COVOVER ARTT II CC LL E

Toilet training: Getting it right the first time By Barton D. Schmitt, MD Successful training benefits both parent and . In this first of two articl e s , a leading ex p e r t explains how to help parents through the training process and avoid pitfa l l s . I n cludes a Guide for Pa r e n t s . oilet training is accom- disposable cost about 25 a d v e rtisements, children in pull-ups plished when a child uses a cents each; pull-ups, 40 cents. a re extremely happy. Delayed toilet or toilet for blad- Once a child is toilet trained, the training has been legitimized, and der and bowel functions options for travel, babysitters, day t h a t ’s good for business. Other fac- during waking hours. c a re, and preschool multiply. Fro m tors are busy, dual-career families TNighttime bladder control usually the child’s standpoint, using the and normal procrastination. occurs later because it re q u i res the toilet can enhance a sense of mas- To keep toilet training in per- ability to suppress the urge to void t e ry and self-esteem as well as pre- spective, remember that more than during sleep or the advanced skill vent the discomfort of rash. 50% of children around the world of awakening from sleep to the sig- F rom a medical standpoint, using a re toilet trained at about 1 year of nal of a full bladder. Even at 6 years the toilet reduces the spread of en- a g e . 1 They are toilet trained by ne- of age, 10% of children still wet teric pathogens such as G i a rdia a n d cessity because many families can’t their bed. R o t a v i ru s . a ff o rd disposable diapers and don’t Successful toilet training is good Yet many parents in the United for both parents and children. Not States postpone toilet training. The having to change diapers and wash p redominant reason seems to be the DR. SCHMITT is professor of pediatrics, University of Colorado School of Medicine, and medical o ff a bottom frees up considerable availability of disposable diapers. director of the Encopresis-Enuresis Clinic, The p a rental time. (And, lest we forg e t , M a n u f a c t u rers of disposable diapers Children’s Hospital, Denver. He is a member of the some parents still wash diapers.) and pull-ups now market larg e - s i z e d editorial board of Contemporary Pediatrics. He has nothing to disclose in regard to affiliation with, Toilet training also saves a signifi- pull-ups, so not being toilet trained or financial interests in, any organization that may cant amount of money. In bulk, at 4 years of age is not a problem. In have an interest in any part of this article.

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KEY POINTS have the time or facilities to wash during the day was 31.5 months cloth diapers. In my experience, Training a child for girls and 34.7 months for boys. even in the US, low-income fam- for the toilet The median age for staying dry ilies toilet train their children earlier during the day was 32.5 months ▼ than the middle class. Single mothers Toilet training begins on the for girls and 35 months for boys. 2 day the parent starts practice also toilet train their children earlier. runs (potty sits) Girls were consistently trained two to three months earlier than boys. ▼ The age of onset Most children can be made The study documented a consistent and completion ready to toilet train between 2 and 21/ years of age l e a rning sequence (Table 4). The of toilet training 2 results should not be considered a ▼ The timing of starting and complet- Readiness training developmental timeline, however, (preparation) should precede ing toilet training in the US has because toilet training (practice 3 toilet training by at least six been changing (Table 1). S o m e months and can easily start at runs) was started much later (at a p a rents are unaware that toilet 18 months of age median of 26.7 months for girls training before 2 years of age is ▼ Early or delayed toilet training and 31.2 months for boys) than in even possible. Some have been ad- is a parental preference, not the Brazelton study. In that study, vised by their health-care pro v i d e r a developmental limitation m o re than 50% of the children had not to start toilet training before 3 a l ready completed training by 26.7 years. Has the pendulum swung months, and more than 85% were too far? Let’s review three studies. training, 26% of the children were trained by 31.2 months. The largest study in this country trained by 24 months, 52% by 27 What accounts for such wide dif- was re p o rted by Brazelton in 1962 months, 85% by 30 months, and f e rences in the age of completion of on 1,170 children in Boston (Ta b l e 98% by 36 months. The sequence toilet training? Clearly, the deter- 2 ) . 4 Toilet training was begun by of completed training was bladder mining factor is when training be- 18 months of age in 19% of the and bowel control simultaneously in gins. Several other studies demon- c h i l d ren, by 21 months in 40%, 79.5% of the children, bowel con- strate that an earlier start leads to and by 24 months in 94%. Using t ro l first in 12.3%, and bladder earlier completion.7 , 8 P a rents can B r a z e l t o n ’s child-oriented, gentle, c o nt rol first in 8.2%. achieve Brazelton’s results by start- and gradual approach to toilet Another interesting study com- ing between 18 and 24 months of p a red 379 children who were toilet trained in 1947 to 71 childre n TABLE 1 TABLE 2 trained in 1975 (Table 3).5 In 1947, T h e t re n d i n b e g i n n i n g 60% of children in the sample were When do childre n toilet training trained by 18 months of age and 95% complete toilet training? by 33 months. By contrast, in 1975, Time period Starting age only 2% of children were trained by % of children 18 months, and 59% by 33 months. Age completely trained 1920–1940 12 mo The main reason for earlier comple- 24 mo 26% 1940–1960 18 mo tion was earlier initiation of training. 27 mo 52% 1960–1980 2 yr This study clearly demonstrates the impact of parental expectations. 30 mo 85% 1980–1990 2.5 yr A more recent study by Schum 36 mo 98% 1990– present 3 yr followed 126 girls and 141 boys in 6 Adapted from Bakker3 Milwaukee from 1995 to 1997. Adapted from Brazelton TB4 The median age for stool contro l

