TYPICAL AGE AT CONSOLIDATION AND TRENDS

Children in the United States typically become toilet trained between 2 and 3 years of age. At this stage, children are neurologically capable of sensing and containing stool and urine, and they have the language and motor skills to get to the toilet. Over the years, the completion of training has occurred at slightly older ages. Data from the late 1980s revealed that children completed toilet training at an average age of 24 to 27 months.¹ In contrast, in the 1990s, U.S. girls were found to complete toilet training at an average age of 35 months and boys at 39 months.²

Several explanations regarding the phenomenon of later toilet training are proposed. With cheaper, more effective, and larger-sized diapers and training pants, older and larger children can easily use them. Cultural norms and parenting styles have also changed. Years ago, parents were given direct parenting advice, specific instructions about when to put the child to bed, how much to give at each feeding, and when and how to toilet train. Beginning with Dr. Spock in the 1940s, parents have been increasingly encouraged to trust their own instincts when parenting a child, rather than to follow the same uniform directions for every child.³ T. Berry Brazelton expanded this mindset specifically to toilet training.⁴ Endorsing a child-centered approach, Brazelton allowed children to take the lead in the training process. Rather than forcing the child to adhere to an imposed schedule of when to train, parents were encouraged to read a child’s signals that indicated readiness. When children express interest in toileting, have the developmental skills to accomplish the task, and have regularity in stooling and urinating, then parents step in to guide the process. Barton Schmitt later reincorporated specific parent responsibilities in the toilet training process, such as prompting practice runs, responding to successes, and responding to accidents.⁵

The parenting perspective may differ from one cultural group to another. For example, African American parents tend to start training their children at younger ages and are more likely than white parents to agree that it is important for a child to be trained before 24 months.² Not surprisingly, nonwhite children are more likely to be trained earlier than their white peers.²

Blum and colleagues studied a large cohort of children to identify factors associated with later toilet training.⁶ More than 400 children, mostly Caucasian children at the top of the social strata, were monitored. The children who completed toilet training after age 3 years were compared with those who were trained before age 3. Later trainers started training later (at 22.3 vs. 20.6 months), were more likely to be constipated (41.7% vs. 13.2%), and exhibited more stool toileting refusal (56.7% vs. 17.9%) than peers who trained earlier. There were no differences between the two groups in parenting stress, birth order, or daycare participation.

TOILETING READINESS

Several developmental abilities are needed for a child to be toilet trained (Table 24-1). These are referred to as readiness skills. When parents ask when to train the child, it is helpful to provide a checklist of what the child needs to be able to do and an age range in which he or she is expected to do it.

TABLE 24-1 Readiness Skills: Age at Acquisition

The first step in training is the child’s awareness of the sensation of a full bladder or rectum. As the rectum fills, stretch receptors send information to the brain that the stool is accumulating. For urine, a more complex interaction between the bladder and central nervous system is involved. Children often respond to these feelings with withholding behavior. This can be kneeling or freezing to hold in urine or “dancing” to hold in either urine or stool. Even infants have a sense of when they are about to stool, arching or crying in such a way that parents often recognize an imminent bowel movement. Before they are trained to use the toilet, some children hide in a corner or go to a specific room to stool privately. In these cases, the child can sense the urge to defecate.

To train, a child should be dry for 2 hours at a time. This indicates regularity and bladder capacity that are adequate for using the toilet at reasonable intervals without interrupting daily activities. The child must communicate the need to go and his or her desire for access to the toilet. This can be accomplished with words, pointing, or signs. Families should be advised to pick toilet words that are socially acceptable and will be recognized in different settings, such as at school and at friends’ homes. To be independent in toileting, a child must have the motor skills to get to the toilet and must be secure enough to sit comfortably on the toilet or potty chair. Children with neurological deficits may need special apparatus so that they are stable on the toilet. The ability to pull down underpants and pants, including fasteners, is an additional requisite motor skill.

A child cannot urinate or defecate on the toilet without relaxing; physiologically, the child has to relax the buttocks for the stool to be evacuated. The child must then push the stool out or relax the bladder’s external sphincter, followed by wiping and flushing. Children should be taught to wipe from front to back to minimize spread of fecal bacteria.

