A history of Bedwetting (primary nocturnal enuresis) is a very strong clue to the diagnosis of ADD/ADHD
Please, do not be fooled into thinking that bedwetting or enuresis (primary nocturnal enuresis) is nothing more than a "developmental" problem that goes away with time. In fact, it does not always stop with maturity and may be present during the adult years. Recently, a 72 year old patient told me that her last bedwetting event was only two years before.
Even in those instances when it does disappear with maturity, the years of bedwetting often wreak emotional havoc on young people moving into adolescence and young adulthood. Bedwetters commonly live in almost mortal fear of being discovered, terrified to sleep over at the home of others, or go to camp and sleep in the same cabin or tent with peers.
But, even more importantly, bedwetting is a very strong clue to the diagnosis of ADD/ADHD. In my experience, bedwetting is an associated characteristic (called a comorbidity by psychiatrists) of the ADD/ADHD syndrome. Keep in mind that one of the most successful
medications for treating ADD/ADHD is desipramine, and desipramine stops bedwetting immediately in about 90% of instances.
Before you can rely on bedwetting as a clue to ADD/ADHD, you must know how to define bedwetting. It is not a complicated diagnosis to make. Simply, a person who is five years old or older who urinates while asleep in bed at night is a bedwetter. One clinical standard is that it must happen at least once a month, but, in fact, the frequency is probably not extremely important. After all, what if bedwetting were to occur several times in a four year old child, only once when the child was five years old, and never again. Perhaps this child outgrew bedwetting at the age of five. In this example, bedwetting would not be a recurring problem at the age of five, but the single occurrence at the age of five would indicate that bedwetting neurology was present. Remember, bedwetting is not supposed to happen at all in five year olds.
You may or may not choose to treat an ADD/ADHD five year old bedwetter, but should your child have tantrums, learning disability, and/or socialization problems that persist or worsen with time, you should at least suspect that ADD/ADHD neurology is, to some degree, a causative factor.
Does awareness that your child has ADD/ADHD neurology with or without bedwetting require that you immediately treated your child with medication and/or psychological therapy or special educational training? Certainly not. On the other hand, if an ADD/ADHD individual is having ADD/ADHD-like problems AND is or has been a bedwetter, you can be quite certain that the person has ADD/ADHD neurology and you might choose early treatment to help prevent future psychological consequences. If these consequences have already occurred, treatment may help dramatically to reduce or eliminate them.
Translated into practical talk, 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, having intermittent EXPLOSIVENESS (tantrums), or has been diagnosed to have "conduct disorder," "oppositional behavior," or dyslexia, you should immediately hurry over to your favorite physician and seek help.
If there is no obvious cause for bedwetting such as diabetes mellitus, diabetes insipidus, anatomical deformity of the bladder or its outflow tract, and the like, then it is called primary nocturnal enuresis (bedwetting without an obvious cause). Primary nocturnal enuresis happens because an ADD/ADHD individual with the genetic tendency to bedwetting is less able to wake up when the urinary bladder is full and be awake enough to make the choice to move to the bathroom toilet when strong urinary bladder muscle contractions and the urge to urinate is present.
What does all this talk about bedwetting mean? Let me emphasize again that if a child currently is a bedwetter or a teenager or adult used to wet the bed while sleeping at night, you can be extremely confident that the individual has ADD/ADHD neurology.
Translated into practical talk, this also means that if you are aware that a bedwetter is having difficulty with paying attention in school, concentrating on academic material, impulsive behavior, fidgetiness, intermittent EXPLOSIVENESS (tantrums), or "conduct disorder," "oppositional behavior," or dyslexia, you should immediately hurry down to and seek help from your favorite physician.
Be sure you tell the doctor you seek help from that you strongly suspect that the person in question is not lazy, stupid or mean but probably has ADD/ADHD. If medication is needed and an appropriate approach to treatment, be sure to ask for medication if it is not prescribed.
It is sad that bedwetting is still a very under-appreciated clue to ADD/ADHD neurology. In my experience based on 1822 cases, 48% of those with classical ADD/ADHD are or have been bedwetters. About 40% of adults who 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 past problem.
There are only a limited number of research reports on the incidence of bedwetting in various populations around the world. In one such report, 17% of children from a community in Ireland and, in another, 52% of "black" students from Kingston, Jamaica, were diagnosed to be bedwetters. In the United States, the estimated incidence of bedwetting is 10-11% of the general population.
If virtually all people with a history of primary nocturnal enuresis (bedwetting) have ADD/ADHD and about half of those with ADD/ADHD have a history of bedwetting, then one can be calculated that the incidence of ADD/ADHD in the population is about twice the incidence of bedwetting. Certainly, it would appear that the incidence varies dramatically from one population to another. It is extremely important not to draw moral or social judgments from this information, however, because ADD/ADHD neurology has positive as well as negative consequences, and many of the most successful and influential people in the history of the world have been identified as probably ADD/ADHD.
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 neurology.
A few more statistical facts of possible interest. Bedwetting is equally as common in hyperactive ADD/ADHD males (47%) as females (37%) and ADD males without a history of obvious hyperactivity (47%). So-called non-hyperactive ADD females have a 22% incidence of enuresis which is not inconsequential but is significantly (P=0.002) lower than it is in other ADD/ADHD individuals. It is not yet clear to me why this difference exists.
What about treatment? First, let's get it very straight that there is a "NO-NO treatment" approach. 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 and have no conscious control over their enuretic 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. This approach involves the use of a medication which does not correct other ADD/ADHD neurological 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 this age group (although these and all medications have potential adverse effects). Tricyclic antidepressants are my first choice of drug because they treat ADD/ADHD in a large percent of individuals and they stop bedwetting in about 90% of those with enuresis.
Even if your physician never asks about bedwetting, be sure to bring it up. And, if necessary, stress to your doctor the value of a history of enuresis with respect to making a diagnosis of ADD/ADHD.