Académique Documents
Professionnel Documents
Culture Documents
ARTIIC L E
Toilet training:
Getting it right
the first time
By Barton D. Schmitt, MD
T
oilet training is accom- disposable diapers cost about 25 advertisements, children in pull-ups
plished when a child uses a cents each; pull-ups, 40 cents. are extremely happy. Delayed toilet
potty chair or toilet for blad- Once a child is toilet trained, the training has been legitimized, and
der and bowel functions options for travel, babysitters, day thats good for business. Other fac-
during waking hours. care, and preschool multiply. From tors are busy, dual-career families
Nighttime bladder control usually the childs standpoint, using the and normal procrastination.
occurs later because it requires the toilet can enhance a sense of mas- To keep toilet training in per-
ability to suppress the urge to void tery and self-esteem as well as pre- spective, remember that more than
during sleep or the advanced skill vent the discomfort of diaper rash. 50% of children around the world
of awakening from sleep to the sig- From a medical standpoint, using are toilet trained at about 1 year of
nal of a full bladder. Even at 6 years the toilet reduces the spread of en- age.1 They are toilet trained by ne-
of age, 10% of children still wet teric pathogens such as G i a rdia a n d cessity because many families cant
their bed. Rotavirus. afford disposable diapers and dont
Successful toilet training is good Yet many parents in the United
for both parents and children. Not States postpone toilet training. The
having to change diapers and wash predominant reason seems to be the DR. SCHMITT is professor of pediatrics, University
of Colorado School of Medicine, and medical
off a bottom frees up considerable availability of disposable diapers. director of the Encopresis-Enuresis Clinic, The
parental time. (And, lest we forget, Manufacturers of disposable diapers Childrens Hospital, Denver. He is a member of the
some parents still wash diapers.) and pull-ups now market large-sized editorial board of Contemporary Pediatrics. He has
nothing to disclose in regard to affiliation with,
Toilet training also saves a signifi- pull-ups, so not being toilet trained or financial interests in, any organization that may
cant amount of money. In bulk, at 4 years of age is not a problem. In have an interest in any part of this article.
KEY POINTS
have the time or facilities to wash during the day was 31.5 months
cloth diapers. In my experience, Training a child for girls and 34.7 months for boys.
even in the US, low-income fam- for the toilet The median age for staying dry
ilies toilet train their children earlier during the day was 32.5 months
Toilet training begins on the
than the middle class. Single mothers for girls and 35 months for boys.
day the parent starts practice
also toilet train their children earlier.2 runs (potty sits) Girls were consistently trained two
to three months earlier than boys.
The age of onset Most children can be made
The study documented a consistent
and completion ready to toilet train between
2 and 21/2 years of age l e a rning sequence (Table 4). The
of toilet training results should not be considered a
Readiness training
The timing of starting and complet- developmental timeline, however,
(preparation) should precede
ing toilet training in the US has toilet training by at least six because toilet training (practice
been changing (Table 1). 3 Some months and can easily start at runs) was started much later (at a
p a rents are unaware that toilet 18 months of age median of 26.7 months for girls
training before 2 years of age is Early or delayed toilet training
and 31.2 months for boys) than in
even possible. Some have been ad- is a parental preference, not the Brazelton study. In that study,
vised by their health-care provider a developmental limitation more than 50% of the children had
not to start toilet training before 3 already completed training by 26.7
years. Has the pendulum swung months, and more than 85% were
too far? Lets review three studies. training, 26% of the children were trained by 31.2 months.
The largest study in this country trained by 24 months, 52% by 27 What accounts for such wide dif-
was reported by Brazelton in 1962 months, 85% by 30 months, and ferences in the age of completion of
on 1,170 children in Boston (Table 98% by 36 months. The sequence toilet training? Clearly, the deter-
2).4 Toilet training was begun by of completed training was bladder mining factor is when training be-
18 months of age in 19% of the and bowel control simultaneously in gins. Several other studies demon-
c h i l d ren, by 21 months in 40%, 79.5% of the children, bowel con- strate that an earlier start leads to
and by 24 months in 94%. Using t ro l first in 12.3%, and bladder earlier completion.7,8 Parents can
Brazeltons child-oriented, gentle, control first in 8.2%. achieve Brazeltons results by start-
and gradual approach to toilet Another interesting study com- ing between 18 and 24 months of
pared 379 children who were toilet
trained in 1947 to 71 childre n
TABLE 1 TABLE 2
trained in 1975 (Table 3).5 In 1947,
The trend in beginning 60% of children in the sample were When do children
toilet training trained by 18 months of age and 95% complete toilet training?
by 33 months. By contrast, in 1975,
Time period Starting age only 2% of children were trained by % of children
18 months, and 59% by 33 months. Age completely trained
19201940 12 mo
The main reason for earlier comple- 24 mo 26%
19401960 18 mo tion was earlier initiation of training.
