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PubMed1991

Advising parents on toilet training.

Toilet training is a potential source of anxiety for parents and children. The proper approach to toilet training involves an assessment of the readiness of both the child and the parents. Parents should have a realistic idea of the chances of success, and they must be patient and supportive. The majority of children are completely toilet trained by two and one-half years of age. Physicians should initiate discussions about toilet training with parents when a child is 12 to 18 months of age.

Child, Preschool↗
PubMed1997

Toilet training and toileting refusal for stool only: a prospective study.

OBJECTIVE: To determine the incidence of toileting refusal for bowel movements and its outcome when toilet training children using a child-oriented approach. DESIGN: Prospective study. SETTING: Private suburban pediatric setting consisting of middle and upper middle class families. METHODS: Healthy children between 18 and 30 months with no signs of developmental delay were enrolled in the study. Parents were given questions regarding their child's toilet training and behavior. Families were followed every 6 months during an office visit or by phone call until the child was successfully day time toilet trained. RESULTS: A total of 482 children (255 males) completed the study. There were 106 children (54 males) (22%) who experienced at least 1 month of stool toileting refusal. There was an association between the presence of younger siblings (P = .023) and parental inability to set limits for the child (P = .017) and stool toileting refusal. Stool toileting refusers trained at a later age than the rest of the group (P < .0001). Fifty percent (22/44) of the children who trained between 42 and 48 months and 73% (8/11) of the children who trained after 48 months experienced stool toileting refusal. Sixty-one of the study children developed stool withholding during toilet training. Forty-nine (80%) of these children were stool toileting refusers (P < .00001). In 77 (73%) of the children no intervention was undertaken. Of these, the behavior lasted more than 6 months in 20. Intervention was undertaken with 29 children, either because of severe stool withholding (23) or the age of the child (6). Interupting toilet training and having the child return to diapers resulted in the child spontaneously using the toilet for bowel movements within 3 months in 24 of 27 children. CONCLUSION: Stool toileting refusal occurred in one in five children in this study population. Two behaviors associated with stool toileting refusal may require the intervention of the pediatrician. The first is stool withholding causing constipation which can result in rectal impaction and primary encopresis. The second is lack of successful toilet training by 42 months of age. A child who is still untrained at this late age can be a source of family conflict and stress requiring the advice and support of the pediatrician.

Behavior Therapy↗
PubMed1990

Epidemiologic aspects of toilet training.

Toilet training is becoming an increasingly important child care issue as child raising becomes an institutional enterprise. This paper reviews the literature of the last 40 years, focusing on the epidemiology of the development of day and night bladder control. The studies indicate that bladder control is usually obtained between 24 months and 48 months of age. Many variations exist between studies, especially the endpoint used to indicate completion of training. Modifying the endpoint used and the related training practices could decrease the age at which children are trained.

Child, Preschool↗
PubMed2004

During toilet training, constipation occurs before stool toileting refusal.

BACKGROUND: Previous studies demonstrated that constipation and painful defecation are associated with stool toileting refusal (STR), but whether they are the result of STR or occur before this behavior is not known. OBJECTIVE: To determine whether constipation and painful defecation occur as a result of STR or occur before STR. METHODS: Three hundred eighty children between 17 and 19 months of age participated in a prospective longitudinal study of toilet training. Children were monitored with telephone interviews every 2 to 3 months until the completion of daytime toilet training. Information obtained in follow-up interviews included parents' reports on the presence and frequency of hard bowel movements, painful defecation, and child toilet training behaviors. Children were defined as completing daytime toilet training when they were experiencing <4 urine accidents per week and < or =2 episodes of fecal soiling per month. Children were defined as having frequent hard bowel movements if the parents reported a hard bowel movement approximately once per week in > or =2 follow-up telephone interviews or more than once per week in 1 follow-up telephone interview. RESULTS: The mean age at the completion of daytime toilet training was 36.8 +/- 6.1 months (range: 22-54 months). Ninety-three children (24.4%) developed STR. Parents of children who developed STR, in comparison with the rest of the sample, were more likely to report that the child had experienced hard bowel movements (67.7% vs 50.9%), frequent hard bowel movements (29.0% vs 14.3%), and painful defecation (41.9% vs 27.9%). Of the children who experienced both STR and hard bowel movements, 93.4% demonstrated constipation before the onset of STR. In that group, parents reported hard bowel movements at almost one-half of all follow-up telephone interviews before the onset of STR. Of the children who experienced both STR and painful defecation, 74.4% experienced the first episode of painful defecation before the onset of STR. Children with frequent hard bowel movements demonstrated a longer duration of STR (9.0 +/- 6.5 vs 4.8 +/- 3.0 months). CONCLUSIONS: When hard bowel movements or painful defecation is associated with STR, the first episode of constipation usually occurs before the STR. The fact that hard bowel movements frequently occur before the onset of STR suggests that for many of these children constipation is a chronic problem that is not being treated effectively. Therefore, hard bowel movements and painful defecation are factors that potentially contribute to the STR and for the majority of children are not caused solely by the STR behavior. Additional studies are needed to determine whether earlier and more effective treatment of constipation could decrease the incidence of STR.

