The mastery of toilet training is perhaps one of the most anticipated and celebrated developmental milestones for parents of toddlers and preschoolers. The process of toilet training, however, invokes a great deal of anxiety, both in the parents and the toddler. Early in the process, it is apparent that it is the parent who is being trained. The parent must become acutely aware of the child's toilet habits and anticipate the child's toilet needs from hour to hour. Parents must recognize that they may need to dedicate many hours per day over a period of several days to weeks to attain the goal of a toilet-trained child. Parents must also be prepared to accept that perhaps their child is not yet physically or emotionally ready to attain this milestone, even if playmates have already been successful.
In the United States, 26% of toddlers achieve daytime continence by age 24 months, 88% by age 30 months, and 98% by age 36 months.1 Girls tend to complete the toilet-training process 2 to 3 months earlier than boys.1 Toddlers, age 18 to 24 months, may not be physically ready to recognize all of their body's soiling cues. However, they are so excited by the praise of their parents and the excitement of using the toilet that they may become trained with little emotional angst. Toddlers age 2 to 3 years may be able to recognize the physical cues of their body. However, because most toddlers desire full control of everything in their life, the mere suggestion by a parent to use the toilet results in refusal and emotional distress. Primary care pediatricians must be able to recognize and discuss the readiness for toilet training of both the parent and child, be prepared to discuss the timing of potty training, as well as offer guidance through the many perils and pitfalls.
If a child totally resists potty training, this may be a sign that they are not yet ready. To determine readiness, parents should take the following steps: (1) assess if the child can stay dry for 2 hours, (2) ascertain if the child recognizes when he or she has a wet diaper, (3) recognize if the child shows interest in the potty itself or if he or she hides to urinate or stool. If there are no signs of readiness, it is best to take a break from potty training. However, the parent should remain positive regarding the process, and continue to take the child into the bathroom, modeling the process of using the toilet. Parents can also read books about going to the potty to spark the child's interest. Once the child initiates interest in toilet training and demonstrates readiness, then it is suitable to resume.
Passes a Bowel Movement or Urinates Right After Getting Off the Toilet
If a child routinely eliminates after getting off the toilet, that is usually a sign that the child is too tense when on the toilet. Toileting anxiety can cause pelvic floor dyssynergia, which results in insufficient relaxation of the pelvic floor muscles to allow voiding or stooling.2 Therefore, as soon as the child steps off the toilet, the child relaxes and then has an accident. This may be a sign of fear of the toilet or that the child is not yet ready. The parents should try reading books or introducing other relaxing activities while the child sits on the toilet. If the child continues to exhibit this behavior, the parents should take a break from potty training and try again in a few weeks.
During the process of potty training, children can develop fears related to the toilet or the bathroom. Often children will refuse to sit on the toilet because they are afraid that they will fall in the bowl. Another common fear many children experience is the fear that they will be sucked into the toilet when it is flushed. If children are afraid of the toilet, it is best to try a small toddler potty that sits on the floor. A small potty is less intimidating than an adult-sized toilet. Because the child sits on the small potty with feet flat on the floor, it will also be easier for them to have a bowel movement. Toilet seat attachments that sit on top of the adult seat are often unstable. If the seat is moving underneath the child or if the child falls off the toilet, the child's fears can be worsened. After using a small potty, the child can help empty the waste into the adult toilet and assist in flushing. Over time, the child will realize that flushing is safe and most will come to enjoy the process.
Only Recognizes the Need to Stool
Many children do not have complete control of their bladder until several months after they have learned to control their bowels; this is normal behavior.1 Continue to praise the child for success with bowel movements and urine control will follow.
Refuses to Move Bowels in the Toilet
It is also quite common for children to become completely potty trained for urine but refuse to stool in the toilet. Up to 20% of normally developing children have stool-toileting refusal.1 There are a number of reasons for stool-toileting refusal, including irrational fears and anxieties, excessive parent-child conflict, difficult temperament, and hard painful stools due to constipation.1–4 If a child asks for a diaper to stool and is having regular soft bowel movements, it is likely they are afraid of stooling on the toilet. Initially, parents should allow the child to have the diaper to stool. Then, bring the child into the bathroom and have the child stool into the diaper near the toilet. Once comfortable, have the child try and sit on the toilet to stool while wearing the diaper. Finally, have the child sit on the potty without the diaper. Whether the child is on a regular toilet or small potty, make sure his or her feet are flat on a step stool or on the floor and that they feel secure. If a child is constipated, they will not want to stool due to fear of pain. It has been shown that usually constipation and painful defecation occurs before stool-toilet refusal.3 Because constipation is prevalent in this age group, it is important that the issue of constipation is addressed with parents prior to initiating toilet training.4
Gets Upset When the Stool or Urine Is Flushed
Many children believe that their stool and urine are a part of their body. Children can find it upsetting and frightening to see it flushed away. Other children are proud of their potty accomplishment and do not want to see it go away. Advise the parent to spend time explaining to the child about how everyone makes waste. Make flushing the toilet the reward for doing a great job of going to the potty.
