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 "Definition, clinical manifestations, and evaluation of functional fecal incontinence in infants and children" and "Treatment of chronic functional constipation and fecal incontinence in infants and children".)
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.