Behavior

Toilet Training

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Toilet Training, Potty Training, Child Continence Training

  • Epidemiology
  1. Toilet Training timing varies by ethnicity and country
    1. U.S. Children: 18 to 36 months
    2. Vietnam: Started at 6 months, and completed by 24 months
        1. Sweden: Only 5% start by 24 months
  2. Now: Toilet Training occurs at a later age in U.S. than in the past
    1. Previously training started at age 18 months and now starts at 21-36 months
    2. Toilet Training is completed in only half of 36 month olds
    3. However, later Toilet Training is associated with higher rates of Toilet Training refusal and prolonged Enuresis
  3. Prior: Usually occurs by end of third year (mean 2.5 years)
    1. Age 24 months: 26% daytime continence
    2. Age 30 months: 85% daytime continence
    3. Age 36 months: 98% daytime continence
  4. Gender impact on timing
    1. Girls toilet train, on average, 3-5 months earlier than boys
  • Signs
  • Toilet-Training Readiness
  1. Child asks to wear underwear or to use toilet
  2. Able to put on and take off clothes, as well as more simple skills (sit, walk)
  3. Autonomy (e.g. Says 'No')
  4. Follows simple commands
  5. Observes parents using toilet
  6. Demonstrates interest in using the toilet
  7. Imitates parent's behavior
  8. Wants a clean diaper when soiled
  9. Diaper stays dry for at least 2 hours and during naps
  10. Bowel Movements occur at predictable times and are regular (with night time bowel control)
  11. Child indicates they need to urinate or defecate
  • Management
  • General (based on AAP, Dr Spock and Dr Brazelton methods)
  1. Start Toilet Training when signs of readiness (see above)
    1. Typically after 18 months
    2. Dr. Spock recommended after 24-30 months
  2. Offer positive reinforcement (praise)
  3. Process should be pleasant and non-threatening
    1. Avoid punishment, shaming or use of force
    2. Avoid negative comments or shaming
  4. Child uses potty-chair voluntarily
    1. Bring to potty-chair 2-3 times daily once child shows interest
  5. Intensive Toilet Training
    1. Frequent reminders for child to use bathroom
    2. When tried before age 27 months, does not result in earlier Toilet Training
      1. However, intensive Toilet Training is NOT associated with adverse outcomes (e.g. Stool Withholding)
      2. Blum (2003) Pediatrics 111:810-14 [PubMed]
  • Management
  • Specific Methods
  1. Brazelton Child-Oriented Toilet Training Method
  2. Azrin and Foxx Toilet Training Method (Toilet Training in A Day Method)
    1. https://www.pottytrainingconcepts.com/A-Method-Azrin-Foxx.html
    2. Negative reinforcements incorporated in this method are discouraged by many pediatricians
    3. Method appears effective and can be modified to exclude negative reinforcements
  • Complications
  1. See Enuresis
  2. See Encopresis
  3. Toilet Training refusal
    1. May occur in up to 20% of children (esp. if Toilet Training started after 3.5 years of age)
    2. Often related to Constipation or skin irritation and associated painful stools (or psychosocial factors)
    3. Consider fiber supplementation and Stool Softeners
    4. Describe stool in positive terms
    5. Positively reinforce stooling in diaper
    6. Hiding to defecate is NOT a concerning behavior and does not result in delayed Toilet Training or stool witholding
  4. Stool Withholding
    1. More severe progression of Toilet Training refusal
    2. Similar management as Toilet Training refusal
    3. Aggresively manage Constipation
  • Resources
  1. AHRQ Toilet Training Method Review
    1. http://www.ahrq.gov/downloads/pub/evidence/pdf/toilettraining/toilettr.pdf
  2. Bright Futures
    1. https://www.brightfutures.org/development/early/toilet.html
  • References
  1. Baird (2019) Am Fam Physician 100(8): 468-74 [PubMed]
  2. Choby (2008) Am Fam Physician 78(9): 1059-64 [PubMed]
  3. Polaha (2002) J Dev Behav Pediatr 23(6): 424-9 [PubMed]
  4. Stadtler (1999) Pediatrics 103:1359-68 [PubMed]