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Posts for category: Behavioral Health

By 'Diji Vaughan, MD.,FAAP
March 16, 2013
Category: Behavioral Health

Potty Training: A synopsis for parents


In pediatric practices across the country, the delicate issue of potty training becomes a theme at preventive health visits typically around the 18th month visit. This period is fraught a good number of developmental changes and milestone acquisition in the toddler.

We frequently encounter children and parents for whom the transition to independent bowel and urinary sphincter control is more challenging than most, here’s a quick outline of steps to successful toilet training culled from the Zuckerman and Parker textbook of Developmental and Behavioral Pediatrics, 3rd ed. that will help. 

·      Buy a potty. Place it in a conspicuous location and colorfully emphasize its importance and purpose using the child’s (and yours) terms for urination and defecation. The whole activity should be fun themed to sustain the toddler’s motivation.

·      Allow the child to familiarize and sit on the potty for about 5min a couple of times daily, typically after meals. This ideally should be about 30 min after a meal, to catch the reflex that propels contents of the colon down the intestines for evacuation. Loose fitting underpants (not diapers) are especially useful during these times. Do not force the child – remember!

·      Move to have the child do the above without underpants on after the child is well acquainted with the potty. Proceed to move the potty from its conspicuous location closer to the bathroom gradually.

·      Encourage the toddler to watch older kids and parents access the bathroom to reinforce the expected behavior.  Involving the child in the process of flushing and participating in throwing the stool from the soiled diaper or potty into the toilet and waving ‘bye-bye” to the excreta is a great idea, as it reinforces the perception as to where the stool really belongs. Make it a fun activity to the extent possible.

·      Ask child during daytime, “Do you want to go potty?” to help child familiarize with bodily and sphincter sensations. Observe closely for signs of impending urination or defecation and help in disrobing and sprint to the potty. Continually praise success and avoid criticizing failure

·      Reinforce positive features of potty training to child (e.g., “just like a big boy.”)

·      With the onset of a semi-consistent pattern of daytime control, involve the child in the process of giving up the diaper “like a big boy/girl” and make a show of disposing them in the garbage and wave the bye-bye to them.

·      Once training with the potty is well advanced, try an over-the-toilet-seat chair

·      Nighttime control happens a few months after daytime typically and remember to involve the child in the decision to try underpants at night.

There is no cookbook approach to this big developmental leap, and the above outline is a guide. Childhood temperament, social and cultural circumstances and pressure from day care centers affect the process of toilet training in many ways outside the scope of this post. The overwhelming caveats are to remember, this is not a contest. It has a number of false starts with ample successes and relapses. The toddler needs to be empowered to take responsibility for attaining the skill and the tendency to transmit a sense of disgust to the toddler should be resisted. The preferred approach to toilet training widely used in the USA is the “child-centered” approach described by Brazelton in 1962. There are cultures where potty training is attained at much earlier ages than expected in our society and we must be cautious in comparing standards since there are other factors not mentioned above that influence social and cultural norms and expectations.


It might not surprise you that video games are big business, but you may find it interesting to learn that the 2009 video game sales in the U.S alone totaled more $19.5bn which actually beats the GNP (the economic performance of a country) of about 90 of the 192 independent nations of the world! The popularity of screen media based devices that have a system of rewarding, or incentivizing the participant, through competitive and interactive plots and designed for recreational use hardly escapes notice wherever you find yourself today in the U.S and indeed most of the developed and developing world.

Do video games have any positive effects on our health? Can video games be useful in improving health outcomes? “Most research related to video games and health has focused on their potential for harm. Ample violence is portrayed in video games, even when they are not labeled as such, and exposure to violent video games has been linked to aggressive cognitions, aggressive behaviors, desensitization to violence, and decreases in pro-social behavior. Research further suggests that active participation with violent video games may increase aggression more than equivalent time passively exposed to movie violence.” A team of researchers led by Dr B.A Primack at the University of Pittsburgh, set out to address some of these questions and published their findings in the June 2012 issue of the American Journal of Preventive Medicine, reviewed in this commentary.

Play is fun and instinctive across many life forms and it captured the attention of the ancient philosopher, Plato who stated in 400 BCE “You can discover more about a person in an hour of play than in a year of conversation”. Certainly, Plato had no ideas about the remarkable vivid imagery seen on many platforms and real-life simulation of combat scenes obtainable today or even the extreme and sad story from a couple’s obsession with raising a virtual child in an online video game, during 12hr long online game sessions that eventually blurred their perception of reality and cost them the death of their own living child from starvation in South Korea in 2010.

