American children are becoming toilet trained at much later ages than was typical decades ago, and, in a significant number of families, they are not mastering the task without some problems, according to research published today in the journal Pediatrics.
The study, the first large-scale examination of potty training in the United States in more than 30 years, should help reassure parents on some aspects of training. But it will also leave many perplexed about how to help their children achieve this developmental milestone and will surely trigger additional research and more debate.
Pioneering work by Dr. T. Berry Brazelton in the 1960s found that most children were fully trained by about 27 months, but the study reveals a much different picture today. Four percent were trained by age 2; only 22% by age 2 1/2; 60% by age 3; 88% by age 3 1/2; and 2% were still not trained at 4.
In addition, the study found that having a mother at home all day did not appear to speed up the training process. The age at which the child was trained was not associated with whether the child attended day care or had a mother who worked outside the home. Nor are behavior problems correlated with delayed training, according to a companion study.
In a 1962 paper in Pediatrics, Brazelton suggested that the strict, coercive method then common to train children at about age 1 be discontinued in favor of waiting until the child expresses interest, usually about age 2, and then guiding the child in a gentle, positive manner.
Brazelton's method has been enthusiastically embraced, although there have been no large studies to demonstrate how effective it is, said Dr. Bruce Taubman, an associate professor of pediatrics at the University of Pennsylvania and author of the new study.
"There is a lot of 'advice' literature on toilet training, but there is no data about it," he said. "I don't think anyone really knew what was happening using the Brazelton approach. Now, we know kids get trained much older than we realized. And we know that the Brazelton approach doesn't totally eliminate problems."
In particular, Taubman's study of 482 healthy children, ages 18 months to 30 months, revealed that many children master urinating on the toilet but develop peculiar, even unhealthy, habits regarding their bowel movements. One in five of the children studied experienced at least one month of "stool toileting refusal," meaning that they were fully capable of using the toilet to urinate but would pass their stools only in a diaper.
In more extreme cases (about 6%), the study found children who would try to hold back their bowel movements for long periods of time, resulting in constipation, hard or painful stools and the risk of more serious gastrointestinal distress.
"In our study population it would appear that bowel training problems continue in a noncoercive environment although in different forms," Taubman said. "I don't think we should throw out Brazelton and go back to training at 1 year of age. But I think we may need some modification in order to train kids earlier and without so many problems."
More research on children's behavior around toilet training would be welcomed by pediatricians, said Dr. Michael Bryant, assistant professor of clinical pediatrics at Childrens Hospital Los Angeles and USC.
"I'm not surprised by the [study's] findings," he said. "We don't have a lot of good information about toilet training. We haven't explored various methods, and we don't understand that cultural factors are important."
A related study in Pediatrics found that children who train late or have problems with stool toileting refusal do not have any more behavior problems than children who are toilet trained. "My feeling is that there are probably a large number of different causes [of training problems]," said Dr. Nathan J. Blum, assistant professor of pediatrics at the University of Pennsylvania and author of the behavioral study. "There are some guidelines we know are helpful. But there may be other things we haven't come up with yet. And parents may need to adapt guidelines to their individual children.
"There has been a tendency to tell parents not to put any demands on their children around toilet training. I don't know if that's a problem, but I think that with some expectations from the parents, a lot of kids could train earlier and without doing any harm."
In Taubman's study, stool toileting refusal did not usually lead to any medical or psychological problems, although these children tended to become fully trained at later ages than other children, Taubman said.
"Most of these kids waited until they got a diaper at nap time [to move their bowels]. They did this for two or three months, then got over it. But 25% started holding their bowel movements for longer periods of time," he said.
The study did not conclude why some children resist using the potty for their bowel movements. But Taubman has a hypothesis that is the subject of a new study, now underway.