046: How to potty train a child

When should I start potty training?  What books should I read?  Can I do it in a day (or a week)?  Do I need stickers (for rewards)?  Does it have to be stressful?

I get these kinds of questions pretty often, and I’d resisted doing an episode on potty training because there are so many books on it already, and everyone has their opinion, and I really didn’t want to wade into it.  But ya’ll kept asking and my resolve has finally crumbled, so today we’re going to talk all about what the research says, what the books say, and how there’s essentially no correlation between the books and the research.  We’ll review the “do it in a day!” methods and what makes them successful, and we’ll also look at child-led methods.  You’ll leave this episode with a clear picture of which is probably going to work best for you, and some concrete tools you can put to work (today, if you need to!) to start what I prefer to call the “toilet learning” process.

 

Other episodes references in this show
021: Talk Sex Today
009: Do you punish your child with rewards?
020: How do I get my child to do what I want them to do? (Unconditional parenting)
042: Manners

 

References
Au, S. &; Stavinoha, P.L. (2008). Stress-free potty training: A commonsense guide to finding the right approach for your child. New York, NY: AMACOM.
Barone, J.G., Jasutkar, N., & Schneider, D. (2009). Later toilet training is associated with urge incontinence in children. Journal of Pediatric Urology 5, 458-461.
Benjusuwantep, B., & Ruangdaraganon, N. (2011). Infant toilet training in Thailand: Starting and completion age and factors determining them. Journal of the Medical Association of Thailand 94(12), 1441-1446.

Blum, N.J., Taubman, B., & Nemeth, N. (2003). Relationship between age at initiation of toilet training and duration of training: A prospective study. Pediatrics 111(4), 810-814.
Butler, J.F. (The toilet training success of parents after reading Toilet Training In Less Than A Day. Behavior Therapy 7, 185-191.
Duong, T.H., Jansson, U-B., & Hellstrom, A-L. (2013). Vietnamese mothers’ experiences with potty training procedure for children from birth to 2 years of age. Journal of Pediatric Urology 9, 808-814.
Fertleman, C., & Cave, S. (2011). Potty training girls the easy way: A stress-free guide to helping your daughter learn quickly. Philadelphia, PA: Da Capo.
Fertleman, C. & Cave, S. (2009). Potty training boys the easy way: Helping your son learn quickly – even if he’s a late starter. Philadelphia, PA: Da Capo.
Gerber, M. (2002). Dear parent: Caring for infants with respect (2 nd Ed.). Los Angeles, CA: Resources for Infant Educarers.
Glowacki, J. (2015). Oh, crap! Potty training: Everything modern parents need to know to do it once and do it right. New York, NY: Simon & Schuster.
Goode, E. (1999, January 12). Two experts do battle over potty training. The New York Times. Retrieved from: http://www.nytimes.com/1999/01/12/us/two-experts- do-battle- over-potty- training.html
Gross-Loh, C. (2007). The diaper-free baby: The natural toilet training alternative. New York, NY: William Morrow.
Horn, I.B., Brenner, R., Rao, M., & Cheng, T.L. (2006). Beliefs about the appropriate age for initiating toilet training: Are there racial and socioeconomic differences? Journal of Pediatrics 149, 165-168.
Kaerts, N., Van Hal, G., Vermandel, A., & Wyndaele, J-J. (2012). Readiness signs used to define the proper moment to start toilet training: A review of the literature. Neurology and Urodynamics 31, 437-440.
Kimball, V. (2016). The perils and pitfalls of potty training. Pediatric Annals 45(6), 199-201.
Koc, I., Camurdan, A.D., Beyazova, U., Ilhan, M.N., & Sahin, F. (2008). Toilet training in Turkey: The factors that affect timing and duration in different sociocultural groups. Child: Care, Health and Development 34(4), 475-481.
Martin, J.A., King, D.R., Maccoby, E.E., & Jacklin, C.N. (1984). Secular trends and individual differences in toilet-training progress. Journal of Pediatric Psychology 9(4), 457-468.
Matson, J.L., & Ollendick, T.H. (1977). Issues in toilet training normal children. Behavior Theraly 8, 549-553.
Shaikh, N. (2004). Time to get on the potty: Are constipation and toileting refusal causing delayed toilet training? Journal of Pediatrics 145, 12-13.
Taubman, B. (1997). Toilet training and toileting refusal for stool only: A prospective study. Pediatrics 99(1), 54-58.

Vermadel, A., Van Kamepn, M., Van Gorp, C., & Wyndaele, J-J. (2008). How to toilet train healthy children? A review of the literature. Neurology & Urodynamics 27, 162-166.

 


Transcript

Hello and welcome to the Your Parenting Mojo podcast.  I had actually resisted doing an episode on today’s topic for quite a while but listeners kept emailing to ask me about it so my resistance has crumbled and today we’re going to talk about potty training.  I prefer to call it toilet learning, but we’re going to look at a lot of different studies on this topic and I’m going to use the language that the individual authors use in their work.

There are SO MANY books about it and everyone seems to have their own opinion about it and I kind of didn’t want to stir the pot. Or even put my oar in it, to mix metaphors.  But you, my dear listeners, have spoken, and so I, your humble research assistant, have listened, and so today we are going to talk about potty training.  And toilet learning.  And we’re going to look at all of this through the lens of respectful parenting, because practitioners of respectful parenting have a fair bit to say on this topic.

