Toilet Training Packet

Your child is toilet trained when, without any reminders, he (or she, or course) walks to the potty, pulls down his pants, urinates or passes a bowel movement (BM), and pulls up his pants.  Some children learn to control their bladder first; others start with bowel control.  You and your child can work on both kinds of control at the same time.  Bladder control through the night normally happens several years later than daytime control.  The gradual type of toilet training described in this Guide usually can be completed in one to three months – if your child is ready.

Toilet training readiness

Don’t begin toilet training until your child is clearly ready!  Readiness doesn’t just happen; it involves concepts and skills you can begin teaching your child at 18 months of age or earlier.  Almost all children can be made ready for toilet training by 3 years, most by 2 ½ years, many by 2 years, and some earlier.  Ways to help your child become ready include the following:

18 months.  Begin teaching about pee, poop, and how the body works.

• Teach the vocabulary (pee, poop, potty).
• Explain to your child that everyone makes pee and poop.
• Point out when dogs or other animals are doing pee or poop.
• Clarify the body’s signals when you observe them: “Your body wants to make some pee or poop.”
• Praise your child for passing poop in the diaper.
• Don’t refer to poop as “dirty” or yucky”
• Make diaper changes pleasant for your child so he will come to you.
• Change your child often so he will prefer a dry diaper.
• Teach him to come to you whenever he is wet or soiled.

21 months. Begin teaching about the potty and toilet.

• Teach what the toilet and potty chair are for (“the pee or poop goes in this special place”).  Demonstrate by dumping poop from diapers into the toilet.
• Portray using the toilet and potty chair as a privilege.
• Have your child observe toilet-trained children use the toilet or potty chair (an older toilet-trained sibling can be very helpful).
• Give your child a potty chair.  Encourage your child to sit on it with clothes on for fun activities, such as play, snacks, and watching television.  Help your child develop a sense of ownership (“my chair”).
• Put the potty chair in the bathroom and have your child sit on it when you sit on the toilet.

2 years. Begin using teaching aids.

• Read toilet learning books and watch toilet learning videos with your child.
• Help your child pretend to train a doll or stuffed animal to use the potty chair.  It doesn’t have to be an expensive doll that pees water.
• Introduce wearing underwear as a privilege.  Buy special underwear and keep it in a place where your child can see it.

The potty chair

Buy a floor-level potty chair.  You want your child’s feet to touch the floor when he sits on the potty.  This provides leverage for pushing and a sense of security.  It also allows him to get on and off whenever he wants to.  Take your child with you to buy the potty chair.  Make it clear that this is his own special chair.  Have him help you put his name on it.  Allow him to decorate it or even paint it a different color.

Then have your child sit on the potty chair fully clothed until he is comfortable with using it as a chair.  Have him use it while eating snacks, playing games, or looking at books.  Keep it in the room in which your child usually plays.  Never proceed with toilet training unless your child clearly has good feelings toward the potty chair.

Steps in Toilet Training

Encourage practice runs to the potty.

A practice run (potty site) is encouraging your child to walk to the potty and sit there with her diapers or pants off.  You can then tell your child, “Try to go pee-pee in the potty.”  Only do practice runs when your child gives a signal that looks promising, such as a certain facial expression, grunting, holding the genital area, pulling at their pants, pacing, squatting, or squirming.  Other good times are after naps, after two hours without urinating, or 20 minutes after meals.  Say encouragingly, “The pee [or poop] wants to come out.  Let’s use the potty.”

If your child is reluctant to sit on the potty, you may want to read him a story.  If he wants to get up after one minute of encouragement, let him get up.  Never force your child to sit on the potty.  Never physically hold your child on the potty.  Even if your child seems to be enjoying it, end each session after five minutes unless something is happening.  Initially, keep the potty chair in the room your child usually plays in.  This easy access markedly increases the chances that he will use it without your asking.  Consider buying two potty chairs.

During toilet training, children need to wear clothing that makes it easy for them to use the potty.  That means one layer, usually the diaper.  Avoid shoes and pants.  (In the wintertime, turning up the heat is helpful.)  Another option (though less effective) is loose sweatpants with an elastic waistband.  Avoid pants with zippers, buttons, snaps, or a belt.

Praise or reward your child for cooperation or any success.

