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When is the best time to start toilet training?
According to the research, the “sweet spot” for toilet training seems to be between 27 to 32 months for most children. However, every child is different, and you should base your timeline on your child’s individual signs of readiness (staying dry for longer periods of time, seeming uncomfortable with soiled diapers, interest in the toilet or wearing underwear, and ability to follow simple instructions).
Research has found that children who are trained at younger ages (in this case, before 27 months) are no less likely to experience accidents or stool refusal than children trained after 27 months. However, this study also found that the younger a child is when beginning the process of toilet training, the LONGER the process will take to complete. More specifically, children who started toilet training between 18 to 24 months took 13 to 14 months on average to complete training, while children who started toilet training after 27 months took 10 months or less on average to complete training.
Another line of research has found that children trained at older ages may also have difficulty with toilet training. In particular, children who are trained after 32 months may be more likely to have accidents and difficulty with toilet training.
What is the most effective method for toilet training?
Anyone who has googled “potty training” will find books and websites which claim to know the ONLY effective method for toilet training your child.... But is there any research that actually supports these claims?
Surprisingly, a systematic review of toilet training conducted by the Agency for Healthcare Research and Quality (AHRQ) found that research on this topic is extremely limited. The big take-away message is that there is NO strong research evidence for a “right” way to toilet train.
However, the authors did find evidence that the Child-Oriented method and Azrin & Foxx’s method of toilet training resulted in effective toilet training for most typically developing children.
Both methods suggest that parents toilet train between 2 and 3 years of age but otherwise the methods are very different. The Child-Oriented approach is designed to be gradual and led by the child, while Azrin & Foxx’s method is intensive and led by the parents.
The Child-Oriented approach (developed by Dr. Berry Brazelton in 1962) is a gradual approach that lets the child decide when they are ready to use the toilet. It involves showing your child the potty and modeling toileting for them. The parent allows the child to sit on the potty wearing clothes with no pressure. After a few weeks of this, the parent then empties a diaper into the toilet to help them to understand where the diaper contents are meant to go. The parent then removes the child’s diaper and pants for short time intervals and the child is encouraged to use the potty whenever they need to (the potty should be near the child at all times).
If the child successfully uses the toilet, the parent calmly praises them. If the child continues to be successful the parent would then put the child in training pants so they can use the potty independently. Throughout this process, the parent praises any success and avoids criticism. For more information, you can find the book (Toilet Training: The Brazelton Way) on Amazon and other book retailers.
The Azrin & Foxx method (developed in 1973) is a parent-led approach that is designed to be more intensive and quicker than the Child-Oriented approach. This approach involves putting the child immediately in underwear, encouraging the child to drink lots of liquid, showing the child what to do on the toilet by using a doll, providing consistent rewards and praise for every step along the way to successful toileting, prompting the child to regularly try to use the toilet, and guiding the child to the bathroom after an accident. For more information, you can find their book (Toilet Training in Less Than a Day) on Amazon and other book retailers.
However, research does suggest that regardless of what method you choose, it is important to stay positive and reduce shame for children. A very interesting study found that a more positive approach may reduce the time it takes a child to toilet train. In this study, some parents were randomly assigned to an intervention in which they were taught to praise the child for having a bowel movement and to avoid using words to negatively refer to defecating (such as “stinky”, “gross”, etc.). The parents who used this more positive approach had children who completed toilet training more quickly than parents who were not taught this approach.
In summary, there is no single “right” method to toilet train according to the research. Feel free to choose whatever method seems best for your child and how your household operates.
Why do some children struggle with toilet training? What might predict whether your child will have difficulty with toilet training?
Research finds that most children typically begin toilet training sometime between 21 to 36 months and only 40 to 60 percent of children are fully toilet trained by 36 months. So, if your child is struggling with toilet training, know that you are not alone!
Research has found that difficulty with toilet training has been associated with the following: the presence of younger siblings during toilet training, parents with difficulty setting limits, and training at an older age (after age 3).
Wondering if there is any truth to boys having more difficulty with toilet training than girls? There is actually some science to back up this parenting myth. Research finds that girls are typically toilet trained 2 to 3 months before boys (32.5 months vs. 35 months) and they begin showing readiness signs 2 months before boys (24 months vs. 26 months).
Finally, if your child continues to struggle with toilet training, check with your pediatrician to be sure that there are no underlying medical issues. Research shows that children with lower urinary tract symptoms are more likely to be toilet trained at a later age. In addition, hard and painful bowel movements have been found to be associated with “stool toileting refusal” behavior (refusing to have a bowel movement on the toilet), a condition which impacts up to 1 in 4 children. Improving your child’s diet and fluid intake may help in this c
What about nighttime toilet training?
