Ask Dr Jessica

Toileting challenges? Pediatric Occupational Therapist, Quiara Smith can help!

December 12, 2022 Quiara Smith OT Season 1 Episode 67
Ask Dr Jessica
Toileting challenges? Pediatric Occupational Therapist, Quiara Smith can help!
Show Notes Transcript

Episode 67 of Ask Dr Jessica discusses childhood toileting challenges with pediatric occupational therapist  Quiara Smith!  Quiara  is a Stanford trained pediatric OT, and she is passionate about helping children and teens who have trouble with their bathroom habits, wether it be bowel and bladder continence.  Quiara is a wonderful resource for children who are experiencing constipation, bedwetting and other bathroom challenges.  She offers many tips in addition to traditional medical advice, including how to track your child’s natural biorhythms, or how to help strengthen their pelvic floor.  She has an active practice in Northern California, uniquely focused on pediatric bowel and bladder incontinence.

You can find Quiara on her website or on her instagram page @alohaintegrativetherapy.  She has an active practice in Northern California and she is available for consultations.

She recently created a stress-free potty training course: click here

Dr Jessica Hochman is a board certified pediatrician, mom to three children, and she is very passionate about the health and well being of children. Most of her educational videos are targeted towards general pediatric topics and presented in an easy to understand manner.

Do you have a future topic you'd like Dr Jessica Hochman to discuss? Email Dr Jessica Hochman askdrjessicamd@gmail.com.

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The information presented in Ask Dr Jessica is for general educational purposes only. She does not diagnose medical conditions or formulate treatment plans for specific individuals. If you have a concern about your child's health, be sure to call your child's health care provider.

Unknown:

Hey everybody, welcome back to ask Dr. Jessica the podcast where my goal is to give you quality medical information to help you along your parenting journey. I'm your host and paediatrician Dr. Jessica Hochman. On today's episode we are going to talk to Chiara Smith about a popular topic that I hear about in my day to day paediatric office. And that is childhood continence. CHIARA is a Stanford trained paediatric OT or occupational therapist, and she is passionate about helping children and teens who have trouble with their bathroom habits. CHIARA is a wonderful resource for children who are experiencing constipation, Bedwetting, and other bathroom challenges. Thank you for listening. And please pass this episode along to anyone who you think may benefit from hearing this conversation. Hi, Chiara, how are you? Great. I'm doing well. Thank you. How are you? I'm good. I'm so glad to know you and to send patients to you. I'd love to pick your brain a little bit about the most common questions that I hear from patients so that they know who you are, and that hopefully they can be helped by your advice. So first, tell me who are you like, what do you do? My name is Chiara Smith. I'm a paediatric pelvic health occupational therapist. I've been a therapist for over 12 years. So working in different capacities in occupational therapy, and then found my passion working in this niche specialty, which is paediatric pelvic health, I never knew about it. And it was just the right fit for me. I was able to get my training at Stanford Children's Hospital, and really hone in my skills to be able to support these kids who have toileting challenges, and bowel and bladder dysfunction. I never knew about it in school, I never knew about it as a working practitioner as well. And that is kind of my special gift is to support parents and kids who are struggling with this because there's not that many resources out there to kind of point them in the right direction sometimes. And I currently have a private practice, it's the first of its kind in the United States. It just serves children who have bowel and bladder dysfunction and toileting challenges with an OT approach. That's amazing. I find that so many doctors, we have a lot of us, we have to figure out how to best help kids who have toileting issues. But our training, to be quite honest, was really more medication approach diet and medication approached. And I love that you can tie in your ot experience to solving the problem. Yeah, and what I really love is, you know, everyone's on the same team. Right, paediatricians, therapists, families, everyone has this common goal to support the child in whatever capacity that is. And I think that, like you mentioned in your training, specifically, you guys are generalists in that area. And those are the types of things that you can support in your practice, for kids that have acute challenges with constipation or toileting issues. But then there's like that percentage of kids who, for whatever reason, they need more support. And that's when they need specialty care. And I think it's just a wonderful conversation to have and a collaborative approach to have with paediatricians and families and therapist. And what I find is, it's actually such a common issue, and I think that this is understandable, but a lot of parents don't talk about it with their friends. I don't think they realise how common it truly is. So I'm really glad that you are here your voice is here to explain some approaches to help. So I wanted to ask you first what, what are the most common questions that you hear from parents? Yeah, so the most common scenarios that I deal with the biggest one, the biggest two, I should say, are constipation withholding, either withholding poop or withholding pee. So those are the biggest ones. And some of the other ones are bedwetting urinary incontinence, which is that daytime urinary leakage as well as nighttime Bedwetting, that's prolonged that goes past the age of six or seven. And that's also known as enuresis fancy word. And there's also another diagnosis or condition called ankle precice. And this is very common with the children that land in my care after they haven't been able to resolve some of the constipation and it has increased significantly to where the child is now having impacted hard stools. And then we're having that softer stool leak around that impaction or blockage and that causes a lot of that faecal incontinence so kids who can't have clean or dry underwear throughout their day at school, and really struggling with this. Also toileting refusal. Anxiety just around toileting is huge especially with the pandemic and expecting children to understand how to use the restroom in the community and out in public. That's been a big one as well as those kiddos who just did didn't get the solid skills for continence. So the toilet training or potty learning process was really challenging to them. The first thing I want to ask you about is the anxiety you mentioned around potty training. If you could tell a parent who's starting from scratch has a has a young kid, what would your advice be about potty training? How can they avoid some of these pitfalls? That's the million dollar question. And I think that there's a lot of perspectives around potty training potty learning, in the media in healthcare. And what I go by is evidence based approaches. So what are the researchers looking at? Or how can we explore what could be best to support these children? Because my aim, and my goal is not to have the child even land in my care in my clinic for dysfunction, right? So how can we support prevention and kind of focused on a developmentally appropriate model. So the misconception is that an 18 month old is has typical skills in order to have good sphincter control, which is not necessarily the case at 18 months is a little bit too early developmentally, for them to have good control of their sphincters of their bladder, as well as their rectum. They're just learning what urge sensation is an association, I feel urge of a full bladder, I know that I need to hold and close the sphincters, close the pelvic floor, walk to the bathroom, and relax everything and let it out. That's a lot of steps, especially for an 18 month old. And so what we're trying to look at in pelvic health therapy is to support the child developmentally but also with their physiology. So we know and according to Johns Hopkins to who has a lot of research on this particular toileting area, is that sphincter control is really better developed when a child is 24 to 30 months old. So that's a significant difference from what people are saying, oh, go ahead and start potty training your child between 18 to 24 months, and some children will show readiness time. So there's the cognitive piece, the physiology piece, the emotional piece, like they could be showing that they're ready, they're interested. But I think for best success, if we wait just a little bit longer, but we still start the conversation around 18 to 