Assessment and Treatment of Childhood Problems: A Clinician's Guide

By Carolyn S. Schroeder; Betty N. Gordon | Go to book overview
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CHAPTER 4
Toileting: Training, Enuresis,
and Encopresis

TOILET TRAINING

Although all parents face the task of toilet-training their children, very little research supports one method of training over another. Cultural and societal attitudes seem more important than data when it comes to deciding when a child is “ready” to be trained and choosing a training method. One early cross-cultural study found that the median age of starting regular toilet training in London was 4.6 months, in Paris 7.8 months, and in Stockholm 12.4 months (Hindley, Fillozat, Klackenberg, Nicolet-Meister, & Sand, 1965). In the United States, the suggested age at which to start training has varied from 1 (!) to 24 months, with current support for 18 months and preferably 24 months (Luxem & Christophersen, 1994). In a review of 40 years of research on toilet training, Berk and Friman (1990) concluded that (1) most children are trained between 24 and 36 months of age, and almost all children are trained by 48 months of age; (2) training focused on independent, voluntary control is completed later than training focused on biological and behavioral indices of toileting readiness; and (3) the trend as of 1990 was in the direction of later completion of training. Luxem and Christophersen (1994) indicate that this trend toward delayed toilet training and permissiveness may have begun to reverse itself, as the risk of acute infectious diarrhea and hepatitis has been increased by greater numbers of children in day care who are not toilet-trained.

Whether toilet-training children earlier will increase parent–child problems related to training is not clear. Even with the more permissive delayed approach, many parents report problems with toilet training, including refusal, tantrums, emotional upsets (both parent and child), avoidance through retention of urine and/or stools, strange behaviors (e.g., extreme interest in toilets and toilet waste), and parent–child conflict (Mesibov, Schroeder, & Wesson, 1977; Schmitt, 1987). Parents' unrealistic expectations for when their children should achieve continence may also increase parent and child stress. Shelov et al. (1981), for example, surveyed 1,435 parents and 446 physicians, and found that parents felt a child should stay dry through the night by age 2.75 years (vs. age 5.13 years for the physicians).

The developmental and scientific literatures, although limited, do give us some general guidelines for toilet training. Although studies and case reports demonstrate that children can signal and withhold (for a short period) their impending bowel and bladder emptying as early as 6 months of age (Smeets, Lancioni, Ball, & Oliva, 1985; Largo & Stutzle, 1977), this does

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