Toilet training is the process of teaching a young child to control the bowel and bladder and use the bathroom for elimination. A child is considered to be toilet trained when he or she initiates going to the bathroom and can adjust clothing necessary to urinate or have a bowel movement. Toilet training is sometimes called toilet learning or potty training.
The average age at which children complete toilet training in the United States is approximately three years old. In some cases children learn bladder control first; others learn bowel control before bladder control. Control is generally first achieved during the daytime, well before a child is able to stay dry at night.
Some children achieve some control over bladder and/or bowel movements as early as nine months of age and are able to cooperate in controlling themselves to some degree by the age of 12 to 15 months. Most experts agree, however, that toilet training should only be initiated when a child exhibits certain signs of readiness that usually appear between the ages of two and three years of age. Unlike infants, toddlers know when they are urinating or defecating and may assume certain postures or become quiet when they are about to move their bowels. They have also learned the vocabulary their family uses for elimination. Another sign is a sense of fastidiousness and desire for order that appears at this stage of development. Children are likely to ask parents to change their dirty diapers right away, and they show a general interest in orderliness that can be harnessed for purposes of toilet training. A child this age also has a pronounced desire to imitate the parent of the same sex, a trait that can be used to advantage in enticing her to use the toilet. Lastly, the child will begin to show signs of being able to delay urination or bowel movements such as waking from sleep still dry or refraining from urinating or defecating for longer periods of time while not wearing a diaper.
Child care experts generally recommend a strategy that uses praise as a motivator, has little pressure from the parents, and is fun for the child. It has been found that when parents wait until their toddler has attained the greatest possible degree of readiness, the process is easier, faster, and accompanied by fewer lapses. The emphasis is on letting the child proceed at his own pace, motivated by the desire to be a "big boy" or "big girl" and imitate his parents. Measures that may cause pressure and anxiety need to be avoided.
The first step in toilet training is to purchase a potty. There are different versions of potties, including ones that sit on the floor and are emptied after each use, ones that have cups to protect against splatters, and ones that sit on top of an adult toilet with or without a step stool for the child to climb up to it. The floor-level model is most often recommended for the first stages of toilet training. Some recommend taking the child to the store to help pick out his or her own potty, then helping to personalize it with a name, stickers, paint, etc., with the general idea of making the potty a prized possession of the child's, not something to be feared.
The child should first spend some time sitting on the potty, first while clothed and then with clothes removed, so that he or she is comfortable sitting on it. The connection between what she is doing on her small potty and what the adults and siblings do on the big potty should be emphasized. One suggestion is to bring the child to the potty with a dirty diaper and the contents placed in it so he or she can see that this is where they belong. Parents should watch for cues from the child that he or she may be about to urinate or have a bowel movement, such as a concentrated look, yanking at his or her diaper, squatting, or grunting. Often this behavior will happen first thing in the morning, right after a nap, or approximately 20 minutes after a meal. The child should be taken to the potty, his or her diaper should be removed, and the child encouraged to sit for at least one minute. Some children may enjoy reading a book or singing a song while waiting. Special read-aloud books about toilet training are popular. Parents should never strap a child into a potty or force him or her to sit on it. If the child has not used the potty after five minutes or so, he or he should be encouraged to get dressed and try again soon.
The general consensus from experts is that much encouragement and praise should be used when a child cooperates with toilet training and when he or she begins to urinate or defecate in the potty. Rewards such as hugs and kisses, verbal praise, stickers, stars, or favorite treats can be used when the child uses the potty or tells a parent he or she has to use it. Pull-up diapers or plastic training pants can be purchased so that the child can remove them him or herself. For many children, simply progressing from diapers to training pants and then to regular underpants is an incentive in itself. When accidents occur, they should be treated casually; punishment, teasing, or chastising should be avoided.
Nighttime training usually begins when a child can stay dry all day, for at least four to six hours. Girls usually reach this point before boys; some girls begin to stay dry at naptime and even occasionally at night before the age of two. After the age of two, dry nights become more frequent: 45 percent of girls and 35 percent of boys stay dry at night at the ages of two to three. With many children, nighttime training is not done until the age of three and, in many cases, not complete until four or five. The signal from the child's bladder has to be strong enough to wake him from sleep and get him to the bathroom at least once or twice a night. As many as 25 percent of children have relapses after they have been dry at night for six months or longer, usually due to a temporary stressor. In a minority of children, nighttime bladder control does not develop until after the age of five; this situation often occurs in families where there is a history of enuresis (bedwetting).
In some cases a child may resist all toilet training efforts from the parents, some going so far as to resist sitting on the potty or even holding back bowel movements. Toilet training resistance may be the result of a parent over-admonishing the child when accidents are made or the child does not use the potty when directed. In some cases the child is simply not ready for toilet learning. More rarely, resistance can be caused by a condition that causes the child pain when he or she uses the potty, such as painful urination associated with a urinary tract infection. If a child is uncooperative during the toilet training process, parents can try letting the child initiate the process when he or she is ready, using rewards and positive feedback each time the child is successful in using the potty or goes a whole day without soiling his or her pants, replacing the child's diaper or training pants with regular underwear or having the child change his or her own clothes when accidents occur.
One potential negative effect of resistance is that the child can hold back bowel movements, resulting in constipation . This in turn makes elimination uncomfortable and even painful, creating even greater reluctance and resistance on the part of the child. Severe cases of constipation can cause painful anal fissures, fecal soiling ( encopresis ), or rectal enlargement. Unusual delays in toilet training normal children or regressions to soiling generally indicate family stress and/or underlying emotional problems and may require counseling to be effectively resolved.
Toilet training is often a dreaded and frustrating task for parents. The process can go more smoothly for parent and child if parents are educated on training techniques that emphasize waiting until a child shows signs of readiness before initiating training and taking a child-oriented approach.
When to call the doctor
Parents should contact a healthcare provider if their child exhibits any of the following behaviors:
- holding back bowel movements or constipation
- evidence of painful urination or defecation
- extended toilet training resistance (i.e. lasts several months)
Encopresis —Fecal incontinence that can occur as a result of stress or fear.
Morgan, Richard. Zoo Poo: A First Toilet Training Book. New York: Barron's Educational Resources, 2004.
Warner, Penny, et al. Toilet Training without Tears or Trauma. Minnetonka, MN: Meadowbrook Press, 2003.
"Toilet Training." Pediatrics for Parents 20, no. 8 (August 2003): 2.
Schmitt, Barton D. "Toilet Training Basics." Clinical Reference Systems (2002): 3263–7.
——. "Toilet Training Problems: Underachievers, Refusers, and Stool Holders." Contemporary Pediatrics 21, no. 4 (April 2004): 71–82.
Schonwald, Alison, et al. "Factors Associated with Difficult Toilet Training." Pediatrics 113, no. 6 (June 2004): 1753–7.
American Academy of Pediatrics (AAP). 141 Northwest Point Boulevard, Elk Grove Village, IL 60007. Web site: http://www.aap.org.
McKinney, Merritt. "Late Start May Delay Toilet Training: Study." MedlinePlus , August 19, 2004. http://www.nlm.nih.gov/medlineplus/news/fullstory_19622.html (accessed September 10, 2004.)
Stephanie Dionne Sherk