 

So for those of you who listen to the show regularly, it probably won’t be enormously surprising for you to hear that toilet learning is profoundly impacted by cultural considerations.  Starting with the earliest possible age for toilet learning, we come to the concept of Elimination Communication, abbreviated to EC, which was popularized anew in Christine Gross-Loh’s book The Diaper-Free Baby, and I’m going to spare you the $13 on Amazon or even the three week wait in your library’s hold queue and tell you that the method basically involves watching for and learning a baby’s signals that he or she needs to pee or poo and providing opportunities to go at that time, providing opportunities to go at regular intervals even when the baby doesn’t indicate readiness, and making a whistling or zzzzz sound while you hold the baby over a potty or a hole in the garden which tells the baby that it’s time to go.  Not much to it, right?

This approach is, of course, most common in countries where interdependence, rather than independence, is prized – since it relies so heavily on reading signals given by others, it’s not surprising that this approach is used in countries like China and Vietnam where a big part of being a citizen in society is developing the ability to read signals given by other people.  The key to all of this is that it’s done when the baby is very young.  And I’m talking infant stage.  A study conducted by a joint Vietnamese-Swedish research team interviewed forty seven mothers about their potty training experiences from the time the babies were newborns until they were 24 months old; the researchers stopped interviewing the mothers when the babies were 24 months because all of the children were potty trained by then.  To a Western audience, that must sound incredible – I was certainly pretty surprised, and I even had some experience with EC.

The Digo tribe in East Africa begins toilet training a few weeks after birth; they expect some dryness at night by around six months and complete dryness at one year.  The babies are in constant contact with the mothers for the first couple of months of the baby’s life and whenever the mothers sense that the baby needs to pee or poop the mother holds the baby between her knees.  When the baby is 3-5 months old a sibling or other female family member aged between 5-12 years takes over primary care of the baby during the day, and if an accident occurs it is actually the caregiver rather than the infant who is punished.  So in the Digo culture, it is primarily the responsibility of parents and caregivers to recognize and respond to the child after the child indicates their need to pee or poop.  This is in stark contrast to Western cultures where the responsibility is primarily placed on the child to indicate that they need to pee or poop and to get themselves to the toilet, undress, void, wipe, and re-dress.  One study looked at mothers from different backgrounds in Turkey, and found that the both the age of initiation of potty training as well as the age of completion was much earlier among rural families that lived in homes without an inside toilet, families using washable diapers, and families who punish children.  Mothers having an education of more than 12 years tended to initiate training much later and used a more child-led approach.

 

We had a pretty traumatic first few months with my own daughter’s peeing; she would cry as soon as she peed and would continue to cry until her diaper was changed.  She was also very gassy as well so she actually cried a lot of the time in those early days and we had the Pamper’s diapers with the stripe on them that turns from yellow to blue when it gets wet.  She would start to cry and we would quickly check the stripe to see if it was blue, and it wouldn’t be blue, and she would keep crying and twenty seconds later it would turn blue – she was actually more reactive than the wetness indicator stripe.  We wondered if she might have a urinary tract infection but sometimes she would pee mid-change and wouldn’t cry at all then.  We went through sixteen diapers a day in the first few months; I know this because I hiked around Mont Blanc with her when she was eight weeks old and I had to count how many diapers we were using each day before we went so we could be sure to carry enough.

I think I read The Diaper-Free Baby when she was about five months old, because my in-laws were living with us from the time she was four through six months old to help take care of her while I went back to work.  I knew they would think I was crazy for trying EC so I waited until the day they left to start.  Within a couple of weeks she was doing pretty much all of her pees and about half of her poops on the potty, and when our nanny started work a few weeks later she was stunned to find a seven month-old mostly using the potty.  And the nanny was actually from Thailand, but I guess she had been in the States for entirely too long because a study out of Thailand reports that 80% of 50 infants who were followed by some Thai researchers were fully toilet trained by 12 months.  That study also found that children who weren’t the first child, and who were taken care of by a well-educated mother, were found to start toilet training late – perhaps exposure to more Western ideas, as well as having enough money to be able to afford diapers, were behind this trend.

I read a few books on potty training to prepare for this episode, along with a whole host of empirical research, and I have to say that that’s where the correlation between the two ends – researchers publish the results of empirical studies, but the people who write books on potty training seem not to read that research – or at least, I’ve yet to meet a book that cites any of it.  So let’s start going through some of that research and I’ll bring in information from the books as it seems appropriate.

If we missed the window for teaching through EC, which by all accounts has to be done early in the child’s life, then we have two-main choices for how to proceed – we can do a parent-led approach where we establish a date when we will “train” the child, and we train them on that day – we expect results the same day or certainly within the same week.  Or we can watch for signs that the child is ready to begin learning how to use the toilet, and allow the child to lead the process.

This readiness is, like many of these kinds of things, something that is culturally determined.  A study of 779 parents visiting child health providers in and around Washington D.C. found that the average age at which Caucasian parents believed toilet training should be initiated was 25.4 months, significantly later than African American parents (18.2 months) and parents of other races at 19.4 months.  Higher income was also associated with later toilet training.  This is certainly later than parents have toilet trained in the past – I found an abstract for a study from 1983 (although I couldn’t find the full study) stating that the first appearance of toileting skills appeared between 18 and 36 months in a dataset from 1975, which itself is described as being much later than in a comparable cohort (we have to assume they mean “mostly white”) from 1947.  Another study found that when children start training at a younger age then toilet training takes longer, although these children do end up completing training earlier than children who start later.  Training before the age of 27 months is apparently not correlated with the earlier completion of training, suggesting that there is little benefit to starting before then.