1 0 6 CONTEMPORARY PEDIATRICS Vol. 21, No. 3 age or Schum’s results by start i n g TABLE 3 between 24 and 36 months. The time re q u i red to move from initia- Later and later onset and completion tion to completion of toilet training of toilet training: 1947 and 1975 is three to six months on average. Table 5 lists the disadvantages of 1947 1975 starting before 18 months of age. Age Onset Completion Onset Completion Readiness criteria Before 18 months 92% 60% 45% 2% The time to start toilet training is Before 26 months 97% 84% 82% 24% after the child is ready to proceed Before 33 months 99% 95% 95% 59% with practice runs (potty sits). 5 Five markers signal readiness for Adapted from Martin JA training: Bladder re a d i n e s s . The child after naps, for example), and doesn’t can postpone the urge to d e f e c a t e recognizes the signal of a full blad- have a physical limitation such as b r i e f l y, and doesn’t have a p h y s i c a l der before urinating, can postpone u rge incontinence. limitation such as toddler’s d i a rrh e a . the urge to urinate briefly, can stay Bowel re a d i n e s s . The child re c- Cognitive re a d i n e s s . The child d ry for more than two hours (is dry ognizes the signal of a full re c t u m , understands what the potty and toilet are for and is interested in us- ing the potty. This interest also can TABLE 4 be taught. When do girls and boys acquire Motor re a d i n e s s . The child can toilet training skills? walk, sit, and get on and off the potty chair. Median age (mo) Psychological re a d i n e s s . T h e child likes to sit on the potty S k i l l Girls Boys c h a i r, is cooperative and likes to Sits on potty when placed for five minutes 26.7 31.2 please his parents (avoid training Knows how to urinate in the potty 28.8 30.9 during the peak of negativism or s t u b b o rnness), and follows simple Urinates in potty with help 29.7 31.7 i n s t ru c t i o n s . Wears training pants or underwear 30.9 33.8 Readiness training Tells before having a bowel movement (BM) 31.0 33.6 (preparation Uses regular toilet without a potty seat 31.4 34.0 for toilet training) Stays BM-free during the day 31.5 34.7 Does readiness for toilet training Tells before having to urinate 31.9 34.7 unfold naturally or can parents ac- celerate the process? The re s e a rc h Urinates while standing by himself NA 38.0 to answer this question remains to Stays dry during the day 32.5 35.0 be done. In my opinion, pare n t s Enters and urinates by self 33.0 37.1 can help their child get re a d y, much as they teach the child other Enters bathroom and has BM by self 34.4 39.5 skills such as playing with diff e re n t Adapted from Schum TR et al6 toys, using new words, eating with

