Toilet Training

Toilet training involves recognition of readiness for and implementation of the separate steps of toileting: discussion, undressing, eliminating, dressing again, flushing, and hand washing.

Most children can be trained for bowel control between 2 years and 3 years of age and for urinary control during the daytime between 3 years and 4 years of age (1). By 5 years of age, the average child can go to the toilet alone. For incontinence in children, see Urinary Incontinence in Children and see Stool Incontinence in Children.

The key to successful toilet training is recognizing signs of readiness to train (usually at age 18 to 30 months) (1):

• Children can sit stably on the toilet.

• Children can remain dry for several hours.

• They show interest in sitting on a potty chair, and express visible signs of preparing to urinate or defecate, or otherwise communicate the need to use the toilet.

• They show discomfort with a wet or soiled diaper and want to be changed.

• They can place things where they belong and can understand and carry out simple verbal commands.

Approaches to toilet training should be consistent among all caregivers.

The timing method introduces the child gradually to toileting behaviors with routine, structured visits to the toilet. Once children have shown readiness, the parent discusses with them what will be happening, selecting words that they can readily understand and say. Children are gradually introduced to a potty chair and briefly sit on it fully clothed; they then practice taking their pants down, sitting on the potty chair for ≤ 5 or 10 minutes, and redressing. The purpose of the exercise is explained repeatedly. Once this connection between the potty and elimination has been made, the parent should try to anticipate children’s need to eliminate and provide positive reinforcement for successful elimination. Children are also encouraged to practice using the potty whenever the need to eliminate is sensed. They should be taught about flushing and hand washing after each elimination. For children with an unpredictable schedule, this type of plan is difficult, and training should be delayed until they can anticipate elimination themselves.

Other methods include the child-centered method, and an operant conditioning–based method that can accomplish toilet training in a child who is ready in as little as one day (1).

Children who resist sitting on the potty should try again after a meal. If resistance continues for days, postponing toilet training for at least several weeks is the best strategy. Behavior modification with a reward given for successful toileting is one option; once the pattern is established, rewards are gradually withdrawn.

Anger or punishment for accidents or lack of success is counterproductive. Power struggles must be avoided because they often cause regression from any progress that has been made and may strain the parent-child relationship. Toilet-trained children may also regress when they are ill or emotionally upset or when they feel the need for more attention, as when a new sibling arrives. Refusal to use the potty may also represent manipulation. In these situations, parents are advised to avoid pressuring children, offer incentives, and, if possible, give children more care and attention at times other than when toileting is involved.