122. Potty training and the pelvic floor with Dr. Quira Smith

In this episode, Occupational Therapist Dr. Quiara Smith and I discuss:

• Potty learning vs potty training
• What do we need to see in our kids to know they are ready to potty train?
• Ideal age?
• How does the pelvic floor relate to potty training?
• What is required for night time continence?
• Tips
• How childhood habits can translate to adult symptoms
• Should we reward?
• Constipation 

Dr. Quiara Smith, OTD, MOT, OTR/L, CEIM has been practicing as an Occupational Therapist for over 15 years in both California and Hawaii working in various settings including hospitals, schools, an equine center providing hippotherapy as a treatment tool, and outpatient clinics. Her pediatric experience encompasses serving neonates through adolescents with various medical conditions and diagnoses. Dr. Smith began working with pediatric pelvic health patients in a Children’s Hospital in the SF Bay Area in 2015 and found her passion in OT in this area of practice.

Realizing the social, emotional, and psychological challenges that pelvic floor dysfunction places on children and families, Dr. Smith decided to create the very first boutique private pediatric pelvic health occupational therapy clinic of its kind in the US in 2020. Her private practice, Aloha Integrative Therapy , exclusively treats children and adolescents with pelvic floor dysfunction and toileting challenges. Dr. Smith utilizes a holistic and integrative approach to pediatric pelvic floor dysfunction. She partners with her canine assistant, Nelly, a Labrador/golden retriever cross, in guiding children toward continence with confidence. Dr. Smith currently serves as an adjunct faculty member in the Occupational Therapy Doctorate Program at Hawaii Pacific University. 

LINKS MENTIONED

Course: A Holistic and Integrative Approach to Pediatric Pelvic health

Instagram @alohaintegrativetherapy

Tinyhood Courses:

Potty Training Prep: Setting Your Toddler up for Success

Potty Training: The Stress-Free Guide to Success

THANK YOU TO THIS EPISODE SPONSOR

SRC Health:  Use the link below for a discount at checkout!

https://srchealth.com/?ref=PELVICFLOORPROJECT

Thanks for joining me!
Here is where you can find out how to work with me:  www.pelvicfloorprojectspace.com/

mel@pelvicfloorprojectspace.com

Transcript

SPEAKER_01 0:00

Welcome to episode 122. Body training. This is a topic I've been asked to cover for quite some time, so it is about time, isn't it? Joining me today is Dr. Kiara Smith, a California-based occupational therapist and clinic owner who specializes in children and adolescents with pelvic floor dysfunction and toileting challenges. She has some amazing resources for clinicians as well as parents and caregivers, so listen up for those. I don't think parents realize how potty training is related to the pelvic floor. As a pelvic health physio that works with adults, I will tell you that habits play a huge role in your bodily functions like peeing and pooping. And where would you guess many of these habits start? Parents and caregivers, you have a big role in this. The learning you provide, the environment you create, the language you use, it goes a long way in the habits and long-term pelvic health of your child, who will one day grow to be an adult. Listeners, before we get rolling, can I ask you a favor? Would you consider downloading the episodes when you listen? The only way podcast uptake is measured is through downloads. Listons without downloading is not captured, and this helps me in so many ways. Alright, let's get on with it. I'll be right back with Dr. Chiara Smith. Listeners, whether you're a busy mom, a fitness enthusiast, or just navigating everyday life, millions of women experience challenges like bladder leaks, prolapse, or pain. It can feel overwhelming. But it doesn't have to be. That's where SRC Restore shorts and leggings come in. These aren't your typical garments. They're revolutionary medically designed compression wear that can help your organs feel supported and minimize bladder leaks. Unlike products that just absorb leaks, SRC Restore helps the function of surrounding muscles, giving you support and confidence. This line of leggings not only provide the trusted compression, but also come with pockets, perfect for on-the-go lifestyle, whether you're working out, running errands, or just relaxing. Hundreds of women have reported real results like improved mobility, reduced discomfort, and enhanced quality of life. With a 100-wash durability guarantee, these garments are made to last. If you're looking to restore confidence, feel supported, and take control of your pelvic health, check out the SRC full range by using the QR code provided in the show notes, and this will automatically provide you with a 10% discount site-wide. All right, Kira Smith, I um mentioned in my introduction to this episode that this is a topic that I've been asked to cover for a while now. And I actually, but I was just waiting for the right person. And somehow I stumbled on your language and your information. And I thought this is exactly who I would like to have on. Because not only are you an OT, which I've been wanting to have a pelvic health OT on this podcast. I just, I have so many topic ideas, amazingly. So I just get to them as I can. But um I also love that you have some resources to share for not only clinicians that want to learn a little bit more about this, but also for parents, and we'll get to that at the end. Um, but why don't you? We're gonna talk today about um potty training. I love your term, potty learning. Um, before we get to that, will you tell the listeners a little bit about yourself so they know who you are?

