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How to toilet train healthy children? A review of the literature

Department of Urology, University of Antwerp, Belgium.
Neurourology and Urodynamics (Impact Factor: 2.87). 03/2008; 27(3):162-6. DOI: 10.1002/nau.20490
Source: PubMed
To review the literature on toilet training (TT) in healthy children.
Through an extended literature search, all data on developmental signs of readiness for TT, TT methods, definitions of being toilet trained, TT problems, and predictive factors for success were reviewed.
Specific studies on this topic are few. Two main methods for TT have been described so far in the last decades: the gradual child-oriented training and the structured, endpoint-oriented training. In the former method parents mainly respond to the child's signals of toileting "readiness". The latter method consists of actively teaching several independent toileting behaviors. Data are too few to be able to compare the methods. Literature does not give a consensus about the optimal age for starting nor on the expected mean age of completing TT. Recent studies show most children to start training between 24 and 36 months of age with a current trend toward a later completion than in previous generations. The consequence of this can be stress for the parents and more use of diapers, with its negative effect on the environment.
There are as yet little data to be found on this important topic, only few studies have been published in peer-reviewed journals. Standardization of terminology and critical evaluation of the described techniques in large sample sizes is needed. With this approach, general principles of training, evidence based and easy to use in the majority of children, may become available to parents.

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Available from: Alexandra Vermandel, Feb 02, 2015
Neurourology and Urodynamics 27:162–166 (2008)
How to Toilet Train Healthy Children?
A Review of the Literature
Alexandra Vermandel,
Marijke Van Kampen,
Chris Van Gorp,
and Jean-Jacques Wyndaele
Department of Urology, University of Antwerp, Belgium
Department of Health Sciences, Division of Occupational and Physical Therapy, Hogeschool Antwerpen, Belgium
Faculty of Kinesiology and Rehabilitation Science, Catholic University of Leuven, Belgium
Aims: To review the literatu re on toilet training (TT) in healthy children. Methods: Through an extended
literature search, all data on developmental signs of readiness for TT, TT methods, definitions of being toilet
trained, TT problems, and predictive factors for success were reviewed. Results: Specific studies on this topic are
few. Two main me thods for TT hav e been described so far in the last decades: the gra dual child-oriented training
and the structured, endpoint-orie nted t raining. In the former method parents mainly respond to the child’s signals
of toileting ‘‘readiness’’. The latter method consists of actively teaching several independent toileting be haviors.
Data are too few to be able to compare the methods. Literature does not give a consensus about the optimal age for
starting nor on the expected mean age of completing TT. Recent studies show most children to start training
between 24 and 36 months of age with a current trend toward a later completion than in previous generations. The
consequence of this can be stress for the parents and more use of diapers, with its negative effect on the
environment. Conclusion: There are as yet little data to be found on thi s important topic, only few studies have
been published in peer-revie wed journals. Standardization of terminology and critical evaluation of the described
techniques in large sample sizes is needed. With this approach, general principles of training, evidence based and
easy to use in the majority of children, may become available to parents. Neurourol. Urodynam. 27:162166,
2008. ß 2008 Wiley-Liss, Inc.
Key words: children; diapers; signs of readiness; toilet training
Toilet training (TT) is one of the challenging aspects of early
It involves a complex integration of neurological,
muscular, and behavioral mechanisms.
Failure of training
can result in significant physical and psychological conse-
quences such as failed autonomy.
Almost every parent participates in TT and therefore it is
surprising that little research has been done so far with only
few evidence-based studies to be found in literature. Parents
do remain with unclear guidance. TT-practice and TT-outcome
continue to be a source of concern for many parents. The
prevalence of toileting problems is significant in the pediatric
population and may be important in the general population as
We reviewed all available literature on TT, including
publications on definitions, developmental signs of readiness,
training methods, TT problems, and predictive factors. The
main attention is given to urinary TT.
A diversity of definitions makes comparisons between
studies difficult and an all-encompassing definition of ‘‘toilet
trained’’ is missing. Also standard definitions related to TT
such as ‘‘success’’ and ‘‘failure’’. There are no strict criteria
stating how long a child must be dry or what components of
the toileting process a child must accomplish independently,
in order to be considered ‘‘toilet trained’’.
Also about a proper age for initiation of TT variation in
definitions makes conclusions difficult. As illustration: Is
training started the moment parents place a potty in the
bathroom or the first time the child is sitting on it? How
many times must a child sit on a potty to be considered having
started actively with training?
During the last 60 years there is a trend toward an older age
of initiating TT.
Sixty years ago, daytime TT was started
mostly before the age of 18 months. Nowadays most children
start training between 18 and 24 months
and intensive
training (child sitting at least three times a day on the potty)
starts at mean 28.7 months.
