Toilet TrainingMaggie Schweig, MD

UCI/CHOC Pediatrics – PGY1

Outline

A bit of history

What to expect

Parent-oriented training

Child-oriented training

Readiness

General guidelines

Problems

Tips

Resources for parents

A bit of history…

Early 1900s – focus was on physiologic readiness with the child as a passive

participant

1920s-1930s – recommended early training and rigid scheduling

1929 Parents magazine claimed most healthy babies could be trained by 8wks old!

1940s – Dr. B Spock advocated for waiting until signs of developmental

readiness because rigid training can lead to behavioral problems

1960s – emergence of two major theories

Parent-oriented approach

Child-oriented approach

What to expect

Age & duration of training varies by time, culture & definition of endpoint

From “continent of bowel & bladder during day and night and able to perform toileting independently” to “continent of urine during day and able to express need to eliminate, whether or not they do so independently”

U.S. – 26% daytime continent by 24mo, 85% by 30mo, 98% by 36mo

Most achieve bowel & bladder control by 24-48mo (1947: by 18mo)

Switzerland – bowel & bladder continence 5% by 2yo, 11% by 3yo, 77% by 4yo, 91% by 6yo

Digo people in East Africa – begin toilet training during 1st weeks of life by relying on caregiver contact & recognition of subtle cues; achieve stooling & urination on command by 4-5mo

What to expect

Most achieve bowel control before or simultaneous to daytime bladder control

10% achieve bladder control first

Nighttime bladder control is achieved months to years later

Do not expect until 5-7yrs old

Average time to achieve toilet training – 6months for daytime urinary continence, 6-7months for stool continence

Earlier initiation of training (<27mo) correlates with longer duration of training

Boys take longer than girls (by approx. 2-3months)

1st children take longer than subsequent siblings (by approx. 2months)

What to expect

Factors consistently associated with completion of training at a later age:

Initiation of training at an older age

Stool toileting refusal

Frequent constipation

Parent-oriented training

Based on structural-behavioral training and operant conditioning

Complete method published in 1974 as Toilet training in less than a day

Basic concepts:

Increased fluid intake

Regularly scheduled toilet times

Positive reinforcement for correct elimination

Overcorrection for accidents

Mean time for training: 3.9hrs (range 0.5-14hrs)

Parent-oriented training

However subsequent studies showed high risk of behavioral problems &

unsuccessful outcomes

Major drawbacks - inadvertent conditioning to perform incorrect behaviors,

possibility of physical abuse during overcorrection

Variations with positive reinforcement only

Timed potty-training – child is brought to potty QID & encouraged to void

Daytime wetting alarm – child is placed on potty when moisture-sensitive alarm

sounds & is encouraged to finish void

Greater success attributed to awareness of body signals

Child-oriented training

Introduced in 1962

Suggests beginning training only after certain physiologic and behavioral criteria

of readiness are met

Stresses importance of allowing child the freedom to master each step at his/her

pace with minimal conflict

Associated with high rates of continence, fairly rapid training times & low long-

term regression rates

AAP currently recommends starting training once child is developmentally ready

Pediatricians should begin to discuss toilet training with parents at all health

supervision visits starting at 12mo

Child readiness

A 2012 review identified 21 different readiness signs

BUT it is unclear how many need to be present before starting training or if any

are more important than others

Age of readiness varies from 22mo to 30mo

Physiologic readiness – control over sphincters

Voluntary coordination achieved at 12-15mo

Myelinization of pyramidal tracts to sphincters completed at 12-18mo

Child readiness

Developmental readiness - motor, language & social milestones

Ambulate to toilet, stability sitting on toilet, ability to remain dry for several

hours, ability to pull clothes up & down, receptive language to follow 2-step

command, expressive language to communicate need

Behavioral readiness

Ability to imitate behaviors, ability to place things where they belong,

demonstration of independence by saying no, expression of interest in toilet

training, desire to please, desire for independence and control of functions of

elimination, diminishing frequency of oppositional behaviors & power struggles

Parental readiness

Be prepared before beginning training

Milestones to be aware of:

15mo – children become aware of accidents

18-24mo – call attention to soiled diapers & verbally distinguish urine & feces

30-36mo - begin to ask to be taken to taoilen

48mo – achieve adult pattern of elimination

Pediatrician should ask parents about: expectations, pressure from family

members or daycare providers, negative memories of their own training

Parental readiness

Many parents mistakenly equate toilet training success with intelligence or

child’s character

Parents must understand that:

Accidents are inevitable

Punishment has no role in the process

General Guidelines

General Guidelines

Step 1

• Decide vocabulary for bodily fluids

Step 2

• Buy a potty chair

• Encourage child’s sense of ownership

Step 3

• Make potty accessible

• One per level,

General Guidelines

Step 4 – Becoming comfortable

• Encourage child to sit on potty fully dressed & look at books or play with toys.

• Begin with parents or siblings using toilet to encourage imitation.

Step 5 – Making the connection

• After a week on step 4, encourage child to sit naked on potty. Make connection by placing soiled diaper or stool in potty.

• Demonstrate disposal of feces or urine in adult toilet.

• Make flushing not frightening by permitting child to flush and wave bye-bye.

General Guidelines

Step 6 – Practice & encouragement

• Use consistent praise

• Use a sticker or star chart for positive reinforcement

Step 7

• Transition to training pants or cotton underwear after at least one week of potty success.

Problems

Setbacks are normal!

Setbacks are expected in times of acute illness, family move, new child care

arrangements or family crisis

Enuresis – involuntary leakage of urine

Nocturnal enuresis – 20% of 5yo & 10% of 6yo, 2-3% of kids with 1° nocturnal

enuresis have an organic etiology

Diurnal enuresis – evaluate for an organic etiology if 1° or 2° diurnal enuresis in a

kid >4yo

Problems

Constipation, withholding and encopresis cycles

Not associated with early initiation of training

Ensure dietary changes to promote soft stool, use stool softener if needed

Resistance or refusal – occurs in up to 20% of developmentally normal kids

Associated factors – attempting training before readiness, excessive parent-child

conflict, irrational fears or anxieties about toileting, difficult temperament

(negative persistence, poor adaptability), chronic constipation

Tips for parents

Do not punish or nag

Encourage imitating parents & siblings by inviting into bathroom

Adopt a positive, loving approach to toilet training

Keep the child in loose, easy-to-remove clothing

Avoid battles over toilet training

Tips for parents

Avoid flushing the toilet while the child is on it

Avoid over-reminders

Teach boys to urinate sitting first & transition to standing after successful bowel training

Keep stool soft by increasing dietary fiber & reducing dairy products

Tips for parents

Use training pants as part of transition from diaper to underwear, not as first step

Nighttime and nap training should wait until the child is consistently dry during the day

Children should be reminded to void upon awakening to avoid accidents

If the child is not making progress, training should be discontinued for 2-3 months

Resources for parents

Books for children

“No more diapers” – JG Brooks

“Your new potty” – Joanna Cole

“Once upon a potty” – Alona Frankel

“P is for potty” – Sesame Street

Videos for children

Elmo’s Potty Time – Sesame Street

Resources for parents

Books for parents

“Toilet training the Brazelton way” – TB Brazelton

“The American Academy of Pediatrics Guide to Toilet Training” – Mark Wolraich

“Parents Book of Toilet Teaching” - Joanna Cole

Mobile apps

Potty Time with Elmo – Sesame Street

Bibliography

Turner TL, Ballard Matlock, K. Toilet Training. UpToDate.com

Potty training: How to get the job done. MayoClinic.org

https://www.mayoclinic.org/healthy-lifestyle/infant-and-toddler-health/in-

depth/potty-training/art-20045230

Toilet training. StanfordChildrens.org

https://www.stanfordchildrens.org/en/topic/default?id=toilet-training-90-

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