This document discusses toilet training and provides guidance for parents. It covers the history of toilet training approaches, developmental and behavioral signs of readiness, common methods including parent-oriented and child-oriented techniques, potential problems like refusal or bedwetting, and treatment options. Resources for parents and children on toilet training are also referenced.

1. Toilet Training
Pediatric Issues Presentation
Amy Carlson
NSG 625

2. Toilet Training
 Description of issue  References
 History  Handout
 Different methods
 Epidemiological issues
 Readiness
 Problems
 Treatment Options

3. Description of issue
 Toilet training is an important milestone for both
parents and children
 This area of pediatric care presents a critical
opportunity for anticipatory guidance
 Parents need guidance in:
 Recognition of readiness
 Helping their child achieve necessary skills
 Addressing problems when they occur

4. History
 Early 1900’s- stressed physiologic readiness, involving
the child as a passive participant
 1920’s & 30’s- early training and rigid scheduling were
recommended
 1940’s- pediatric experts began advocating parents wait
until they observed signs of developmental readiness
 1960’s- 2 major theories emerged:
1. The Parent Oriented Approach
2. The Child Directed Approach

5. Parent Oriented Training
 Developed by Azrin & Foxx, 1972
 Consists of speed training using 4 basic concepts:
1. Increased fluid intake
2. Regularly scheduled toilet times
3. Positive reinforcement for correct elimination
4. Overcorrection for accidents (eg, verbal reprimands or
time out from positive reinforcement)
 Mean time of training: 3.9 hours (range 0.5 to 14
hours)

6. Child-Oriented Training
 1962- Dr. T. Berry Brazelton
 Begin toilet training only after certain physiologic and
behavioral criteria and readiness are met
 Stressed importance of letting the child master each step
at his or her own pace with minimal conflict
 Associated with:
 High rates of continence
 Fairly rapid training time
 Low long-term regression rates
 Many current toilet training methods are based upon this
approach

7. Comparison of the two Methods
 Both parent-oriented and child-oriented approaches
resulted in quick, successful toilet training among
healthy children
 The two methods have not been directly compared- so
we cannot make any definitive decisions of method
superiority

8. Epidemiological issues
 Age of Toilet Training varies by:
 Culture
 Timing
 Gender

9. United States
 26% of children achieve daytime continence by 24
months of age
 85% by 30 months
 98% by 36 months
 Most children achieve bowel and bladder control by 24-
48 months.
 In 1947 most U.S. children achieved this by 18 months
old.

10. Cultural Differences in US
 Most African Americans believe potty training should be
started at age 18 months.
 Caucasians more commonly propose 24 months as a
starting time.
 50% of African American parents, compared to 4% of
Caucasian parents agree that it is important to be
trained by two years of age.

11. Timing
 The average length of time required to achieve toilet
training is:
 6 months for daytime urinary continence
 6-11 months for stool continence
 Earlier initiation of toilet training (<27 months old) is
assoc. with longer duration
 First born children take longer than subsequent siblings
(2 months longer)

12. Gender
 Girls generally achieve nighttime dryness before boys.
 Age 4
 25% of boys wear nighttime diapers
 12% of girls wear nighttime diapers
 Age 6
 5% of boys wear nighttime diapers
 2% of girls wear nighttime diapers
 Nighttime dryness should be achieved by age 7.

13. Developing Continence
 Continence depends on:
 Complete and functioning renal system
 Maturation of nervous system
 Opportunity/support given to the child to void
 Cultural expectations
 Maturation of control mechanisms usually take up to 5-7
years for healthy children to be dry in the day and
overnight
 Older age of the child, non-Caucasian race, female sex,
and a single parenthood were significant predictors of
toilet-training completion.

14. Readiness
 AAP recommends only beginning training when a child is
developmentally ready
 At the 2-year visit clinicians should assess the child’s
readiness, motivation to learn, ability to cope, and level
of cooperation with tasks
 Ask the child to perform several tasks- such as pointing to
several body parts, sitting, standing, walking and imitating
 Assess the child’s bowel habits, history of constipation, ability
to adapt to new situations, attention span, and distractibility
 Constipation should be addressed and resolved before
the initiation of toilet training

15. Physiologic readiness
 Must have control over sphincter muscles before he or she
can be trained (usually after 12 to 18 months of age)

16. Developmental Readiness
 The ability to ambulate to the toilet
 Stability when sitting on the toilet
 The ability to remain dry for several hours
 Ability to pull clothes up and down
 Receptive language skills that permit the child to follow
a two-step command
 Expressive language skills that permit the child to
communicate the need to use the toilet

17. Behavioral Readiness
 Ability to imitate behaviors
 Ability to place things where they belong
 Demonstration of independence by saying “no”
 Expression of interest in toilet training
 The desire to please
 The desire for independence and control of the functions of
elimination
 Diminishing frequency of oppositional behaviors and power
struggle

18. Parental Readiness
 Start the discussion at age 12 months with parents.
 Parents should be informed of the important
developmental milestones for toilet training:
 Children become aware of accidents by 15 months
 Children call attention to their soiled diapers and can verbally
distinguish between urine and feces by 18 to 24 months
 Children announce need to eliminate by 24 months
 Children begin to ask to be taken to the toilet for elimination
by 30-36 months
 Children achieve the adult pattern of elimination by 48 months

19. Parental Readiness
 Clinician should ask the parents about:
 expectations
 the existence of pressure for toilet training from other family
members or day care providers
 Whether they have any negative memories relating to their
own toilet training
 Parents should postpone training until they can allow it to
be driven by the child’s motivation, interest, and
acquisition of skills
 One caregiver should be able to devote time and emotional
energy necessary to be consistent on a daily basis for a
minimum of 3 months

20. Parental Readiness
 Training should be delayed if parents are motivated by:
 Anticipated birth of a new child in the home
 Moving to a new home
 Mother returning to work
 Specific daycare requirements
Too many changes in a child’s life make it more difficult to
train and thus increase risk of initial failure.

