Toilet Training

Most children complete toilet training between 18 and 37 months of age. There is some variations in whether bladder or bowel control is established first. Nighttime control of bladder function usually comes later and may be delayed for years in some individuals.

Recent studies have found that the average age of toilet training is increasing world-wide.  Specifically, in the United States, it has progressed from under 18 months in 1947 to over 3 year in 2003.  This difference likely reflects a shift from end-point oriented methods ( e.g. Azrin-Foxx, "Train in a day") to child-orientedtraining (first prpoposed over a half century aga by Brazelton and Dr. Spock, and adopted by the AAP in 1998 and later tby the AAFP and CPS.)  There have been no controlled studeies comparing different metholdology of toilet training. 

Girls complete training earlier than boys and African Americans usually start earlier and complete training before Caucasians. There are cultural differences and since there are different believes among physicians.  In addition, socio-economic factors may play a role because of the cost of disposable diapers.

The most important tip for toilet training is not to initiate training until the child is ready and to cease with the process if the child is not interested or unsuccessful. You may then try again in a few months. As it is a child-centered process, a universal method is not realistic, which is often frustrating to parents.  Indeed, a recent literature review found that there are only three published guidelines, the AAP, AAFP, and the CPS.

Indications of Readiness for Toilet Training

  1. child has developed the intelligence level and vocabulary to understand toilet training. They must comprehend words such as pee-pee, poop, wet, dry, and potty. They must also be able to walk to potty, pull down their pants, clean themselves after going.
  2. They must understand what the purpose of the potty is. This will be developed by watching parents and sibs using the bathroom and trying to imitate their actions.
  3. The child appears to dislike being wet and dirty. They want to be changed and enjoy it. 
  4. They are aware that they have to go. This will be illustrated by pulling on their genitals, hopping around, squatting, and telling the parents that they have to go .
  5. The child demonstrates sphincter control by being dry and clean for longer intervals.
  6. Children have the desire to please.
Steps to Initiate Toilet Training
  1. Begin the process during emotionally relaxed times. For example, the birth of a new sib, divorce, or recent move would not be an ideal time to start.
  2. Buy the child their own potty chair that enable the child to have their feet on the ground. Involving the child in the purchase and being excited about the purchase is helpful.
  3. Try to place the child on the potty chair when the chance of success will be high. Behaviors like touching genital areas or squatting may be cues. Also, after meals or following naps are also good times to sit on the potty. 
  4. Positive reinforcement. This can start with praising the child for just sitting on the potty chair. May also give the child a small reward if they are successful like snacks or stars. 
  5. Be patient if the child is unsuccessful or has an accident. Change the child soon after they go to avoid mixed messages. 
  6. "Big boy or girl" pants are often helpful in encouraging the child. Use diapers for naps and sleeping time only.
  7. Encourage both parents to be on the same wave length throughout the process.
  8. After meals is a good time to encourage sittin on the potty seat.
  9. If potty training is delayed, you should perform a developmental assessment as well as physical exam concentrating on neurological and genito-urinary tract areas. Also, ask about chronic constipation.
It is important to reiterate to parents that toilet training is not a competitive event and some children are trained at different rates than their sibs or friends' children. Most children will be trained by 3 years of age and often by themselves. Pressure, punishment, and negative feedback will often prolong the process and cause complications and stress for the child.

Although the professional societies emphasize the child-oriented approach over operant methods, the AAFP guidelines note that recent studeies show lower SES correlataes with earlier training by as much asa a half a year, possibly reflecting parental outlooks shaped by factors such as the cost of diapers and daycare requirements.  Consequently, the AAFP and others note that is is important for the clinician assess not only child readiness but also family and SES factors that may shape biopsychosocial outcomes, when advising parents on toilet traintng strategies.

References

  1. Brazelton TB et al. Instruction, Timeliness and Medical Influences Affecting Toilet Training. Pediatrics. 1999; 103(6):1353-1358.
  2. Michel RS. Toilet Training. Pediatrics in Review. 1999; 20:240-245.
  3. Stadtler AC, Gorski PA and Brazelton TB. Toilet Training Methods, Clinical Interventions and Recommendations. Pediatrics. 1999; 103(6):1359-1361.
  4. Blum N, Taubman B, and Nemeth N. Relationaship Between Age at Initialtion of Toilet Training and Duration of Training: A Prospetive Study. Pediatrics. Voll 111 No. 4  pg. 811 April 2003
  5. Schmitt B. Toilet training: Geting it right the first time. Contemporary Pediatrics March 2004
  6. The Effectiveness of Different Methods of Toilet Training for Bowel and Bladder Control www.ahrq.gov/clinic/tp/toilettrtp.htm
  7. Choby BA and George S.  Toilet Training.  American Family Physician 2008
  8. Canadian Pediatric Society.  Toilet Training: Anticipatory guidance with a child-oriented approach.  Pediatrics and Child Health.  2000 5(6)
  9. Howell et. al Toilet Training.  Pediatrics in Review. June 2010