Instruction, Timeliness, and Medical Influences Affecting Toilet Training

Contemporary toilet training derives from two accepted models: child-oriented gradual training and structured-behavioral, endpoint-oriented training. The former approach views toilet training as a process by which a parent systematically responds to a child's signals of toilet “readiness,” whereas the latter views toilet training as a process of eliciting a specific chain of independent toileting behaviors. Practically speaking, contemporary theoretic constructs of toileting behavior diverge with respect to training endpoints (ie, defined differently or deemphasized altogether), emphasis on self-esteem, development of goals, and timing of initiation. A scientific basis cannot be established for a universal timeline for toilet training, because each method has its own definition of the toilet training process. It remains unclear, for example, how long children must remain bowel- and bladder-continent to be considered trained, and to what extent children should be able to toilet themselves independently of caregivers.1Both child-oriented gradual and structured-behavioral approaches to toilet training evolved in the United States during the past 40 years within a scientific milieu that came to accept toilet training as a developmental milestone requiring a child's active participation. This common view of toilet training as a developmental process has provided clinically useful overlapping concepts of mature toileting behavior. The child-oriented gradual method, proposed by T. Berry Brazelton in 1962, defined the parameters of toilet readiness; a decade later, N.H. Azrin and R.M. Foxx designed a structured-behavioral method that detailed the components of independent toileting. Widespread acceptance of readiness and independent toileting have since been supported by clinical experience and resulted in agreement that a child should be ready to participate in toilet training at approximately 18 months of age and be trained completely by 2 or 3 years old. Global trends continue to support this concept despite technologic advancements and conveniences such as diapers, which have enabled delayed training.Toilet readiness is a powerful conceptual tool and requires an objective look both at a child's willingness to begin and progress with training and at the parent's preparedness for training the child. In addition to readiness, it is important for the practitioner to recognize other extenuating issues and conditions that can complicate the toilet training process. These may include the child being separated from the parent for many hours each day, such as when in day care, or health conditions such as developmental delays, chronic illness, or disabilities.The clinical community (including physicians, pediatric nurse practitioners, child psychologists, and other child care experts) concedes that although no one theory or method can address every toilet training problem, the individual practitioner who becomes familiar with a child and family situation can effectively advise parents during the process. Objective guidance from the care provider therefore requires an understanding of toilet training theories and methods, as well as the practical issues surrounding the timing of toilet training. Establishing each child's best “window of opportunity” can be crucial for toilet training success.Child-oriented gradual training was designed in 1962 on the recommendation of T. Berry Brazelton2 and still is the standard of practice for the majority of children. Brazelton took the position that toileting behavior emerges from physiologic attainment of bladder and bowel control and sufficient neurologic maturity for the child to voluntarily accept the responsibility to participate in toilet training. This maturational/behavioral model of toileting behavior was developed after World War II, at which time toilet training research and technologic advances prompted researchers to revisit the passive approach to toilet training that had been introduced at the turn of the century; this passivity was discarded in favor of a rigid, parent-centered approach to training in the 1920s and 1930s.3–5 By the 1940s, attitude changes had led pediatric experts including Benjamin Spock to reject absolute rules for toilet training on the theory that rushed, rigid training may fail and may even cause behavioral problems.4 Also at this time, professional advice to parents introduced observance of signs of readiness in the child before training was to start.4Child-oriented gradual training focuses on toilet readiness, advising parents that a child should be allowed to experiment and become comfortable with different aspects of independent toileting behavior as the child's interest and ability allow.2 Intuitive support of child-oriented gradual training has derived from observations that most children trained in this way eventually become independent toileters without experiencing major problems. Brazelton conducted the largest toilet training survey in the United States in a retrospective chart audit for the 10-year period, 1951–1961, on 1170 children of well-educated parents in Boston, MA.2 In reviewing the children's records, Brazelton reported that 26% of the parents said that their children achieved daytime continence by age 24 months and 52.5% by age 27 months. By age 30 months, this figure rose to 85.3%, with 98% of the children reportedly trained by age 36 months. Initial success (defined as an understanding of the use of the toilet rather than full mastery of toileting) reportedly was achieved with bowel training first in 12.3%, and with bladder training first in 8.2% of the children, with the remainder achieving initial success in