Strength-Based Pediatric Pelvic Health

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Transcript

Lindsey: My guest today is Dr. Quiara Smith, who is a pediatric pelvic health occupational therapist. Her work focuses on providing holistic and integrative pediatric pelvic health interventions for babies, school-age children, and teens who are experiencing bowel and bladder issues and toileting challenges. This is Quiara’'s second time on the podcast, and I'm so excited to catch up with her today.

Lindsey: New and seasoned OTs are finding their calling in pelvic health.After all, what's more ADL than sex, peeing and poop? But here's the question, what does it take to become a successful, fulfilled and thriving OT in pelvic health? How do you go from beginner to seasons and everything in between? Those are the questions and this podcast will give you the answers. We are inspired OTs. We are out of the box OTs.

We are Pelvic Health OTs. I'm your host, Lindsay Vestal and welcome to the OTs and Pelvic Health Podcast. 

Lindsey: Quiara, I am so thrilled to have you as a guest back on the OTs for Pelvic Health podcast. I was just reminiscing, you were like one of my very first interviews when I started this podcast years ago when I was still living in Paris, and it's such a joy to have you back on.

Quiara: Oh, thank you so much for having me. I'm happy to be back.

Lindsey: Well, of course, you are our go-to for all things pediatric pelvic health, and so I have a community, Pelvic OTPs United. It's all  social media, and recently there have been a ton of questions that have been coming in regarding how we can support our kiddos in pelvic health.

And so that's, it was just for me, it was clear you needed to be a return guest, a repeat guest on the podcast. So I'm going to kind of go through the list of questions that I've been getting, and just in the meantime, so, so excited to kind of talk with these things, through these things with you, and just to kind of help either our pelvic floor therapists that are seeking to specialize in pediatrics, or those that just want to help out people in their community. So I'm really excited to get, to get started with you today.

Quiara: Awesome. 

Lindsey: My first question is, and again, this came directly from the Pelvic OTPs United community, is when someone seeks pelvic floor therapy for their child, are there things like a red flag list or a list of symptoms that the parent can immediately raise their hand and go, oh, my kiddo needs, my kiddo needs pediatric pelvic floor therapy?

Quiara: Love this first question, because it's kind of where we start. And I would say the symptoms that would be red flags for me on a checklist specifically would be constipation.

So constipation that's not managed, meaning that you've been to the pediatrician or another provider, and you're still struggling with constipation in your child, and it's affecting different areas of your life. And as pediatric pelvic health occupational therapist, I'm looking at function. How is this particular difficulty affecting a child and a family's function? And when we're looking at constipation that's not well managed, meaning you're just giving medication and there's no change of symptoms, that's definitely a red flag to say, we need more support around this particular symptom that my child is having.

Another one is bedwetting. So bedwetting and constipation go hand in hand. Oftentimes the constipation is the driver of bedwetting that is not, you know, known about yet.

And so bedwetting that lasts beyond a typical age range from five to seven years old, and looking at that and making sure that, you know, a pelvic floor therapist who sees children is able to support in figuring out the more root causes of that and interventions that could be helpful.

Lindsey: That's amazing. And I really appreciate you defining well managed, because that does make a big difference.

Constipation I think is so clear. And I also appreciate you making the connection with bedwetting because sometimes I think constipation is one of those things that can kind of go on. It's not always an emergency for parents because they may not even realize, but bedwetting I bet is one of those things where, okay, it's preventing potentially sleepovers, right? It's preventing maybe even summer camps and things like that.

So it becomes more apparent for parents to go, okay, this is a problem we need to solve. Are there any other conditions or symptoms that pediatric kids experience that you often see at your office? 

Quiara: Yeah. I see children who are demonstrating withholding behaviors of either stool or urine or both.

So children who are maybe going through the potty learning potty training stage and parents are noticing that the child is just withholding after saying that we're not doing diapers anymore and they are just not letting anything out. They're not voiding. And that would be a really big red flag for a parent to seek pelvic floor therapy for their child to help support their child in understanding kind of what's expected of them, but also looking at other components of the potty learning potty training process.