Will Only Use the Toilet at Home
Many children refuse to use any potty other than their home toilet. Other children will only go to the potty for certain people (ie, mom or dad). Public toilets are large and often have an automatic flusher that may scare children. If a child is afraid to use unfamiliar toilets, start at the home of a familiar person—a friend or grandma's house. If the parent needs to take the child to a public restroom, bring the child's home potty chair or child toilet seat cover. When children will only use the toilet for a particular caregiver, try having two people take the child to the bathroom. The next time, have the new person stay in the bathroom and have the primary caregiver stand in the doorway. As the child becomes more comfortable with the new caregiver, the primary caregiver can continue to step back.
Regression Back to Diapers
During a time of stress, fully toilet-trained children will often regress back to wearing diapers. This is most classically seen after the birth of a new sibling. The child is envious of the attention surrounding the new baby and wishes to wear diapers to shift the focus back to him or her. Other examples of stress associated with regression to diapers are the change from the crib to a bed, a new care provider, move to a new house, and death of a loved one. If this behavior develops, it is important for the parent to withhold any anger or negative attention toward the child. Instead, allow the child to wear diapers for a few days. The parent should also spend special positive alone time with the child. If the regression is related to a sibling, often having the older child help with diaper changes and feedings will help alleviate some of the stress and instill the positive association of becoming a “big boy” or a “big girl.” In other situations, giving “big boy” or “big girl” tasks will also help shift the focus from “baby behaviors” such as wearing a diaper. Usually as the stressful situation dissipates, the child can again be encouraged to use the toilet.5
Accidents are a normal and frustrating part of potty training. Some accidents happen because the child does not get to the toilet in time. Others happen because the child is busy playing and forgets to use the toilet. Regardless of the reason for the accident, parents should be advised to stay positive and treat the accident lightly. If a parent scolds or acts too disappointed, the child is more likely to regress back to diapers. The parent should always keep a dry change of clothes when they go out. If accidents are becoming more regular, set a timer that reminds the child to use the toilet. Also, assess whether the child is constipated. Urine and stool incontinence are more common if constipation is present.
Many children become completely toilet trained during the day but continue to wet themselves at night. Nocturnal enuresis occurs in 20% of 5-year-old children and 10% of 6-year-old children. After age 6 years, spontaneous resolution of nocturnal enuresis then occurs at a rate of 15% per year.1 Nocturnal enuresis during the toddler and early childhood years is caused most commonly by small bladder size, inability to recognize the need to urinate during sleep, and muscle relaxation during deep sleep. For most parents, reassurance from the pediatrician that nighttime bedwetting will eventually resolve itself is all that is needed to calm any concerns. If a child has a history of staying dry at night and then suddenly regresses, a more thorough history and physical examination is warranted. Other strategies to help prevent nighttime wetness include having the child urinate immediately before bed, limiting liquids in the evening hours, and withholding all caffeine; however, waking the child to urinate is controversial.
The average age for a child to be toilet trained is approximately 30 months, with most children trained by age 36 months.1 However, parents must be reminded and reassured that every child is unique regarding readiness and willingness to be toilet trained. With enough patience, encouragement, and a good dose of stickers and special treats they will soon be diaper free.
- Turner TL, Matlock KB. Toilet training. http://uptodate.com/contents/toilet-training. Accessed May 12, 2016.
- Fleisher DR. Understanding toilet training difficulties. Pediatrics. 2004;113(6):1809–1810. doi:10.1542/peds.113.6.1809 [CrossRef]
- Blum NJ, Taubman B, Nemeth N. During toilet training, constipation occurs before stool toileting refusal. Pediatrics. 2004;113(6):e520–e522. doi:10.1542/peds.113.6.e520 [CrossRef]
- Schonwald A, Sherritt L, Stadtler A, Bridgemohan C. Factors associated with difficult toilet training. Pediatrics. 2004;113(6):1753–1757. doi:10.1542/peds.113.6.1753 [CrossRef]
- Howell DM, Wysocki K, Steiner MJ. Toilet training. Pediatr Rev. 2010;31(6):262–263. doi:10.1542/pir.31-6-262 [CrossRef]