There are four guidelines that Lucy Daniels Center mental health staff suggest parents, teachers, pediatricians, and others consider when thinking about whether a child's emotional and social development would need professional attention. These guidelines involve an assessment of 1) the pervasiveness of the symptom, 2) the coexistence of excessive challenges in other social and emotional areas, 3) the trajectory of a child's development, and, 4) the modifications being made by adults. We will explain what these guidelines mean with the help of two contrasting illustrations of children who were having some struggles with toilet training.

Ken was a three and one-half year-old child who had resisted toilet training for over a year. Although he had recently begun urinating in the potty during the day, he was adamant about not using the potty for bowel movements. If his parents were insistent, Ken would stamp his feet and call his parents names. He was otherwise a reasonably cooperative, affectionate, and contented boy. He separated comfortably from his parents and was not overly fearful. At school, he would not allow his teachers to change him, although he had begun to let them know if he had a bowel movement and was uncomfortable. He otherwise participated actively at school and had successful friendships.

Jonah was another three and one-half year-old child who had resisted toilet training for over a year. He would not use the potty at all, and was liable to have a full tantrum if his parents even suggested that he use the potty. Jonah opposed many other behavioral expectations as well, particularly at times of transition. Although sometimes happy, Jonah would often whine or fret. His parents felt that they and Jonah had few times of mutually enjoyable interaction. At school, he clung tenaciously to his mother at times of separation. He engaged in most school activities, but avoided some learning activities such as circle time. Jonah played with only a few children, and tended to boss them. Teachers and parents were always searching for new "strategies" to help or discipline Jonah.  

Let's use the four guidelines to help with a decision about whether Ken and Jonah's parents should seek professional consultation. First, Jonah's struggles with potty training were more extensive than Ken's struggles. Jonah was not using the toilet for either bowel movements or urination, and he reacted with more upset to efforts to guide him to the potty.

Next, Ken's potty training was a relatively isolated issue; he did not have other coexisting areas in which he was experiencing excessive challenge. Jonah, on the other hand, did have coexisting problems in a range of areas. He had difficulty maintaining a positive emotional tone and his relationships with his parents had become excessively negative. Jonah's avoidance of circle times and some other activities, and his limited peer relationships were indications of an emerging emotional interference with Jonah's ability to learn and relate socially.

The developmental trajectory of symptoms refers to the child's rate of improvement or growth. Ken's efforts to work out his toileting challenges were on a positive trajectory, as he had taken the steps of urinating in the toilet and being able to share his discomfort with his teachers. Because Jonah had many coexisting challenges, we have many developmental trajectories to examine, such as his ability to separate, to relate to peers, to participate in school activities, and to maintain a good mood. Jonah had made small progress in these areas over the past six months. However, his improvement, as welcomed as it was, was not sufficient to allow us to be comfortable with his development. The gap between his trajectory and those of his peers grew over the six months, and therefore, in comparison to age-expectable achievements, he was actually on a downward trajectory!

Lastly, Ken's parents did not need to make special modifications for their son. They did what "came naturally" for them, although, in the isolated area of his toileting, they did think a little more about finding the best balance between providing expectations and allowing Ken to make his own choice. Ken's teachers didn't make special modifications besides the usual ones that they made for each individual. Parents and teachers made many modifications for Jonah. They constantly thought about how to arrange the environment and daily routine to avoid difficulties, what discipline strategy would work, and how to say their words and show their feelings in just the right way. At school, for example, his teachers appropriately thought about who Jonah should sit near, how best to prepare him, how to arrange circle time so that he might be able to participate, and how to set limits very carefully, and how to arrange a very carefully designed behavior program. Although caring and dedicated adults can sometimes help a child - particularly a preschooler - to function better, a prolonged need for extra help may indicate that the child is not bringing enough capacities and flexibility to the table.

These guidelines help us see that there are reasons to be concerned about Jonah and to be reassured about Ken. Ken's problem with toilet training appeared to be a minor sticking point of the sort that all children have from time to time. Jonah's situation was quite different. His difficulties with toilet training seemed to be static rather than improving. Although his difficulties with toileting were his "noisiest" symptom, his difficulties extended into many areas of development. Despite some personal growth, the gap between Jonah and his peers was growing, and his general level of functioning was excessively dependent upon very specific assistance from his caretakers.  Jonah needed a careful professional evaluation.  

There is no "bright-line standard" to know when a parent or teacher should be worried about a child's emotional development. We must use careful judgment and weigh a variety of factors. We advise teachers and parents who are unsure to seek an initial consultation with a qualified professional and sort out whether a further evaluation is sensible.  A first call is a big step, but it is generally one that will either provide reassurance or begin the process of providing needed help for the child.

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