Parental Tolerance Scale (PTS)

Abstract

The Parental Tolerance Scale (PTS), initially introduced in the clinical literature as the Maternal Tolerance Scale, is a specialized psychometric assessment instrument developed by clinical psychologist Richard J. Butler, Chris R. Brewin, and W. Ian Forsythe (1986). Designed specifically within pediatric behavioral medicine and child clinical psychology, the instrument systematically measures parental emotional, cognitive, and behavioral reactions toward nocturnal enuresis (bedwetting) in children. Comprising 16 dichotomously scored items (Yes/No response format), the PTS captures the continuum extending from empathetic acceptance, benign attribution, and parental forbearance to intolerance, punitive coercion, frustration, and perceived intentionality. Psychometrically, the PTS demonstrates sound internal consistency (Kuder-Richardson 20 / Cronbach’s alpha coefficients consistently reported between .75 and .84 across empirical investigations) and reliable test-retest stability across clinical baseline intervals. Factor analytic studies delineate two primary dimensions: parental empathy/understanding versus intolerance/punitive intent. Crucially, empirical research has validated the scale as an indispensable clinical predictor of non-adherence and premature attrition in behavioral conditioning protocols, notably enuresis alarm interventions (the bell-and-pad method). Furthermore, the scale serves as an operational window into the cognitive appraisals that mediate parental frustration and punitive disciplinary practices, rendering it an essential screening and diagnostic tool in pediatric clinics, community mental health settings, and behavioral pediatrics research.

Keywords

Parental Tolerance Scale, Nocturnal Enuresis, Maternal Tolerance, Pediatric Psychology, Attribution Theory, Bedwetting, Enuresis Alarm, Parent-Child Interaction, Behavioral Pediatrics, Psychometrics

Authors

The Parental Tolerance Scale was conceptualized, operationalized, and psychometrically validated through an interdisciplinary collaboration between clinical psychologists and pediatricians specializing in developmental bladder control and behavioral enuresis management in the United Kingdom:

• Richard J. Butler, Ph.D., CPsychol: Consultant Clinical Psychologist at the Department of Clinical Psychology, Leeds Community Healthcare NHS Trust and High Royds Hospital / St James’s University Hospital, Leeds, United Kingdom. Dr. Butler is internationally recognized as a leading authority on the psychological impact, etiology, and multi-modal treatment of pediatric nocturnal enuresis and daytime wetting disorders.
• Chris R. Brewin, Ph.D.: Emeritus Professor of Clinical Psychology at University College London (UCL), United Kingdom. An internationally distinguished clinical psychologist widely celebrated for his seminal work on cognitive attribution theory, intrusive memory processes, and post-traumatic stress, Dr. Brewin contributed methodological and theoretical expertise regarding parental causal attributions and emotional reactivity.
• W. Ian Forsythe, M.D., FRCP: Consultant Paediatrician and Reader in Paediatrics at the Department of Paediatrics and Child Health, University of Leeds and the Leeds General Infirmary, Leeds, United Kingdom. Dr. Forsythe conducted pioneering clinical trials on the neurophysiological and pharmacological mechanisms of enuresis and spearheaded early clinical audit systems evaluating conditioning alarms.

Purpose

Pediatric nocturnal enuresis is one of the most prevalent developmental disorders of childhood, affecting approximately 15% to 20% of five-year-olds and persisting in up to 2% to 3% of adolescents. While historically pathologized through either purely psychoanalytic hypotheses (viewing bedwetting as a manifestation of repressed intrapsychic conflict) or strictly physiological models (emphasizing nocturnal polyuria, detrusor overactivity, or arousal thresholds), contemporary clinical science recognizes enuresis as a complex biobehavioral condition. The daily management of nocturnal incontinence places substantial physical, financial, and emotional strain on families. The primary clinical and empirical purpose of the Parental Tolerance Scale (PTS) is to quantify the parent’s—most often the mother’s—attitudinal stance, tolerance threshold, and behavioral propensity toward punitive retribution or empathic support in response to their child’s involuntary wetting episodes.

