“Big, Bad John! A “Cheeky” Look at Toilet Training

Harla B. Frank, M.S., BCBA

bSci21 Contributing Writer

Rules governing defecation, hygiene, and pollution exist in every culture, at every period in history.  It may, in fact, be the foundation of civilization: What is toilet training if not the first attempt to turn a child into an acceptable member of society?  – Rose George

Many would take exception to the idea that independent toileting is a primary characteristic of an “acceptable member of society,” but it is certainly a skill that parents strive to teach their children during the “tender years.”  Not for the faint of heart, toilet training appears to come with a moderate degree of parental dread.  Prior to embarking on this training, parents often read the “how to” guides that have been available since the invention of the printing press (Well, I may be exaggerating just a bit.).  But, suffice to say, there is no limit to the number of experts and laymen offering guidance in THE way to potty train your child.

As a behavior analyst, I have designed many different toilet training programs – all different to meet the individual needs of the child.  Some of the programs have been quite simple – others, not so much.  The clients’ parents typically reach out to me for help with this developmental milestone when their children are anywhere from 3-5-years-of-age.  As a professor of Applied Behavior Analysis (ABA), my students often embark on heated debates about the best time for toilet training, and the best method.  Because each child is different, there may not be ONE method that works with all children.

Just as the pundits on the 24-hour news stations are all considered experts in their fields, so too are the “pundits of potty.”  One would think that experts would have similar opinions regarding their areas of expertise, but that isn’t always the case.  It would seem that evidence and data do not always guide opinion.  This is true of experts on politics and science, and experts on potty training.  Popular books and magazines have provided decades of answers to the age-old question, “How can I potty train my child?”

Dr. Benjamin Spock, pediatrician and author of the best-selling book, Baby and Child Care, first published in 1946, recommended that parents wait until the child is ready for potty training, which he felt typically occurs between 18- and 24-months (Spock, 1992).  At this age, certain developmental milestones become evident, such as an awareness of the sensation of needing to go (Spock, 1992).  Children are also more interested in imitating the actions of others at this age so parents or siblings modeling the chain of behaviors associated with toileting can be particularly effective in preparing children for toilet training (Spock, 1992).  Dr. Spock recommended a potty chair close to the floor for children up to approximately 30-months of age (Spock, 1992).  He felt that the child should become familiar with the “seat” prior to actually beginning training, so he advised that the child be allowed to sit on the seat fully clothed (Spock, 1992).  Dr. Spock also recommended that once the child is familiar with the new seat, that verbal instruction should be provided as to what to do on the seat, as well as modeling the proper toileting behavior by siblings or parents (Spock, 1992).  Once these initial steps have been taken, it is time to begin the training in earnest (Spock, 1992).  This often entailed parents watching their children closely for cues as to the need to go or placing the child on the potty according to a schedule (Spock, 1992).

While Dr. Spock had his own approach to potty training, he also discussed another pediatrician’s successful approach to this training, i.e., Dr. T. Berry Brazelton.  Dr. Brazelton, who had an 80% success rate in toilet training children by, on average, 28-months-of-age, felt that children should be “trained of their own free will – no coercion at all” (Spock, 1992, p. 462).  According to Dr. Brazelton, there should never be any parental signs of “disapproval” or any demands for the child to remain on the potty any longer than the child wishes (Spock, 1992, p. 463).

In his book, Toilet Training the Brazelton Way (2004), Dr. Brazelton discusses the importance of readiness for toilet training.  At 2-years, the child’s ability to imitate others, he states, is sufficiently developed to facilitate toilet training (Brazelton & Sparrow, 2004).  Dr. Brazelton also discusses the child’s growing sense of independence and awareness of others’ toileting habits as indicators of readiness (Brazelton & Sparrow, 2004).  Dr. Brazelton recommends that parent and child shop for the new potty together (Brazelton & Sparrow, 2004).  For a time, the child should be allowed to “play potty” by making believe his/her stuffed toys or dolls are using the potty (Brazelton & Sparrow, 2004).  Then, it is recommended that the child sit on his/her potty at the same time that Mommy or Daddy are sitting on the big potty (Brazelton & Sparrow, 2004).  This modeling is an important component in both Dr. Spock’s and Dr. Brazelton’s methods.  Finally, when the child is interested, the diaper can be removed and potty training can begin (Brazelton & Sparrow, 2004).  Praise for success and encouragement for those little failures is important (Brazelton & Sparrow, 2004).

Dr. Nathan Azrin and Dr. Richard Foxx provide a “fast track” to potty training that is behavioral in nature.  In their book, Toilet Training in Less Than a Day (1974), Azrin and Foxx report that they had devised a training method that incorporated “language ability, imagination, imitation, verbal rehearsal, and verbal instructions,” as well as “association” and “reward” to effectively toilet train a child in less than a day – typically in 3-4 hours (Azrin & Foxx, 1974, p. 10).  In fact, the authors discuss their study of 200 children, ranging from just under 2-years to 4-years-of-age, in which the older children actually needed, on average, only 2 ½ hours of intensive training, while younger children, under 26-months, required approximately 5 hours (Azrin & Foxx, 1974).  Incredible as it seems, the authors profess a success rate of close to 100% of the 200 children in the study (Azrin & Foxx, 1974).  While the methods seem very similar to the methods described by Dr. Spock and Dr. Brazelton, the intensity of the training definitely differs.  Success appears to depend on the absence of distractions; increased fluid intake, thus increased need to urinate; and lots of reinforcement in the form of hugs, praise, and tangible items (Azrin & Foxx, 1974).