A variety of researchers have produced impressive-looking charts of signals that a child is ready to begin potty training.  One literature review graphed twenty one signs of readiness according to when the sign appears – some of these included the ability to sit and to walk, which appear between four and 18 months, acquiring voluntary control of the pelvic muscles which appears between 9-24 months, and understanding and responding to directions or questions and being able to follow simple commands appears between 9 and 26 months.  The majority of researchers as well as lay authors writing about potty training stress the importance of readiness, but there is no consensus whatsoever in the literature about how many of these readiness signs need to be present for the child to start potty training, which ones are more important in terms of judging an individual child’s readiness.  Many of the authors who say “a child must be ready” often give ages at which certain readiness signs should be present give different ages from each other.

 

So that gives us some information about when we might start thinking about toilet learning, but what do we actually do when we think that window has opened?  Well, it seems as though there are basically two approaches, and some people who attempt a middle ground between the two.  One approach seems to see toilet learning as the process of “getting urine and feces in the toilet,” as Magda Gerber, who founded the RIE approach to parenting, puts it.  Parents who see toilet training in this way will do whatever it takes to get the urine and feces in the toilet, typically making extensive use of rewards to make that happen.

Let’s cover the with the parent-led approach to toilet training first, which was formally developed by two psychologists named Asrin and Fox in 1974.  Any book published since then that promises parents they can potty train in a defined and short period of time probably uses some elements of this approach, although what they invariably neglect to state is that it was actually developed for “retarded and brain-damaged children,” and then the researchers appear to have decided that it was also applicable to normally developing children as well.  I should be up-front here and say that I haven’t read the book; I couldn’t get it from the library and honestly I didn’t want to give the researchers any money by buying it.  So if you’re considering this approach you should certainly read the book, but the gist of it is that once children are 20 months old (I’m not sure why this is the magic number) and can meet a variety of other criteria like being able to walk, staying dry for a couple of hours at a time, and following simple instructions, you set aside a day for potty training.  You set up a potty in an area big enough to play in, like the kitchen, and you show the child how to use the potty by showing a doll “drinking” water and “urinating” on the potty after taking its diaper off.  You do this a couple of times, first successfully, so the doll “pees” on the potty and gets a reward, and then “unsuccessfully” so the doll wets its underwear and then has to do a practice drill of going to the potty even though they don’t need to go.  You make sure your child drinks lots of fluids so he needs to pee.  Then repeat the same process with the child – when the child pees on the potty, he gets a reward.  If the child pees in his underwear, he has to do the drill of sitting on the potty.  Azrin and Fox tested their method on 34 children with the average child completing training in 3.9 hours and having a 97% decrease in accidents the week after training.  Sounds good, right?

Apparently there were so many reports about failures of parents to train their children using the book that people began to form classes to train parents in using the Asrin and Fox method.  One researcher noted that parts of the procedure are subtle (so don’t try to use this method just from my description; you’ll have to go and read the book) – and parents might lack the self-control required for this method.  It turns out that having extra support ends up being fairly critical for success – one admittedly very small study of ten children randomly assigned the children to either have a parent who would just read the book, or have a parent read the book as well as have an experienced trainer available for “supervision and prompting.”  Children whose mothers just read the book had about five accidents per day at the beginning of treatment, which dropped to about four over the course of five days of treatment, but actually rebounded to a peak of SEVEN accidents per day seven weeks after training before dropping again slightly to a level that was still above where they were when they started.  Children whose parents read the book and had “supervision and prompting” started with four accidents per day and dropped to an average of half an accident per day by day three, and maintained somewhere between half and one accident per day for the next ten weeks.

Now a couple of things stuck out to me here.  Firstly, that the researchers said that ALL of the mothers reported “emotional side effects” in their children, primarily consisting of tantrums and avoidance behavior.  These behaviors were more evident in mothers who only read the book and didn’t get support, and among younger children and usually occurred after an accident when the child didn’t want to sit on the potty again when they didn’t need to go.  Four of the ten mothers felt so uncomfortable that they wanted to stop the training, but “encouragement” resulted in three of the four continuing.

Does this remind you of anything?  Anything at all?  I’m thinking back to Stanley Milgram’s famous experiment on authority figures where he led study participants to believe that they were giving electric shocks to a learner who answered word pair problems incorrectly.  The participants often asked to stop the experiment to see if the learner was OK, but each time they asked to stop a series of verbal prods was given: “Please continue.”  “The experiment requires that you continue.”  “It is absolutely essential that you continue.”  “You have no other choice; you must go on.”  The participants were clearly stressed by the experiment, but a massive 65% of them gave the final 450-volt shock that marked the upper limit of the fake equipment.  The researchers in the paper on training parents to potty train children don’t state what form of “encouragement” they provided to the parents who wanted to stop the procedure; at its most benign, the experimenter might have emphasized the benefits of potty training for the child and what parent *wouldn’t* take the advice of a licensed psychologist who says that something is good for their child?  At its most nefarious, the researchers might have coerced the parents into continuing with the study “because the experiment requires that you continue,” or because it was important for the researchers to collect data from all participants.

