Little scientific evidence exists to say one toilet training method trumps another for little ones making the switch from diapers or pull-ups, says a pediatric urologist.
Darcie Kiddoo, who wrote a commentary on the subject for this week's Canadian Medical Association Journal, says toilet training should be started when both the child and parent are willing and able to participate.
"Boys are less interested in it than girls are," Dr. Kiddoo said Monday from Edmonton, where she's with the division of pediatric surgery and urology at the University of Alberta.
"It does begin to start around 18 months of age, where they're beginning to be interested in those things. … I think it's safe if you're positive about it and it's not causing battles in the family to start to look at it at 18 months."
She's adamant on one count: A reward system can make sense if the child is older and can actually understand it, but it's important to differentiate between daytime and nighttime incontinence.
"It gets me quite upset when people come in and talk about a reward system for nighttime accidents because kids really don't have control over the nighttime," Dr. Kiddoo said.
"It's not fair to actually associate rewards with nighttime because they just don't have control over it."
In her commentary, she looks at the literature and refers to a study published in 1962 that involved a child readiness approach starting at 18 months. In a group of 1,170 children, daytime continence was achieved by a mean age of 28.5 months.
A rapid method of toilet training published by Richard Foxx and Nathan Azrin in 1973 required the child to be physiologically and psychologically ready. Once readiness was determined, a four-step method was used that included increased intake of fluids, scheduled toileting, positive reinforcement and overcorrection of accidents.
"Two small studies of 34 and 49 children used this method, and children who had passed the readiness test were trained in a mean of 4.5 hours," Dr. Kiddoo wrote.
The commentary notes that there is some evidence to suggest more disorders of elimination may develop in children who toilet train late.
Is there any particular approach that will make the transition from diapers to the potty easy?
"No," Dr. Kiddoo said, laughing.
"Being positive about the approach, taking children to the bathroom on a timed basis, is kind of the best way to go about it. Positive reinforcement … getting excited about it, but also not being negative when they don't go to the bathroom."
In terms of going No. 2, it's important to ensure kids aren't constipated as the pain of a bowel movement could be negative reinforcement for going to the toilet, she indicated.
Potty training away from home can be tricky because most adult bathrooms are not kid-friendly.
"I actually had one parent who told me that she just bought a small little Ikea toilet and took it around with her, and it made it easier," Dr. Kiddoo said.
"It was the practical approach rather than evidence-based, but it obviously would work a bit better because a lot of the bathrooms just aren't set up for little kids."
Parents should seek help if the child is starting school and there's still no interest in toilet training and it becomes difficult from a social standpoint.
Sometimes, school routines aren't set up well and teachers may not let the children go to the bathroom, Dr. Kiddoo noted. The kids hold it in – until it's too late – because they don't like to use the washroom at recess because they're busy having fun.
The medical community could do with more evidence about what works and what doesn't, Dr. Kiddoo said, but it's complicated to conduct studies involving lots of families and social situations.
In particular, she's interested in knowing what approaches might be harmful.
"That's what people are trying to address, is looking at kids who down the road do have bladder problems, and see if it relates to anything that happened earlier," she said.
"In general, healthy kids will toilet train, but the question is, 'What about those ones who have difficulties later on?' I think that's the biggest question to address, if there's anything parents do early on that might be harmful."
The Canadian Press