1962;29;121PediatricsT. Berry Brazelton

A CHILD-ORIENTED APPROACH TO TOILET TRAINING  

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ISSN: 0031-4005. Online ISSN: 1098-4275.PrintIllinois, 60007. Copyright © 1962 by the American Academy of Pediatrics. All rights reserved.

by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village,it has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication,

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A CHILD-ORIENTEDAPPROACH TO TOILETTRAININGT. Berry Brazelton, M.D.

Department of Pediatrics, Harvard Medical School, and the Massachusetts General Hospitaland the Children's Medical Center

P EDIATRICIANShave a unique opportunityto prevent problems for the child in the

area of bowel and bladder control. Sincethe advent of streamlined diaper care hasliberated mothers in our culture from thereal need to “¿�train―their children early,this step may be viewed more honestly asa major developmental task for the child.Proper timing of this may enable him toachieve mastery for himself. The ultimatevalue of such self-achievement can beeasily weighed against the adverse effectsof inopportune training by an adult society. The pediatric and psychiatric literahire reports complications resulting fromadverse toilet training.1'2 This paper willpresent the results of a program for training in which utilizing the child's developmental capacities and interest was the primary goal.

Parents and pediatricians are aware thatthe child's autonomous achievement in anydevelopmental area frees him to progressto more advanced areas. Faulty masterymay leave him with a deficit that results inregression under stress. The relationshipof coercive toilet training to chronic constipation has been pointed out.7 Garrardand 411 presented six cases offunctional megacolon with psychogenicetiology, in which the environmental pressure expressed in training practices were aprimary factor. Glicklich5 summarized psychogenic factors in enuresis. Encopresis2'4'9'1' and urinary incontinenc&―3'14 canbe traced to adverse or punitive trainingpractices. Such pathologic symptoms usually reflect a fundamental psychologic disturbance in the child's adjustment. But inhealthful situations, parents can be encouraged to produce a positive reaction in thechild to his control of bowel and bladder.

This paper will outline a child-orientedapproach to “¿�toilettraining― at around 2years, geared to each child's developmentalcapacities. The results from 1,170 childrenin 10 years of pediatric practice, for whomthis program was suggested, are summarized.

THEORY

The method suggested was constructedon several assumptions based on observations of physical and emotional maturationin children.

Voluntary Control of Sphincters

Local conditioning of reflex sphinctercontrol can be effectively elicited as earlyas 9 months and has been the basis for anearly introduction of@ Voluntaryco-operation may be elicited as early as12 to 15 months, and this period has been

79, 12, 15 as optimal for training.

However, myelinization of pyramidal tractsto these areas is not completed until thetwelfth to eighteenth month.16 Associatedwith the transition from reflex compliance toa more voluntary type of developmental accomplishment, there is usually a perceptible

time lag. In this period there is a kind ofsubtle inner resistance to outside pressureon the part of the child. This may be seenin many other developmental areas, suchas reflex standing at 5 months to voluntarystanding at 10 months, and vocalizations inthe first year to verbal expressions in thelatter half of the second year. This periodis probably an important period of incorporation and of gathering inner forces forthe child. In a complex area such as toilettraining, it would be even more likely thatany training based on early reflex compliance would go through a subsequent period

ADDRESS: (Office) 51 Brattle Steet, Cambridge 38, Massachusetts.

121

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122 TOILET TRAINING

of bag and breakdown before voluntarycompliance on the part of the child couldensue.

Postponed breakdown in a controlachieved before 12 to 18 months is muchmore frequent than that seen when control is accomplished after 18 months.7' “¿�20That this breakdown in control can be circumvented by pressure from the environment is easy to see in some European cubtures, where the incidence of postponedbreakdown is much lower than in our ownless rigid 24,19However the severity and intractability of the symptoms pro

duced in the deviant cases in these countries is good evidence for the strength ofthe child's inner resistances, which bringabout such breakdowns. The incidence offailure in England is reported as varyingfrom 10 to 15%.2,13

Motor Adjuncts to Training

Other aspects of motor developmentparticipate in the ease with which a child

achieves training. He must be abbe to sitand to walk in order to maintain some degree of autonomy about leaving the pottychair, and some understanding of verbalcommunication is a help.

The developmental energy invested inlearning to walk on his own is freed after15 to 18 months and can be transferred tothe more complex mastery of sphincter control and toilet training.

