SPEAKER_01 0:01

Hi friends, this is Rita, and welcome to this week's Beyond the Story, where we break things down and dive a little deeper. Now, this week's topic, in case you haven't noticed, it is about potty training. If you haven't heard the story or read it on our app, I highly suggest you to go back one episode, listen to the story, and read it with your child on our Gucci app that you can download on App Store. The story is free and it really addresses some of the things that we don't often think about or talk about when it comes to potty training. It is a rite of passage. Humans have done it as long as we have been around, yet it is still one of the most difficult things to go through as a new parent. And now the interesting part and sometimes not talked about part of potty training is that if we don't quote unquote do it right for the lack of better terms, some of these issues can last well into teenagehood, which really really surprised me. I am so lucky to have met Chiara. Chiara is a pediatric pelvic health specialist based out of Santa Rosa, California, who focuses on all things pelvic health, specifically for children. And she is here to give us insights on what she sees in her clinic and some of the misconceptions that we often have around toileting and training our children. I hope you enjoyed this episode as much as I enjoyed making it. Please let me know how I did. If you enjoy the conversation, recommend it to your friends and family and those who you know maybe starting to potty train their kiddos or are in the process of it. Thank you so much for tuning in. Welcome to this week's Beyond the Story. And if you and your kiddo has listened to the episode before this, you know this week's topic is potty training. And I am so excited to have Dr. Chiara here with me. Dr. Chiara, welcome, welcome, welcome. Thank you so much for having me, Rita.

SPEAKER_00 2:45

I'm happy to be here.

SPEAKER_01 2:47

I always love talking to you. For like, you know, we've kind of come across each other's paths a few times in the last few years as I started, you know, exploring this fun parenting space. And the things that you have to share is always mind-blowing. But before we get into all the juicy stuff, I want to have a little origin story from you. Like, what do you do and how did you discover your passion for this specific field? Pediatric pelvic floor specialist.

SPEAKER_00 3:24

Yeah, so I came upon pediatric pelvic floor therapy as a surprise. I didn't learn about it in graduate school when I went to become an occupational therapist many years ago. And I just so happened to be working at a children's hospital where they were serving pediatric pelvic floor patients. And they said, Kiara, I really think you have a wonderful skill set to be able to support these kids and these families with this difficulty. And I fell in love with it because it wasn't talked about. There weren't a lot of resources to direct parents to. And it was something that I felt that was such impactful work because it really was required in order for the kids to live their lives to the fullest and for the families to really enjoy each other. Because when there is dysfunction in toileting, it can make relationships difficult. It can make other aspects of life really challenging. So I loved to support and guide children and families with this difficulty.

SPEAKER_01 4:29

Is toileting the main thing? Or so what are some other things that you work on as a pediatric pathway school? I think a lot of the moms know what it is mean, what that means for moms. But what does it look like in kids?

SPEAKER_00 4:42

For kids, it's really looking at anything that affects bowel and bladder function in children. So an example is a child who has continued bed wetting, a child who has fecal or urine incontinence during the day and the nighttime, kids who are struggling with functional constipation, kids who are fearful of going to the bathroom or letting it out in a toilet. So it encompasses a lot of different things, but really looking at bowel and bladder function and looking at the underlying maybe developmental skills that are delayed or lagging in that child, and also possible sensory differences that could be impacting their ability to have continents across all environments.

SPEAKER_01 5:28

I think you're just leading me into right into my next question, right? I've I have two girls, and this is a it's been a minute since we talked about potty training and all the things. And I remember back in the days, we have seen all the books and charts and stickers and social media posts, or you know, the three-day method where when it's warm, you just let them go naked naked, and miraculously they will somehow know. Where do these conventional conversations fall short? What are we not talking about?