When questioned about it,
parents themselves positioned the age at which TT should be
initiated at 20.6 7.6 months.
No conflict of interest reported by the author(s).
Chris Winters led the review process.
Master in Physiotherapy.
Professor in Rehabilitation Science.
Professor in Urology and Urological Rehabilitation.
*Correspondence to: Jean-Jacques Wyndaele, MD, DSci, PhD, Department of
Urology, University of Antwerp, Wilrijkstraat 10, B-2650 Edegem, Belgium.
Received 13 May 2007; Accepted 26 June 2007
Published online in Wiley InterScience
DOI 10.1002/nau.20490
ß 2008 Wiley-Liss, Inc.
Page 1
Reasons for later TT may be the introduction of disposable
diapers, more efficient laundry facilities
and the fact that
parents lack time as both go out to work.
Another reason can
be that parents consider their child to be too young to train,
especially if a child-oriented approach is used.
generations, on the contrary, believed strongly in the benefits
of ‘‘drilling’’ and used strict schedules for TT.
TT is ended mostly between 24 and 36 months and almost
in all children at 48 months.
Ideas about the
optimal time for bowel and bladder training do not only vary
among generations, but also among cultures.
A great variety of data have been published comparing age
at onset and duration of TT. Bakker et al.
observed a similar
training time of <6 months for children raised 60 years ago,
40 years ago, and nowadays, although the age of initiation
differed. Using the child-oriented approach, Blum et al.
reported a negative correlation between earlier initiation of
intensive TT and duration of training. Foxx and Azrin
that children of all ages can be trained in an average of 3.9 hr.
Bloom et al.
found an average of 5.8 months and 6.4 months
bladder training in females and males, respectively. Late
ending of TT (at least >42 months of age) was associated with
a later age of initiating TT, lower language score at 18 months,
stool toileting refusal, increased constipation, and hiding to
avoid potty visits during TT.
Lower maternal education,
younger maternal age, lower household income, and the
presence of two or more siblings were (univariate) predictive
for the age of the child at the end of TT.
According to literature, parental expectations for TT are
different in boys than in girls.
Boys would be starting and
finishing training later than age-related girls.
Since 1900, training guidelines in the US have balanced
between a more controlled management and passive permis-
Two major approaches in TT used in Western
societies are the ‘‘child-oriented’’ method of Brazelton and
the Azrin and Foxx method. Both have been proposed by
physicians to parents starting training for the first time.
Other methods include variations of operant conditioning,
assistant infant TT, and the Spock method (a maturation
guided gradual, passive approach). In 1962, Brazelton
described the ‘‘child-oriented approach’’. The basic idea behind
this approach was that children must gently, but systemati-
cally be encouraged to experiment with toileting behavior.
Although recent guidelines of the American Academy of
Paediatrics (AAP)
and Canadian Pediatric Society (CPS)
still based on this approach, no efficacy studies or randomized
controlled trials have been done. It remains uncertain whether
the approach is reasonably successful.
The method proposed by Foxx and Azrin in 1973, on the
other hand, is much more intensive and structured.
This TT
method was presented in a book in 1974 ‘‘Toilet Training in
Less Than a Day’’.
According to Matson
and Butler et al.
the professional supervision is essential to reach success using
the intensive procedure. In both studies emotional side effects
were reported, consisting of temper tantrums, hitting, and
avoidance behavior.
In a RCT by Candelora,
the Azrin and Foxx method was
compared to the Spock method
in 71 healthy children.
Number of accidents, number of successes, and number of wet
mornings were evaluated. The Azrin and Foxx method was
found to be superior to the Spock method in all three
outcomes. Polaha,
investigating current practice and recom-
mendations to parents of normal developing, first-time
learning children, found that the more gradual, passive
approach seems to get more approval of physicians, despite
the lack of evidence.
Less known, but applied for centuries before the Western
methods were described, is the assisted infant TT used in
China, India, Africa, South America, Central America, and parts
of Europe.
De Vries et al.
studied this method in the Digo
people tribe in East Africa. This method indicates that early
training can be effective.
So far, there has been no evidence
that a genetically accelerated development accounts in any
major way for the effectiveness of this early training.
The results seem related mainly to the method itself as shown
by the success in a case study of assisted TT in a Western
The only premise is a very active involvement of the
As a conclusion we can state that although all children
undergo TT, there is only limited research concerning the
effectiveness of different methods, which makes it difficult to
quide clinicians in advising parents on how to toilet their
A description and comparison of the TT methods is given in
Table I.