Clinically, the instrument serves three interrelated operational functions:

• Pre-Treatment Triage and Risk Stratification: Behavioral conditioning via the nocturnal enuresis alarm is recognized globally as the first-line intervention with the highest long-term curative success rate. However, successful alarm implementation requires profound parental commitment, persistent nocturnal waking, and non-punitive support over an average course of 12 to 16 weeks. A parent characterized by severe intolerance, hostile attributions, and punitiveness is at high risk for premature treatment discontinuation, escalating parent-child conflict, or sabotaging the behavioral regimen. Administering the PTS prior to initiating an alarm protocol enables clinicians to identify families needing structured cognitive restructuring or supportive counseling before introducing nocturnal conditioning.
• Detection of Covert Secondary Maltreatment: Epidemiological studies reveal that children with nocturnal enuresis face an elevated risk of physical abuse, verbal castigation, and emotional shaming directly provoked by wetting episodes. The PTS directly interrogates whether parents endorse physical discipline (“A smack following bedwetting never did any harm”) or open hostility (“I punish my child for bedwetting”), providing clinicians with an ethically imperative, non-judgmental screening device for emotional and physical maltreatment within pediatric encounters.
• Treatment Outcome Monitoring and Psychoeducational Evaluation: In longitudinal interventions, the scale serves as a standardized evaluative metric to determine whether parental psychoeducation, cognitive reframing of the involuntary nature of enuresis, and bladder rehabilitation successfully shift parental cognition from blaming, anger, and intolerance toward empathetic understanding and constructive collaboration.

Psychological Construct

The Parental Tolerance Scale measures a multidimensional psychological construct that reflects the intersection of parental cognitive appraisal, emotional equilibrium, and behavioral reactivity toward a child’s chronic functional impairment. Parental tolerance in the context of developmental wetting disorders is not merely a passive absence of frustration; rather, it denotes a psychological capacity to maintain emotional stability, empathetic perspective-taking, and developmentally appropriate expectations despite ongoing domestic burden and disrupted sleep routines.

The construct encompasses three primary conceptual domains:

1. Causal and Controllability Attributions

A central pillar of the construct concerns whether the parent attributes nocturnal enuresis to factors under the child’s volitional control or views it as an involuntary physiological delay. As demonstrated by psychological research into parental cognition, parents who believe their child “could stop bedwetting if they tried hard enough” or link the symptom to developmental immaturity and intentional obstinacy (“If he/she would grow up a bit we wouldn’t have all the trouble”) experience elevated rates of subjective anger and resentment. Conversely, high parental tolerance is defined by the recognition that the symptom lies outside the child’s conscious control, neutralizing blame and fostering benign causal inferences.

2. Empathy, Shared Embarrassment, and Affective Reassurance

The empathic dimension reflects the caregiver’s ability to decentrate from their personal inconvenience and appreciate the internal emotional world of the affected child. Items in this domain capture parental recognition of the child’s stigmatization, secondary social restriction, and distress (“I feel sorry for any child who wets the bed,” “I try to help him/her not to be upset,” “It’s a pity the bedwetting stops him/her doing so many things”). High-tolerance caregivers actively mitigate the child’s shame through explicit verbal reassurance (“I tell him/her it does not matter”) and emotional buffering.

3. Perceived Domestic Burden and Punitive Behavioral Reactivity

The third dimension operationalizes parental tolerance through behavioral and practical parameters. Chronic enuresis creates significant domestic labor, characterized by relentless laundering of bedding, urine odor management, and sleep deprivation. Intolerant parents perceive these demands as an unfair personal affliction and domestic disruption (“The bedwetting is a nuisance to the rest of us,” “I find it difficult to get used to wet beds”). When domestic frustration interacts with hostile attributions, it manifests in punitive actions, such as deliberately inducing guilt (“I try to make him/her realize the unpleasantness the bedwetting causes for others”), displaying overt behavioral rejection (“After a wet bed I show him/her I am disappointed”), or administering physical punishment.