SPEAKER_00 6:04

I love that question because that falling short piece is kind of where we as pediatric public floor specialists can really do our magic because there are different factors that contribute to a child's difficulties of using the toilet. I mentioned briefly their sensory system. How is their body feeling urge sensation or not? How are they taking in their environment, such as a noisy bathroom, automatic flushers, bright lights? How are those things impacting their ability to have opportunities to build skill? Another piece of it could be their physiology. How is their gut motility? Are they more prone to slow digestion because of food allergies or sensitivities? Maybe it's their gut microbiome that needs some support. Maybe their diet is restrictive. So making sure that we're looking at all these different components in order to build skills. So I think conventional strategies aren't really looking at the whole picture. And we're looking in the past at maybe behaviorist approaches where we want to support a child's learning experience with the potty, but there it's it's not looking at the physiology or the development or the sensory pieces that really make up this child.

SPEAKER_01 7:26

So I guess for a parent who is thinking they should be potty training their child, whatever that means, whether it's social pressure, whether it's because they need to go to daycare or they need to go to a preschool, that is one of their enrollment requirements. Um what are the things that they should be looking for? And what are the things that they should be paying attention as to like what readiness actually means?

SPEAKER_00 8:01

Yeah, there's a lot of readiness cues that are out there which are really good, meaning that they're looking at the physiology of the child, they're looking at urge sensation. Can a child notice if they're feeling wet or dry? Can they nerve notice when they feel urge sensation? Physiology, can they have the appropriate postural control to be able to manage their clothing, be able to transition off different surfaces? Can they have good enough balance? So those are some readiness cues that I feel across the board folks are already looking at. And then the social emotional ones that I think are really helpful. So, social emotional, meaning when we're talking about this particular self-care skill in child development, how is the response to some of the things when we're reading the books or we're talking about the bathroom or we're talking about our body urges, what is the response of your child? Are they shy? Are they running away? Do they not want to talk about it? And looking at those cues to be able to direct our uh intention around how to get them more comfortable with even just broaching the topic of one day you're not gonna have your pull-ups or your diapers, and all the pee and poop is gonna go in the toilet. So having that early conversation when children are, you know, before two years of age can be helpful with familiarity, association, and understanding.

SPEAKER_01 9:37

So it sounds like this talk needs to start to happen as a daily routine rather than this threshold. Like we're ready to cross now, so that's read some hottie training books. Yes. Okay. I think one thing that really comes to mind is this preschool question, which I always find it fascinating, and especially after what you said what you said, about just all of these differences in sensor and physiology and everything. What is that kind of policy that we currently have bring up for you, given what you have seen in your practice?

SPEAKER_00 10:17

I know. That question is such a loaded question because I have strong opinions and perspectives about policy that has to do with potty training and continence for children at the preschool level. And when children are in preschool, they're under the age of five. And typically we see in our, you know, Western society here in the United States that the potty training journey can happen between the ages of 18 months all the way to four years of age. I've seen that range. But we know through science that better sphincter control, meaning closing and opening of the sphincter surval and bladder, can be more mature between the ages of 24 to 30 months. So that is two to two and a half. That is more helpful. That range is more helpful to start kind of learning the process, to introduce it in a way that the child is actually practicing that skill based on some of the readiness, right? The physiological, the psychological, the emotional readiness skills that they might demonstrate. And understanding that, that two, two and a half years of age, that maybe they start that potty training, potty learning journey, we give six months to 12 months of learning and mastery. So then that child, say they started at two and a half, I would anticipate for maybe a year that they continue to learn this skill. They get better connections with their brain, their body, and the nervous system to be able to stay dry and stay clean across all contexts, across day and nighttime. But when we have children that might have a little bit more of a delay in age, right? Maybe they start at three or three and a half or older with a potty training, potty learning journey, it could be some, there can be some difficulties of them being able to master the skill before they start preschool. And I don't think that's fair for families or for kids because it's essentially forcing development and saying you have to be able to do these things in order to come into this academic setting. I see many kids who are very bright in different areas of academics and other skill sets, but this is just a sticking point for them and they are limited to participate. And it breaks my heart because this shouldn't be a major factor as to how a child is accepted or not into a school setting.

