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A Study of Training in Voluntary Control of Urination in a Group of Problem Children

1943; Lippincott Williams & Wilkins; Volume: 5; Issue: 3 Linguagem: Inglês

10.1097/00006842-194307000-00005

1534-7796

Mabel Huschka,

Pediatric Pain Management Techniques

A study of training in voluntary control of urination in a group of 215 problem children has been made, with particular reference to the age at which training was started, the methods employed, the age dryness was achieved and the reaction of the children to the training. The historical method was employed, the data being secured by the author in connection with routine psychiatric examination of the children. The findings are presented in percentages in terms of the total number of patients in whom information was obtained regarding the particular topic under investigation. A review of the literature reveals that our medical knowledge with respect to the optimum age at which training in voluntary control should be started is still inadequate. On the basis of the knowledge at present available, it is concluded that training in voluntary control which begins before the age of 10 months is premature and therefore coercive. It was found in the present study that in 68% of the children the training was started before the age of 10 months and in 43% it was achieved before the age of 2 years. Since pediatricians (Holt and McIntosh) and psychiatrists (Michaels) do not consider as enuretic a child still wetting under the age of 3 years and since Gesell's studies of development reveal that the child is not dry nights without being taken up until well past the age of 3 years, it seems reasonable to conclude that dryness achieved before the age of 2 years may be considered premature. There were 36 children over 3 years of age who were still wetting at the time of the psychiatric examination, their ages ranging up to 14 years. In 6 the wetting was diurnal only, in 28 nocturnal only and in 5 it was both. In 28% of the patients the method employed in training the child was coercive and in some it was drastic either physically or psychologically or both. The reaction of the child to the training was examined with reference to its potentiality for laying down a pattern of unhealthy psychosomatic adaptation in the future. It was found that 63% of the children known to have been coercively trained, both in the sense of premature institution of training and coercive method, responded in an undesirable manner in the sense outlined above. Definite conclusions as to what these percentages mean cannot be made because of the lack of controls in this survey and those of other investigators which could be used for comparison. It is of interest that of the 59 children responding undesirably, 41% did so by continuing to wet, also that in 92% of those so responding, the training was started under the age of 10 months. Further study of the undesirable responses reveals them to be a seed-bed of psychopathology, many of them being manifestations of anxiety or of aggression related to anxiety. Finding that punitive methods of training were frequently employed and that many of the children responded with some form of aggression raises the question of the possible relation between these two factors and leads to the conclusion that this problem well warrants further investigation in the interest of better understanding the genesis of psychopathology. Of the total group of children studied, 136 presented data as to whether the history for functional enuresis was positive or negative. Seventy-nine of these, or 58%, had a positive history. Again, because of lack of controls, it cannot be stated whether there is any correlation between this high incidence of enuresis and the findings with respect to coercive bladder training. It is to be hoped that in time comparative studies will enable that question to be answered. Of the 79 children having a history of enuresis, 50 had never been able to establish control of urination. This large number is particularly arresting in view of Michaels' conclusion that enuresis of this character is a prototype of psychopathic personality. The present study suggests that this area offers a particularly fruitful field for further psychiatric investigation, especially in the preschool age period. In 29 of the enuretics the wetting started at some time after control of urination had been achieved. The circumstances at the onset of the symptom, in the 15 children presenting data on this point, were for the most part especially difficult, the child having to meet an unusually disturbing emotional situation and as a rule one prone to stir up anxiety. The findings regarding these two groups of enuretics are discussed in the light of Michaels' conclusions that enuresis in the patient who has never been dry and psychopathic behavior are character problems, while enuresis which follows a period of dryness is a symptom of neurosis and therefore has a more favorable therapeutic outlook. If this is true, the importance of distinguishing between these two types of enuresis as early as possible is obvious. Finally, the frequent employment of punitive measures in the training of these children, the responses in terms of aggression, the high incidence among the enuretics of children who had never achieved dryness (which as Michaels concludes may be a prototype of psychopathic personality and we know psychopaths often are unusually aggressive), stimulate interest in further investigation of the problem of aggression in relation to urinary function, or in other words, the problem of the genesis of urethral sadism.