In this podcast, Dr John Harrington of Eastern Virginia Medical School and Dr Michael Paul and Rena Vanzo of Lineagen discuss genetic testing for autism spectrum disorders and genetic counseling. … Read More
The recent research on prevalence rates mirrors what many of us on the frontlines have known for several years now: more children than ever are receiving a diagnosis on the ever-widening autism spectrum. … Read More
Pediatricians can help guide the families of children with an autism spectrum disorder through the maze of interventions, toward the goal of optimizing these children's potential for a productive, independent, brighter future. … Read More
A 4-year-old boy with a history of autism presents to his pediatrician's office with a complaint of right leg pain. He is presumed to have pulled a muscle.… Read More
Consultant for Pediatricians.
Toilet Training: Strategies for Success in Children With Developmental Disabilities
By ALISON SCHONWALD, MD
Harvard Medical School |
June 30, 2009
Dr Schonwald is assistant professor of pediatrics at Harvard Medical School in Boston.
ABSTRACT: The readiness of a child with a developmental disability to begin toilet training is determined by his or her achievement of the requisite developmental milestones rather than by chronological age. The specific strategies used in training are determined by the child's specific diagnosis. Children with attention–deficit/ hyperactivity disorder may benefit from a wristwatch that beeps to remind them to stop what they are doing and take a bathroom break. Children with an autism spectrum disorder may require visual aids that indicate toileting steps and expectations. For children with sensory processing differences, interventions that optimize stool comfort and regularity may be needed. Both children and their parents benefit when toileting is broken down into the various discrete skills and steps that are involved.
Success at toilet training is a significant milestone for every child and his or her family. Through mastery of this most basic self–help skill, the child gains independence and the parents are freed of the considerable time, effort, and cost previously required. Succeeding at toilet training is just as important for children with developmental disabilities and their families; however, these children may need specific methods and a different time frame to achieve the desired goal.
CONTINENCE: NOT ONE SKILL, BUT MANY
To achieve continence, a child must master a series of skills (Table 1). First, he has to "feel it coming." Some parents recognize by the look on their child's face that he knows he "needs to go." Next, the child has to be able to "hold it in." When parents see their child do the "pee pee dance" or the "doody dance," kneel on a heel, or stand very still in an effort to postpone urination or defecation, they may be inclined to view such attempts to hold it in as avoidance techniques. Instead, parents can be encouraged to recognize the ability to hold it in as an important and necessary step toward continence. At this point, the child must be able to communicate, either with words or gestures, his need to get to a toilet; this skill is essential for those times when he is in unfamiliar environs or far from a known bathroom. Motor skills are also needed to get to the bathroom physically.
Many children who are not yet toilet trained will regularly go to the same spot in their home to have a bowel movement—for example, behind a couch, under a table, or to their own bedroom. These children are demonstrating a number of toilet readiness skills: feeling it coming, holding it in, and getting to another place to toilet privately. However, rather than "toilet trained," they are "couch trained" or "dining room table trained"! Again, taking this perspective is helpful because it encourages the family to recognize what the child already can do, rather than focusing solely on his failures.
Once in the bathroom, the child needs the motor skills to pull pants and underwear down and to climb up and sit comfortably and securely on the toilet. The ability to relax while sitting is also essential: you can't poop when you're clenched. For this reason, one of the first things we ask all children to do when teaching them to use the toilet is to practice sit–down times; the goal is to master the essential skill of relaxing while sitting. Typically, sit–down times take place 30 minutes after meals, to take advantage of the gastrocolic reflex. Each sit lasts 10 minutes, and the goal is simply to practice being relaxed on the toilet, not immediately to produce urine or stool.
The child now needs to empty the bladder or evacuate stool. Stool evacuation requires pushing. A child can use the simple biofeedback technique of placing one hand on the lower abdomen while blowing, and feeling the abdomen protrude as a sign of a successful Valsalva maneuver. Pretending to blow out birthday candles or blowing on a kazoo or other party blow toy are additional options. Wiping comes next, a skill that requires fine motor coordination and hand strength. Getting off the toilet, pulling up underwear and pants, flushing, and hand washing complete the sequence.
Breaking toileting into these 13 steps not only clarifies the skills needed to consolidate training but also provides a framework for identifying the many skills a child may already possess. For typically developing children who are struggling with toilet training, breaking the toileting process into these discrete skills focuses frustrated parents on the many abilities the child does demonstrate and lays the groundwork for a plan to add the small steps still needed to produce continence.
DR HARRINGTON ON AUTISM
Transition to Adulthood for Youths With Autism and the Need to Advocate an Early Start
April 6, 2011
The recent article in Archives of Pediatrics & Adolescent Medicine by Shattuck and colleagues should act as a wakeup call to all policymakers about the use of resources for families with disabilities. The transition from being a dependent adolescent with autism to an independent adult requires a major financial and social investment from schools, families, and entire communities.
Genetic Testing for Autism: What Can Be Done, How Helpful Is It?
January 26, 2011
In this podcast, Dr John Harrington of Eastern Virginia Medical School and Children’s Hospital of The King’s Daughters, and Dr Michael Paul, CEO and Rena Vanzo, Genetic Counselor of Lineagen—provider of a new integrated genetic testing and counseling service FirstStepDx—discuss the diagnosis of autism and genetic testing for autism.
Autism Spectrum Disorders: What to Make of the Latest Statistics?
February 12, 2010
Two recent reports, one conducted by the Health Resource and Service Administration (HRSA) and a second from the CDC, now estimate that the current prevalence of autism spectrum disorders (ASDs) in children born in the United States has risen from 1:150 to around 1:100. The HRSA report was based on a telephone survey of 78,037 parents involved in the 2007 National Survey of Children's Health. However, for its study, the CDC used a rigorous identification and confirmation system called the Autism and Developmental Disabilities Monitoring Network, which cross-references educational and health data in 11 states.
Vaccines, the Public Trust, and the Importance of the Medical Home
November 1, 2008
I thoroughly enjoyed the articles "Anti-Vaccine Media: Its Impact-and Strategies to Combat It" by Linda Nield, MD, and "Vaccinations: Immunizations Do Not Cause Autism Spectrum Disorder . . . They Prevent Disease" by Golder Wilson, MD, PhD, and Miranda Ramirez, MD (both of which appeared in the Special Issue on Vaccines that accompanied the September 2008 issue of CONSULTANT FOR PEDIATRICIANS).
August 1, 2008
The easiest way to explain what "people-first" language is might be to examine what it is not. We can do this by considering commonly accepted uses of titles that we may hear every day-usages such as "Coach Pat" or "Doctor Bob."
FROM PHYSICIANS PRACTICE
Five Steps to Improving Patient Access Judy Capko,
May 21, 2013
Patient access is getting increased attention through reform initiatives. Here are five steps you can take to make sure patients get appropriate access to care in your office.
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