Slate’s Definitive-ish Guide to Potty Training

Advice for parents
July 8 2013 5:30 AM

Slate’s Definitive Guide to Potty Training

Just kidding—we have no idea either.

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Other techniques promise “rapid” toilet training, but only one of them has been scientifically tested, and that’s a method developed in the 1970s by behavioral psychologists Nathan Azrin and Richard Foxx and popularized in their best-selling book Toilet Training In Less Than A Day. Foxx and Azrin developed their method for children with mental disabilities, but they found it worked in healthy kids, too. It goes something like this:

1) The child is rewarded, often with sweets, for showing interest in the potty, going to the bathroom in it, or pulling down his pants.

2) The child is given extra fluids so that he frequently has to go to the bathroom.

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3) The child is told that an imaginary person is “happy that you are learning to keep your pants dry.”

4) The child is verbally reprimanded and given brief time-outs for accidents and required to change his pants by himself.

5) The child is shown how to empty the potty basin into a toilet, flush the toilet, replace the basin, and wash his hands.

6) The child is given “pant checks” every few minutes and rewarded for having dry pants. All in one day.

In their initial 1973 study, Azrin and Foxx used their technique to potty train 34 healthy children between the ages of 20 and 36 months in an average of just under four hours (one kid was fully trained in half an hour!), and the children were still using the potty four months later.

With these results, why isn’t the Foxx/Azrin method the one most recommended by pediatricians? Well, for one thing, in their study, trained professionals were used to teach the technique, not parents—in a 1976 study in which parents were trained to use the method on their kids, it worked only 77 percent of the time. And in every study, some kids had temper tantrums during their training sessions, which has raised concern among doctors that the approach might have “emotional side-effects.” But honestly—wouldn’t you have a tantrum if you were forced into an all-day intensive training session at the age of 2? And despite concern, there’s no evidence that this method causes any lasting harm. (If tantrums were a sign of emotional damage, my son would be in trouble.)

Indeed, the idea of diaper-free speed-training persists and has morphed into several Foxx/Azrin spin-offs that promise rapid toilet training in a slightly less intense format—these include the popular e-book Oh crap. Potty Training by Jamie Glowacki; 3-Day Potty Training; and the Diapers Free Toddler Program developed by Julie Mellom. But no peer-reviewed published studies have been conducted on the effectiveness of these plans, and none were developed by doctors or scientists, so parents either have to trust the authors or hope that what worked for their friends will work for their kids, too. (One friend raved to me about Oh Crap. Potty Training whereas another said she gave up on the technique when her son proudly announced that he had peed on his pants instead of in the potty.) Diaper-free methods can also be tough to implement if your child is in preschool or day care—some centers won’t allow untrained kids to run around without diapers as some of these approaches recommend. And the day care center also known as your home may not want to be covered in pee either. Still, parents continue to try these speed strategies, probably because who doesn’t want to get this all over with as quickly as possible?

Edward Christophersen, a pediatrician and psychologist at Children’s Mercy Hospitals and Clinics in Kansas City, Mo., has written an entire book on toilet-training problems and says that no technique is fail-safe: Problems arise in kids no matter how you do it. What kind of problems? Well, one out of every five kids in the middle of potty training temporarily refuses to poop in the potty, a behavior clinically referred to as “stool toileting refusal.” No one is certain why children do this, but because it’s more common in kids who hide while they poop in their diapers, it could have something to do with the fact that these kids think of poop as something “bad” that happens in private, and they don’t feel that pooping on the potty affords them the privacy they need. (Kids really don’t like to shut the bathroom door.) This behavior isn’t dangerous if it’s short-lived, but over time, if the child isn’t using diapers, it can create a vicious cycle: withholding poop causes it to harden and become more painful to pass, which reinforces the child’s desire not to go.

Although experts aren’t sure how to prevent the withholding from happening in the first place, a 2003 study found that when parents talked positively about poop and praised their kids for pooping in their diapers prior to toilet training, their kids were just as likely to develop this problem as other kids, but they got over it more quickly than did children of parents who talked negatively about poop and who didn’t praise their kids for pooping in diapers. One study found significantly more toilet training problems among kids whose parents had told them to “push,” make noises or who had turned on the tap when their kids didn’t go (maybe that’s “hovering within the prompt”?) compared to parents who just postponed using the potty if their kids didn’t go—so staying relaxed when your kids are on the potty might make things go more smoothly.

What about “elimination communication,” the practice in which parents learn their infants’ bathroom cues and hold them over toilets, sinks, grass, and the like to pee and poop rather than putting them in diapers? It’s common in Africa and India, where parents have less access to disposable diapers and spend more time outside, but it is also growing in popularity among progressive U.S. parents (recently profiled in the New York Times, no less). Although it’s environmentally friendly to say no to diapers, there’s no evidence that the practice provides benefits to babies, Christophersen says, and if parents get frustrated when it doesn’t work and blame the baby for it, it could be emotionally damaging. Plus, the method can, to say the least, prove awkward. “I don’t know about the people you socialize with, but most of the people that we socialize with were born inside and lived inside, and they don’t want stool on their carpets,” Christophersen says.

So what’s the “best” approach to toilet training? I think it depends on your temperament as a parent and the temperament of your child. If you’re a Type A “let’s do this thing” parent, try a rapid method—heck, maybe even buy Foxx and Azrin’s book, because it’s the only rapid technique that’s been backed by solid evidence. You may want to tone it down a tad—one 2002 paper suggested that parents skip the time-outs, but that the technique’s use of  “predictable, immediate, and salient consequences “ makes a whole lot of sense. If, on the other hand, you think you, your toddler or your house wouldn’t survive intensive training, go with Brazelton’s method.

“The hardest thing a child does between the time they’re born and fully toilet trained is the toilet training,” Christophersen told me. She has to learn to recognize feelings in her colon and bladder that parents can’t point out; when she has them, she’s supposed to stop what she’s doing, find a bathroom, take off her diaper or underwear, go, wipe herself clean, and pull her clothes back on again—not a tiny feat for a toddler who might still have trouble climbing steps and eating yogurt. So to help her along, before you start training, teach her some of the skills she’ll require, like how to push down her pants and flush a toilet. Pediatrician Nathan Blum also suggests that if you’ve been training for a month and your child is not making much progress, take a break for a month or two and come back to it (or try a new method). Finally, take a deep breath. As Blum and your mother say, “The number of healthy un-toilet trained kids in high school is pretty low.”

Melinda Wenner Moyer is a science writer based in Cold Spring, N.Y., and is DoubleX’s parenting advice columnist. Follow her on Twitter.