Working with children in pelvic rehabilitation is a deeply meaningful and highly specialized area of practice. It also comes with unique ethical responsibilities. Pediatric pelvic health involves treating conditions such as enuresis, constipation, pelvic floor dysfunction, and developmental delays — all within the context of a child’s developing autonomy, family dynamics, and sensitive anatomical areas.

As clinicians, our ethical frameworks must evolve to accommodate not only clinical best practices but also the emotional, developmental, and psychosocial needs of the child.

Here, we examine the critical ethical principles that should guide our work in pediatric pelvic rehab.

Consent, Assent, and Autonomy
Unlike adult patients, children cannot legally provide informed consent — this must be obtained from a parent or legal guardian. However, ethical practice also requires assent from the child: their affirmative agreement to participate in the therapy process. This includes:

• Explaining the treatment plan in age-appropriate language
• Respecting a child's refusal or hesitation
• Avoiding coercion, even indirectly, from caregivers

When working in the pelvic region, where the potential for discomfort or boundary violation is high, ongoing, iterative assent is essential. Even young children have a right to bodily autonomy and should feel empowered to say “no” at any time.

Scope of Practice and Referral Boundaries
Pediatric pelvic dysfunction can sometimes signal deeper issues: developmental disorders, psychosocial stressors, or even trauma. Therapists must maintain clarity around scope of practice, referring out when behavioral or psychological concerns arise that are beyond the purview of physical therapy.

Examples include:

• Suspected abuse or trauma history
• Complex toileting behaviors tied to anxiety, OCD, or family systems
• Significant delays in emotional regulation or sensory integration

Collaborative care — with pediatricians, psychologists, occupational therapists, and social workers — is often essential for truly holistic treatment.

Privacy and the Triadic Relationship (Child–Parent–Therapist)
Pediatric pelvic rehab takes place in a triadic dynamic: therapist, child, and caregiver. This requires delicate communication boundaries. While transparency with caregivers is important, so is the child’s right to privacy, particularly as they age into adolescence.

Key ethical questions to consider:

• How much of the session content should be shared with parents?
• Does the child want to speak with the therapist alone?
• Are we creating a space where the child can speak freely without fear of being reported back to their parent?

Navigating this triad ethically means validating the caregiver's role while protecting the developing autonomy and emotional safety of the child.

Touch and Trauma Sensitivity
Because pelvic therapy inherently involves close proximity to intimate body regions, we must always practice trauma-informed care, regardless of the child’s known history. That includes:

• Using neutral, non-threatening language to describe anatomy
• Modeling consent with every interaction
• Offering alternatives to internal assessment (e.g., external palpation, biofeedback, or movement-based therapy)
• Ensuring the child never feels “examined,” but instead “participates” in treatment

Even well-intentioned treatment can be experienced as invasive if delivered without attunement to the child’s comfort and nervous system cues.

Gender Diversity and Inclusive Care
As gender-diverse children and adolescents become more visible in healthcare, it is ethically incumbent upon us to provide affirming, inclusive care. This includes:

• Using the child’s chosen name and pronouns
• Avoiding assumptions about anatomy, gender identity, or toileting goals
• Providing education and support for caregivers navigating unfamiliar terrain

If you’re not yet comfortable or informed in this area, seek training — not just for ethical compliance, but to provide competent and compassionate care.

Documentation and Legal Reporting
Ethical practice in pediatric care also includes accurate, sensitive documentation — especially when required to interface with schools, insurance providers, or legal systems.

Additionally, as mandated reporters, pelvic health professionals must know the signs of possible abuse or neglect and report concerns appropriately. This responsibility is both legal and ethical and should never be avoided due to discomfort or fear of disrupting rapport.

Ethical care in pediatric pelvic health is not just about following rules — it’s about respecting the whole child, honoring their voice, and creating a space where healing can happen safely. In this sensitive area of practice, our ethics must be as carefully honed as our clinical skills.

Through trauma-informed care, developmental awareness, and collaborative practice, we can offer children and families the support they need — while upholding the highest ethical standards of our profession.

Take the next step in this learning journey, and earn your ethics CEUS by joining Mora Pluchino, PT, DPT, PRPC, in Ethical Considerations for Pediatric Pelvic Health on July 27th. This one-day remote course covers ethical considerations for professionals working in the area of pediatric pelvic health. In general, healthcare professionals have many day-to-day ethical considerations to “do no harm.” This includes fundamental decisions related to billing, patient care, safety, and compliance.

If you saw Ethical Considerations for Pediatric Pelvic Health and thought “Why are they making ANOTHER ethics class?” please let me take a moment to explain its origin and purpose in the Herman and Wallace course offerings. I wrote my Pediatric Pelvic Floor Play Skills course when I had colleagues asking for ways to play with their patients. When I started teaching this class, some of the most common questions that came up seemed like ETHICAL questions. How do we handle pediatric care in different settings? How do we get consent from minors? If a child says no but their legal guardian wants the assessment done, what does the provider do?