24 months wonderful. We build familiarity around the topic in this subject, we use play to support the expectation of one day not having to use the diaper to let pee and poop out. There's so much skill building that goes on with continence, if we're looking at, you know, bowel and bladder control, you need to know what urge sensation is, and you need to understand your body and how aware is a child at 18 months versus say 2430? It's very different if we're looking at development. So if we can kind of start building that what we call the interoceptive awareness, how can we help build the understanding of what the internal feelings of the body are with young children and then help them kind of guide them through that expectation of this is what this means when you're feeling this kind of maybe heavy feeling on your bladder, that means you have to release and we're going to release in the toilet. So it's kind of this approach that I take versus using hard fast rules on age ranges. And, you know, there's a lot of pressure on families to have their child be potty trained at for preschool or daycare settings, which doesn't really support a child's health and well being in my opinion. No, I agree with that. And so it sounds like just to summarise a child at 18 months, you can support them you can familiarise them with the potty but not to expect them to be actually physically ready to successfully be potty trained. Tell two to two and a half. Is that right? Yeah. Correct. And I say that because sometimes as parents and caregivers, we have to step back and say like, what is our realistic expectations? And are we putting these task demands on this child you know, in the most loving way if we don't know any better, we think that we're helping them along but it actually can backfire. And children can then later on, you know, down the road exhibits some pelvic floor dysfunction. And an example of that is I had a client this morning who came in and their child was six years old. The child was fully potty trained at 18 months they didn't have any leaks or accidents. The parents thought that this child was a genius could do you know potty learning on their own and had no problems. But what the the parents didn't understand is that child was a chronic with holder they were holding to the point of not release Seeing at certain intervals and their pelvic floor just got super tight and tense. And over time, it starts to shift the coordination patterns of how the pelvic floor relaxes and contracts. And so there's just a lot of nuance things that I think not many people speak about. And especially when it has to do with continents, continents is so layered with, you know, that emotional piece, that social piece, and parents don't want to say, hey, like I'm struggling, because it's this, you know, comparison game, which is not something that helps parents in our day and age. I do agree, I do think there is this, people get an idea in their head that their child should be potty trained by a certain age or right, maybe because of preschool pressure, maybe they have an idea in their head, and maybe their friends or their friends child's already potty trained. But I do agree that it's that things are most successful when you wait till your child shows signs of readiness. Yeah. Okay. So let's say let's say that there's a kid who's two and a half, or getting close to three, and is still not interested in potty training. What would your advice to a parent at that point be? Yeah, that's a great question. Because that two and a half, that is a prime time for them to start connecting, you know, the urge sensations, their interoceptive awareness with their physiology. And so if they're not showing readiness cues, that could be a sign of lagging skills. So Dr. Ross green, who's a wonderful clinical psychologist in the paediatric world, talks about lagging skills. And that means that the child doesn't yet have the capacity for whatever reason to be successful with that particular task and will take potty training right for our example. And but that doesn't mean that we can help we we don't help them along, we help them along. So we can include activities throughout the day to support their practice of the skill, we bring out the potty, we use social play, we talk about the different body parts just to get them more aware of what is going to happen one day, and I also like to use that language. Well, one day, we're not going to use the diaper. But you know, right now you need it because you feel safe and secure to let it out. Right now, but one day, it's all going to go all the pee and all the poop is gonna go in the toilet or the potty chair. And we're just continually helping them develop skill and practice. And so that's a big piece of it and tracking bio rhythms. So people are like, Well, what does that mean Chiara? And I say, well, it's really difficult for children to understand association between urgent action when you're putting them on the toilet every 30 minutes every 15 minutes, because you read or you've heard that that's a really great way to train the bladder in the bowels. And I will tell you from a pelvic health standpoint, that's training, urgency and frequency in a child, right, they don't have the opportunity to understand Wow, this is what it feels like to have a full bladder and I need to empty it, if you keep taking them every 15 minutes, you don't get that opportunity. So if you're tracking natural bio rhythms, you can see Oh, at every interval, Jessica, between two hours, she's has a wet diaper, oh, and then another two and a half hours, she has another wet diaper. So then you start to incorporate their natural bio rhythms into maybe a potty toilet sit practice, where you're just sitting and taking a pause from play, but you're not skewing their natural rhythms of how their bodies are working. And so this is a big component of maybe the difference between what people are doing versus like my approach. That's really interesting. I've actually never heard of this before. So, you know, I'm assuming kids urinate when they first wake up. So you track their urine, and as well as their typical stooling patterns. I know kids typically stool the same time every day. That's yeah, that makes sense to me. Yeah. So an example would be if your kid is a pooper at 4pm, after they've come home from school, maybe you do, like a toilet sit at 345. And you say, Oh, we're just going to take a rest break. And we're going to sit on the toilet or we're going to sit on the potty chair, whatever it is, to give them that their body that opportunity for like motor programming and to remember, Oh, I was sitting I was in this position, my pelvic floor was relaxed, and maybe something comes out and maybe it doesn't. But that's not the end goal. So in the learning process, and I make this very clear with the parents that I work with when we're trying to establish routines, self care routines, around body autonomy and agency around the body is if we can keep things as close to a child's natural bio