SPEAKER_01 13:03

And what is an emotional toll too when accepted? Uh I know. And there's another thing, too, you mentioned about day and night. In my own experience, too, and I think many of the other parents out there, there usually is a lag. There is a difference in between as to when this child is able to go potty and do all the things during the day, but they keep the nighttime diaper much longer. Can you talk a little bit about that? I mean what what is the reason behind it? What should be parents like, you know, looking for? And is that trainable?

SPEAKER_00 13:41

Yeah, so that is definitely a normal process. We typically see daytime urinary continents come first, and then we have daytime fecal continence come second, and then we see the nighttime for urine, like the last piece. So it's being able to understand physiology and development that that last piece to stay dry for urine overnight is usually the last phase of that cycle because the brain, the nervous system, and the organ, such as the bladder, have to become more mature. And that typically happens between the ages of four to six. And you'll see that age range kind of shift depending on what you're reading, like where your resources are coming from in the research. But I say that that age range from four to six actually is pushed further out. So, like five to seven, if the child has had difficulties with daytime continence for pee and poop because they've had constipation, or they have some sensory differences where they're not feeling urge sensation as accurately for their bladder. And that sensory system that I'm talking about specifically is interoception. So interoception is how does our body from the inside feel and register to be able to let us know things like when we have to pee or poop, when we're hungry or thirsty, when we're angry or we're sad. So it's these internal sensations that need to be processed, and then an output by the child is then kind of the response to that. And many kids that I see have those difficulties where they can't feel urge sensation for when they have to poop, but for P, they feel it more strongly, or vice versa. So there's definitely those little nuances that kids are experiencing in their interoception awareness and awareness skills. Is there something to help to develop those skills? Is there something that the parents can do? Yes, absolutely. And that goes back to occupational therapy services and interventions. Okay. Seeing a provider who understands and is experienced in providing sensory integration, sensory processing, skill development with children. There are different resources that practitioners who have the training are able to help these kids with feeling more in their body. And that increases body awareness, postural stability, regulation, emotion, being able to be in their body to experience the world in a way that's comforting for them.

SPEAKER_01 16:38

This is wild. Like, no, we're now we're basically talking about like, are we in our body or not? And that's kind of what this is about, or not in their body. That kind of breaks my heart a little bit.

SPEAKER_00 16:51

Yeah, and then there's comorbidities with that, meaning sometimes when we see pelvic floor dysfunction or toileting difficulties, we often see this overlap of diagnoses. So comorbidities such as some neurodivergent conditions, ADHD, autism, OCD. So, and that makes sense because their nervous system is taking in information different ways, and they're not able to accurately and consistently, based on the context and their environment and their task demands on them, be able to register that internal sensation and then come up with an appropriate response or reaction, right? It's an a big example is hey, my kid, you know, they're doing really well with going to the bathroom for pee. But for some reason, when he starts to get on his device and he starts to play his, you know, video games with his friends, he has like no sensation of what his bladder is doing. And he continually leaks through even like the pull-ups that he's wearing. And, you know, he's seven and I'm not sure what's happening with this. And that child also has ADHD. So we start to see these patterns. And what I really want to encourage parents that are listening in caregivers and all other practitioners too, is like become curious as to like why this is happening. And it's not just a behavior that the child is choosing to do. There is a root cause as to why it is happening, and we have to get really creative as to figure out what the reason is, and reasons, I should say, uh, work with someone that can help us find those answers. Wow. That's wild.

SPEAKER_01 18:31

That's just there's got it's gotten so deep. Now, this is kind of an interesting question, and for me personally, I grew up in Taiwan, and I don't remember this, but apparently somebody, one of my cousins has told me that I think my grandparents, my mom, try to train me, probably at the age of one. And they do that because everybody else did that. So, sure, a lot of these countries, Vietnam diapers, disposable diaper, has never really been a thing until recently. So, for those cultures, for for people from those countries and those cultures, how do you approach those conversations when it comes like, well, the rest of us did it when we were eight months old? It works, for instance.