SPEAKER_00 3:22

Absolutely. Thanks so much for having me. Um, I am Dr. Kiara Smith. I am a pediatric pelvic health occupational therapist. I've been in practice for over 15 years, but over a decade has been spent in pediatric pelvic health. Um, I did not know anything about pediatric pelvic health when I was in grad school, and then I stumbled upon it when I was an outpatient therapist in a pediatric children's hospital, and I fell in love with it. And that's kind of my journey to getting to this space. And currently I have a private practice. I opened the very first boutique private practice, specifically treating children with bowel and bladder disorders as an occupational therapist. And you're located in California? Correct. I'm in Northern California in beautiful Sonoma County, so that's a little north of San Francisco. Cool.

SPEAKER_01 4:17

Okay, so potty training, and actually, I I naturally we're gonna transition maybe a little bit to the to the term potty learning, which I really like. I think it was listening to something that you did that made me, oh my gosh, that's a really good way to put it. This, I feel like there's just a lot of talk around potty training, around like, okay, when did you start? How did you do it? This is the method we used. Um, can you just start a little bit with like what like what do we, what needs to happen in a child in order for them to be even ready for potty training? Like, I want to talk a little bit at the kind of like the neurological level for a second. Like what needs to be, what do they need to be able to do? And we you hear a lot of talk around the term the micturation reflex and when this is mature in a child, and you know, when can their brain recognize signals? When is their bladder ready to hold, if you will, and how the pelvic floor relates. I guess I just want you to start a little bit with like how what needs to be able to be happening in the background before we even entertain the idea of potty training in our children?

SPEAKER_00 5:25

Yeah, I mean, that's the million-dollar question. And there's so many opinions out there from different areas of thought, right? We have the behaviorists, we have um the educators, we have the therapists, the developmental psychologists. And I think from just my clinical experience and my background as an occupational therapist, treating pediatrics for many years, I'm really focused on development. And so development is not just physical development, it's social emotional, it's sensory, it's psychological, it's spiritual, it's um relational development. And I think that's where my perspective is a little bit different than maybe ones out there who have been more of a behavioral approach, with is the training. Like, how do we train this particular skill? And what you were talking about previously of kind of that neurological piece, that is definitely really important, and that ties into the physiological piece because if our nervous system or if there's a part of our body that is not receiving information efficiently or effectively, it's gonna impact continence and then it's gonna impact other things. Um, and so when I'm looking at supporting children with bowel and bladder dysfunction and things like potty training, potty learning, I'm really looking at the whole child. And that goes from, you know, the physical readiness. So is that child able to feel urge sensation? Can they stay dry overnight or during naps? Um, are they able to do things like uh lower body dressing? Um, so these are kind of some readiness signals that I would I would anticipate a child to be able to do. And around the age of 24 to 30 months is really when sphincter control is more mature. And so you'll see in literature or other books on parenting that, you know, let's start at 18 months of age, or let's start when the child is is showing just readiness cues um based on age. And I don't really believe in that, particularly as a primary reason to kind of start the process.

SPEAKER_01 7:43

I find it's interesting because again, you work with um children, I work with adults, and I think about how often when someone, let's talk about an adult for just a second, they come in with bowel or bladder symptoms, and I always pull out images I have on my computer, or I draw kind of the relationship between the brain, the bladder, the rectum, and the pelvic floor, and in just very simply, just because we can't use images in a podcast, I'll draw that, you know, kind of like a circle up at the top of the page to represent the brain, a little circle to represent the bladder, and then a tube to represent the rectum, and then show that the pelvic floor is like a valve and explain just how adults don't even understand this for the most part that you know, your bladder, for example, is a storage bag. It's a muscle, it's storing urine, it's always keeping your brain up to date on how full it is. The pelvic floor will help to create a seal on the bag at the bottom just to make sure nothing comes up out when we don't want it to. And the same thing's happening in the rectum. Um, as the stool makes its way down to the end of the intestines, that stretch in the rectum will notify the brain that there's something there. In the meantime, the pelvic floor will make sure nothing comes out, and it's when we go to the toilet that the brain recognizes that this is a safe place back from potty training days. And so adults are like, wow, I didn't know how that works. And so I'm looking forward to now hearing, um, like, you know, how I'm, I guess I'm trying to say, like, given that adults don't know this, do you really think most of them know that this is what's working in their child? Like this is what's behind the scenes, all of these different intricacies. And so, like you said, the child also needs to be able to recognize those sensations. Um, and and I just want you to talk a little bit more about that, some of the things that you come across with, you know, tiny adults really.

SPEAKER_00 9:42

Yeah, yeah. And you're spot on because when I am describing just what you're talking about with how um urge sensation works in the bladder for a child, I will get a balloon and I will fill it with water and I will do um a demonstration of what the body is doing and describing in child-friendly terms. And parents are like, their minds are blown. They're like, I had no idea. And then I use my hands as the pelvic floor, and then I talk about sphincters. We have internal sphincters and external sphincters, and for the rectum, I'll use play-down or I use clay. And I'm really doing this um education piece, not only for the child, but for the families and the parents and caregivers, because it is uh very interesting when we have our conversations, especially the first evaluation or the first session. Parents are saying, Well, you know, Dr. Chiara, I had those issues when I was little and I had no idea what was going on. And now I have pelvic pain, or now I have prolapse, and I just had no idea that these things started probably in childhood when I was withholding or if I was pushing or straining. So it's really amazing to see their self-awareness improve because that helps their child. And that's when the real magic happens, when the knowledge that the parent and caregiver is receiving is landing in a space that they can help um and support their child. So it makes my job a lot easier.