Another study which I saw reported as an example of a study showing the success of the approach didn’t have *any* parents just reading the book; instead, all parents attended training classes on how to use the procedures.  The children averaged ten urine accidents on the training day which quickly declined in the first few days after training and stabilized at less than one accident per day for days 9-14.  Again, it sounds pretty effective, but again the authors note the “negative reactions of children to the use of practice trails after accidents.”  Now “negative reactions” and “emotional side effects” sound a bit sterile; what do they really mean?  It isn’t often that I turn to Amazon as a credible information source but I want to quote from a review of the Azrin & Fox book from Amazon:

This book is a good read on potty training. It is a breath of fresh air from the current trend of late potty training. Earlier potty training isn’t right for every family but it was right for us. Persistent diaper rash and power struggles on the changing table were our motivators (and as a side note from me, I could see persistent diaper rash being a reason why you’d want to get your child out of diapers because it’s really a health issue, but virtually all children go through a period of power struggles on the changing table late in their first year and virtually all of them seem to come out the other side a month or two later).  Back to the review: As stated, this method is not a gentle “wait and see if they’re ready” method. It is for motivated parents who are not afraid to be the authority in their child’s life.

Unfortunately for us our strong willed daughter fought us tooth and nail but was potty trained after a week. If you are the parent of a strong willed child this process will not be a day or two. If you know your child is stubborn set realistic expectations for yourself as you read.

Things from book that we used:
No diapers, panties from the start. Rewarding for dry pants and successful potties. POTTY DRILLS FOR ACCIDENTS. I cannot emphasize this enough. When you have a strong willed child and tell her to go potty she will throw the candy in your face and say NO. Our response was “ok. If you have an accident we will have to practice.” after 5 days of potty drills (walking/dragging her multiple times from scene of accident to potty and making her help clean the mess) our stubborn daughter started taking initiative to potty on her own. This is the key to the Azrin method that stood out to us and worked. By day 7 we were mostly accident free. This process isn’t fun but it works.

*Note: some feel that running potty drills is “shaming” your child. As long as one is calm and not berating their child, I would disagree. It is consistently showing them that a potty accident is not a desired thing to have. It is teaching them to take ownership in the accident and help clean up.These are life lessons not just potty lessons! Happy training.

So it seems clear that the Azrin & Fox method is not for the faint of heart.  A paper reviewing a variety of potty training methods notes that it has the advantage of a short training time and reduces compulsive parental pressure, by which I assume the authors mean that there is a lot of parental pressure during the training but after that the parents can back off and not have to say “when are you going to start using the potty?” on a daily basis.  Unfortunately, these reviewers noted far more disadvantages to the method, including the “emotional side-effects” that we’ve already discussed, as well as,

secondly, rushed, rigid training may fail and may even cause behavioral problems,

thirdly that it isn’t effective without professional supervision,

fourthly that taking the child to the potty as punishment when they don’t need to go could lead the child to regress,

and fifthly the practical barriers like not having a specialized trainer available.

Your success is likely to be linked to how stoic you are in terms of accepting what seem to be the inevitable tantrums that will come when you start taking the child to the potty as punishment.  If you can remain firm, you stand a good chance of success.  If not, perhaps not so much.

If you’re feeling that a hard-core parent-led approach isn’t for you, perhaps a middle ground would be a better fit – something that still makes extensive use of rewards, but perhaps a little less use of punishments.  I’m going to quote from the book Potty Training for Girls The Easy Way, which is actually co-written by a doctor: “Little girls love stickers, so hunt out some that she hasn’t had before and thinks are a bit special.  A reward chart helps spur on most girls – you can buy a ready-made chart from large supermarkets and office supply stores…Write a list of training achievements down one side, such as sitting on the potty, peeing in the potty, pooping in the potty, pulling down underpants, pulling up underpants, and washing hands.  Every time your little girl completes an activity, she gets a star or a sticker – you can buy these or just draw on stars.”  Once you start training, “suggest that your daughter sit on the potty and explain that she has to pull her underpants down.  Chances are she won’t need to go the first time, but give her lots of praise anyway. Tell her she’s a clever girl just for sitting.”  Then they really bust out the big guns for what the authors call “her first success” – “The first time your daughter pees or poops in the potty, go crazy with the praise.  Clap, kiss her, phone Daddy to tell him, and award her a particularly pretty sticker.  Give her your full attention and loads of praise for at least a few minutes, and she’ll soon be on that potty again.”  Honestly, it was really kind of hard for me to read that book.  And I’m ashamed to say it was written by English authors – they changed all the “mummy”s to “mommy”s but they left in some key clues like “make sure she knows you aren’t cross if she has an accident” and the real doozy in the boy’s version of the book – calling a penis a “willy.”  If you missed the episode on Talk Sex Today, I’ll just say here that it’s really important to use anatomically correct terms, not “fanny” or “willy” or, heaven forbid, “twinkle” or “minkie” as these authors suggest.  If your child is being abused and can’t tell anyone because nobody understands that “someone is touching my twinkle,” then we have a real problem on our hands.

I was pretty shocked that the Potty Training Girls the Easy Way approach to rewards was actually one-upped by none-other than the Distinguished Psychologist for 2005 in Dallas, Texas, who wrote a book called Stress-Free Potty Training: “For potty training, a consequence like praise is different from tangible rewards like the ever-popular M&Ms or stickers.  Both are reinforcing to a child, and the little candies may be more potent in the short term, but the effect is fleeting and there is no carry-over.  The behavior is associated with the M&M only.  Positive statements, praise, and hugs are much more potent in the long run and will be more likely to stimulate the intrinsic motivation that we all want our kids to have because they represent something much more valuable than a tiny piece of chocolate – our respect and admiration.  Any child’s desire for this grows – more so than her desire for another M&M.”  Honestly, I’m not even sure what to say about this one.  The fact that a Distinguished Psychologist could think that positive statements, praise, and hugs stimulate intrinsic motivation when so much research states the exact opposite is, frankly, very confusing to me.  If you’ve been listening for a while you might recall the episode we did on Alfie Kohn’s book Punished by Rewards, where we learned that rewards are not qualitatively different from punishments; they’re kind of on the same continuum as punishments and are actually more pernicious than punishments because what we’re essentially saying to the child is “I’ll show you I love you, as long as you pee on the potty.”  We’re ultimately talking about showering our child with love and attention because they performed a natural bodily function, and removing the child’s intrinsic motivation to do this activity and replacing it with the extrinsic motivation of our love.  And maybe a few stickers.

