For Families > Disorders and Treatments > A-Z Disorder Guide > Enuresis

The Old Toilet Training and the New Potty Mastery

by Anita Gurian, PhD and Robin F. Goodman, Ph.D.

Updated by Kathleen Kiely Gouley, Ph.D.

Introduction

Many a parent is daunted by the thought of toilet training. Parents worry they will never get it right; they worry that if they get it wrong the child will be marked for life. The reality is that most children figure it out, even those with toileting problems. The main things to keep in mind are:

  1. the child must be ready for the task,
  2. the parent may need help in order for the child to achieve mastery and
  3. everyone needs to have a relaxed attitude about the whole process.

Real Life Stories

My mother-in-law can't understand why my son, who's 2 years old, is still wearing pull-ups. All her children trained by the time they were 2.

My son is 2 years and 3 months, and he seems frightened every time he hears the water flushing in the toilet or going down the drain in the bathtub.

When my daughter was 3, she suddenly announced one day she didn't want bulky diapers, so she just decided to use the toilet and hasn't had an accident since.

What's the big deal? My twins are 5 and one of them still wets his bed at night. I know he'll stop eventually.

Toilet training: a closer look

When
Most children become physically and emotionally ready to master their urine and bowels some time between the ages of 2 and 3. At this time they are better able to control their physical urges, and they want to be more grown up. But timing is more than a date on the calendar. Children will indicate their readiness for the job by other accomplishments, such as following simple instructions in other areas of life, staying dry for longer periods of time while in diapers (a general sign of readiness is staying dry for two hours), making sounds and acting as if they are on the toilet, and curiosity about bathroom activities. Other signs include regular and predictable patterns of bowel movements, and growing discomfort with soiled diapers and a wish to be changed. Remember, girls generally master toilet activities earlier than boys and each child has his or her own mastery time table. Also keep in mind that daytime control often comes before nighttime dryness, so some type of diaper may be needed until round-the-clock control is accomplished by age 4 or 5.

Power
One of the biggest stumbling blocks in toilet training is the power struggle that can ensue between parent and child. Some parents may feel pressured to get the job done, which in turn can create undue pressure for the child. It seems logical then, that one of the best ways for a child to communicate that he's upset about being pressured is to have "accidents." Some children just are not yet ready to take this grown up step and feel the need to languish in the more infant-like state of wearing diapers. This may be due to a cautious temperament or to some other stress in life, such as the birth of a sibling or a change to a new day care center.

Language
There is no need to find cute names for body parts or body products. Children learn the word "elbow" and can learn the words "penis" or "vagina." Urine and bowel movement are somewhat sophisticated terms, and the more common "pee" and "poop" are generally accepted vocabulary. Parents should also make an effort to differentiate these two functions when the child is learning to go to the bathroom, so they learn the difference between urinating and having bowel movements. Lastly, in the midst of training, it is best to avoid negative words like "smelly" so that the child doesn't feel embarrassed or unclean.

What to do—some approaches

Each in his or her own time
This approach advocates allowing the child to warm up to the idea. A first step is letting the child play and get used to the actual tools, the potty in particular. Have the child sit on it or even carry it around. Eventually a parent should show how it is used, have the child sit on it without clothes, and even take a bowel movement from a diaper and put it in the toilet. Many experts believe that using pull-ups can be confusing and compromise success. These new inventions are so effective that the child may not actually feel the urine or bowel movement while he is wearing them. Thus, cloth-training pants may be a better alternative. Very recently, less absorbent diapers have also been introduced for just this reason- to provide a child "on the cusp" of toilet mastery the opportunity to feel damp after wetting. Certainly at some point, regular underwear, rather than any diaper or pull-up, may be necessary to actually help the child feel wet or soiled, thereby learning what it is they need to control. In the short term there will be accidents but they will decrease.

Organized practice
Although this approach incorporates many of the same steps and methods outlined above, many parents structure the learning in a more specific way. With this approach, parents have the child sit on the potty several times a day. The child may or may not produce any urine or bowel movement. Parents can talk about the issue at this time and make the experience generally pleasant, but the child is not forced to use the potty. The process is helped if the parent tracks when the child generally urinates, either in a diaper or the potty, and then structures times that are most likely to yield success. Parents can also look for signs that the child needs to urinate or defecate and try to quickly get the child to the potty to help him associate the activity with the new routine.

Do it in one shot
Some advocate the (almost) one-day training. This approach was originally developed as a way to help special needs children learn mature toilet behavior, but has since been adapted for all children. It involves setting aside one or two days for intensive training, including doll play, checking for dry pants, and praise for correct behavior. Some parents are sold on the idea and some do some variation on this method. Proponents find the results to be long-lasting. However, detractors feel there is no need to pressure the child with such an intense program and worry about the all-or-nothing goal over such a short period of time.>

Rewards
Experts differ on the quantity and style of rewards for children while they are being toilet trained. One approach suggests motivating children with small tokens such as stickers immediately after a successful use of the potty. Charts can be useful in helping children see their progress. Some children can be motivated by a reward requiring more steps, such as getting a small prize for staying dry for an entire day. And while some professionals, and other parents, go the route of effusive praise and applause, others say a more nonchalant attitude can help keep the activity in perspective.