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a spoon, dressing, and re a d i n g . They overlook the simple prepara- Why wait until 2 or 3 years of age TABLE 5 tion that can go on for six months to start the teaching? Learning nor- or more before toilet training mally occurs through re p e t i t i o n . Drawbacks of early starts. Ways to help a child become re a d y toilet training, The purpose of readiness train- include the following: b e f o re 18 months ing is to pre p a re a child for earlier 18 months. Begin teaching and easier success. There are no about pee, poop, and how the Process may take longer p r oven harmful effects. Wi t h body works. Bladder and bowel accidents are more p a rental help, some children fulfill n Teach the vocabulary (pee, poop, l i k e l y readiness criteria by 18 months of p o t t y, etc.). age, many by 2 years, most by Regression is more likely 1 n Make it clear to the child that 2 ⁄2 years, and almost all by 3 years. e v e ryone makes pee and poop. Child is more easily distracted If someone advises a parent not to n Point out when dogs or other Child needs more ongoing supervision begin toilet training before 3 years animals are doing pee or poop. (or some other arbitrary age) or to n Clarify the body’s signals when wait for the child to train herself, you observe them: “Your body wants with clothes on for fun activities help the parent understand re a d i- to make some pee or poop.” such as play, snacks, and television. ness training. If a child shows inter- n Praise the child for passing poop Help the child develop a sense of est in this process, the window of in the diaper.9 ownership (“my chair”). o p p o rtunity should not be ignored. n D o n ’t refer to poop as “dirty” or n Put the potty chair in the bath- S c h u m ’s recent study of re a d - “ y u c k y. ” room and have the child sit on it iness skills found that childre n n Make diaper changes pleasant for when the parent sits on the toilet. master them between 22 and 30 the child so he will come to the 2 years. Begin using teaching months of age (Table 6).6 P re v i o u s p a rent for changes. a i d s . studies suggested that these skills n Change the child often so he will n Read toilet learning books and develop between 18 and 24 prefer a dry diaper. watch toilet learning videos. m o n t h s . 4 Based on his excellent n Teach the child to come to the n Help the child pretend she’s s t u d y, Schum recommends re v i s i n g p a r ent whenever he is wet or training a doll or stuffed animal on u p w a rd the age at which physicians s o i l e d . the potty chair. It doesn’t have to be recommend starting toilet train- 21 months. Begin teaching an expensive doll that pees water. i n g . 6 The limitation of Schum’s about the potty and toilet. n I n t roduce underwear as a priv- study is that there was no concert e d n Teach the child what the toilet ilege. Buy special underwear and e ff o rt to teach readiness skills (the and potty chair are for (“pee or keep it in a place where the child potty chair was introduced at a me- poop goes in this special place”). can see it. dian age of 23 to 25 months). Demonstrate by dumping poop The most common error pare n t s Another possible interpretation of f rom diapers into the toilet. in this country make is doing noth- the study, there f o re, is that re a d i- n P o rtray using the toilet and potty ing to pre p a re the child until the ness skills need to be intro d u c e d chair as a privilege. week they start toilet training. They and taught rather than allowed to n Have the child observe toilet- f o rget to tell the child that they, the develop by chance. The age at trained children use the toilet or g r a n d p a rents, the school, and soci- which a child attains re a d i n e s s potty chair (an older toilet-trained ety in general expect the child to m o re likely reflects the interest and sibling can be very helpful). someday put her pee and poop in expectation of the parents than any n Give the child a potty chair. the potty. They neglect to generate innate developmental limitations. Encourage the child to sit there curiosity about bathroom events. Delaying the onset of toilet training

