The hows and when-tos of toilet training

Nappies have their place, but a toilet is the elusive goal. Melanie Woodfield shares her findings on the hows and when-tos of toilet training.

We all want a toilet-trained child, but often we dread the process involved in getting there. Months and months of paying through the nose for disposable nappies (or breathing through the mouth with cloth nappies) are pretty strong motivators to get stuck in and train that toddler. But, as many a parent can attest, toilet training doesn't always go smoothly. To have a higher chance of success first time, both you and your child must be ready - psychologically and physiologically. Busting to get stuck in? Read on to find out if you're ready.

Are you ready?

Toilet training times have changed. Michael Luxem and Edward Christophersen point out that in 1929, Parents magazine claimed that almost every healthy child could be trained to not soil their nappy by the time they were eight weeks old! This notion seems almost laughable in this day and age - our culture around toilet training has changed so much. However, interest in the idea of very early toilet training has continued, especially since several non-Western cultures still practice this very early training. Min Sun and Simone Rugolotto from the University of Verona in Italy have recently written about a very interesting case of an infant in a "Western" home who started toilet training at 33 days old (!) and was toilet trained (for bowel motions) by about five months of age. Dr Sun and Dr Rugolotto point out that their example, while obviously based on a single case study, shows that early infant toilet training is indeed still possible. This kind of early training does require considerable time and attention from caregivers. There are other down-sides - Drs Sun and Rugolotto also note that very early toilet training has been associated with later encopresis (soiling) or constipation.

As a society, we've been slowly moving towards starting toilet training later and later. According to Drs Luxem and Christophersen, these days, most parents start toilet training when their child is around two years old, and it takes most children three to five months to become fully toilet trained. Almost all children are toilet trained by four years old. There are a lot of reasons for later toilet training, including the convenience of disposable nappies, more efficient laundry technology (compare your washing machine with your grandmother's "copper"!), and the fact that many parents don't have time to toilet train due to work commitments. The downsides of later toilet training include higher nappy costs, negative effects on the environment and, some say, increased risk of the spread of infectious bacteria through nappy-changing at large day care centres.

We can't wait too long, though. There is emerging evidence suggesting that late toilet training can be related to ongoing toileting problems. In 2009, Carol Joinson and her colleagues from the University of Bristol published an article suggesting that starting toilet training after 24 months of age "may be associated with increased odds of experiencing problems with daytime bladder control in some children". Dr Joinson surveyed 8,000 parents in the UK. The study was fairly rigorous, and involved excluding other probable explanations for the results. Despite these precautions, there was still evidence that starting toilet training after two years of age is linked to problems with achieving and maintaining bladder control. It's very important to note, however, that the two being linked doesn't mean that later toilet training causes problems with bladder control.

So the question remains - is your child ready? Despite the fact that sometimes toilet training is hurried along by the impending arrival of a sibling, or other "family" factors, we ought to be looking at the individual child for signs of readiness. As an infant, babies empty their bladders as a reflex, with no conscious control. As the months and years progress, children become aware that their bladder is full, and the process of emptying it becomes more deliberate, rather than reflexive. To begin toilet training, children will typically be at an age and stage where they can remain dry for several hours, empty their bladder completely when they do urinate, and show some awareness that they need to pass urine (Gimpel and Holland, 2003).

Children also need to show their readiness in other ways. Gretchen Gimpel Peacock and Melissa Holland summarise these areas in their 2003 book Emotional and Behavioural Problems of Young Children, as follows:

• Children must be able to carry out the physical steps involved e.g. walking to the bathroom, removing appropriate clothing, and sitting on the toilet.
• Children must have basic language skills, and be able to both understand and express basic words related to toileting.
• Children must be able to follow basic instructions from their parents - kids who are rebellious may be more difficult to successfully toilet train.

Studies have suggested that voluntary control over the bowel and bladder reflexes happens around nine months of age and an ability to co-operate with an adult's instruction occurs at about 18-24 months (see Sun and Rugolotto, 2004). This has led to some professionals suggesting that toilet training shouldn't begin before 18 months of age (e.g. the American Academy of Pediatrics). As we've seen, there are pros and cons of both "early" and "late" toilet training. The best guide is your child himself.

Get set...

Once you've determined that you and your child are ready,  it pays to spend some time thinking and/or reading about methods of toilet training. There are several different methods for toilet training a toddler, which are usually based on either Brazelton's approach (1962), or Azrin and Foxx's 1974 method. Brazelton's "child-oriented" approach is the least formal, and the approach that most of us take intuitively. It involves slowly introducing the child to toilet training from about 18 months of age. Children are given a potty, and initially sit on it fully clothed for a few minutes each day. Next, the child sits on the potty with no nappies on, and, as the child becomes used to the potty, may be taken to the potty when their nappy is full. The nappy can then be dropped into the potty, to show what the potty is used for. The potty is then placed within easy reach of play areas, and the child is encouraged to use it whenever they need to. Once the child begins to use the potty, their successes are praised and encouraged. If the child doesn't make good progress, this method suggests that toilet training should be stopped, and resumed a few months later. Overall, the method is common, gradual, easy, and child-oriented.

The other main approach, pioneered by Azrin and Foxx in the 1970s, has been adapted several times over the years, for different groups of children (e.g. developmentally delayed children, and children who have longstanding bedwetting issues). This approach is far more structured and formal than Brazelton's. It's typically faster, and usually very successful, but requires more time and attention from parents. Various versions are available, and as this approach has a higher potential for problems, including tantrums, it should ideally be undertaken in consultation with a professional (e.g. psychologist, paediatrician).

One of the components of the more "formal" approaches, which are often used for children with longstanding bedwetting issues, is the alarm system. There are numerous studies that highlight the effectiveness of the bedwetting alarms, and some toilet training programmes even use an alarm that can be fitted to the child's nappies (see Vermandel et al, 2008). In a nutshell, the system uses a moisture-sensitive pad that is fitted to the child's mattress or nappy. As soon as the first drops of urine hit the pad, a discreet alarm (or vibrating wristwatch for older children) sounds. The child is trained to go straight to the toilet and finish passing urine there. These systems are highly effective, and can be a wonderful relief for children and families who have struggled with bedwetting. They are available in New Zealand for hire or purchase through a number of companies (Google "bedwetting alarms"). No need to reach for these as a first point of call, but wonderful to know they're around for backup if need be.

Go!

So if the cost or inconvenience of nappies is getting you down, and your child is at least 18 months old (or 18 minutes old, depending on your philosophy!), you may be ready to toilet train. Bear in mind that most children take three to five months to become toilet trained. Take your time, and enjoy the process.

Dr Melanie Woodfield is a child and adolescent Clinical Psychologist. She lives with her husband and two children in Auckland.