- Teri Lee Turner, MD, MPH, MEd
Teri Lee Turner, MD, MPH, MEd
- Associate Professor of Pediatrics
- Baylor College of Medicine
- Kimberly Ballard Matlock, MD
Kimberly Ballard Matlock, MD
- Cook Children's Health Care System
- Fort Worth, Texas
- Section Editors
- Carolyn Bridgemohan, MD
Carolyn Bridgemohan, MD
- Section Editor — Developmental and Behavioral Pediatrics
- Assistant Professor of Pediatrics
- Harvard Medical School
- Jan E Drutz, MD
Jan E Drutz, MD
- Section Editor — General Pediatrics
- Professor of Pediatrics
- Baylor College of Medicine
The mastery of toilet training is an important developmental milestone for children and parents. This area of pediatric care presents a critical opportunity for anticipatory guidance; parents need guidance in recognizing signs of readiness, in helping their child achieve the necessary skills, and in addressing problems when they occur [1,2].
The approach to toilet training and common problems in toilet training are reviewed here. The diagnosis and management of enuresis and encopresis are discussed separately. (See "Nocturnal enuresis in children: Etiology and evaluation" and "Nocturnal enuresis in children: Management" and "Functional fecal incontinence in infants and children: Definition, clinical manifestations and evaluation" and "Chronic functional constipation and fecal incontinence in infants and children: Treatment".)
The methods used for toilet-training children in the United States have evolved over the last century. In the early 1900s, techniques for toilet training stressed physiologic readiness, involving the child as a passive participant . During the 1920s and 1930s, early training and rigid scheduling were recommended . A 1929 "Parents" magazine claimed that most healthy babies could be trained by eight weeks of age . By the 1940s, pediatric experts, including Dr. Benjamin Spock, began to advocate that parents wait to begin toilet training until they observed signs of developmental readiness in their children. They believed that rushed, rigid training would be unsuccessful and lead to behavioral problems . In the early 1960s, two major theories on toilet training emerged: the parent-oriented approach, the major contributors for which were Azrin and Foxx; and the child-directed approach, developed by T. Berry Brazelton [1,2,4].
The age at which children begin to toilet-train has increased over time. In a survey study, individuals in Belgium were asked about the toileting habits of children they had trained. The researchers divided the respondents into three groups according to their age: >60 years, 40 to 60 years, and 20 to 40 years. Initiation of daytime toilet training began at less than 18 months of age in 88 percent of the children of respondents who were >60 years of age, 50 percent of respondents in the 40 to 60 age range, and 22 percent of respondents in the 20 to 40 age group. There was no statistically significant difference in the duration of training among the children in any of the three groups. In this study, methods of training also appear to have changed over time, with trainers in the youngest cohort using more than one method to train their children, in comparison to a single method (diaper removal) used by respondents in the >60 age group .
A cross-sectional survey of parents found racial differences in beliefs concerning the appropriate age to start toilet training. On average, African-American parents believed in starting toilet training at 18 months of age, in comparison with 25 months of age for Caucasian parents . A systematic review of the effectiveness of different methods of toilet training revealed that both the parent-oriented and child-oriented training approaches resulted in quick, successful toilet training among healthy children . The two methods have not been directly compared, and therefore definitive conclusions regarding the superiority of one method over the other cannot be made.
- Michel RS. Toilet training. Pediatr Rev 1999; 20:240.
- Stadtler AC, Gorski PA, Brazelton TB. Toilet training methods, clinical interventions, and recommendations. American Academy of Pediatrics. Pediatrics 1999; 103:1359.
- Robson WL, Leung AK. Advising parents on toilet training. Am Fam Physician 1991; 44:1263.
- Luxem M, Christophersen E. Behavioral toilet training in early childhood: research, practice, and implications. J Dev Behav Pediatr 1994; 15:370.
- Lieberman, L. The changing ideology of socialization: toilet training, mass media, and society. Int J Contemp Sociol 1972; 9:179.
- Bakker E, Wyndaele JJ. Changes in the toilet training of children during the last 60 years: the cause of an increase in lower urinary tract dysfunction? BJU Int 2000; 86:248.
- Horn IB, Brenner R, Rao M, Cheng TL. Beliefs about the appropriate age for initiating toilet training: are there racial and socioeconomic differences? J Pediatr 2006; 149:165.
- Klassen TP, Kiddoo D, Lang ME, et al. The effectiveness of different methods of toilet training for bowel and bladder control. Evid Rep Technol Assess (Full Rep) 2006; :1.
- Azrin NH, Foxx RM. Toilet Training in Less Than a Day, Simon and Schuster, New York 1974.
- Schmitt BD. Seven deadly sins of childhood: advising parents about difficult developmental phases. Child Abuse Negl 1987; 11:421.
- Vermandel A, Weyler J, De Wachter S, Wyndaele JJ. Toilet training of healthy young toddlers: a randomized trial between a daytime wetting alarm and timed potty training. J Dev Behav Pediatr 2008; 29:191.
- Schonwald A. Evidence-based toilet training (commentary). AAP Grand Rounds 2008; 20:13.
