Whether potty training isn’t going as planned, or you’re just nervous about gearing up to undertake your child’s’ transition out of diapers, that added pressure, frustration and anxiety can create a vicious cycle, making potty learning more difficult— for you and your child.

Here to offer a podcast style “potty class” for parents so they can identify potential problem areas (physically and emotionally), and avoid potty training pitfalls, is the owner of Aloha Integrative Therapy, Occupational Therapist Quiara Smith.

Quiara shares incredible insights about when it’s time (or more importantly when it’s too early) to start potty training, the importance of coregulation, and she breaks down the basics of our child’s anatomy and physiology so we can effectively support them through everything from bedwetting to constipation or whatever toileting or pelvic health challenges may lay ahead.


Quiara (00:00):

You’re not just gonna make them go to the bathroom every 30 minutes. That’s a no no. That’s a myth because what we’re training there is urgency and frequency. They’re not learning what a full bladder feels like if we’re taking them every 30 minutes.

Dr. Sarah (00:20):

When potty training isn’t going as planned, that added pressure and frustration can begin a vicious cycle that is really hard to break here to help identify potential problem areas, both physically and emotionally, and also how parents can avoid potty training pitfalls is Occupational Therapist, Quiara Smith. Quiara specializes in treating children and adolescents with pelvic floor dysfunction and toileting challenges by using a holistic and integrative approach. So she has so much wisdom on this subject and amazing insights to share. So whether you’re gearing up for the potty training process, or you just wanna be better informed about your child’s anatomy and physiology, so you can support them in times of constipation, bedwetting, or whatever toileting challenges might lay ahead, this is a great episode for you.

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Dr. Sarah (02:22): 

Hi, I’m Dr. Sarah Bren, a clinical psychologist and mom of two. In this podcast, I’ve taken all of my clinical experience, current research on brain science and child psychology and the insights I’ve gained on my own parenting journey and distilled everything down into easy to understand and actionable parenting insights. So you can tune out the noise and tune into your own authentic parenting voice with confidence and calm. This is Securely Attached.

Dr. Sarah (02:52): 

Hi everybody. I’m really excited to welcome Quiara Smith to the podcast today. Quiara Smith is the owner of Aloha Integrative Therapy, and she’s a pediatric pelvic health occupational therapist. And thank you for being here. I’m so happy.

Quiara (03:10):

Thank you so much for having me.

Dr. Sarah (03:14):

So pediatric pelvic health, occupational therapist. I bet you, there are a lot of people listening who do not know what that specifically entails. Can you share a little bit with us about the work you, how you got into it and the work that you do with families?

Quiara (03:27):

Yeah, so like most people, I didn’t know what pediatric pelvic health was until I started working in a specialty hospital in California. Some of you may know it. It’s Lucile Packard Children’s Hospital at Stanford. I was one of the outpatient therapists there and they asked me one day, if I wanted to learn how to treat this specific population. And I said, of course I would love to learn more. I never knew about it in school. And so this was an opportunity for me to increase my professional skills and it seemed like a really good fit. So I was able to jump right in and train with a wonderful senior therapist there. And I just fell in love with the population because one, they were underserved. And two, there was a lot of holistic somatic brain and body kinds of interventions that I utilized in my practice already. And also my own personal life that was helpful for these families and these children that I was working with.

Dr. Sarah (04:26):

That’s amazing. And it’s so aligned with like a lot of, I mean, I feel like there’s a lot of overlap in our work. It’s very different, but there’s this like sort of mind, body connection piece that’s and like this sort, I mean, at least in the work that I try to do with my, and not all psychologists do sort of this integrative nervous system approach, but the more I’ve learned about the nervous system, the more I realize that like the mental health piece can’t really be separated from it. And I would imagine the more you do work with the pelvic floor and potty training kids, like the, like they’re, so the nervous system can’t be separated from it.

Quiara (05:11):

Absolutely. And so you were just speaking about kind of the focus of pediatric pelvic health is what I do is support children who are having bowel and bladder dysfunction or toileting challenges. So children who come into clinic are looking for support for bedwetting or constipation or fecal leakage, and the list goes on and on, and this is just a topic that’s not spoken about as much as it should be. And I think it really gives parents a journey to which they feel that there aren’t as much resources available to them, which is something that I’d like to change. And I know a lot of other people in this space who work for children are trying to do as well.

Dr. Sarah (06:00):

Yeah. And would you say that people come to you mostly when, like their pediatrician recommends it, that like they’re having health issues and health complications, or is it like parents who are just trying to teach their kid how to use the potty and they’re having no success and they’re getting frustrated and the kids are getting frustrated.

