Toilet Training

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Toilet Training

• Krista Matsen, MD
• March 2003

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History

• Turn of the century permissiveness
• 1930s rigidity, strict structured schedules,
  coerciveness, parents encouraged to train
  children as early as possible
• 1940s-50s influenced by psychoanalytic theory
  and developmental theories leniency in training
  resumed
• . . .Since then a variety of training techniques
  have been described

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Techniques. . .

• Some emphasize developmental stages of children
• Some use behavioral or operant conditioning
  approaches
• Some emphasize that children will eventually
  train themselves through a natural maturation
  process if left alone

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Commode Quiz. . .

• Mothers in the East African Digos Tribe starts
  toilet training at . . .
• a. few weeks of age
• b. 6 months old
• c. puberty

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Age of dryness

• Physical development
• infant elimination is reflexive, no
  conscious control of cortical movement
• 1-2 yrs awareness of sensations that
  accompany bladder fullness
• 3 yrs able to retain urine by voluntary
  conscious control
• 4yrs able to initiate micturition
• 6-7 yrs can void at will with any amount of
  bladder distention

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Other factors

• Infants weighing less than 2500g at birth are
  slower to achieve day and night dryness
• Gender differences girls more likely to achieve
  day and night dryness by age three than the boys.
  
• Racial differences after the age of three all
  girls and Caucasian males were drier than aa
  males (children in Maryland)
• In US 75 achieve dryness by age 4
• In Israeli kibbutzim 69 dryness by age 4
• In Great Britain and Sweden, children reach
  dryness at a younger age (Sweden 92 by age 4, GB
  88 by age 4)
• In East African Digos infants achieve bladder
  control by age 12mos

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When to train?

• Consider three areas
• Bladder control urinates a good deal at one
  time, capable of staying dry for several hours,
  is aware of the need to go
• Physical readiness can pick of small objects,
  capable of walking easily from room to room
• Instructional readiness assessed by asking the
  child to carry out 10 small tasks (touching ones
  nose, retrieving a small object child is ready
  if can do 8/10)

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Avoid

• Starting at stressful times
• New baby, moving, divorce
• Pushing to fast to try to get training done by a
  deadline (ie for the start of preschool)
• Punishing mistakes

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Our role as Pediatricians

• Initiate discussion about toilet training 1yr
  visit
• To assess parents plans, goals and expectations
  for toilet training (50 of mothers surveyed at
  time of birth expected to start toilet training
  at 16 months and to have dryness accomplished by
  2y/o)
• To help educate parents on reasonable
  expectations and assess readiness
• To help parents recognize when additional help or
  medical assessment is need

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How to train

• Various approaches
• kibbutz multiple caregivers, but a metapelet/
  primary care giver assigned to task, gradual
  conditioning process that is child oriented
• East African Digos, moms recognize when they need
  to go and place them in special position between
  there legs and make a shuss sound. Child then
  rewarded with feeding or attention

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Commode Quiz 2

• What is a nappy?
• a. a paper napkin
• b. a diaper
• c. the few minutes of extra rest you get in
  the Chicopee Agawam room at 745 each morning
• d. a back pack or knap sack

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Timing method

• - introducing to the training pot once at the
  right age, then required to spend some time
  sitting on it, then parents try to limit the
  sitting time to when they think the child needs
  to go eventually the child eliminates on the
  pot and is rewarded

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Modeling

• Having child learn behavior from watching parents
  or demonstrating toileting with a stuffed animal
  or on a cartoon video
• Can use a doll that wets to show each step
  required to toilet independently, then have the
  child help the doll the child should be
  instructing through each step involved (walk to
  bathroom, pull down pants etc . . .

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Trouble shooting

• Case one
• Peters mother is in for his 3y/o WCC visit and
  she reports though toilet training is going well,
  he insists on voiding sitting down.
• - Should she be concerned? What are some ways to
  change this behavior?

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• It is normal for boys to learn to void sitting
  down
• He may change behavior on his own, but it may
  help for him to watch his Dad or brother voiding
  standing up (modeling)
• May be more interested if there is a target . . .
  Cheerios or fruit loops work well

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CASE 2

• You are home on phone call and get a frantic call
  from Mrs. Kranz who is very distraught because
  she came home to find her 28m/o girl, Heather had
  been playing with her feces (and has added some
  new artistic features to her room)
• What is your response?

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• This is not uncommon at this age, it stems from
  curiosity and exploring
• She should firmly state that this is not
  something to be played with
• Consider giving her a task to help clean
• Frequent hand washing is never a bad idea
• On a lighter note, someday she may be a great
  artist

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Commode Quiz 3

• What is a Toodle Loo ?

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Case 3

• Mrs. Leonard comes in with her youngest who is
  nearly three, she states that Hazel refuses to
  have BMs in the toilet. She is dry all day and
  when she needs to have a BM she goes and puts a
  diaper on herself and finds some out of the way
  place to hide while she goes.
• What is your response?

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• Though Hazel is physically ready for the next
  step in toilet training she may not be
  emotionally ready
• Start by letting her use the diaper but try to
  get her to go while in the bathroom
• Have her dump the poop into the commode herself
  and flush it down
• Consider showing her the diapers and tell her
  that once it is gone there wont be anymore
• Consider a special ceremony when they are all
  gone
• Fiber, Fiber, Fiber so constipation and holding
  it doesnt become a problem

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Case 4

• A Dad comes into the office because of concern
  that although his son Lance is toilet trained at
  daycare he refused to use the toilet at home
• What is your advise?

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• If the child is closer to age two it may be a
  matter of maturity, consider backing off at home
  and being patient he is physically capable but
  may not be emotionally ready
• Talk to the daycare providers about what their
  routine is a school to try to be consistent at
  home

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Ways to overcome Willfulness

• Transfer responsibility to child- set up
  guidelines (clean clothes must be worn before
  engaging in any other activity etc)
• Try reverse psychology I am sure you wont want
  to use the potty today so we will just put the
  diaper on
• Avoid No answers by telling them its time to
  try instead of asking do you have to go
• Give choices Do you want to take you pants off
  or should I? Do you want to use the big potty or
  the small one?

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