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Nocturnal enuresis
Nocturnal Enuresis ELSEVIER
Marsha D. Rappley, MD DEPARTMENT OF PEDIATRICS AND HUMAN DEVELOPMENT, COLLEGE OF HUMAN MEDICINE, MICHIGAN STATE UNIVERSITY, EAST LANSING, MICHIGAN
Pediatrics Update Abstract Nocturnal enuresis is a common c h i l d h o o d condition. The overwhelming majority of cases are due to maturational issues and normal variations in bladder size. The most effective treatments are behavioral. Medications have a role as adjunctive or temporary intervention. Families may need help understanding and approaching this problem in a manner that is not punitive and helps the child to achieve competency and to master control over urination. MEDICAL UPDATE FOR PSYCHIATRISTS 1;1:18-20, 1996.
Introduction Case Vignette Mrs. Watson reports to you that she is exasperated with the nighttime wetting of her eight-year-old son. Her husband says that he was wet at night until he was ten and the child will grow out of it. But Mrs. Watson states with a great deal of anger that she is the one who has to launder sheets daily and get the calls from school about the child smelling of urine when he has tried to hide the evidence. They are planning a family camping trip. Mrs. Watson expects a great deal of teasing and fighting to occur due to the child's wet sleeping bag. She asks you if it is normal for an eightyear-old to wet the bed at night.
Understanding the Range el Normal Nocturnal enuresis affects 40% of children age three years, 12% of children age five years and 3% of youth age 12 years (1,2). Enuresis is the inability to control micturition past an age at which control is expected. Nocturnal enuresis is nighttime wetting without daytime symptoms. It affects three times as many boys as girls and there is often a family history. Nocturnal enuresis will resolve spontaneously in 15% of children each year after age five (1). Possible etiologies for 97% of cases include inability to delay micturition, failure to sense and awaken to a full bladder, a small bladder capacity, evening polydipsia, and a variation in the nocturnal secretion of antidiuretie hormone (ADH). The remaining three percent of eases are important to recognize and treat. These include urinary tract infection (UTI), diabetes mellitus,
S SDI "10~2/!~)~'~15[9~001)4_G
Reprint requests to: Dr. Rappley, B240 Life Sciences Building, Department of Pediatrics and Human Development, College of Human Medicine, Michigan State University, E~tst Lansing, Michigan 48824.
diabetes insipidus, fecal obstruction and constipation, neurogenie bladder associated with neurologic or spinal anomalies, ectopic ureter, lower urinary tract obstruction, including foreign body, and sleep apnea. The possibility of child abuse should also be considered ( 1-3 ).
Evaluation The history provides important clues to understanding an individual child's problem. Primary enuresis is that which has always been present, without any significant periods of dryness at night and is the more common complaint. A child may develop secondary or new onset nocturnal enuresis as part of regressive behaviors in response to a new sibling or in conjunction with a urinary tract infection. Nighttime enuresis should be distinguished from daytime wetting. Dysuria, frequent urination, voiding small amounts, or constant wetness or dampness throughout the day may indicate problems with infection or obstruction. A history of neurologic tramna or condition, including spina bifida, changes in gait, or other neurologic symptoms may indicate neurogenic bladder. The association of constipation and encopresis may suggest fecal obstruction or a more pervasive neurologic problem. A history of recurrent urinary tract infections suggests an anatomic problem that requires evaluation. The story of how the child drinks and voids during the day and night should be told in detail. The child may be drinking large quantities of liquid with a nighttime snack and the family may not associate this with wetting. An unusual urinary stream may not be recognized by the child or parents. Polydipsia and polyuria that occur throughout the day suggest an endocrine problem. The pattern of nighttime wetting, whether the child never awakens or wets more than once each night, may greatly influence the approach to treatment. The physical examination will be ira-
Nocturnal Enuresis
MEDICAL UPI)ATE FOR PSY(JII1ATRISTS
portant to explore the possibilities raised in the history. An examination of the head may reveal obligatory mouth breathing that ,nay be associated with sleep apnea. It is important to note birth defects that might be associated with neurologic conditions. The general neurologic exam will rule out gait, muscle strength, or deep tendon reflex abnormalities. Distended bladder or fecal obstruction may be found during an abdominal exam. The sacral area and genitalia are important to examine carefully. Spina bifida occulta may not have been previously diagnosed; a deep sacral cleft may be associated with this condition. The meatus and vulval area may reveal signs of chronic irritation, structural abnormality, or evidence of trauma or abuse. A rectal exam may be helpful if there is a suggestion of constipation. The urinalysis is extremely useful in the differential diagnosis. The presence of excessive white cells, bacteria, or leukocyte esterase should be followed up with a culture. A child with diabetes mellitus will have glycosuria. Urine specific gravity greater than 1.015 will rule out diabetes insipidus. Radiologic studies, including voiding cystourethrogram and ultrasound of bladder and kidneys, are indicated if there is evidence of UTI or anatomic problems. These studies are not routinely indicated. A measurement of the child's bladder capacity will be important for diagnosis and treatment. This can be clone at home or in the office by asking the child to drink 12 ounces of liquid, then to hold the urine as long as he or she can, Normal capacity is roughly measured in ounces as the child's age plus two (4). A small bladder capacity will greatly influence behavioral interventions.
