By Steve Hodges, M.D.
A mom recently emailed me with a question about toilet training, one of my areas of research. She wrote: “A book I’m reading says if you wait until a child is ‘ready’ to train, you could end up with a 6-year-old who requests diapers to poop. Is this true?”
In two words: heck no.
I was so intrigued by this bad advice that I bought the book, which described potty training past 30 months of age as “a chore for you and your child." Out of curiosity, I bought a few other potty-training books. And then a few more. After reading 14 — yes 14! — books on potty training, I can say this: There is some seriously bad advice floating around — advice that will land many children in pediatric urology clinics like mine.
Most of the books have one chief mission: getting your child out of diapers ASAP. The promises are enticing: Potty train in 3 days! In a weekend! In less than a day! As early as 6 months of age!
But these promises are off base. I advise parents to aim for a more important goal: setting your child up for a lifetime of healthy toileting habits. I know that’s not nearly as exciting as ditching diapers this weekend, but doing it right is more important than doing it fast.
I’ve treated thousands of children who potty trained quickly and easily, only to develop enuresis (wetting problems), encopresis (poop accidents), and/or recurrent UTIs in grade school. That’s when the holding habits they developed as toddlers finally caught up with them. Potty training is prime time for children to become constipated, and the holding habit can become deeply ingrained — two facts unmentioned or glossed over in nearly all the books I read.
In this post, I highlight the potty-training advice I consider most harmful. What’s the best approach to take? I offer my take in a slim booklet called “7 Super Important Rules for Potty Training Success: A Guide for Parents.”
For a more comprehensive, step-by-step approach, I recommend Stress-Free Potty Training by Sara Au and Peter Stavinoha, Ph.D., who state, wisely, “Our methods are not tricks we guarantee will work in a prescribed amount of time.” Also, Let’s Get This Potty Started! by Heather Wittenberg, Ph.D., offers wise advice, such as: “Set your expectations aside, and let your child drive the process.” Both books take constipation seriously but don’t ffers specifics on how to treat it aggressively.
OK, on to the myths I found while binge-reading potty-training books.
Myth #1: There is a “window of opportunity for effortless potty training” between 20 and 30 months. If you miss the window, you’ll end up with a “potty refuser.”
This notion is everywhere! One author writes: “What do you suppose will happen if he decides he doesn’t want to use the potty and that the diaper is working just fine for him? . . . . It’s really hard to potty train children over three. They have free will and they know how to use it.”
This is line of thinking overlooks an important fact: When children over age 3 have difficulty training, it is not because they are “willful.” It’s because they are constipated. And when a child is constipated, toilet training is a futile, frustrating endeavor for parent and child alike.
Several authors maintain that the concept of “readiness” is bogus — that waiting for a child to be “ready” to train is responsible for the vast majority of “potty training drama.”
Again, untrue. Children who demonstrate readiness to train are far less likely to struggle than those who are less mature. “Ready” doesn’t just mean showing interest in using the toilet and noticing a wet or dirty diaper. More than anything, “ready” means being willing to interrupt activities to use the toilet.
Most children become willing around age 3, give or take. Sure, if you place a 2-year-old — or even a 1-year-old — on the toilet at the right moment, she’ll pee in it. But that’s entirely different from having the judgment to promptly respond to nature’s call. Toddlers tend to be so engrossed in their tower building and finger painting that they ignore their body’s signals, holding their pee or poop until they absolutely can’t.
Many parents take pride when their children train early, the same way they beam when their kids talk or read before their peers. One author warns readers to “be wary of well-meaning friends who tell you that your child is too young . . . They have an emotional investment in your failure . . . You are going to have awesome bragging rights.”
But having a toilet trained toddler is nothing to brag about! It can be a disaster in the making. Toddlers simply aren’t equipped to make major life decisions on their own — and I assure you, deciding every day when (or if) to poop is a decision with consequences. The most seriously constipated among my patients are those who trained earliest and most easily. In other words, they’ve been in charge of their toileting — when to hold, when to let it out — the longest.
Myth #2: Early potty training reduces a child’s risk of having accidents and urinary tract infections.
The folks who promote myth #1 believe early training is not only easier but also healthier for children. One author writes: “If your child isn’t fully trained by age 4, the likelihood of the child being a bedwetter are increased by 50%.”
Another writes: “There is no evidence that children trained early have any increase in the amount or frequency of accidents throughout childhood.”
Actually, I have strong evidence! In a study titled “The association of age of toilet training and dysfunctional voiding” and published in Global Pediatric Health, my clinic found that children under age 2 have triple the risk of becoming constipated and developing daytime wetting problems than children trained later. (This does not mean training at 2 ½ is a good idea.)
While it’s true that children who aren’t “fully trained” by age 4 have high rates of bedwetting, this is not because parents initiated toilet training too late. It’s because chronic constipation made it impossible to train the child earlier. Constipation — not late training — is the direct cause of bedwetting.
A common argument among early-training advocates is, “The sooner you start, the sooner your finish.” In truth, potty training doesn’t have a finish line. It’s not a skill like riding a bike, where the concept just “clicks” and your child is set forever. A child can be potty trained and develop the holding habit; it might just take a few years for the habit to start triggering accidents.
Don’t assume you’re out of the woods if you have a 2-year-old who stays dry. Rather than think in terms of finishing, stay vigilant after your child’s transition to underwear, monitoring him for the 12 signs of constipation.
Myth #3: “Before you start for real, you must set some goals.”