Quiara (06:17):

Yeah. And that’s a great question because when I was working for that large organization, I was getting my referrals from the specialty doctors. So pediatric GI doctors, pediatric urologists. Those were the main sources of my referrals, cuz I was in a clinic in a big healthcare system. But then when I pivoted into my own private practice I found out that social media was something that would really be helpful to get the knowledge that I had out to parents and other providers who were struggling to find resources for families and kids who were struggling with toileting and bowel and bladder dysfunction. And so nowadays parents are coming to me directly and finding me through word of mouth or social media, and then other providers are also referring their patients and their clients to me because like I mentioned, there’s not enough providers out there who, who know how to treat this type of dysfunction in children.

Dr. Sarah (07:15):

Yeah. It’s hard. I mean, I have people coming to my practice regularly. Oftentimes because there’s a behavioral component, that’s accompanying the potty training, potty learning difficulties. And oftentimes the link isn’t even made initially, like parents will come in and say, my kid is hitting in school or really can’t, you know, keep it together or they’re, they’re acting out and I can’t get them to cooperate. Oh. And by the way, we’re having a lot of trouble with potty training too. And it’s like a little bit of, after a little bit of investigation, it’s pretty clear for a lot of times there’s a link between the two that there’s like just the, either the, the frustration of it not going well or the perceived pressure of it. Or just maybe there’s a physical component that’s going on. That’s making the kid really uncomfortable and that is leading to dysregulation in other domains behaviorally or emotionally or things like that. Yeah. Do you see that as well?

Quiara (08:18):

Absolutely. And so when a child is having say a physiological issue with constipation just at baseline, and then you ask them to start this new developmental milestone of putting all their pee and all their poop into a potty or into a toilet and letting go of diapers, that can be a big transition and in a kind of trigger to the nervous system saying, wait, but I don’t wanna do that. And then I already have constipation and then you’re gonna have me do this thing that I have no idea what it’s about. I mean, it’s, it can be very overwhelming for the child. And then it trickles down to the parent cuz they’re saying, well, what else do I do? I’ve I’ve read these books. I’ve, I’ve listened to the pediatrician. My child is still resisting. They’re still having accidents. I don’t know what to do.

And so oftentimes, like I mentioned, that’s when people come to me and say, we’ve been on this journey for about six months to a year and you know, we’re on all these medications and the child is still having these accidents. What else could it be? Is it a behavior issue? Is it more than just a physical issue? Is it a mental issue? And so when I’m looking at this and taking this on with my holistic and integrative lens as a pediatric OT, I really look at all the domains of what makes up this child, right? So there’s that spiritual domain. There’s the physical, the musculoskeletal, the sensory system. And I’m looking at how are all those systems working? Is the sensory system having some imbalances, meaning maybe the child doesn’t feel urge at baseline. They don’t feel the urge like their peer of when they have to pee what a full bladder feels like or what a full rectum feels like.

And so if you don’t have those signals strong enough and accurately enough going from the brain to the organ and vice versa or the muscle group, you’re not gonna be able to know how you’re controlling these functions. And so this is kind of what I do in my practice is educate parents and other providers on how the, the body works and why their child might, or why, why their patient or client might not be able to control these functions yet. And I say yet, because there is a resolution parents think, oh, is my child gonna be wearing diapers in, in high school? And I say, no, they’re not because you’re here and you’re getting the support you need, but this is where, you know, that underserved kind of topic comes up where there’s not that many resources yet for parents to know about.

Dr. Sarah (10:51):

Yeah. And so like, if you’re trying to help you, you’ve sort of diagnosed one of the potential issues, which is that there’s not this mind, body physiological awareness, whether it’s because their, their there’s something actually interrupting the signal or their awareness of the signal and their ability to give meaning accurate, meaning to that signal is not yet developed enough. Right? Sometimes we’re talking about really, really young kids, right? Where potty learning happens at a pretty young age for, and sometimes I think it’s too early and that’s why part of this issue is occurring. Like they’re not, cognitively their brain’s just not developed yet enough that mind body connection just isn’t sophisticated enough to be able to consistently interpret those cues accurately and then go through the subsequent steps of, okay. I noticed that urge, I labeled it. I have to now move my body stop, whatever fun thing I’m doing. So inhibit impulse. Yeah. Go to the bathroom, physically, take off my clothes, sit down or stand up and go. Yeah. Like, like let go of my like release. So there’s like a number like there’s a lot of cognitive steps that have to occur to be able to physically do this.

Quiara (12:09):

Yes, absolutely. And cognitive, emotional and physical. Right. So you just talked about inhibiting impulse, being able to mobile, like be mobile enough to get to a toilet and to manage your clothing, to be able to have enough muscular support and stability to sit in an unsupported position, you don’t have a back rest on a toilet. So it’s you all these things that we have to take into consideration when we’re working with children who may be demonstrating their challenges with some of these skills. And so it’s a really wonderful kind of topic that you’ve brought up with potty training or potty learning too early. And so I think there’s a disconnect too, between what the readiness cues are, right? So people are talking about, oh, if your child’s ready, they’re doing X, Y, and Z. And we wanna understand that development happens and on a continuum, right?