Parents usually use a parent-led approach to training because they want to initiate training before their child has shown some signs of readiness.  And I want to say that there *are* legitimate reasons to be concerned about later potty training – potty training after the age of 32 months is associated with dysfunctional voiding, which is another way to say a frequent need to pee and dribbling pee rather than the ability to hold it and go when they get to the potty.  Dysfunctional voiding can lead to Urinary Tract Infections and other kinds of undesirable outcomes, some of which I can’t pronounce.  Some parents don’t have a choice about what kind of daycare or preschool their child attends, and some of those options unfortunately require that a child be potty trained before they start attending.  If your daycare wanted you to get your child potty trained before they start and you have a choice about which daycare to use then I’d say “choose the other daycare,” but sometimes you just don’t have that option.  If you must potty train before the child has indicated they are ready, rewards – with some punishment as you feel it’s necessary – are the way to get that done.

At the other end of the spectrum from the Azrin and Fox method and even pretty far from the stickers and praise methods is the approach promoted by both Magda Gerber and the famous pediatrician Dr. T. Berry Brazelton himself, who isn’t such a household name as he used to be back in the 1980s and early 1990s.  In general, we can summarize their approach as “wait until the child is ready.”  If we need any more evidence of the dichotomy between these two approaches then we can look no further than a 1999 New York Times article which quoted parenting expert John Rosemond, who actually has a podcast called “Because I said so,” which I’d probably suggest you avoid if you’re a fan of this show, who considers it to be “a slap to the intelligence of a human being that one would allow him to continue soiling and wetting himself past age 2” – the process, he says, should be as simple and straightforward as housebreaking a 4-month-old puppy.  Dr. Brazelton, on the other hand, advocates for waiting until the child decides they are ready – and while he has been promoting this viewpoint for a while, we should also note that later on he developed a substantial motivation for maintaining this approach – he was the national spokesperson for Pampers diapers for a while, and even appeared in their commercial for size 6 diapers, suitable for children 35lbs and over.

What all Brazelton and Gerber – as well as the Azrin and Foxes and stickers and praise proponents, actually – agree on is that the child needs to be ready – actually three different kinds of ready – before you start toilet learning.  The child has to be physically ready – they have to have the muscle control to physically hold their pee when they need to go; they have to be cognitively ready, which means they have to understand what it means to use the potty, and they have to be emotionally ready, which means that they have to be ready and willing to use the potty and have confidence that they can do it.

So I guess the part that I don’t understand in the behaviorist, dog-training types of advice is that if the child is physically, cognitively, and emotionally ready to use the toilet, why do we need to “train” them?  Surely if they truly are ready in all of these different ways, wouldn’t they pretty much just train themselves?  What it seems to me is really going on is that parents can recognize when their child is physically and cognitively ready, and can use the techniques in these kinds of books to say “well, he’s not emotionally ready to use the potty so I’m going to use stickers and praise and hugs to *make* him emotionally ready.”  And *that* is where we get to the heart of the cultural debate on this potty training issue.  Do we believe that we have the right to exert our will over our children, or do we believe that our children should let us know when they are ready to do things and not do them until then?

I give Jamie Glowacki, author of the Oh Crap! Potty Training book, a lot of credit for discussing this frankly – she refers to Pamela Druckerman’s book Bringing up Bebe and the concept of cadre that Druckerman describes – and here I must apologize to any French-speaking listeners for my appallingly Anglicized French accent, but my vocabulary is at least half-decent, and “cadre” means “frame” or “framework” in French.  So French children are given a strict framework, but a lot of freedom within that framework.  This is pretty much how we operate – we have limits about what my daughter is allowed to do, and within those limits she has flexibility.  For example, our kitchen is very small, and it’s really not safe for my newly three-year-old to be wandering around in there while I’m cooking because it’s hard for me to keep track of whether she’s standing right behind me when I whirl around with a hot pan in my hands.  So we have a rule that if she’s in the kitchen, she has to be in her helping tower.  She doesn’t have to be in the kitchen while I’m cooking; she can do jigsaw puzzles or play with Lego or do some beading in the other room if she likes.  If she’s in the tower she can help me cook, which she likes to do, or play with water in the sink, or just hang out and eat raisins.  But if she’s in the kitchen, she must be in the tower.  The framework is firm, but there is flexibility within it.