Another symptom or condition that I typically will see as a pelvic floor therapist is pelvic pain or like stomach aches that are associated with, you know, tying back to the bowels and constipation, but also just having anxiety can be something that I see in my practice that is causing pelvic floor tension or pain. 

Lindsey: So another question that came in, and I love this one because I think it'll help us paint a picture, Chiara, to your practice, which I think is probably very different maybe than some other pelvic floor therapy centers, which is our Pelvic OTPs United audience would love to know, like, what does a typical session with you look like? And are there play-based activities that can support pelvic floor and core development?

Quiara: Well, it looks like lots of fun, first and foremost, because we are working with children and families. And play-based is the biggest focus because we're wanting to make sure that there's the developmentally appropriate and educational component of supporting a child's understanding, but also a parent and caregiver's understanding.

So that looks like we're doing explanations through books or videos. I'm doing demonstrations and explanations on dolls or stuffed animals. Maybe there's some science experiments about the body, arts and crafts.

And the focus really is on how to build relationship and connection with the child and their family first, and then exploring that education piece is huge. The environment setup, my environment is really set up to facilitate play. So that's a lot, maybe that's different than an adult type of clinic because we're really looking at how do we support children through play we know that they are learning so much. And this is something that pediatric pelvic floor specialists are really good at. I feel like they're able to be play-based and they can incorporate different activities that support just the, the social-emotional piece of a child, but also the physiology of a child.

Lindsey: Yeah, and I remember last time we talked, you had a therapy dog in your practice. Do you still have that dog?

Quiara: Yes, Nelly, I still have her. She's 10.

She provides animal-assisted interventions in the practice. So that looks like if we're doing an obstacle course or we're doing games to help strengthen our body, our core, our pelvic floor, all the things that she's engaged with kids, getting some of the toys, getting some of the supplies, and then having the children motivated to play with her, but also motivated to do the exercises and the therapeutic activities with all the fun stuff like swings or therapy balls and scooter boards and crash pads, you name it. That's kind of where we focus our play.

Lindsey: Oh, that's so great. I love that. Another question that I've been getting a lot is, does pelvic floor pediatric care serve both regular and special needs children?

Quiara: Yes.

Pediatric pelvic health in general benefits all children. And when I say all children, children with differences, children with a variety of medical conditions that are affecting bowel and bladder management incontinence, a pediatric pelvic floor specialist can definitely support them. The difference I would say would be, how do we support children who might have additional needs or who are neurodivergent or who learn differently? It's we have to find what fits for them.

And I'm a real firm believer of strengths-based approaches. How do we meet the child where they're at with the skills that they have and work on their strengths in order to then work on their areas of growth? And I feel like building on confidence first is really important when working with children, especially with children who are experiencing bladder dysfunction and toileting difficulties. They tend to already feel some embarrassment, some shame, lack of confidence.

So making sure that we're kind of leading with a strengths-based approach and figuring out what their interests are and integrating that within our plan of care is huge.

Lindsey: That makes so much sense. And then there was a question that came in about like developmental or even like developmental delays, poor coordination and decreased core stability.

Are there particular resources or thoughts you have on supporting children with those needs?

Quiara: Yeah. Again, going back to leading with a strengths-based approach, I think we have to really focus on where is that child develop mentally? Like where can we meet them? And then we have to understand where they're going. So child development is something that in grad school we go over.

I think it's just not so focused if you're not in pediatrics, right? You're not necessarily like, oh, I know when a child's supposed to like jump on one leg or be able to demonstrate 10 seconds of core contraction in a Superman pose. Like you just don't have that in your back pocket if you're not necessarily working with children. But I think that's an essential piece of understanding what can we do in order to support them in addressing their toileting needs with development in general.