Management The most effective treatment interventions are those that require a high degree of c*3mmitment from parents and child. These include self awakening programs, enuresis alarms, motivational techniques, and bladder stretching. Medications most commonly used are imipramine and desmopressin (DDAVP). These medications may be effective when given but file overall cure rate is significantly less than with the behavioral and conditioning interventions (5). An important c~nsideration in
recommending treatment is file child's developmental age. A behavioral or c~nditioning program must be appropriate for the child and the nature of the individual child's problem as well as be acceptable to the family (2). The fundamental goal of treatment is to achieve consistently dry nights. This should be discussed with the family as a long-term goal, with the notion that treatment will focus on shaping the child's behavior and ability to control urination over time. The main objectives of treatment are to teach the child to awaken to the sensation of a full bladder, increase control over micturition, and perhaps decrease the volume of urine production during the night. Self-awakening is a strategy that teaches the child what he needs to know--that he must wake up and go to the bathroom during the night. This is a strategy that generalizes to all situations, whether the problem is bladder capacity or too much liquid before bed. Although it is obvious to most parents, many children may not realize that they need to wake up to go to the bathroom. Schmidt (2) describes children who tell themselves to "hold it till morning," which may not be possible for many children. There are clearly defined steps that can be taken to establish a bedtime routine, rehearse nighttime waking and walking to the bathroom, and schedules can be set to help the child with nighttime waking. Cure rates as high as 92% with a relapse of 20% have been reported with the more intensive of these techniques (2,6). Self hypnosis has been described by Olness (7) as effective in 77% of cases in children over 5 years of age. There are very useful parent handouts and children's literature to help in this process (2,8). Enuresis alarms condition the child to awaken to a full bladder by alarming as they become wet. Current devices in which the moisture sensing device is attached to the child's underwear are more comfortable than the older bell and pad type models. However, the principle remains the same, that waking the child at the moment of urinating will allow him to awaken and hold it long enough to get to the bathroom. Not only does the bed stay relatively dry, but the child begins to feel greater control over voiding. These devices have the highest consistent "cure" rates of any interven-
19
tion. A study combining the many available products found a 68% success rate with a relapse of 10-15% that responded to a second course of treatment (9). The difficulty with enuresis alarms is that of the behavioral techniques, the family must be motivated and committed to making them work. The course of treatment is over two to three months and may well require a longer course. Some children ,nay need to be taught to awaken to the alarm and not sleep through it. A combination of self-awakening and alarms is often required. These devices range in cost from approximately $30 to $60. Some brand names include Potty Pager, Dry Night Training System, Nytone, and Wet Stop. They are available in pharmacies and often have toll free phone numbers for further information. Some insurance companies will consider this a "medical device" if prescribed by the physician. Families should be cautioned about companies and individuals who offer to treat enuresis with special programs that cost as much as $1000. These are not likely to be more successful than the strategies described here. Children can also be taught to increase bladder capacity by systematically prolonging the time between voiding during the day. This may be enhanced with exercises and a variety of rewards. This training is usually part of the behavioral and conditioning programs and is not very successful when used alone (2). Medicationshave long been used as treatment for nocturnal enuresis. Controlled studies have shown less efficacy than the behavioral/conditioning approaches and a greater degree of relapse when the medication is terminated. However, they are useful as intermittent therapy for critical times when it is important for a child to be dry at night. They are also useful in combination with other strategies in difficult eases. Desmopressin (DDAVP) is an intranasal preparation that reduces nocturnal urine production. It is a synthetic analogue of vasopressin and has been in use for enuresis for more than ten years. The product delivers 10 #g/spray and is administered as one spray in each nostril at bedtime, increasing as needed to a maximum total dose of 40 /zg. The problems associated with DDAVP include treatment failure and a high de-
