Toilet training is a vital social skill and developmental milestone for children. For parents, toilet training requires patience, understanding and realization that setbacks will occur. This process is often more difficult for children with special needs (such as those with certain disabilities or developmental delays).

Toilet training usually begins between the ages of 18 months and 24 months, but it may begin earlier or later. Over the years, a number of approaches to and theories about toilet training have been proposed. The child-oriented approach is one of the more accepted methods. This approach stresses the importance of a child meeting certain physical and behavioral criteria before attempting toilet training.

The parent-oriented approach is a second method that was once favored. This approach is much more structured and involves increased drinking, positive and negative reinforcement (such as praise or reprimands), and regularly scheduled toilet times. Although in some cases results may be quicker, it is often more stressful for the child. It may be better suited for children with certain disabilities or behavior problems.

The American Academy of Pediatrics (AAP) recommends that toilet training not begin until the child is physically, mentally and emotionally ready (the child-centered approach). The child must have the physical abilities required for toilet training, such as bladder and bowel control and the ability to walk to the toilet, undress, sit on the toilet, wipe and dress. The child must be able to understand and follow instructions. Finally, the child must have the self-esteem, independence and motivation to learn, including the desire to please, imitate and identify with parents and caregivers.

Toilet training is a gradual process that requires time and attention. Parents and caregivers can look for signals that the child is urinating or having a bowel movement and ask the child about them. This helps the child to recognize the feelings of needing to urinate or have a bowel movement. The child can be encouraged to tell the caregiver when he or she has urinated or had a bowel movement. Eventually, the child learns to tell a parent or caregiver before urinating or having a bowel movement.

Toilet training is a vital social skill and developmental milestone for children. It involves teaching the child about the proper techniques in using the toilet, the importance of hygiene and other necessary skills children will need as they grow.

Toilet training takes time, patience and compassion. In general, children develop the ability to control the urinary and anal sphincters after age 18 months. However, children begin at different ages and the time to master toilet training can vary widely.

The American Academy of Pediatrics (AAP) recommends waiting for children to signal when they’re ready to begin toilet training. Rushing children into toilet training before they are physically, mentally or emotionally ready can cause stress for the child and family. It is also likely to take much longer.

Parents and caregivers should be prepared for inevitable setbacks during the process. In addition, numerous issues can prolong or delay toilet training. For instance, periods of stress (e.g., birth of a sibling, moving to a new home, new daycare setting, family trauma) can delay the process or cause toilet-trained children to regress.

Problems with the child’s health, such as a chronic illness, disabilities or developmental delays, can make toilet training more difficult. For example, certain medications can increase (or decrease) the frequency of elimination, or they may interfere with a child’s ability to recognize the need to go to a toilet. Hospitalization and bed rest can interrupt the toilet training process and the illness itself can cause problems (e.g., polyuria, incontinence, fatigue). Some children with developmental disabilities may not ever be completely trained.

Toilet training continues in daycare settings, which may include home settings (e.g., relatives, babysitters), places of worship and community centers. Due to interaction with other children, daycare providers may be the first to recognize when a child is ready to begin toilet training. Many daycare providers are also excellent sources of toilet training information and advice. Furthermore, associating with toilet-trained children of similar ages can help to motivate a toilet-training child.

There are a number of methods that can be used to toilet train. Two of the more common are child-centered and parent-centered.

The child-oriented approach is the most widely accepted process and is recommended by the American Academy of Pediatrics (AAP). This approach emphasizes that a child be physically, mentally and emotionally ready before beginning toilet training. The child must have the physical abilities required for toilet training, such as bladder and bowel control and the ability to walk to the bathroom, undress, sit on the toilet, and dress. The child must be able to understand and follow instructions. Finally, the child must have the self-esteem, independence and motivation to learn, including the desire to please, imitate and identify with parents and caregivers.

The parent-oriented approach is a parent- or caregiver-based process. This approach focuses more heavily on bladder training, although similar techniques have been successful in bowel training, as well. It teaches the child to distinguish the signals for the need to urinate using increased fluid intake, regularly scheduled toilet time, positive reinforcement for using the toilet and punishment for accidents.

Children often show signs of readiness at some point between the age of 18 months and 24 months. However, it is generally recommended that the child be at least 2 years (24 months) of age before starting toilet training. Some children may be closer to an age of 3 years before they are ready to begin toilet training. In some cases if both the child and the parents are ready, toilet training can begin before the age of 2.