Theoretical Framework

The theoretical architecture of the Parental Tolerance Scale is firmly grounded in Bernard Weiner’s Attribution Theory of motivation and emotion, integrated with cognitive-behavioral models of parent-child interaction dynamics and psychological stress models developed by Richard Lazarus and Susan Folkman.

According to Weiner’s attributional model, human affective and behavioral reactions to an event are mediated by the causal explanations generated for that event along three primary dimensions: locus of causality (internal vs. external), stability (stable vs. unstable), and controllability (controllable vs. uncontrollable). When an outcome is perceived as negative, attributing causality to an internal, controllable factor within another person evokes primary emotions of anger, moral indignation, and retributive behavior (such as punishment or reprimand). In contrast, when the negative outcome is judged to be uncontrollable by the actor, the observer responds with empathy, sympathy, and helping behaviors.

Butler, Brewin, and Forsythe operationalized this cognitive paradigm within pediatric medicine. Nocturnal enuresis represents an ambiguous stimulus: because urination is normally brought under voluntary diurnal control by early childhood, parents often struggle to comprehend why nocturnal control remains elusive. If a parent generates an internal, controllable attribution (e.g., “the child is lazy,” “they do not bother to get out of bed,” or “they are acting out”), Weiner’s model predicts an acute affective state of parental hostility, leading directly to punitive parenting practices. The PTS operationalizes these cognitive appraisal processes by measuring the degree to which parents hold the child responsible versus recognizing nocturnal enuresis as an involuntary maturational phenomenon.

Furthermore, the scale draws upon Gerald Patterson’s coercive family process model. In Patterson’s framework, negative parent-child exchanges escalate through reciprocated aversive behaviors. In households where parents display low tolerance and apply punitive pressure to an enuretic child, the child’s elevated anxiety and decreased self-esteem frequently exacerbate secondary emotional difficulties, sleep fragmentation, and behavioral resistance. This destructive dynamic impairs the behavioral conditioning required for successful nocturnal arousal training. Thus, the PTS captures the critical parental cognitive node that either sustains or de-escalates these coercive familial cycles.

Validity

The psychometric validity of the Parental Tolerance Scale has been established through empirical investigations exploring construct, criterion, convergent, and predictive validity across pediatric and child clinical psychology.

Construct and Known-Groups Validity

Initial validation studies conducted by Butler, Brewin, and Forsythe (1986) demonstrated strong known-groups and construct validity. Mothers seeking clinical treatment for their enuretic children exhibited a broad, normally distributed range of tolerance scores. Construct validity was confirmed by examining the systematic relationship between PTS scores and explicit maternal attributions of controllability. Mothers who scored low on the tolerance scale were significantly more likely to rate their children’s bedwetting as intentional, to report feelings of direct anger upon waking to a wet bed, and to hold the child morally accountable for the wetting episodes.

Predictive and Criterion Validity

The predictive utility of the PTS represents its most empirically substantiated feature. In a landmark prospective investigation, Butler, Redfern, and Forsythe (1993) evaluated the prognostic capacity of the Maternal Tolerance Scale among children undergoing conditioning treatment via enuresis alarms. The authors demonstrated that pre-treatment parental tolerance scores significantly predicted two critical clinical outcomes:

• Treatment Drop-out: Mothers exhibiting low baseline tolerance demonstrated significantly higher rates of premature treatment abandonment prior to completing the required 14 consecutive dry nights protocol. Intolerant parents found the nocturnal disruptions inherent in alarm sounding intolerable, misinterpreting initial alarm-triggered wet beds as behavioral failure rather than an expected step in classical conditioning.
• Long-Term Relapse: Lower parental tolerance at baseline correlated with higher rates of post-treatment relapse at 6-month and 12-month follow-up assessments, illustrating that parental hostility and lack of emotional buffering undermine the durability of acquired continence.

