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Conditioning two types of enuretics
Behav. Res. & Therapy, 1973. Vol. 11, pp. 65’3 to 654. Pergamon Press. Printed in England
CASE HISTORIES
AND SHORTER
COMMUNICATIONS
Conditioning two types of enuretics* (Received 21 March 1973) enuretics (children who resume wetting after a period of dryness) have been distinguished from persistent enuretics (children who were never dry) in that the wetting of the former has been viewed as symptomatic of conflict and not modifiable by conditioning procedures. The present study compares these two types on measures of ~nditioning outcome and effectiveness, initial pathology and ~st-tr~tment adjustment. Ss were 50 persistent and 12 acquired enuretics of both sexes, with a median age of 8 yrs, 6 months (range S&14), and no differences in age or sex between the groups. The criterion for acquired enuresis was a Previous history of at least 6 months completely dry, followed by at least 6 months wetting. The average dry period was 1 yr (range 6-36 months). Conditioning was by means of an alarm device approach. The results here reported are derived from an analysis by enuretic type of the conditioning data presented by De Leon and Mandetl (1966), plus new data from additional sample accumulation of 11 SS. The percentage cured was 84 per cent for persistent enuretics and 83.3 per cent for acquired enuretics. Also, there were no significart differences between the groups with respect to percentage relapsed, days to cure, or severity of wettin:, in relapse. Acquired enuretics did reveal, non-significantly, fewer days to relapse. Figure 1 shows the mean Enuresis Ratio (ER = No. of wets/No. of nights) for the basal phase (2-week period between the initial telephone call and the initial clinic visit), for the period between the initial clinic ACQUIRED
c--e
l3CS.d
Post bowl
Acquired
Weeks in treutment Phases
FIG. 1. The enuresis ratio over three phases of the study. The values in the basal and post_ basal phases are data of several weeks combined while those plotted in the treatment phaseare weekly means. Each mean is an average of subjects ERs.
* This research was supported in Part by Grant No. MH 12083-01 from the National Institute of Mental Health, U.S. Department of Health, Education and Welfare, Public Health Service. A version of this paper was presented at the meeting of the Eastern Psychological Association in Boston, 1972 *_ .-.
Requests for reprints should be sent to Stanley Sacks, 657 Castleton Avenue, Staten Island, New York 10301. em. 11[4-
653
654
CASE HISTORIES AND SHORTER COMMUNICATIONS
visit and the initiation of treatment (post-basal phase) and for the 12 weeks of the treatment phase. For both groups, there is a decrease in severity of wetting during the 12 weeks of treatment. The form of the weekly treatment curves for both groups was similar and resemble the familiar acquisition functions seen in learning and conditioning literature. However, the severity was lower for acquired enuretics prior to and throughout the 12 weeks of treatment, with the differences between the groups reaching significance only at 1 week. The lower wetting severity of the acquired group appears consistent with their background of previous training. Both groups were within the normal range on initial measures of symptom frequency, anxiety, extraversion-introversion, psychological disturbance, behavior problems and academic achievement. At 1 month follow-up, only the number of symptoms showed a significant drop. However, this decrease could not be unequivocably attributed to conditioning since it occurred for most Ss including those of an untreated control group (Sacks, De Leon and Blackman, 1972). There appears to be a relationship between changes in severity during the first week of treatment and stability of outcome. Seventy-five per cent of the persistent and 50 per cent of the acquired enuretics showed a rise in wetting at 1 week which was not related to initial severity nor was it an artifact of the accuracy of machine recording. This effect could not be analyzed for acquired enuretics since the N was too small. However, among persistent enuretics a comparison of the 28 Ss whose 1 week severity rose (‘risers’) with 22 Ss whose 1 week severity dropped (‘failers’), revealed that the former: (a) had a significantly lower initial severity of wetting; (b) had a significantly higher ER at 1 week (which defines the group), and consistently higher ERs throughout treatment, with the differences for both groups gradually diminishing over the 12 treatment weeks; and (c) were not different on days to criterion but did take significantly longer to relapse (ic = 132 days vs x = 64 days, t = 5.6, df = 29, p < O.OOl), a finding also not related to initial severity. The initial rise in severity of wetting remains to be explained. However, the more stable training effects of the ‘risers’ (more days to relapse) may be understood in terms of the relationship between number of trials and resistance to extinction; that is, the increased wetting at 1 week produces more wet-buzz training trials, which in turn leads to greater resistance to extinction. These 28 children, then, are reminiscent of the ‘hard learners’ seen in learning literature, who early in training may worsen or show little improvement, recover to rapidly reach criterion, and then characteristically display a greater retentiveness, i.e. resistance to extinction. In summary, acquired enuretics, whose background of intermittent wetting has been regarded as symptomatic of conflict, were similar to persistent enuretics as to the course and outcome of conditioning as well as on measures of initial pathology and post-treatment adjustment. The present results cast doubt on the utility of the labels persistent and acquired enuresis, at least as defined in the present study. However, children whose wetting severity rose at 1 week showed significantly better stability of training, demonstrating the feasibility of empirically determining conditioning subject differences. STANLEYSACKS
North Richmond C.M.H.C. 657 Castleton Avenue Staten Island, New York 10301, U.S.A. Wagner College Staten Island, New York, U.S.A.
GEORGEDE LEON
REFERENCES DE LEONG. and MANDELLW. (1966) A comparison of conditioning and psychotherapy in the treatment of functional enuresis. J. Cfin. Psychol. 12, 326-330. SACKS S., DE LEON G. and BLACKMANS. (1972) Conditioning functional enuresis: Changes in symptomatology, adjustment, and personality. (Unpublished) Wakoff Research Center, Staten Island, New York.