SPEAKER_00 19:18

Yeah. So having, you know, cultural humility and respect and respecting other people's ways of life is first and foremost something that I absolutely do. And I do have a lot of clients and I have worked with a lot of patients who come from diverse cultural backgrounds and who have come to the United States but still want to use the values that they had when they were younger. And in East Asian, Southeast Asian countries, and other countries that don't have access to disposable diapers and it's part of their culture to do the toilet training with infants. I think that is something that when we're looking at a biosocial lens, so looking at that specific environment, that culture, and the and the social norms, we have to understand that for many generations that worked for them. There's different components to that as well. You look at environment, you look at healthcare, you look at food, like what is that? What is their diet and their culture and the things that they have that make them their culture that could be more supportive to maybe a process like that, potty training, potty learning, and that specific culture. Here in the United States, we have ultra-processed foods. We have different environmental toxins in our environment that can be affecting how our children are experiencing some of these toileting difficulties. Societally, there has been disposable diaper use for a really long time. So I think looking at those variables and understanding, like for those children and those families in that particular culture and that environment, what makes most sense to them. And I'm going to work with families to be able to support that. But I think there are some barriers too, you mentioned like with the school systems and the expectations of others, like that is also a reality for when other people come from different countries to another cultural context and have to assimilate to that. So being able to hold those things as respectfully as I can and then offer just the education around it, like, hey, that might work for many of the children, but what happens when it doesn't work? And so that's kind of where I'm coming in and saying, Well, it's great if you don't ever need me and your kid did fine without it. But what happens when it doesn't work? And and we're used to this type of process. And that can be really hard for families from different cultures saying, like, hey, like you were mentioning, there was never Diapers that we put on our kids. Why now is my grandchild like wearing a diaper and they're four? Like, I don't understand that. So understanding how to support families and kids where they're at, but also providing them different options, I think is really valuable and perspectives.

SPEAKER_01 22:18

Yeah, for sure. Now, this is the interesting part. I think this is like getting that the interesting part of the conversation is from our private. I know you don't see those toddlers. That's correct. I know there is a population of children, teenagers even perhaps out there who still need quite a bit of support when it comes to toileting. What are some of the roads that could lead there? What are, you know, and especially this is one of those moments where I want to tell people out there, yes, it happens. And and yes, and if you're out there and your child is struggling and they're in middle school, you're also not alone because it is it it's out there. Can you speak just in general, like what could be some of the causes? Is it all physiological? Is there some emotional um causes that can lead them there? Like in your experience, what are some of the stories?