Other Help
A number of books and videos can help parents and children understand this new activity. Parents should consider the value of using themselves as models for their child and the use of doll play (with a doll that wets). Rehearsal, practice, and imitative learning are powerful tools. Watching parents provides children with a chance to actually see what it is they are trying to accomplish and also gives them incentive to be "just like mom or dad." Practicing with dolls helps orient children to the toilet mastery idea and can help a parent understand where a child stands in the process. Possibly even more important, play affords parents a way to predict trouble spots and identify a child's misconceptions.

Warning Signs

Encopresis (soiling) is the diagnosis given to an individual who passes feces in inappropriate places either with or without intent. Some estimate that it affects from 3 to 8% of the general population of children, with boys being four to five times more likely than girls to have encopresis. According to the Diagnostic and Statistical Manual - IV, which delineates disorders, for a child to be diagnosed with this problem, he must be at least 4 years old, not have some physical or medical problems and must exhibit the problem behavior at least once a month for three months.

Similarly, for a child to be diagnosed with enuresis (involuntary urination) he must urinate in inappropriate places, be at least 5 years old, urinate inappropriately at least twice a week for three consecutive months, or have enuresis impact negatively on his life. The diagnosis is often divided into daytime or nighttime wetting. About 40% of all 3-year-olds and possibly 15 to 20% of all 5-year-olds wet their beds at night, with boys being twice as likely as girls to be bed wetters. Daytime wetting is much less prevalent, with rates as low as 3% of 6-year-olds.

Children do not achieve bladder or bowel control for various reasons. Parents should first work with their pediatrician to rule out any physical or medical cause for a wetting or soiling problem. The possible causes for encopresis may be psychological, anatomical, physiological, or dietary. Thus treatments for soiling are tailored to the different possible sources of the problem. Under the guidance of a professional, some combination of enemas and suppositories, reward systems, behavioral training, monitoring of fiber intake, and even family therapy are usually used. There is no clear, single cause for enuresis. Possible theories include an undeveloped bladder, a hormonal problem, a child's inability to recognize the need to urinate, or enuresis may signal that the child is under some stress. In addition, there may be a hereditary factor. A child has a 40% chance of having enuresis if one parent had the problem and a 70% chance if both parents had the problem. For enuresis, treatment may include any and all of the following: medication, urine alarm, behavior modification, muscle control exercises, rewards, and relaxation training. For both problems, for unknown reasons, up to 15% of the children may get better without any treatment.

Questions & answers

Should I worry that my 3-year-old son isn't toilet trained yet?

Gone are the days when experts told parents there was a magic age at which to train their child. We now realize that children develop the ability and the desire to master the toileting functions at different ages, just as they learn to walk and talk at the time that is right for them. In fact, a recent study in the Journal of Pediatrics suggests that children whose parents start training at a younger age actually take longer to master toileting (Blum, Taubman, and Nemeth, Pediatrics, 2003). However, just as with other developmental milestones, children do need help from their parents. A parent should decide the technique that best suits them and their child. We do not even consider it a problem until a child is at least 4 years old and has not achieved bowel control, and 5 years old and has a problem with wetting.

My 6-year-old still has "accidents" and soils his pants. Should I make him clean it up?

A 6-year-old child with a soiling problem should be evaluated. It is important to rule out any physiological reason for the problem. Without a physical or medical cause, parents may do best with guidance from a mental health professional about setting up an appropriate behavioral plan. One of the most important tasks for parents to do is to handle their own frustration with the child's "accidents." If a child is involved in the cleanup, it should be done without fanfare. It is best for a parent to stay calm about the situation rather than embarrass or reprimand the child.

Does it help or hurt to let my child see me going to the bathroom?

Children are master imitators. They often learn new behaviors by modeling the behavior of older siblings or parents. Children at the toddler stage are naturally curious and may benefit from actually seeing how it is done. Certain parents must keep in mind their own standards about privacy and limit exposure as children get older.

Which is best, diapers, pull-ups, or underwear?

At some point it may be necessary to actually have your child use underwear, even before he is fully trained. The problem with pull-ups and training pants are that they are almost too successful. Because the toddler doesn't feel wet, she may have difficulty making the connection between the urge to urinate and what happens. At this in-between stage, parents may try just using the pull-ups on outings and leave the underwear for training time at home. Also, some children have been known to be quite motivated to achieve mastery when they own underwear with their favorite cartoon or movie character. Finally, a new alternative may be diapers with less absorbency, developed for children at this age, that enables children to feel damp after wetting so that they can make the connection between physical urges and their consequences.

Should I send my 7-year-old to sleepovers even though he's still a bedwetter?

A number of issues are involved. First, it is often helpful to consult a professional about special night time training behavior or a urine alarm system. It would be unfortunate if the bedwetting problem created social problems for the child. Parents should talk to their child about the situation, find out what peers know, and how the child feels about bedwetting. Sleepovers might still be possible if the parent talks to the host parents to find out the sleeping arrangements in advance and discuss options, such as bringing a sleeping bag or even discreetly using some type of training pants at night. And certainly, one solution may be to have the sleepovers at the child's own home.

About the Authors

Robin F. Goodman, Ph.D., is a clinical psychologist specializing in bereavement issues.

References

Blum, Taubman, and Nemeth (2003) Relationship Between Age At Initiation of Toilet Training and Duration of Training: A Prospective Study. Pediatrics, 111; 4: 810–814.