Toilet training

As the weather is warming up and the start of preschool looms for MissC, we have started the process of toilet training. However aside from the purchase of monster underwear and finding some extra towels for cleaning up accidents, I have done surprisingly little preparation for such a large step. This is because the majority of the information is focused on readiness and non-evidence based criteria. The reason for this I discovered after reviewing the literature is that there is suprisingly little research into the most appropriate toilet training methods.
There are two major toilet training methods however there is an abscence of studies comparing training methods to each other to determine which is best. These involve either the active participation of the child to determine appropriate elimination stimuli via increased fluid intake, regularly scheduled toilet times, positive reinforcement for correct elimination and overcorrection of accidents 9 or a more gentle manner which assumes the child will learn in their own time 11.
There are some established advantages and down falls of both. The first method should be a quicker toilet training method and has the advantage of scheduled voiding which is found to be protective against voiding problems 12. However if established too quickly or strongly the child may inadvertantly learn the wrong behavior, alternatively it may result in frustration and power struggles if the child does not learn quickly.
The second method has the advantage of waiting until the child is ready. Many problems in toileting are caused by training either too early or too late 11. Training is considered too early if it occurs before neccessary skills are present and late if the child is not trained in spite of having necessary skills.

Tips for toilet training

  • Don't encourage excessive 'holding on': Holding on leads to the development of unihibited bladder contractures, lower bladder capacity and compliance which can result in dysfunctional voiding patterns including later continence issues 1. This is particularly risky during the time when the bladder is undergoing transition associated with toilet training 11. Toddlers can not 'hold on' for more than a few seconds so any attempt to encourage it is likely to result in excessive pressure and toilet training problems. Be aware however that some ability to hold on is advantageous for the avoidance of bladder problems such as overactive bladder syndrome - 'bladder drills' may be advantageous after initial potty training 6.
  • Not to encourage delaying pooing: Encourage the child to poo as soon as they feel the urge and allow them to take as long as they need to use the toilet 9. Some children feel excessive pressure to poo quickly and may withhold their poo if they feel it is taking too long. Constipation, including incomplete emptying and delaying pooing can compromise bladder capacity 2. It can also lead to a repeating cycle where the child delays pooing leading to poos becoming harder and more difficult to pass causing the child to hold onto poos even more. This can result in permanent damage of the bowel known as encopresis. 
  • Avoid excessive pressure: Both stool withholding 10 and bladder problems 12 are linked to parental pressure, a relaxed pressure feel atmosphere is considered crucial in avoiding this 9. If the child does not pass urine or a stool on the toilet they should not be encouraged to push or any additional noises or cues used.
  • Have realistic expectations: Bowel and bladder readiness occurs much later than many people realise, most children do not have the necessary skills until well after their second birthday and children are rarely completely dry until over the age of 3 7. Bowel and bladder control is a maturaltional proess which can not be accelerated by early or intense training. Unrealistic expectations and a lack of consideration for development or readiness skills required can lead to frustration and delaying in toilet training.
  • Make sure the toilet environment is appropriate: their feet should be comfortably on the floor or a stool that they can push against when pooing. The potty should not be too low to the floor as it is inappropriate for bladder emptying and an adapter seat should be used if the child is using an adult toilet  11.
  • Appropriate communication with daycare: Continuation of the training program should be as close as possible between daycare and home, as such there should be good communication of the child's toileting abilities and plans for toilet training between them 9.
  • For problems such as toilet refusal or refusal to pass stools on the toilet: Interrupt toilet training and return the child to diapers - this result in spontaneous use of the toilet within 3 months for a majority of children who were refusing to pass stools on the toilet 4.  Taking a break from training provides a buffer against power struggles that lead to difficult to correct behaviour cycles that will block future progress 9.

One in every five children goes through a stage of toilet refusal that may lead to problems in bladder and bowl control 11. Regression is best dealt with via a simple training program that merely rearranges the natural contingencies for toilet use and accidents 9.


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