All cooperation with practice sessions should be praised.  You might say, for example, “You’re sitting on the potty just like Mommy,” or “You’re trying real hard to go pee-pee in the potty.”  If your child urinates into the potty, you can reward him with treats, such as animal cookies, or stickers, as well as praise and hugs.  Although a sense of accomplishment is enough to motivate some children, many need treats to stay focused.  Reserve big rewards (such as going to the toy store) for occasions when your child walks over to the potty on his own and uses it or asks to go there with you and then uses it.

Once your child uses the potty by himself three or more times, you can stop the practice runs.  For the following week, continue to praise your child often for using the potty.  (Note: Practice runs and reminders should not be necessary for more than one or two months.)

Change your child after accidents as soon as convenient.

Respond sympathetically.  Say something like, “You wanted to go pee-pee in the potty, but you went pee-pee in your pants.  I know that makes you sad.  You like to be dry.  You’ll get better at this.”  If you feel a need to criticize, restrict criticism to mild verbal disapproval and use it rarely (“Big girls don’t go pee- pee in their pants,” or mention the name of another child whom your child likes and who is trained).  Change your child into a dry diaper or training pants in as pleasant and non-angry a way as possible.  Avoid physical punishment, yelling, or scolding.  Pressure or force can make a child completely uncooperative.

Introduce underpants after your child starts using the potty.

Underwear can increase motivation.  Switch from diapers to underpants when your child is cooperative about sitting on the potty chair and has passed urine into the toilet spontaneously 10 or more times.  Take your child with you to buy the underwear and make it a reward for his success.  Buy loose-fitting underpants that he can pull down easily and pull up by himself.  Once your child starts wearing underpants, use diapers only for naps, bedtime, and travel outside the home.

Overcoming Toilet Training Inertia:  The Bare-Bottom Weekend

If your child is over 30 months old, has successfully used the potty a few times with your help, and clearly understands the process, committing six hours or a weekend exclusively to toilet training can lead to a breakthrough.  Avoid interruptions or distractions during this time.  Younger siblings must spend the day elsewhere.  Turn off the TV, and don’t answer the telephone.  Success requires monitoring your child during training hours.

The bare-bottom technique means that your child does not wear diapers, pull-ups, underwear, or any clothing below the waist.  This causes most children to become acutely aware of their body’s plumbing.  They dislike pee or poop running down their legs.

You and your child must stay in the vicinity of the potty chair, which can be placed in the kitchen or another room without a carpet.  A gate across the doorway may help your child stay on task.  During bare-bottom ties, refrain from all practice runs and most reminders.  Allow your child to learn by trial and error with your support.

Create a frequent need to urinate by offering your child lots of his favorite fluids.  Have just enough toys and books handy to keep your child playing near the potty chair.  Keep the process upbeat with hugs, smiles, and good cheer.  You are your child’s coach and ally.

If your child resists training

Request the parent guide on toilet training resistance if:

• Your 2 ½ year-old child is negative about toilet training.
• Your child is over 3 years old and not daytime toilet trained.
• Your child won’t sit on the potty or toilet.
• Your child holds back bowel movements.
• The approach described here isn’t working after six months.

Books on toilet training for parents

Parent’s Book of Toilet Teaching, by Joanna Cole (New York, Ballantine Books, 1999)

Mommy! I Have to Go Potty! A Parent’s Guide to Toilet Training, by Jan Faull (Raefield-Roberts Publishers, 1996)

Toilet Learning: The Picture Book Technique for Children and Parents, by Alison Mack (Boston, Little, Brown and Company, 1983)

Potty Training for Dummies, by Diane Stafford and Jennifer Shoquist (New York, Hungry Minds, 2002)

Potty Training Your Baby, by Katie Van Pelt (New York, Signet, 2002)

The American Academy of Pediatrics Guide to Toilet Training (New York, Bantam Books, 2003)

Keys to Toilet Training, by Meg Zweiback (Hauppauge, N.Y., Barron’s Educational Series, 1998)

Toilet Training Resistance:

Daytime Wetting and Soiling

Children who refuse to be toilet trained either wet themselves, soil themselves, or try to hold back their bowel movements (thus becoming constipated).  Many of these children also refuse to sit on the toilet or will use the toilet only if the parent brings up the subject and marches them into the bathroom.  Any child who is older than 3 years, healthy, and not toilet trained after several months of trying can be assumed to be resistant to the process rather than undertrained.  Consider how capable your child is at delaying a bowel movement (BM) until he (or she) is off the toilet and has had a chance to hide.  More practice runs (as you used in toilet training) will not help.  Instead, your child now needs full responsibility and some incentives to respark his motivation.

