Potty Training (Toilet Training)

• Toilet training is a natural function that requires biological maturation coupled with a child's desire to master controlling urination and bowel movements.
• Cultures have various expectations regarding when to start toilet training and when a child should be expected to be toilet trained.
• Setbacks and accidents are a normal part of the toilet training experience. Punishment should not be used during the process of toilet training.
• Nighttime dryness is not a "willed" behavior, as such a young child cannot be trained to be dry at night.
• A pediatrician should be consulted for children who develop a pattern of resisting bowel movements or the development of daytime wetting or nighttime wetting if he has been continuously dry for more than 6 months.

Potty training is assisted learning for a child to develop controlled elimination of urine and stool. Potty training is also referred to as toilet training. Toilet training incorporates the ability of a child to anticipate the need to urinate or have a bowel movement and successfully void or eliminate stool into the toilet. Successful toilet training is an important milestone for both the child (gains independence and self-mastery of his body) and his parents (freedom from diapers). This implies awareness of body sensations and a purposeful behavioral response. For this reason, successfully remaining dry while asleep is often not considered a prerequisite to being considered to be toilet trained. A more stringent definition would imply complete control during both sleep and wakeful periods.

During the 20th century, American parents approached potty training with a broad array of techniques. In the 1940s, Dr. Benjamin Spock recommended a more developmental approach and encouraged parents to notice a series of developmental signs before beginning the process of toilet training. He argued that a more rigid approach would commonly lead to behavior problems. In the 1960s, developmental pediatrician T. Berry Brazelton refined the Spock approach, combining the natural maturation of the child's physiology and emotional maturity and characteristic desire for independence.

Expectations have been shown to exist in different American racial groups. Most African-American parents believe potty training should be started at 18 months of age, while Caucasian parents more commonly propose 24 months of age as a starting time. Recent American epidemiologic studies note that approximately 25% of 2-year-old children are daytime potty trained, 85% by 30 months of age, and 98% by 3 years of age.

In contrast to the American approach, the Digo culture of East Africa begin toilet training during the first few weeks of life and have achieved urination and stooling on command by 4 to 5 months of age. Anthropologists note that this culture maintains essentially constant physical contact between mother and child during the first year of life. Pediatricians have noted the difference between urination and stooling on parental command (Digo culture) with a self-motivated and completed activity with limited parental involvement (Western culture).

Three separate, though related, developmental skill sets are necessary before successful potty training is possible.

1. Physiologic: maturity of bladder and bowel function. Willful control of bladder and rectal sphincter control implies neurological maturity that is generally completed by 18 months of age. The ability to avoid urination and stooling for several hours is an effective milestone for parents to expect before embarking on the potty training pathway.
2. Developmental skills: The toddler can walk to and sit on the toilet, is capable of pulling clothes up and down, has receptive language skills to follow a two-step command, and has expressive language skills to enable the child to verbally indicate his need to use the toilet.
3. Behavioral maturity: The child shows an interest in toilet training, enjoys imitating others, and has a desire to please coupled with an interest in independent behavior while balanced against a lessening of oppositional behavior and repetitive child-parent power struggles.

Parental readiness should be present before embarking upon the task of toilet training their child. It is necessary that the child's desire for potty training must come from within rather than be imposed by the parents. Parents must realize that certain times are more likely to be associated with failure of successful potty training. Stressful times, such as the birth of a new sibling, new daycare facility, a new home, new bed, new bedroom, or the mother returning to the work force, can interfere with potty training. Parents should realize that a large commitment of time and emotional energy will be necessary during this process, which may last several weeks to a few months. Lastly, parents must anticipate "accidents" during the potty training process and be able to "roll with the punches." Avoid comparison with other parents as potty training is a natural developmental process, not a competition.

Pediatric developmental specialist T. Berry Brazelton has proposed a rational (for parents) and developmentally appropriate (for children) step-by-step approach. The following are his suggestions:

1. Decide on a vocabulary for body fluids (pee, poop) that will be used consistently. Remember that these terms will be used both at home and out in public.
2. Buy a potty chair. Attempting to use an adult toilet prevents the leg leverage necessary for ease of bowel movements for the young child. Many toddlers enjoy decorating their potty chair; this activity creates an emotional "investment" into this important piece of furniture.
3. Practice sitting on the toilet (initially, fully clothed is fine) and look at a favorite book. This allows familiarity and pretend play without the stress of "performing."
4. Practice sitting on the potty chair without a diaper. Some parents will transfer diaper urine or stool into the potty chair to help the child better understand the goal. The urine and stool can then be transferred into the toilet and flushed away. Some children may be scared by the flushing toilet; practicing with toilet paper alone often helps any intimidation factor.
5. More practice: Develop a routine/ritual regarding predictable times for sitting (without diaper) on the potty chair. A common time for many is just before taking a bath. Some children have very predictable bowel movement patterns; "catching them in the act" allows for an opportunity for praise and a small reward (for example, hand stamps or stickers)
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6. Transition to training pants or underwear: When the child expresses a desire for "big boy/girl" pants and has been successfully using the potty chair for one to two weeks, an option to transition (for progressively longer periods each day) out of diapers may be offered. Such a move should be viewed by the child as a reward for his efforts and should not intimidate the child.
7. When comfortable with his potty chair, many children express a desire to use the adult toilet. An over-the-toilet-seat lid and a step stool are important to facilitate this final transition.

