Toilet Training

Introduction

Toilet training is a big step toward independence and control in a child’s life, and it can also pose unique challenges for children and families. The process of toilet training takes into account a wide range of parental preferences, expectations, cultural factors, and acceptable approaches and methods.

As such, there is no consensus regarding the best method or standard definition of toilet training, and there are limited evidence-based recommendations.

Background

There is no definitive answer as to what age to begin training. Physicians usually bring up topic of toilet training around 18- or 24-month visit. Most children complete toilet training between 18 and 37 months of age.

The average age of completion of toilet training has been increasing steadily in the US in recent decades. In the late 1940s, the average age was 18 months. In 2003, the average age was 37 months.

Certain factors may influence when toilet training is initiated:

Sex – Girls tend to complete toilet training 2-3 months earlier than boys.
Cultural beliefs – African American caregivers usually start toilet training earlier.
Family stressors – Divorce, death, new baby, or a move provide poor environments for the child and parents to begin training. Additionally, it has been shown that caregivers from lower SES have expectations for earlier training, which may be due to diaper cost and daycare initiation.

The most important tip for toilet training is not to initiate training until the child is ready and to cease with the process if the child is not interested or unsuccessful. You may then try again in a few months. As it is a child-centered process, a universal method is not realistic, which is often frustrating to parents.

Indications of Readiness for Toilet Training

Many factors influence readiness and should be taken into account when determining if a child is ready to begin training.

Child Readiness

Can follow directions
Aware of urges and is able to communicate them
Has dry periods of two or more hours
Has the desire to remain dry
Desires to emulate family members
Has the motor skills to sit still on toilet and pull clothes and underwear up and down
Demonstrates independence by saying “no”

Parent Readiness

Have knowledge about training process
Are open to alternative suggestions
Have reasonable expectations
Have a block of time to devote to toilet training
Are able to be in control of training and resist pressures from other family members, friends, outside influences
Have the ability to provide consistent training amongst caregivers (relatives, day care workers, babysitters, etc.)

Strategies for Toilet Training:

Proper setting and diet
- Toilet training should start at a time when the child is not ill and not undergoing any other life changes.
- A potty chair/toilet should be used that is comfortable and supportive for the child.
- The child should be encouraged to eat a well-balanced, high-fiber diet to help form softer stools and obtain bowel regularity.

Method 1: Passive, Child-oriented approach (AAP supported)

This method takes weeks to months to complete and is a relaxed, minimal-stress approach that emphasizes the importance of the child’s interest in toilet training.
The child is introduced to a potty chair and progresses from simply sitting on it to using it appropriately.
Positive reinforcement is used for encouragement and accidents are acknowledged but not punished.

Method 2: Toilet-train-in-a-day method
- This method takes 24-48 hours and is an intense period of instruction that occurs in one room.
- The child is shown a doll that demonstrates wetting and toileting. The child is then taken through the motions him/herself. He/she is then given large amount of liquid to induce urge to urinate and then reminded frequently to toilet and checked for dryness.
- Positive reinforcement is used, and if accidents occur, the child is reprimanded and given the responsibility of changing into dry clothes.
Use of diapers and training pants
- During training, diapers may be used to help contain stool or urine until continence is achieved.
- Training pants can be a good transition from diapers to underwear, but aren’t recommended at the initiation of toilet training and are better to use when child is ready to take on the training process himself.
- Keeping a child in a wet diaper is not beneficial to the training process and can cause rashes.

Practical Tips & Suggestions

Begin the process during emotionally relaxed times. For example, the birth of a new sib, divorce, or recent move would not be an ideal time to start.
Give the child their own potty chair that enable the child to have their feet on the ground. Involving the child in the purchase and being excited about the purchase is helpful if possible.
Try to place the child on the potty chair when the chance of success will be high. Behaviors like touching genital areas or squatting may be cues. Also, after meals or following naps are also good times to sit on the potty.

Positive reinforcement. This can start with praising the child for just sitting on the potty chair. May also give the child a small reward if they are successful like healthy snacks or stars on a star chart.
Be patient if the child is unsuccessful or has an accident. Change the child soon after they go to avoid mixed messages.
"Big boy or girl" pants are often helpful in encouraging the child. Use diapers for naps and sleeping time only.
Encourage both parents to be on the same page throughout the process.

Reasons for delay or inability to achieve toilet training success:

Pressure on child
Constipation
Parental anxiety
Developmental delay
Physical disability
Genitourinary abnormalities

It is important to reiterate to parents that toilet training is not a competitive event and some children are trained at different rates than their siblings or friends' children. Most children will be trained by 3 years of age and often by themselves. Pressure, punishment, and negative feedback will often prolong the process and cause complications and stress for the child.

Toilet Training in Children with Special Health Care Needs

Children with intellectual disabilities

Some children may be able to achieve success. Children with receptive language skills and easy access to a toilet may have better outcomes. As with all other children there is no one best proven strategy for toilet training in this population.
Given the spectrum of abilities and disabilities among mentally handicapped children, physicians, parents, and other caregivers must be flexible and patient in implementing and trying different strategies.

Children with physical disabilities

Certain conditions may limit bowel and bladder function (eg. spina bifida, Hirschsprung’s disease, congenital anal anomalies).
The favored approach to toilet training for children with physical disabilities is a multidisciplinary one that involves the child, parents, psychologist, physical therapist, and the physician.
Some methods that have shown to be successful are timed evacuation via intermittent clean catheterization, stool softeners, suppositories, and enemas. Support groups can also be helpful for parents and families to find unique solutions.

Physician’s Role in Toilet Training

Support, educate, and encourage child and parents. Understand the child’s development and provide realistic expectations.
Be aware of and sensitive to parental and cultural perspectives.
Encourage toilet training in children with developmental and physical disabilities.
Inquire about parents’ plan, expectations, and concerns. If desired, help select toilet training method and help instruct parents on initiating it.
If delays or difficulties occur, screen for developmental delay, genitourinary abnormalities, constipation, Hirschsprungs, dietary fiber intake; may need urinalysis, urine culture, renal/bladder ultrasound or further workup
Remain aware that more child abuse occurs during toilet training than any other developmental step and provide parents with effective nondisciplinary training techniques
Offer resources and materials. Educational resources for parents and physicians from the AAP can be found at the link below: