Toilet Training – A Major Developmental Miestone

Developing independent toileting skills is an important milestone for children and families to overcome. Graduating from diapers to the use of toilet is seen as a critical step in the development of young children and helps to promote positive social experiences, successful interactions in the home and to boost confidence in the child. Often times, however, it can become a frustrating experience for parents of children with and without developmental disabilities alike. Refusal behaviors and repeated accidents contribute to the stress parents experience surrounding the issue. More pressure is added when entry to daycares or camps requires the child to be toilet trained. To further add to the problem, most experts, such as pediatricians, are either in conflict on the advice they give to parents or give advice that ignores findings within the scientific literature in favor of popularized notions surrounding toilet training.

Factors Affecting Toileting

A child needs to display the ability to control the muscles used in elimination in order to successfully acquire toileting skills. This includes voluntarily postponing voiding, as well as initiating relaxation (for stools) or contraction (for urinating) of the muscles required for elimination. Research suggests that these skills typically develop between the ages of 3 and 4, but these skills can be acquired at earlier ages.

Child readiness also needs to be considered before toilet training. A popular theory suggests that initiation of self-dressing or undressing, interest in the potty and use and comprehension of words involved in toileting are indicators that the child may be ready for training. Within the behavioral research, readiness skills include simple gross motor actions (i.e. ability to walk), compliance with parental demands and some bladder continence is sufficient to begin toilet training.

Other factors that could affect toilet training are the age at initiation (associated with longer training durations), medical factors such as urinary tract infections or constipation and previously failed attempts at toilet training.

When making the decision to begin toilet training, it is always best to check with your pediatrician to make sure that there aren’t any medical conditions that could negatively impact your efforts to train your child.

The Child Centered Approach to Toilet Training

There are two approaches to toilet training that are widely recognized. The Child-Centered approach was initially introduced by Dr. B. Spock in the late 1940s, and later popularized by Dr. T.B .Brazelton, a pediatrician. The idea was to move away from stricter methodologies in favor of a more gradual toilet training process. Parents were encouraged to look for and follow the signs from the child that he or she was ready for toilet training. The method includes allowing the child to explore the potty chair without any pressure, reading books on the subject, talking about the potty and using peer and parental models as motivation. It is a gradual process that has been embraced as the industry standard by most pediatricians, though there have been no empirical studies to validate this approach (Polaha et.al, 2002, Mota et. al. 2008 & Christopherson, E. 2003).

The Behavioral Approach to Toilet Training

The most cited study of behavioral toilet training was conducted by Azrin and Foxx in 1971 with institutionalized adults. It was a comprehensive protocol in which researchers outlined the teaching protocol that is used in almost all training programs for children with disabilities today. This study has been replicated with adults and children with disabilities, typically developing children, and children with previously failed attempts at toilet training.

Key components of a behavioral approach to toilet training are:

  1. Finding powerful reinforcers and using them only as reinforcers for appropriate toilet use
  2. Verbal praise during dry checks and for sitting on the toilet
  3. Setting up a schedule of toileting that will ensure success as well as making sure the trainer has time allocated to spend with the child constantly during the initial phase of training
  4. Gradually increasing the time between scheduled toilet sits
  5. Initially increasing fluid intake – an important note here is that offering salty snacks to encourage drinking actually causes the child to retain water. Also, offering too many fluids can result in an electrolyte imbalance. Quickly fade this to a more natural schedule of fluid intake.
  6. Dry pants checks. Initially around every 5 – 10 minutes. This schedule is also gradually faded
  7. Generalizing – when the child is able to remain dry for a 2 hour period, begin increasing independence and start training in other environments.
  8. Accidents – either an overcorrection procedure is used in which the child helps to clean up after an accident, or accidents are cleaned up without drawing attention to the incident.

Suggestions for Training a Child with Developmental Disabilities

Toilet training a child with autism or other developmental disabilities presents challenges that need to be accounted for when making a training plan.

It often takes these children longer (an average of 1.6 years for urination, almost 2 for stools) acquire complete independence. Also, the entire toileting sequence might need to be taught individually, including teaching the child how to initiate toilet use. It can be difficult for some children to generalize toilet training to other environments as well. As such, consistent practice, powerful reinforcement systems and patience become key factors in teaching this skill.