Child Behavior↗
PubMed1982

Toilet training and enuresis.

Toilet training is often taken for granted because it appears to occur so readily in such a large majority of children. It would be easy to hypothesize some internal mechanism which, if triggered at the right point in time, results in the initiation of a preprogrammed process that terminates with the child being trained. Variations across cultures regarding the age at which children are trained, the multitude of training procedures used by parents, and the variety of problems encountered during toilet training suggest that such is not the case. Toilet training has not been the focus of extensive systematic research as incontinence appears to impose no immediate or uncompromising physical threat to the child. Our apparent insensitivity to the emotional and psychological discomfort is perhaps highlighted by our rather cavalier attitude regarding the necessity of treating the younger (6 to 10 year old) child. Enuresis takes on added significance to the extent that it seems to be the symptom of some underlying neurologic or urologic abnormality. Once the enuresis is determined to be functional in nature, we are often satisfied with allowing the child and family to deal with the matter on their own and to return if the problem persists into adolescence. If treatment is begun at an early age, it seems to have a greater chance of success with fewer complications. It need not be particularly time-consuming once an adequate assessment has been carried out. Nurses, paraprofessionals, mental health technicians, and so forth, can be trained and utilized effectively in following the process of the parent and child. A compassionate, understanding, and systematic approach encourages compliance and patients on the part of the child and parents.

Behavior Therapy↗
PubMed1994

A stimulus control technique for improving the efficacy of an established toilet training program.

Standard toilet training regimens used with children with developmental disabilities have demonstrated effectiveness at achieving bladder and bowel continence. However, in some clinical applications in everyday practice, success has not been achieved, necessitating research into possible modifications of the current approaches. A widely used toilet training program was modified to reduce toileting accidents of a referred child. The modification involved the assessment of the discriminative stimulus for eliminating, namely, his undergarments. By removing the undergarments when an elimination became imminent, an "errorless" learning paradigm was established that allowed for more rapid and enduring acquisition of toileting skills than seen in previous training attempts. The results indicate the present procedure could expedite training for individuals who are difficult to teach appropriate toileting skills through an analysis of the controlling antecedent stimulus for accidents and subsequent manipulation of such stimuli.

Autistic Disorder↗
PubMed1998

A group treatment approach to failure to toilet train: the case of Max.

Toilet training is a major developmental milestone for children and parents. Accurate statistics on the prevalence of toilet-training failure do not exist; however, it is estimated that approximately 4% of 4-year-olds are not bowel trained. A number of biopsychosocial and developmental factors can interfere with toilet training. Frequently, a cycle of withholding and constipation with painful bowel movements and/or overflow incontinence ensues. A case study of a 4-year-old boy with encopresis and pervasive developmental disorder will highlight an interdisciplinary team's approach to helping children (4-6 years old) toilet train. Along with individual patient care management, parents and children attended (separately) a six-session medical and psychoeducational group called "Toilet School." This group model employs the principles of behavior modification, the concepts of children's preoperational thinking, and a philosophy of care that values collaborative relationships between caregivers and families.

Autistic Disorder↗
PubMed2004

Why is toilet training occurring at older ages? A study of factors associated with later training.