Impulse Control

There must be a psychologic readinessassociated with a desire to control the finpulses to defecate and urinate. These finpulses are associated with a kind of primitive pleasure and an immediacy. The realization of and wish to control them is dependent on influences from the environment. Chief among them are 1) securityand gratification in the relationship withparent figures, resulting in a desire to pleasethem; 2) the wish to identify with and imitate his parents and other important figures in his environment; and 3) the wishto develop autonomy and mastery of himself and his primitive impulses.8@17,21,22

These psychobogic processes come to the forein the latter half of the second year and appear to reach a peak of readiness in mostchildren beginning at 18 months and increasing to 30 months.

Other Psychologic Processes

At about 2 years of age there is a periodin most children in our culture that ischaracterized by organizing and settingthings in their proper places. Even a trendtoward personal cleanliness may develop.These trends are useful in understanding areadiness for toilet training.

There is an ebb and flow of negativism inthis period of development, and it must beaccounted for in urging new accomplishments. As it is difficult for a parent orphysician to evaluate the degree of negativism that is active at any particular time,it is necessary to pace any such programslowly and with enough elasticity to allowfor these subtle variations.

PARENTAL INVOLVEMENT

Sears et al.18 pointed to many of the complexities of parental feelings about toilettraining in our culture. The child's abilityto learn by imitation is complicated bytaboos centered around modesty and thesexual feelings of the parents. For parentswho wanted to train their children earlyin order to avoid such complex areas as1) sexuality, 2) cultural pressure from oldergenerations, or 3) strong compulsive feelings about cleanliness, pressure to delaytraining increased the parents' anxieties.They found, however, that many of theirgroup of young parents were “¿�intransitbetween old and new theories― (p. 109)and were in conflict about the age at whichtraining might best be instituted. The“¿�new―theories12'20 suggested waiting for thechild's readiness. In the group who wereable to postpone training, less time wasrequired to complete it. But Sears et al.wondered whether parents who werepushed to delay against their wishes mightnot increase the tension around this areafor the child.

We have found that a “¿�child-oriented―

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ARTICLES 123

approach in the group of parents in ourstudy could divert some of their own anxiety, provided there was the “¿�guidingear―of a third person, such as the pediatrician.

The conviction that this was “¿�betterfor thechild― undoubtedly acted as a counterbalance to the older cultural influences, aswell as to their own sexuabized taboos inthis area. Since the child's autonomousachievement was constantly the focus,there was the implication that there wasless parental responsibility for failure inthe child's lack of accomplishment. Tension could be reduced by airing parentalconflicts and by assurance that the childwould achieve control in his own time.

PROCEDURE

Advice was geared to each individualsituation. At the 9-month visit the questionof future toilet training was raised with theparents. Because the grandparents' generation usually began to press them at thistime, it has proven to be an optimal periodfor the discussion of future plans in thisarea. With a program planned, the parentswere better able to withstand outside pressure to institute an early attempt at training the child.

Before suggestions were introduced, theparents' own feelings in this highly-chargedarea were explored. A repeated opportunityfor them to express their own resistancesand anxieties about toilet training was finportant in preventing their expressing themunconsciously to the child. The importanceof a relaxed, unpressured approach to training for the child was constantly stressed.

This method was presented as an adjunctto helping the child meet society's demandsin this area. Because there is little innatein the child that leads him to want to beclean and dry, it must be understood as akind of compliance to external pressure.The act of giving up the instinctual methodof wetting and soiling to comply is evidenceof 1) healthy maturation in the child,coupled with 2) a wish to identify with anadult society.17 Hence the optimal timingfor such pressure must be geared to eachchild's physical and psychological readiness

to cooperate. With his autonomous achievement of this major task, the reward for himis equivalent to that seen with his masteryof standing and walking and becomes avaluable step in his developmental progress. The danger of residual symptoms isthen at a minimum.

The importance of timing the introduction of this method to the child's readiness,and of allowing him freedom to mastereach step at his own pace, was reiteratedat each subsequent visit. Problems withthe child and resistances or questions fromthe parent were discussed at each opportunity. Since this was not necessarily anattempt to prejudice parents for this particular approach to toilet training, everyeffort was made to help them with theirown method. However, when problemsarose, the child's interests were placed foremost in the discussion.

Method of Training

At some time after the child is 18 monthsof age, a “¿�pottychair―on the floor is introduced as the child's “¿�ownchair.― Duringthe period of getting familiar with it, association between it and the parents' toiletseat is made verbally. At some routinetime, the mother takes him each day to siton his chair in all his clothes. Otherwise,the unfamiliar feeling of a cold seat caninterfere with any further co-operation. At

this time, she sits with him, reads to him orgives him a cookie. Since he is sitting on achair on the floor, he is free to leave atwill. There should never be any coercionor pressure to remain.