both systems simultaneously.2 The high rates of success of this method compared with those from earlier studies were associated with a fairly rapid training time (average ages of initiation and completion of training were 24 and 33 months, respectively) as well as by a low long-term regression rate (1.4% at age 5 years).2 These results must be balanced with the fact that many parents underestimate the age at which a child completes toilet training as well as the amount of time it takes to become completely continent.6,7A crucial way in which child-oriented gradual training deviated from previous toilet training approaches was to delay training onset until age 18 months. Brazelton proposed using a group of physical and behavioral parameters of toilet readiness that included voluntary control over bowel and bladder reflex actions (expected to emerge at age 9 months), ability to cooperate with training (expected to emerge at age 18–24 months), and sufficient neurologic development to transfer some of the developmental energy required for walking and other gross motor tasks to be used in the mastery of toileting behavior (expected to emerge at age 18 months).2 Brazelton traced the notion of “sufficient neurologic development” to the complete myelinization of the pyramidal tracts; a subsequent review qualified that although it is impossible to assess myelinization directly, this probably is present by the time a child walks (normally by age 18 months).8The readiness parameters designed by Brazelton have been widely accepted as a convenient base on which the practitioner can encourage and support the child's goal and parent's expectations. These insights have been supported over the years by continued informal observations that have shown signs of maturational toilet readiness after 18 months. Furthermore, signs of fully developed bowel and bladder continence were not recognized until 2 to 3 years of age, regardless of when toilet training was initiated.8 In a 1993 sampling of 1192 American children, Bloom reported a similar mean age (2.4 years) for achieving bowel and bladder control, as described by Brazelton.7Structured-behavioral training first emerged during the 1960s and 1970s and has been accepted as a viable approach to toilet training.9 This approach was popularized in 1971 by the Azrin-Foxx method for teaching bladder control, which appeared as a series of research articles on toilet training a population of institutionalized mentally disabled adults and, later, normal children. They subsequently published outcome research on the treatment of nocturnal enuresis in the same population.10In 1974, Azrin and Foxx published a full protocol description in the spuriously titled popular book, Toilet Training in Less Than a Day.11 The book was based on empirical observations gained from the authors who toilet trained 34 normal, healthy children. The children were trained within a mean time of 3.9 hours, with a 97% decrease in accidents during the first posttraining week.12,13 Although the book's title emphasized the speed of training, there were numerous cautionary statements throughout the book that alerted readers to circumstances that might not permit a speedy, successful response.The Azrin-Foxx method derives from an applied behavior analysis of toilet training in which they identified a number of component skills that could be taught to a toddler. Using this approach, a child would be toilet trained once all the component skills were learned.11,12,14 Although Azrin and Foxx's protocol is a parent-oriented approach that is specific to bladder training a child. The principles behind it have been applied successfully to bowel training as well.15 The theoretic antecedent of structured-behavioral training was the applied behavior-analysis movement of the 1960s and 1970s, an approach that became popular when the then-dominant model for training a wide variety of behaviors was extrapolated to toilet training. The applied behavior-analysis model was a vast improvement over the conditioned stimulus response or operant-conditioning model that emphasized strictest regularity and made no allowances for deviations or failures.4Modern structured-behavioral theory emphasizes active participation by the child in learning to distinguish appropriate elimination stimuli. The now widely popularized method of applied behavior analysis has been compared favorably with other methods and has been used to document the efficacy of the component approach more than any other method.1416–20 However, all these versions use the same four basic protocols: increased fluid intake, regularly scheduled toilet times, positive reinforcement for correct elimination, and overcorrection for accidents.14Although these components have some advantages in gradual training, they are not as favorable in the structured-behavioral model.12 Quick elimination of inappropriate toileting behaviors could reduce compulsive parental pressure, but if enforced too quickly or strongly, it could lead the child to regress rather than face failure or conflict. Moreover, the overcorrection component is unsuitable for unsupervised caretakers, particularly with very young children or where there is a likelihood of physical abuse.15 Structured-behavioral training presents obvious practical barriers for children who cannot tolerate increased fluid intake, such as those with heart or renal disease, and may be impractical in situations where a specialized trainer is not readily available.14 Because the Azrin-Foxx method is based on a stimulus-control model, there is always a risk of inadvertently conditioning the child to perform incorrect behaviors, such as when a child learns to avoid the toilet (because it might be a foreign sensation