HABIT DISORDERS: Enuresis and Stuttering
HABIT DISORDERS
The habit disorders comprise a group of diagnoses that are united by a single
fact: the troublesome behavior has a habitual physical component. They include
such problems as the inability to control bowel or bladder, eating too
much or too little, and stammering or stuttering. While the causes of these
disorders are not entirely clear, their psychological consequences are dramatic.
To be a bed wetter or much overweight in Western society is to be
stigmatized and to have to deal regularly with the taunts of others and assaults
on one's self-esteem.
ENURESIS
Enuresis is arbitrarily defined as involuntary voiding of urine at least twice a
month for children between five and six, and once a month for those who
are older. Most children gain bladder control between eighteen months and
four years of age. Thereafter, the proportion of children who have difficulty
containing urine, either during the day or while in bed, drops markedly. At
age five, 7 percent of boys and 3 percent of girls are enuretic; at age ten, 3
percent of boys and 2 percent of girls are still having difficulty with continence.
At age eighteen, 1 percent of boys continue to be enuretic, and the
disorder is nearly nonexistent for girls.
As with the other physical disorders, the problems of the enuretic are
compounded by the social consequences of the disorder. Parents object to
soiled clothes and bedding and commonly stigmatize the enuretic as immature.
Schoolmates and friends are likely to tease the child who has an occasional
"accident," the more so when those accidents are regular
occurrences. Enuretics find it nearly impossible to accept overnight invitations
from friends or to go to camp. These social consequences may create a
fertile ground for other more serious psychological problems.
Causes of Enuresis
The social consequences of enuresis are especially unfortunate because little
is known about its causes. Lay persons often think of it as a disorder of learning
or as flawed self-control. But the weight of evidence suggestsa strong biological
component to the disorder. Approximately 75 percent of enuretic
children have first-degree relatives who are or were enuretic, and the concordance
for enuresis is higher in identical (MZ) than in fraternal (DZ)
twins. That is, the more similar a person's genetic blueprint is to an enuretic's,
the more likely the individual will also be enuretic.
Treatment
Some drugs, such as the amphetamines or imipramine, suppress bed-wetting
temporarily. How these drugs work is not understood, and usually children begin
to bed wet again once the drug is stopped. Even so, a few dry
nights can be an enormous morale-booster to an enuretic child, particularly
ifit allows the child to visit friends overnight or go to camp without fear of
embarrassment. Bear in mind, however, that these drugs may have significant
side effects that outweigh their usefulness. Imipramine, for example,
has induced occasional toxic death in children (Rohner and Sanford, 1975).
There are two treatments in particular that have been quite successful
with enuresis, far more successful than drug treatment. Both treatments are
fundamentally behavioral. The first is a procedure that was first described
nearly fifty years ago (Mowrer and Mowrer, 1938). The child sleeps in his or
her own bed. Beneath the sheets is a special pad which, when moistened by
urine, completes a harmless electric circuit that sounds a bell and awakens
the child, who then goes to the toilet. A number of studies have shown that
approximately 90 percent of children treated by the "bell and pad" method
gain bladder control during the two-week treatment period. There is a relapse
rate of up to 35 percent, but that can be reduced by giving a longer
treatment period or by offering an additional "booster" dose of treatment
(Lovibond and Coote, 1970; Shaffer, 1976; Doleys, 1979).
A more intense procedure amplifies this approach (Azrin, Sneed, and
Foxx, 1974). About an hour before bedtime, a "trainer" tells the child and
his or her parents about the "dry-bed" procedure. At this time, the child
drinks a favorite beverage. Then, the trainer attempts to develop in the child
the habit of rousing and urinating. With the lights out, the child lies on the
bed and counts to fifty. Then, he or she rises slowly, heads for the bathroom
and attempts to urinate. This procedure is repeated many times over the
course of that night's treatment. Subsequently, the child is given more to
drink, reminded of these procedures, and told that he or she will be awakened
each hour to practice going to the toilet. If there is an "accident," the
child will have to change the bed sheets and practice using the toilet several
times. And, of course, if there is no accident during the hour, the child will
be praised for that continence. This procedure is rather more intensive than
the bell and pad treatment, and it is even more effective. After four nights of
such treatment, all of the children were continent throughout the six-month
follow-up period.
STUTTERING
Stuttering or stammering is a marked disorder in speech rhythm. While
most children go through transient periods of hesitating over particular
words, the dysrhythmia is both more pronounced and more prolonged in
those who arc regarded as stutterers. Often, it is the initial consonants in
certain words, particularly explosive sounds, that cause real problems. "I
d-d-d ... don't know what to d-d-d-do!" is a typically problematic sentence
that is often accompanied by a flushed and pained face.