In many cultures, infants are “trained” to defecate and urinate over the toilet.⁷ This training is behavioral, accomplished by a parent very closely watching the child for signs of imminent voiding, such as a red face, a typical cry, or a typical posture. The parent removes diapers or underwear and holds the infant over a toilet. Infant training necessitates a great deal of consistency from parents and regularity in stooling and urinating patterns in infants. Interest in the US has resurged as “Elimination communication”, considered an extension of parent-child connections and a step toward toilet training. Studies of the benefits, side effects, and long-term outcomes of infant toilet training are not available.

COMMON TOILETING STRATEGIES

In the United States, most children are trained easily and quickly through Brazelton’s child-centered approach. Parents may first buy a potty chair, encouraging the child to pick it to boost excitement and investment. They can place the potty chair in the bathroom, and while parents use the big toilet, the child uses the small one, or pretends to do so. Parents may augment this experience with books and videos about toilet training. When the child is dry for at least 2 hours at a time, he or she may help choose new underwear, often decorated with superheroes or favorite cartoon characters. After stooling or urinating, the child can wear the special new underwear for an hour, successfully experiencing dryness. When parents see signs indicating that the child senses a full bladder or bowel, they can encourage the child to use the toilet. Often they can reward the child with a hug, sticker, or small treat. During the period that children are consolidating continence, they often make a transition from diapers to disposable training pants that can be pulled up and down like underwear.

Another common approach some parents use is to remove diapers or training pants altogether. Children who have the needed readiness skills and an easygoing temperament may do better with this method than do more developmentally impaired children or those with a less easygoing temperament. Parents prepare the child so that over a few days, the child learns to use the toilet. They often may chose a warm summer weekend for the house to become a “diaper-free” zone, when the child wears no diaper or training pant for much of the time. The child and parent stay home, waiting for the urine or stool to come so that the toilet can be used. Initially, they should expect accidents. Some parents increase output by having the child drink more than usual or even eat salty food to create more thirst. Although these techniques are an effective method in many instances, children at risk for physical abuse should not be trained this way, because of the high risk of accidents and often intense nature of this method.

Toilet sitting is another common technique that can be effective. Children are expected to sit on the toilet for 5 minutes at a time, at 2-hour intervals throughout the day and after each meal. Each time, the parent asks the child to try to urinate. When the child sits after meals, the natural gastrocolic reflex makes defecation more likely, and so the child is asked to stool. When bearing down, the child may place his or her hand on the lower abdomen to feel it push out. Parents usually give small rewards at first for trying and later for success. Reading books and singing songs can help make the sitting time pass pleasantly while the expectation is reinforced. Children who are toilet trained at preschool or daycare often learn through this method: they may be taken to the toilets at intervals, when they line up and wait their turns outside the bathroom. Peer activities can be an added incentive to motivate the children.

RELEVANT RESEARCH

There is little research support for a single best, evidence-based method of toilet training a child.⁸ One review concluded that no randomized, controlled studies of preschoolers provide evidence for treating problems related to toilet training.⁹ The largest body of evidence stems from Azrin and Foxx, whose intensive approach breaks training into individual steps and is effective for both developmentally abnormal and typically developing children.¹⁰ Although Brazelton’s child-oriented approach is currently perhaps the most commonly used,¹¹ no outcome data have been published since his original report.

WHAT IS KNOWN ABOUT THIS PROBLEM?

Increasing data are available regarding children who are not able to toilet train or have more trouble than expected. Based on his extensive experience, Schmitt suggested that the most common cause of delayed toilet training is refusal or resistance but also emphasized that these children are often enmeshed in a power struggle with their parents.¹² Schonwald and associates furthered the understanding of difficulty in toilet training by demonstrating these children’s significant tendency to have difficult temperamental traits outside of their toileting difficulties.¹³ Children who were referred to a tertiary care center for failure to toilet train were less easygoing temperamentally and were more likely than easily trained children to have a negative attitude, be poorly adaptable, be less persistent, and be more hesitant in new situations. They were also substantially more constipated than were peers who trained easily. In comparisons of parents of such children with parents of typically trained children, no difference in parenting styles were found. Blum and colleagues confirmed that constipation in children with toilet training difficulty occurs before the toilet refusal¹⁴; theoretically, it hurts the child to stool, and so the temperamentally at-risk child then avoids stooling; this leads to more constipation and pain, and a vicious cycle ensues.