There’s a range of, of skills that we anticipate a child to be able to do, or to be able to show us they can do within a certain timeframe, but we don’t necessarily force development. And so that’s a big thing that I actually partnered with Tinyhood, which is a parent education company that provides online courses for parents. And I just created a course that is based in rooted in child development and pelvic health for children. And it’s a step by step framework for parents to follow, to support pelvic health throughout the child’s lifespan. And it’s a really wonderful resource. We talk about trying to start the potty learning process actually closer to the age of 24 months where you hear 18 to 24 months is that prime window, but we’ve seen, and also in practice that the earlier is not necessarily the better kids are really masters at withholding.

So withholding is when you withhold the urge to urinate or defecate. And so when children are potty trained too early, we see that in our clinic with pelvic floor dysfunction is that, oh, parents say, well, my child can hold and hold and hold. Their pelvic floor is so strong and it’s so good, but that doesn’t equal efficiency when you’re going to relax and release. So those children might be releasing just minimal amounts of urine in their bladder. And they’re retaining post void, residual urine, which can cause UTIs and other things along the way as they grow and develop. So this is kind of something that we’re bringing to the forefront and, and giving parents education on how to support pelvic health from a very young age. So your child doesn’t have to land in a clinic to see someone like myself.

Dr. Sarah (14:55):

Yeah. And I think that’s so important for parents to hear, cuz I think I hear this all the time in all kinds of other milestones, right? Like there’s this sort of, I don’t know exactly where it comes from. I think it’s part of our society and it’s like deep achievement. Yeah. Heavy like energy, but this, and like this competitive energy that we have in American culture potentially. But I think this idea that like, why not sooner? Yeah. How fast can we do this? My kids advanced. Right. And like, I, I actually think that that can get in our way, a lot of times with our kids, like your kid is very naturally biologically primed to learn these skills when they’re ready. And if we can let go of any agenda we have and sort of sit back and trust that our kid is gonna do this when they’re ready and we’ll know, we’ll know when they’re ready, because they will basically tell us, I’m ready now give me that potty. Like that, there’s a way in which we, we can sometimes accidentally get in the way with our agenda and then actually can slow the, til the process and create like milestone anxiety in our, in our children or well milestone anxiety in us that leads to a delay. Yeah. Developmentally in our children.

Quiara (16:16):

Yes. And I think that that anxiety that the parent or caregiver has is definitely something that the children that land in my care are absorbing from the very beginning. And this is something I’m like, oh, this needs to be studied. How many parents that have children who have bound bladder dysfunction or toileting challenges at baseline have anxiety. And then how, how does that show up in their child? Because I see for the most part, it’s really anxiety management that I’m doing in helping the parent with strategies on coping around this overwhelming challenge in their life because not only does continents affect the person, but it affects the caregiver and it affects the, the social environment and the psychological component of a child and physical, there’s so many parts of continent that is an everyday life, right? So a child not being able to go to a sleepover or being scared to go to school and someone finding out that they’ve had an accident or a leak you know, and all these things that parents don’t really know how to manage. And they’re coming to see us when the child is younger or maybe they’re already in middle school or they’re in high school. And they’re just really lost in, in this kind of journey.

Dr. Sarah (17:43):

Yeah. And it’s very hard. It’s like, I mean, I have a lot of empathy for families that deal with this because it, there is a little chicken or egg, right? Is it that I at baseline, maybe I’m an anxious parent. And so the, the struggles that naturally occur in potty learning make me like activate my anxiety in a way that then makes this whole process really sort of more stressful for me, more stressful for my kid. And then it there’s a, there’s like a cascade or the other way around where there’s this natural stressor. Maybe my child has difficulty with this, or they are a little delayed in this. And as a parent, who’s vulnerable to seeing that delay or this struggle as a stressor becomes highly anxious or hyperfocused on the issue. And then it can inadvertently increase the perception of pressure that the child feels because you, in your most loving, caring state are trying to help them. But the way that we might be helping them is actually making the problem a little bit harder for the kid. Like there’s just more eyeballs on me. There’s more expectation. I feel the weight of this. And when I feel the weight of this, what happens to my nervous system, I go into fight or flight, I get tight. I don’t like you need to relax and feel safe in your body to be able to eliminate.

Quiara (19:01):

Absolutely. And so if the parent is like that and helping a child in the bathroom and their moment of need that child is getting that same vibration. And so their pelvic floor clenches, their diaphragm doesn’t move. They’re not breathing, they’re not helping that good defecation dynamics to happen, to avoid. And then you have more of that vicious cycle of, I tried, I didn’t go, I wasn’t successful. Now. My caregiver’s mad at me now parents feel ashamed because they were frustrated with the child, like just go to the bathroom. And I know you have to go, you’ve been holding it for four hours, you know, and it’s, it’s coming out. Like you said, out of this place of love, of course, unconditional love. But then they’re having this overwhelming feeling of that anxiety and that nervousness of their child’s health.

