Commentary on Ronen T, Hamama L and Rosenbaum M (2012) Enuresis--children's predictions of their treatment's progress and outcomes. Journal of Clinical Nursing 22, 222-232.

Abstract

Ronen et al. (2012) discuss children’s ability in predicting their enuresis treatment’s progress and outcomes. There are numerous studies on childhood enuresis; however, few explore the predictability of determining outcomes. The study focuses on children being active participants in their treatment and acknowledges Bandura’s (1977) concept of self-efficacy in recognising that individuals are capable of achieving the behaviours they are asked to perform. This is linked with motivation and positive reinforcement and is used in the management of enuresis and other behaviour change interventions (Thiedke 2003). Ronen et al. (2012) diagnose enuresis using the Manual of Mental Disorders (DSM-IV; American Psychiatric Association 1994); however, this gives little information about the cause of enuresis. The three-system approach by Butler and Holland (2000) is often used in practice to diagnose the cause of enuresis and appropriate treatment. Butler and Holland (2000) suggest that nocturnal enuresis can be due to a lack of antidiuretic hormone (vasopressin), small functional bladder capacity or lack of arousal. It is not clear within the study whether these data have been collected and this may be a reason why some of the participants did not improve. Furthermore, group therapy may not have been the most appropriate form of treatment. Ronen et al. (2012) sampled 101 children aged 8–14 randomly assigned to three groups. One predicted baseline outcomes, one predicted weekly outcomes and one did not predict at all. The children had training completing a practice prediction curve, by predicting how many hours of television they will watch over the next few weeks; however, this seems a rather limited measure – there appears to be no evidence to support accuracy in terms of prediction, given the variances in age and cognitive ability of 8to 14-year-olds. Indeed, the authors of the study have identified that conclusions cannot be easily drawn as most children progressed, regardless of which group they were in. Similarly, the questions asked prior to treatment may be beyond the cognitive ability of some of the sample, the questions are similar with only subtle differences, and there is no account of the children’s responses that would support or refute this. Given the age range of the sample, it is worth noting that levels of self-efficacy can be difficult to determine as this is linked to cognitive ability; however, positive reinforcement and belief of success can be a strong motivator. This effect may be more evident in the weekly predictive group as they are being prompted to reinforce their own self-belief which may be the causative factor. The intervention lasted 16 weeks, and it is unclear how many children would have stopped bed-wetting naturally (Thiedke 2003). Maintenance of the behaviour is also worthy of further study as 35 participants had received previous treatment. Ronen et al. (2012) provide useful information about self-efficacy and motivation in treating enuresis; the ability of children to predict treatment outcomes is less convincing, and further study on the development of reliable tools is warranted.