SPEAKER_01 11:19

Yeah. And I think that that's where I think when you describe all the other things like that are going on in a child, you can't just say an age is the be all and end all. So, but is there a time? So when you say, I think, did you say 24 to 36 months? Is that because are all of those abilities in the physical body there to be able to? I guess what I'm saying is, is the brain at a maturity level? Is the bladder at a maturity level, like the the smooth muscle, the pelvic floor, is that all at a developmental ability to be able to? And then we have all those other factors to consider?

SPEAKER_00 11:57

Yes, and I will say a caveat, right? And we're talking about more neurotypical children. So no children that have you know congenital medical conditions that were at birth or children who are also neurodivergent. So that is um a broad age range. And like I'm saying, when that is stated 24 to 30 months, people say, isn't that a little bit too old? Like I feel like that's you know, going and waiting too long. But like you're saying, it really is when brain maturation is better able to build the skill and then to master it. So I'm looking at mastery of skill versus skill acquired, and then you think that that's it. Acquisition of skill happens over time. When children are under the age of five, brain and body development is super rapid. So we want to make sure that we're getting them on the right trajectory to be able to master the skill of continents. So being able to have good pelvic floor function, have good bowel and bladder control across all environments, no matter where or what they're doing. And that's a pretty large ask for kids, especially when we're looking at children who do have sensory processing differences, who do have neurodivergent conditions. So um, this is just kind of a a good starting and basic foundational knowledge to um impart on neurotypical children first.

SPEAKER_01 13:30

Because I can imagine I'm thinking about all the factors. Like, for example, um, like I have two different, I have two kids, and wow, the difference is just in personality, right? I think about things like um, you know, I don't want to throw my kids under the bus here at all. So um I think about one who, who, who literally was, okay, sure, I'll go to the bathroom. Whereas the other one, I think she's very sensitive to um needing to be in a very certain specific place. Like there was one bathroom that they would use in our house only to go to the bathroom, right? They wouldn't go in any other bathroom. They would hold if we were in public. Camping was a nightmare. Like that was a personality difference that that kind of changed what happened. I can imagine that just personalities or tendencies would make a big difference.

SPEAKER_00 14:19

Yeah, personalities definitely play a role in how children start to go on the potty learning journey. Um, we have kids that are really empathetic, deeply feeling kids. Um, and sometimes that's tied into some of those sensory differences. But also, I just let parents know, parents and caregivers know, like the child who's in front of you, it has so many strengths and gifts. And then there's areas of growth, just like everyone. And the comparison thing, especially if you have more than one child, it's sometimes hard for parents because they're like, they're so smart in so many different ways. Like, I just can't understand, like, why this is such a sticking point. And I say there's something about it that just is not landing so safely yet in their body about what we're expecting them to do. And this is our job to number one, give ourselves grace, but give our child grace in understanding that we have to think maybe outside of the box for them. Maybe you have to set things up a little bit different than we didn't have to do for our older child. Um, and it's a really wonderful opportunity, I like to say opportunity to grow more deeply in connection with your child when you do have these difficult moments. And sometimes parents say, I just can't do it anymore. And I'm like, Yes, I hear you, I understand, and I want to be there to support you. And I also know that you have the strength to do it. And you're here, right, in in clinic, or you're here trying to find support. And that's the number one thing is that you're trying to find the help you need to help be a better parent and caregiver for your child who's struggling with this.

SPEAKER_01 16:04

I think of your visual representations of the balloon with the water and the whatever you use kind of with the clay or the play-doh, and that visual of the pelvic floor holding them closed. And I think it's hard for people to understand when you explain it to them that that there needs to be a let go in our body and in our nervous system to allow the organ to do its thing, allow the organ to dump. And um, it needs to come from a safe place. Like we need to feel, we need to feel relaxed, we need to feel not rushed. Like this, I can't believe how many parallels to the adults that I see that this is why they have issues. But um, I just think of a couple examples here. I had a a woman, an older um like my age client come in. I just mean not a pediatric client, and I'm not old. No, you're not in. And um, she said, I grew up in a house of six kids, and my mom was always rushed, and I was always on the clock to go to the bathroom. Like there was no peace and quiet. Um, and I also think of again a difference between my two kids and the nervousness of the automatic flush on the toilet, the public toilets and how they couldn't let go to pee because they were so nervous of that. So I just think about how many examples that show up in our day, whether we're rushing or whether it's going to hurt, or whether there's pressure, whether they don't like the splash from the poop. Um, this is such a big one of not being able to relax and let go. And I think again, I can imagine that your visuals help people understand, oh my gosh, I think maybe as parents, I as a parent or a caregiver, I'm not helping my child relax.