Several items will facilitate potty training for both the child and the parents. First and foremost is a potty chair (see the information above). A good supply of "training pants" and cotton underwear are also important for two reasons. They serve as a "carrot" to motivate the child during the toilet-training process; they also have a utilitarian value of what to wear in lieu of diapers. Many parents will encourage their child to help pick out underwear as part of this ritual. Many will choose those with a theme (Disney princesses, Sesame Street characters, etc.).

While the above ideas are worthwhile, the number one "product" to invest in during toilet training is patience. Like walking, toilet training is a natural process - and your child will succeed at an individualized pace.

Besides their new underwear, many parents will employ a reward system to encourage their children during the toilet-training time period. A kiss, "high five," clapping, stamps, stickers, or a reward chart all work well. For the child attending day care, moving up to the "big kid" (toilet trained) room provides a strong motivational factor.

Listed below are several children's books that may be helpful during the toilet training process:

1. No More Diapers for Me! by Katherine Sully and Claire Tindall
2. Your New Potty by Joanna Cole
3. Once Upon a Potty by Alona Frankel
4. All By Myself by Anna Grossnickle Hines
5. Going to the Potty by Fred Rogers ("Mr. Rogers")
6. Koko Bear's New Potty by Vicki Lansky

Presuming both the child and parents are ready (see above regarding these areas), most children will be daytime toilet trained after a few weeks of effort. Many parents will say that the major challenge the child must overcome is discovering the connection between the sensation of impending urination or passage of stool and "relaxing" to allow the evacuation. "Pushing" (especially with urination) may be counterproductive.

The attainment of nighttime toilet training is indicative of a neurological maturation milestone and as such is beyond parental control. Girls generally achieve nighttime dryness before their male counterparts. At 4 years of age, approximately 25% of boys wear a nighttime diaper while approximately 12% of girls need a nighttime diaper. By 6 years of age, these percentages have reduced to 5% and 2%, respectively.

Most parents quickly discover that a large gulf may exist between the biological capability of being toilet trained and the emotional and psychological readiness to anticipate the impending need to use the bathroom. Children will often need reminders of need for a "potty break" during periods of play and before setting out on any duration of car ride, bath, or pool event. Wise parents also discover that commanding the child to "pee and poo right now because we are late" often is met with resistance or refusal and thus more parental frustration. A better approach involves the child merely sitting on the toilet with no expressed or implied need to perform. In the majority of times, once the pressure is off, the child will successfully comply with the parental goals. Punishment of the child rarely accomplishes anything. Remember: Toilet training is probably the biggest accomplishment your child can remember. This obvious evidence of maturity is a much more tangible goal than color and/or number recognition. The child wants to succeed and please him/herself and the parents.

As noted above, nighttime toilet training is a step along the continuum of toilet training. Studies have repeatedly shown that restriction of fluids in the evening, repeated child waking by the parents and avoidance of certain foods (other than caffeine) will not accelerate this timeline.

There are children who have not achieved nighttime dryness by 7 years of age. For these individuals, there are several programs/devices that are often helpful. Please read MedicineNet's bedwetting (enuresis) article.

Regression of toilet training skills are commonly encountered and generally are not a cause for alarm. Childhood illness and emotional stress (such as the birth of a new sibling, new day-care facility, a new home, or the mother returning to the work force) may all disrupt the toilet-training process. For the child who suddenly is refusing bowel movements (BMs), parents need to consider whether the child experienced a painful BM or became scared (such as from flushing to toilet while the child was still seated on the commode). Under these circumstances, the child may logically infer that avoiding the bowel movement process will guarantee avoidance of repeating such an experience. If parents notice establishment of such a pattern, they should discuss the issue with their child's pediatrician. Similarly, if the child experiences repeated daytime wetting or nighttime wetting after having been dry for more than six months, this should be brought to the pediatrician's attention. Such events are more likely associated with medical issues and not a "stage."

1. Keep a positive attitude and let that reflect in your interaction with your child during this process.
2. Keep the child in loose-fitting clothing that is simple to remove.
3. Keep an extra set of clothing (especially pants) in the car at all times. Accidents will happen. Follow the Boy Scout motto: "Be prepared."
4. Teach boys to urinate in a seated position. Many parents will reserve the standing position following successful bowel movements in the toilet.
5. Make bowel movement expulsion an easy task by keeping stools soft by encouraging high-fiber foods and watching for excessive foods that lead to constipation (such as excessive milk/dairy products, large amounts of bananas, large amounts of pasta).
6. If your child looses interest or resists toilet training, stop and drop back to diapers for a few weeks.

Toilet Training: The Brazelton Way by T. Berry Brazelton, MD, and Joshua D. Sparrow, MD

The American Academy of Pediatrics' Guide to Toilet Training (available at http://www.AAP.org)

The Potty Journey: Guide to Toilet Training Children With Special Needs, Including Autism and Related Disorders by Judith A. Coucouvanis