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Tips for toilet training tots

New book guides parents through this inevitable and often trying stage of their child's development. Read an excerpt of Dr. T. Berry Brazelton's new book, "Toilet Training: The Brazelton Way."

Dr. T. Berry Brazelton's calm and positive approach to childrearing has earned him the title of America's most trusted pediatrician. Now 85, Dr. Brazelton hasn't lost his enthusiasm for children. He's actively involved in guiding moms and dads through those important first years of life, from infancy through the preschool years. His down-to-earth advice helps them better understand what a baby needs to thrive both physically and emotionally. Now, his book series, "The Brazelton Way" tackles two tough topics: feeding and toilet training. In part one of his discussion on “Today,” he shares some of his thoughts on toilet training. Read an excerpt of “Toilet Training: The Brazelton Way” here:

Toilet Learning: The Child's Role
We don't always realize what we are asking of small children when we ask them to give in to toilet training. First, they must feel a bowel movement coming on. Then, they've got to hold onto their bowel movement, get where we tell them to go, sit down — and do it. Then, flush. After all that, they'll have to watch it disappear forever. They'll never see that part of themselves again!

What a lot to ask of a young child just at a time when he's trying to understand himself! At this age, children never know where their bowel movements have gone. This question may haunt them afterward. "Where is my poop? Why have they taken it away from me?"

Many years ago, a very large toilet, big enough for big children to climb in and all the way through, was constructed at the Children's Museum in Boston. They couldn't wait to see where their bowel movements had been going. Children 9, 10, and 11 years old lined up for blocks to try to find out where their "productions" had gone. They were still wondering, even at these ages.

The late Fred Rogers once asked a famous astronaut, Buzz Aldrin, to appear on his children's television show, Mr. Rogers' Neighborhood. He invited his guest to answer all of the children's questions. One little boy said to the astronaut: "Do you get scared when you go up in space?" Mr. Aldrin bravely replied, "Well, I used to, but I don't anymore." A little girl asked, "Does your mommy get scared when you go up in space?" The astronaut answered, "Yep. She still does. Every time I come back to Earth, she's grateful." Then a 4-year-old boy had his turn: "What happens to your poop in space?" The astronaut turned beet red, shuffled around, and was unable to answer. The next question came as a relief.

Observations like these have helped me understand just how much we're asking of children in these formative years when they begin toilet training. We need to initiate the process with utmost respect for the child — and for his ultimate decision to comply. Training a small child to use the toilet must be taken in steps that respect his willingness to cooperate. Parents also need to feel comfortable discussing these issues, and recognizing feelings about toilet training left over from their own childhood.

In the 1960s I introduced "A Child Oriented Approach to Toilet Training" to my patients and their parents. They (and I) were ready. The incidence of toilet training failures was rising in our country (including toddlers who smeared their stools, children who were holding back on bowel movements, causing severe constipation, and older children with continued bedwetting). Back then it was common to employ rather rigid practices, pushing 1- and 2-year-olds to be trained. Parents tried to respond to a child's body's signals by rushing him to the toilet, well before he was aware enough of these signals to be an active participant. If he complied, he was rewarded. If he didn't, he was reprimanded or punished.

It didn't work. Parents were trained in the method, but children were resistant. At this time in England, a rigid approach to toilet training was widespread: It was reported that 15 percent of 18-year-olds who were inducted into the service there were still wetting the bed. The other symptoms among children — withholding bowel movements, soiling, smearing stools — were also all too common. Many of these symptoms seemed to result from the child's resistance and resentment. Parental anxiety and the resulting pressure on children seemed to be interfering with the child's motivation for toilet training. It seemed to me that without the child's motivation, toilet training was often a lost cause. Soon my goal became to protect parents from feeling pressured so that together we could learn how to let their children lead us to their own readiness.

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 bedwetting 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 bedwetting. 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 bedwetting 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.

Excerpted from "Toilet Training: The Brazelton Way," by T. Berry Brazelton, M.D. Copyright 2003. All rights reserved. Reprinted by permission of DaCapo press.