rhythms. You have more success because you're not altering you know, you're it's not on my time, right. It's on their time. And it helps kind of solidify the expectation of, oh, we have to take these, these rest breaks and bio breaks throughout our day to keep our body in balance. So we're not feeling you know, Cranky or off or fatigued. Because if we keep, you know, waste products in our body, urine or stool, it affects the child, their behaviour and those sorts of things. So I do know that when parents are first potty training, I noticed they're frequently taking their kids to the potty. They're constantly asking them, do you have to go? Let's try. Let's go. So I think tracking their typical habits make things a little easier on family. So that's good to hear. Yeah, definitely. Do you dressed? Absolutely, no. And I've heard I don't know if you experienced this, but I've heard that there's a window in which to potty train that if you wait too long to potty train, you might have trouble later on. Have you experienced this? Yeah, I haven't experienced it, per se. I think every child and every parent and family unit is so unique, that it's really dependent within that family unit and that child's personality and level of skill and developmental level, really. But I have not seen like, Okay, we've started too late. And that's the sole reason why my child is having issues. Now. It's more multifactorial than that. And some of those factors include, you know, how is gut motility and that child if we're looking at bowel issues? How are is their pelvic floor function? Are they do they have low tone, low muscle tone that can contribute to not using the pelvic floor or the diaphragm correctly? Do they have other comorbidities like other medical conditions that could cause a little delay in bowel and bladder control. And in there's so many boxes to check off and not just age. So it sounds like just to summarise your general feelings towards potty training. You want to wait till they're at least two, two and a half. And then you really want to follow their signs of readiness. And when they do show those signs of readiness, you want to support them follow their natural rhythm, make it a fun experience, incorporate play, and then let the child take it from there. Yes. Okay, so now question for you about a common question I get from families is that children have fear over pooping. Something that comes up all the time, they'll tell me that their kid a won't either poop at school, they're nervous to poop at school, or they won't poop in a bathroom. They have to poop in a diaper at home. I hear so many repeated patterns of typical anxieties for young kids. What's your approach for kids that have fear over going to the bathroom? Yeah, another big, big question that there's so much to unpack with with those questions. But the similar themes, it's okay, this similar themes with those difficulties are that first and foremost, the child's nervous system is not feeling safe or secure, for whatever reason. And so that's kind of my focus and my approach. And going back to Dr. Ross Greene's work kids want to do well. And if they are not doing well, it's because we have to become more curious. And we have to explore the root causes of some of these challenges. And it will stay with the piece about withholding and not wanting to use the restroom at school or only preferring a diaper. Sometimes those are sensory differences that are overlooked in children, meaning that the way that they're experiencing their outer world and their inner world is a little bit different than their typical peers. And when we're comparing especially when educators have a roomful of 20 children. And the majority of kids don't have you know, quote unquote, problems with this, but maybe one or two do, it's overlooked as a behaviour issue. It's they're not wanting to do it, it's a control thing. They're being defiant. But I urge people if you're listening to this to look beyond the behaviours and you know, Dr. Mona della hook and other wonderful clinician in this space really looks at how the sensory system is part of this overall kind of piece that is often overlooked, like I said, with the safety and comfort of a child being in different environments, with different task demands and expectations placed on them. Sometimes the difficulty is shown in this particular behaviour toileting, another could be feeding, you know, failure to thrive kids not wanting to eat, there's maybe a sensory component, a comfort, a security component, and then sleep is another one. So those three big areas of child development, drive parents crazy because ultimately we can't force a child to go to the bathroom sleep or Eat. And so this is kind of the biggest part is to look at how that child is feeling safe or secure. And maybe the reasons why they're not some of the sensory differences in a public restroom at school, it's dirty, some of the kids visually cannot tolerate being in that environment, the smells, the sounds, the echo the feeling of their body on a on a toilet seat, that's not their home. There's so many things that as an occupational therapist working in pelvic health, that I look, I have a checklist, I look at the environment, I look at the child's skills, I look at the child's, you know, ability to navigate different life circumstances, and how are they responding to them? I have to say, feel for some of these kids, because I remember, especially in elementary school, I remember it not seeming very clean, not seeming appealing, and not really wanting to use the restroom. And so I know that it's the healthiest thing to go to the bathroom when you feel the urge to go. But I don't blame kids that want to hold it while they're at school. Yeah, absolutely. And this is the reality. And I hope that this conversation shifts the perspective of kind of the schools and how they can better support children's pelvic health throughout their childhood, because, as you know, in development, we have early childhood where this is happening. And then we move into middle childhood, and then adolescents and teens. And my goal was to be able to start it early childhood to say how can we look at the environment to support independence and bowel and bladder function number one, like you said, cleaning the bathrooms making them more appealing, you know, the proximity to some of the restrooms, even in truly early childhood, you know, you have to walk 500 600 feet from a classroom to reach it. And sometimes those children who are still learning can't hold. So then what they do is they'll just hold hold hold, so they don't have an accident or a leak, getting to the bathroom, they rather just hold all day. And they cognitively they don't understand yet, that's not the best choice. But if we can provide education to, you know, the educators in the schools and other health care providers, school nurses, to give them this, this kind of information and knowledge to move forward to better support overall pelvic health in children, that would be