means by which peers try to exert that
In summary, the transition into adolescence does seem to be associated with
greater sub-cortical reactivity to facial expressions of emotion ( notably
happiness and sadness ) ; but not all of this increased reactivity is indicative
of emotional uncertainty and limited capacity to resist peer influences. It is not
the case that increased sub-cortical brain activity beginning in adolescence
will inevitably lead to impulsive and risky behaviour. Instead, such increased
activity can mark the capacity for increased regulation of reaction to
The practical implication was for selecting early adolescence as the time for
interventions designed to lead to better emotional regulation, including the
ability and willingness to resist negative influences from peers and to reject
those peer norms related to risky and anti-social behaviours. The
recommendation was for focusing upon those young people who already have
a history of behavioural difficulties and of being easily led into inappropriate
While the report concerning the relative effectiveness of different interventions
for nocturnal enuresis can speak for itself, one might just comment on the
situation described by the authors where there is an apparent
compartmentalisation of actions and little combined and cooperative working
In this country, there has been much talk of multi-professional teams, but, to
the present writer at least, the teamwork has appeared largely to involve the
coming together of staff from various groups within the same profession (
Education ) rather than a true overlap and sharing of knowledge and action
among Education and Health and Social Services.
Further, it may not be made clear what are the major roles and responsibilities
of members of these (so-called) multi-disciplinary teams with the risk lest the
impression is given that all the professionals within the team are much the
same. There may be an overlap in expertise and experience, but there are, or
should be, clear differences in prime roles and training and background
otherwise it would not be much of a team !
One can appreciate, too, the pressures of time upon the various professionals
in all the different domains and the need to shift culture towards a greater
sharing of ideas and activities … with enuresis a good example of the kind of
disorder where there may well be a real overlap of medical, psychological,
and social issues ( and one notes the current finding of the likely benefits of
combining behavioural and pharmacological interventions ). … but the anxiety
is that, in the current financial climate with threats to staffing levels, the
opportunity for meaningful liaison will not get any greater but may well
become more limited.
It is worrying, too, to note the authors’ comment about the gap between
research evidence and actual practice ( in dealing with enuresis in this
instance ), highlighting the common need to determine how to ensure
meaningful continuing professional development … otherwise the concept of
evidence-based practice will remain more of an ideal than a reality.
In respect of Seasonal Affective Disorder, the message appears to be that
one should be a little cautious and not too generous in applying this
classification to self or others. SAD appears to be part of a spectrum of
depressive states, with an actual and major depressive disorder at one end,
and the common experience of mildly negative feelings and relative inertia
during the dark Winter months at the other. SAD would fall somewhere
between these extremes, probably nearer to the lower end of the spectrum.
The notes on young teenagers and peer pressure highlights the way in which
observable behaviour and attitudes is a matter of the interaction of
maturational, environmental, and social factors.
Therefore, while noting the logic of implementing behavioural programmes
designed to reduce the probability of antisocial or risky activities at a time
when neural development has created a receptivity ( and before any problem
behaviour has become entrenched ), it may prove common for there to be
marked individual variation in the response to such an intervention. The likely
need is for access to a range of preventive and remedial strategies and
programmes in order to accommodate the range of individual needs and
The concept of readiness for learning appears to apply to social and
emotional curricula as much as to academic curricula.
* * * * *
Brown M., Pope A., and Brown E. 2011 Treatment of primary nocturnal
enuresis in children : a review. Child : Care, Health, and Development 37(2)
Ghaemi N. 2011 The saddest time of year. Medscape Psychiatry and
Mental Health. February 3rd 2011
Glazener C., Evans J., and Peto R. 2004 Treating nocturnal enuresis in
children : review of evidence. Journal of Wound, Ostomy, and Continence
Nursing. 31 223-234
Pfeifer J., Masten C., Moore W., Oswald T., Mazziotta J., Iacoboni M., and
Dapretto M. 2011 Entering adolescence : resistance to peer influence, risky
behaviour, and neural changes in emotion reactivity. Neuron 69 1029-1036