And then understanding the sensory system, I think is a big part of just child development in general, but specifically for toilet training, toilet learning, understanding how that system can impact the way that the child is actually demonstrating these skills or demonstrating the difficulties of these skills. Poor coordination, we're always assessing functional gross motor skills. Like in clinic, I'm always looking at first when a child comes in, like how are they navigating their environment? How are they in their body? Are they even in their body? This shows me a lot of information about how their coordination could be potentially in the pelvic floor area and how are they connected to that.

Decreased core stability, that's something I often see. And how do we address it? Again, looking at functional gross motor skills and then figuring out how do we pinpoint activities or exercises through play that can help support and improve the core stability plus the coordination piece in order to have more functional gains over bowel and bladder skills over time.

Lindsey: That's amazing.

You know, you had touched on constipation earlier. And I think there's so many people inside Pelic OTP United that are dying to learn more about that. And I'm sure you could probably spend hours on this and probably do in your courses on this topic alone.

But would you mind kind of giving us like a sneak peek or a snapshot into the way constipation can affect children and maybe even like a very common intervention that you use to help them?

Quiara: Yeah, constipation is a big thing. And when I first got into the space of pediatric pelvic floor therapy, I didn't really know too much about it. But I would say 99% of the time 99% of the day, that's what I'm talking about with my clients, because it's so something that affects a lot of the clients I see because of the symptoms, meaning if a client is coming in, and they're talking about bedwetting, like I mentioned earlier, when we talk about bowel patterns, and how they're managing their bowels, we start to uncover things like the child's not stooling every day, they're having hard stools according to the Bristol stool scale.

And we know that if a child is not frequently going to the bathroom, and they're not voiding or having a bowel movement, that this can impact bladder function. And typically, I'll see kids who are experiencing constipation that they don't even know that they're having. And they're experiencing bedwetting as their chief complaint.

But we uncover through our work together, that the bowels are also misbehaving. And when kids get past a certain age, parents aren't necessarily in the bathroom with them. So when they're getting, you know, more independent toileting, and parents think that the child has got it, you know, they've got the skills, they're past preschool age, or they're past, you know, kindergarten, first grade, and they're still kind of seeing the bedwetting, but pediatricians are saying, Oh, like, don't worry about it, wait till they're 12, or seven or eight, giving all these different ages, I'm hearing that it's not a problem.

But we tend to find out the child isn't really having a stool every day, or they're having incomplete emptying, plus having hard stools. And once we manage the constipation, the bedwetting gets better. I'm not saying that the majority of kids I see, I see the kids who are really having difficulties even when constipation is managed.

But there's another piece about maybe hormones aren't effectively working. Or there's another piece about sleep disordered breathing that hasn't been uncovered. So sometimes those are the more, I would say, complex cases.

But typically, when we're seeing bedwetting, and it's caught sooner rather than later, and constipation is caught sooner rather than later, we're seeing better outcomes when we're getting really good interventions with that.

Lindsey: And what are some of the, I guess, maybe you're at this point in time, your more favorite interventions that you use to help these kiddos?

Quiara: Yeah, favorite interventions for constipation?

Lindsey: Yes.

Quiara: Favorite interventions for constipation. I really like the body work. So doing abdominal massage, maybe we'll do some visceral manipulation. I do some myofascial release. So being able to do the body work has been really helpful because I've noticed that with kids who have constipation, sometimes their sensations of feeling urge are sometimes muted when they're constipated. So they're not necessarily feeling like they need to go. So doing the body work has shown to be really effective for them.

So an example is I had an eight-year-old this morning, and I did an abdominal massage. I did some tension release. And five minutes later, they were able to feel urge more and go to the bathroom.

Usually, they would be not feeling any urge or saying that their stomach hurt, but they wouldn't be moved to act to take themselves to the restroom. But today, they actually felt a different sensation, and they were moved to act to go to the restroom, which was great. And it prevented a leak, a fecal leak, which was amazing.