This study clearly demonstrates the 27 mo 52%
19601980 2 yr
impact of parental expectations. 30 mo 85%
19801990 2.5 yr
A more recent study by Schum 36 mo 98%
1990 present 3 yr followed 126 girls and 141 boys in
Adapted from Bakker 3 Milwaukee from 1995 to 1997.6 Adapted from Brazelton TB4
The median age for stool contro l
fluids. Increased fluid intake re- r a re, some more common erro r s
NEXT MONTH
sults in frequent urination and can lead children to resist toilet
m o re opportunities to practice training. One is forcing the child to Toilet training trouble
bladder control. sit on the potty chair when he How to deal with
underachievers, refusers,
P rovide incentives. Increasing doesnt want to. Another is holding and stool holders
the incentive for releasing pee or the child on the potty chair when
by Barton D. Schmitt, MD
poop into the toilet can jump-start he wants to get up. Such heavy-
toilet training inertia. Examples of handed tactics cause most parent-
incentives include stickers, food child power struggles to become ACKNOWLEDGMENT
For the past seven years, Ive held community forums
t reats, or 10 minutes of playtime embedded. In addition, hurried toi- on toilet training twice a year, with the objective of
with a special toy. let training to meet a preschool re- preventing toilet training resistance and stool holding.
My thanks to the thousands of parents who have
Use time-ins. A time-in is the quirement usually is unsuccessful. shared their questions and ideas with me.
opposite of a time-out. Time-ins are
brief displays of physical affection Completion doesnt
mean perfection The parent guide on pages 120122
given to children by their parents may be photocopied and distributed
(hugs, gentle touch, a smile, a Toilet training can be considere d to families in your practice without
kiss).11 Time-ins are more powerful completed when a child uses the permission of the publisher.
than praise. Some children who are toilet or potty on his own with no
REFERENCES
not making headway with toilet reminders from his parents. Toilet
1. deVries MW, deVries MR: Cultural relativity of toilet
learning feel discouraged. Frequent training, from start to finish, training readiness: A perspective from East Africa.
time-ins help them remember that takes three to six months on aver- Pediatrics 1977;60:170
2. Schum TR, McAuliffe TL, Simms MD, et al: Factors
their parents love them and are age. The child may continue to associated with toilet training in the 1990s. Ambulatory
their allies in this process and give ask the parent to accompany him Pediatrics 2001;2:79
3. Bakker E, Wyndaele JJ: Changes in the toilet training
them a good reason to change. to the toilet for several additional of children during the last 60 years: The cause of an in-
months. crease in lower urinary tract dysfunction? BJU Int 2000;
Toilet training Completion also can be defined 86:248
4. Brazelton TB: A child-oriented approach to toilet
errors as 99% bowel control and 95% training. Pediatrics 1962;29:121
5. Martin JA, King DR, Maccoby EE, et al: Secular
Punishment has no place in toilet bladder control. Wetting under- trends and in dividual d iff erences in t oilet-training
training. It always makes the child wear once or twice a week when progress. J Pediatr Psychol 1984;9:457
6. Schum TR, Kolb TM, McAuliffe TL, et al: Sequential
uncooperative and also hurts the the child is distracted or in a new acquisition of toilet-training skills: A descriptive study of
c h i l d s self esteem. Spanking, setting is normal and may continue gender and age differences in normal children. Pediatrics
2002;109(3e). Available at www.pediatrics.org/cgi/
threatening to punish, or scolding for six to 12 months. Some boys c o ntent/full/109/3/e48
the child for accidents is always may have normal, mild, intermit- 7. Taubman B: Toilet training and toileting refusal for
stool only: A prospective study. Pediatrics 1997;99:54
counterproductive. At its extreme, tent wetting episodes caused by de- 8. Blum NJ, Taubman B, Nemeth N: Relationship be-
punitive toilet training in the hands lays in getting the belt on their tween age at initiation of toilet training and duration of
training: A prospective study. Pediatrics 2003;111:810
of a volatile parent or other care- pants loose or the zipper down. 9. Taubman B, Blum NJ, Nemeth N: Stool toileting re-
taker can escalate to child abuse; This can also happen to girls with fusal: A prospective intervention targeting parental
b e h a v i o r. Arch Pediatr Adolesc Med 2003;157:1193
encopresis interpreted by the par- tight leotards. Girls may experience 10. Schmitt BD: Community forums on toilet training
ent as deliberate is the second most mild wetting caused by norm a l (unpublished surveys) 1997-2003
11. Christophersen ER, Mortweet SL: Parenting that
common trigger for lethal child vaginal reflux of urine combined Works: Building Skills that Last a Lifetime. Washington
abuse.12 For this reason, its impor- with getting up from the toilet too D.C., APA Books, 2002
tant to examine the genitals of any quickly.13 C h i l d ren of either sex 12. Schmitt BD: Seven deadly sins of childhood: Advising
parents about difficult developmental phases. Child Abuse
child brought to you for toilet can have fecal smears (skid marks) & Neglect 1987;11:421
13. Mattsson S, Gladh G: Urethrovaginal refluxA common
training problems. on the underwear resulting fro m cause of daytime incontinence in girls. Pediatrics 2003;
While punitive responses are inadequate wiping. h 111:136
Continued on page 120
(Continued)
(Continued)