The most common cause of resistance to toilet training is that a child has been reminded or lectured too much.  Some children have been forced to sit on the toilet against their will, occasionally for long periods of time.  Others have been spanked or punished in other ways for not cooperating.  Many parents make these mistakes, especially if they have a strong-willed child.

Most children younger than 5 or 6 years who have daytime wetting or soiling (encopresis) without any other symptoms are simply engaged in a power struggle with their parents.  They can be helped with the following suggestions.  (If your child holds back BMs and becomes constipated, medicines will also be needed.  Ask your doctor for the Guide for Parents on stool holding.)

Transfer all responsibility to your child.  Your child will decide to use the toilet only after he has realized that he has nothing left to resist.  Have one last talk with him about the subject.  Tell him that his body makes pee and poop every day and that it belongs to him.  Explain that his pee and poop wants to go in the toilet, and his job is to help the pee and poop come out of his body.  Tell your child you’re sorry you forced him to sit on the toilet or reminded him so much.  Tell him from now on he doesn’t need any help.  Then stop all talk about this subject (“potty talk”).  Pretend you’re not worried about it.  When your child stops receiving attention for nonperformance (not using the toilet), he will eventually decide to perform for attention.

Stop all reminders about using the toilet.  Let your child decide when he needs to go to the bathroom.  Don’t remind him to go to the bathroom nor ask if he needs to go.  He knows what it feels like when he has to pee or poop and where the bathroom is.  Reminders are a form of pressure, and pressure keeps the power struggle going.  Stop all practice runs and never make him sit on the toilet against his will because these tactics always increase resistance.  Don’t accompany your child into the bathroom or stand with him by the potty chair unless he asks you to.  He needs to gain the feeling of success that comes from doing it his way.

Give incentives for using the toilet.  Your main job is to find the right incentive.  Special incentives, such as favorite sweets or video time, can be invaluable.  When encouraging your child to use the toilet for BMs, initially err on the side of giving too much (several food treats each time).  You can increase the potency of incentives by reducing your child’s access to them except when he uses the toilet.  If you want a breakthrough, make your child an offer he can’t refuse, such as going somewhere special.  In addition, give positive feedback, such as praise and

hugs every time your child uses the toilet.  On successful days, consider taking 20 extra minutes to play a special game with your child or take him to his favorite playground.

Give stars for using the toilet.  Get a calendar for your child and post it in a visible location.  Have him place a star on it every time he uses the toilet.  Keep this record of progress until your child has gone one month without any accidents.

Make the potty chair convenient.  Be sure to keep the potty chair in the room your child usually plays in.  This gives him a convenient visual reminder about his options whenever he feels the need to pass urine or stool.  For wetting, the presence of the chair and the promise of treats will usually bring about a change in behavior.  Don’t remind your child to use the potty chair even when he’s squirming and dancing to hold back the urine.

Replace diapers or pull-ups with underwear.  Help your child pick out underwear with favorite cartoon or video characters on it.  Then remind him that the characters “don’t like poop or pee on them.”  This usually precipitates the correct decision on the part of the child.  Persist with this plan even if your child wets the underwear.  If your child holds back BMs, allow him access to diapers or pull-ups for BMs only.  Preventing stool holding is very important.

Remind your child to change his clothes if he wets or soils himself.  As soon as you notice that your child has wet or soiled pants, tell him to clean himself up.  Your main role in this program is to enforce the rule: “people can’t walk around with messy pants.”  If your child is wet, he can probably change into dry clothes by himself.  If he is soiled, he will probably need your help with cleanup.  If you child refuses to let you change him, ground him in his bedroom until he is ready.

Don’t punish or criticize your child for accidents.  Respond gently to accidents, and do not allow siblings to tease the child.  Pressure will only delay successful training, and it could cause secondary emotional problems.  Your child needs you to be his ally.

Request that the preschool or day care staff use the same strategy.  Ask your child’s teacher or day care provider to allow him to go to the bathroom any time he wants to and to take the same approach to accidents as you do.  Keep an extra set of clean underwear at the school or with the day-care provider.

Call our office during regular hours if:

• Your child holds back his BMs or becomes constipated.
• He experiences pain or burning when he urinates.
• He is afraid to sit on the toilet or potty chair.
• Resistance has not decreased after one month on this program.
• Resistance has not stopped completely after three months.

Using Incentives to Motivate Your Child

Incentives are rewards for good behaviors.  Incentives are especially helpful for overcoming resistance when children are locked in a power struggle (control battle) with you over toilet training.  They give the child a reason to leave the power struggle.

