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A Definitive Potty Training Guide

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POTTY TRAINING
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Just kidding -- we have no idea either.

Written by Melinda Wenner Moyer for Slate

I can’t think of two words that elicit more anxiety and confusion among parents of toddlers than potty training. As the mother of a (still diaper-donning) 26-month-old boy, I am approaching the peak of toilet trepidation, and it isn’t helped by the fact that every piece of information I come across contradicts a recommendation I already filed away. Training pants? No, go diaperless. Praise him for peeing in the potty? Well, if you get too excited you’ll never, ever get him on a toilet again. Prompt him to go? Yes, but be careful not to over-prompt, and whatever you do, don’t “hover within the prompt.”

My usual solution for information overload is to drown myself in even more information, until I come out the other side bearing a nugget of understanding. So that’s what I’ve done with toilet training. I’ve read studies with titles like “Dry Pants: A Rapid Method of Toilet Training Children,” published in journals with names like Neurourology and Urodynamics. I’ve talked to several developmental pediatricians who have spent their careers studying toilet training. And what I’ve discovered is that, although there’s some good information suggesting when parents should potty train, and studies detailing which kids have an easier or harder time doing it, the how best to potty train part has still been largely unanswered. Why? One report put it this way: “Toilet training for healthy children is not a subject that invokes passion among researchers.”

I get it -- cure cancer, or watch kids poop all day? I know what I’d choose. But the net result is that parents are bombarded with “best” techniques that have never been backed by much (if any) science. Worse, much of the research that does exist is hard to decipher. (I still don’t know what it means to “hover within the prompt.”)

First, let’s tackle the (relatively) easy stuff. How do you know when your kid is ready to potty train? One review surveyed 23 studies on potty training and identified 21 “signs of readiness” that parents should look for. Some are obvious: Your kid has to be able to sit up, take her pants/diaper off, follow simple commands, and understand potty words. It also helps if she sometimes keeps a diaper dry for at least 90 minutes, a sign that her bladder muscles are under the control of her brain (rather than contracting reflexively -- often hourly -- as happens in babies), and if she doesn’t poop in the middle of the night anymore. Bonus if your child is showing an interest in the potty. These skills and behaviors come together at the different ages depending on the child, but it’s rarely before the age of 18 months, and -- yes, it’s true -- boys often train later than girls. Earlier is not necessarily better, either: One study found that when parents started to intensively toilet train their children before the age of 27 months, the training took quite a bit longer than it did for parents who waited until their kids hit the 27 month mark. (Yes, some parents start training much, much earlier -- I’ll get to that below.)

As for methods, let me start by saying that the ones parents use today are a lot better -- and by that I mean less emotionally scarring -- than the ones parents used several generations ago. In 1932, the U.S. Government published a book called Infant Care that recommended that kids be done with toilet training by the age of 8 months. To facilitate the process, parents were told to insert “soap stick” rectal conditioners into their babies’ butts to get them to poop on command in the toilet. This “coercive bowel training,” as it was called, eventually elicited frowns from child psychologists, who linked it to constipation, refusal to poop on toilets (wouldn’t you?), anxiety and rage. In response, Harvard pediatrician Berry Brazelton developed a much more gradual “child-oriented” toilet training approach in the 1950s, which attempted to potty train in a way that “utilized the child’s developmental capacities and interest.” Fewer soap sticks; more praise.

The Brazelton approach still forms the basis for the American Academy of Pediatrics’ toilet training recommendations (in fact, Brazelton co-authored them; the main difference between the two is that the AAP doesn’t recommend rewarding children with food as Brazelton does). The technique has four stages, which go something like this:

1) Kid meets potty and sits on it, fully-clothed.

2) Kid sits on potty with pants and diapers off and is praised -- though not TOO heartily, some experts warn, as that can build pressure -- if she goes.

3) Kid is put on potty after she soils her diaper and the dirty diaper is emptied into the potty; parent explains that poop and pee go into the potty.