Dr. Sarah (19:49):

Yeah. So what could parents do? Like if someone’s listening to this and been like, oh, you know what? I recognize myself in this description a little bit. Like maybe it’s not to the point where I, you know, we’re having serious issues. Maybe we are, maybe we’re really struggling with, with potty learning completely. Maybe it’s just, okay, I could see this playing out more, getting ready to potty train. Like what are some things that parents can do to facilitate a more relaxed approach to the, to this process?

Quiara (20:21):

I say first to prepare yourself mentally. And by that meaning, understanding like where are you at? Are you having a lot of, you know, stressors in your life with work or personal things? And, and maybe not right now is not the time to jump into the potty learning process, but wait, till things kind of smooth, smooth out a little bit for yourself first, cuz you’re gonna be the guide. And secondly, to prepare the environment and prepare the child. So doing that through play is huge. You’re gonna prepare the environment. Maybe have a little potty chair, have figurines your kids’ favorite play toy and having them role play in different situations of, oh, they’re playing outside and pep needs to use the bathroom. Her body gives her a feeling, oh, where do you feel it pep? Oh, you feel it down here. And I’m pointing to where the body part is and naming that body part in the real terminology that it is.

And so this is a big thing when we’re trying to build body autonomy and just body awareness for children before we’re going to expect them to void in a potty or a toilet is being able to give them that step step or the steps and the familiarity of what this, this topic or this idea is about taking care of their body. And I like to frame it in that way because I can’t do it for them. Right. So it’s having that conversation about sometimes our body is giving us signals that has to go. And so for me, when I’m feeling like I have to pee, I feel it down here and you can point, you know, to where it is. And I take my body there or pep takes her body there and she goes to the bathroom and then you, you go through the steps and this is just in play.

This is not in, you know, we’re gonna go in that three, three day potty training boot camp. We’re gonna go do this. Now. It’s like, this is in preparation. Like I said, between the 18 and 24 month age range is a good time because cognitively they can understand cause and effect. They’re starting to build an association. They’re starting to get better at body movements. They can help kind of practice wiping, wiping off Peppa after she goes to the bathroom and playing role playing a little bit more. So that’s kind of what I would say is to kind of look at that and start there. And then I would start tracking body patterns when your child wakes up at seven o’clock okay. Is their diaper. We I’m gonna mark that off. Okay. Maybe two hours later, their wedding and their diaper again. Okay.

That’s 10 o’clock. So you’re understanding what their natural rhythms are because when you start into the process, you’re not just gonna make them go to the bathroom every 30 minutes. That’s a no, no, that’s a myth because what we’re training there is urgency and frequency. They’re not learning what a full bladder feels like if we’re taking them every 30 minutes. So if you’re understanding their body patterns and you can know, oh, I know around this time before snacks, she has to go to the bathroom. Maybe then that’s when I implement a sit time for us to rest and take a pause and take care of our bodies. So it’s not, do you need to use the potty? Do you need to go? There’s no questions, there’s statements.

We are taking care of our body. Now I’m here to help you. Should we take peppa? Should we take George? Right. Transitional objects are really great to bring and it’s in this gentle way. And it’s a matter of fact, right? I’m not, I’m not super excited. I’m not like bouncing off the walls because some kids they’re nervous system can’t take that. It’s actually more discomforting or they’re not able to tolerate that type of stimulation. So that kind of neutral, calm, gentle tone is what is more resonated into their nervous system to make them feel safe and secure and that eye contact and being at their level, I’m here to help you. Right. Even though sometimes maybe I feel like, ah, I don’t have the time to do it. Then, then you don’t say that you do it at a time when you have it, have the time to do it.

Dr. Sarah (24:29):

So basically what you’re doing is co-regulating with your kid, because your sort of your confidence, your assuredness, your neutral tone, this is all helping communicate to your child, like I’m in charge of this. And also this is fine. This is safe. This is normal. It’s, there’s like this sort of this neutrality to it and that, and our kids are gonna feel that in their body.

Quiara (24:58):

Yeah, absolutely. And so when parents are talking with their children in this way, and there’s a shift from maybe the anxious type of communication that the child is used to, and then the, the parent is now shifting in this way and transforming into this more confident caregiver, who’s there and saying, I know you can do it. And I see that it’s hard for you that the child over time slowly but surely believes in that and believes in themselves. And that’s when I see that that change happen, which is beautiful because the parents are really learning the skill to trust. Right. And to trust in the process like you were saying earlier and, and just be supportive of their child in this journey.

Dr. Sarah (25:46):

Yes. And I think for a lot of parents who might be listening to this and are like, I haven’t been doing it this way, like, did I mess it up? Like a lot of times when I, when parents come to me to do potty training work and like, I will say if I, if we’ve identified a couple ways in which maybe they’ve been inadvertently been like undermining the process a little bit, like adding too much pressure or, or, you know, not, not regulating their own anxiety enough, or maybe having too high of a demand on the kid. Right. Not having developmentally appropriate expectations for their kid, not understanding what developmentally appropriate expectations are. Right. Not cuz they’re being hard on their kid, but because they thought their kid could do something and then they had this high expectation and then they’d get frustrated that they weren’t meeting that expectation.

All understandable. Right. Yeah. But what I’ll say to parents is if you’re gonna try a new way, if you’re gonna do, do a reset, be transparent about it, name it with your kid, don’t just switch to a more delicate approach. Actually lay it outta the table, say, Hey, you know what? I’ve been learning a little bit more about learning about the potty. And I’ve realized that some of the things that I’ve been doing with you to help you might not have been actually helping so much. And so I wanna start over, can we do a reset? Let’s do a reset. And I would even do a couple days of like, we’re not even gonna think about the potty for a couple days. We’re just gonna let it be, go to your, you know, relax about it a little bit ourselves and then, then give them a heads up. Hey, tomorrow we’re gonna start it a new way. And those are the things that I’m gonna start doing. And these are the things that we’re gonna do together and lay it out for them. What do you think about that strategy of like a reset?

Quiara (27:32):

Yeah, I think that’s wonderful. And oftentimes I would recommend the same thing, especially when we’ve hit a plateau. So say parents have done all the work that we’ve, you know, planned and created together and there’s just still no movement. Then I say, let’s take a reset, let’s take a pause and let’s revisit it because it allows everyone to just kind of decompress a little bit, right. And taking the stress and the press pressure off everyone. And what I really like too is being able, like you said, to be transparent and saying, this is this hasn’t worked and this is how we’re going to change it, to make it better and we’re gonna work together in this. And so there, you know, the dynamic of having to work with children and families, we’re always trying to figure out how that dynamic is working at different places in life.

And so I think that’s what is really wonderful about kind of being gentle and having this approach of it’s not all or nothing, it’s, you can, you can go, you can push a little bit, but then you can soften. You can, you can push a little bit and then you can ease up. And that’s how life goes. It’s not just this trajectory of A plus B equal C and you have to do it this way. And I think just that, that pressure that you were talking about with just parenting in our society has made maybe these developmental milestones, such as, you know, toilet learning, potty learning, something that people are scared and overwhelmed already to begin with. So then you have that from, from baseline. But I will say there are families that the children really does have this physiological issue that turns into more of what people would consider behavioral, right? Their pelvic floor muscles are not strong enough or they’re not coordinated enough. They think that they’re relaxing when they’re actually contracting or that they don’t have enough core strength to actually push all the contents through their body. So there’s, there’s these things that we kind of have to look at when things are showing when signs are, are being shown that they’re having difficulties that are prolonged.

Dr. Sarah (29:46):

Yeah. So when would you recommend, like if a family is working on potty learning and they’re having issues it’s not going smoothly, there’s emotional resistance. There’s behavioral resistance. There’s lots of accidents. There’s tears. When would it be time to get some support?

Quiara (30:05):

Yeah, that’s a great question. And I will say that if the child has gone six months to a year of potty learning potty training, and there’s still so many accidents or leaks that they should reach out to their pediatrician and ask for a pediatric pelvic health referral. And that could be someone like myself, who’s an occupational therapist or a physical therapist. So tho those are the two predominantly referred to healthcare providers that treat children with toileting and bowel, bladder dysfunction. If you’re in another country, it’s a physiotherapist. But I would definitely reach out to them because we are able to figure out all those different systems. So how is the neuromuscular system working? How is a digestive system working the urinary system? And we give parents actionable steps to take immediately to be able to remediate some of these issues right away.

And I would say if your child is at least four years of age that’s when it’s a good time to start to do the, the pelvic floor stuff, because anything younger is a little bit hard cognitively to understand, but that doesn’t mean you can’t still get support with figuring out good posture or looking at diet, looking at supplements and medications that they’re on. But for the actual, like when people think about pelvic floor therapy, they think of like women’s health and doing all those kind of internal exams. When, when children it’s not anything internal or looking at how the external Peral area is working as well as how the core and the diaphragm is working and the hips we’re looking at the whole body and also to the sensory system.

Dr. Sarah (31:54):

Right. So now I’m curious, cuz if you wouldn’t start doing that work until four or older, but most of the potty learning issues are gonna come online around, let’s say two and a half, three years old. What would, what can parents do in that window of time? Can they still work with someone like you?

Quiara (32:13):

Yeah, they could still work with someone like me. Because what I do is that education piece, they wouldn’t necessarily like the child wouldn’t be going through pelvic floor exercises, types of things. So people think also too, when they’re a little bit older, they, if they’re appropriate enough or cognitively, if they can cognitively understand how to use a biofeedback machine, that’s another part of pelvic floor therapy for children. We use real time ultrasound. There’s all these different tools that we use in therapy, but for the younger kids, it’s most of the education piece and getting them into play activities that facilitate pelvic floor, relaxation, contraction, good diaphragmatic breathing, good supports for their sensory system. So all those things, I definitely target for children who are two to that four year age. And I do parent coaching for people all over the world. And I also do OT direct services for those in the state of California and Hawaii in North Dakota.