SPEAKER_00 23:27

Yeah, thank you for highlighting that it's not just young children, right? And I have a practice that serves a a wide range of children from newborns all the way to 17-year-olds with a variety of conditions. But specifically for those middle schoolers and teenagers, what I notice the most is that they come in with their chief complaint as bedwedding. So bedwetting, nocturnal aneurysis in the medical term terminology is when children are having urine incontinence at night while they're sleeping. And one of the major reasons this happens for children who are older is because they actually have functional constipation that has not been managed when they were younger. And that's one of the reasons that could be the root cause of some of the bed wetting. But say we work together and we manage that constipation and we know, hey, we are really getting a good empty. There's nothing left in the rectum to push on the bladder overnight, then what else do I look at? Well, I look at daytime habits. How are they emptying their bladder during the day? Many of the kids that I see will hold pee for the whole day. They don't want to go because of dirtiness of a bathroom at school, not having enough passes to use the restroom, not wanting to go into the restroom because it's an area where they could get bullied. There's a laundry list of reasons why kids do not want to use the bathroom during the day. This is often something that is a pattern that I see when we talk about the history of these things, and it happens earlier. So in early childhood. Think around the transition into kindergarten, and then that pattern stays with them until they get into middle school. So the daytime patterns for bladder management is poor. Well, what are the results of that? Well, one of the things that can happen is that bladder, the muscles in the bladder can actually be overactive and they can squeeze and cause muscle spasms at nighttime as well. Another piece of it could be if they're not emptying their bladder throughout the day at regular intervals, the urine in the bladder becomes more concentrated, which then irritates that bladder at night. And then you have an empty of that bladder during sleep. When we look at those things and say, okay, we've gotten those better. Oh, okay, what else could it be? Well, it could also be hormones that their body is not producing hormones enough to suppress the production of urine overnight, and they would need to get a workup from a pediatric urologist to get medication for that. And there could be airway issues. So a lot of the kids that I see might have airway dysfunction that is causing them to have bed wetting overnight, as well as retained primitive reflexes that didn't go away in infancy. So we're looking at all these different things to come up with like, why is our, you know, 13-year-old still wetting the bed at night? So that's just one example of how I work with older kids because that's one of the most common conditions for the oldest, older kids that I see.

SPEAKER_01 26:51

What would you tell the parents who has been quietly carrying this? You know, I can only imagine they're like, what is wrong with my child? Or what is wrong with me? What am I doing wrong?

SPEAKER_00 27:03

Yeah, it it is something that I always tell the families I work with, especially those families who have older children who have been struggling for years, is that it will get better because now you are in front of somebody that understands and gets it, and we'll get to the bottom of it and we'll figure it out together. And I wish I could say that this is accessible to all parents, this type of education and this type of health care. It's not yet. And I I love the power of yet because I really believe in it. And one day it will be accessible care to every single children, every single teenager and adolescent who is struggling with bowel and bladder dysfunction. And we're we're just getting started. So I'm hopeful about that. And what I do know is that older children, this impacts their childhood. It impacts their future in adulthood. And we have to do better by giving more resources and interventions for these families because once we know why this is happening, it resolves. And the child and the family are completely different. They are just like two different families from the beginning of the work that I've done with them to like the end when they're like just not having to worry about any of it. And it's so amazing.

SPEAKER_01 28:29

I bet. I guess knowing what you know and what I know now. What is real accommodation in this world like will look like to you in terms of friends and family, in terms of school? For all of the all of us, you know, like what does that look like? What kind what kind of questions should we be asking? At this point, I feel like this is almost like basic human right. Uh, and how do we build a world to support all of that? This is such a basic human, you know, bodily function. Yeah. And just from this conversation, knowing like there's so many things that could happen to a child either in early childhood or you know, it could affect something that is so basic that we really all take for granted.

SPEAKER_00 29:21

Yeah. And I always say if it's working fine and you don't have to manage the dysfunction of something, then you just have no idea how difficult it can be for other people. Right. And just understanding that this is a real problem that children and families have that does not have to do just with behavior. Again, it's not just a behavioral issue. And if you know somebody or you hear about somebody whose child is experiencing this is just to like share compassion for them and non-judgment because being a parent in this world is very difficult. And when you layer on top of it, a medical condition that there seems to be no resolution for because you've done everything and everything, and still your kid is having this difficulty, it breaks your heart as a parent. And it's it's something that we have to be kind about. So when you hear somebody experiencing this, I encourage you to say that like I see how hard this is for you, and I'm sorry this is happening. And I also want you to know that there are other people who are struggling with this. People just don't talk about it and that it actually does get better. And here is some resources because you've heard this podcast episode, you know that there are resources that there are pediatric pelvic floor specialists that work with families with these difficulties and just to give them grace. And when we're looking at accommodations for kids that are having these difficulties, it's really looking at how do we support development as a whole? How can we look at the systems we have in place in the schools? How can we look at our expectations, our rules and our regulations and our policies around this and put the child first? Because often it's not. It's not a child first-led policy-making plan in our education system today, or even in our healthcare system. So, I mean, in an ideal world, that's what it would look like. How can we make the environment supportive for these children and teens to take care of their body and not to punish them or embarrass them or marginalize them because they have this thing that we think is a behavior? And it's like, it's not, it's not a behavior. And it is a medical condition that can then turn into more of behavior and emotional difficulties over time. Right. Oh.

