Thursday, April 30, 2009

Bedwetting ADHD Kids and Depressed Dads: Is there a connection?

ADHD and Bedwetting (Nocturnal Enuresis): How are the two related?

There is a relatively recent publication that came out within the last couple of weeks on the relatively high rate of occurrence in bed wetting (enuresis) among ADHD children, which I believe is worth sharing. We have previously investigated this ADHD and bed wetting connection (note that bed wetting may be more likely to be seen alongside the inattentive subtype of ADHD). However, this study offers some additional insight into this strange association between the two disorders. Here are some important points worth mentioning:


  • Overlapping Drug Treatment for ADHD and bedwetting: It stands to reason that if a particular drug or agent is effective in treating multiple disorders, there may be a distinct possibility that those two or more disorders may share some type of underlying cause(s) or defect(s). For example, Tofranil or Imipramine, a drug used to treat enuresis and depressive disorders can possibly be useful as a treatment option for ADHD. We have also investigated the potential role of Reboxetine as a potential ADHD treatment in previous entries. Some work has found Reboxetine to be useful in treating therapy-resistant enuresis as well.

  • Prevalence of Enuresis in ADHD: Enuresis refers to urinary incontinence which is limited to the night-time. Additionally, the term is typically limited to individuals over the age of 5 (i.e. a 3-year-old child who frequently pees in their pants would not be considered as suffering from enuresis, at least in the context of this study). The article cites other studies in which the rate of bedwetting (enuresis) in ADHD is as high as 30%, although other studies have it down around 10-20%. Still, compared to the general population, (factoring in things such as the age of the child, of course)the high rate of bed wetting in ADHD is especially noteworthy. There is some evidence from other studies that ADHD and enuresis may be more intricately linked than previously imagined. For example, one particular study has shown that treating urinary incontinence has a higher rates of failure in children with ADHD vs. non-ADHD children.

  • The role of Oppositional Defiant Disorder (ODD) on Bed wetting: The study examine several different psychiatric disorders which frequently occur alongside of (or are comorbid to) ADHD. These include depression, anxiety disorders, obsessive compulsive disorders, tic disorders, nail biting, bruxism (teeth grinding), conduct disorders and oppositional defiant disorders. However, out of all of these different disorders which often appear alongside ADHD, the only one which exhibited a statistically significant correlation to increases in bedwetting was oppositional defiant disorder. Interestingly, oppositional defiant disorders have been associated with bedwetting in other ADHD studies.

    As its name suggests, Oppositional Defiant Disorder is a disorder in which a child exhibits disobedience, irritability and hostility towards authority figures beyond the range of normal age-appropriate behaviors. Of course there is a significant gray area with regards to what is age appropriate, especially when the child's environment is considered. Nevertheless, Oppositional Defiant Disorder (or ODD) is much more than just routine temper tantrums. Oppositional Defiant Disorders may also be associated with auditory processing issues and ADHD. It is somewhat interesting that anxiety disorders, which have also been correlated to oppositional behaviors, did not elicit a significant positive correlation to bed wetting.

  • The autonomic nervous system as a potential underlying cause of ADHD, bedwetting and Oppositional Defiant Disorders: The autonomic nervous system is the part of the nervous system responsible for involuntary muscle actions such as digestive processes, blood vessel contraction, etc. It is subdivided into the sympathetic and parasympathetic nervous systems, which often act in a sort of "push-pull" opposition to each other. For example, the sympathetic nervous system does things such as boosting heart rate and constricting blood vessels, while the parasympathetic nervous system is in charge of activities such as reducing heart rates and relaxing sphincter muscles (which plays a role in bladder control).

    Typically, the sympathetic and parasympathetic components of the nervous system are kept in balance, but this balance may be thrown out of whack and result in numerous disorders. For example, it is believed that the parasympathetic nervous system is over dominant in cases of Oppositional Defiant Disorders (ODD). The study found that for ADHD and Oppositional Defiant Disordered children, functions such as heart rate were controlled excessively (if not almost exclusively) by the parasympathetic portion of the nervous system (while non-ODD and non-ADHD children had both sympathetic and parasympathetic controls operating on their heart rates. This suggests a common underlying imbalance among the different components of the nervous system which is common to ADHD and ODD individuals and often separates them from the non-ADHD'ers. Interestingly, other studies have indicated that bedwetting or generalized incontinence problems may also be caused by an overactive parasympathetic nervous system, which suggests that ADHD, ODD and night-time bedwetting may all share some underlying causes within the nervous system.