wonderful. Sometimes I'll tell parents that the optimum time to have kids try to make a bowel movement is right after eating, you know, within that first, like 1020 minutes after eating. So if you know a child's resisting going at school, maybe try to make it open the opportunity while they're at home. So maybe after dinner when they're not in a rush. Give them some time to try to use the restroom. Yeah, yeah, absolutely. That's a wonderful strategy that we recommend to. And if the child is at school, usually they have a recess and they say, you know, Miss cure, I don't want to miss recess. And so I say, I understand that I would hate to miss recess, too. But the alternative and if this is the child who can understand these these ideas, is if you don't, and you know that your bladder kind of has a leak and is full, or your rectum is full and has to have a poop, then you're going to kind of have a smear, and you're going to have to take that extra time to change. So you have the choice, right? It's giving the child empowering the child to make the health full choice for their body. Ultimately, it's nice, you're listening to them, you're sensitive to what they're saying. But you're using logic. Yeah. Now I have a question for you. When you talk to parents. You know, we always talk about diet, how diet really helps going to the bathroom, high fibre, fruits, vegetables, but I'm just curious, do you find that these kids that have troubled? Is it? Is it more diet related in your opinion? Or is it usually more behavioural or a mix? I'm just more curious. It's a mixed. A lot of the kids that lay into my care for toileting challenges. And bowel and bladder dysfunction are selective eaters. Meaning that their diet is not an array of fruits and vegetables, maybe their carb heavy, maybe they have the beige diet, right? More processed foods, and that's going to slow gut motility that increases your chances for constipation. And we know if we have constipation, that the rectum and the bladder their neighbours, so it doesn't necessarily mean if you have bowel issues, that you're not going to have bladder issues and vice versa. They affect one another just like if you have a naughty neighbour, they can affect your life. Right? And so this is kind of how they work and sometimes I kind of like to give them that education piece because we have to work on the feeding and the diet part that's that's imperative in the work, but also the other piece the behavioural modifications, right? How do we modify behaviour and I'm talking behaviour as setting routines. Looking at expectations, the schedule, the environment, these behaviours that we can shift and change to support this child where they're at, but then help move them through the continuum to be able to feel urge sensation, act upon urge, not withhold, and go at the appropriate times, right. And I'm saying never withhold. Of course, if you're in the car, and you need to go to the bathroom, that's an appropriate time to hold. What we're not wanting is that child to just be holding because they're anxious, and they're nervous about letting it out in a public space, such as a school bathroom. And we kind of help them throughout that process. And is this where you can use your pelvic floor knowledge to help kids achieve continence? Yeah, because most of the kids have some in coordination of the pelvic floor, how their pelvic floor and their sphincters are working, are actually working, paradoxically, meaning that they think that they're relaxing and going to the bathroom, but they're actually contracting their pelvic floor and contracting their sphincters when they're trying to defecate. So vacation dynamics, the way that you poop is actually something that we assess and address in kids and help give them strategies and exercises that help get that relaxation needed for sphincter control. And for pelvic floor control. This is the piece that I find so interesting that you talk about that most doctors don't have the education about so. So just so people understand. Can you explain in layman's term what what is pelvic floor health? Yeah, so pelvic floor health is how we can support a child's bowel and bladder function, and reproductive function, all the things, there's actually five functions of the pelvic floor. But for just our talk, today, we're just thinking about, you know, organ support, and sphincter control. And what we really want to do is understand how that system is working optimally and efficiently to be able to void the bladder and the rectum completely. And also have the ability for that child to understand what urges and how to act upon it appropriately across all environments, regardless of you know, where they're at. Wonderful, wonderful. Now, can you can we conclude with some advice for parents, like if their child's having if they're listening right now, and they're, they're one of these parents where their kids having trouble? What's their future going to look like? Do you find that most kids get success over time? Any any words of optimism? Yeah, so over time, when you kind of take the perspective, like I shared in our talk today of being curious and exploring maybe the underlying reasons why a child is having some of these challenges, we're first looking at their bio rhythms is something off within, you know, their health, their gut health, their pelvic floor. Also, what are the expectations that are placed upon them at home or at school with taking care of their body? Is it the same? Is it very different? How is our language around how they're helping their body, and then also to try not to do the comparison game I know, that's really hard, but you have the child that is in front of you, because you are the perfect fit for this child, you have the skills needed, and you have the love and the compassion to help them through these challenges. And to advocate I think advocacy for parents, when it doesn't sit right with you is 100%. Okay, and partner with your health care providers and your child's school educators. You're right, I think I like what you said about how every every parent's situation is unique. Every kid is unique. It's so true. There's so much variability about when a child is ready, and when they're gonna achieve continence. And I think I think taking pressure off everybody, parents kids is so helpful, and leads to successful potty training. Yes, I agree. Well, thank you, thank you so much for your time. I really am excited to know you and if anyone's listening who's having any issues. CHIARA is such a wealth of knowledge, and I will leave your contact information below. Sounds great. Thank you so much for Thank you for listening to this week's episode of Ask Dr. Jessica. If you know anyone who might benefit from listening to this week's podcast, please send it along their way. Also, if you could take a moment and leave a kind review, I would greatly appreciate it. It really makes a difference to help this podcast grow. You can also follow me on Instagram at ask Dr. Jessica. See you next Monday.