SPEAKER_00 17:55

Yeah. And it's not a shame thing, right? It's it's a self-awareness. And they come to the realization that, oh, when I know better, I do better. And because you've brought this to my attention, and when we go through this, like, what does your typical day look like? And what you were describing with your client growing up with six kids in the family always being rushed, it gives the parent an opportunity to like have a bird's eye view, like, oh, actually, now I kind of know why they're withholding or they can't let go. And going back to, you know, parents and caregivers, how we can be supportive of them is really looking at how can we evaluate our expectations, meaning, what what do we think our child should be doing with this particular self-care skill that may not be aligned with who the child is or where they're where they are in their journey. Um, and then I kind of help families figure that piece out is like, you know, do you expect zero accidents? Do you expect them to sit down and poop and it takes one minute? Like all these things we explore together because it gives them an idea of, well, yeah, I can modify that, I can shift that. And then we start seeing progress in the right direction. Oh, instead of, you know, asking, hey, Melissa, do you need to use the bathroom? I'm gonna make a statement. Oh, Melissa, it's been, you know, two hours, you were done with soccer. I think it could be a really nice time to help your body right now, right? So giving them the language as well and coming to an understanding that, you know, my expectations might not be helpful for my child in this particular situation because of, you know, the comparison game or the internal or external pressures I'm feeling about what my child should be able to do and needs to be able to do by a specific age. Um, so I think that plays uh a part in it.

SPEAKER_01 19:55

100%. And I think um, like I listened to you providing just generally like some some overall helpful tips. And I I I think about how often kids learn through play. And so I can imagine just with you showing the kids when they come in, but I'm sure there's lots of ways that parents can, whether they use dolls or figurines or whatever they do. Sometimes I've I found my kids for sure, one of them in particular did so much better when I didn't direct anything at them, but I more just kind of showed them, and that's how they learnt better. Um I I I I look forward to you just if there's any other tips that you have besides kind of like, yeah, the play, the showing them. I think of another one I I used to do, I used to just announce whenever I went to the bathroom. I'm gonna go pee now, and or I'm gonna go poop now, just to normalize it.

SPEAKER_00 20:51

Yeah, and that's something I always encourage parents and caregivers when you're having a body sensation, and we'll do this in clinic first. Okay, I'm gonna go, and then mom's gonna go, and then you're gonna go. And we're gonna talk about where in the body do we feel it, or we're gonna point to the doll, or we're gonna point to like I have a therapy dog, a facility dog, and I'll say, Oh, now he feels it here when she has to pee. Um, and then what does it feel like? Oh, sometimes it feels really heavy, sometimes a lot of pressure, sometimes like butterflies. So we start to name it, and again, like you said, bring it to like normalization of how we talk about our body. And then it gives another point of reference for kids to say, Oh, yeah, I remember. Like when mom said she had to go to the bathroom and when she had to poop, she felt like there was a but like there was a kid the other day who said, I feel like there's a potato on my butt, Dr. Kiara. I'm like, Great, that's wonderful. Like, you know, just whatever it is is encouraging that communication and that talk. And what I find too is that um when, you know, for your example. With the automatic flush. So something parents can do is, you know, use a post-it note when they're going out in the community and using the restroom to cover that and then talk about it. We're going to put a post-it note before we go and target on the toilet so then your body feels comfortable enough so it won't be unexpected that the toilet flushes. Oh, that could be so unexpected and surprising and kind of scary. I get it, right? So being able to validate the child's feelings about whatever it is, even if you feel like it's so silly, because to them and their reality and their experience, it isn't. And this is something that I help, again, parents and caregivers just evaluate and become curious about. And then they start to understand, let me get on my child's level to understand what they're experiencing. And that can be super helpful.

SPEAKER_01 22:49

Because that's another thing I hear from adults all the time is I was never able to openly talk about this in my house. And so I think that um you you don't realize how much um permission or or safety you give to your kids when you just talk about it and normalize it. So when something's wrong, whether it hurts, you know, does it, you know, it hurt, does it hurt to go or, you know, that would be weird if you didn't ever talk about that, right?

SPEAKER_00 23:16

Yeah, absolutely. And there are a lot of families culturally who they don't talk about that and those things aren't discussed. And so we have to meet also families where they're at and understand um how their lifestyles are and their cultural beliefs to support um gaining the knowledge, but also moving them in the right direction in a respectful way, of course. But I think uh parents sometimes will share that same exact situation. It's like I never had that conversation with my mom or dad. I mean, it was taboo, and I said, I hear you, that that must be really feeling like maybe alone in that, in that feeling of fear when you had, you know, constipation as a kid. And I said, Oh, but look at you now. You are supporting your child so well by finding providers to help them with this particular issue that's gonna be in the rear view mirror one day. And they're they look at me like you're nuts. Because this constipation thing with my kid has been happening since they were six months old and now they're six years old. So what it is like, nope, you're on the right track, even though it seems like this crazy uphill battle, you're on the right track because you're getting the support you need and you're open to doing things a different way than how you were raised.