to the skin) or learns the wrong behavior (eg, wetting in clothing or on the floor) simply because it happens more often than does the correct behavior.14 Variants of the Azrin-Foxx method utilizing systematic manipulation of the positive discriminative stimulus for accidents (eg, the underpants) may be the most logical way to train children with mental disabilities or behavior problems, or in other settings that make learning toilet skills difficult.14In addition to widespread acceptance of the method itself, the Azrin-Foxx model has made an important contribution to the contemporary concept of mature toileting. Clinical recommendations since midcentury, primarily in response to the momentum created when Spock, Brazelton, and other authorities first advocated the concept of readiness, have been to pace toilet training according to the child's capacity for independent toileting. Azrin and Foxx were among the first researchers to draw on these earlier insights used to define the components of independent toileting. The impetus for this effort was the recognition that in addition to evaluating when to begin training, it also is important to evaluate when a child can carry out complex discriminations and motor patterns that go beyond simply eliminating at the proper times.9 Parents might define completed toilet training as the child's ability to avoid bowel and bladder accidents most of the time, but Western culture also requires that children restrict elimination to socially acceptable sites, adopt proper postures for eliminating (including dressing and undressing and closing the bathroom door), and use appropriate sanitary measures, including flushing toilets, using toilet tissue, and washing hands.9The chronologic disparity between initial success and toilet mastery may be reflected in the fact that parents tend to misjudge the age at which a child completes training as well as the amount of time required for toilet training (which averages 5.8 months and 6.4 months for bladder training in females and males, respectively, and 6.3 and 6.9 months for bowel training).6,7,21 It also was widely recognized by the 1970s that a child's cognitive ability to assimilate the learning tasks for independent toileting compensates for the lack of full bladder maturation, which usually does not appear until age 4 years.1,22Thus, it became important to describe how children prepare for independent toileting behavior as well as to define the components of independent toileting. In 1973, MacKeith and colleagues a developmental timeline over which children this reported that became of their accidents and to be to to and to distinguish between and age children also their to although often not in time to go to the By age to 3 children their elimination and in time to be to the at this age also may go to the toilet but they may become and to By age children the of toileting including using the bathroom and the 1974, Azrin and Foxx detailed the specific components in independent toileting and the behavioral and physiologic components of readiness for these a practical this provided with empirical for a child's progress toilet on this has Azrin and Foxx's two major components of physiologic readiness continence and physical and readiness this bladder readiness is defined as control over bladder and the therefore at a time, remain for hours at a and are of their to readiness also sufficient to carry out the physical components of independent the ability to from to and and for 5 to at a of toilet readiness include the cognitive ability to and adopt mature toileting as well as the to use these In their book, Azrin and Foxx described a method to readiness by a child can perform at of actions on of these actions include to and walking to a with a a and familiar in a This was the first use of objective that parents could use to their children in readiness for toilet constructs of independent toileting and readiness that no two children train on the same and that there are physical and behavioral to when a child is ready to toilet parents to and on these requires the health care professional to the individual child's response to training, in the of the child's age, as well as of with parental It can be that children not a to cooperate or an ability to an active in achieving toilet training until they are at to 18 months there may be signs that a child has not to bladder and bowel control and that an to toilet train is probably regardless of a child is not ready for toilet training by age months, one practical approach is to an 3 This from training a that from for independent which in turn would or the of behavioral (eg, chronic and that tend to and research were as a of Azrin and Foxx's because it taught other researchers to include children who were disabled or often from their is the with the widespread use of day care example, one review out that some disabled children not independent toileting even after the most complex endpoint-oriented training and that these children regress when they a specialized training and are to their normal Moreover, a normal child who has achieved toileting skills still may have for this could be that the toilet is too clothing is to a in is an or are created by situations to the toilet learning such as a family a or child care or a family In such it would be inappropriate to training to toileting a from training or training which the for toilet use and may be all that is for toilet training also in and between and as well as in a child's ability to to on the age of toilet training onset and completion that the age at which initial readiness signs appear (ie, voluntary control and at some of interest in eliminating on the toilet or is similar for and However, it