21. Parental Readiness
 Parents must understand that accidents are inevitable
and that children should not be punished during the
process.
 Toilet training can set the stage for abuse. Parents who
are easily frustrated, impatient, or not supportive of
their children during office visits should be instructed to
wait until at least 30 months to start training.

22. Guidelines for Toilet Training
 Steps involved:
 Communicating the need to go
 Undressing
 Eliminating
 Wiping
 Re-dressing
 Flushing
 Hand washing
 Going through these steps consistently helps reinforce
proper toileting skills

23. Guidelines for Parents
 Use consistent vocab for body fluids
 Buy a potty chair with your child. Place it in a convenient location.
 Encourage the child to sit in the potty chair fully clothed, and look at books or
play.
 Talk about the potty with books or videos.
 Make regular practice trips to the potty chair after waking, meals
 After your child is comfortable sitting in the chair dressed, encourage him to sit in
the chair with no diaper.
 Encourage the child to tell you when they need to go
 Do not punish, threaten or speak harshly
 Transition to training pants (washable, thicker underwear)

24. Tips
 Keep a positive, loving attitude
 Keep the child in loose, easy-to-remove clothing
 Keep an extra set of clothing on hand at all times
 Do not flush the potty with the child on it
 Teach boys to urinate while sitting first, once they have bowel control they can
switch to standing
 Keep stools soft by modifying diet
 Wait to use underwear at night till the child is consitently dry during the day
 Remind the child several times during the day to use the potty
 If the child is not making progress, stop for 2-3 months, then restart.

25. Problems
 Enuresis
 Diurnal(daytime)
 Nocturnal (nighttime)
 Resistance/ Refusal
 Constipation/Withholding

26. Nocturnal Enuresis
Common Experience in early childhood
 Dx made when the involuntary passage of urine, during sleep,
occurs in a child ages 5 years or more, in the absence of any
congenital or acquired defects of the nervous system
 20% of 5-year-olds, 10% of 6-year-olds, and 7% of 7-year-olds
wet the bed at night
 Organic causes of primary nocturnal enuresis are found in
only 2-3% of children

27. Nocturnal Enuresis
Causes/Factors
 Neurological Hormone production (ADH)
Developmental Delay
 Physical Abnormalities
 Genetics
 Psychological
 ADHD
 Sleep problems (sleep
 Caffeine apnea, sleepwalking)
 Constipation  Stress
 Infection
 Insuffiecient Anti-diuretic

28. Diurnal Enuresis
 Children older than 4-years-old who have primary or
secondary diurnal enuresis should be evaluated for
organic etiologies
 Most cases can be determined through:
 History taking
 Complete PE
 UA/C&S
 Looking for glucose, WBC’s
or RBC’s

29. Treatment Options
 Bedwetting Alarms
 Successful in 2/3 of all cases
 Approx. 3 month commitment
 DDAVP (desmopressin)
 Average of 1.4 fewer wet
nights/week
 The recommended starting dose for the tablet is
0.2 mg, and the drug can be titrated as necessary to a
maximum of 0.6 mg
 Tricyclic antidepressants
 usual dose, taken 1-2 hours before bedtime, is 25 mg for patients
aged 6-8 years and 50-75 mg for older children and adolescents

30. Resistance or Refusal
 Children with toilet refusal have achieved bladder
control but not bowel continence. Up to 20% of
developmentally normal children have this problem
 Possible causes:
 Attempting training too early
 Excessive parent-child conflict
 Irrational fears or anxiety about toileting
 Difficult temperament
 Hard, painful stools from chronic constipation

31. Tips for Toilet Refusal for Parents
 Do not punish or nag the child
 Discontinue training for a few weeks
 Encourage the child to imitate parents/siblings
 Continue to discuss training with the child
 Treat constipation with dietary changes, medications
 Create positive feedback system, such as a star chart
 Regression lasting >6months should be brought to
clinicians attention

32. Resources
 For children:
 “No More Diapers” by JG Brooks
 “Your New Potty” by Joanna Cole
 “Once Upon a Potty” by Alona Frankel
 “All by Myself” by Anna Grossnickle Hines
 “Going To The Potty” by Fred Rogers
 “KoKo Bear’s New Potty” by Vicky Lansky
 For Parents:
 “Toilet Training the Brazelton Way” by TB Brazelton
 “The American Academy of Pediatrics Guide to Toilet Training”
 “The Potty Journey: Guide to Toilet Training Kids with Special
Needs” by JA Coucouvanis

33. References
1. Klassen, T., Kiddoo, D., Lang, M., Friesen, C., Russell, K.,
Spooner, C., & Vandermeer, B. (2006). The effectiveness of
different methods of toilet training for bowel and bladder
control. Evidence Report/Technology Assessment, (147),
1-57.
2. MacGregor, J. (2008). Introduction to the anatomy and
physiology of children: A guide for students of nursing,
child care and health. New York, NY: Routledge.
3. Mersch, J. (March 10, 2010). In Potty Training (Toilet Training).
MedicineNet.com. Retrieved April 1, 2012, from
http://www.medicinenet.com/script/main/art.asp?articlek
ey114293.
4. Turner, T., & Matlock, K Toilet Training. In: UpToDate, Torchia,
M.M.(Ed), UpToDate, Waltham, MA, 2012