Signs that a child may be ready for toilet training include:

• Ability to control the muscles involved. Remaining dry for at least two hours at a time, remaining dry after naps, and bowel movements that are regular and predictable are signs.
  
  
• Ability to recognize the need to urinate or have a bowel movement. The child may demonstrate this by stopping an activity, moving to a special room or area, or through facial expressions, posture or words.
  
  
• Ability to get to the toilet. The child needs to be able to physically walk to the toilet, sit on it, get off and be able to dress or partially dress.

Signs that a child may be mentally ready to begin toilet training include:

• The child is able to follow simple instructions.
  
  
• The child is able to understand the words involved in toilet training including understanding the words for body parts, urine, stool, and toilet. Simple words may be preferred by some children and parents.
  
  
• Ability to put things where they belong. For example, putting away toys.

Signs that a child may be emotionally ready for toilet training include:

• Child is not comfortable in soiled or wet diapers and informs the caregivers that he or she needs to be changed.
  
  
• Child expresses direct interest in using the toilet or wearing underwear.
  
  
• Child demonstrates independence, such as saying “no.”

According to the American Academy of Pediatrics (AAP), encouragement and praise are both very important throughout the toilet-training process. Parents and caregivers need to remain relaxed and calm. Accidents will happen and punishing the child will not help prevent them. It is best to treat toilet training in a calm, matter-of-fact manner.

The child’s temperament, including attention span and how the child acts in new situations, must be taken into account. For example, shy or withdrawn children may require more initial encouragement and direct questions. Children who are very sensitive or easily frustrated may need more soothing and constant encouragement. It is also important that all caregivers (e.g., day-care providers) know about the child’s toilet training and the methods that the parents are using.

Toilet training is a gradual process that requires time and attention. Bladder control usually, but not always, occurs before bowel control. According to the AAP, bladder training takes an average of 5.8 months for girls and 6.4 months for boys. Bowel training, the AAP reports, takes an average of 6.3 months for girls and 6.9 months for boys. However, many children are trained much faster (e.g., as little as three months) or take much longer (e.g., over a year). Staying dry during the night typically takes months or years longer, especially for boys.

It is beneficial to consult a child’s pediatrician before beginning toilet training. The physician can help determine whether the child is ready and can give advice and information. If any concerns arise during or after toilet training, another visit to the pediatrician can help.

Parents and caregivers can teach the child about the toileting process before toilet training begins. The child should learn words to describe the body parts, urine, stool and other important concepts. To prevent confusing the child, these words need to be simple but proper. It is important to use simple sentences and concepts that the child can understand and to avoid negative terms.

Parents and caregivers can look for signals that the child is urinating or having a bowel movement and ask the child about them. This helps the child to recognize these sensations. It also helps if the parent or caregiver recognizes the child’s bowel patterns. The child can be encouraged to tell when he or she has urinated or had a bowel movement or is in the process. Eventually, the child learns to tell a parent or caregiver before urinating or having a bowel movement.

Parents and caregivers who are toilet training their children can choose from child-sized chairs and seats. A “potty chair” is a separate chair designed for small children to use as a toilet. It is sized especially for small children and can be emptied into the toilet. This is generally the preferred option because it is easier to use and more stable than seats and less frightening than a full-sized toilet. However, these are typically not used in daycare facilities in order to prevent contamination and infection.

The seat is sized for young children and fits over the toilet seat. It helps a child to feel secure and stable. These seats need to fit securely on the toilet and should not wobble. When a seat is used, a stepping stool is recommended to help the child reach the seat and securely place the feet.

A child-sized potty chair or seat should be placed in every bathroom. It is also recommended that a potty chair be kept in the car for emergencies and traveling. It may also help to keep a chair in the child’s bedroom for convenient or emergency nighttime use.

It is important to let the child become familiar with the potty chair. If the child shows interest, allow him or her to pick out the potty chair. Treat the potty chair as the child’s personal property. Allow the child to personalize it (e.g., with stickers) and keep the chair in a play area before toilet training begins. The child can begin sitting on the potty chair clothed, like any other chair. Then, he or she can sit on it in a diaper. Eventually, the child will be comfortable sitting on the chair bare-bottomed.

Disposable training pants can be useful as a transitional step and for nighttime protection. When the child begins to remain dry for several days or nights, it may be time to switch to underwear. However, some children may consider training pants to be a different form of diaper and use them accordingly instead of going to the toilet.

It is typically recommended that boys sit to both urinate and have a bowel movement at first. This is generally easier and less confusing. The child can learn to urinate while standing later.

