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A history of Bedwetting (primary nocturnal enuresis) is a very strong clue to the diagnosis of ADD/ADHD.


A history of bedwetting (Primary Nocturnal Enuresis) is a very strong clue to the diagnosis of ADD/ADHD brain chemistry.

Please, do not be fooled into thinking that bedwetting or enuresis is nothing more than a "developmental" problem that goes away with time. In fact, it does not always disappear with maturity and is a problem that some adults face. I can recall a seventy-two year old patients of mine who reported that she had been a bedwetter since childhood and that the last episode was only two years before her initial interview with me.

Even in those instances when it does disappear with maturity, the early years of bedwetting often wreak emotional havoc especially on young people moving into adolescence and early adulthood. Bedwetters commonly live in almost mortal fear of being discovered, terrified to sleep over at the home of others, and fearful to be in a summer camp and sleep in a cabin or tent with peers for fear of being exposed and deprecated.

But, even more importantly, bedwetting is a very strong clue to the diagnosis of ADD/ADHD. In my experience, bedwetting is an ADD/ADHD characteristic (called a comorbidity by psychiatrists), a history of which is present in half of those with documented ADD/ADHD. Keep in mind that one of the most successful medications for treating ADD/ADHD is desipramine, a mdication that stops bedwetting in about 90% of treated cases.

Before you can use bedwetting as a clue to the diagnosis of ADD/ADHD, you must know how to define bedwetting. A conservative definition of a bedwetter is a person who is five years old or older who has had at least one episode of urinating while asleep in bed at night. There do not have to be repeated episodes. I am aware that one clinical standard is that it must happen at least once a month, but, in fact, the frequency itself is not of diagnostic importance. After all, it is possible that bedwetting could occur several times in a four year old child, only once when the child is five years old, and never again. Bedwetting is not supposed to happen at all in five year olds.

Does awareness that your child has a history of bedwetting and, therefore, ADD/ADHD require that you, the parent or guardian, immediately treated your child with medication and/or psychological therapy or enroll the child in special educational classes? Certainly not.

But, if your child is suffering from tantrums, learning disability, and/or socialization problems that persist or worsen with time, you should at least suspect that ADD/ADHD is an underlying, contributory factor that could be treated. Importantly, it also means that ADD/ADHD brain chemistry may be making your child less receptive to even good parenting and that you are not, just in case you thought you were, a "bad" child-rearer.

You can be quite certain that the child has ADD/ADHD brain chemistry if he or she has a history of bedwetting, and you might choose to start treatment early to help prevent future adverse psychological consequences. Practically speaking, if you are aware that a bedwetter is having difficulty with paying attention in school, concentrating on academic material, showing impulsive behavior, frequently acting fidgety, being intermittently explosive (i.e., tantrums), or has been diagnosed to have "conduct disorder," "oppositional behavior," or dyslexia, you should hurry over to your child's physician and ask for an ADD/ADHD assessment and, if indicated, treatment.

Why do ADD/ADHD people bedwet? Some have specific causes such as diabetes mellitus, diabetes insipidus, anatomical deformity of the bladder or its outflow tract. If no obvious medical cause can be found, then it is labeled as primary nocturnal enuresis or bedwetting without an obvious cause and presumably due to inherited brain chemistry. Primary nocturnal enuresis happens because the ADD/ADHD individual is less able to wake up when the urinary bladder is full or be awake enough to get up and go to the toilet when the urge to urinate is present. Difficulty waking in the middle of the night is similar to difficulty waking in the morning which is present in 91% of those with ADD/ADHD.

Be sure you tell the doctor you seek help from that you strongly believe that the person in question is not lazy, stupid or mean but probably has ADD/ADHD. And, be sure to ask about the possible benefit of medication if it has not been included in the treatment plan.

It is sad that bedwetting is still a very under-appreciated clue to ADD/ADHD brain chemistry by health professionals. In my experience based on 1822 cases, 48% of those with ADD/ADHD are or have been bedwetters. Only about 40% of adults who, as adults, are asked if they have a history of bedwetting are able to remember such a history while about 8% do not recall or have suppressed awareness entirely. By the way, none of my patients have ever considered bedwetting as a positive experience. Most are still embarrassed even to talk about their history of bedwetting even though they are adults who no longer have this problem.

There is a familial pattern to the transmission of bedwetting and evidence for genetic inheritance much as my research experience shows that there is for ADD/ADHD. Of course, this would make sense if bedwetting was just one more consequence of ADD/ADHD brain chemistry.

What about treatment? First, let's get it very straight that there are "NO-NO treatment" approaches. Scolding, punishment and attempts to embarrass young people are not useful approaches to the treatment of bedwetting. Moreover, they are harmful since they cause pain, embarrassment and the further loss of self-esteem in children and teenagers who are already suffering from and have no conscious control over this behavior.

Alarms and other devices that wake children from sleep as a reminder to use a toilet are reported by parents to be of help in some cases. This approach is relatively safe and requires no medication and no doctor visits.

DDAVP, a synthetic analogue of a natural human antidiuretic hormone that affects water conservation in the kidney, can stop bedwetting but does so by drastically reducing the ability of the kidney to make urine. I am uncomfortable with this manipulation of normal human physiology even though it can stop bedwetting in many cases. Be aware that this treatment approach involves the use of a medication which does not correct any other ADD/ADHD problems.

The tricyclic antidepressant medications are effective ADD/ADHD treatment in about 80% of children whether or not they are bedwetters. They have virtually no side-effects in those under the age of 15 (although all medications have potential adverse effects). Tricyclic antidepressants are my first choice of drug when treating ADD/ADHD bedwetters because these drugs are effective in a large percent of ADD/ADHD individuals and stop bedwetting in about 90% of those with enuresis. Strattera may stop bedwetting in those with ADD/ADHD but research has not yet adequately documented this possible treatment benefit.

Even if your physician never asks about bedwetting, be sure to bring the problem up if the history exists. And, if necessary, stress to your doctor the value of a history of enuresis with respect to making the diagnosis of ADD/ADHD.