“Elimination communication” is a method used in many countries to meet an infant’s elimination needs . . .yes, I did say, “infant.”  This communication often begins at birth – but may be started at any time during the baby’s first year of life.  The idea behind this movement (if I may call it that) is that babies are born with a sense of their own elimination needs – or urges, just as they are their feeding needs and that they exhibit behaviors that indicate their need to urinate or defecate (Tremblay, 2009).  A mother learns her child’s unique cues that elimination is imminent and, when such a cue is given, will hold the infant over the potty (Tremblay, 2009).  Time is also spent learning the baby’s elimination rhythms in order to facilitate awareness in the mother of when the child will likely need to go (Tremblay, 2009).  Proponents of this method support its use by listing all the advantages of not using cloth or disposable diapers, such as saving money and the environment (in the case of piles of disposable diapers in landfills); eliminating the potential for diaper rash; and fostering a closer bond between mother and baby (Tremblay, 2009).

The Journal of Applied Behavior Analysis (JABA) has published many studies of various methods of toilet training, some based upon the Brazelton method and others on the Azrin and Foxx method.   Most of these studies used a combination of dense toileting schedules; reinforcement; and a component as yet unmentioned – the replacement of disposable diapers or pull-ups with training pants or regular underwear (Greer, Neidert, & Dozier, 2016).  Greer, Neidert, and Dozier (2016) found that the switch from disposable diapers or pull-ups to regular underwear appeared to be a stronger factor in toilet training success than dense toileting schedules and differential reinforcement.

Tarbox, Williams, and Friman (2004) conducted a study on the differential effects of diapers versus underwear on continence and found that wearing diapers increased accidents and decreased successful elimination on the toilet.  While this study was conducted with an adult subject, it seems logical to assume that this finding can be generalized to toddlers.

So, as a behavior analyst and a parent, I feel compelled to share my opinion on “steps to successful toilet training.” I believe that the approaches of each of the “potty pundits” discussed have merit. I began potty training my daughter at 10-months and my son at 11-months, and both were fully trained at 10 ½ months and 11 ½ months, respectively.  This was accomplished through the following steps:

• Began toilet training process prior to 1-year-of-age
• Desensitization: I took my child into the bathroom with me each time I went.
• Identified elimination rhythms: Used cloth diapers in order to note each elimination and recorded the time to determine the average length of time between eliminations.
• After two weeks of “desensitization,” I began training by switching to regular underwear and placing my child on the toilet just before the anticipated elimination time (determined by recording my child’s rhythms).
• Provided lots of hugs and praise for each time on the potty (The reinforcement was not based on urination or voiding, but rather for the attempt.)

An important aspect of my approach was making sitting on the potty enjoyable.  If it was the typical time for my child to have a bowel movement, I brought a favorite book in with us and I sat on the floor and read while he/she sat on the potty.  Also, I never required my children to sit on the potty for more than 2-minutes, unless they were engaged in elimination.

Interestingly, I never read articles or books about popular methods of toilet training, but my method did share components of the methods that have emerged in popular culture and research.  From my own experience, and from the research that has been conducted on toilet training methods, one can draw some conclusions regarding the components that are necessary for success:

1. Nurturing an acceptance of the toileting experience by bringing baby with Mommy and Daddy when they have to go
2. Beginning early
3. Learning your baby’s elimination rhythms and allowing those rhythms to guide the potty schedule.
4. Switching from disposable diapers or pull-ups to underwear to promote an awareness of the sensation of “fullness” that occurs just before an accident. Disposable diapers and pull-ups are so effective at absorption of urine that the child is less likely to learn the physical cues that occur just before urination.  But with the use of underwear, the child very quickly makes the association between the full feeling and the discomfort of trickling urine.
5. Providing reinforcement!

All children are different, as are all parents.  What worked for me may not work for you.  Take courage!  As Dr. Spock said, “Trust yourself.  You know more thank you think.”

Behind every young child who believes in himself is a parent who believed first. – Matthew Jacobson

Do you have experience with toilet training?  Share some of your own best practices in the comments below, and be sure to subscribe to bSci21 via email to receive the latest articles directly to your inbox!

References

Azrin, N. H., & Foxx, R. M.  (1974). Toilet training in less than a day. New York, NY: Pocket

Books.

Brazelton, T. B., & Sparrow, J. D. (2004). Toilet training the Brazelton way. Cambridge, MA:

Da Capo Press.

Greer, B. D., Neidert, P. L., & Dozier, C. L.  (2016). A component analysis of toilet-training

procedures recommended for young children.  Journal of Applied Behavior Analysis, 49,

69-84.

Spock, B. & Rothenberg, M. B.  (1992). Dr. Spock’s baby and child care (6^th ed.).  New York,

NY: Pocket Books.

Tarbox, R. S. F., Williams, W. L., & Friman, P. C.  (2004). Extended diaper wearing: Effects on

continence in and out of the diaper.  Journal of Applied Behavior Analysis, 37, 97-100.

Tremblay, R.  (2009, September 1).  There is another choice. Natural Life, 129, 14-15

 

Harla Frank, M.S., BCBA earned her Master’s degree in Psychology, with an emphasis in Applied Behavior Analysis, from Florida State University.  Since receiving her certification as a Board Certified Behavior Analyst (BCBA) in 2007, she has worked primarily with children and young adults on the Autism Spectrum, but has also worked with adults with a variety of diagnoses and needs. She has served as an expert witness for Applied Behavior Analysis (ABA) in the Colorado court system and has had the privilege of providing “ABA approaches” training to foster care staff and families.

Since 2010, Harla has taught ABA course sequences, as well as general psychology courses, for Kaplan University.  Currently, she also contracts with a pediatric home healthcare company in Denver to provide ABA therapy to children with a variety of diagnoses. You can contact her at [email protected].