has been shown that tend to complete toilet training than when and training, but for mastery of toileting the by are more by whereas more on physiologic It is that who training earlier because can for (ie, control over as an to parental for In toileting mastery to be more to of (ie, the child's ability to in time to such that earlier onset of training because of parental does not earlier completion of training. This could be supported in of the among and may more complex and behavioral (eg, of postures for that to in empirical of a child's toilet readiness becomes particularly when parents have or lack of control over the toilet training process and the child's in this In some of these a child many readiness for toilet mastery but has a chronic health that parental of the child ability to fully to training. parental with respect to the time to toilet train is by of for the training is one more that the should not have to In some the of toilet training does not even to parents with the many of the child's that toilet training is a more crucial developmental milestone for the child with chronic than it is for the healthy and that it is important to the best time for toilet training for children as for their on it is that all ready children who have no physical or conditions that toileting begin training the age at which full bowel and bladder control to (normally to 3 parameters are for as for other children, whereas the of of bowel and bladder voluntary bowel and bladder control, of and appropriate and skills are considered when the empirical parameters of toilet readiness are the same for and normal children, the of chronic that the care provider the to which the child is in toilet training and, the to which the parents are to begin the Moreover, a child may time to and more and from the care provider and parents in the of In child and parental toilet training readiness, the health care provider to the many and in which chronic can with appropriate timing and of example, and that cause and in obvious with whereas and can be but of or may a child's or ability to cooperate with of also can cause for the child's success with components of toilet The may cause or during its or of can both the child and the parents the child may have that training in one or normal of readiness, such as in the child with a renal who has the sensation of bladder children often have developmental in motor physical or cognitive as well as other physical that can independent In the best time to train children, the health care practitioner not to and associated with chronic illness, but also to evaluate the child's positive to independent skills at the appropriate time, particularly if the developmental in other such as gross motor and physical day care settings practical issues with respect to and control over the toilet training to a by the in participate in toilet training. to this of American children than age 5 years regularly care, of which is conducted of the day care, which and other child care as well as day care of young children. This group not is the in institutionalized care but also one that more and than of training of have not been able to with the increased of children these systems because of and training long hours, and that often are than the to for A day care for example, may many children who are toilet training but who not and during their training. is the to toilet training in day care more obvious or than in the of and particularly in of that young children are the common in these the of child care many can be a powerful on toilet readiness as to make training in all of institutionalized children to parental pressure, they to to toilet training and, as with parental has been to maturational In the most common children who are in have an to who are 3 and therefore are to and many toileting However, day care authorities that some children may specialized with toilet training, as in the of the child who does not readiness to the same as other children of the same of children in day care differently to parental control contribution to the toilet training process. parents to training, particularly if their child to remain in day care, a situation that can and toilet training practice and the child from to any example, parents may a child in training at although the child in day care, or parents may the child to use the toilet at even although the child is to a in day In this the child may not become trained on parents may too training responsibility to the day care parental many for appropriate timing of toilet training. avoid such a the parents and the to or issues with the child's toileting and popular training used by many parents is to the child to become of and wetting a is for day care first is to avoid clothing and bathroom are particularly with to and of clothing and training and as favor children in to avoid the of and children undressing themselves of children the to become of their and wetting parental in toilet training can also lead to with and problems. example, both may that the child at or at the and the child as a and chronic when parents with their child's toilet training and with the day care can be a child's best “window of opportunity” for toilet training, the health care practitioner is with useful concepts of toilet readiness and independent concepts that are based on two widely accepted approaches to training and supported by of clinical However, many practical from and also on parents and have on training timing and The health care professional to recognize these from the and and advice for appropriate toileting behavior within that to the Objective guidance on toilet readiness is an component of and actions for successful toilet training for children.