MEDICALUPDATEFOR PSYCtlIATRISTS
M. D. Bappley
gree of relapse when the medication is discontinued (10). Side effects seem to be relatively few, although short-term water retention may pose a problem for children at risk for hyponatremia. Other side effects include headache, abdominal discomfort, nausea, and irritation of the nasal mucosa. Imipramine is a medication with a long history of use in enuresis. The doses used for this purpose, 25-7,5 rag, depending on the child's age and administered an hour before bedtime, are lower than often needed for antidepressant effect. Larger doses are not more effective. This medication has both a noradrenergic effect to decrease excitability of the bladder detrusor muscle and an anticholinergic effect of increasing bladder capacity. Overall effectiveness for long-term cure ranges from 2540%. Relapse rates are high when the medication is abruptly discontinued (9.,3). There are major risks of fatal poisoning for all tricyclic antidepressants. Children are especially vulnerable because of small size and because they are not likely to understand the potential danger of prescribed medications ( 11 ). Other side effects include feelings of anxiety, mood lability, insomnia, and lowering of seizure threshold. When used in a single low dose, monitoring of serum levels is not commonly done. Imipramine is used in the treatment of attention deficit hyperactivity disorder and recommendations in that context are to monitor electrocardiograms prior to and during treatment (12). A successful treatment plan is geared to the developmental age of the child, the needs and understanding of the family, and the physiology or pathophys-
iology of the enuresis. Combined treatment might be helpful with awakening strategies, alarm, bladder stretching exercises, and the use of DDAVP in a child with decreased bladder capacity. Other families may be reassured by the normal aspects of this condition and be content to work over time on self-awakening strategies. Schmidt (2) has elaborated a hierarchy of treatment interventions based on the child's age that may be useful to consider. Considerable effort may be needed on the part of the physician to offer support for alternatives to punitive measures sometimes employed. Parents may lack a repertoire of strategies, may be reacting to harsh punishment or shame experienced in their own childhood, or they may simply have unrealistic expectations of their child.
Conclusion
Nocturnal enuresis is a common childhood condition. It is usually not associated with significant pathophysiology. However, variations in physiology that result in small bladder capacity, decreased sensation to a full bladder, and poor control over urination can result in significant disturbance for the child and family. Successful interventions are largely behavioral and conditioning with adjunctive use of medications. A careful history, physical, and urinalysis are required not only to work through the differential diagnosis but to design an intervention appropriate for the age and nature of the problem faced by the child and family. Parents may need support to avoid punitive interventions and to
20
promote mastery of the child over urination. References 1. Behrman RE, (Ed). Nelson's Textbook of Pediatrics. 14th Edition. Philadelphia: W.B. Saunders, 1992;58:1375. 2. Schmidt B. Special report in enuresis. Contemporary Pediatrics. November 1995:1-14. 3. Norgaard JP, Rittig S, Djurhuus JC. Nocturnal enuresis: An approach to treatment based on pathogenesis. J Pediatr 1989:114,705. 4, Berger RM, Maizsels M, Moran GC, et al, Bladder capacity (ounces) equals age (years) plus 2 predicts normal bladder capacity and aids in diagnosis of abnormal voiding patterns. J Urol 1983:129347. 5. Devlin JB, O'Cathain C. Predicting treatment outcome in nocturnal enuresis. Arch Dis Child 1990:65:1158. 6. Azrin NH, Thienes PM. Rapid elimination of enuresis by intensive learning without a conditioning apparatus. Behav Ther 1978;9:342. 7. Olness K: The use of self-hypnosis in the treatment of childhood nocturnal enuresis: A report of forty patients. Clin Pediatr 1975; 14:273. 8. Mack A: Dry All Night. Boston, Little Brown & Co. 1989. 9. Forsythe WI, Butler RJ. Fifty years of enuretic alarms. Arch Dis Child 1989:64:879. 10. Miller K, Goldberg S, Atkin B. Nocturnal enuresis: Experience with long-term use of intranasally administered desmopressin. J Pediatr 1989; 114:723. 11. Herson VC, Schmitt BD, Rumaeh BH. Magical thinking and imipramine poisoning in two school-aged children. lAMA 1979;241:1926. 12. Ryan ND. Heteroeyclic antidepressants in children and adolescents. J Child Adol Psychopharm. Vol 1, No 1. 1990:21-31.