Making the Decision to Train

Embarking on toilet training is a full-time endeavor, especially in the beginning. While child readiness plays a role, parental readiness is also a key factor for success. It takes a significant amount of time in the initial stages and your schedule has to be open in order to fully attend to your child. Accidents will happen no matter which training methodology you follow. Putting the child in training pants or even thick underwear is confusing to the child and should be replaced with regular underwear from the beginning. It is also important to gradually increase independence based on the performance of your child. It is more important that the child makes it to the toilet to eliminate than it is that they pull down their pants and wash their hands independently during the initial phases. Also, bowel movement training should be targeted only after the child is successfully bladder trained. This involves a different physiological mechanism and requires that the child be comfortable.

While many view toilet training to be a difficult hurdle to overcome, it can be a very rewarding process for both the parent and the child. Being prepared, remaining consistent, celebrating successes and most of all, being patient with yourself and your child is key while moving through the steps towards independence!

*Please Note: Parents are encouraged and urged to seek the consultation of a professional in the field, preferably a Board Certified Behavior Analyst for the most successful treatment outcome.

References:

Azrin, N., & Foxx, R. (1971). A Rapid Method of Toilet Training The Institutionalized Retarded. Journal of Applied Behavior Analysis 2, 89 – 99.

Berk, L., Friman, P. (1990). Epidemiologic Aspects of Toilet Training. Clinical Pediatrics 29 (5) 278 – 282.

Blum, N. Taubman, B. & Nemeth, N. (2003) Relationship Between Age at Initiation of Toilet Training and Duraiton of Training: A Prospective Study. Pediatrics 111 (4), 810 – 814.

Blum, N. Taubman, B. & Nemeth, N. (2004) Why is Toilet Training Occurring At Older Ages? A Study of Factors Associated with Later Training. The Journal of Pediatrics 145(1), 107 – 111.

Brazelton, T., Christophersen E., Fraumna, A., Gorski, P. Poole, J., Stadtler, A., & Wright, C. (1999). Instruction, Timeliness and Medical Influences Affecting Toileting. Pediatrics 103 (6) 1353 – 1358.

Christophersen, E. (2003) The Case for Evidence-Based Toilet Training. Journal of Pediatric and Adolescent Medicine 157, 1153 – 1154.

Cocchiola, M., Martino, G., Dwyer, L., & Demezzo, K. (2012) Toilet Training Children with Autism and Developmental Delays: An Effective Program for School Settings. Behavior Analysis in Practice 5(2) 60 – 64.

Kroeger, K. & Sorensen-Burnworth, R. (2007) Toilet Training Individuals with Autism and Other Developmental Disabilities: A Critical Review. (2009) Research in Autism Spectrum Disorders 3, 607 – 618.

Mota, D., & Barros, A., (2008) Toilet Training: Methods, Parental Expectations and Associated Dysfunctions. Jornal de Pediatria 84 (1), 9 -17.

Peternel, K. (2016) Toilet Training Children with Autism [PowerPoint slides].

Polaha, J., Warzak, W. & Dittmer-McMahon, K. Toilet Training in Primary Care: Current Practice and Recommendations from Behavioral Pediatrics. Developmental And Behavioral Pediatrics 23 (6), 424 – 429.

Rinald, K. & Mirenda, P. (2012) Effectiveness of a Modified Rapid Toilet Training Workshop for Parents of Children with Developmental Disabilities. Research in Devleopmental Disabilities 33, 993 – 943.

Ritblatt, S., Obegi, A., Hammons, B., Ganger, T., & Ganger, B. (2003) Parents’ and Child Care Professionals’ Toilet Training Attitudes and Practices: A Comparative Analysis. Journal of Research in Childhood Education 17 (2), 133 – 146.

Schum, T., Kolb, T., McAuliffe, T., Simms, M., Underhill, R. and Lewis, M. (2002). Sequential Acquisition of Toilet-Training Skills: A Descriptive Study of Gender and Age Differences in Normal Children. Pediatrics 109 (3), 109 – 116.

Van Nunen, K., Kaerts, N, Wyndale, J-J., Vermandel, A., & Van Hal, G. (2015). Parents’ Views on Toilet Training (TT): A Quantitative Study to Identify The Beliefs and Attitudes of Parents Concernting TT. Journal of Child Health Care 19(2), 265 – 274.

 

Recent Posts