CASE HISTORIES
AND SHORTER
COMMUNICATIONS
Conditioning two types of enuretics* (Received 21 March 1973) enuretics (children who resume wetting after a period of dryness) have been distinguished from persistent enuretics (children who were never dry) in that the wetting of the former has been viewed as symptomatic of conflict and not modifiable by conditioning procedures. The present study compares these two types on measures of ~nditioning outcome and effectiveness, initial pathology and ~st-tr~tment adjustment. Ss were 50 persistent and 12 acquired enuretics of both sexes, with a median age of 8 yrs, 6 months (range S&14), and no differences in age or sex between the groups. The criterion for acquired enuresis was a Previous history of at least 6 months completely dry, followed by at least 6 months wetting. The average dry period was 1 yr (range 6-36 months). Conditioning was by means of an alarm device approach. The results here reported are derived from an analysis by enuretic type of the conditioning data presented by De Leon and Mandetl (1966), plus new data from additional sample accumulation of 11 SS. The percentage cured was 84 per cent for persistent enuretics and 83.3 per cent for acquired enuretics. Also, there were no significart differences between the groups with respect to percentage relapsed, days to cure, or severity of wettin:, in relapse. Acquired enuretics did reveal, non-significantly, fewer days to relapse. Figure 1 shows the mean Enuresis Ratio (ER = No. of wets/No. of nights) for the basal phase (2-week period between the initial telephone call and the initial clinic visit), for the period between the initial clinic ACQUIRED
c--e
l3CS.d
Post bowl
Acquired
Weeks in treutment Phases
FIG. 1. The enuresis ratio over three phases of the study. The values in the basal and post_ basal phases are data of several weeks combined while those plotted in the treatment phaseare weekly means. Each mean is an average of subjects ERs.
* This research was supported in Part by Grant No. MH 12083-01 from the National Institute of Mental Health, U.S. Department of Health, Education and Welfare, Public Health Service. A version of this paper was presented at the meeting of the Eastern Psychological Association in Boston, 1972 *_ .-.
Requests for reprints should be sent to Stanley Sacks, 657 Castleton Avenue, Staten Island, New York 10301. em. 11[4-
653
654
CASE HISTORIES AND SHORTER COMMUNICATIONS
visit and the initiation of treatment (post-basal phase) and for the 12 weeks of the treatment phase. For both groups, there is a decrease in severity of wetting during the 12 weeks of treatment. The form of the weekly treatment curves for both groups was similar and resemble the familiar acquisition functions seen in learning and conditioning literature. However, the severity was lower for acquired enuretics prior to and throughout the 12 weeks of treatment, with the differences between the groups reaching significance only at 1 week. The lower wetting severity of the acquired group appears consistent with their background of previous training. Both groups were within the normal range on initial measures of symptom frequency, anxiety, extraversion-introversion, psychological disturbance, behavior problems and academic achievement. At 1 month follow-up, only the number of symptoms showed a significant drop. However, this decrease could not be unequivocably attributed to conditioning since it occurred for most Ss including those of an untreated control group (Sacks, De Leon and Blackman, 1972). There appears to be a relationship between changes in severity during the first week of treatment and stability of outcome. Seventy-five per cent of the persistent and 50 per cent of the acquired enuretics showed a rise in wetting at 1 week which was not related to initial severity nor was it an artifact of the accuracy of machine recording. This effect could not be analyzed for acquired enuretics since the N was too small. However, among persistent enuretics a comparison of the 28 Ss whose 1 week severity rose (‘risers’) with 22 Ss whose 1 week severity dropped (‘failers’), revealed that the former: (a) had a significantly lower initial severity of wetting; (b) had a significantly higher ER at 1 week (which defines the group), and consistently higher ERs throughout treatment, with the differences for both groups gradually diminishing over the 12 treatment weeks; and (c) were not different on days to criterion but did take significantly longer to relapse (ic = 132 days vs x = 64 days, t = 5.6, df = 29, p < O.OOl), a finding also not related to initial severity. The initial rise in severity of wetting remains to be explained. However, the more stable training effects of the ‘risers’ (more days to relapse) may be understood in terms of the relationship between number of trials and resistance to extinction; that is, the increased wetting at 1 week produces more wet-buzz training trials, which in turn leads to greater resistance to extinction. These 28 children, then, are reminiscent of the ‘hard learners’ seen in learning literature, who early in training may worsen or show little improvement, recover to rapidly reach criterion, and then characteristically display a greater retentiveness, i.e. resistance to extinction. In summary, acquired enuretics, whose background of intermittent wetting has been regarded as symptomatic of conflict, were similar to persistent enuretics as to the course and outcome of conditioning as well as on measures of initial pathology and post-treatment adjustment. The present results cast doubt on the utility of the labels persistent and acquired enuresis, at least as defined in the present study. However, children whose wetting severity rose at 1 week showed significantly better stability of training, demonstrating the feasibility of empirically determining conditioning subject differences. STANLEYSACKS
North Richmond C.M.H.C. 657 Castleton Avenue Staten Island, New York 10301, U.S.A. Wagner College Staten Island, New York, U.S.A.
GEORGEDE LEON
REFERENCES DE LEONG. and MANDELLW. (1966) A comparison of conditioning and psychotherapy in the treatment of functional enuresis. J. Cfin. Psychol. 12, 326-330. SACKS S., DE LEON G. and BLACKMANS. (1972) Conditioning functional enuresis: Changes in symptomatology, adjustment, and personality. (Unpublished) Wakoff Research Center, Staten Island, New York.