How to use incentives

Four conditions are required to make incentives powerful:

• Your child strongly desires the incentive.  Ask for your child’s input (“What would help your remember to look after your poops?”).
• You give the incentive immediately after the child meets the goal (releases urine or stool into the toilet, for example).
• You allow your child access to the incentive for 30 to 60 minutes.
• You, not your child, continue to own and control the incentive.

The last requirement is essential.  The child’s access to the incentive (a bike, costume, videotape, remote-control car, paint set, or whatever) must be time-limited.  In essence, the child earns a privilege, not another possession.  That’s the only way to maintain the value of the incentive.  None of the incentives discussed here is essential to normal child development, and that is why they can be selectively withheld.

Incentives to choose from

• Access to a new or favorite toy. (Examples: time with a tricycle or bicycle, train set, Star Wars toys, Lego sets, cars and trucks, remote-control car or dog, dinosaur toys, jewelry kit, art or drawing supplies, water pistol, magic sword)
• New costume or outfit.  (Examples: Batman or Superman, Snow White or Belle, nail polish, special shoes)
• Video time.  (Examples, new videos, tapes of favorite TV shows, trip to the movie theater, new computer games)
• Special foods.  (Examples: candy or other sweets, ice cream or popsicle, favorite cookies, other favorite foods such as pizza or strawberries, trip to the grocery store to pick out a favorite food or to a favorite restaurant or snack shop)
• Money
• Grab bag of surprises (written on pieces of paper)
• Triple reward for breakthroughs: Fast food restaurant, then video store and stay up late to watch the movie.

Never withhold social reinforcers

Social reinforcers include physical affection (hugs and kisses) and parent-child activities (going to the library or zoo, reading stories or playing board games).  Never withhold social reinforcers and use them as incentives because they are essential for your child’s emotional growth and mental health.  Moreover, nurturing makes your child more receptive to parental rules and requests.  Never withhold physical activity (playing catch, walks, or going to the park) because fitness and endurance are essential to physical health.  You can offer extra parent-child activities as incentives, however.

Stool Holding: When Your Child Holds Back Bowel

Movements and is Not Toilet Trained

About 5% of children refuse to be toilet trained.  They get into a tug-of-war with their parents over using the toilet.  Some of these children decide to hold back bowel movements (BMs).  That behavior can lead to constipation, painful BMs, and even complete blockage (stool impaction).  Impacted children constantly leak (ooze) stool in small amounts (soiling or encopresis).

If the impaction persists for long, the rectum and colon become stretched out of shape and are no longer able to squeeze out stool.  Unblocking the bowel may require some enemas.  Keeping the child unblocked requires three to six months of laxatives or stool softeners.  Stool holding is an important problem to recognize early and treat vigorously.  The following steps can help you help your child end stool holding and soiling:

Clarify the goal with you child.  Remind your child that his (or her) job is to make a poop come out every day.  Tell him “your body makes a poop every day” and “the poop wants to come out every day.”  Emphasize poop production and release.  Older children who don’t like stool leakage can be told “If you poop every day and keep your body empty, nothing will leak out.”

Give laxatives to keep the rectum empty.  Most stool holders need a laxative.  Laxatives (bowel stimulants) cause the large intestine to contract, pushing the stool toward the rectum.  Most laxatives contain senna, a natural plant extract.  Don’t worry that you child might become dependent on laxatives-that is, that the bowels won’t move well without them.  Laxatives can be withdrawn gradually, even after your child has used them for many months.  The most important goal is to keep the rectum empty.

Give stool softeners for hard bowel movements.  Stool softeners make stools softer and easier to pass.  Unlike laxatives, they do not cause bowel contractions or pressure.  Some commonly prescribed stool softeners are mineral oil, milk of magnesia, Miralax, and high-fiber products.

Transfer all responsibility to your child.  Your child will decide to use the toilet only after he realizes that he has nothing left to resist.  Have one last talk with him about the subject.  Emphasize that his body makes poop every day and that it belongs to him.  Explain again that his poop wants to go in the toilet and his job is to help the poop come out of his body.  Tell your child you’re sorry you forced him to sit on the toilet or reminded him so much.  Tell him from now on he doesn’t need any help.  Then stop all talk about the subject (“potty talk”).  Pretend you’re not worried about it.  When you child stops receiving attention for nonperformance (not using the toilet and holding back stool), he will eventually decide to perform for attention.

