What is toilet training?
Toilet use may seem simple, but it is a complex skill. Children must learn to produce both urine and bowel movements on the toilet, stay dry when not on the toilet, clean themselves, dress and undress, initiate going to the toilet without being reminded, and stay dry while asleep. Most children are fully toilet trained—dry all day and night with complete independence in cleaning and dressing—by the age of four. All successful toilet training methods have three things in common: timing, consistency, and a positive approach.
Two kinds of timing are important. First, training should begin when the child is ready. The child is physically ready when voluntary control over the urethral and anal sphincters is established, usually between twelve and twenty-four months of age. Behavioral signs of physical readiness include a reduction in the frequency of urination. Another sign of readiness is seeking out privacy, often under or behind furniture, before defecating.
The child may indicate psychological readiness by showing awareness of being wet, revulsion or irritation when soiled, or interest in watching parents and older children in the bathroom. Some children show these signs of readiness as early as twelve months of age; others never do. Most children can begin toilet training successfully by twenty-four to thirty-six months of age.
The second type of timing is in visiting the toilet. Children need to use the toilet after meals, every one or two hours between meals, and before bedtime or long car trips, much as adults do. Encouraging the child to sit on the toilet at these times for a few minutes each visit usually produces results.
Consistency is also important. A consistent schedule for meals and visits to the toilet is helpful, as is a consistent place for the child to use the toilet, such as a child-sized toilet (or potty), in the bathroom. Training pants help children to recognize when they are wet and may be worn every day once toilet training starts; diapers, plastic mattress covers, or training pants may be used at night, which is the most difficult time for the child to master elimination. Finally, parents should respond consistently, showing pleasure every time that the child is successful and remaining calm when accidents occur.
A positive approach includes giving children encouragement and affection regardless whether they succeed, discussing toilet use with the child in a calm and encouraging manner, and potentially providing small treats or special activities to celebrate successes. Picture books for toddlers can provide an easy way for parents to talk to their child about toilet use.
Methods for toilet training children with disabilities or developmental delays are similar to those for children without disabilities, but the onset of training, timing of toilet use, and other factors must be tailored to the individual child's needs, abilities, and preferences.
Children who have developmental delays or physical disabilities may have difficulty with toilet use. Sometimes, mild developmental delays or health problems are first discovered because of problems with toilet training. Special training methods for these children include positive reinforcement; liquid intake, food intake, and bathroom trips scheduled to maximize the chance of success; high-fiber diets; timers to remind children to use the bathroom; and sensors in clothing that trigger an alarm when wet. In some cases of physical malformation or disease, biofeedback, medication, or surgery may be attempted. Even children with very severe disabilities can learn to use the toilet, although they may continue to need reminders or physical assistance.
Toilet use problems of typically developing children include enuresis; fear of the toilet, urine, or feces; encopresis (involuntary movement of bowels) and hiding or playing with feces; retention of feces or urine; and frequent tantrums and accidents. It is normal for children under the age of four occasionally to have any of these problems, stressful as they are for parents. Such problems are especially likely during times of high stress for the child, such as a move, birth of a younger sibling, or other transition, and may resolve on their own as the child adjusts. Constipation and urinary tract infections can occur in children during and after toilet training, so parents should seek medical care if they notice or suspect these conditions.
For older children, medical causes should be ruled out. Family therapy directed at both toilet use and discipline problems is often helpful. Nighttime enuresis, or bed-wetting, is the most common toilet use problem experienced by older children and adults. The cause of most cases of bed-wetting is probably developmental immaturity and may be inherited; it is rarely caused by mental illness, as many once believed. Effective treatments are available for this common problem.
In European history, toilet training recommendations have ranged from sitting the child on the toilet at three months to giving no training at all. Punitive methods such as tying the child on the toilet, forcing food or drink, or hitting the child were common. By the early twentieth century, two schools of thought on toilet training had developed. Sigmund Freud, the founder of psychoanalysis, believed toilet training that was too early, punitive, indulgent, or sexualized would cause lifelong personality problems. The behaviorist school of thought held that with the right technique, children could be toilet trained quickly at any age in as little as a day. Neither camp had any direct evidence in support of its position.
Freudian ideas dominated popular advice on child care in the United States from the 1940s through the 1960s, leaving many parents anxious about ruining their children’s lives with the wrong toilet-training methods. During the 1960s, researchers discovered the variety of actual toilet-training practices around the world. They found that toilet training before thirteen months was not effective and that training after thirteen months through age three was typical and rarely led to problems. Often, children who were punished during toilet training not only developed toilet-use problems but also had nightmares, tantrums, and discipline problems throughout childhood. In addition, they found that children and adults with disabilities—previously thought to be untrainable—could be toilet trained using positive methods. By the early 1980s, developmental psychologists concluded that consistency, encouragement, and patience produce the best long-term results.
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