SPEAKER_01 24:36

Listeners, I know many of you are physios that are perhaps new to the area of pelvic health and feeling like you could benefit from some guidance as the complexity of your caseload goes up. I offer mentorship and I'm here to help. Let's figure out a structure that works best for you. My contact details are in the show notes, so please do reach out. So we've talked about how one of the most helpful things we can do as parents is normalize it, but also just, you know, tie it to something that involves relaxation or like letting go without pressure or without you have to go now or I'm standing here till you do it. I like we kind of talked about the benefit of you know, like a safe space, having time. How are you gonna set up your day to allow that time? Um, any other suggestions for parents or caregivers to set up an environment that's relaxing or calm?

SPEAKER_00 25:34

Yeah, I would incorporate the things your child loves. So if they're into Paw Patrol or they're into Disney princesses, maybe you decorate the bathroom with a couple of posters and you bring in some fun lights, and you have a small potty if you're going through the journey and it's in the beginning phases, and you have a floor potty, you might have them decorate it with stickers and you have their, you know, princess dolls playing on it before. So there's a level of preparation that you want to be able to have before you spur it on the child, like, okay, well, today there's gonna be no diapers or whatever it is that you're gonna um do. But having that preparation is really important, and that's a resource that I created too, like the preparation phases. What can you do before the 24 months when your child is maybe 18 months or 12 months or even younger, and you're talking about the body and talking about toileting? Um, it gives them a reference point again, an association of when I'm talking about this, when I'm going into this space of the bathroom or looking at this or playing with this particular object, it's safe and secure because I'm doing it through play, through a um loving and caring parent and caregiver together. And we're actually bonding and we're having good attachment. And that essentially is what needs to be kind of the foundation of helping your child through any kind of life skill or kind of skill acquisition, is they need that bonding and attachment. And what I often see is when parents go through this potty training, potty learning journey, it brings up a lot of triggers for them, right? And going back to the expectations of like, I think my child is gonna be, you know, accident-free in the first day, and like the child is having, you know, leaks and accidents all day long, and then the the parents frustrated and getting, you know, overwhelmed, and the the child can feel that. So then that association becomes like I'm not doing well, the child internally saying that to themselves, even though they probably can't verbalize it in their developmental age. Um, but they're feeling that from their caregiver. Oh, I'm not doing something right. When I have this feeling, my parent gets mad at me, or when this happens, my parent shames me. And this is something that I think when we're more prepared for and we're really looking at what approach aligns with us as a person and us as a parent or caregiver, it helps our child uh gain that mastery skill better. And then you actually become closer. You're the stable, sturdy parent. You're the parent who, even though they lose it because you're not a robot, you're not perfect, that you have enough grace to say, Oh, I was so frustrated because you know, you're learning, your body is learning how to pee in the potty and you missed it this time, but next time you're gonna get it, and oh, I was just kind of tired. I'm so sorry. And people are like, you would talk like that to a 12-month-old or 18-month-old or 24-month-old. Um, yes, I talk to newborn babies like that. I asked permission to touch them, etc. So it's it's kind of a different perspective. And uh, and again, it's not for everyone, but for parents who are looking for that type of connection and that type of guidance, it has done amazing things for their relationship and the skill building for their child.

SPEAKER_01 29:02

Would you say that your, you know, suggestion would be first that you're watching a child to see that they're getting the bodily sensations and then teach them to go to the potty? Or would you say that you're teaching or you're suggesting that they spend time on the potty before a sensation? I'm just curious. I know every kid is different, but any thoughts on that? Because I know at the end of the day, we're learning to respond to a body sensation. Correct.

SPEAKER_00 29:29

I'm doing the um the introduction and the practice of sitting on a potty with our clothes on, playing with it, um, and then sitting on it with reading a book. And this is not the expectation of I'm gonna potty train my child in a week. It's maybe in a couple months, but I'm I'm introducing these things. Um, and then you you talk about in tandem, you're talking about how the body works. Oh, sometimes you'll feel it here. You know, you're going through going through the potty training books, um, potty learning books, the children's books, right, with what they're expected to do. There's really great ones out there nowadays with talking about urge sensation and talking about getting to the bathroom and then relaxing to let it out. So there's a lot of that that goes on. Um, and then right when they're really starting to show kind of those readiness cues, again, the physical, social, emotional, and other cues. Um, you know, they're demonstrating better bladder control for brief moments or even minutes at a time. They're having maybe more dry diapers. Um, this is something that you can start when they're getting closer to that 24, 30 month um age range than you can anticipate to look at their biorhythms. So their natural biorhythms are when they are wetting, and then you anticipate that to have them actually sit on the toilet to try and um void.