  • Connection to Parental Depression: I personally found this observation to be interesting. The study found that the prevalence of bedwetting in ADHD children was higher if the father (but not the mother) of the child was suffering from some sort of major depressive illness. The article did not express an opinion as to whether these depressive symptoms were due in part to the child's bed wetting problems or whether there was some underlying mechanism at work.

  • ADHD medications may Influence Enuresis: The authors highlight some other works in which popular ADHD medications may either increase or decrease the risk of bedwetting in ADHD children. For example, the article highlighted a case study (by the same author) in which treatment with methylphenidate induced nocturnal enuresis. Methylphenidate is one of the most common ADHD drugs, and often goes by the common trade names Ritalin, Concerta, Metadate and Daytrana (the patch form of the drug). Of course this is based on only one individual case, but for those of you who have read this blog on a frequent basis, will know that I like to report on some of these abnormal occurrences (for reference sake, here is an earlier blog post I have done on the possible connection between methylphenidate and excessive talking. While based on an isolated case report, I believe that this zany potential side effect was at least worth a mention). On the flip side, however, the non-stimulant alternative ADHD drug, Atomoxetine (Strattera) can be a useful treatment for enuresis. This blogger would personally like to see additional studies on whether ADHD children with a comorbid bedwetting condition actually saw a better reduction in their ADHD symptoms while on Strattera than while on methylphenidate. If this were the case, then bedwetting may actually served as a useful tip-off as to which type of ADHD medication would work best for that particular child.

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45 comments:

Anonymous said...

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gerkfritz@brainbalancecenters.com said...

First let me say I love your blog. Great information!
Next, you might want to check out persistent primitive (neonatal) reflexes as a cause of many co-morbidities (including enuresis). The work of Jane Ayers and of Sally Goddard-Blythe come to mind. We work with kids who have neuro-developmental disorders and frequently find any number of persistent primitive reflexes.
Thanks again.
Dr. Gary

Patti said...

Interesting article. My 8 y.o. son has ADHD treated with Focalin and up until 3 months ago had frequent (2x week) bed wetting. 3 months ago we started him on 1/2 mg of melatonin to help with sleeping issues and we haven't had an accident since. Doctors have no explanation.

Anonymous said...

I had the same experiace with my son when he was 7. He has ADHD and constantly wet the bed. If we gave him half a melatonin tablet, an hour before he went to sleep he NEVER wet his be. If he did it was because we forgot the tablet. The problem stopped when he hit puberty and has never been an issue since.

Heather said...

My daughter's night wetting occured with less frequency when she began taking adderall. Once she was given prozac in addition, the wetting completely stopped. During the summer, she stopped Adderall but continued with Prozac and nightly bed wetting returned. She woke up dry after the first day Adderall was taken this school year. What a relief for my nine year old (and for my non-stop washing...I couldn't bear to put her back in pull-ups this summer!) !

I love your blog...thanks for all the great info!

Heather

Anonymous said...

my son is 13, when had started taking Adderall his bedwetting reduced dramatically, when he started taking it consistently (not just school days), it has all but disappeared.

Paros said...

My 9 year old son's incidents of enuresis declined until he was put back on stimulant medication. Since then (beginning early Jan.) it has escalated significantly. I think I may try the melatonin.

Heather M said...

My 9 year old daughter was diagnosed with ADHD in April and has been taking Focalin for a little over a month now. She is also a nightly bed wetter. A week ago, she ran out of pull ups and decided she wanted to try and sleep without one. She has not had an accident since. This connection is fascinating to me.

Anonymous said...

I am really thankful that you have taken the time to compile this information. My 10 year old son has had a significant problem with bed wetting every night. He was placed on 10mg of Strettara a while back for ADD (no unusual hyper-activity) and his bed wetting stopped the first night. If we miss a dose, he has an accident. I wet the bed until I was a freshman in college and so did my father. Prior to my father ‘s death he had a life long battle with anxiety (self-medicated with alcohol). Likewise, I suffer from depression and anxiety and take the maximum dose of Effexor to help. My son shows all the earmarks of high personal and social anxiety. We are currently in conversation with our physician as to possible treatments. As your blog suggests there must be a common thread.

Anonymous said...