The researchers combed through six premium medical literature databases and with proper scientific scrutiny chose 38 studies for analysis from an initial pool of >1400 studies. Only the studies that met the high pedigree of testing known as RCT and lent information to the question, whether video games may be useful in improving health outcomes were reviewed. Video games improved 69% of psychological therapy outcomes, 59% of physical therapy outcomes, 50% of physical activity outcomes, 42% of health education outcomes, 42% of pain distraction outcomes, and 37% of disease self-management outcomes. There is still a need for higher quality research in this regard; for example, two thirds (66%) of studies had short follow-up periods of <12 weeks, longer follow-up periods of participants give a clearer sense of what the long term effects of the intervention applied would be and generally a better sense of its applicability to the vast majority of the public. More so only 11% of the selected studies enhanced the scientific rigor applied further by blinding researchers during the test period and making themselves unaware which participant was getting what intervention and vice-versa to avoid biased observations.

Far from making this out as a eulogy on video games, we need to remember also that video gaming demands substantial screen time that has been associated with inactivity and the development of obesity. As a pediatrician this has been a recurring area of concern. The playing of video games also has been linked to adolescent risk-taking in traffic, poor school performance,video game addiction,unfavorable changes in hemodynamic parameters, seizures, motion sickness, and physical injuries related to repetitive strain.The American Academy of Pediatrics recommends that children get no more than 2hours of educational content screen time daily, this includes both TV and video gaming time.

The typical gamer today in the US is actually not always the gawky pre-adolescent and 10th grader holed away for hours in his chosen corner of our good planet as one might be quick to assume is the case. The researchers showed that long-held stereotypes do not apply here and the average game player is 34 years old; 40% of players are female, and 26% are aged >50 years. In 2009, 67% of U.S. households owned either a console or a personal computer (PC) used to run entertainment software or both. Therefore, video game playing is now a phenomenon woven into the fabric of American life. This didn't escape the attention of policy makers who in West Virginia made substantial investments in the active video game “Dance Dance Revolution” in all of its 765 public schools to increase physical activity, despite a lack of comparative effectiveness data.

There are clearly gains to be made with these gaming consoles just as there are ills inherent with abuse, their visibility and impact on everyday life hopefully will foster more quality research from the medical community to guide us all. Plato’s surmise of the potential benefits of a hour of play sounds to me like a good spot to begin, game on!

By Disruptive Youth Behavior- Ideas that work
April 19, 2012
Category: Behavioral Health
Tags: ADHD  


The title song in this 1966 classic, Follow me, boys! is more than ode to the Boy Scout movement or the last production with Walt Disney’s thumbprints on it. The redemption of the troublesome youth in town and the odyssey of Lemuel “Lem” Siddons intertwine as he earns the respect of the town folk and loyalty of the youth. Disruptive youth behavior with attendant global socioeconomic stressors makes parenting more challenging today and remains a widely prevalent problem. The dim reality that pharmacologic therapy with pills alone will not suffice even in the 21st century and indeed needs a full spectrum of support for success when indicated makes me wonder if Lem’s experience, expertise and approach to solving this problem fictionally would be applicable today

The town of Hickory and the trouble it faced with it’s youth in the 1930’s bear some semblance to the disruptive behavioral problems plaguing youth in diverse neighborhoods nationwide today with a view from 30,000 feet. Perhaps, the remarkable gains at the end of the story and community empowerment through the selfless leadership shown by Lem Siddons’ character played by Fred MacMurray certainly appeals as plausible to common sense but it may have found even more traction scientifically in a Randomized Controlled Trial study published in the March 13, 2012 issue of the British Medical Journal.

The team of investigators selected one of the poorer boroughs of London in 2010 and set out to evaluate the effectiveness of a peer led parenting intervention for disruptive behavior problems in children ages 2-11. 116 children and their respective parents were recruited for the study and split into two identical groups at baseline.

Peer mentors from the community were selected, paired and assigned to administer the intervention to small groups of about 7 to 14 parents drawn from the one-half of study participants to be treated. The intervention consisted of a structured manual and using validated methods themed on, social learning, structural, relational, and cognitive behavioral theories and methods for the treatment of disruptive behavior in children. These total of 8 weekly, 2-hr sessions involved sharing of information, group discussion, role play, reflection, and planning/review of homework tasks.

These peer mentors, the study reports were themselves parents from the local community who had successfully completed an accredited training program that included workshops (totaling 60 hours), submission of a written portfolio, and a period of supervised practice.

The results are promising and showed that this peer led parenting intervention  dubbed “empowering parents, empowering communities”  by the investigators could significantly address child behavior problems and improve parenting competencies, just like Lem Siddons’ bold intervention through the Boy Scout program the town of Hickory decided to spare from the blocks redeemed the youth. This could evolve into  a promising method for providing effective and acceptable parenting support to families considered hard to reach otherwise, as their parents try to grapple these issues and others.

The study design had its strengths and flaws but inherently met the well regarded pedigree of a randomized controlled trial and other questions raised as a result of this merit further evaluation. Formal economic evaluations are yet to be completed, the interventionmay in the interim offer an economically viable method for increasing provision of evidence based parenting support for families oblivious to the benefits of equipping parents with skill sets to specifically address disruptive behavior problems in their children. I hope we’ll find the will to follow the gains of this study, explore ways of implementation and lead the children away from disruptive behavior, the way Lem Siddons has showed us all for more than a half century. Follow me, Folks!