4) Kid goes diaperless for short periods of time and is encouraged to use the potty independently. (If, during this process, the child ever resists the potty, the parent is supposed to immediately stop training for one to two months and then start it over again.)

The Brazelton approach is easy for doctors to support because it’s simple, safe and it makes sense. “It is consistent with views of positive approaches to parenting and with our increasing understanding of brain development,” says Nathan Blum, a behavioral pediatrician at the Children’s Hospital of Philadelphia, who has studied toilet training. But little research has been done to evaluate how well the Brazelton method actually works. Brazelton himself reviewed the charts of 1,170 of his patients in a 1962 paper and reported that most of the kids were potty trained by 28 months (remember this was back when parents started toilet training much earlier), but the kids weren’t necessarily trained using his method -- he sometimes helped parents with other techniques, so it’s impossible to conclude much from these findings. A second study published in 1997 evaluated 482 children who had been toilet trained using the Brazelton approach and found that 88 percent of the kids were toilet trained at 3 ½ and that 98 percent were trained by age 4. But the Brazelton approach doesn’t work overnight -- research suggests that it can take five to 10 months from start to finish. And some critics point out that it’s funny that Brazelton advocates gradual training considering that he has also been a paid spokesperson for Pampers diapers—obviously, the longer toilet training takes, the more diapers children wear.

Other techniques promise “rapid” toilet training, but only one of them has been scientifically tested, and that’s a method developed in the 1970s by behavioral psychologists Nathan Azrin and Richard Foxx and popularized in their best-selling book Toilet Training In Less Than A Day. Foxx and Azrin developed their method for children with mental disabilities, but they found it worked in healthy kids, too. It goes something like this:

1) The child is rewarded, often with sweets, for showing interest in the potty, going to the bathroom in it, or pulling down his pants.

2) The child is given extra fluids so that he frequently has to go to the bathroom.

3) The child is told that an imaginary person is “happy that you are learning to keep your pants dry.”

4) The child is verbally reprimanded and given brief time-outs for accidents and required to change his pants by himself.

5) The child is shown how to empty the potty basin into a toilet, flush the toilet, replace the basin, and wash his hands.

6) The child is given “pant checks” every few minutes and rewarded for having dry pants. All in one day.

In their initial 1973 study, Azrin and Foxx used their technique to potty train 34 healthy children between the ages of 20 and 36 months in an average of just under four hours (one kid was fully trained in half an hour!), and the children were still using the potty four months later.

With these results, why isn’t the Foxx/Azrin method the one most recommended by pediatricians? Well, for one thing, in their study, trained professionals were used to teach the technique, not parents -- in a 1976 study in which parents were trained to use the method on their kids, it worked only 77 percent of the time. And in every study, some kids had temper tantrums during their training sessions, which has raised concern among doctors that the approach might have “emotional side-effects.” But honestly -- wouldn’t you have a tantrum if you were forced into an all-day intensive training session at the age of 2? And despite concern, there’s no evidence that this method causes any lasting harm. (If tantrums were a sign of emotional damage, my son would be in trouble.)

Indeed, the idea of diaper-free speed-training persists and has morphed into several Foxx/Azrin spin-offs that promise rapid toilet training in a slightly less intense format -- these include the popular e-book Oh Crap. Potty Training by Jamie Glowacki; 3-Day Potty Training; and the Diapers Free Toddler Program developed by Julie Mellom. But no peer-reviewed published studies have been conducted on the effectiveness of these plans, and none were developed by doctors or scientists, so parents either have to trust the authors or hope that what worked for their friends will work for their kids, too. (One friend raved to me about Oh Crap. Potty Training whereas another said she gave up on the technique when her son proudly announced that he had peed on his pants instead of in the potty.) Diaper-free methods can also be tough to implement if your child is in preschool or day care -- some centers won’t allow untrained kids to run around without diapers as some of these approaches recommend. And the day care center also known as your home may not want to be covered in pee either. Still, parents continue to try these speed strategies, probably because who doesn’t want to get this all over with as quickly as possible?

