The immediate goal of the toilet-training process is the consistent deposit of urine and feces in the toilet. However, the long-term effect is to put in place flexible, adaptive mental attitudes about the body and its products which will last a lifetime. Spanning the interval from approximately age 2 until the elementary school years, the shift from wetting and soiling to bowel and bladder control results in nothing less than major personality growth and transformation.
Before beginning a focused discussion of toilet training , let’s consider the biological and environmental factors which are involved.
Biological and Environmental Factors:
The biological factors include the maturation of the nerves to the lower extremities, the bladder and anal openings. This makes walking and bowel and bladder control possible, as well as the the ability to purposely retain or expel urine and feces.
The environmental influences include the primary caretakers' attitudes toward these actions and products, as well asthe process of toilet training itself.
As the nerves controlling the lower extremities continue to mature during the second and third years of life, the toddler develops the capacity to walk and to consciously open and close the sphincter muscles of the anus and bladder. Toddlers find those actions, along with the products, highly pleasurable. Consequently, urine and feces are touched, smelled, tasted, and played with. These body products are not reacted to with the avoidance and disgust that characterizes most adult responses. Thus, there is nothing in the mental awareness or physical sensations of the two –year- old that pushes the toddler toward toilet training.
That stimulus comes from the parents and is gradually accepted by the toddler. During the second and third years of life, the toddler is increasingly aware of the parents’ ability to control every aspect of his life. This awareness stimulates a conflict between the pleasurable, physical sensations associated with wetting and soiling and the parents’ demands for cleanliness. Eventually, the desire to grow up and be a big boy or big girl, and the need for parental love and approval, override the pleasures associated with wetting and soiling. And the child eventually becomes trained—sometimes fairly easily, sometimes only after a battle lasting weeks and months.
As the toilet training process becomes a central aspect of the relationship between toddler and parent, the actions of withholding and expelling urine and feces and the body products themselves become increasingly connected in toddlers’ minds with feelings about their parents. As this occurs, the actions of urinating and defecating become vehicles for expressing a wide range of thoughts and feelings about the parents--love, anger, stubbornness, and compliance, to name just a few.
THE STEPS INVOLVED IN TOILET TRAINING
The following information is provided in an attempt to offer a method of toilet training and depict the mental and emotional changes taking place in the child as a result of the parents’ efforts to train the child. Conceptualized as beginning at age 2 and continuing into the elementary school years, the goal of the toilet training process is to help the toddler develop the ability to comfortably control her elimination processes. But in addition, the goal is to stimulate adaptive mental and emotional attitudes and capabilities which boost self esteem and contribute to a positive attitude toward others and life in general. Thus, the approaches described below are a far cry from those claiming to accomplish toilet training in a morning or a day.
The toilet training process can be subdivided into four phases.
The first phase, which begins at birth, is described as the complete freedom to wet and soil. It continues until the toilet-training process is initiated.
The second phase, active toilet training, should be begun by the parents when the child is developmentally ready to participate in the process, at approximately age 2. The reasons for choosing age 2 will be explained shortly.
Parental attitudes toward the process, as well as the child’s, are extremely important if a healthy process is to occur. Parents should be sensitive to the child’s pleasure in wetting and soiling and her increasing desire to control her body and its actions. When such sensitivity is present, Mom and Dad will patiently, consistently and sympathetically balance the parental expectation for compliance with the toddler’s desire for control. And the toilet training will proceed gradually and with a minimal degree of struggle .
The third phase encompasses the period of weeks or months during which the child gradually accepts the parental expectation for control of urine and feces and adopts the parents’ and societies’ attitudes toward cleanliness. From then onward, the striving for cleanliness is an internal, not an external, expectation. And the child begins to manifest the typical disgust toward urine and feces found in all older children and adults.
Have you noticed that you don’t like the smell of other peoples’ stools, but don’t mind the smell of your own? An increased ability to control powerful feelings, particularly aggression, occurs at the same time.
During the fourth phase, which continues well into the elementary school years, bowel and bladder control becomes wholly secure and a physical and mental capability now disconnected from its parental origin. Bowel and bladder control lapses do not occur, even at times of stress. And the use of the toilet is completely disconnected from parental knowledge, dictates, or support.
Mind you, I didn’t say that your seven –year- old always wipes well enough or uses just the right amount of toilet paper.
In the physically and psychologically healthy individual, this state continues for the remainder of life or until some point in old age when physical infirmity undermines the long-standing autonomy and competence of bowel and bladder function.
The Mechanics of Toilet Training
With these concepts in mind, let’s turn our attention to the process of toilet training. As previously mentioned toilet training should begin at approximately 2 years of age because by that time, the toddler is physically and psychologically capable of complying. In order to cooperate, the child must be able to understand what the parents want, to consciously control the muscles related to urinating and defecating, and to communicate their thoughts and feelings verbally.
Toilet training should be an active process, initiated by the parents.
“Mary, Mommy and Daddy are going to help you be a big girl. From now on, no more diapers. You’re going to wear big girl panties.”