Marsha D. Rappley, MD DEPARTMENT OF PEDIATRICS AND HUMAN DEVELOPMENT, COLLEGE OF HUMAN MEDICINE, MICHIGAN STATE UNIVERSITY, EAST LANSING, MICHIGAN
Pediatrics Update Abstract Nocturnal enuresis is a common c h i l d h o o d condition. The overwhelming majority of cases are due to maturational issues and normal variations in bladder size. The most effective treatments are behavioral. Medications have a role as adjunctive or temporary intervention. Families may need help understanding and approaching this problem in a manner that is not punitive and helps the child to achieve competency and to master control over urination. MEDICAL UPDATE FOR PSYCHIATRISTS 1;1:18-20, 1996.
Introduction Case Vignette Mrs. Watson reports to you that she is exasperated with the nighttime wetting of her eight-year-old son. Her husband says that he was wet at night until he was ten and the child will grow out of it. But Mrs. Watson states with a great deal of anger that she is the one who has to launder sheets daily and get the calls from school about the child smelling of urine when he has tried to hide the evidence. They are planning a family camping trip. Mrs. Watson expects a great deal of teasing and fighting to occur due to the child's wet sleeping bag. She asks you if it is normal for an eightyear-old to wet the bed at night.
Understanding the Range el Normal Nocturnal enuresis affects 40% of children age three years, 12% of children age five years and 3% of youth age 12 years (1,2). Enuresis is the inability to control micturition past an age at which control is expected. Nocturnal enuresis is nighttime wetting without daytime symptoms. It affects three times as many boys as girls and there is often a family history. Nocturnal enuresis will resolve spontaneously in 15% of children each year after age five (1). Possible etiologies for 97% of cases include inability to delay micturition, failure to sense and awaken to a full bladder, a small bladder capacity, evening polydipsia, and a variation in the nocturnal secretion of antidiuretie hormone (ADH). The remaining three percent of eases are important to recognize and treat. These include urinary tract infection (UTI), diabetes mellitus,
S SDI "10~2/!~)~'~15[9~001)4_G
Reprint requests to: Dr. Rappley, B240 Life Sciences Building, Department of Pediatrics and Human Development, College of Human Medicine, Michigan State University, E~tst Lansing, Michigan 48824.
diabetes insipidus, fecal obstruction and constipation, neurogenie bladder associated with neurologic or spinal anomalies, ectopic ureter, lower urinary tract obstruction, including foreign body, and sleep apnea. The possibility of child abuse should also be considered ( 1-3 ).
Evaluation The history provides important clues to understanding an individual child's problem. Primary enuresis is that which has always been present, without any significant periods of dryness at night and is the more common complaint. A child may develop secondary or new onset nocturnal enuresis as part of regressive behaviors in response to a new sibling or in conjunction with a urinary tract infection. Nighttime enuresis should be distinguished from daytime wetting. Dysuria, frequent urination, voiding small amounts, or constant wetness or dampness throughout the day may indicate problems with infection or obstruction. A history of neurologic tramna or condition, including spina bifida, changes in gait, or other neurologic symptoms may indicate neurogenic bladder. The association of constipation and encopresis may suggest fecal obstruction or a more pervasive neurologic problem. A history of recurrent urinary tract infections suggests an anatomic problem that requires evaluation. The story of how the child drinks and voids during the day and night should be told in detail. The child may be drinking large quantities of liquid with a nighttime snack and the family may not associate this with wetting. An unusual urinary stream may not be recognized by the child or parents. Polydipsia and polyuria that occur throughout the day suggest an endocrine problem. The pattern of nighttime wetting, whether the child never awakens or wets more than once each night, may greatly influence the approach to treatment. The physical examination will be ira-
Nocturnal Enuresis
MEDICAL UPI)ATE FOR PSY(JII1ATRISTS
portant to explore the possibilities raised in the history. An examination of the head may reveal obligatory mouth breathing that ,nay be associated with sleep apnea. It is important to note birth defects that might be associated with neurologic conditions. The general neurologic exam will rule out gait, muscle strength, or deep tendon reflex abnormalities. Distended bladder or fecal obstruction may be found during an abdominal exam. The sacral area and genitalia are important to examine carefully. Spina bifida occulta may not have been previously diagnosed; a deep sacral cleft may be associated with this condition. The meatus and vulval area may reveal signs of chronic irritation, structural abnormality, or evidence of trauma or abuse. A rectal exam may be helpful if there is a suggestion of constipation. The urinalysis is extremely useful in the differential diagnosis. The presence of excessive white cells, bacteria, or leukocyte esterase should be followed up with a culture. A child with diabetes mellitus will have glycosuria. Urine specific gravity greater than 1.015 will rule out diabetes insipidus. Radiologic studies, including voiding cystourethrogram and ultrasound of bladder and kidneys, are indicated if there is evidence of UTI or anatomic problems. These studies are not routinely indicated. A measurement of the child's bladder capacity will be important for diagnosis and treatment. This can be clone at home or in the office by asking the child to drink 12 ounces of liquid, then to hold the urine as long as he or she can, Normal capacity is roughly measured in ounces as the child's age plus two (4). A small bladder capacity will greatly influence behavioral interventions.
