A 2-year-old female came to clinic for her well child check. The parents had no concerns and she was developing normally. The past medical history was non-contributory. The pertinent physical exam showed a healthy female with growth parameters in the 75-90%.
The diagnosis of a healthy female was confirmed. The parents asked about when to begin toilet training. The pediatrician recommended to follow the child’s cue and when she seemed interested, could verbalize her toileting wants/needs, seemed to not like soiled or wet diapers, and could take care of at least part of her clothing, then they probably would have more success with trying to train her. The pediatrician warned that the child could be slow to toilet train while others did it quite quickly, and that staying dry at night would come much later.
Toilet training is a normal developmental process but has very little research. In 1962 Dr. Barry Brazleton published the first standardized method using a “child readiness” approach that was unregimented and child-focused. The child had to be physiological and psychologically ready and the parent had to be psychologically ready to proceed with toilet training. Studies beginning at 18 months of age using this approach had a mean daytime continence achieved by 28 months. In 1973, Azrin and Foxx described a method that was structured and parent-focused. Again both the child had to be physically and psychologically ready and the parents had to be psychologically ready. In smaller studies this approach were trained in several hours.
Readiness cues for toilet training from the literature have been looked at. Unfortunately which signs predict success are lacking. Part of this is due to the inconsistent definitions. For example does toilet training success mean being dry when while awake (i.e. still needs a diaper during naps) or is dry during all daylight hours? Does success mean recognizing that he/she needs to toilet and can wait until an adult helps with clothing, or does that mean that the child recognizes the urge, takes care of all clothing, successfully uses the toilet and performs all his/her own hygiene along with replacement of clothing? Developmental readiness also depends on which cue is used to determine the readiness. Below is a list developed from the literature and the range of ages in months when most children can perform them.
2-25 – Child imitates toileting behavior
4-16 – Child is capable of sitting stable and without assistance on toilet/potty chair
8-18 – Walks without help
9-18 – Able to pick up small objects
9-24 – Can say No as sign of independence
9-24 – Has voluntary control over bladder and bowel reflex actions
9-27 – Responds to directions and simple commands
9-36 – Indicates need to toilet by non-verbal cues or by words
10-22 – Enjoys putting things in containers
12-24 – Awareness of bladder sensations and need to void
12-27 – Understanding toilet-related words and has adequate vocabulary him/herself
12-28 – Shows interest in toilet training
12-32 – Has a larger bladder capacity
12-36 – Insists on completing tasks him/herself and is proud of new skills
12-36 – Asks for toilet/potty chair
18-24 – Is distressed by wet/dirty diapers/clothing
18-24 – Wants to wear grown-up clothing
18-36 – Able to pull clothing up and down
22-26 – Is Bowel movement-free overnight
22-27 – Able to put items where they belong
25-32 – Can sit still on toilet/potty chair for 5-10 minutes
When should children start toilet training depends and there is little data to support exact timing or the best method. Today most children start to train between 18-24 months with more intensive training starting at ~27 months. When asked, parents in one study said 20.6 +/- 7.6 months.
A systematic review of 34 studies found “Both the Azrin and Foxx method and the child-oriented approach resulted in quick, successful toilet training, but there was limited information about the sustainability of the training. The two methods were not directly compared; thus, it is difficult to draw definitive conclusions regarding the superiority of one method over the other. In general, both programs may be used to teach toilet training to healthy children. The Azrin and Foxx method and operant conditioning methods were consistently effective for toilet training mentally handicapped children. Programs that were adapted to physically handicapped children also resulted in successful toilet training. A lack of data precluded conclusions regarding the development of adverse outcomes.”
An author of this systematic review states that “Toilet training should be started when both the child and parent are willing to participate” and that, “[a] positive, consistent approach to toilet training is unlikely to cause long-term harm.”
Questions for Further Discussion
1. When do you recommend that children begin toilet training?
2. Do you use any readiness cues and which ones?
- Disease: Toilet Training and Bedwetting
- Symptom/Presentation: Behavior Problems | Developmental Delay | Enuresis and Urinary Incontinence
- Specialty: Developmental Disabilities | General Pediatrics
- Age: Toddler
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.
Information prescriptions for patients can be found at MedlinePlus for this topic: Toilet Training
To view current news articles on this topic check Google News.
To view images related to this topic check Google Images.
To view videos related to this topic check YouTube Videos.
Klassen TP, Kiddoo D, Lang ME, Friesen C, Russell K, Spooner C, Vandermeer B. The effectiveness of different methods of toilet training for bowel and bladder control. Evid Rep Technol Assess (Full Rep). 2006 Dec;(147):1-57.
Vermandel A, Van Kampen M, Van Gorp C, Wyndaele JJ. How to toilet train healthy children? A review of the literature. Neurourol Urodyn. 2008;27(3):162-6.
Kaerts N, Van Hal G, Vermandel A, Wyndaele JJ. Readiness signs used to define the proper moment to start toilet training: a review of the literature. Neurourol Urodyn. 2012 Apr;31(4):437-40.
Kaerts N, Vermandel A, Lierman F, Van Gestel A, Wyndaele JJ. Observing signs of toilet readiness: results of two prospective studies. Scand J Urol Nephrol. 2012 Dec;46(6):424-30.
Kiddoo DA. Toilet training children: when to start and how to train. CMAJ. 2012 Mar 20;184(5):511-2.
ACGME Competencies Highlighted by Case
1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
2. Essential and accurate information about the patients’ is gathered.
3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
4. Patient management plans are developed and carried out.
5. Patients and their families are counseled and educated.
8. Health care services aimed at preventing health problems or maintaining health are provided.
10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.
13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital