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