Convergent and Discriminant Validity

Convergent validity has been established through correlations with standardized psychometric measures of family dysfunction, maternal psychological distress, and child behavioral pathology. Lower scores on the PTS correlate positively with maternal scores on the Malaise Inventory and higher scores on the General Health Questionnaire (GHQ-12), indicating that broader parental distress diminishes specific tolerance for nocturnal incontinence. Furthermore, low tolerance correlates with elevated maternal ratings of internalizing and externalizing problems on the Child Behavior Checklist (CBCL); notably, when objective child assessments are compared, this correlation frequently reflects maternal perceptual bias and maternal intolerance rather than actual child behavioral maladjustment (Butler, 2001).

Reliability

The reliability of the Parental Tolerance Scale has been confirmed across clinical audits and research studies evaluating pediatric elimination disorders:

• Internal Consistency: Because the PTS employs a dichotomous (Yes/No) scoring architecture across its 16 items, internal consistency is evaluated using the Kuder-Richardson Formula 20 (KR-20) as well as standardized Cronbach’s alpha coefficients. In initial clinical samples of mothers of enuretic children, Butler et al. (1986) reported an internal consistency reliability coefficient of .78. Subsequent replications in outpatient pediatric clinics (Butler et al., 1993) demonstrated comparable coefficients ranging between .75 and .84. These metrics signify a robust degree of item homogeneity, confirming that the 16 items reliably tap a unified underlying dimension of parental tolerance versus intolerance.
• Test-Retest Stability: Test-retest reliability was evaluated during pre-intervention baseline periods where no active clinical intervention was introduced. Over a 4-to-6-week waiting list control period, the scale demonstrated notable temporal stability, yielding test-retest correlation coefficients ($r$) exceeding .80 ($p < .001$). This stability confirms that maternal tolerance represents a persistent cognitive-attitudinal disposition rather than a volatile affective state, remaining stable until direct clinical intervention or cognitive reframing occurs.
• Split-Half Reliability: Split-half reliability estimates, adjusted via the Spearman-Brown prophecy formula, have consistently yielded coefficients exceeding .76, confirming that both halves of the instrument sample the attitudinal domain with balanced measurement precision.

Factor Analysis

Exploratory factor analyses (EFA) using principal components analysis with varimax and oblimin rotations have repeatedly elucidated the internal structure of the 16-item PTS. These psychometric investigations reveal a clear two-factor solution that accounts for a substantial proportion of the total variance:

Factor 1: Intolerance, Attribution of Blame, and Punitive Coercion

The primary factor accounts for the largest share of explained variance (approximately 28% to 34% across empirical studies). This factor is dominated by items expressing frustration, perceived domestic nuisance, causal blame, and behavioral punishment. Salient item loadings on Factor 1 include:

• Item 15: “I punish my child for bedwetting” ($lambda > .70$)
• Item 16: “A smack following bedwetting never did any harm” ($lambda > .68$)
• Item 13: “Children could stop bedwetting if they tried hard enough” ($lambda > .65$)
• Item 11: “The bedwetting is a nuisance to the rest of us” ($lambda > .62$)
• Item 10: “I try to make him/her realize the unpleasantness the bedwetting causes for others” ($lambda > .60$)
• Item 9: “After a wet bed I show him/her I am disappointed” ($lambda > .58$)

Factor 2: Empathy, Child Perspective-Taking, and Benign Acceptance

The secondary factor accounts for approximately 14% to 18% of the common variance and consists of items assessing parental empathy, emotional support, and recognition of the child’s lack of control over nocturnal wetting. Characteristic item loadings include:

• Item 2: “I try to help him/her not to be upset” ($lambda > .66$)
• Item 5: “I don’t mind the washing because he/she can’t help it” ($lambda > .64$)
• Item 1: “I feel sorry for any child who wets the bed” ($lambda > .61$)
• Item 6: “I tell him/her it does not matter” ($lambda > .55$)
• Item 3: “It’s a pity the bedwetting stops him/her doing so many things” ($lambda > .52$)

While these two sub-dimensions provide nuanced diagnostic profiles, Butler and colleagues demonstrated that the items combine into a reliable unidimensional total score, which serves as the most robust predictor of treatment adherence in clinical practice.