And family and I cheered, of course. But that visceral work or that body work is really one of my go-tos. Another one is diaphragmatic breathing is really important just to help with intraabdominal pressure, to help with good defecation dynamics.

So always getting kids in good posture to facilitate good breathing has been helpful with bubbles, feathers. I do pinwheels. I have little pom-poms that we play games with with straws.

I mean, you name it. We have so many different ways that we use our little tools with kids to facilitate good breathwork and breathing.

Lindsey: That's amazing.

And that leads me to one of the other questions we received, especially because I'm thinking about some of that visceral work and body work. I'm guessing you are teaching family and kiddo how to do that between sessions?

Quiara: Yeah. So that's part of the home programming.

And it is something that is expected of all families when they work with me is that they are hands-on, literally hands-on, doing the interventions that they see me doing with their kiddo at home. And there's an agreement that as part of the home program, they will participate in this with their child, not only for pelvic floor health, but also bonding and attachment and nurturing touch. And people are like, what are you talking about? And the reason I say that is there's an agreement about this because I explain to families when they finally get the chance to land in my clinic and in my care, there's been a lot of things that they've experienced because of their child's symptoms and their conditions that landed them in my clinic.

And we see a lot of difficulties in relationship and resistance and embarrassment, shame of both parent and child of, you know, how they behaved in the past because of some of the difficulties they're experiencing with their pelvic floor dysfunction and bowel and bladder difficulties. And so part of the focus is really how do we connect together? How can we come back to repair this relationship? And how can we rely on one another? And I try to empower and encourage the parents and caregivers I work with to take on the thought of, you know, what was in the past is in the past. Now I know better, and now I can do better.

And the kids can see that as well because I have that frank conversation with them about, you know, these things happen, but now that you're here, we can move forward together. And really encouraging parents to always in their mind's eye, see the end goal of their child achieving whatever it is that they want for them. Meaning if it's clean, dry underwear every day, or if it's being able to go to a sleepover camp, that they can really envision that in their mind and do that kind of neural activity.

And it's fascinating the things that I've seen in my practice when people really do that practice.

Lindsey: Oh my goodness, Quiara. I have to admit, just like hearing you say that, I got goosebumps because I would imagine that is such, it takes such a thoughtful, thorough clinician to really recognize like, wait a second.

Okay. Definitely disruption has happened between parent and child with, and very understandably. So it's, I'm sure it's an extremely frustrating experience, but recognizing that's actually part of the therapeutic role that you are having in modeling, not only for a child to see, we can have a disruption, multiple disruptions and move forward and repair our relationship, but to remind the adult.

And I'm sure that carries over also to the adult in their own relationships, whether it's with their spouses, their partners, their siblings, you know, their own parents. It's one of those things where it's a, it's a bigger meta message that not only serves your clients in the moment when they're coming to you with these issues, but it's just reinforcing what we know is at the core of a lot of this, which is the relationship, right? That relationship can serve to heal moving forward. So that is so beautiful.

Your clients are so lucky to have you.

Quiara: Thank you. And I always tell them, you know, I'm, I'm just the guide and I know certain things about this particular thing, but you guys know each other the best.

And I'm just the person who can, you know, suggest a few things that could be helpful, but ultimately you as a triad or dyad, or however they come into my care, you guys are the ones who are making the magic happen. And it's been challenging to up to this point. And I want to validate that.

And I want to speak on that, but also I want to say that there's so much more hopefulness ahead because they feel so hopeless when they come to see me in the beginning. And then they leave empowered and kids like stand up taller and they're smiling and they can actually look in my eyes when I'm talking to them or talking to them about their bodies. And it's just, it's amazing.

Lindsey: Are there any cases where you're educating parent and child alone, separate from one another, or just because of what we just talked about, I imagine that the three of you or the four of you are together, right? Meaning the client, the parent of the client and you, are there ever any cases where you would be educating them separately?