Edward Christophersen, a pediatrician and psychologist at Children’s Mercy Hospitals and Clinics in Kansas City, Mo., has written an entire book on toilet-training problems and says that no technique is fail-safe: Problems arise in kids no matter how you do it. What kind of problems? Well, one out of every five kids in the middle of potty training temporarily refuses to poop in the potty, a behavior clinically referred to as “stool toileting refusal.” No one is certain why children do this, but because it’s more common in kids who hide while they poop in their diapers, it could have something to do with the fact that these kids think of poop as something “bad” that happens in private, and they don’t feel that pooping on the potty affords them the privacy they need. (Kids really don’t like to shut the bathroom door.) This behavior isn’t dangerous if it’s short-lived, but over time, if the child isn’t using diapers, it can create a vicious cycle: withholding poop causes it to harden and become more painful to pass, which reinforces the child’s desire not to go.

Although experts aren’t sure how to prevent the withholding from happening in the first place, a 2003 study found that when parents talked positively about poop and praised their kids for pooping in their diapers prior to toilet training, their kids were just as likely to develop this problem as other kids, but they got over it more quickly than did children of parents who talked negatively about poop and who didn’t praise their kids for pooping in diapers. One study found significantly more toilet training problems among kids whose parents had told them to “push,” make noises or who had turned on the tap when their kids didn’t go (maybe that’s “hovering within the prompt”?) compared to parents who just postponed using the potty if their kids didn’t go -- so staying relaxed when your kids are on the potty might make things go more smoothly.

What about “elimination communication,” the practice in which parents learn their infants’ bathroom cues and hold them over toilets, sinks, grass, and the like to pee and poop rather than putting them in diapers? It’s common in Africa and India, where parents have less access to disposable diapers and spend more time outside, but it is also growing in popularity among progressive U.S. parents (recently profiled in the New York Times, no less).

Although it’s environmentally friendly to say no to diapers, there’s no evidence that the practice provides benefits to babies, Christophersen says, and if parents get frustrated when it doesn’t work and blame the baby for it, it could be emotionally damaging. Plus, the method can, to say the least, prove awkward. “I don’t know about the people you socialize with, but most of the people that we socialize with were born inside and lived inside, and they don’t want stool on their carpets,” Christophersen says.

So what’s the “best” approach to toilet training? I think it depends on your temperament as a parent and the temperament of your child. If you’re a Type A “let’s do this thing” parent, try a rapid method -- heck, maybe even buy Foxx and Azrin’s book, because it’s the only rapid technique that’s been backed by solid evidence. You may want to tone it down a tad -- one 2002 paper suggested that parents skip the time-outs, but that the technique’s use of “predictable, immediate, and salient consequences “ makes a whole lot of sense. If, on the other hand, you think you, your toddler or your house wouldn’t survive intensive training, go with Brazelton’s method.

“The hardest thing a child does between the time they’re born and fully toilet trained is the toilet training,” Christophersen told me. She has to learn to recognize feelings in her colon and bladder that parents can’t point out; when she has them, she’s supposed to stop what she’s doing, find a bathroom, take off her diaper or underwear, go, wipe herself clean, and pull her clothes back on again -- not a tiny feat for a toddler who might still have trouble climbing steps and eating yogurt. So to help her along, before you start training, teach her some of the skills she’ll require, like how to push down her pants and flush a toilet. Pediatrician Nathan Blum also suggests that if you’ve been training for a month and your child is not making much progress, take a break for a month or two and come back to it (or try a new method). Finally, take a deep breath. As Blum and your mother say, “The number of healthy un-toilet trained kids in high school is pretty low.”

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Around the Web

Guide to Potty Training - Parenting.com

Potty Training Basics | BabyCenter

Potty-Training Guide: A complete resource for toilet-training

Your Complete Potty Training Guide - Parents

Potty training: How to get the job done - MayoClinic.com

Potty training tips - Pregnancy and baby guide - NHS Choices

Slate's Definitive Guide to Potty Training