Recent studies suggest that children are completing toilet training much later than the preceding generation. Our objective was to identify factors associated with later toilet training. Children between 17 and 19 months of age (n=406) were enrolled in the study. At enrollment, parents completed the Parenting Stress Index and the Receptive-Expressive Emergent Language Scale. Follow-up parent interviews were conducted every 2 to 3 months until children completed daytime toilet training. Information obtained at follow-up interviews included steps parents were taking to toilet train their child, child toilet training behaviors, presence and frequency of constipation, birth of a sibling, and child care arrangements. In a stepwise linear regression model predicting age at completion of toilet training, 3 factors were consistently associated with later training: initiation of toilet training at an older age, presence of stool toileting refusal, and presence of frequent constipation. Models including these variables explained 25% to 39% of the variance in age at completion of toilet training. In conclusion, a later age at initiation of toilet training, stool toileting refusal, and constipation may explain some of the trend toward completion of toilet training at later ages.

Age Factors↗
PubMed2003

Relationship between age at initiation of toilet training and duration of training: a prospective study.

OBJECTIVE: To study the relationship between age at initiation of toilet training, age at completion of toilet training, and the duration of toilet training. METHODS: A total of 406 children seen at a suburban private pediatric practice were enrolled in a study of toilet training between 17 and 19 months of age, and 378 (93%) were followed by telephone interviews with the parents every 2 to 3 months until the child completed daytime toilet training. Information obtained at follow-up interviews included how often parents were asking their child to sit on the toilet or potty and where the child urinated and defecated. Parents were considered to have initiated toilet training when they first took out a potty chair and discussed some aspect of training with the child. Intensive toilet training was defined as asking the child to use the toilet or potty >3 times per day. RESULTS: Age of initiation of toilet training correlated with age of completion of training (r = 0.275). The correlation between age at initiation of intensive training and age at completion was even stronger (r = 0.459). Younger age at initiation of intensive toilet training was not associated with constipation, stool withholding, or stool toileting refusal. However, age at initiation of intensive toilet training was negatively correlated with duration of toilet training (r = -0.481), indicating that initiation of training at younger ages was associated with a longer duration of training. In addition, the correlation between age at initiation of intensive toilet training and age at completion of training was not significant for those who began intensive training before 27 months of age (r = 0.107). CONCLUSIONS: Early initiation of intensive toilet training correlates with an earlier age at completion of toilet training but also a longer duration of toilet training. Although earlier toilet training is not associated with constipation, stool withholding, or stool toileting refusal, initiation of intensive training before 27 months does not correlate with earlier completion of toilet training, suggesting little benefit in beginning intensive training before 27 months of age in most children.

Age Factors↗
PubMedDate not supplied

Control issues in toilet training.

There are many control issues surrounding toilet training that involve the child, the family, and the environment. Loss of control by the child during this period can result in significant physical and psychologic consequences as well as a failure to complete the developmental task of autonomy. A review of both professional and lay literature showed various approaches to toilet training with little reference to the control issues involved. Toilet training is a dynamic process that does not always go smoothly. Constipation often develops during toilet training and may be related to control issues. Neuman's Systems Model is used to identify the types of control issues often involved in toilet training. Anticipatory guidance specifically developed to address issues of control may help alleviate problems in the toilet training process. Changes for current practice are recommended.

Child, Preschool↗
PubMed1994

Behavioral toilet training in early childhood: research, practice, and implications.

The process of toilet training children has received surprisingly little attention in the medical research literature, and many parents may welcome guidance from their physician on how best to carry out this important parental duty. Theory and prescription for toilet training in the United States since 1900 has traced a pendulum's path between the polar opposites of passive permissiveness and systematic control. Since midcentury, the trend in the United States has been toward delayed toilet-training, typically between the child's second and third year. Like all trends, however, this one may reverse. Given children's developmental differences, a new trend toward early toilet training, if it emerges, may be accompanied by an increase in toilet-training problems. If so, physicians who advise parents and treat pediatric populations may wish to become more familiar with data-based behavioral management of toilet training and the implications of this approach for early toilet training and the treatment of toileting-refusal behavior.

Behavior Therapy↗
PubMedDate not supplied

Factors associated with toilet training in the 1990s.