Quiara: I don't tend to do that for a few reasons. I know there's other providers that do have the, the separate conversations, but I tend to have them together because I feel that having that transparent communication actually helps with the repair and the relationship. Because there's nothing that I'm telling a parent that's going to be different than what I'm going to tell the child to do or what I'm holding them accountable for.

So it's really just my, my approach, my own personal style. And I'm doing that again to hold everyone accountable, but also that everyone's in agreement of what we're discussing. And I think oftentimes parents, I notice, will feel like they can't talk honestly about what's happening with their child because they don't want to disclose too much or they don't want them to hear what's happening.

But I always like to encourage parents because they know that we're going to have the conversation in front of the child is to think about how it would land for the child to hear what you're going to say. And if you feel like it might land differently, then maybe we should reevaluate like maybe the words that you're going to say or something else. And that if there is something that comes up like that, there might be a quick email to me and then we go over it, but it's not anything in length or in detail about yeah.

So everyone is on the same page. I do it together.

Lindsey: I love that.

So the last question that, that I received was a little bit more with things around informed consent and the process with sort of a minor and a guardian slash parents. So this particular member of our community was wondering if there's any ethical considerations or challenger challenges that practitioners may face with topics such as abuse or trauma or sexuality or autonomy? 

Quiara: Well, I always have informed consent and assent at the beginning of our clinical work together. I have it in documentation as well as in each session, the parents are legal guardian.

They know they always have to be present for the entirety of the session. And, they provide me consent and assent each time. and I also ask consent and assent from infants to school aged children to teens before touching them in any capacity.

So people are like, what do you mean? Like an infant? I literally look at the infant and I put my hands up and I say, you know, Quiara, I'm going to do a belly massage. Are you ready for it? And if the baby is smiling and, you know, happy and I asked parent, is it okay if I do this with care? Yes, this is, this is good. Baby is smiling. Yes, it's good. If baby was crying and screaming and not in a good mood, I'm not going to put my hands on them. Same with the child, same with a teen.

And they know in our beginning phases of work together, a parent or legal guardian or a caregiver always has to be present no matter what, if it's a teen and they're talking about adolescent sexuality. This is an agreement that we all have, based on what is, outlined in my consent forms and my documentation. Uh, so no one is surprised about it.

Lindsey: That makes so much sense. Chiara, I know that you are up to some amazing things these days. Would you share with our listeners what you're up to and where we could find you?

Quiara: Absolutely.

Very excited because the third annual pediatric pelvic health virtual summit is coming up November 9th, which is a Saturday. And that is going to be amazing because we have this year, a wonderful array of expert speakers who are talking about different topics on, um, pediatric pelvic floor therapy, but also how their specialty area is integrated. So we have, colorectal surgeons.

We have some amazing OTs who are speaking about how they support,pediatric pelvic floor clients in the school setting and outpatient practice and so many more. So, check it out, the pediatric pelvic health virtual summit. I also have my own course that I created in 2020, and that is called a holistic and integrative approach to pediatric pelvic health.

And that's a self-paced course, which gives you, you know, all the new things to consider when taking on pediatric pelvic floor clients. There's templates, there are demonstration videos, and you can start seeing clients right away with that course and you get to have recordings for up to six months.

Lindsey:  Fantastic, Quiara, I can't thank you enough for coming on a second time to speak to us on the podcast. just so, so much love and appreciation for the work that you do and the support that you give our entire community. Thank you so much.

Quiara: You're very welcome. Thanks so much for having me.

Lindsey: Thanks for listening to another episode of OTs and Pelvic Health. If you haven't already, hop onto Facebook and join my group, OTs for Pelvic Health, where we have thousands of OTs at all stages of their pelvic health career journey. This is such an incredibly supportive community where I go live each and every week. If you love this episode, please take a screenshot of this episode on your phone and post it to IG, Facebook, wherever you post your stuff, and be sure to tag me and let me know why you like this episode. This will help me to create in the future what you want to hear more of. Thanks again for listening to the OTs and Pelvic Health podcast.