So Jamie Glowacki says that one of the biggest challenges parents face during potty training is getting the child to sit on the potty.  She suggests reading or singing to them, or even using a phone as a distraction in the very beginning.  She says that this might sound harsh in the context of potty training but if it’s time to sit down for dinner and your child is bouncing around, and you tell your child to sit and he doesn’t, what do you do?  She says that what you do in that situation should be what you do in potty training.  Now Ms. Glowacki is clearly on the side of telling the child to sit but she doesn’t really say what she would do if they don’t.  You can’t force a child to sit.  (Well, perhaps you could, but it would be pretty unpleasant for you as well as for the child, and you might not try it twice.)  So why do we try?  Why not offer a choice?  At the dinner table, we could say “I see you don’t want to sit still right now.  I don’t think it’s safe for you to bounce around on that chair.  If you’d like to eat your dinner, please sit still.  If you don’t think you can sit still, you can be excused and go and bounce somewhere else.  I’ll leave your dinner on the table until we’re done eating, but after that there will be no more food until tomorrow.  What would you like to do?”  If I say something like that, sometimes my daughter chooses to sit still.  Sometimes she just needs to bounce.  But either way I haven’t put myself into the awkward position of telling her to do something I can’t *really* force her to do and then having to figure out how to deal with that.  So why not do the same with the potty?  Could you imagine someone telling you you had to sit on the toilet, whether you needed to use it or not?  Ms. Glowacki says “when it’s potty time, it’s time to sit on the potty” – but why?  What if we well-meaning parents missed a signal and our lovely toddler was just dancing, and not doing the potty dance, and she doesn’t actually need to go?  Wouldn’t it be better to teach her to understand her own body rather than to arbitrarily sit her on the toilet whenever you think it’s time for her to go?

Ms. Glowacki notes the difference between a child who isn’t ready to use the potty and one who is playing you.  She says that if you’re feeling sad that potty training isn’t going as you’d hoped, then your child probably needs to learn about it some more.  If you feel like strangling your kid, then you’re being played.  She says that when you feel you’re being played, which means the child is peeing in her pants on purpose, the “absolute best thing to do is to give a small, immediate, appropriate consequence” – like taking away the toy he was playing with when he wet his pants.  Now regular listeners might recall that I did an episode on time outs and consequences (and to her credit, Ms. Glowacki does say that time outs aren’t usually effective for “accidents”) a while back, based on Alfie Kohn’s book Unconditional Parenting.  The premise of that book is that we should consider not just the behavior our child is showing us, but what it really means.  So our child probably isn’t peeing in her pants just to piss us parents off; she’s doing it because he’s afraid of the potty.  Or she’s not old enough to hold her pee yet.  Or she’s annoyed that you put him in time out earlier this morning because she knocked over a glass of water.  Ms. Glowacki has clearly read Alfie Kohn; she directly discusses how consequences are the opposite of rewards, but she still thinks that consequences are an acceptable way of dealing with behavior we don’t like.

But how can we possibly know whether a child is peeing on the carpet because they truly aren’t ready, or because she is exhibiting “bad behavior”?  Well, how about asking them?  A two-and-a-half-year-old is just about capable of lying so there is a chance you might not get the truth, but most two-and-a-half-year-olds simply aren’t deceptive enough to repeatedly lie about why they peed on the floor.  So why not ask them?  If they can’t answer you right then and there, how about waiting for a calm moment later in the day and saying something like “I’ve noticed you’ve been interested in the potty a lot lately, which is a sign that you’re getting ready to use it.  But you’ve also peed on the carpet a couple of times now and I don’t like it when that happens because it makes the carpet dirty and it’s difficult for me to clean up.  What do you think we could do about this?  Could we bring a potty into the living room so you don’t have to walk as far?  Would you like to have a special book to read while you sit on it so you don’t get bored?”  Your child may have their own suggestions for what they want to do to make the process of using the potty acceptable, in which case use them!  If they can’t quite articulate this yet, they probably can select from a suite of options you provide (so make sure all of the options you present are acceptable to you).  I agree that “taking away a small toy as a consequence is not going to scar your child for life.”  It’s not.  And if you really feel as though there are no other alternatives to figure out whether your child *can* use the potty if they know their toy is going to get taken away if they pee on the floor then you can go ahead and try it.  But my personal approach to raising my own daughter is that if I use consequences for potty training, then why not for something else like teaching my child to use manners?  And my answer to that is because I truly believe that consequences deliberately imposed by the parent have no place in the respectful relationship I want to have with my daughter.  As we discussed in the episode we did recently on manners, I had been using a very, very mild form of consequences when she failed to say “please” after demanding something like a banana – I would say “Can you think of a better way to let me know you’d like a banana?” and then I would withhold the banana until she produced a “please,” which she usually did immediately (so it’s not like I was starving her or anything).  But then I learned about how to apply Parent Educator Robin Einzig’s approach of Modeling Graciousness to the learning of manners – and simply modeling the behavior I want to see.  So now I say “You’d like a banana, please?  Sure, I’d be happy to get you one,” and most of the time my daughter does use my modeling to reframe her request.  I was uncomfortable with even the mild consequence of waiting an extra ten seconds for a banana, so why would I take away a favorite toy for peeing on the carpet?  Taking away a toy is so unrelated to peeing on the carpet that we shouldn’t really call it a “consequence” anyway; we should use it’s proper name: a “punishment.”

So if you’ve started potty training and are having trouble, can I suggest that you wait for a quiet time (not right after you’ve just had a big fight over whether or not she sits on the potty) and ask her what’s going on?  Jamie Glowacki says that the one thing to watch out for is overtly defiant behavior, so when your child looks you in the eyes and pees on the carpet, because that indicates the kind of anger that really warrants seeing a therapist, and I have to say that I agree.