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until after 30 months may have some disadvantages (Table 7). TABLE 6 In the final analysis, a child is ready for practice runs if: When do girls and boys acquire n the parent can sometimes re c o g- readiness skills? nize or predict when the child has a full bladder or re c t u m , Median age (mo) n the child can stay dry for two Skill Girls Boys hours or longer, Understands potty words 22.8 24.5 n the child has enjoyed sitting on the potty chair for two weeks or Has potty chair/seat available 23.2 25.2 l o n g e r, and Shows interest in using the potty 24.1 26.2 n the child usually cooperates with Tells parent during or after having a bowel movement 24.6 27.0 p a rental requests. Has regular bowel movements 24.9 26.2 Toilet training Stays dry for more than two hours 26.0 28.9 Toilet training begins on the day Indicates the physical need to go to the bathroom 26.3 29.3 the parent first encourages the child to sit on the potty chair with- Tells parent during or after peeing 28.4 32.6 out a diaper and try to pass urine Adapted from Schum TR et al6 or stool (these attempts are called practice runs or potty sits). To i l e t the bladder is not full until 3 years g runting, pushing on the posterior training consists of three pare n t a l of age. At any age, re- d i a p e r, and passing gas. Signals actions (Table 8): q u i res a full rectum. Hence, most of imminent include n p rompted practice ru n s initial toilet training is bladder s q u i rming, dancing, pacing, hold- n response to successes training. ing the genital area, pulling at the n response to accidents Common body signals for immi- d i a p e r, and sitting on the heel. So- All of these actions need to be exe- nent defecation are squatting, called silent voiders, who do not cuted in a positive, loving, and up- give clear signals of impending uri- beat ambiance (see the “Guide for nation, can sometimes be re c o g- TABLE 7 P a rents” on page 120 for details). nized by facial expression or fre e z- Potty sits should be brief—usually, Drawbacks ing (no movement). When any of no longer than five minutes. As to delayed toilet these signals occur, the parent can soon as the child seems restless, he initiate a practice run by stating, should be allowed to get up. If training, after “The poop (or pee) wants to come possible, the parent should en- 30 months out. Let’s find the potty. ” courage him to get up before he Based on surveys of pare n t Child accepts or likes diapers even asks to. Unsuccessful potty sits g roups, 90% of parents can tell d e s e r ve an encouraging comment Child likes passing urine without when their child needs to defecate, (“good try”). waiting to get to the potty but only 50% can tell when the Practice runs must be synchro- Child dislikes change and has no child needs to urinate.1 0 For those nized with body signals indicating reason to change silent voiders, practice runs need that the child needs to pass urine Child becomes smarter and more to be based on probabilities. The or stool. Unlike adults, most young capable of testing adults most reliable ones are 45 minutes c h i l d ren can’t initiate urination if after consuming a large amount of

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beginning, however, helps keep the TABLE 8 child focused on the goals. Pare n t s TABLE 10 should also give the child praise Toilet training and physical affection for cooperat- Catalysts for at a glance ing with the practice runs, especially successful toilet for trying to use the potty. t r a i n i n g Start practice runs (potty sits) If the child wets or soils himself Synchronize practice runs with body soon after getting off the potty, Potty chair easily available s i g n a l s the pare n t ’s response needs to be Use of buckets for boys e n couraging. Parents can say, For successes, praise and reward Convenient clothing the child “You wanted to go poop (or pee) U n d e r w e a r For accidents, change the child in the potty, but it came out in without any negative comment your diaper. That’s okay. You can Bare-bottom technique do it. Keep trying.” They must Adequate time (six hours or a maintain a positive atmosphere as weekend devoted to training) fluid or two hours without urinat- they change the child. You can I n c e n t i v e s ing. Children who do not give a counsel them that feeling anger clear signal of an urge to defecate toward their child at this time can can be asked to sit on the potty af- be normal, but it’s important not P a rents can shift from practice ter a large meal when they have to show it. runs to gentle reminders given not had a bowel movement in when they notice the child is ignor- m o re than 24 hours. The normal progression ing a strong body signal. As soon as How often should parents try a of toilet training possible, they should stop re- practice run? In relaxed toilet Toilet learning follows a pre- minders as well because re m i n d e r s training, parents initiate practice dictable sequence of steps (Ta b l e also can antagonize the child. runs a few times a day. Because too 9). Practice runs (walking the many practice runs can be over- child to the potty) can be discon- Catalysts for whelming for the child, I some- tinued when a child decides spon- accelerating times tell parents they are allowed taneously to use the potty three or toilet training a total of 100 practice runs and m o r e times. Excessive practice The ultimate goal is to have chil- need to use them wisely. Blum de- runs can be detrimental and lead d ren use the potty without pro m p t- fined intensive toilet training as to resistance. ing (to “remind themselves” as many asking the child to use the potty p a rents of my patients say). The m o re than three times a day.8 H e following approaches can motivate TABLE 9 found little benefit in beginning a child to greater potty aware n e s s intensive toilet training before Steps in toilet ( Table 10). 27 months of age. l e a r n i n g Make the potty chair easily If the child releases urine or a v a i l a b l e . The potty chair can stool into the potty, the pare n t Child pees or poops on the potty s e r ve as a visual reminder if it is should praise and re w a rd her. I 1 . With practice runs (parent walks placed in the room in which the once thought that praise alone was child to potty) child spends most of her time (that adequate for routine toilet training is n o t the bathroom). Parents can With parent reminders or prompts and that incentives should be re- 2 . p rotect the floor or carpet with a s e r ved for slow learners. Using 3 . On his own initiative sheet of plastic. Better yet, re c o m- food treats and stickers from the mend that parents put two potty