Research finds that most children are not developmentally capable of remaining dry at night until 4 or 5 years old. A large study found that about 30% of children experience bedwetting at 4.5 years and about 9.5% still experience it at 9.5 years. Research has also found that children attain nighttime dryness an average of 10 months after achieving daytime dryness,
However, if your child continues to struggle with nighttime toilet training after the age of 5 years, you might want to try some strategies to help your child to stay dry at night. The easiest strategies to try are waking up your child to use the bathroom before you go to bed yourself and limiting fluid intake before bedtime. If those strategies do not work, a great evidence-based strategy is an alarm which wakes your child up when they start urinating. One of the most common of these alarms is called TheraPee, which you can find on Amazon and other online retailers. Six randomized controlled trials (the “gold standard” of study designs) have found that bedwetting alarms are very effective in helping children to stay dry at night. Specifically, these studies have found that 77% of children using these alarms are able to stay dry for 14 nights in a row, while only 2% of children in the study without these alarms had 14 dry nights in a row. Children in these studies ranged in age from 8 to 10 years and the treatment lasted between 10 to 20 weeks.
A hormone treatment referred to as desmopressin has also been found to be effective in reducing nighttime bedwetting. A review combining 47 randomized controlled trials found that desmopressin treatment results in 81% of children achieving 14 dry nights in a row (while only 2% of children without the treatment achieved this goal).
Studies find no difference in the effectiveness for bedwetting alarms versus desmopressin (research finds that both methods are very effective). However, the effectiveness of the alarm treatment may last longer, as more children were able to stay dry after treatment was completed with the alarm than with desmopressin. Additionally, desmopressin is associated with serious (but rare) side effects, while the alarm has no side effects (besides potentially disrupting your own sleep!).
References
Blum, N. J., Taubman, B., & Nemeth, N. (2004). During toilet training, constipation occurs before stool toileting refusal. Pediatrics, 113(6), e520-e522.
Blum, N. J., Taubman, B., & Nemeth, N. (2003). Relationship between age at initiation of toilet training and duration of training: a prospective study. Pediatrics, 111(4), 810-814.
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Blum, N. J., Taubman, B., & Nemeth, N. (2003). Relationship between age at initiation of toilet training and duration of training: a prospective study. Pediatrics, 111(4), 810-814.
Barone, J. G., Jasutkar, N., & Schneider, D. (2009). Later toilet training is associated with urge incontinence in children. Journal of Pediatric Urology, 5(6), 458-461.
Bakker, E., Van Gool, J. D., Van Sprundel, M., Van Der Auwera, C., & Wyndaele, J. J. (2002). Results of a questionnaire evaluating the effects of different methods of toilet training on achieving bladder control. BJU international, 90(4), 456-461.
Klassen, T. P., Kiddoo, D., Lang, M. E., Friesen, C., Russell, K., Spooner, C., & Vandermeer, B. (2006). The effectiveness of different methods of toilet training for bowel and bladder control. Evidence report/technology assessment, (147), 1-57.
Brazelton, T. B. (1962). A child-oriented approach to toilet training. Pediatrics, 29(1), 121-128.
Foxx, R. M., & Azrin, N. H. (1973). Dry pants: A rapid method of toilet training children. Behaviour research and therapy, 11(4), 435-442.
Brazelton, T. B., Christophersen, E. R., Frauman, A. C., Gorski, P. A., Poole, J. M., Stadtler, A. C., & Wright, C. L. (1999). Instruction, timeliness, and medical influences affecting toilet training. Pediatrics, 103(Supplement_3), 1353-1358.
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Bakker, E., Sprundel, M. V., Auwera, J. V. D., Gool, J. V., & Wyndaele, J. J. (2002). Voiding habits and wetting in a population of 4332 Belgian schoolchildren aged between 10 and 14 years. Scandinavian journal of urology and nephrology, 36(5), 354-362.
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Butler, R. J., & Heron, J. (2008). The prevalence of infrequent bedwetting and nocturnal enuresis in childhood: a large British cohort. Scandinavian journal of urology and nephrology, 42(3), 257-264.
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UK, N. C. G. C. (2010). Enuresis Alarms in the management of bedwetting. In Nocturnal Enuresis: The Management of Bedwetting in Children and Young People. Royal College of Physicians (UK).
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