Dr. Sarah (33:20):

Oh, that’s amazing. Cause I think, yeah, cuz I mean, I think that there’s, there’s a range, right? We’re I’m probably getting people who are having like the first line of difficulty. And then I think you’re probably getting people, once things have gotten really challenging. Like once the shit hits the fan, no pun intended. But I feel like I even feel like I’m seeing people, who’ve tried a lot of things and it’s not working. And a lot of times, I mean, if a family comes to me and they’re having issues, they often come to me with issues around pooping, not peeing pooping seems to be a much more challenging. I think there’s a more psychologically challenging component to letting go around pooping honestly. And I’m, I’m curious what your take is too. The difference. Why some kids learning how to go pee on the potty can be a breeze, but when, but they get very resistant and emotionally kind of reluctant to, to engage with that, this, you know, going poop.

Quiara (34:25):

Yeah. And I will say that that’s the same observations that we’ve had in the pelvic health world, in, in pediatrics for poop and defecation. There has to be some correlation between the child and their digestive system, how it’s working and gut health as well as their urge sensation. So most of the children urge sensation for, for bladder for urine is stronger than for poof. And so when you have a child who is constipated, typically they will feel urge sensation to defecate in their stomach, which is a problem because you don’t feel urge sensation correctly. If you’re feeling it in your stomach, that means that you’re probably backed up. You should feel it in your rectum or your anus area when you have the urge to poop. And so I always tell parents, it’s like, you guys have to go home and you have homework to do when you feel urge, where do you feel it?

Okay. And when you ask your child, depending on how old they are, sometimes they’ll say it in the right place. I feel pee. You’re in where in my penis or in, by my vagina or when I feel, feel poop, miss Kiara, I feel it in my butt, it wants to come out. Some kids will say, I feel it in my arm. Some kids say I feel it in my chest. So can you imagine if you have a urge sensation that you have to defecate or void and you’re feeling it in your chest, that could be anything right? You could, maybe you, you are playing and you don’t know, is that, do I have to go to the bathroom or is it that I just was running a lot at recess? Like, so that’s that nervous system that I’m talking about in the interception system that needs more balancing.

And so this, these conversations happen with parents and families that land in my care. And we explore these things with children, but for poop, it’s a lot harder too with coordinating pelvic floor. So coordinating the pelvic floor, it’s like a gate. So it closes and opens. You have spanks and you have muscles that open and close at the right times when you have a child who is withholding stool, the rectum is not a storage facility. It’s a sensory organ, but they start using it as a storage facility. Meaning that the hold and hold, the bladder has a capacity, meaning you can’t hold past a certain amount and pass a certain time. Right? So the bladder, you can empty a lot easier, I would say. And I’m using just blanket terms easier, but for poop, you can actually have difficulties with that closing and opening of the spanks and the muscles. If you have issues with withholding. So that’s like, I’m at daycare. I don’t wanna go in that bathroom. I’m gonna hold and hold. But then when they wanna go, they might not have the understanding of letting go because their muscles are so used to this. That even when they do go, now they strain. So when you strain and you push and you’re pushing from the pelvic floor, you’re not gonna get anything out. You’re gonna actually trap it in.

Dr. Sarah (37:34):

So there’s a lot

Quiara (37:34):

Of things that can happen.

Dr. Sarah (37:36):

Yeah. So if you have a young kid who’s maybe a little, maybe they’re on the anxious side, maybe they, they, they don’t wanna go to the bathroom at daycare. Maybe they, they feel a little nervous about the potty and they need to be in a more comfortable place. So they’re kind of avoiding it in certain places. And then, but then when, like you’re saying now they’re home, they’re safe, but they can’t make it come out. Yeah. And so they want, they start to wanna avoid there too. What are, are there any exercises or, or interventions parents could do with their kids to teach their children how to physiologically release?

Quiara (38:10):

Yeah, absolutely. So the number one thing to do is, is look at your child’s posture. And so when we’re looking at good defecation dynamics, we wanna make sure that the feed are supported. So that means if your child is on a floor potty great, because their knees are higher than their hips, which helps the anal rectal angle be straight. So if you’ve seen the Squatty potty videos or know about the Squatty Potty, it puts you in that great position for good defecation, meaning that you’re emptying your rectum to the full capacity. It can be which we want. And so if your child is not being supported with their feet and their feet are hang hanging, and they’re like dangling off the toilet that is putting the pelvic floor on a, on, on like this contraction. So, they’re not really able to relax and release.