About 1 percent of all children are stutterers, and another 4 to 5 percent
experience transient stuttering for a period of up to six months. For unknown
reasons, boys outnumber girls as stutterers by four to one.
The causes of stuttering are still unclear, but as in other physical disorders,
the consequences are enormous. Stutterers tax the patience of other children
and teachers. They are often taunted and ostracized by peers.
Teachers may avoid calling on them in class, with the result that their academic
interest and performance may flag.
Treatment
By the time a stutterer seeks help, he or she is likely experiencing considerable
tension that both results from the speech problem and magnifies it.
Consequently, most treatments of stuttering combine psychotherapeutic
counseling with specific re-educational techniques. The latter serve to distract
the stutterer from his own speech while training him to speak fluently.
Three techniques seem particularly promising. The first is called delayed
auditory feedback and involves hearing one's own speech played back over
earphones at about a .1 second delay. When fluent speakers hear their own
speech delayed in this manner, they stutter enormously. But when stutterers
receive delayed auditory feedback, they become nearly fluent. These paradoxical
findings suggest that feedback from their own speech is what maintains
stuttering, and that any interference in that feedback will reduce it.
The problem, of course, is affecting feedback outside of the treatment situation.
Delayed auditory feedback works quite well in the clinic but transfers
hardly at all outside of the clinic.
Shadowing is a variant of the delayed auditory feedback technique. Here,
the therapist reads from a book, and the stutterer repeats the therapist's
words shortly after the latter has spoken them (and without reading the
words). This requires the stutterer to concentrate carefully on what the therapist
is saying, and in the process, to ignore his own stuttering. Several studies
indicate that shadowing may be useful in alleviating stuttering (Cherry
and Sayers, 1956; Kondas, 1967).
A third method, called syllable-timed speech, requires stutterers to speak
in time to a metronome or beeper that sounds in an earpiece. This procedure,
too, may have the effect of distracting the stutterer from his own stuttering.
Combined with a system of rewards for maintaining non-stuttering,
this procedure has been found relatively effective in reducing stuttering
(Meyer and Mair, 1963; Ingham, Andrews, and Winkler, 1972). None of
these three techniques, however, can be described as more than "promising"
for the treatment of stuttering.
The habit disorders comprise a group of diagnoses that are united by a single
fact: the troublesome behavior has a habitual physical component. They include
such problems as the inability to control bowel or bladder, eating too
much or too little, and stammering or stuttering. While the causes of these
disorders are not entirely clear, their psychological consequences are dramatic.
To be a bed wetter or much overweight in Western society is to be
stigmatized and to have to deal regularly with the taunts of others and assaults
on one's self-esteem.
ENURESIS
Enuresis is arbitrarily defined as involuntary voiding of urine at least twice a
month for children between five and six, and once a month for those who
are older. Most children gain bladder control between eighteen months and
four years of age. Thereafter, the proportion of children who have difficulty
containing urine, either during the day or while in bed, drops markedly. At
age five, 7 percent of boys and 3 percent of girls are enuretic; at age ten, 3
percent of boys and 2 percent of girls are still having difficulty with continence.
At age eighteen, 1 percent of boys continue to be enuretic, and the
disorder is nearly nonexistent for girls.
As with the other physical disorders, the problems of the enuretic are
compounded by the social consequences of the disorder. Parents object to
soiled clothes and bedding and commonly stigmatize the enuretic as immature.
Schoolmates and friends are likely to tease the child who has an occasional
"accident," the more so when those accidents are regular
occurrences. Enuretics find it nearly impossible to accept overnight invitations
from friends or to go to camp. These social consequences may create a
fertile ground for other more serious psychological problems.
Causes of Enuresis
The social consequences of enuresis are especially unfortunate because little
is known about its causes. Lay persons often think of it as a disorder of learning
or as flawed self-control. But the weight of evidence suggestsa strong biological
component to the disorder. Approximately 75 percent of enuretic
children have first-degree relatives who are or were enuretic, and the concordance
for enuresis is higher in identical (MZ) than in fraternal (DZ)
twins. That is, the more similar a person's genetic blueprint is to an enuretic's,
the more likely the individual will also be enuretic.
Treatment
Some drugs, such as the amphetamines or imipramine, suppress bed-wetting
temporarily. How these drugs work is not understood, and usually children begin
to bed wet again once the drug is stopped. Even so, a few dry
nights can be an enormous morale-booster to an enuretic child, particularly
ifit allows the child to visit friends overnight or go to camp without fear of
embarrassment. Bear in mind, however, that these drugs may have significant
side effects that outweigh their usefulness. Imipramine, for example,
has induced occasional toxic death in children (Rohner and Sanford, 1975).
