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-
P02300