They might release a little, but there could be stool, still trapped in the rectum, which can cause a back up. So even though your child is pooping every day, and this is something to really, really consider some parents will say, well, my child poops every day, it’s that smooth sausage type four, it’s soft. It’s good. They’re not constipated. They can’t be constipated, but you’ll be surprised. Little bodies have, can have a lot of poop in it. And so sometimes what happens is that they’re not fully emptying their rectum and then they eat digestion continues to happen and they get backed up over time. And then they start having urine leaks or they start have bedwetting at night or they’ve always had bed wedding. And so usually constipation is the number one culprit for urinary continents. And so that’s, that’s another thing that most parents don’t know about. And so once that constipation is damaged, they see that urinary continents go away and resolve over time. So posture.

Dr. Sarah (39:54):

Yeah. That’s interesting. Yeah. I always tell families that come to me for poop help. The first thing I say is you have to check in with your pediatrician to find out if they’re constipated, like you gotta have like a sonogram or some type of like, x-ray like something, you gotta rule that out because we could do all the behavioral interventions in the world. But if they’re constipated, we’re not gonna solve the problem.

Quiara (40:16):

Absolutely. Yeah. So that’s kind of what we look at first is, is posture. So getting their knees slightly above the hips, the feet are supported. The hips are slightly forward with the forearms resting on the thighs. So sometimes you’ll have kids who are just so forward and they’re like laying on their legs or they’re leaning back on the toilet. And that is when we’re like, BA we need to work on that because that’s not helpful for defecation. And then seeing where they’re naturally like pushing from, right? So we shouldn’t push. We’re not having a baby. We’re not we’re we shouldn’t be pushing anything. Right. The pushing and what people say, like push the poop out or push the pee out or whatever kids think that they have to like actually like forcefully push. So they start straining. And when you strain, you’re closing off those thinkers and the pelvic floor.

And so instead we’re squeezing and we’re pushing down from the tummy. So with the families I work with in the children, I show them ai diagram of the body and how digestion works and where the poop is and how we’re trying to get it out and where the muscles are and how we’re using them. And so when we’re looking at trying to have good defecation dynamics, we wanna make sure that we’re breathing through the belly. So we’re not breath holding. So most of the kids that I see will strain, right? When you strain, you’re not breathing. And so there’s that cylinder of the core that we really wanna use that intro abdominal pressure to push down. So all the contents go out of our large intestine out of our rectum and out of our body. And how do we do that through breath? Right? So blowing pinwheels, bubbles, musical instruments, singing, activating the vagus nerve, all these things are really wonderful to help just relax the pelvic floor and then also get that good intro, abdominal pressure to push the contents out.

Dr. Sarah (42:10):

Yes. I always tell my daughter breathe your poop out. Which is so funny, like to say that, but like, it just made more sense to me that like, don’t push breathe and it actually it’s the inhale that actually pushes the poop out, right? Cause like, if you’re inhaling, you’re filling your diaphragm up where it that’s where the downward pressure is coming from. 

Quiara (42:34):

Yeah. And then when you’re breathing well, when you inhale your breathing and the downward pressure is going down. Yeah. And you wanna make sure that you have a, a firm contraction of your lower abdominal, so your transverse abdominal muscle. So the ones below the belly button, that should be hard on kids.

Dr. Sarah (42:57):

Okay. When they’re inhaling,

Quiara (43:00):

When you’re exhaling.

Dr. Sarah (43:02):

Oh. When they’re exhale, when they’re exhaling. Yeah. So there’s a contraction. Yeah. Got it. Yeah. So would they inhale? It’s like a balloon, right? When you inhale the belly expands like a balloon like a lot of times kids will inhale and they’ll suck their tummy in and they’ll lift their chest up. So we have to like help them to be like, well know when you inhale, you’re filling the belly up like a balloon. And when you exhale, you’re bringing your belly into your spine and you’re making your belly like a raisin.

Quiara (43:27):

Yeah. And it’s exactly like with that kind of piston system, but what we want is more of a 360 breathing too. So like when you’re seeing kids, when I assess them and I say, show me what you do when you take a belly breath. Like, I just wanna see like how you fill your belly. When you see this reciprocal breathing pattern, it shows you a lot. And usually these kids have this flared rib posture anyway, which puts them at an angle that makes it difficult for their pelvic floor to actually engage and their diaphragm to actually work efficiently. So then we do some, you know, visceral work manipulation massage, different types of things to help get that rib angle down so they can have really good umdo pressure to push

Dr. Sarah (44:13):

Amazing. This is also helpful. There’s and there’s, and this is just like scratching the surface. I mean, I think it, it, this is great that you have this course, because I think, you know, we can only cover so much. I feel like this is obviously you’ve done years and years of study to learn how to do this. And I, this is even what my specialty is. I’m really helping parents kind of put some of the pieces together to like address the behavioral issues that can often come along with potty training challenges. But like, it’s great to know that there are resources for, you know, a much more comprehensive way of approaching this. And it sounds like this course is also gonna be a huge resource to parents. So I’ll  put it in the show notes so people can find it. What’s the name of the course?