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chairs in diff e r ent loca- stay in the vicinity of the tions. In the summert i m e , potty chair, which can be one location can be outside Children like pull-ups put in the kitchen or other in the yard . room where there is no Use a bucket for boys. because they are carpeting. A gate across the Some boys insist on stand- door of the room may help ing to urinate, but standing gender specific and the child stay on task. In on a stool in front of the the summertime, the child toilet can be precarious. A have favorite video can be trained outside (he wide bucket or dishpan or she may need to wear a can be used instead. characters on them long shirt to appease the P rovide convenient cloth- neighbors). During bare - ing. During toilet training, b u t , in my experience, bottom times, the pare n t c h i l d r en need to wear should supervise the child clothing that’s conducive they are not very helpful but refrain from all prac- to using the potty. That tice runs and most re- means one layer, usually for toilet training. Like minders, allowing the the diaper. Avoid shoes child to learn by trial and and pants. (In the winter- a diaper, they give e rror with parental sup- time, turning up the heat is a child permission p o rt. helpful.) Another option Devote a block of time (though less effective) is to pee now rather than exclusively to toilet train- loose sweatpants with an i n g . After the child has elastic waistband. Av o i d use the potty. successfully used the potty pants with zippers, but- a few times with the par- tons, snaps, or a belt. ents’ help and clearly un- Use underwear as an derstands the pro c e s s , i n c e n t i v e . Underpants with car- is taught how to pull them down. committing six hours or a weekend toon characters or action heroes or In my opinion, they are useful exclusively to toilet training using h e roines are powerful motivators. mainly for children who have grad- the above strategies (especially the Who would want to pee or poop on uated to underwear but are not yet b a re-bottom technique) can lead to t h e m ? I n t roduce them after a child fully trained. Parents can use pull- a bre a k t h rough. There should be has used the potty five to 10 times. ups for trips outside the home and no interruptions or distractions. Use disposable pull-ups or at bedtime. Younger siblings must spend the washable training pants judi- Try the bare-bottom technique. day or weekend elsewhere. Pare n t s c i o u s l y. C h i l d ren like pull-ups be- Not wearing any diapers, pull-ups, should turn off the TV and not an- cause they are gender specific and u n d e rw e a r, or other clothing below swer the telephone. They should have favorite video characters on the waist makes most childre n have just enough toys and books them but, in my experience, they acutely aware of their body’s handy to keep the child playing in a re not very helpful for toilet train- plumbing. Children innately dis- the vicinity of the potty chair. ing. Like a diaper, they give a child like pee or poop running down Success re q u i res monitoring the p e rmission to pee now rather than their legs. If the parent is willing to child during training hours. use the potty. Pull-ups or training dedicate a weekend to this tech- I n c r ease fluid consumption. pants may help if they are pur- nique, the success rate is rather P a rents should encourage the child chased in a large size and the child high. The child and parent must to drink lots of his or her favorite