- Kroeger, KA, Sorensen-Burnworth, R. Toilet training individuals with autism and other developmental disabilities: A critical review. Res Autism Spectr Disord 2009; 3:607.
- BRAZELTON TB. A child-oriented approach to toilet training. Pediatrics 1962; 29:121.
- Berk LB, Friman PC. Epidemiologic aspects of toilet training. Clin Pediatr (Phila) 1990; 29:278.
- Parker, S, Sices, L. Toilet training. In: The Zuckerman Parker Handbook of Developmental and Behavioral Pediatrics for Primary Care, 3rd ed, Augustyn, M, Zuckerman, B, Caronna, EB (Eds), Lippincott Williams & Wilkins, Philadelphia 2011. p.393.
- Seim HC. Toilet training in first children. J Fam Pract 1989; 29:633.
- Schum TR, Kolb TM, McAuliffe TL, et al. Sequential acquisition of toilet-training skills: a descriptive study of gender and age differences in normal children. Pediatrics 2002; 109:E48.
- Largo RH, Stutzle W. Longitudinal study of bowel and bladder control by day and at night in the first six years of life. I: Epidemiology and interrelations between bowel and bladder control. Dev Med Child Neurol 1977; 19:598.
- deVries MW, deVries MR. Cultural relativity of toilet training readiness: a perspective from East Africa. Pediatrics 1977; 60:170.
- Blum NJ, Taubman B, Nemeth N. Relationship between age at initiation of toilet training and duration of training: a prospective study. Pediatrics 2003; 111:810.
- ROBERTS KE, SCHOELLKOPF JA. Eating, sleeping, and elimination practices of a group of two-and-one-half-year old children. V. Elimination practices: bladder. AMA Am J Dis Child 1951; 82:144.
- Taubman B. Toilet training and toileting refusal for stool only: a prospective study. Pediatrics 1997; 99:54.
- Schum TR, McAuliffe TL, Simms MD, et al. Factors associated with toilet training in the 1990s. Ambul Pediatr 2001; 1:79.
- Blum NJ, Taubman B, Nemeth N. Why is toilet training occurring at older ages? A study of factors associated with later training. J Pediatr 2004; 145:107.
- American Academy of Pediatrics. Toilet Training. Guidelines for Parents. AAP, Elk Grove Village, Ill 1998.
- Kaerts N, Van Hal G, Vermandel A, Wyndaele JJ. Readiness signs used to define the proper moment to start toilet training: a review of the literature. Neurourol Urodyn 2012; 31:437.
- Christophersen ER. Toileting problems in children. Pediatr Ann 1991; 20:240.
- Brazelton TB, Christophersen ER, Frauman AC, et al. Instruction, timeliness, and medical influences affecting toilet training. Pediatrics 1999; 103:1353.
- Howe AC, Walker CE. Behavioral management of toilet training, enuresis, and encopresis. Pediatr Clin North Am 1992; 39:413.
- US Census Bureau. Who's minding our preschoolers? Washington, DC. Department of Commerce; Fall 1994.
- Ellis NR. Toilet training the severely defective patient: An S-R reinforcement analysis. Am J Ment Defic 1963; 68:98.
- Dalrymple NJ, Ruble LA. Toilet training and behaviors of people with autism: parent views. J Autism Dev Disord 1992; 22:265.
- Schmitt BD. Nocturnal enuresis. Pediatr Rev 1997; 18:183.
- Robson WL. Diurnal enuresis. Pediatr Rev 1997; 18:407.
- Partin JC, Hamill SK, Fischel JE, Partin JS. Painful defecation and fecal soiling in children. Pediatrics 1992; 89:1007.
- Blum NJ, Taubman B, Osborne ML. Behavioral characteristics of children with stool toileting refusal. Pediatrics 1997; 99:50.
- Schonwald A, Sherritt L, Stadtler A, Bridgemohan C. Factors associated with difficult toilet training. Pediatrics 2004; 113:1753.
- Blum NJ, Taubman B, Nemeth N. During toilet training, constipation occurs before stool toileting refusal. Pediatrics 2004; 113:e520.
- Schmitt BD. Instructions for Pediatric Patients, WB Saunders, 1992.
- Issenman RM, Filmer RB, Gorski PA. A review of bowel and bladder control development in children: how gastrointestinal and urologic conditions relate to problems in toilet training. Pediatrics 1999; 103:1346.
- Taubman B, Blum NJ, Nemeth N. Children who hide while defecating before they have completed toilet training: a prospective study. Arch Pediatr Adolesc Med 2003; 157:1190.
- HISTORICAL PERSPECTIVE
- Parent-oriented training
- Child-oriented training
- Child readiness
- - Physiologic
- - Developmental
- - Behavioral
- - Chronically ill child
- Parental readiness
- GUIDELINES FOR TOILET TRAINING
- DAY CARE
- THE CHILD WITH AUTISM SPECTRUM DISORDER OR INTELLECTUAL DISABILITY
- - Nocturnal enuresis
- - Diurnal enuresis
- Resistance or refusal
- Constipation and withholding behavior cycles
- INFORMATION FOR PATIENTS