Management The most effective treatment interventions are those that require a high degree of c*3mmitment from parents and child. These include self awakening programs, enuresis alarms, motivational techniques, and bladder stretching. Medications most commonly used are imipramine and desmopressin (DDAVP). These medications may be effective when given but file overall cure rate is significantly less than with the behavioral and conditioning interventions (5). An important c~nsideration in
recommending treatment is file child's developmental age. A behavioral or c~nditioning program must be appropriate for the child and the nature of the individual child's problem as well as be acceptable to the family (2). The fundamental goal of treatment is to achieve consistently dry nights. This should be discussed with the family as a long-term goal, with the notion that treatment will focus on shaping the child's behavior and ability to control urination over time. The main objectives of treatment are to teach the child to awaken to the sensation of a full bladder, increase control over micturition, and perhaps decrease the volume of urine production during the night. Self-awakening is a strategy that teaches the child what he needs to know--that he must wake up and go to the bathroom during the night. This is a strategy that generalizes to all situations, whether the problem is bladder capacity or too much liquid before bed. Although it is obvious to most parents, many children may not realize that they need to wake up to go to the bathroom. Schmidt (2) describes children who tell themselves to "hold it till morning," which may not be possible for many children. There are clearly defined steps that can be taken to establish a bedtime routine, rehearse nighttime waking and walking to the bathroom, and schedules can be set to help the child with nighttime waking. Cure rates as high as 92% with a relapse of 20% have been reported with the more intensive of these techniques (2,6). Self hypnosis has been described by Olness (7) as effective in 77% of cases in children over 5 years of age. There are very useful parent handouts and children's literature to help in this process (2,8). Enuresis alarms condition the child to awaken to a full bladder by alarming as they become wet. Current devices in which the moisture sensing device is attached to the child's underwear are more comfortable than the older bell and pad type models. However, the principle remains the same, that waking the child at the moment of urinating will allow him to awaken and hold it long enough to get to the bathroom. Not only does the bed stay relatively dry, but the child begins to feel greater control over voiding. These devices have the highest consistent "cure" rates of any interven-
19
tion. A study combining the many available products found a 68% success rate with a relapse of 10-15% that responded to a second course of treatment (9). The difficulty with enuresis alarms is that of the behavioral techniques, the family must be motivated and committed to making them work. The course of treatment is over two to three months and may well require a longer course. Some children ,nay need to be taught to awaken to the alarm and not sleep through it. A combination of self-awakening and alarms is often required. These devices range in cost from approximately $30 to $60. Some brand names include Potty Pager, Dry Night Training System, Nytone, and Wet Stop. They are available in pharmacies and often have toll free phone numbers for further information. Some insurance companies will consider this a "medical device" if prescribed by the physician. Families should be cautioned about companies and individuals who offer to treat enuresis with special programs that cost as much as $1000. These are not likely to be more successful than the strategies described here. Children can also be taught to increase bladder capacity by systematically prolonging the time between voiding during the day. This may be enhanced with exercises and a variety of rewards. This training is usually part of the behavioral and conditioning programs and is not very successful when used alone (2). Medicationshave long been used as treatment for nocturnal enuresis. Controlled studies have shown less efficacy than the behavioral/conditioning approaches and a greater degree of relapse when the medication is terminated. However, they are useful as intermittent therapy for critical times when it is important for a child to be dry at night. They are also useful in combination with other strategies in difficult eases. Desmopressin (DDAVP) is an intranasal preparation that reduces nocturnal urine production. It is a synthetic analogue of vasopressin and has been in use for enuresis for more than ten years. The product delivers 10 #g/spray and is administered as one spray in each nostril at bedtime, increasing as needed to a maximum total dose of 40 /zg. The problems associated with DDAVP include treatment failure and a high de-
