Toilet Training 101

Toilet Training

  • An important milestone for children and parents
  • One of the first real opportunities a child is given to independently manage an activity of daily living
  • Recognizing signs of readiness
  • Guidance on methods of toilet training

When Should We Start?

  • Age varies by time, culture, and definition of endpoint of toilet training
  • US: 98% children are potty-trained by 36 months
  • Digo people in East Africa begin toilet training infants during first weeks of life, usually achieve stooling and urination on command by 4-5 months old
  • A study out of Belgium in 2000 showed the age at which children begin to toilet-train has increased over time
  • US: Daytime vs nighttime bladder control
    • Nighttime bladder control not expected until 5-7 years of age

Toilet-Training Methods

1) Parent-oriented:

  • Structural-behavioral training and operant conditioning
  • Speed training, increased fluid intake, regularly scheduled toilet times
  • Positive reinforcement for correct elimination
  • Overcorrection for accidents

2) Child-oriented:

  • Only after certain criteria of readiness are met
  • Permitting the child freedom to master each step at own pace
  • Fairly rapid training time, high rates of continence, low rates of regression

Assessing Readiness

Child:

  • Physiologic: Sphincter control (reflex ~9-12 mo, voluntary conditioning ~12-15 mo)
  • Developmental: Ambulate, stability while sitting, remain dry for several hours, pull clothes up/down, language skills (receptive to follow command/expressive to communicate need to use toilet)
  • Behavioral: Ability to imitate behaviors, place things where they belong, show independence by saying “no,” expression of interest, diminishing oppositional behaviors/power struggles
  • Toilet-training should not be delayed in children with chronic illness

Parent:

  • Clinicians should discuss toilet training with parents at each health supervision visit beginning at age 12 months
  • Plan toilet training when at least one caregiver can give the time/energy necessary to be consistent on a daily basis for a minimum of 3 months

Choosing a Potty!

  • Once the child demonstrates readiness, parents can bring a potty into the home
  • Encourage child to play with it, set it where he wants, sit on it fully clothed, to help with “ownership”
  • Some place the potty in the bathroom, some find greater success by keeping the potty in the bedroom where it is easily accessible after a nap, or kitchen after a meal
  • Deciding on a vocabulary for bodily fluids to use consistently
  • After a week of sitting on the potty fully clothed, child should be encouraged to sit on the chair naked
  • Placing a soiled diaper or stool in the potty and explaining that this is the purpose of the chair
  • Demonstration of disposal of the feces or the urine into the “adult” toilet
  • Transition to training pants or cotton underwear after at least 1 week of success using the potty

Toilet-Training Tips!

  • Pretend play even before starting toilet training
  • Reading kids books on toilet training
  • Trying not to refer to pooping as “stinky” or “smelly” (try not to make them averse to the toilet)
  • Positive reinforcement
  • Sounds of toilet or disappearance of feces may scare child, can try encouraging them to flush toilet paper itself or wave “bye-bye” to feces before flushing
  • “It’s not a reflection of your parenting, every child is different!”

Children with Intellectual Disability

Length of time to establish bladder training:

  • Nonverbal > verbal
  • Intellectual disability > no intellectual disability

Operant conditioning principles:

  • Scheduled bathroom visits based on identified patterns of voiding
  • Nonverbal “toileting language” (e.g. pictures, sign language, gestures)
  • Increasing fluid intake
  • Reinforcement/rewards
  • Treating and preventing constipation, which may provide negative reinforcement

Setbacks & Problems…

  • Enuresis
  • Resistance/refusal
  • Constipation/withholding behavior
  • Toilet training may set the stage for child abuse

Take-Home Points!

  • Age at which toilet training happens, varies by country, time, culture
  • Parent-oriented model versus child-oriented model
  • Assessing readiness of child by physiologic, developmental, and behavioral cues
  • Using the potty training toilet to help the child transition
  • Every child is different, not a reflection of parenting

Further reading (and listening)!


Blog post based on Med-Peds Forum talk by Ann Ding, PGY3