CONTEXT: Few studies have systematically evaluated the factors influencing toilet training in children with normal development. OBJECTIVES: To determine those child, parent, and environmental factors associated with toilet training completion, focusing on the influence of the child's temperament and development. DESIGN AND SETTING: Cross-sectional descriptive study of normal children, ages 15-42 months, attending 1 of 4 pediatric clinics in Milwaukee in 1995 and 1996. METHODS: Demographics for child, parents, and household were surveyed. Temperament was assessed using the Toddler Temperament Scale and the Behavioral Style Questionnaire. Child development was measured using the Bayley Scales of Infant Development II. MAIN OUTCOME MEASURE: Toilet training status was by parental report and was categorized as not trained, not currently training, in training, or training complete. RESULTS: The study population included 496 children, comprising 219 that had not started training, 70 that were not currently training, 148 that were in training, and 59 that were completely trained. The ages at which 50% of the children were predicted to be toilet trained were 35 and 39 months for girls and boys, respectively. In the multivariate regression model, statistically significant factors best predicting toilet training completion were older age, non-Caucasian race, female gender, and single parenthood. Temperament, development, maternal employment, or use of day care were not statistically significant factors. CONCLUSION: Innate factors such as older age, non-Caucasian race, and female gender are the best predictors of completing toilet training (rather than a child's temperament and developmental stage). Day care and maternal employment appear to be unimportant variables. Parents should not be discouraged, because children are completing toilet training at older ages. Research is needed to discover why single parents are more successful at toilet training.

Age Factors↗
PubMed1992

Behavioral management of toilet training, enuresis, and encopresis.

Toileting problems are a matter of great concern to parents and are a frequent source of family discord, but proper handling of toilet training as well as enuresis and encopresis can ameliorate any untoward effects of these problems. Both the pediatrician and the pediatric psychologist can play a major role in this area.

Behavior Therapy↗
PubMed2003

Children who hide while defecating before they have completed toilet training: a prospective study.

OBJECTIVE: To examine the incidence and age at onset of hiding while defecating in children before they have been toilet trained and its association with difficulties in toilet training. DESIGN: Prospective study. SETTING: Suburban private pediatric practice. Subjects Three hundred seventy-eight children aged 17 to 19 months. METHODS: Children were followed up by telephone interviews with the parents every 2 to 3 months until the child completed daytime toilet training. Children who were described at any follow-up telephone call as always or almost always hiding when defecating prior to completing toilet training were defined as the hiding group. The remainder of the children, who were described as never hiding or only sometimes hiding, was defined as the nonhiding group. RESULTS: Two hundred sixty-three children (69.6%) met the criteria for the hiding group. The median age at initiation of hiding for the group was 22 months. Thirty-eight began hiding before toilet training was initiated and 64 started hiding after intensive toilet training had begun. The nonhiders (115 [30.4%]) were significantly less likely to have stool toileting refusal, frequent constipation, or stool withholding. They also completed toilet training at an earlier age than the hiders (34.5 +/- 5.9 months vs 38.1 +/- 5.9 months; P<.001). CONCLUSIONS: The behavior of hiding while defecating before completion of toilet training is associated with stool toileting refusal, constipation, and stool withholding. These behaviors may make toilet training more difficult.

Case-Control Studies↗
PubMedDate not supplied

Investigation of a reinforcement-based toilet training procedure for children with autism.

Independent toileting is an important developmental skill which individuals with developmental disabilities often find a challenge to master. Effective toilet training interventions have been designed which rely on a combination of basic operant principles of positive reinforcement and punishment. In the present study, the effectiveness of a reinforcement-based toilet training intervention was investigated with three children with a diagnosis of autism. Procedures included a combination of positive reinforcement, graduated guidance, scheduled practice trials and forward prompting. Results indicated that all procedures were implemented in response to urination accidents. A three participants reduced urination accidents to zero and learned to spontaneously request use of the bathroom within 7-11 days of training. Gains were maintained over 6-month and 1-year follow-ups. Findings suggest that the proposed procedure is an effective and rapid method of toilet training, which can be implemented within a structured school setting with generalization to the home environment.

Autistic Disorder↗