MANAGEMENT OF TOILET REFUSAL

Few interventions regarding late toilet training have been studied.¹⁵ Successes associated with such interventions have been minimal. Taubman and coworkers demonstrated that (1) discouraging negative terms for feces and (2) praising children who defecate into diapers before training began (using a child-oriented approach) did not decrease the incidence of stool toilet refusal but did shorten its duration.¹⁶

Late toilet training interventions must account for the child’s temperament, constipation status, and the parent-child dynamics that often develop around the toilet training power struggle. A group treatment approach has been one effective model that addresses these elements in a 6-week program.¹⁷

THE HIDDEN PROBLEM

Unfortunately, the private nature of toileting and the shame and disgust sometimes associated with defecation make encopresis a challenging disorder to identify. In the pediatric office, a child can demonstrate skills in walking, communicating, and socializing but is not expected to show the doctor his or her toileting skills! On occasion, providers find stool leakage in a child’s underwear on examination, or a particularly stressed or worried parent asks for guidance. In general, the topic of encopresis must be explicitly queried by the provider to elicit the problem. Parents are often too embarrassed to bring up the subject on their own.

Unlike more obvious developmental and behavioral issues, encopresis is not easily discussed among parents. In contrast to children with sleep problems and tantrums, families of children with encopresis have rarely heard of another child with the same problem. Typically, families approach encopresis as a behavior problem, attributing willfulness as the cause. They may associate encopresis with filth, embarrassment, and serious psychiatric pathology, with no understanding of its underlying cause. Although Internet access creates unprecedented opportunities for research about medical conditions in the privacy of a parent’s own home, few parents would know to search “encopresis.”

INCIDENCE HARD TO CONFIRM

It is difficult to determine the true prevalence of encopresis because of its private nature and families’ and children’s reluctance to discuss it. Some authors report that 1% to 3% of children between ages 4 and 11 years suffer from encopresis²⁰ (Table 24-2); similarly, the prevalence of encopresis was 4.1% among 5- to 6-year-olds and 1.6% among 11- to 12-year-olds in a large, population-based study in The Netherlands, with an increased incidence among those with psychosocial problems.²¹

TABLE 24-2 Incidence of Encopresis

EMOTIONAL EFFECT RATHER THAN CAUSE

Traditionally, the perceived association between encopresis and serious emotional problems triggered mental health referrals for children presenting with stool leakage or larger accidents.²² Children with stool accidents are at risk for physical and sexual abuse, perhaps because their accidents trigger anger in uninformed caregivers, although encopresis may also be a physical response to anal trauma.²³ Children who are traumatized can lose continence as a sign of regression, like all other fragile developmental skills that deteriorate in times of stress. Stool incontinence can also be a protection against abuse; a child may discover that stool in the underwear will keep an abuser away. In all cases of children presenting with encopresis, possible abuse must be explored, although it is rarely found.

Children with encopresis can develop emotional problems, which may be a consequence of being teased and embarrassed, leading to poor self-esteem, anxiety, reduced school performance, and impaired social success.²⁴ They may suffer when uneducated families exacerbate their sense of failure, expecting the child to stop the accidents despite his or her inability to control them. However, in most cases, encopresis is not symptomatic of a larger psychiatric problem.²⁵

CONSTIPATION OF VARYING DEGREES

Most children with encopresis are constipated.²⁶ However, mild constipation can lead to overflow incontinence, whereas some severely constipated children have no encopresis. The critical variable seems to be the amount of rectal dilatation, not the absolute amount of stool in the bowel. Historical details elucidate the degree of impaction and dictate the intensity of intervention.

CAUSES OF CONSTIPATION

Constipation is common in U.S. children, affecting 5% of children aged 4 to 11 years.²⁷