SPEAKER_01 32:11

If you could tell, if you could put one thing on a billboard, if there is one thing that you want the parents who is listening right now, everybody who is out there, educators, caretakers, if there is one thing that you want them to take away from our conversation today, what would it be?

SPEAKER_00 32:27

Oh, that is a great question. And I would love to have that opportunity one day to have a billboard with something I would say. I would put up on that billboard that children's pelvic floor matters. And then on that, it would have images of different things like different aged children and teenagers in different contexts, like a child at a daycare sitting on a floor potty, a teen girl holding a tampon with a worried look on her face because she has pelvic pain, you know, and a gymnast who is crouching down on the ground because he just had a leak because he has pelvic floor dysfunction. Yeah, a kindergartner in the school bathroom crying because they're scared to let a poop out. You know, like I would love to have that to bring awareness to this is a healthcare issue. It's a it's a pediatric healthcare and developmental issue that needs more spotlight.

SPEAKER_01 33:39

Oh my goodness. That was absolutely amazing. And I think my biggest takeaway is is big it's like so many of these things is we think it's behavioral, we think it's expectation. Somehow, like, you know, when you're frustrated, and I get that. Toddler years for a lot of parents are really hard and it's intense and a little different pieces, and you have little people, you can't really reason with them. Uh so everybody is short, but at the same time, just knowing that they're not doing this to spite you.

SPEAKER_00 34:19

No. Yeah. My biggest thing is if they could, yeah, I always say if they could, they would, and we wouldn't have this conversation. You wouldn't be sitting in my clinic. And there's a reason that we haven't figured out, we haven't uncovered the missing puzzle piece yet to point us in the right direction of why this is so difficult for him or why this is so difficult for her, but we're on the right track.

SPEAKER_01 34:43

Yeah, like just remembering that and knowing our children, really learning how to feel in their body to be in the interpret all of those signals. Uh yeah, well, thank you so much, Kira.

SPEAKER_00 34:58

That was fantastic as usual. I really appreciate you. Oh, you're most welcome. Thank you again for having me.

SPEAKER_01 35:06

And before I let you go, please tell all the audience out there where they can find you, people like you, how to work with you, all the good stuff.

SPEAKER_00 35:17

Yeah, so you can find me on Instagram, and my handle is at Aloha Integrative Therapy. I have a lot of resources there for families to look through. I also have a potty training, potty learning course that I created with Tinyhood. It is a self-paced course that parents can dive into at their own time to really set themselves up and their children up for success. It's rooted in pelvic health as well as child development. So there is nothing like this out. I created it in, I believe, 2022. So it's been out for a while. And there is also a free pre-potty training course on tinyhood that you can kind of check out too if your child is under the age of two and you want to get some strategies on how to support them in a developmentally appropriate way to support their pelvic health. That's available as well. Thank you so much. You're welcome.

SPEAKER_01 36:16

Thank you, thank you. And that's all we have for this week's Beyond the Story. Take good care, and we will see you next time. Thank you so much for spending this time with us on Beyond the Stories. If this conversation was helpful, we'd love for you to share with a friend, a fellow parent, or anyone who might benefit from it. And if you feel moved to, please leave us a five-star review wherever you get your podcast. It truly helps more people find these conversations. You can also find more stories and resources by downloading the Gucci app in Apple App Store. All the links and resources, as well as ways to connect with us, are in the podcast description. And if you have any questions, episode requests, or topics you would love us to explore, would truly love to hear from you. Thank you so much again for listening, and we will see you next time.