My 9 yr. old son has always had a bedwitting problem. As a young child, loud noises really bothered him (auditory processing). He used to take desmopressin for the bedwetting, which did work, but after years it stopped working. Recently, his attention problems were getting worse, and he just started Concerta 36mg 3 weeks ago. He has not had an accident since. However, he's had difficulty falling asleep, so we've been giving 500mcg of Melatonin. So...which is it? The Concerta or the Melatonin? My guess is Concerta. Strangely, my other son, who is more hyperactive than inattentive, takes both concerta and melatonin. He has never had an enuresis problem. but he does talk excessively. I believe this is due to comorbidity of mild Asperger's-like symptoms, as he talks even MORE excessively without the concerta.

Anonymous said...

My 9 year old daughter took various stimulants last year and stopped bedwetting when she was on them. We took her off medication for the past 6 months and she began wetting the bed again. We started her on Concerta 18 mg about 1 month ago and she immediately stopped wetting the bed. However, we just upped her dose to 27 mg 5 days ago and she has wet the bed before 11 pm at night every night since then!! She has taken a 1 mg Melatonin tablet ever since she went off stimulants 6 months ago and we continue to give it to her now. So, why would she start wetting again - and so early in the night - at the exact same time as we upped her Concerta? It seemed like the Concerta was helping her stay dry. We are so confused.

Anonymous said...

My son was diagnosed at age 8 although we pretty much knew for 4 years prior that he had it. He was a bed wetter (nocturnal and daytime). He wet the bed most nights and had daytime accidents about 3-4 times a week (usually when playing).

We started him on a very low dose of concerta (18 mg) and the wetting completely stopped. Not just reduced, but stopped. Dr had no idea why when we told him.

He takes Concerta every day. But just this past Tuesday, we forgot to give him his pill before he went off to school. By the time we realized it, it was too late in the day to give him his pill. When he got home, he played outside with a friend and had a small accident. That night he wet the bed very heavily.

I have no doubt there is a direct correlation between his ADHD and the Bed wetting and a direct correlation between taking the Concerta and eliminating the bedwetting (as well as the ADHD symptoms).

Manuel Mota Castillo said...

Do you really believe in ODD. That will go against the theories of several "founders" of psychiatry who stated that before the age of 10 years children have chosen if they are going to be "rules followers" or unruly. In my experience ODD is a symptoms of several treatable illnesses such as OCD, Social Anxiety Disorder, bipolar spectrum disorder, etc.
Please check this website: www.psychiatricanswers.com

Manuel Mota-Castillo, M.D.

Manuel Mota Castillo said...

I believe that ODD is not a real diagnosis but a symptom of several treatable illnesses such as OCD, Social Anxiety Disorder, bipolar spectrum disorder, etc. I have never found one child that continued exhibiting "oppositional-defiant" behavior after proper treatment for the real condition. a child has introyected social moreWe should remember that it is well-accepted in our field that by the age of 10 years s and respect (or disrespect) for rules. A "good boy" does not become "ODD" just because he enjoys been bad.
We should pay more attention to family history and also remember that amphetamines worsen aggressive behavior and anxiety.

Manuel Mota Castillo said...

Just an observation to the mother that mentioned Asperger and ADHD. If you check the DSM-IV, the official APA classification of diagnoses does not allow to Diagnose ADHD in a child with a pervasive development disorder. The reason is very logical: There is already a reason for the lack of attention. Sadly many autistic children are given amphetamines with the bad consequence of a severe worsening of the obssesions and temper tantrums.

muebles en barcelona said...

For my part everyone ought to glance at it.

Anonymous said...

Hi I just wanted to mention that my 8 yr olf son has been on Strattera for a year. He is a huge bedwetter. He wets, two to three times per night. Even when I limit his drinks after dinner. Being on Strattera has not improved this at all for us.

Anonymous said...

Also, as per my bedwetting comment. My son's father does suffer from depression and substance abuse.

sports handicapping services said...

hello friends I think that if there must be connection simply live together that children are like sponges that absorb everything going on around whether good or bad and these are the consequences

Anonymous said...

Thanks so much for your mention of Methylin being linked to bed wetting. My 7-year-old son has the same problem. On the medication, he's a bed wetter. Off the meds he's not. I think I'll try the melatonin & see if that helps.

Dr. Flanders said...

