Toilet Training

1. Epidemiology
   1. Now: Toilet Training occurs at a later age than in the past
      1. Previously training started at age 18 months and now starts at 21-36 months
      2. Toilet Training is completed in only half of 36 month olds
   2. Prior: Usually occurs by end of third year (mean 2.5 years)
      1. Age 24 months: 26% daytime continence
      2. Age 30 months: 85% daytime continence
      3. Age 36 months: 98% daytime continence
   3. Gender impact on timing
      1. Girls often toilet train earlier than boys
2. Signs: Toilet-Training Readiness
   1. Child asks to wear underwear or to use toilet
   2. Able to put on and take off clothes, as well as more simple skills (sit, walk)
   3. Autonomy (e.g. Says 'No')
   4. Follows simple commands
   5. Observes parents using toilet
   6. Imitates parent's behavior
   7. Wants a clean diaper when soiled
   8. Diaper stays dry for at least 2 hours and after naps
   9. Bowel Movements occur at predictable times and are regular
   10. Child indicates they need to urinate or defecate
3. Management: General (based on AAP, Dr Spock and Dr Brazelton methods)
   1. Start Toilet Training when signs of readiness (see above)
      1. Typically after 18 months
      2. Dr. Spock recommends after 24-30 months
   2. Offer positive reinforcement (praise)
   3. Process should be pleasant and non-threatening
      1. Avoid punishment, shaming or use of force
      2. Avoid negative comments or shaming
   4. Child uses potty-chair voluntarily
      1. Bring to potty-chair 2-3 times daily once child shows interest
4. Management: Specific Methods
   1. Brazelton Child-Oriented Toilet Training Method
   2. Azrin and Foxx Toilet Training Method (Toilet Training in A Day Method)
      1. Negative reinforcements incorporated in this method are discouraged by many pediatricians
      2. Method appears effective and can be modified to exclude negative reinforcements
5. Complications
   1. See Enuresis
   2. See Encopresis
   3. Toilet Training refusal
      1. Often related to Constipation and associated painful stools
      2. Consider fiber supplementation and Stool Softeners
      3. Describe stool in positive terms
      4. Positively reinforce stooling in diaper
   4. Stool withholding
      1. Similar management as Toilet Training refusal
      2. Aggresively manage Constipation
6. Resources
   1. AHRQ Toilet Training Method Review
      1. http://www.ahrq.gov/downloads/pub/evidence/pdf/toilettraining/toilettr.pdf
7. References
   1. Choby (2008) Am Fam Physician 78(9): 1059-64
   2. Polaha (2002) J Dev Behav Pediatr 23(6): 424-9
   3. Stadtler (1999) Pediatrics 103:1359-68