After the parents tell the child about the process. And over a short period of time, diapers are removed during the day and at night and are replaced by training pants. The consistent use of training pants rather than diapers (even though it means wet clothes, floors, and beds for a period of time) both represents the parents’ consistent expectations and focuses the child's attention on the mechanisms of urination and defecation.
At the same time, a potty chair is introduced and explained. “This is your special chair for doing pee pee and poo poo. It’s just for you.” The potty chair’s use allows the toddler to sit comfortably with feet planted firmly on the floor, thus eliminating concerns about falling or balancing. Some children will begin to comply rather quickly, while others will resist mightily, sometimes for extended periods of time. In either event, compliance should be responded to with praise. “That was great. You did poo poo just like Sandy (big sister).”
Resistance can take the form of sitting on the potty chair for 15 minutes while Mom or Dad patiently encourages Mary, only to have her go behind the couch to make a BM in her pants immediately after getting off the potty chair. Parental frustration is kept in check with a cheery, but insincere “That’s Ok. You’ll go in the potty next time. Now lets clean you up and put on another pair of big girl pants. I know you don’t like being dirty.”
Under ideal circumstances, the toilet-training process will take place in the presence of physical health and environmental stability. Delays or regressive loss of control can be expected during times of illness and environment instability, such as the birth of a sibling or parental separation. In most instances, consistent control of bowel and bladder functions, day and night, will be achieved between ages 3 to 4. Complete autonomy, meaning that the parents are no longer involved in the child’s bowel and bladder behavior, is acheived by age 7 or 8.
Pathologic outcomes occur when parents fail to actively train the child. This usually results from an unconscious fear of their own aggression which is stimulated by the toddler's resistance. Or Mom and Dad may have a misguided belief that the potty training process is unnecessary because the toddler will do it when she is ready, without needing parental coaxing.
Bed wetting or soiling may result from either approach. When a consistent expectation is not presented to the toddler, he becomes confused and often more resistant, thus delaying achievement of bowel and bladder control.
Such an approach to toilet training is often observed in association with other inconsistencies in limit-setting interactions regarding weaning and establishing a consistent bedtime. In addition to problems with bowel and bladder control, these children often have difficulty in social relationships with peers and adults and are frequently observed to be self -centered and immature.
At the urging of their families, Linda and Joe decided to train Joe Junior when he was a year old. They told Joe that they wanted him to do “poo poo” and “pee pee” in the toilet and sat him on their toilet. He sat there somewhat unsteadily, seemed to understand what they wanted, and once or twice made “pee pee” in the toilet; but otherwise he continued to wet and soil his diapers.
After a few months, Linda and Joe gave up. But they didn’t tell their families for fear of criticism. When Joe Jr. was 18 months old they tried again, with much the same result. Joe Jr. continued in diapers and showed no interest in complying. Indeed, there were times when he would sit on the toilet for ten to fifteen minutes, as one or both of his parents sat by encouraging him, only to hide behind the couch minutes later and have a BM in his diaper. When they came to see me shortly before Joe Jr.’s second birthday, they sheepishly admitted to great exasperation at Joe’s obvious non-compliance. They even admitted to swatting his bottom several times after cleaning up his BMs. They were at their wits end.
After two or three meetings during which I provided the information described in the preceding paragraphs in this section, they began the toilet training process again. The first order of business was to buy a potty chair that Joe could sit in comfortably. Next was a trip to the store to buy an abundant supply of training pants—not the ones which are actually modified diapers, but underwear which would cause urine to run down Joe’s leg when he wet and caused him to smell his feces when he defecated. I had prepared Linda and Joe for some wet beds and soiled clothes. But they were unprepared for my statement that Joe Jr. would be in training pants all of the time -day and night - including those occasions when the family left home, . After a pep talk, they were ready to begin.
Now two years old, Joe Jr. clearly understood what they asked of him. He particularly liked the statement that they wanted him to be a big boy and use the toilet like his father and older cousins. He was fascinated by the potty chair and enjoyed sitting on it fully clothed. He liked the big boy pants, too. At first Joe really seemed to be trying. He was dry on occasion at night and did “poo poo” and “pee pee” in the potty chair on several occasions. For a while, this kind of compliance alternated with days in which Joe would purposely wait until he had finished sitting on the potty chair to wet and soil. Although they acknowledge that they sometimes they raised their voices when this occurred, they did not swat Joe’s behind or punish him for his non-compliance.
Over the course of five to six months, the episodes of compliance began to outnumber the episodes of stubborn resistance. One day, to their surprise, Joe Jr. asked his Mommy to come and see that he had done a “jobby” in the potty chair on his own. He glowed with pride when he was praised by both Mom and Dad. He was a “big boy” now, he exclaimed. Occasional “accidents” occurred for another few months. But by the time he was 3, Joe rarely wet or soiled. His parents were surprised when Joe reacted to getting dirty and willingly agreed to wash his hands before eating. Now 3- years- old, Joe Jr. had completed Phase 3 of the toilet training process. Within a few years, his bowel and bladder functions would become autonomous, secure and private. And Joe no longer needed any parental involvement .