Potty-training book authors are all about goals. “For example,” one writes, “you want her toilet trained by her third birthday in two months’ time. That is a lovely goal.”
Other authors recommend setting daily goals. For instance: “Goal on day 2 is to go out and come back without the child having an accident.”
Goal-setting is great if you want to, say, run a marathon or earn a promotion; it should play no role in potty training.
You can’t compel a child to poop or pee in the toilet any more than you can compel her to sleep. Micromanaging the process with goals (or rewards) can backfire in a big way. Step aside and allow your child to own this milestone, on her own timetable.
You may need to adjust your definition of “success.” One author writes: “The biggest measure of success is when your child can remain dry,” but she has it backward. If there’s any goal that matters, it’s the goal of responding to your body’s urges in a timely manner. A child can stay dry by ignoring her body’s signals — in other words by withholding pee or poop. This is not "success."
Myth #4: “It needs to be decided whether you’re going to just focus on daytime training or try to take your child out of diapers at night as well.”
One author advises that “becoming dry at night still requires a devoted effort on your part. Don’t shirk your parental responsibilities at this final hurdle!”
In reality, you have no responsibilities here. There’s no “decision” to be made. “Nighttime training” is not a thing. You simply cannot train a child to be dry overnight. It’s something that happens naturally, almost always by age 4.
Don’t withhold fluids at night, wake your child overnight to pee, force him to sleep in underwear to “feel” the wetness, or take any other measure designed to speed up overnight dryness.
If your child turns 4 and is not dry overnight, she’s probably constipated. Want to know for sure? Have your child X-rayed. (Yes, it's safe.)
Do not wait until your child is 7 to take action! I recommend treating bedwetting at age 4, ideally with an enema-based program such as the Modified O’Regan Protocol (M.O.P.). If you think that’s too young, read “Don’t Assume Your Child Will Outgrow Bedwetting” or “Teenage Bedwetting: Everything You’ve Been Told is Wrong.”
MYTH #5: “When the child has not been successful . . . show that you are slightly disappointed.”
One author advises, “Be kind while at the same time being firm,” adding, “The child must never feel that . . . she can do whatever she wants.”
Another recommends giving “consequences” for accidents. For example, “After a few days, and when you are certain she knows the ropes, take away her toy. Whether it’s intentional rebelliousness or just being lazy, it’s still behavior.”
No, accidents are not “behavior.” If accidents persist, this means either a) your child was not ready to train or b) your child is constipated. Accidents have absolutely nothing to do with laziness or behavior, but this idea is so ingrained in our culture — and so damaging to children — that I was compelled to write Bedwetting and Accidents Aren’t Your Fault.
I cannot emphasize this enough: Never, EVER show disappointment in your child for having an accident. You can seriously sabotage toilet training, not to mention damage your child’s self-esteem, with even the most subtle suggestions of blame.
Potty training is not a time for a parent to exert control.
Myth #6: “A child cannot stay constipated forever. If you know her diet is good, at the very least you can rule out a purely physical problem.”
It’s the rare potty-training book that even mentions constipation. But even those that do tend to treat the topic as a minor, passing issue — and one that’s related entirely to diet.
Every day in my clinic I treat children who have been constipated “forever” — like for 10 or 15 years. Some children become constipated as infants, for reasons I explain in The M.O.P. Book. Many more kids become constipated while toilet training. But regardless of when their rectum became clogged and stretched, constipation can persist throughout childhood and into adulthood.
While a highly processed diet is certainly a major contributor to constipation, many children with excellent eating habits nonetheless become chronically constipated, often because they toilet trained too early. And many severely constipated children poop every single day; they just never fully empty.
It is critical for parents to recognize the signs of constipation, and in this regard, most potty-training books fall short.
One author writes that “grunting, going red in the face, or hiding in a corner or behind the couch” are signs your child needs to poop. Nope: They are signs your child is constipated! (Download our free infographic, 12 Signs Your Child is Constipated, here.)
Another author, in a section about cleaning up after accidents, writes: “If you are particularly lucky, the stools will be well formed and captured in your toddler’s underpants.” Again: Nope! Well-formed stools indicate constipation. They may be easier to clean up, but they are a sign of impending trouble. As I emphasize in Jane and the Giant Poop (a must-read for potty-training families!) healthy poop looks like frozen yogurt or mushy blobs, not logs or pellets.
Yet another author, demonstrating a lack of understanding about constipation, writes, “
“For soiling, re-teach the wiping technique.”
In reality, soiled underwear and “skid marks” are signs of constipation, not poor wiping technique. They indicate a child is not fully emptying.
What do you do if your child is constipated? Make sure your child eats a nutritious, whole-foods diet, and follow the steps I spell out in “What To Do If Your Child is Constipated (Hint: Treat Aggressively).” In short: enemas, laxatives, and pooping with a tall stool such as the Squattypottymus.
Possibly the biggest myth about potty training is that it’s a nightmare. That’s true when a child is not ready or is constipated. But a child who is truly mature enough to leave diapers behind, feels no pressure, and shows no signs of constipation can transition to underwear without any big ordeal.
Steve Hodges, M.D., is an associate professor of pediatric urology at Wake Forest University School of Medicine. He is the co-founder of BedwettingAndAccidents.com and co-author of Bedwetting and Accidents Aren't Your Fault, Jane and the Giant Poop, and The M.O.P. Book: A Guide to the Only Proven Way to STOP Bedwetting and Accidents.