Materials for this week:
- Case and discussion, originally written by Dr. Heather McPhillips
- Toilet Training: Common Questions and Answers, Amer Fam Phys, 2019 and In Brief from Pediatrics in Review
- Toilet training from kidshealth.org with a helpful embedded video about the process for parents
- Article reviewing toilet training tips for children with Autism Spectrum Disorder and a toilet training guide from Autism Speaks
- Fascinating CNN article featuring toilet training around the world – spoiler: there’s a huge range! (more below)
Take home points on toilet training:
- Why has the age of toilet training changed in the US? Toilet training in the US has moved later in toddler years (combination of factors including availability of better disposable diaper options, children in child care settings, and cultural norms/approach to training). Average age at which toilet training begins has increased from earlier than 18 months to between 21 and 36 months. Worldwide in countries without access to diapers or machine washing, infants as young as 4-6 months can be taught through “elimination communication” or “assisted infant toilet training” where parents watch facial cues and hold children over a toilet, often training with a specific sound,, with minimal to no diapers. I’ve had a number of families toilet train children earlier and support that approach if the family chooses, especially given the cost and environmental impact of diapers.
- How does starting earlier affect the length of time to potty train? Generally the earlier that children start, the earlier they complete it, though it may take longer to fully potty train. On average, female children usually begin and complete toilet training about 2-3 months before male children in the US.
- What is the most commonly used approach in the US? The child-centered toilet-training approach is most common. As described by Dr. Barry Brazelton and recommended by the AAP, this approach suggests that children are more likely to be developmentally ready after 18-24 months. This approach follows the child’s lead, looks for developmental readiness cues and provides positive encouragement for attempts at toilet training but avoids forcing / coercing or any negative comments. Studies highlighted above have shown that children raised in other countries potty train much earlier, like France, where 2 years old is more normative. We in the US probably have among the latest age for potty training (and also a bigger environmental impact, as many now acknowledge).
- What’s the “train in a day” type approach? As described by Azrin and Foxx, this potty training “bootcamp” is often done in a dedicated day/weekend using an operant conditioning model with positive reinforcement and negative reinforcement for accidents. One element of the “bootcamp” we found helpful at our house was to set a “potty timer” to remind when to go make an attempt-about every 30-60 minutes to avoid accidents (families can start with more frequent then gradually spread them out).
- What’s the evidence behind different approaches? Both of the most common approaches have been shown to work in practice to effectively teach typically developing children how to potty train. As above, given the different approaches used around the world, clearly all can be effective in context. Pediatricians who have experience with elimination communication are now advocating for more broad discussion and adoption of this approach, as well as those exploring options for reducing environmental impact. We can help explore with families what they are comfortable with trying in their home.