After a week or more of his co-operationin this part of the venture, he can be takenfor another period with hia diapers off, tosit on the chair as the routine. Still no attempt to “¿�catch―his stool or urine is made.“¿�Catching―his stool at this point canfrighten him and result in his “¿�holdingback― for a longer period thereafter. Thisgradual introduction of the routine is madeto avoid setting up fears of strangeness andof loss of “¿�partof himself.―

When his interest in these steps isachieved, he can be taken to his pot a sec

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124 TOILET TRAINING

ond time during the day. This can be afterhis diapers are soiled, to change him onthe seat, dropping his dirty diaper underhim into the pot, and pointing out to himthat this is the eventual function of hischair.

When some understanding and wish tocomply coincide, there will be verbal oractive compliance on the first routine trip.Then he can be taken several times a dayto “¿�catch―his urine or stool, provided heremains willing.

As interest in performance grows, thenext major step becomes feasible. All diapers and pants are removed for shortperiods, the toilet chair is placed in hisroom or play area, and his ability to perform by himself is pointed out. He is encouraged to go to his own pot when hewishes and by himself. He may be remindedperiodically that this is indicated. When heis ready to perform alone, this becomes anexciting accomplishment, and many children take over the function entirely at thispoint. Training pants can be introduced,the child instructed as to their removal, andthey become an adjunct to his autonomouscontrol. The excitement which accompanies mastering these steps by himself iswell worth the postponing until he canaccept them.

Teaching a boy to stand for urination isan added incentive. It becomes a part ofidentifying with his father, with other boys,and is often an outlet for a normal amountof exhibitionism. It is most easily learnedby watching and imitating other male figures. It is better introduced after boweltraining is complete. Otherwise, the excitement of standing for all functions supersedes.

Nap and night training are left untilwell after the child shows an interest instaying clean and dry during the day. Thismay be 1 to 2 years later, but it often be.comes coincident with daytime achievement. When the child evidences an interestin night training, the parent can offer tohelp him by rousing him in the early evening and offering him a chance to go to thetoilet. A pot painted with luminous paint

by his bedside is often a useful “¿�gimmick.―He is reminded that this is there for earlymorning use also. Some children who areeager and ready to remain dry at nighthave needed further help from the parentsto awaken in the early morning for an interval. When this is not forthcoming, theyfail in their efforts at night, lose interestand feel guilty in their failure. Then, enuresis and “¿�givingup―may follow.

These steps are stressed as the child'sachievement, and when there is a breakdown the parent is urged to stop the process and to reassure the child. He needs thereassurance that he is not “¿�bad―in hisfailure to achieve, and that someday hewill co-operate when he is “¿�ready.―

RESULTS

The results are compiled from unselected

records of 1,170 patients over 10 years ofpediatric practice ( 1951-1961) in Cam

bridge, Massachusetts. Upper-middle-classwell-educated parents comprised the majorportion of patients in this group. They livedunder economic pressure, and mothers werewashing their own diapers, so there wassome practical pressure to achieve training.But their desire to give their children athoughtful environment freed them in mostcases to want to follow the suggestedmethod.

The sample consisted of 672 (57.4%) maleand 498 (42.6%) female children, of whom660 (56.4%) were first children and 450(43.6%)weresecondor later.It wasfoundthat the position in the family was a factorin determining the kind of environmentalpressure which existed. With the first childthere was usually more anxiety shown bythe parents about waiting to train the child,more ambivalence about this “¿�delayed―method, but surprise and relief when training was accomplished. The later childrenwere given more freedom to train themselves at their own speed. However somepressure on these later children to conformcame from the older siblings. Imitation ofthe older children often facilitated trainingin the younger ones.

The daytime training of first children

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ARTICLES

Fic. 1. Ages at which toilet training was instituted.

125

NUMBEROF CHILDREN

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AGE MONTHS

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was effected 1 to 2 months later than intheir younger siblings. Night training wasdelayed 1 to 7 months longer in first children than in subsequent siblings. Figure 1summarizes the ages at which training wasstarted. The preponderance of patients whostarted around 24 months reflects these parents' willingness to accept this advice, and,with second children, their own choiceabout such timing. Figure 2 summarizesthe ages at which parents reported the

NUMBEROF CHILDREN450425-

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child's initial success, which was maintained. One hundred forty-four (12.3%)achieved bowel training first, 96 (8.2%) were

trained for urination first, and 930 (79.5%)were reported as training themselves simultaneously for bowel and bladder control.Of the 930, some 839 (90.3%) were between24 and 30 months of age. The average ageof the total group who accomplished initialsuccess was 27.7 months.