Pediatric Pelvic Floor Play Skills is a class written to help providers take the pelvic health knowledge they have, and learn activities they can perform with different ages of children to help work on their pelvic floor function. One of the tricky parts of working with children is including the child in their care plan and coordinating with caregivers. In this course, talk about specific concerns and considerations by age, as well as strategies to bring to a provider's practice. This class is for the provider who does not have a lot of experience treating pediatric patients and wants to learn how to make sessions enjoyable and effective. While in Ethical Considerations for Pediatric Pelvic Health, we review the different overall milestones, as well as what age-appropriate expressions of sexuality may look like as children develop toward adulthood.

Let's talk about Pediatric Care
When we say “pediatric” this can span from infants to teenage age groups. Dealing with a crying baby will be different decision-making versus a toddler in a tantrum or a defiant teen. The pediatric population is a vulnerable group because they can’t advocate for themselves, their own interests, and their health to protect themselves from harm. When we consider decision-making with a child, a therapist should consider things like their development, family structure, competence, and education levels. Children develop in a variety of areas including their fine and gross motor skills, language, cognitive, social, emotional, and behavior.

In pediatric care, obtaining informed consent has two parts because it requires therapists to secure consent from caregivers and to seek assent from the child. Once they have obtained the parent’s permission, therapists should explain the procedures, potential benefits, and risks in an age-appropriate manner to the child. Therapists have to make sure the child feels comfortable and involved in their care at each step.

Pelvic health providers should establish clear guidelines about what information will be shared with caregivers and what will remain confidential when working with children, especially tweens and teens. This helps the therapist to build trust with the patient and encourages open communication with the patient. We must also consider what the caregivers are entitled to hear about their child’s life and medical care. For example, if a tween wants to talk to you about sex, do you feel equipped with the ethical implications for yourself in your practice? What about if a child discloses a sexual assault at school? What about if a teenager tells you they are pregnant but hasn’t told their parents? This class will give some guidelines to make these decisions and provide a peer “think tank” to further discuss.

One of the easiest ways to be an effective pediatric provider includes communication with the patient and their support system. Make sure to review topics like the condition, treatment options, and expected outcomes to empower them to make informed decisions. Keep your communication clear and provide educational materials that are accessible and understandable. Make sure to check with caregivers about what words and pictures they are comfortable with the child seeing and hearing. Some children or caregivers may have personal, religious, or cultural implications that may limit what education they want the child to be exposed to.

Every child is unique, and their treatment should reflect their individual needs, preferences, and circumstances. Therapists should listen to the child and their support network, and incorporate their feedback into the plan of care. Consider their life and routine to make sure their care and homework fit into their daily schedule. Advocating for the needs and rights of pediatric patients is a critical aspect of ethical care. Therapists may need to recommend resources, treatments, and accommodations, and promote awareness and education about pediatric pelvic health issues within the broader community. This may include coordinating with a child’s daycare, school, or other medical providers.

What course is right for you?

• Ethical Considerations for Pediatric Pelvic Health on October 13th - Learn more about the ethical challenges pediatric pelvic health practitioners may experience including consent, managing situations of trauma and abuse, and managing autonomy for minors. If you work with pediatric patients on a regular basis, this class can be an additional step in your practice. It will review topics like consent, abuse, education, communication, and diagnoses that tend to have more ethical considerations with pediatric patients. Join us to review background information and then discuss, as a group, different cases and ethical situations to help further your pediatric clinical practice.
• Pediatric Pelvic Floor Play Skills on October 20th - This is a beginner-level course and is a good fit for providers who do not have a lot of experience treating pediatric patients and want to learn how to make sessions enjoyable and effective. In this course, we discuss specific concerns and considerations by age, strategies to bring to a provider's practice, sample home programs, equipment purchase lists (with a budget in mind), tips for helping get families on board with the implementation of care, and resources such as outcomes measures, developmental milestone checklists, and recommendations things parents ask for like how to talk about periods and sex.

AUTHOR BIO:
Mora Pluchino, PT, DPT, PRPC

I am a graduate of Stockton University with my BS in Biology (2007) and Doctorate of Physical Therapy (2009). I have experience in a variety of areas and settings, working with children and adults, including orthopedics, bracing, neuromuscular issues, vestibular issues, and robotics training. I began treating Pelvic Health patients in 2016 and now have experience treating women, men, and children with a variety of Pelvic Health dysfunction. There is not much I have not treated since beginning this journey and I am always happy to further my education to better help my patients meet their goals.

I strive to help all of my patients return to a quality of life and activity that they are happy with for the best bladder, bowel, and sexual functioning they are capable of at the present time. In 2020, I opened my own practice called Practically Perfect Physical Therapy Consulting to help meet the needs of more clients. I have been a guest lecturer for Rutgers University Blackwood Campus and Stockton University for their Pediatric and Pelvic Floor modules since 2016. I have also been a TA with Herman and Wallace since 2020 and have over 150 hours of lab instruction experience.