There are two treatments in particular that have been quite successful
with enuresis, far more successful than drug treatment. Both treatments are
fundamentally behavioral. The first is a procedure that was first described
nearly fifty years ago (Mowrer and Mowrer, 1938). The child sleeps in his or
her own bed. Beneath the sheets is a special pad which, when moistened by
urine, completes a harmless electric circuit that sounds a bell and awakens
the child, who then goes to the toilet. A number of studies have shown that
approximately 90 percent of children treated by the "bell and pad" method
gain bladder control during the two-week treatment period. There is a relapse
rate of up to 35 percent, but that can be reduced by giving a longer
treatment period or by offering an additional "booster" dose of treatment
(Lovibond and Coote, 1970; Shaffer, 1976; Doleys, 1979).
A more intense procedure amplifies this approach (Azrin, Sneed, and
Foxx, 1974). About an hour before bedtime, a "trainer" tells the child and
his or her parents about the "dry-bed" procedure. At this time, the child
drinks a favorite beverage. Then, the trainer attempts to develop in the child
the habit of rousing and urinating. With the lights out, the child lies on the
bed and counts to fifty. Then, he or she rises slowly, heads for the bathroom
and attempts to urinate. This procedure is repeated many times over the
course of that night's treatment. Subsequently, the child is given more to
drink, reminded of these procedures, and told that he or she will be awakened
each hour to practice going to the toilet. If there is an "accident," the
child will have to change the bed sheets and practice using the toilet several
times. And, of course, if there is no accident during the hour, the child will
be praised for that continence. This procedure is rather more intensive than
the bell and pad treatment, and it is even more effective. After four nights of
such treatment, all of the children were continent throughout the six-month
follow-up period.
STUTTERING
Stuttering or stammering is a marked disorder in speech rhythm. While
most children go through transient periods of hesitating over particular
words, the dysrhythmia is both more pronounced and more prolonged in
those who arc regarded as stutterers. Often, it is the initial consonants in
certain words, particularly explosive sounds, that cause real problems. "I
d-d-d ... don't know what to d-d-d-do!" is a typically problematic sentence
that is often accompanied by a flushed and pained face.
About 1 percent of all children are stutterers, and another 4 to 5 percent
experience transient stuttering for a period of up to six months. For unknown
reasons, boys outnumber girls as stutterers by four to one.
The causes of stuttering are still unclear, but as in other physical disorders,
the consequences are enormous. Stutterers tax the patience of other children
and teachers. They are often taunted and ostracized by peers.
Teachers may avoid calling on them in class, with the result that their academic
interest and performance may flag.
Treatment
By the time a stutterer seeks help, he or she is likely experiencing considerable
tension that both results from the speech problem and magnifies it.
Consequently, most treatments of stuttering combine psychotherapeutic
counseling with specific re-educational techniques. The latter serve to distract
the stutterer from his own speech while training him to speak fluently.
Three techniques seem particularly promising. The first is called delayed
auditory feedback and involves hearing one's own speech played back over
earphones at about a .1 second delay. When fluent speakers hear their own
speech delayed in this manner, they stutter enormously. But when stutterers
receive delayed auditory feedback, they become nearly fluent. These paradoxical
findings suggest that feedback from their own speech is what maintains
stuttering, and that any interference in that feedback will reduce it.
The problem, of course, is affecting feedback outside of the treatment situation.
Delayed auditory feedback works quite well in the clinic but transfers
hardly at all outside of the clinic.
Shadowing is a variant of the delayed auditory feedback technique. Here,
the therapist reads from a book, and the stutterer repeats the therapist's
words shortly after the latter has spoken them (and without reading the
words). This requires the stutterer to concentrate carefully on what the therapist
is saying, and in the process, to ignore his own stuttering. Several studies
indicate that shadowing may be useful in alleviating stuttering (Cherry
and Sayers, 1956; Kondas, 1967).
A third method, called syllable-timed speech, requires stutterers to speak
in time to a metronome or beeper that sounds in an earpiece. This procedure,
too, may have the effect of distracting the stutterer from his own stuttering.
Combined with a system of rewards for maintaining non-stuttering,
this procedure has been found relatively effective in reducing stuttering
(Meyer and Mair, 1963; Ingham, Andrews, and Winkler, 1972). None of
these three techniques, however, can be described as more than "promising"
for the treatment of stuttering.
For the psychological issues related to Stuttering and Enuresis
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