I am a pediatrician and started biphnetin for a 7 year old with classic ADHD. Not only did his ADHD symptoms dramatically improve, but his primary nocturnal enuresis completely disappeared. If he missed a dose, then that night he wer his bed. Have you ever seen this before? Could it be that there is residual psychostimulant in his system causing a lighter sleep?

Anonymous said...

www.adhdfree.com

I have accidents all the time but not when I was on Addroll. I told my parents that it was the ADHD but they don't beleive in ADHD.

I use to hide my problems by using my brothers diapers. ( I guess that is why girls thought I was cute) when my issue, thanks to maxie pads I was able to hide the isssue.
Later in life my parents told me they knew I still had the problem and desided that as long as I did not have a big problem they were going to keep my secret.

Patricia said...

So, I do not really believe it will have effect.

May said...

Thanks so much for your post, pretty helpful information.

mylene sai said...

Thanks for the sensible critique. Me & my neighbor were just preparing to do some research about this.combating depression

Chrissy Adeoye said...

Hi my son is 4 years old and over the top (ADHD) but he has not been diagnosed yet and he also is having the same exact problem. Plz tell me what I can do bc my moms answer to the problem is a spanking all the time. I know he doesn't mean to and his uncontrollable behavior. He is truly a smart child and I don't want to medicate and dumb him down. Plz plz help.

Health and wellbeing said...

Some people use buzzers or alarms attached to night wear, which are triggered by moisture, so she can get up and go to the loo. The aim is to ‘re-programme’ the brain to alert her to wake before she has to wee.

Obat Kutil Kelamin Herbal said...

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Anonymous said...

As an adult who's always struggled with having nocturnal enuresis I was amazed that when I finally got myself diagnosed with ADHD and started taking ADDERALL I haven't had a night time episode.

Anonymous said...

My 8 year old son's bed wetting stopped within 1 week if starting straterra. As he grew that year, and needed his dosage adjusted, the bed wetting returned. As soon as we increased his Straterra dosage, his bed wetting resolved.

Anonymous said...

My 11 yr old son was diagnosed with ADHD 2 years ago and has struggled with bed wetting all his life. He takes Concerta which gives him insomnia. This summer we took him off his Concerta for a month and he only had 1 accident and was sleeping great. The day after starting him back on his Concerta he wet his bed. This along with the return of this insomnia is frustrating for him. The medication works wonderfully otherwise.

J&S Creations said...

14 year old son adhd bedwetting every night. New diagnosis ODO. Kicked out if 3 schools star athlete kicked off of 3 football teams. 2 weeks into new school wanting him out now. Only in 8th grade. Very anxious with low self esteem but no respect for authority. On probation had tether broke into 2 house stole money. Some OCD....sent to bootcamp. I'm lost please please help I'm loosing my little boy

Unknown said...

We were going through something very similar. My daughter turned 9 over the summer and was so embarrassed to be wearing pull-ups (I totally understand the constant washing! ). When school started she began taking Concerta and the bed wetting reduced from 5-7 times a week to 1-2 times a month.

Nicole Santos said...

We were going through something very similar. My daughter turned 9 over the summer and was so embarrassed to be wearing pull-ups (I totally understand the constant washing! ). When school started she began taking Concerta and the bed wetting reduced from 5-7 times a week to 1-2 times a month.

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Cindy Martin said...

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Anonymous said...

Okay so I've seen a lot of replies that refer to their child having concerta and stopping bedwetting. My child is on concerta 54 and still is having trouble with bedwetting. This doctor has just prescribed desmopressin for the bed wetting. Does anyone have experience with the combination of both concerta and desmopressin? I guess my main concern is that the combination of the two medications could raise his blood pressure high very high and my family has a history of high blood pressure. Should I be concerned about this and does anyone have any suggestions?

Alex Neil said...

Bedwetting is the loss of bladder control during the night. The medical term for bedwetting is nocturnal enuresis or enuresis. Bedwetting can be an embarrassing issue, but in many cases, it is perfectly normal.

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chellie05855 said...

I am a 48 year old who has been taking provigil for many years to treat narcolepsy. I am on my 2nd cycle of initiating adding Ritalin to help daytime sleepiness. My first cycle ended when after a few days of starting ritilan to the mix, I started wetting the bed. I went off the ritilan and after a few days I stopped. That was over a year ago. My doctor wanted to try adding it again as he thought that maybe it was a fluke. I started Ritalin last Friday and last night (Monday), I was awoken in full stream of urinating. So I truly believe that this may be an adult side effect of Ritalin.