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holding on


My 7 year old son has ADHD and was late (41/2) to toilet train. He has never been dry at night but in the last few months he has been holding on too long during the day. He gets wet undies, urine scald and smells of urine but is not motivated to get to the toilet on time. We have a lot of compliance issues with him and he has trouble leaving a fun activity. Should we get him checked for other problems?


The first step would be to get his urine tested at the GP to rule out urine infection as a cause for his strong urine and urgency.  Is he on any medication for his ADHD?  Sometimes medications can reduce the awareness of the need to void until it is extremely urgent.  I wouldn't worry about the night time wetting until the day time is under control.
How structured is his school day?  Regular toileting as part of the daily routine is a good step.  I encourage many of the other young boys that come and see me to toilet to a schedule rather than waiting until they feel the urge, and I usually suggest toileting as soon as they wake, perhaps again before school, at play time, lunchtime, afternoon tea time, dinner time, and bedtime.  This gives the bladder a chance to fill and empty, and increase the bladder strength and capacity.  If he is always in a hurry to go and play, he could perhaps be given permission and a prompt to go to the toilet before he goes to play, perhaps just before the bells go for breaks at school.
Try to encourage regular fluid intake to dilute his urine, again around the times he toilets.  This is actually harder than it sounds for a child to do, so start with small goals (regularity and volumes) and increase slowly over time.  Lemon barley is helpful in reducing the acidity of the urine, so put it in his drink bottle if his school allows drinks other than water.  Also, put measures or lines on his drink bottle so he can see when he meets his drinking goal.  If you get him to measure his urine weekly he will be able to visualise how the drinking is helping his bladder muscle getting bigger.  Kids seem to be very visual so seeing the difference is encouraging to them.
Initially the increased fluid will make him want to toilet more frequently and actually wet more at night, but once his bladder gets used to holding the increased fluid this will settle down - usually it is about a week and the increased wetting reduces again.
Reward the effort rather than the outcome as it is very hard to establish new routines. 
Give yourself a pat on the back for being a good parent and addressing problems as they arise.  There are more children than you probably realise that have similar problems, and it is not a reflection on parenting or that your child is lazy.  Hang in there and take it slowly.  If there is no progress or change within a couple of months, and he is making a great effort, ask the GP to refer him to a paediatrician to rule out any medical cause for the wetting.  There are medications that can be helpful, but they are generally prescribed after basic bladder retraining has been tried and little progress made.
I wish you all the best.