Toilet training 101
Potty training in less than a day? Or child-directed bowel and bladder control? A recent report supports the use of either of these training methods.
- Copyright © 2007 by the American Academy of Pediatrics
One of the most common questions parents ask pediatricians concerns toilet training, but which approach is most effective?
The Academy commissioned a review of scientific evidence for various toilet training methods. Conducted by the Agency for Healthcare Research and Quality, the review concluded that the two most common approaches are both effective: the child-oriented toilet training method and the Azrin and Foxx “Toilet Training in Less Than a Day” method.
Researchers reviewed 26 observational studies and eight controlled trials.
They analyzed factors that impact the effectiveness of training, whether certain training methods contribute to adverse outcomes and optimal toilet training for children with special needs.
The child-oriented approach
The Academy recommends parents use a child-oriented approach when the child is behaviorally, developmentally and emotionally ready, usually no sooner than 18 months. With a child-oriented approach, the potty chair is introduced slowly, and parents educate the child as soon as he/she shows interest in the potty. Par ents are advised not to push the child.
“The type of recommendation AAP endorses is going to be the form of toilet training that's most acceptable and practical for most families,” said Nathan J. Blum, M.D., FAAP, a member of the report's technical expert panel and a developmental-behavioral pediatrician.
The Azrin and Foxx method
The method promoted by Nathan Azrin, Ph.D., and Richard Foxx, Ph.D., uses behavior modification. Children are given plenty of fluids and snacks and placed on the potty at regular in tervals. They are re warded for using the potty and reprimanded and retrain ed following an accident.
“If a patient wants to use a method like Azrin and Foxx, there is enough evidence to support that,” Dr. Blum said. “I wouldn't discourage them.”
But parents need to know that Azrin and Foxx is an intensive process, said Leonard A. Rappaport, M.D., M.S., FAAP, peer reviewer for the report.
“With behavior modification, you have to be very supportive and reward approximations and small successes,” Dr. Rappaport said.“ If you wait until the child gets a little bit older, you can educate them, and they'll do it themselves with a little support.”
Influencing factors, special conditions
All toilet training techniques are believed to be influenced by a variety of factors, including the child's gender, age at initiation and race. While data were limited, the report found some evidence that late training can be associated with adverse events and that girls trained earlier than boys.
Children with physical handicaps are successfully toilet trained using adapted programs, and training is enhanced when supported by a multidisciplinary team, the report stated.
Operant conditioning programs and the Azrin and Foxx method were effective in training mentally handicapped children, researchers found. Parents of children with cognitive disabilities would benefit from the help of a psychologist experienced in toilet training children with disabilities, Dr. Blum advised.
Insufficient evidence prevented researchers from determining if certain training methods caused adverse outcomes. However, aggressive toilet training methods were associated with urinary tract symptoms.
The report recommended that future research should directly compare two training methods within the same population, as well as document adverse outcomes and determine if training is affected by age, sex, race or culture. Research also is needed on toilet training children with behavioral disorders.
The full report, The Effectiveness of Different Methods of Toilet Training for Bowel and Bladder Control, is available at www.ahrq.gov/clinic/tp/toilettrtp.htm#Report.