Toilet Training
Steven Parker
Laura Sices
I. Description of the problem. Toilet training is one of the great developmental challenges of early childhood. After 2 years of glorious indifference to social niceties regarding the process of excretion, in Selma Fraiberg’s phrase, “The missionaries arrive … bearing culture to the joyful savage.” Armed with Dr. Spock rather than the Bible, the adults try to cajole the skeptical child into making a dramatic developmental leap without clear benefits. It is a difficult sales pitch and is best attempted only after the child exhibits developmental readiness to understand and master the complex physiologic and psychological tasks of toilet training (Table 84-1). This “child-centered” approach, described by Brazelton in 1962 is the most commonly used in the United States and almost always effective. However, for situations in which immediate results are needed, the motivated parent can attempt the “toilet training in less than a day” method.
A. Epidemiology.
In the United States, 26% of children achieve daytime continence by age 24 months, 85% by age 30 months, and 98% by age 36 months.
Nighttime continence usually occurs within a few months after daytime control is achieved.
The average time to successful toilet training is 3 months.
Girls are usually faster than boys in achieving control.
Differences exist in expectations for timing of toilet training between racial and ethnic groups in the United States; for example, on average, African American parents may expect initiation of toilet training to occur earlier than Caucasian parents. There have been secular trends in the United States toward later initiation of toilet training over time.
II. Management. Suggestions for parents on toilet training strategies are set out in Table 84-2.
A. Information for parents. The issue of toilet training is best discussed as part of anticipatory guidance at the 15- to 18-month visit. A number of key principles should be discussed with the parents:
1. There is usually no hurry or benefit to early toilet training. Although the process can be initiated in response to outside pressures (e.g., childcare requirements), there are good reasons to try to wait until the child is developmentally prepared.
2. Like most other developmental challenges of childhood, it is best to empower the child to take responsibility for achieving continence. Since control of stool and urine will be achieved sooner or later, the most important outcome of toilet training is a boost in the child’s self-esteem at mastering the task. This is a long-term goal that should never be sacrificed to the short-term strategies to achieve continence.
3. Toilet training is not a contest; it proceeds by fits and starts, with successes and frequent relapses; if the timing is wrong, it can always be postponed.
4. The parents should not transmit a sense of disgust toward the stool but treat it as a wonderful gift from the child.
B. Resistance to toilet training. Some children resist toilet training, even if the parental technique is impeccable. The primary care clinician can make these suggestions to the parents:
1. Do not fight, punish, shame, or nag under any circumstances. Be sympathetic and try to understand the resistance from the child’s point of view. (Children with difficulty toilet training are more likely to have intense or less adaptable temperament traits than children who toilet train easily).
2. Discontinue training for a few weeks or months if the child is emphatically negative.
3. Continue discussions with the child about toilet training and emphasize the maturity demonstrated by such behavior.
4. Encourage the child to imitate parents and siblings by inviting the child into the bathroom.
5. Read potty training books or view potty training videos together.
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