Initial success reflects an understanding

438

324

252

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Fic. 2. Areaof firstachievementin training.

245

125

47 48rn

60 60fin

rTlllBOWELLiii TRAINING

a URINETRAINING

D URINE AND BOWELTRAIN INSSIMULTANEOUS

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126 TOILET TRAINING

384

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NUMBEROF CHILDREN

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Fic. 3. Ages at completion of daytime training.

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I I I I I I I I I I

AGE—MONTHS It IS IS SI 24 27 30 33 36 39 42 45 45

of the use of the toilet rather than amastery of the process. Figure 3 summarizes the ages of completion of daytimetraining. Nine hundred forty-four (80.7%)accomplished this between the ages of 2and 2%years. The average was 28.5 months.No significant difference was noted between males and females. Day trainingmeans an absence of accidents under theusual stresses. When a breakover occursunder stress, it is of temporary durationonly (less than 1 month).

Night training implies 1) that subsequentfailure was reduced to less than once aweek and 2) that enuresis returned under

NUMBEROFCHILDREN

unusual stress only, e.g., a new baby, moving, absence of a parent, etc., and resolveditself again in a short time (less than 2months). Figure 4 summarizes the ages ofnight training. Sixteen (1.4%) children areincluded who had residual problems ofenuresis, encopresis and constipation beyond the age of 5 years. In the total group940 (80.3%)were completely trained by theage of 3 years. The average age of all training was 33.3 months. Females were completely trained 2.46 months before males.

There were 150 children in this groupwhose training was not completed until3%years. Forty-eight, or approximately one

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Fic. 4. Agesat completionof night training.

I'S

ISO

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ARTICLES 127

third of these, were started to be trainedbefore 18 months. One hundred and eight(9.2%) were untrained by 4 years. Of these70 or two-thirds had started training be

fore 18 months. Of the 16 problem children only two had started early, and thetime of training them seemed to have littleinfluence in creating their more severe dif

ficubties.Of these 16 children, 12 were enuretic

after 5 years of age, 4 soiled in stress situations, and 8 had chronic constipation.There were environmental problems in allof these cases, and it was obvious that ineach of these children the above symptomsreflected deeper disturbances of a psychogenic nature. But of the other 1,154 in thegroup, there were often similar environmental stresses present, and it is encouraging that these did not produce problemsin the training area. This suggests that byallowing the child more freedom to develophis controls at his own speed, problems insuch an area may be prevented, providedparental anxiety in this area can be avertedalso. It is not possible in this paper topresent the details of techniques availableto pediatricians which can facilitate thehandling of incipient problems, but theseresults bead one to believe that such achild-oriented approach does divert environment tension from this area and mayreduce the incidence of subsequent difficulties.

SUMMARY

Results of toilet training obtained fromthe records of 1,170 children in pediatricpractice over a 10-year period are summarized. The suggested method stressedthe child's interest and compliance in developing autonomous control. This was instituted at about 2 years of age and depended on his physiologic and psychobogicreadiness.

Initial success was achieved simubtaneously in both bowel and urinary control in79.5% of the cases, 12.3% in bowel controlalone, and 8.2% in urinary control. This firstaccomplishment was reached at an average

age of 27.7 months. Daytime training wascompleted between 2 and 2% years of agein 80.7% of this group. The average age forday training was 28.5 months; males andfemales showed no significant difference;first children were 1.2 months slower thantheir siblings. Night training was accomplished by 3 years in 80.3% of cases. Theaverage age for completion of all trainingwas 33.3 months. Males took 2.46 monthslonger for complete training. First childrenwere delayed 1.7 months in complete training in relation to their siblings.

Of the children who had chronic diffi

culties in this area, 76 (6.5%)were untrainedat 4 years, and 16 (1.4%) were failures bythe age of 5 years. The value of such achild-oriented program in preventing residual symptoms is stressed.

REFERENCES

1. Bell, A. I., and Levine, M. I. : The psychologicaspects of pediatric practice : I. Causes andtreatment of chronic constipation. PzmATRICS, 14:259, 1954.

2. Bodian, M., Stephens, F. D., and Ward, B. C.H. : Hirschsprung's disease and idiopathicmegacolon. Lancet, 1 :6, 1949.

3. Davidson,M.: Constipationand fecal incontinence. Pediat. Clin. N. Amer., 5:749, 1958.

4. Garrard, S. D., and Richmond, J. B. : Psychogenic megacolon manifested by fecal soiling.Pznwrmcs, 10:474, 1954.

5. Glicklich, L. B.: An historical account ofenuresis. PEDIATRICS, 8 :859, 1951.

6. Greenacre,P.: Urinationand weeping.Amer.J. Orthopsychiat., 15:1, 1945.

7. Huschka, M. : Child's response to coercivebowel training. Psychosom. Med., 4:301,1942.

8. Isaacs, S.: On Bringing Up of Children. NewYork, Brunner, 1952.

9. Prugh, D.: Childhood experience and colonicdisorders. Ann. N. Y. Acad. Sd., 58:355,1954.

10. Reichert, J. L. : Constipation in infants andyoung children. Pediat. Clin. N. Amer., 2:527, 1955.

11. Richmond, J. B., Eddy, E. J., and Garrard,S. D. : Syndrome of fecal soiling and megacolon. Amer. J. Orthopsychiat., 24:391, 1954.

12. Spock, B., and Huschka, M.: The PsychologicAspects of Pediatric Practise, Vol. 13. (Practitioner's Library of Medicine and Surgery).New York, Appleton-Century, 1938, p. 775.

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128 TOILET TRAINING

13.Bromfeld,J. M., and Douglas,J.W.: Bedwetting prevalence among children aged 4-7 years. Lancet, 270:850, 1956.

14. Cole, N. J.: Assessment current parental practises. Amer. J. Orthopsychiat., 27:815, 1957.

15. Gesell, A., and Thompson, H.: Psychology ofEarly Growth. New York, Macmillan, 1938,p.142 if.

16.Ford,F.R.:DiseasesoftheNervousSysteminInfancy, Childhood and Adolescence. Springfield, Ill., Thomas, 1952.

17. Escalona, S.: Emotional Development in theFirstYearof Life.New York,Macy, 1952.

18. Sears, R. R., Macoby, E. M., and Levin, H.:Patterns of Child Rearing, Evanston, Ill.,Row, Peterson & Co., 1957.

19. Conrad, S. J.: Study of preschool children.Amer. J. Orthopsychiat., 18:340, 1948.

20. Hill, L. F.: Expected behavior in children.Minnesota Med., 41:114, 1958.

21. Leitch, M., and Escalona, S.: Reactions of infants to stress, in Psychoanalytical Study ofChild, Vols. 3 & 4. New York, InternationalUniversitiesPress,1949.p.121 if.

22. Senn, M. J. E.: The Healthy Personality, Vol.2. Macy, 1950.

A P@nc@i.@ OUTLINEFORPREPARINGM@ICAL TALKS AND P@i@iis, Robert M. Zollin

ger, M.D., William G. Pace, III, M.D.,

and George J. Kienzle, B.A. New York,Macmillan, 1961, 57 pp., $1.95.

This booklet of 64 pages is as simple, practical, and prosaic as the reminders inside itsfront and back cover for the medical man when(A) returning from meetings (“Answeraccumulated mail. Report interesting and newinformation to staff. Outline plans for newprojects.―) and when (B) preparing for visitors

(“Plancoffee breaks. Special honorarium mustbe arranged well in advance.―).Between thesecovers there is a wealth of useful detail, someof it also a little self evident, but well worth thetime of any speaker or writer, and required

reading for most.The eight pages devoted to medical writing

are scarcely enough for their purpose, but therest of the booklet, with its brief sections onthe various sorts of self-made slides and ofthose requiring technical assistance, is excellent. Perhaps most welcome of all is the sectionon projection screens, with its diagrams ofproper relationships between screen size, roomsize, wattage of bulb, and focal length projector.

The Director of the Department of VisualEducation of the Children's Hospital MedicalCenter tells us: “¿�Thisbooklet is well done,authentic. I approve heartily.― Coming fromF. B. Harding, this approval is impressive.

C.A.S.

BOOK REVIEW

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1962;29;121PediatricsT. Berry Brazelton

A CHILD-ORIENTED APPROACH TO TOILET TRAINING  

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Online ISSN: 1098-4275.Copyright © 1962 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0031-4005. American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007.has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked by the PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication, it

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