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fluids. Increased fluid intake re- r a re, some more common erro r s NEXT MONTH sults in frequent urination and can lead children to resist toilet m o re opportunities to practice training. One is forcing the child to Toilet training trouble bladder control. sit on the potty chair when he How to deal with underachievers, re f u s e r s , P rovide incentives. I n c re a s i n g d o e s n ’t want to. Another is holding and stool holders the incentive for releasing pee or the child on the potty chair when by Barton D. Schmitt, MD poop into the toilet can jump-start he wants to get up. Such heavy- toilet training inertia. Examples of handed tactics cause most pare n t - incentives include stickers, food child power struggles to become A C K N O W L E D G M E N T For the past seven years, I’ve held community forums t reats, or 10 minutes of playtime embedded. In addition, hurried toi- on toilet training twice a year, with the objective of with a special toy. let training to meet a preschool re- preventing toilet training resistance and stool holding. My thanks to the thousands of parents who have Use time-ins. A time-in is the q u i rement usually is unsuccessful. shared their questions and ideas with me. opposite of a time-out. Time-ins are brief displays of physical aff e c t i o n Completion doesn’t mean perfection The parent guide on pages 120–122 given to children by their pare n t s may be photocopied and distributed (hugs, gentle touch, a smile, a Toilet training can be considere d to families in your practice without k i s s ) . 1 1 Time-ins are more powerf u l completed when a child uses the permission of the publisher. than praise. Some children who are toilet or potty on his own with no not making headway with toilet reminders from his parents. To i l e t R E F E R E N C E S 1 . deVries MW, deVries MR: Cultural relativity of toilet l e a rning feel discouraged. Fre q u e n t training, from start to finish, training readiness: A perspective from East Africa. time-ins help them remember that takes three to six months on aver- P e d i a t r i c s 1 9 7 7 ; 6 0 : 1 7 0 2 . Schum TR, McAuliffe TL, Simms MD, et al: Factors their parents love them and are age. The child may continue to associated with toilet training in the 1990s. A m b u l a t o r y their allies in this process and give ask the parent to accompany him P e d i a t r i c s 2 0 0 1 ; 2 : 7 9 3 . Bakker E, Wyndaele JJ: Changes in the toilet training them a good reason to change. to the toilet for several additional of children during the last 60 years: The cause of an in- m o n t h s . crease in lower urinary tract dysfunction? BJU Int 2 0 0 0 ; Toilet training Completion also can be defined 8 6 : 2 4 8 errors 4 . Brazelton TB: A child-oriented approach to toilet as 99% bowel control and 95% training. P e d i a t r i c s 1962;29:121 5 . Martin JA, King DR, Maccoby EE, et al: Secular Punishment has no place in toilet bladder control. Wetting under- trends and individual differences in toilet-training training. It always makes the child wear once or twice a week when progress. J Pediatr Psychol 1984;9:457 6 . Schum TR, Kolb TM, McAuliffe TL, et al: Sequential uncooperative and also hurts the the child is distracted or in a new acquisition of toilet-training skills: A descriptive study of c h i l d ’s self esteem. Spanking, setting is normal and may continue gender and age differences in normal children. P e d i a t r i c s 2002;109(3e). Available at www.pediatrics.org/cgi/ t h reatening to punish, or scolding for six to 12 months. Some boys c o n t e n t / f u l l / 1 0 9 / 3 / e 4 8 the child for accidents is always may have normal, mild, interm i t- 7 . Taubman B: Toilet training and refusal for stool only: A prospective study. P e d i a t r i c s 1 9 9 7 ; 9 9 : 5 4 c o u n t e r p roductive. At its extre m e , tent wetting episodes caused by de- 8 . Blum NJ, Taubman B, Nemeth N: Relationship be- punitive toilet training in the hands lays in getting the belt on their tween age at initiation of toilet training and duration of training: A prospective study. P e d i a t r i c s 2 0 0 3 ; 1 1 1 : 8 1 0 of a volatile parent or other care- pants loose or the zipper down. 9 . Taubman B, Blum NJ, Nemeth N: Stool toileting re- taker can escalate to ; This can also happen to girls with fusal: A prospective intervention targeting parental b e h a v i o r. Arch Pediatr Adolesc Med 2 0 0 3 ; 1 5 7 : 1 1 9 3 e n c o p resis interpreted by the par- tight leotards. Girls may experience 1 0 . Schmitt BD: Community forums on toilet training ent as deliberate is the second most mild wetting caused by norm a l ( u n published surveys) 1997-2003 1 1 . Christophersen ER, Mortweet SL: Parenting that common trigger for lethal child vaginal reflux of urine combined Works: Building Skills that Last a Lifetime. Washington 1 2 a b u s e . For this reason, it’s impor- with getting up from the toilet too D.C., APA Books, 2002 1 3 1 2 . Schmitt BD: Seven deadly sins of childhood: Advising tant to examine the genitals of any q u i c k l y. C h i l d ren of either sex parents about difficult developmental phases. Child Abuse child brought to you for toilet can have fecal smears (skid marks) & Neglect 1 9 8 7 ; 1 1 : 4 2 1 1 3 . Mattsson S, Gladh G: Urethrovaginal reflux—A common training problems. on the underwear resulting fro m cause of daytime incontinence in girls. P e d i a t r i c s 2 0 0 3 ; While punitive responses are inadequate wiping. h 1 1 1 : 1 3 6 Continued on page 120