Quiara (44:58):

So it is A Stress-Free Potty Training course at Tinyhood. And it is a wonderful resource. Like I mentioned, with step by step processes on how to bring your child from diapers all the way to peeing and pooping in the potty. There’s troubleshooting with poop issues. There’s a whole section on that. There there’s a whole section on frequently asked questions with traveling daycare, schools, you name it, caregivers. There’s so many handouts and so many really valuable resources that parents can tap into. And it’s an online self-paced course as well.

Dr. Sarah (45:41):

Oh, perfect. All right. That’s great to know about, I will certainly let people in my practice know about that too, because I don’t know. I, I don’t know how we ended up getting so many potty learning challenge referrals. Somehow we just, maybe it’s just cuz it’s the age of the population that we serve, but we get very regularly. We get families coming us for help around this. So it’s nice to like have more of a referral system too, to help people get if it, you know, if, if we can get people to the exact right place, that’s always really helpful.

Quiara (46:12):

Yeah, absolutely. And the behavioral stuff, I mean, I think the work that you’re doing is so important because there’s only so many minutes that I have with families and parents and I’m looking at all those things. I mentioned today in our, in our chat with, you know, diet and nutrition and intake and musculoskeletal function and all these things. But then that other really, really important piece was supporting the parents and figuring out strategies and ways to get children and themselves in a good space to follow through on some of these activities and plans of care is kind of where you are really wonderful in, in supporting families in that way. And I think there’s just so many families in need and they just don’t know where to turn to and I think if there’s right, different providers that can support them in all these ways, it’s, it’s just gonna help the, the child and the family a lot better.

Dr. Sarah (47:13):

Yeah. And I think it’s so important too. Like the work that you’re doing on your Instagram, just to commute, like teach about this stuff. I think one of the reasons why people wait so long to get help is because they one think they’re just doing it wrong and they need to figure out a better way. And they’re sort of parents are blaming themselves or their kids for not being able to figure this out. And it’s, you know, sometimes it’s a lot bigger than that and it it’s totally okay to get help, but people it’s, you know, people don’t like to talk about bathroom stuff, so people just don’t talk about it. And so parents kind of have to figure this all out by themselves. And then of course there’s resources out there that I think are meant to be helpful, but can kind of create this illusion that like you’re supposed to be able to do this in three days or you’re supposed to be like, you know, I, I think I even, you know, I’m thinking like the Oh Crap method, I like aspects of that. I integrate aspects of that when I was helping my own children learn. But I think the idea that we could do it in three days and that’s a reasonable expectation sets families and kids and parents up to feel really like what’s wrong that this isn’t working.

Quiara (48:17):

Yeah. Yeah. And really the learning process it’s skill mastery. It’s not just like you get the skill and then it’s done. It’s, that’s why I say six months to a year. You give it that long to have your child really independent and continent. And so, you know, a child can learn a skill in three days for sure. But are they mastering it? Are they independent in it? Not necessarily. Right. Cause that’s not how development works. And so I think just having that understanding and having parents realize that and giving them self grace can go a long way.

Dr. Sarah (48:56):

Yeah. Yes. And I think, you know, for the most part, all kids are gonna learn to do this. You know some kids are gonna need more support than others, but this is something that we can really trust our kids in. And the more trust, even if it’s a challenge, the more trust we can have in them, the better we’re gonna all be for it.

Quiara (49:17):

Absolutely. Yeah. And there are people that can help if they are having trouble. Right. 

Dr. Sarah (49:23):

Yes. Yes. thank you so much for coming on and sharing all this wisdom with us. If people wanna get in touch with you, how can they find you?

Quiara (49:32):

They can find me on Instagram @alohaintegrativetherapy and you can also visit my website. There’s a lot of helpful information on there. I have a blog with a lot of great articles. More information about the services I provide with parent coaching and OT services to support kids who have bowel, bladder dysfunction and toileting challenges. And that’s www.alohaintegrativetherapy.com.

Dr. Sarah (50:00):

Awesome. We’ll put links to everything in the show notes too. So people can just click and find this stuff. Thank you so much. And I hope you have an amazing day.

Quiara (50:08):

Oh, you too. Thank you so much, Sarah.

Dr. Sarah (50:16):If you are a toddler parent, you’re probably experiencing lots of limit testing, independence, exerting and hearing a lot of “no, no, I do it!” One of the most common times that toddler parents find themselves engaging in power struggles is when it’s time to say goodnight. If you are nodding your head right now, feeling exhausted just thinking about your child’s bedtime routine, you are gonna wanna check out my free toddler sleep workbook. In it I arm you with seven concrete strategies to turn your bedtime struggles into solutions. Plus pro tips to help you take these techniques to the next level and personalize them to your child. To download my free guide, Addressing Sleep Struggles During the Toddler Years, go to my website, drsarahbren.com and click the resources tab. That’s drsarahbren.com. See you next week. And until then don’t be a stranger.

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63. Potty training, bed wetting and constipation: A conversation about pediatric pelvic health with Quiara Smith