Toilet training steps and tips include:

• Soothe toilet anxieties. The loud sounds and flushing away of materials may frighten some children. It may help to allow the child to flush pieces of toilet paper or to say goodbye to his or her urine or stool as it is flushed.
  
  
• Dress the child appropriately. Use simple clothes that the child can remove and put on by him or herself.
  
  
• Demonstrate toilet use. Place stool from the child’s diaper into the potty seat or toilet. Parents and caregivers can also allow the child to watch while they or others (e.g., siblings) use the toilet. The child can also be encouraged to sit on the toilet chair while watching.
  
  
• Set routine potty time. Have the child sit on the potty chair or toilet as a part of the everyday routine. If the child shows signs of or actively says that he or she needs to use the toilet, this is also a good opportunity for toilet time. However, do not force the child to sit on the toilet.
  
  
• Consider a reward system. Offering rewards (e.g., stickers, activities) for successfully using the toilet can help to motivate a child. A chart may help keep track of successes. Even if a reward system is not used, the child should be praised after every success.
  
  
• Consider time without a diaper. Bare-bottom time or time in normal underwear may help the child recognize the feeling of needing to use the toilet. This is because some diapers and training pants are designed to draw moisture away from the skin, so children do not feel them as well.
  
  
• Keep hygiene in mind. Teach the child how to wipe correctly. For example, girls need to wipe from the front to the back. This prevents drawing bacteria from the rectum towards the vagina and urethra. Washing hands after every use of the toilet is also very important for both genders.

Accidents happen both during and after toilet training. However, frequent accidents throughout the training process may indicate that the child is not ready for toilet training. Children who have been trained may relapse during times of stress, such as the arrival of a new sibling, a move to a new home or childcare facility, or periods of familial stress. It is not recommended to begin toilet training during stressful times because the process may be affected.

Many toilet training problems result from using improper training techniques or applying too much pressure on the child. Improving the technique used and avoiding pressure can help. Anxiety can also be a problem. The toilet can be very frightening to some children. They may believe that pieces of their body are being flushed away or that they will be sucked into the toilet. Explaining the purpose of body wastes and allowing the child to flush pieces of toilet paper or say goodbye to the waste as it is flushed can help relieve these anxieties.

Common problems associated with toilet training include:

• Constipation. If a child is experiencing hard, painful stools, he or she may be constipated. Maintaining a nutritious, well-balanced diet with plenty of fiber and water can help. Sometimes, reducing the amounts of dairy products that the child consumes can also help. A pediatrician can recommend treatment options.
  
  
• Withholding. Holding back bowel movements. Children may do this when they are under too much pressure, have constipation or have some other physical problem (e.g., anal fissure). Withholding can also cause constipation. A child who is withholding may also be testing parental limits or rebelling. Consulting a pediatrician can rule out or treat physical problems.
  
  
• Resistance or refusal. Occurs when the child continues to use diapers or have bowel movements in clothing or elsewhere and refuses to use the toilet. The child may even ask specifically for a diaper to have a bowel movement in. This may occur because the child is not ready, is under too much pressure, is afraid of or anxious around the toilet, or is constipated. A positive feedback system (e.g., praise, encouragement, rewards) often helps.
  
  
• Enuresis or encopresis. The involuntary leakage of urine (enuresis) or stool (encopresis).  Bedwetting, or nocturnal enuresis, is common until about age 5. This is because nighttime bladder control often takes longer than daytime control. Frequent daytime leakage may be due to a variety of factors and a pediatrician should be consulted.
  
  
• Playing with stool. Some children attempt to play with their stool. This can be prevented by informing the child in a non-accusative manner that stool is not a toy and it belongs in the toilet.

Preparing questions in advance can help parents have more meaningful discussions with their child’s physician regarding toilet training. The following questions related to toilet training may be helpful:

1. Is my child ready for toilet training?
   
   
2. What should I say to relatives or others who are insisting I rush my child’s toilet training?
   
   
3. What words could I use to describe urine, stool and other toilet-related concepts?
   
   
4. Do you recommend any specific kind of toilet chair or seat?
   
   
5. Would my child benefit from the use of disposable training pants?
   
   
6. Would my child benefit from bare-bottomed time?
   
   
7. What kind of rewards could I offer to keep my child motivated?
   
   
8. Could my child’s toilet training be complicated by constipation?
   
   
9. Could there be a medical problem that’s complicating toilet training?
   
   
10. How long is toilet training likely to last for my child?
    
    
11. How should I handle accidents during and after toilet training?