The relative weight of maturation and of training in the TT
process is still subject for disagreement in the literature. Some
authors are convinced that there is no influence of train-
Largo et al.
found that postponement of TT and
less prompting did not postpone bladder control at day or
night. A recent prospective study showed that an early
initiation of intensive TT (i.e., before 27 months of age)
correlated negatively with duration of training, indicating
that earlier initiation could lead to a longer duration of
A longitudinal survey of Schum
suggests post-
poning the age of maturation related TT start to 2230 months
old, as only 2 out of 11 signs of readiness were reached by girls
and even none of the signs were reached by boys before a
median age of 24 months. These results question the
usefulness of implementing a strict, structured training
programme at a younger age when the maturation of the
child will make such approach perhaps not necessary any-
more at a later age. In contrast with this are the successes seen
in previous generations when strict TT was the custom.
Disadvantages of later training are discussed in several
articles: Problems of hygiene,
skin irritations, and diaper
labour saving effects,
environmental cost of disposable diapers,
refused admission
to preschool,
excessive dependence on the parents,
parental stress, frustration and tension,
spread of
disease (infectious diarrhea and hepatitis A) in day-care
social embarrassment,
and environmental
Developmental signs indicating the child’s readiness for TT
differ strongly between authors and between methods. Foxx
and Azrin
valued physiological readiness and psychological
readiness. The ‘‘child-oriented’’ approach describes the read-
iness of the child as consisting of motor signs, reflex sphincter
Neurourology and Urodynamics DOI 10.1002/nau
Toilet Training in Healthy Children 163
Page 2
control, and psychological signs. Also a tendency for personal
cleanliness and organizing objects in their proper places can
be seen as signs of readiness.
Parents who raised their
children 40 years ago reported a dry afternoon nap as a
readiness sign.
Even nowadays, a dry nap is interpreted as
A longitudinal weekly survey of toileting behavior inves-
tigated the sequential acquisition of TT skills. The earliest
toileting skill would be the understanding of potty-related
words. Following TT skills are more self-help skills, like
‘‘flushes toilet by himself’’, where late TT skills seem to be
more advanced skills, like ‘‘uses a regular toilet’’.
ness of dirty or wet pants, interest in TT, and language and
motor skills are the most important signs of readiness selected
by pediatricians in a questionnaire who examined the
recommendations given by pediatricians to parents of a first
child in Nebraska. A very low response rate limits the value of
the survey.
One can conclude that many different signs of readiness
have been described, adding to a lot of confusion for parents
who need to judge on the degree of maturation of their child. A
variety of factors may affect outcome of TT. In a descriptive
cross-sectional study in 496 children,
the most highly
correlating factor to successful TT was older age, non-Causian
race and female gender.
Similar results were found by Largo
et al.
Imitation of older children
and wearing underwear,
small post-void residual volume at age 6 months or large
bladder capacity
facilitate the development of toileting
skills. Children who avoided having bowel movements in the
potty for more than a month after learning to urinate
consistently in it, completed training at a later age.
TT to a child is most of all an assignment for the parents
and unsuccessful attempts are not to be interpreted as a direct
failure of their competence or authority
nor as a direct
reflection of their parenting skills.
When a child is judged as not ready for TT by age 20 months
and initial training trial is unsuccessful, it is proposed to wait
for an additional 3 months
or even to temporarily abandon
TT and re-establishing trust and cooperation in the child
parent relationship first. According to the CPS, a child should
Neurourology and Urodynamics DOI 10.1002/nau
TABLE I. Comparison Between Different Methods of Toilet Training Described in Literature
TT-methods Intensive-structured approach
Child-oriented approach
The assisted caregiver method
Design . Single cohort/prospective . Single cohort/retrospective . Qualitative data based on
observation and maternal
. Guided training and follow-up
during 4 months
Observation and guidance of
-N ¼ 43 children -N ¼ 1,170 children
Age initiation 20 months 18 months of age Between 2 and 3 weeks
Duration of TT Average 3.9 hr Average 9 months Average 46 months
Age at completion of TT Average 25 months Average 28.5 months As soon as the child can walk
. Operant conditioning caregiver
. The parents must learn the
infant’s evacuation signals
and when they occur the
infant is placed in a special position
Readiness child
. Intensive learning procedure
. Operant conditioning
the child is an active participant
. Gentle but systematically
. Operant conditioning
. The importance of readiness
. A gradual training
. Stimulus control model:
. Increasing fluid intake
. Regularly scheduling TT-time
. Overcorrection for accidents
. Positive reinforcement for
correct behavior
. A relaxed unpressing approach:
never any coercion or pressure
. The importance of timing the
. A gradual introduction of the potty
. Parents must be willing to TT the
child and participate in TT
. Positive reinforcement
. Environmental standards more
determining than
. Toilet trained when child can
. High involvement of the
. Physiological, psychological
. Physiological, behavioral
-periods of dryness
-being physically able to perform
tasks related to TT
-able to follow instructional
. Short training time
. Reduce compulsive parental
. Emotional side effects
. Rushed, rigid training may fail
and may even cause behavioral
. Not effective without
professional supervision
. Overcorrection component
could lead the child to regress
. Practical barriers
- increased fluid intake for some
- no specialized trainer
-some degree of bladder and
bowel control
-having the neurological
maturity to co-operate
-voluntarily participation, and
interest in TT
. Very attractive to parents
. Less parents-child conflict and
. Less education time from
. Older age completion
. More frustration for
164 Vermandel et al.
Page 3
then be returned to diapers for 13 months before TT is
The use of prompting has changed over the years.
Sixty years ago, parents used to prompt children more
than nowadays.
Also the reaction of the parents when the
child’s attempts to void were unsuccessful was significantly
different. Parents who trained their children 3040 years ago
used running water to provoke voiding and encouraged them
by making special noises, while most parents of later
generations just asked the child to try again later.
the child to stay on the potty as well as actively provoking
voiding, has a risk for the development of abnormal bladder-
sphincter co-ordination.
Over the last three generations, only minor changes in the
use of punishing and/or rewarding have occurred.
and Azrin
gave a lot of importance to reinforcements, social,
and tangible. To discourage accidents, reprimands and a
short time-out of positive reinforcement were proposed.
According to Brazelton
pressure, punishment, and neg-
ative feedback will often prolong the process and cause
complications and stress for the child.
At age 1 year, if a child in the Digo tribe evacuates in the
living area he is at first warned and then physically
Trends in TT have changed over the past decades. Although
some information is available on TT methods, almost no
procedures have been evaluated in studies published in peer-
reviewed journals. There is a lack of high-quality evidence-
based research to help guide clinicians in advising parents
on how to optimally train their children. One could get
the impression that the way training is done is of little
consequence as long as it has been nalized before children
attend school. However, the emotional negative and often
painful experience children and their families go through
when TT fails, shows the need to clarify further this important
Only limited research on the effectiveness of the different
methods has been described. Standardization of definitions,
such as ‘‘toilet trained’’, ‘‘success’’, and ‘‘failure’’, is an essential
first step to high-quality evidence-based research. Studies
with larger sample sizes should be undertaken. This way,
sufficient evidence might be gathered that permits to
conclusive answers regarding the optimal TT method.
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    • "12. Support Families. Continence is consistently rated by parents as an area of significant concern and high stress (Fereday, Kimpton, & Oster, 2013; Macias et al., 2006; Rinaldi & Mirenda, 2012; Vermandel, Van Kampen, Van Gorp, & Wyndaele, 2007; Weaver & Dobson, 2007 ). The significance of toilet training is so great that the cognitive ability to toilet is one of eight items in the brief Disability Rating Scale (Bellon, Wright, Jamison, & Kolakowsky-Hayner, 2012 ), and is listed as an item that should be given a high priority to reduce the stress of children with special health care needs and their families (Macias et al., 2006). "
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    • "И, наоборот, на несколько месяцев затягивается начало и, соответственно , позже завершается освоение туалетных навыков дефекации в условиях несформированного ритма дефекаций. В работах иностранных авторов выявлены схожие закономерности [5, 10]. Формирование навыков туалета существенно замедляется , когда родители испытывают трудности в организации режима дня ребенка вследствие особенностей эмоциональной сферы ребенка и/или детско-родительских взаимоотношений, что было показано на детях, засыпающих путем укачивания или со взрослым в одной кровати. "
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    • "2–4,16,17,19,20 Children have to be aware of bladder sensations, of their need to void. Most authors agree that the ability to be aware of a full bladder occurs when the child is between 1 and 2 years old.23416,17,19,20,23,24,26,3233343539 Children need to understand potty words and need an adequate vocabulary of their own. "
    [Show abstract] [Hide abstract] ABSTRACT: Confusion exists about when to start toilet training, which causes stress and anxiety. Another consequence can be the actual postponement of the toilet training process, which has created extra social problems. Therefore, in this review we will focus on the proper moment to start toilet training, more specific on readiness signs. This will clarify on which topics further research is necessary. We searched databases for publications on toilet training. Next, we gathered information about the normal development of healthy children and at which age skills needed for each readiness sign are acquired. Twenty-one readiness signs were found. Our results show that there is no consensus on which or how many readiness signs to use. Depending on the readiness sign, the moment to start toilet training can vary a lot. More studies are needed to define which readiness signs are most important and how to detect them easily.
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