Stop all reminders about using the toilet.  Let your child decide when he needs to go to the bathroom.  He knows what it feels like when he has to poop and where the bathroom is.  Reminders are a form of pressure, and pressure keeps the power struggle going.  Stop all practice runs and never make him sit on the toilet against his will because this always increases resistance.  He needs to gain the feeling of success that comes from doing it his way.

Because stool holders are hurting their body, there are some exceptions to the no reminders rule:

• If your child complains about abdominal pain, clarify how to make it go away.  Tell him: “The poop wants to come out; the poop needs your help.  Holding back causes a tummy-ache.”  Offer to help him sit in a basin of warm water to relax the anal sphincter.  If he refuses, tell him, “I can’t help you.  You have to help yourself.”  Then ignore your child or put him in time-out.  Tell him to come back after the poop is out.  Do not give positive attention for stool-holding behavior.
• If your child is obviously holding back a BM, initially say nothing in hopes he will do the right thing.  If he holds back for more than five minutes, give a pleasant verbal reminder.  First say, “Your body is talking to you.  What does it want you to do?” If necessary, add, “The poop wants to come out and go into the toilet.  The poop needs your help.”  Tell your child that you want sitting on the potty to be lots of fun.  What would he like to do (such as read favorite books)?  If he declines your offer to provide a special potty activity, say nothing more and let him decide how he wishes to respond to the pressure in his rectum.

For stool leakage, put your child in “poop jail.” If your child is leaking stool, ground him until he passes a BM.  Tell him: “When poop leaks out, it always means there’s a large poop inside trying to get out, and you need time to think about how to help your body get it out.”  Tell your child he’s grounded in “poop jail” until he passes a big poop.  He can leave “poop jail” only for essential events: meals, preschool or school, scheduled classes such as music lessons, or team events.  Otherwise he must stay in his bedroom with no TV, videos, computer games, or visits from friends until he completes his assignment.

Using the tem poop jail keeps the intervention humorous and more acceptable for most children.  To protect your role as your child’s ally, you can attribute the restriction to “doctor’s orders.”  If you child complains, give him a hug and blame the doctor.  If this approach doesn’t work, consider restricting your child to the bathroom informing him that he can’t come out until he produces a normal-sized poop.

If your child goes two or three days without passing a BM, ground him until he passes a big poop (at least the size of a banana).  Remember that holding back stool causes it to become larger and wider.  After four or five days, it will become too wide to pass.

Give incentives for using the toilet.  You must find the right incentive to encourage your child to go poop into the toilet.  Initially err on the side of giving too much (several food treats each time).  The potency of incentives is increased by reducing access to them except when your child uses the toilet.  If you want a breakthrough, make your child an offer he can’t refuse, such as going somewhere special.  (See the “Guide for Parents:  Using incentives to motivate your child.”)  Also, give positive feedback, such as praise and hugs ever time your child tries to use the toilet.  On successful days, consider taking 20 extra minutes to play a special game with your child or taking him to his favorite playground.

Give stars for using the toilet.  Get a calendar for your child and post it in a visible location.  Call it the “Good Pooper Chart.”  Have him place a star on it every time he poops into the toilet.  Keep this record of progress until your child has gone one month without any soiling.

Make the potty chair convenient.  Be sure to keep the potty chair in the room your child usually plays in.  This gives him a convenient visual reminder about his options whenever he feels the need to pass stool.

Allow your child to use diapers or pull-ups for BMs if necessary.  You want your child to look forward to releasing BMs rather than holding them back.  If your child refuses to sit on the toilet, having BMs in diapers or pull-ups is always better than stool holding.  Give your child access to diapers or pull-ups, but don’t let him wear them all day.  Keep him in loose-fitting underwear so that he has to decide each time he has an urge to pass a BM whether to use the toilet or to come to you for a diaper.  To help him make the right choice, offer major incentives, such as a trip to a favorite restaurant or toy store, for BMs in the toilet.  Offer minor incentives, such as candy, for BMs in the diaper.  (Note: Keeping your child in underwear also gives him an incentive to maintain bladder control and stay dry.)

Help your child change his clothes if he soils himself.  Don’t ignore soiling.  Your main role in this treatment program is to enforce the rule that “people can’t walk around with messy pants.”  Your child will probably need your help with cleanup, but keep him involved.  Make changing underpants a neutral, quick interaction.  If you child refuses to let you change him, ground him or put him in time-out until he is ready.