MEDICALUPDATEFOR PSYCtlIATRISTS
M. D. Bappley
gree of relapse when the medication is discontinued (10). Side effects seem to be relatively few, although short-term water retention may pose a problem for children at risk for hyponatremia. Other side effects include headache, abdominal discomfort, nausea, and irritation of the nasal mucosa. Imipramine is a medication with a long history of use in enuresis. The doses used for this purpose, 25-7,5 rag, depending on the child's age and administered an hour before bedtime, are lower than often needed for antidepressant effect. Larger doses are not more effective. This medication has both a noradrenergic effect to decrease excitability of the bladder detrusor muscle and an anticholinergic effect of increasing bladder capacity. Overall effectiveness for long-term cure ranges from 2540%. Relapse rates are high when the medication is abruptly discontinued (9.,3). There are major risks of fatal poisoning for all tricyclic antidepressants. Children are especially vulnerable because of small size and because they are not likely to understand the potential danger of prescribed medications ( 11 ). Other side effects include feelings of anxiety, mood lability, insomnia, and lowering of seizure threshold. When used in a single low dose, monitoring of serum levels is not commonly done. Imipramine is used in the treatment of attention deficit hyperactivity disorder and recommendations in that context are to monitor electrocardiograms prior to and during treatment (12). A successful treatment plan is geared to the developmental age of the child, the needs and understanding of the family, and the physiology or pathophys-
iology of the enuresis. Combined treatment might be helpful with awakening strategies, alarm, bladder stretching exercises, and the use of DDAVP in a child with decreased bladder capacity. Other families may be reassured by the normal aspects of this condition and be content to work over time on self-awakening strategies. Schmidt (2) has elaborated a hierarchy of treatment interventions based on the child's age that may be useful to consider. Considerable effort may be needed on the part of the physician to offer support for alternatives to punitive measures sometimes employed. Parents may lack a repertoire of strategies, may be reacting to harsh punishment or shame experienced in their own childhood, or they may simply have unrealistic expectations of their child.
Conclusion
Nocturnal enuresis is a common childhood condition. It is usually not associated with significant pathophysiology. However, variations in physiology that result in small bladder capacity, decreased sensation to a full bladder, and poor control over urination can result in significant disturbance for the child and family. Successful interventions are largely behavioral and conditioning with adjunctive use of medications. A careful history, physical, and urinalysis are required not only to work through the differential diagnosis but to design an intervention appropriate for the age and nature of the problem faced by the child and family. Parents may need support to avoid punitive interventions and to
20
promote mastery of the child over urination. References 1. Behrman RE, (Ed). Nelson's Textbook of Pediatrics. 14th Edition. Philadelphia: W.B. Saunders, 1992;58:1375. 2. Schmidt B. Special report in enuresis. Contemporary Pediatrics. November 1995:1-14. 3. Norgaard JP, Rittig S, Djurhuus JC. Nocturnal enuresis: An approach to treatment based on pathogenesis. J Pediatr 1989:114,705. 4, Berger RM, Maizsels M, Moran GC, et al, Bladder capacity (ounces) equals age (years) plus 2 predicts normal bladder capacity and aids in diagnosis of abnormal voiding patterns. J Urol 1983:129347. 5. Devlin JB, O'Cathain C. Predicting treatment outcome in nocturnal enuresis. Arch Dis Child 1990:65:1158. 6. Azrin NH, Thienes PM. Rapid elimination of enuresis by intensive learning without a conditioning apparatus. Behav Ther 1978;9:342. 7. Olness K: The use of self-hypnosis in the treatment of childhood nocturnal enuresis: A report of forty patients. Clin Pediatr 1975; 14:273. 8. Mack A: Dry All Night. Boston, Little Brown & Co. 1989. 9. Forsythe WI, Butler RJ. Fifty years of enuretic alarms. Arch Dis Child 1989:64:879. 10. Miller K, Goldberg S, Atkin B. Nocturnal enuresis: Experience with long-term use of intranasally administered desmopressin. J Pediatr 1989; 114:723. 11. Herson VC, Schmitt BD, Rumaeh BH. Magical thinking and imipramine poisoning in two school-aged children. lAMA 1979;241:1926. 12. Ryan ND. Heteroeyclic antidepressants in children and adolescents. J Child Adol Psychopharm. Vol 1, No 1. 1990:21-31.