Instrument / Measurement Tool

The Parental Tolerance Scale is structured as a brief, self-administered clinical questionnaire designed for rapid administration and unambiguous scoring in busy pediatric and primary care environments.

• Instrument Name: Parental Tolerance Scale (PTS); historically referenced in original research as the Maternal Tolerance Scale (MTS).
• Target Respondent: Primary caregivers (mothers, fathers, or legal guardians) of children and adolescents experiencing nocturnal enuresis.
• Format & Administration: Paper-and-pencil questionnaire or digitized self-report survey. It requires approximately 3 to 5 minutes to complete.
• Number of Items: 16 concise declarative statements.
• Response Format: Forced-choice dichotomous scale: Yes or No.
• Scoring Architecture and Rules:
  • The scale is scored such that higher aggregate scores indicate greater parental tolerance, while lower scores reflect intolerance, frustration, and punitiveness.
  • Tolerant Items (Direct Scored): For items expressing empathy, acceptance, and understanding (Items 1, 2, 3, 4, 5, 6, 7), endorse a response of “Yes” = 1 point and “No” = 0 points.
  • Intolerant Items (Reverse Scored): For items reflecting intolerance, nuisance, blame, disappointment, and punishment (Items 8, 9, 10, 11, 12, 13, 14, 15, 16), endorse a response of “No” = 1 point and “Yes” = 0 points.
  • Total Score Range: 0 to 16 points. Higher total scores denote high parental tolerance and empathy; lower total scores (typically $le 8$) indicate high maternal/parental intolerance and elevated risk of treatment non-compliance and parent-child friction.

Permissions & Fee and Test Year

The Parental Tolerance Scale was originally published in 1986 by Richard J. Butler, Chris R. Brewin, and W. Ian Forsythe in the peer-reviewed journal Behaviour Research and Therapy. As detailed in Joel Fischer and Kevin J. Corcoran’s standard reference sourcebook, Measures for Clinical Practice and Research: A Sourcebook (4th ed., Oxford University Press, 2007, Vol. 1, pp. 398–399), the instrument is placed in the public domain for clinical practice and non-commercial research use.

No user fees or royalties are required to administer, score, or integrate the PTS into non-profit clinical workflows or academic research protocols. Researchers and healthcare practitioners are expected to cite the original validation literature appropriately. For commercial redistribution or incorporation into proprietary digital health platforms, permission should be sought from the copyright holders and the original publishing entity (Elsevier / Oxford University Press).

References

• Butler, R. J., Brewin, C. R., & Forsythe, W. I. (1986). Maternal attributions and tolerance for nocturnal enuresis. Behaviour Research and Therapy, 24(3), 307–312. https://doi.org/10.1016/0005-7967(86)90189-9
• Butler, R. J., Redfern, E. J., & Forsythe, W. I. (1993). The maternal tolerance scale and nocturnal enuresis. Behaviour Research and Therapy, 31(4), 433–436. https://doi.org/10.1016/0005-7967(93)90104-e
• Butler, R. J. (2001). Impact of nocturnal enuresis on children and young people. Scandinavian Journal of Urology and Nephrology, 35(3), 169–176. https://doi.org/10.1080/003655901750291935
• Butler, R. J. (2004). Childhood nocturnal enuresis: Developing a conceptual framework. Clinical Psychology Review, 24(8), 909–931. https://doi.org/10.1016/j.cpr.2004.07.001
• Fischer, J., & Corcoran, K. J. (2007). Measures for Clinical Practice and Research: A Sourcebook (4th ed., Vol. 1: Couples, Families, and Children, pp. 398–399). Oxford University Press. https://global.oup.com/academic/product/measures-for-clinical-practice-and-research-9780195329728
• Weiner, B. (1985). An attributional theory of achievement motivation and emotion. Psychological Review, 92(4), 548–573. https://doi.org/10.1037/0033-295X.92.4.548

Items of the Scale