SPEAKER_01 31:03

That's again so interesting how they're all so different. I remember one of my children just I don't think that the sensation triggered, it's just other things going on that didn't make it to the priority list of her brain, or whereas my other one was so sensitive to sensations and they would hide in the same place all the time when it was time to have a poo. And we would offer because they didn't want to say, if you go, you're in trouble. So I would say you can either go on the potty and have a treat, or you can go there in your diaper. You choose. Yeah. But they always chose the treat. Um, but um, I think it's hard not to sometimes I hear parents or caregivers reflect and say, Oh, I did it wrong. I punished them when they had an accident. Um, can you talk a little bit about rewards? Because I think this is something people are like, Am I supposed to reward this as a bodily function? Just your every kid is, I know there's no black and whites here, but your thoughts on that?

SPEAKER_00 32:00

Yeah, that's uh a big one because there are different trains of thought for rewards, especially if you're doing like a behaviorist approach versus um child-led, right? And I will say just because in the work that I do and what I've seen in my clinical experience with kids who potty learning, potty training went awry and they're having pelvic floor dysfunction because of it, um, it's it sometimes rewards don't matter. It doesn't matter what you are going to reward your child with, a trip to Disneyland, a new video game. They don't care because what is overriding is their fear and their nervous system saying, it is not safe. I don't care if you, you know, give me what I would dream of. This thing is is too hard for me to get past. So that's one thing about rewards I wanted to kind of mention because parents will say that I've I've told them I'd give them a new puppy or this and that, and they still are holding and still having accidents. And I say, I go back to kind of that growth mindset of they don't have the skill yet. If they could, they would. And kids want to do the right thing, they want to make their kid uh families proud, they want to make their parents proud. And, you know, just they're not there yet. But I will say for rewards, there are certain things that children can control. And when I describe this to parents is, you know, they can control um sitting on a toilet if they've showed success with this before, you know, sitting on a toilet for one minute and then, you know, jumping off and finishing to go in a in a pull-up for like a withholding situation. So I would reward that because they were able to sit on the toilet, because that was one of the big sticking points. Like, I don't even want to sit my bottom on a toilet. And it's a reward based on the um the work and the effort that you did. So I wouldn't reward continence per se. So I wouldn't say, oh, because you have a dry underwear or whatever, you're gonna get a reward. I like to reward effort. Oh, you did your five exercises for the day. You get to pick, you know, the Netflix show for 20 minutes that we're gonna watch. So it's like not these huge rewards, but I like kids to feel motivated and excited about them making steps towards their goal of the continents. So you'll see that that difference, I think, from other providers will say, like, okay, well, if you have clean under seven days a week, you get to go to, you know, Disneyland or whatever it is. And I just don't feel as a clinical um provider in this space, I don't feel that um some kids can control that. So that's why I wouldn't necessarily do that particular reward system.

SPEAKER_01 34:59

Another question I have, so in adults, we see a lot of um kind of behaviors or issues around urinating too often, like just starting the habit of every single time I get a sensation, I go. And a lot of people re reflect and say, This is ever since I was a kid, my mom said, Go, go, go, go, go.

SPEAKER_00 35:17

Yes.

SPEAKER_01 35:18

Um, and again, if if we go back to how the anatomy works, the bladder's a storage bag and it's supposed to hold um, you know, a certain amount, and it's not supposed to empty every time something's in it. And I often use an analogy like, we're not supposed to eat all the time. Sometimes you'll get hunger cues and you start to think that you're hungry, but that's sometimes where overeating comes, is that we respond to every hunger cue. Can you talk a little bit about because this is a hard one? I mean, our kids don't always recognize signals in advance. So I think it's easy for us as the caregiver to go say, go again, go again, we're leaving the house, go again. Yeah. Can you talk a little bit about the just in case P and some tips around that?

SPEAKER_00 36:05

Yeah, that's a hard one, especially for kids. When I've seen in a lot of my colleagues in the pediatric pelvic floor space too, see when children are prompted too often, say, you know, they're going every 30 minutes, every 45 minutes, they're being prompted during the potty training, potty learning journey. Um, you're training bladder urgency, right? Like, oh, okay, I'm gonna start every little feeling, I'm gonna think I need to go to the restroom. And um, I try to, when that happens and I have a a client, we try and obviously increase the time with distraction, with talking, and you know, that could be 30 30 seconds, one minute, one and a half minutes, like sometimes that small of increments um between the time to get up to an hour, hour and a half, two hours, just depending on how their bladder is is functioning. Um, but the just in case P, I think if you're monitoring your child and it hasn't been the window of two hours or three hours that they haven't voided yet, I'm gonna say, I'm gonna prompt them. I'm gonna say, Oh, it's been a while. And I do this with my seven-year-old. I'm like, it's been a while that I I've noticed that you went to the restroom. I wonder if it could be helpful before we leave the house to check what your bladder balloon might be feeling. And then it's like, oh yeah, I haven't. But she's able to sense urge. And this is really important for kids who can't sense urge as strongly that they they need the prompt. They need the timed void zit. And over time you hope to retrain the bladder. But I'm I'm a thumbs up for just in case P if it has been a certain amount of time for kids um before leaving the house.

