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Expert Q&A

	By Dr. Bunni Tobias Kid Detective Psychologist

We are adopting our nephew who is a shaken baby survivor. Austin's disabilities from his injury include: partial paralysis (left hand and lower left arm) and delayed learning. Essentially, the entire right half of his brain is dead. In spite of Austin's disabilities, he is able to walk, talk, eat, feed himself and has improved in all these areas and more.

Our concern, however, is that Austin is now 4 1/2 years old, injured at 2 1/2, and is still not showing a great deal of interest in using the toilet as opposed to diapers. He knows what the toilet is, he tells us after he soils his diaper, but not prior to, and he shows some real discomfort when placed on the toilet. Austin is in a developmental preschool and a mainstream daycare, all of whom are "trying" to generate more interest in the potty.

Can you make any suggestions that might help us help Austin overcome this tough task? We have tried to read to him while he is on the potty, and that appears to be the one thing that keeps him from jumping off or crying the whole time he is sitting on the potty. Any help would be appreciated."

Though the circumstances are so very sad, Austin is fortunate to be blessed with you as his parents.

You mentioned that there are developmental deficits, and I'd like to tell you about one issue that is not uncommon in these circumstances. If you think about it, getting the "urge" to use the potty, organizing the thought with the motor planning involved in getting to the toilet, pulling down pants, diapers, etc., and the act of sitting on the potty itself is a very tedious set of actions. Sitting him on the potty until he goes serves to frustrate everyone and does not guarantee that even if he does actually go, that he ties this whole process together. I spoke with a good friend a couple of years ago about this very subject, and she explained this process to me. Once I thought about it I realized its complexity! Let me first explain motor planning or "praxis" as it is professionally termed.

Motor planning (praxis) is the planning required in the brain before the body is able to perform a series of movement patterns. This is absolutely necessary for the development and refinement of gross and fine motor skills. Motor planning is the first step in learning new skills. It requires that the brain receive accurate information from all of the sensory systems of the body. Each time a child is presented with an unfamiliar motor task or a new assignment, the ability to motor plan comes into play. When children have deficits that interfere with this process, therapies are available to support appropriate development (sensory integration).

My suggestion would be to back off for a while. When the weather gets warm, put Austin in training pants over the weekend. That means just training pants and maybe a shirt, but that's all. This will mean limiting the undressing portion to pulling down pants. By the way, if he can't do that yet, pull on/off shorts or long pants managed independently is a logical first step. Then, don't plan on going anywhere for the weekend. Every 20 to 30 minutes, gently say that it's time to use the potty and happily go to it. If the sensation of the toilet is uncomfortable, you can purchase terrycloth or other soft covers for it, or make one. He may have some tactile sensitivities. This experience of cause and effect simplified may create a successful situation.

Since I don't know how impaired Austin is, this is a fairly generic approach. What I would also recommend is that you seek out an occupational therapist in your area who is certified in sensory integration therapy. That is a very important question to ask. Their approach is different and imperative in your situation. That professional can view medical information, perform their own assessment and provide you with a clinic-based and home-based program that will support growth and development in all areas. In my practice, I can't imagine what I would do without the important role they play in establishing a foundation of skills necessary in all areas of development, including motor, language and attention as examples. They can also provide you with reading material and help you understand Austin's unique strengths and deficits.

If I can be of further assistance, please let me know. And thank you again for your generosity and dedication to this little cherub!"

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