1 1 6 CONTEMPORARY PEDIATRICS Vol. 21, No. 3 G U I D E F O R PA R E N T S

Toilet training your child: The basics ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦

our child is toilet trained when, without any 21 months.Begin teaching about the potty and toilet. reminders, he (or she, of course) walks to the ♦ Teach what the toilet and potty chair are for (“the p o t t y, pulls down his pants, urinates or passes pee or poop goes in this special place”). Demonstrate Y by dumping poop from diapers into the toilet. a bowel movement (BM), and pulls up his pants. ♦ P o rtray using the toilet and potty chair as a Some children learn to control their bladder first; p r i v i l e g e . others start with bowel control. You and your child ♦ Have your child observe toilet-trained children use can work on both kinds of control at the same time. the toilet or potty chair (an older toilet-trained sibling Bladder control through the night normally happens can be very helpful). several years later than daytime control. The gradual ♦ Give your child a potty chair. Encourage your child type of toilet training described in this Guide to sit on it with clothes on for fun activities, such as usually can be completed in one to three months— p l a y, snacks, and watching television. Help your child develop a sense of ownership (“my chair”). if your child is re a d y. ♦ Put the potty chair in the bathroom and have your Toilet training readiness child sit on it when you sit on the toilet. 2 years. Begin using teaching aids. D o n ’t begin toilet training until your child is clearly ready! Readiness doesn’t just happen; it involves ♦ Read toilet learning books and watch toilet learn i n g concepts and skills you can begin teaching your child videos with your child. at 18 months of age or earlier. Almost all children can ♦ Help your child pretend to train a doll or stuff e d be made ready for toilet training by 3 years, most animal to use the potty chair. It doesn’t have to be an 1 expensive doll that pees water. by 2 ⁄2 years, many by 2 years, and some earlier. Ways to help your child become ready include ♦ I n t roduce wearing underwear as a privilege. Buy the following: special underwear and keep it in a place where your child can see it. 18 months. Begin teaching about pee, poop, and how the body works. The potty chair ♦ Teach the vocabulary (pee, poop, potty). Buy a floor-level potty chair. You want your child’s feet ♦ Explain to your child that everyone makes pee and to touch the floor when he sits on the potty. This p o o p . p rovides leverage for pushing and a sense of security. It ♦ Point out when dogs or other animals are doing pee also allows him to get on and off whenever he wants to. or poop. Take your child with you to buy the potty chair. Make ♦ Clarify the body’s signals when you observe them: it clear that this is his own special chair. Have him help “ Your body wants to make some pee or poop.” you put his name on it. Allow him to decorate it or ♦ Praise your child for passing poop in the diaper. even paint it a diff e rent color. ♦ D o n ’t refer to poop as “dirty” or “yucky.” Then have your child sit on the potty chair fully ♦ Make diaper changes pleasant for your child so she clothed until he is comfortable with using it as a chair. will come to you. Have him use it while eating snacks, playing games, or ♦ Change your child often so she will prefer a dry looking at books. Keep it in the room in which your d i a p e r. child usually plays. Never proceed with toilet training ♦ Teach her to come to you whenever she is wet or unless your child clearly has good feelings toward the s o i l e d . potty chair.

This guide can be photocopied and distributed without permission to give to your patients’ parents. Reproduction for any other purpose requires express permission of the publisher, Advanstar Medical Economics Healthcare Communications. Copyright © 1974–2004, Barton D. Schmitt, MD 1 2 0 CONTEMPORARY PEDIATRICS Vol. 21, No. 3 G U I D E F O R P A R E N T S