SPEAKER_01 37:59

What about um nighttime continents? This is a hard one. This is one usually that has to come a little bit later. What um, because usually the daytime is easier to work on. Can any thoughts for, you know, what do you want people to know about a nighttime continent?

SPEAKER_00 38:17

Yeah, so nighttime continents happens between four or five years of age. You'll see some in the literature, that's the the age range. Sometimes you'll see five to seven. Um, so when children are going through the potty training process in the beginning, you know, that 24 to 30 months, they're way younger than four to seven years of age if we're gonna do that larger age range. Um, and that's because the maturation of the body to stop producing urine overnight matures more in that um age range. So if your child is still bed wetting and they're still going through the potty learning journey and they're under four, you would anticipate that to happen and it's no biggie. Um, but I think parents think that they can train the physiology of that, which um, you know, you you can't really force um to your kid to be dry overnight and they, you know, wake their child up and they, you know, maybe do a bed alarm. And sometimes that actually can uh cause more issues, different types of issues if you're kind of doing that too young. So parents, um, you know, I think that's a misconception sometimes too. And then we see the other end of it. Oh, your child's bed wedding and they're 12 years old, that'll go away. So some providers will say, oh, don't worry about it, they'll outgrow it. There's a genetic component for sure, um, but all oftentimes it's constipation and poor daytime habits, meaning that they're not having good, just like adults, they're not having good um daytime habits for um their bladder management, and then they're not emptying their rectum fully or they're constipated, even though that they're you know letting stool out every day, a child still could be constipated, and that can cause bad wedding overnight.

SPEAKER_01 40:09

That's a big one. I get a lot of friends reach out saying, What what are your suggestions? And I always think, you know, it's not my expertise, but for anyone listening, is this something that you cover in your resources? Like for parents that are struggling with um, yeah, nighttime wedding that's gone beyond what would be considered normal. Yeah.

SPEAKER_00 40:29

Yeah, absolutely. And um there's a few, I want to say, posts on my social media about um bed wedding past a certain age. And then I also offer um parent coaching if you if they want you know one-to-one support, I definitely offer that support.

SPEAKER_01 40:47

Okay, we'll link all of that in the show notes. Um, you mentioned constipation. Um, I this is where I usually have to bring up an image because people don't understand the anatomy and how how that would affect anything, but there's not a lot of space in the pelvis. And if you in your analogy of using the clay or the play-doh, if you fill up a lot of the pelvic space with that, it just puts so much more pressure on the bladder. And yeah, constipation is it's really hard to know because you can't see it, right? And so um, this will be you mentioned it for daytime or sorry, nighttime wedding, but obviously this would be something you'd be thinking about too if if kids were having issues with wedding in the daytime. Constipation big one for kids, yeah.

SPEAKER_00 41:29

Yeah, so you we typically will see um, you know, both daytime and nighttime urine uh incontinence. And we have to kind of go through our checklist, okay? Let's do constipation first, and then you know, then we do the hormones, and then we did it, or is it an overactive bladder? What other things are we going down our checklist to figure out what is the root cause of this? Um, sometimes it can be uh dietary-based, meaning that the child is having bladder irritants that they're really sensitive to, or they have food sensitivities that have not yet been uncovered that is causing some of the slow gut motility plus the bladder um issues and symptoms.

SPEAKER_01 42:14

What um how what are your suggestions? And feel free to refer to your resource and resources because again, there's no one size fits all. But if someone suspects that their child might be constipated, this and I don't know the answer when people ask me, like, where where should they start? Because it's not that no, not everybody needs to go see a doctor right away. Like, what what are what are we supposed to do as parents if we don't know if our kids are constipated?

SPEAKER_00 42:44

Yeah, if you don't know your kids are constipated, first you have to be the detective, meaning you need to see what they're eating and drinking when. So you're tracking from the moment they wake up to the moment they go to bed what their bowel and bladder habits are on top of what they're eating and drinking. Um, and then you're seeing what's coming out, right? You're asking them, and if they're a little older, sometimes it's it's embarrassing to kids, but you just have to have that frank conversation of um that you're the support and you're the sturdy parent to help find out, you know, why this is happening. So looking at the Bristol stool type of stools that they're having in volume. And then you can also see once you're tracking three, five, seven days, you have a good data set to say, hmm, this is what happened, this is what's happening. I'm noticing my kids not drinking enough water, they're not voiding, you know, urine or or poop every day like I thought, right? So there's just another level of awareness. So then after that, you can then reach out to your pediatrician first or the general primary provider of your child and say, you know, I've tracked this, this is what's happening. How can I support them? And And I will say typically they'll say, oh, you know, give them some medication first to help with this constipation. And if it's acute, right, you're not sure. If it's acute, then you'll probably get something of an osmotic laxative. That's the first line treatment. And then toilet sit schedule. They're saying, oh, put your kid on the toilet every time after snacks or meals. And then make sure that they're getting enough hydration and fiber. And after that, sometimes things resolve. Oh, okay. You know, we are doing better. And then you can wean away from using that osmotic laxative. But for the kids that I see, that's not necessarily the magic thing that happens. Um, and they need maybe a stimulant laxative, maybe they need to go on an NMO or suppository protocol. There's other steps that um happen if kind of that first line treatment isn't uh successful.