If you haven’t started training yet and are looking for information on how to start, if you’re interested in the more behaviorist approaches then I say “go for it and good luck,” because as we’ve seen it can be a difficult process although it is likely to be blessedly short.  We used a much more child-led approach at our house.  We already had the potty from when we had used Elimination Communication (my daughter actually started refusing the potty at around fifteen months after using it most of the time for most of the previous year.  We just went back to diapers at the time, but we kept the potty in the bathroom and it was pretty much ignored for several months.  When she got to around eighteen months I would leave the bathroom door open while I used the toilet and would talk about what I was doing, and mention the potty, and tell her that when she felt ready she could use the potty like I was using the toilet.  We didn’t do much more than talk about it for a solid month, and then when I used the toilet I would ask her if she would like to use the potty.  We also started asking before she went in the bath and before she went to bed, and a lot of the time in the beginning she would say ‘no,’ but sometimes she would say ‘yes’ and over time there would be more ‘yes’s and fewer ‘no’s.  It was also pretty obvious when she was pooping in her diaper by then because if we were home she would hide under the dining room table and she was obviously straining; we would always offer the potty immediately but mostly she would refuse, poop in the diaper, and then ask to be changed.

Another part of this was that she loves fleece pajamas; she would resist getting dressed because she wanted to “feel the fluffy on her body.”  One day she wanted to take her diaper off so she could “feel the fluffy on her bum,” and we told her she could do it but if she needed to pee or poop, she had to let us know.  She would wear her pajamas around the house for an hour or two until she had to get dressed because we were going out somewhere, at which point we would put her in a diaper and, over time, we shifted to a pull-up instead of a diaper.  She probably did about three weekends of feeling the fluffy at home, for increasingly long periods of time, and would ask us to use the potty when she needed it – only for pees, not for poops until the last weekend.  We bought some underwear a few weeks previously which we had told her she could wear when she wasn’t wearing diapers any more, and the Monday after she asked to poop in the potty and did it successfully I asked her if she would like to wear underwear to school, which she said she wanted to do.  I was a bit taken aback when her daycare teachers told me that morning when we got to school that once she started wearing underwear at school she wasn’t going back to pull-ups, and I did wish I’d been prepared for that as I might have waited another week or two.  But she made it through that first week with no accidents except right after nap on two different days, when she needed to use the bathroom but couldn’t communicate it to anyone quickly enough after she woke up.

A week or so later we did have three days where we had one accident each day, all at home, and she actually requested a diaper for a day or two in the evenings which I let her wear, as my standards aren’t quite as rigid as at daycare.  I was getting a little frustrated by the daily accidents but the daycare staff said it wasn’t uncommon to have a bit of a regression a couple of weeks after being mostly dry, and to stick with it, which we did, and over time the accidents grew less frequent.  Sometime in this period she would start asking to go to the bathroom when she needed to go; I would send her ahead as she could pull down her pants and sit down on the potty by herself but she couldn’t wipe properly yet or pull her pants back up.  Incidentally, the chart of different skills needed for potty training readiness in one of those research papers says that self-wiping ability doesn’t come until about age four, and I’ve heard anecdata from other parents to say that for some children it comes much later than that.

My daughter learned how to pee and poop on the potty at the same time, but a couple of research papers point out that it’s pretty common for children to pee on the potty before they are willing to poop on it – apparently around 20-25% of children exhibit this “stool refusal” or “stool withholding.”  Another paper notes firstly that most parents don’t find this to be a problem, secondly that it usually resolves by itself, and thirdly that children who exhibit stool refusal don’t have more behavioral problems than children who don’t.  Another paper notes, though, that if stool refusal persists until around age three and a half, then it’s worth talking with your pediatrician about it.  The longer the stool sits in the colon the more water the colon continues to extract from it, which leads to very hard poops that are difficult and painful to pass, and chronic soiling behavior.  If there’s anything that can make it harder to toilet train a child it’s having a child who associates going to the toilet with being in pain, so it’s definitely worth talking with your pediatrician if your child is willing and able to pee regularly in the toilet but won’t poop there.  In one experimental study the parents were instructed to put the child back in diapers and that underpants could only be worn when the child both pees and poops in the toilet on a regular basis.  11 of 28 children started pooping on the potty after a month, and 14 within 3 months, and behavior modification (i.e. rewards) was used successfully with the remaining children.

My own daughter used the potty and the toilet pretty much interchangeably for a couple of months – she was quite happy to perch on the toilet holding onto the sides with both hands, and eventually I decided I was tired of cleaning out the potty so I gave it one more thorough cleaning and it’s now out in the garage awaiting its next owner (drop me an email if you want it).  She’s now three and is proud of her ability to balance briefly on the toilet using no hands.

 

A couple of other things that helped us were having a foldable travel potty that we could pull out on a moment’s notice while we were out and about.  We usually just have her pee on the ground if there’s a suitable place to do it and if not, she pees (and always poops) in the travel potty and we tie up the bag and throw it away.  We still keep it in the car and continue to use it.

Another thing we had to figure out the hard way was what to do about grubby public bathrooms.  This might fall into the category of TMI, but *I* don’t sit on a public toilet so I certainly don’t want my daughter sitting on one.  I tried holding her legs while she was in a sitting position, Elimination Communication style, but she ended up not being able to go while I was holding her like that.  Finally we realized that she could stand on the seat; if she puts her feet so they stick out just a bit over the edge of the seat I can brace her feet with my knees to make sure she doesn’t slip off.  I then put my hands under her arms and hold her while she squats; you do have to be a bit careful – I don’t know if this is the same for all girls, but my daughter forces the pee out pretty fast and it comes out almost horizontally, so I have to have her squat *way* back on the toilet for pee and then be sure to move her forward if she needs to poop so she doesn’t crap on the seat.  I imagine parents of boys have different problems; perhaps you could have your son stand on the seat, perhaps with or without a squat?  I’m not sure – and then hold his penis down so it goes in the toilet rather than all over the room.  I don’t have any direct experience on that front, I’m afraid.

