Toilet training can be challenging for parents and caregivers as they struggle to decipher the appropriate time and method for teaching a child this universally essential skill. Interestingly, a review of toilet training literature published in the journal, Ambulatory Pediatrics, shows that the average age to complete toilet training has been increasing steadily in the US over the decades, from younger than 18 months of age in the 1940s to 27 months in 1980 to 37 months in 2003.1 The introduction of disposable diapers, increasingly efficient laundry facilities, and the number of families with both parents working outside of the home are three plausible influences contributing to these changes.
Other research shows that parental preferences and expectations toward toilet training vary by ethnicity and culture. In a study lead by Dr. Timothy Schum and published in the journal, Pediatrics, 50% of African-American parents, compared to only 4% of Caucasian parents, agreed that it was important for a child to be toilet trained by the age of two.2 This finding is supportive of the research showing that children of minority cultures in the US successfully achieve toilet training at an earlier age than do children of majority cultures.
Despite generations of discussion among parents, physicians, and researchers, questions remain as to what is the optimal age to begin training and which approach is the most successful. Schum et al. evaluated the age (by gender) at which normally developing children acquire the individual toilet training skills necessary for successful toilet training. Evaluated skills included:
- understanding potty words,
- showing an interest in using the potty,
- staying dry for more than two hours, and
- being able to wash their hands by themselves.
Although contemporary literature has maintained that toileting readiness skills typically develop from 18-24 months of age, Schum et al. found that most children have not mastered these skills by this early age range. These researchers suggested a revision of the starting age to the range of 22-30 months. Results showed that girls attained toilet training skills at younger ages than the boys did in all readiness categories except two areas; ‘flushes toilet by self’ and ‘washes hands by self.’ They also found that nighttime bowel control is an early toilet training skill, whereas night-time urine control is one of the last skills to develop for both genders.
A child must be physiologically and behaviourally ready to begin training. This readiness includes the ability to follow directions, be aware of his or her urges, and have the necessary motor skills to sit still on the toilet, and pull clothes and underwear up and down. Toilet training methods have very different approaches, from child-oriented with the freedom to master each step at the child’s own pace, to a more structured and intensive tactic such as the ‘train-in-a-day’ approach.
Child Readiness Toilet Training
In 1962, Brazelton3 developed the ‘child readiness’ approach with an emphasis on gradual training. In this approach, parents are responsible for recognizing the signals their child communicates indicating readiness to begin toilet training. First, the child becomes familiar with his or her own toilet chair by sitting on it while clothed and then without clothes or a diaper. The next step is to empty the diaper contents into the chair while verbally explaining to the child that this is the proper place for eliminations.
The parents then encourage the child to use the chair for urination and defecation and provide positive reinforcement to the child when successful.
Parent-Oriented Toilet Training
Nearly a decade later, Azrin and Foxx developed a parent-oriented method toward toilet training. They created a list of component skills, both physiological and psychological, to help parents determine if their child is ready to begin training. This involves an intense period of instruction designed to achieve continence in 24-48 hours.
Once a child seems ready, parents begin a four-step stimulus control model by:
- increasing the child’s fluid intake,
- scheduling toilet training time,
- positively reinforcing correct behaviour, and
- over-correcting accidents.
Assisted Infant Toilet Training
Parents and caregivers in China, India, Africa, South America, Central America, and parts of Europe commonly use assisted infant toilet training. For this method, parents must learn their infant’s facial signals for elimination and respond by placing the infant on the toilet in a voiding position. When the infant is on the toilet, the parents make a specific noise as the infant eliminates. This is a form of conditioning so that, in the future, when the infant hears the noise again, s/he will know to void. Parents reward infant’s successes with affection or food. This method begins at a very early age, when the baby is only 2-3 weeks old.4 A very similar method known as elimination communication has been growing in popularity within North America. The main associated benefits include reduced diaper expenses, fewer disposable diapers polluting the environment, less laundry impact on the environment from re-usable cloth diapers, strengthened infant-parent bonds, and increased infant comfort.
Child-Oriented Toilet Training
The Canadian Paediatric Society (CPS) stresses that each child is different. Therefore, there is no concrete approach to toilet training, nor a specific age by when toilet training should begin, nor when a child should have acquired toilet use skills. CPS promotes the child-oriented approach and encourages family physicians to open up the topic for discussion at the child’s first-year check-up.5 Parents and/or caregivers should prepare for the process by deciding on what vocabulary they will use in their home, ensuring that the potty chair is easily accessible and secure for the child, and determining what form of positive reinforcement they will offer their child. The average time from the start of toilet training to its attainment is 3-6 months.
Toilet training is a life skill that every child must master. When to begin training and the technique used is the personal preference of parents, with culture and environment often having an influence. It is important for parents to stay positive and flexible throughout the process, keeping in mind that every child learns differently even within the same family.