SPEAKER_01 44:56

So what I hear you like kind of, if I was to think about putting this all together a little bit, um I think we used to think that um kids just need to be trained, kind of like a dog needs to learn to shake a paw and they need to be trained to go to the bathroom. But again, just based on what I see, the knowledge of adults is is, you know, what if we first understand the system? So maybe one of the first steps would be that the parent or the caregiver should invest some time into just educating themselves how the system works and whether, and I look forward to some resources that you share on how people can do this, but how does it all even work? Um, start to teach the kids at their level of education about it, talk about it, help them understand it, normalize it at home, and then based on your individual child, start to notice some of the cues for readiness around do they notice sensations in their body? Do they know where the toilet is? Um, can they take off their pants? Um, things like that, and just meet them where they're at. Um, and be patient because for some this will go easier than others. Trying to be careful that we or be mindful that we're creating a relaxing environment. And so if it doesn't go well, we have to think about our reactions or our response because that could shape what they do moving forward. Um, and that they should ideally be continent in the day or show signs of that success before we have expectations for nighttime. We should expect that to be closer to five to seven years before that's successful. Anytime, this is not always smooth, but when it's you know, when it's falling outside of normal, don't just brush it off or like look into resources to help figure out your individual child and different strategies. So someone like yourself or um someone else in the area that does a lot of work in in this. Um, any other, but but yeah, there'll be some other factors, like for example, personality differences, you know, constipation, the things they eat, um, their environment at school or the expectations at daycare or school, or do they feel safe asking the teacher to go to the bathroom? There's so many factors.

SPEAKER_00 47:28

Yeah, absolutely. I think you do you hit the nail on the head. Those are kind of the most essential pieces, I think, for parents and caregivers to understand that there are these different blocks that you need as a parent and caregiver of knowledge in order to support your child along the journey. It's not just like, let me read a book and it's done. For some families, I mean, that's great. Like they've had that success. But what about the others? You know, and like if your child is not doing that, it's not a reflection of you or them as um being deficient in any way. It's just like it's just another journey. It's just gonna look different, and that's okay. Um, but also you have to feel like you have the right support and resources in order to move them along the way and help them together. So I think that that is a wonderful overview of kind of what I would say is essential for that potty training, potty learning journey. And there's gonna be all these different nuances, right, between kids and families and um finding a provider that can bring that all together and who can understand that can be so supportive.

SPEAKER_01 48:45

Um, so just in summary, so you have you, you know, you mentioned that you do some online coaching. So I'll make sure that I have your your contact details in the show notes. You also have a course that's geared towards clinicians that, you know, want to kind of add this to their skill set or to their knowledge base. And then and then you have a resource for parents to help guide them along this step-by-step journey.

SPEAKER_00 49:11

Yeah. So the clinician course that I created was in 2020, and it was a resource for OTs, PTs, or physios who are looking to get into the space of treating pediatric pelvic health clients and patients. Um, and it gives you six hours of information. There's templates, modules, intake forms, um, video demonstrations of me working with kids, and you can see how I'm talking and communicating and the scripting that I'm using with both parents and their kids during sessions. Um, and that's been really wonderful. So I have therapists who are experienced in the pelvic health space. So seeing adults who are looking to open their practice up to seeing PEADs, which is amazing. And then I have PEADs therapists who are, you know, really interested in the pelvic health world, specifically with children. So this has been a really wonderful resource for them to get into the work. Um, it's an introductory level course, so you don't feel like you have to have experience in either PEADs or pelvic health. You can just jump in and have um really good things to implement the day that you get back to the clinic. And then I have a Tiny Hood course, uh, which is an online self-paced course. Tinyhood actually wanted me to help develop a potty training, potty learning course that really focused on child development and pelvic health. So this is where, again, I go through all the basics. So the education of what is the digestive system doing? What is the respiratory system doing? What is the nervous system doing during this time, and how can we support that throughout the process? And then there is just me guiding you hand in hand through this journey. Um, there, I don't know how many modules, there's a lot of modules in that. And there are PDFs of uh templates that parents fill out as they're tracking um what's happening during the different phases of the potty learning journey with that tiny hood course.

SPEAKER_01 51:17

Great. Well, is there anything else, Kara, that I haven't asked you that you feel is important to be shared in this episode?

SPEAKER_00 51:25

I don't think so. I think you asked amazing questions and we were able to have a good conversation about how to support parents and kids through this often difficult self-care skill. But I'm so happy that you are bringing it out to your community for more people to know about.

SPEAKER_01 51:44

Awesome. Well, I thank you so much for your time and your busy schedule, and I appreciate everything you do. So thank you.

SPEAKER_00 51:51

Thank you, Melissa.

SPEAKER_01 51:54

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