So my overall impressions of my experience with toilet learning were that it was pretty much a non-event.  The whole thing was rather more fluid – pun intended – than I’d expected, although perhaps I should be used to that by now.  When we transitioned out of the crib we had several weeks of going back and forth between the crib and the mattress on the floor, and toilet learning was no different, with the “feel the fluffy” days interspersed by pull-up wearing days at school, and then the mini-regression before she was consistently dry.  She’s a little over three now and still does have the occasional accident – usually after nap time at school – and I’ve also heard from friends that excitement can be a cause for accidents as well.  She also peed while napping in the car on our drive from Kansas City to Springfield a couple of weeks ago, although she drank so much water out of a cool new bottle right before we left that perhaps I should have seen it coming and put her in a pull-up just in case.  Overall the whole thing has been pretty stress-free, and was achieved without a single reward or punishment or even a “good job.”  When she would say “I peed in the potty!” I would just say “yes you did!”.  It really didn’t seem like there was any need to say anything else.

The child-led approach is associated with later training so if this is a concern for you for medical or daycare or other reasons, then you might find that it’s not right for you.  But if those things aren’t an issue for you, I’d highly recommend you start by buying a potty and talking with your child about it, and letting your child lead you from there.  I can’t tell you that your own toilet learning journey will be like mine – it might be harder or it might even be easier – because all children are different.  Boys and girls seem to approach it differently too, with girls displaying several of the readiness signals 1-3 months before boys.  But if you use the child-led approach then toilet learning will at worst be a neutral event in your child’s life and at best something that enhances your relationship with your child as she learns that you are willing to help and support her to undertake this task associated with growing up, but that you’re willing to let her take the lead and tell *you* how it’s actually going to happen.  Because as our children get older, don’t we want them to know that we’re there to support them as they use the things they’ve learned about their bodies and their minds to live their own lives?  And if that is our goal, why not start down that path now?

I should also acknowledge that nighttime training is a very different thing from daytime training.  One meta-analysis of many studies on potty training found that nighttime dryness was possible but pretty rare by around age two, and was mostly completed by age 4, although around 20% of five year olds and 10% of six year olds continue to wet the bed at night although the condition resolves itself at a rate of about 15% per year after that.  The most common causes are small bladder size, the inability to recognize the need to urinate during sleep, and muscle relaxation during deep sleep.  One pediatrician says that if the child has been dry at night for a while and then suddenly regresses it’s worth seeing a doctor, and strategies to encourage dryness include having the child urinate right before bed, limiting liquid intake in the evenings, and not allowing any caffeine, which can cause overactive bladder.  This pediatrician says that “waking the child to urinate is controversial,” although unfortunately she doesn’t tell us why.  The potty training books (which we already know are rarely based on scientific evidence) usually do advocate for night time waking (if they mention nighttime training at all); the child apparently essentially sleepwalks to the toilet. I guess the part that isn’t clear to me about this is how it helps the child to recognize that they need to use the toilet when it’s the parent who does the waking, and it’s that recognizing the need to urinate that’s really the critical factor in nighttime dryness.  Sleep is precious in our house and frankly the thought of waking my daughter up is not very appealing.  We get one dry night at random every couple of weeks, and I plan to monitor this and see if the dryness gets more frequent.  If we go a few more months and don’t see much of an increase in frequency then I’ll revisit the idea of waking her at night.

 

I hope this has been helpful to those of you who have asked for the episode, as well as those of you who haven’t yet started – or finished – training.  If you really feel as though you can’t do this thing without a book to read, then I’d recommend Jamie Glowacki’s Oh Crap! Potty Training, which I can’t say is essential because I didn’t read it before I started (and actually I deliberately avoided all books related to the topic), but in my mind it has the best balance of advice on things like rewards, on which the author says “I personally thing a “good job” once in a while is fine, though in my own parenting, I try not to say it over and over just for something to say.  If you don’t feel comfortable praising your child, you can always “reflect” back to them with no judgment.  This would look like “Oh, you peed on the floor,” or “You peed in the potty.”  I do think, since there really is only one desirable outcome, that there should be *something* in your voice that says “Yay” this or “No” that.  You do have to let your child know, in some manner, that peeing on the floor is “not good” and on the potty is “good.”  I don’t recommend those words, but you must find a way to convey the notion because otherwise you’re teaching your child that it’s okay to pee wherever, which is not what potty training is about.  I’m particularly fond of having the parent say “you did it,” and/or having the child say “I did it!.’  This gives the success over to your child as theirs and, for some kids, has more impact than standard praise or mirroring.”  Now you all know that I don’t really use praise at all with my daughter – I prefer to let her know I appreciate her in other ways – but I appreciate Jamie Glowacki’s giving us options that we can select from in whatever way best fits our parenting style rather than just telling us to go all out with the praise and the stickers.  If you get this book and end up singing the praises of it to other people you can actually become a Certified Oh Crap potty trainer if that kind of thing floats your boat.

If you have any questions about all of this then do drop me a line at jen@yourparentingmojo.com; if I get enough of them I’ll do a Q&A in a future newsletter which I send out every other week, and which you can receive by subscribing to the show at yourparentingmojo.com – just enter your email address in the box and hit ‘subscribe.’

All of the references for today’s episode can be found at yourparentingmojo.com/potty


Also published on Medium.

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