T. Berry Brazelton, M.D. Child-Centered Toilet Training Method

Don't Give Into Potty Training Social Pressure

Yesterday we started discussing the T. Berry Brazelton, M.D. Child-Centered Toilet Training Method. Today we post an excerpt from his book The Brazelton Way.

"I thought it would be more effective to wait until the child showed signs of readiness for toilet training, and readiness to feel that it would be his own achievement. I began to work toward an approach of patience to offer parents. Many of them felt that they'd been traumatized by toilet training in their own childhoods and feared that they would repeat with their own children the pressured approach they'd experienced themselves.

I recorded the progress of 1,190 families in my practice who were willing to go along with my waiting-and-watching-for-the child's-readiness scheme. (See Chapter 2 for this step-by-step approach to toilet training.) Together, we discovered that it really worked! Constipation was reduced to a minimum and bed wetting in children 5 years old and older dropped to an incidence of around 1 percent! Amazing.

When I published these results in Pediatrics, one of the journals most frequently read by pediatricians, this new, child-centered approach quickly took hold. Most pediatricians began to recommend a more sensitive approach, which meant waiting for the child's own mastery of toilet training challenges.

Many of the symptoms I'd been so concerned about seemed to vanish in my own practice. Rarely did I have to prescribe treatment programs for smearing, severe constipation, soiling, and bed wetting. Putting the child's understanding that this achievement was his own before his parents' wishes for him to comply had naturally led to successful training and fewer problems later.

But there are still many obstacles and vulnerabilities that can threaten a child's success in this important developmental task:

1. A child may not be ready to face toilet training as soon as a parent is. With the pressures of nursery school or other caregivers, parents may find it hard to wait. Chapter 2 describes the signs of a child's readiness for toilet training, on which a parent might rely.

2. The temperament of the child can play an important role. A very quiet, sensitive child, for example, may need time to digest each step of toilet training, and decide when he is ready, before he will take it on. Children who are hypersensitive to touch will have to decide when they are ready to start sitting on an uncomfortably cold potty seat.

3. At the other end of the temperament spectrum, an active child at first won't sit still long enough for the potty. He may have to act out each step with a favorite toy, such as a dump truck before he's ready to try it himself. Even then, he may sit still just to please others, not himself. A wise parent will watch for the child's cues of readiness and acceptance. Playacting the steps with toys and/or modeling clay may make it more understandable to the child. When he brightens and seems proud to have understood the meaning behind each step, it is time to leave it to him so he can feel this process is his to master.

4. Ghosts in parent's nurseries — for example, parents' bad memories of their own toilet training — are likely to make them anxious about their child's training. Many of the parents in my study were ready to admit that the fear of reproducing their own traumatic experience prevented them from introducing each step to the child without anxiety. I wish that all parents like this could recognize and accept their need for help to sort through their own past experiences. For such parents, it is all too easy to put on pressure, or to overreact — without meaning to — to a child's delay or failure in taking each step.

For many years after this study, a child-oriented approach to toilet training became widely accepted in this country. But as more parents of young children have had to go to work, as more children were started in childcare at earlier ages, pressure to toilet train children by a fixed, chronological deadline reemerged. Parents feel pressured by the requirement that their children be dry and clean for admission to childcare programs. (See "Preschool Pressure" in Chapter 3.) I think their children are responding to this pressure too: With these changes, I have noted a recurrent surge of delays in successful toilet training.

The Children's Hospital Guide from Children's Hospital Boston provides these more recent statistics on children's progress with toilet training between the ages of 2 and 5:
• 22 percent were out of diapers by age 2 and one-half years;
• 60 percent were out of diapers by age 3 years;
• 88 percent were out of diapers by age 3 and one-half;
• 20 percent were bed wetting up to age 5.

I'd be concerned whether this large number of 5-year-olds who wet the bed is evidence of the pressure that parents, and, in turn, children are feeling.

Specialized pediatric toilet training clinics are being set up for parents of 4-, 5-, and 6-year-olds who have not complied to toilet training pressure. An expert in pediatric urinary tract disorders at the Children's Clinic in Wilmington, Delaware, told me of his concern (and that of other pediatric specialists) about 3- and 4-year-old children who withhold urine as well as bowel movements. In extreme cases, the consequences of holding back on urine could be seen in X-rays of these children's enlarged ureters (tubes that carry urine from the kidneys to the bladder). Enlarged intestines in children who are holding back on bowel movements also seem, to me and to other pediatricians, to be on the rise again.

Parents are feeling the social pressures to get their children trained at an early age. These pressures are real. Often parents can't get their children accepted into childcare programs unless they are trained. Many involve institutional policy issues that cannot be solved by individual parents unless they band together. However, I would urge that we keep in mind the child's own role in his toilet training. This book offers a model intended to prevent problems such as these by focusing on the child's need to feel in control of his or her own body.

The remarkable thing to me is how thrilled a child can be when he does master this important step in his development. "Mommy, I'm dry! I'm clean!" What a triumph! Do we want to ignore that?

By 3 or 4 years, children face pressure from each other at preschool. One child is bound to ask another, "Are you dry at night?" The other nods his head vigorously, and asks, "You don't wear diapers?" "No!" the first child will emphatically answer. And yet, his bravado gives him away. Any sensitive adult watching this scene would know that the bragging child still wears diapers himself.

The pressure that children put on each other to be dry and clean is an important factor by the age of 4. We, as parents and professionals, had better not add to it, so we can support a child who is not ready yet. I hope this book can help parents be patient and understanding — and ready to admire a child as he works hard to make toilet training his own success, step by step.