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Steps in toilet training

Encourage practice runs to the potty. hugs. Although a sense of accomplishment is enough A practice run (potty sit) is encouraging your child to motivate some children, many need treats to stay to walk to the potty and sit there with her diapers focused. Reserve big re w a rds (such as going to the or pants off. You can then tell your child, “Try to toy store) for occasions when your child walks over go pee-pee in the potty.” Only do practice ru n s to the potty on his own and uses it or asks to go there when your child gives a signal that looks with you and then uses it. p romising, such as a certain facial expre s s i o n , Once your child uses the potty by himself thre e g runting, holding the genital area, pulling at her or more times, you can stop the practice runs. For pants, pacing, squatting, or squirming. Other good the following week, continue to praise your child times are after naps, after two hours without often for using the potty. (Note: Practice runs and urinating, or 20 minutes after meals. Say encouragingly, reminders should not be necessary for more than “The pee [or poop] wants to come out. Let’s use one or two months.) the potty. ” If your child is reluctant to sit on the potty, you Change your child after accidents may want to read her a story. If she wants to get up as soon as convenient. after one minute of encouragement, let her get up. Respond sympathetically. Say something like, “Yo u Never force your child to sit on the potty. Never wanted to go pee-pee in the potty, but you went physically hold your child on the potty. Even if pee-pee in your pants. I know that makes you sad. your child seems to be enjoying it, end each session You like to be dry. You’ll get better at this.” If you after five minutes unless something is happening. feel a need to criticize, restrict criticism to mild I n i t i a l l y, keep the potty chair in the room your verbal disapproval and use it rarely (“Big girls don’t child usually plays in. This easy access markedly go pee-pee in their pants,” or mention the name of i n c reases the chances that she will use it without another child whom your child likes and who is your asking. Consider buying two potty chairs. trained). Change your child into a dry diaper or During toilet training, children need to wear training pants in as pleasant and non-angry a way clothing that makes it easy for them to use the as possible. Avoid physical punishment, yelling, p o t t y. That means one layer, usually the diaper. or scolding. Pre s s u re or force can make a child Avoid shoes and pants. (In the wintertime, turn i n g completely uncooperative. up the heat is helpful.) Another option (though less effective) is loose sweatpants with an elastic Introduce underpants after your child waistband. Avoid pants with zippers, buttons, starts using the potty. snaps, or a belt. U n d e rwear can increase motivation. Switch fro m diapers to underpants when your child is Praise or reward your child cooperative about sitting on the potty chair and for cooperation or any success. has passed urine into the toilet spontaneously 10 All cooperation with practice sessions should be or more times. Take your child with you to buy the praised. You might say, for example, “Yo u ’ re sitting on u n d e rwe ar and make it a re w a rd for his success. the potty just like Mommy,” or “Yo u ’ re trying re a l Buy loose-fitting underpants that he can pull down h a rd to go pee-pee in the potty.” If your child urinates easily and pull up by himself. Once your child into the potty, you can re w a rd him with treats, such s t a rts wearing underpants, use diapers only for as animal cookies, or stickers, as well as praise and naps, bedtime, and travel outside the home.

March 2004 CONTEMPORARY PEDIATRICS 1 2 1 G U I D E F O R P A R E N T S

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Overcoming toilet training inertia: The bare-bottom weekend

f your child is over 30 months old, has successfully You and your child must stay in the vicinity Iused the potty a few times with your help, and of the potty chair, which can be placed in the clearly understands the process, committing six kitchen or another room without a carpet. A hours or a weekend exclusively to toilet training can gate across the doorway may help your child lead to a bre a k t h rough. Avoid interruptions or stay on task. During bare-bottom times, re f r a i n distractions during this time. Younger siblings must f rom all practice runs and most re m i n d e r s . spend the day elsewhere. Tu rn off the TV, and don’t Allow your child to learn by trial and error with answer the telephone. Success re q u i res monitoring your support . your child during training hours. Create a frequent need to urinate by offering The bare-bottom technique means that your child your child lots of her favorite fluids. Have just does not wear diapers, pull-ups, underw e a r, or any enough toys and books handy to keep your child clothing below the waist. This causes most childre n playing near the potty chair. Keep the process to become acutely aware of their body’s plumbing. upbeat with hugs, smiles, and good cheer. You are They dislike pee or poop running down their legs. your child’s coach and ally.

If your child resists training Request the parent guide on toilet training resistance if: 1 ♦ Your 2 ⁄2- y e a r-old child is negative about toilet training. ♦ Your child is over 3 years old and not daytime toilet trained. ♦ Your child won’t sit on the potty or toilet. ♦ Your child holds back bowel movements. ♦ The approach described here isn’t working after six months. Books on toilet training for parents P a re n t ’s Book of Toilet Teaching, by Joanna Cole (New York, Ballantine Books, 1999) Mommy! I Have to Go Potty! A Parent’s Guide to Toilet Training, by Jan Faull ( R a e f i e l d - R o b e rts Publishers, 1996) Toilet Learning: The Picture Book Technique for Children and Parents, by Alison Mack (Boston, Little, Brown and Company, 1983) Toilet Training Without Tears, by Charles E. Schaefer (New York, Signet, 1997) Potty Training for Dummies, by Diane Staff o rd and Jennifer Shoquist (New York, Hungry Minds, 2002) Potty Training Your Baby, by Katie Van Pelt (New York, Signet, 2002) The American Academy of Pediatrics Guide to Toilet Training (New York, Bantam Books, 2003) Keys to Toilet Training, by Meg Zweiback (Hauppauge, N.Y., Barro n ’s Educational Series, 1998)

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