Toilet training: Does anyone really know the best approach?

In our house, toilet training wasn’t easy. Faced with our son’s complete lack of interest in getting started with the process -- and unwavering refusal to cooperate once we did prod him toward the WC -- we, like many parents, ignored relatives’ well-intentioned urgings to hide the child’s diapers, make him run around naked until he got with the program, ply him with rewards or otherwise ask/wheedle/humiliate/trick/force him to use the potty.

Instead, we consulted our pediatrician for advice. He recommended a wait-until-he’s-ready and reward-based approach that my mother and sister, back East, mocked as “sooo California.”

It turns out neither they nor our doctor really know the proven best way or time to toilet train a kid. An article published Monday in the Canadian Medical Assn. Journal reports that pediatricians have little concrete evidence on which to base their toilet-training advice.

Dr. Darcie A. Kiddoo, a pediatric surgeon at the University of Alberta, looked over the literature on toilet training and found little scientific data to review. Noting that methods of getting kids to use the toilet have “fluctuated over the last 100 years from passive and lacking in structure, to coercive and regimented, to child-oriented and semistructured,” she wrote that experts such as T. Berry Brazelton and Benjamin Spock advocated child-oriented approaches based on kids’ readiness, while Nathan H. Azrin and Richard M. Foxx’s rapid method urged parents to comply to a four-step method that scheduled trips to the toilet and depended on positive reinforcement and “overcorrection of accidents.”

But Kiddoo could only report on a handful of studies examining the different approaches -- and none that provided comprehensive head-to-head comparisons. She wrote that there is some evidence that children who start to train late may suffer more elimination problems, citing one study (whose results may not be clinically significant, she added) that found that training kids after 32 months was associated with more cases of urge incontinence and another study that found that training after 24 months was associated with higher odds of daytime wetting.

But Kiddoo also wrote of a study that found that kids trained at earlier ages took longer to learn to use the toilet (but didn’t suffer in the process), and of research showing that age at toilet training was not a predictor of whether a child would develop urologic problems.

The upshot for pediatricians when baffled parents like me ask how to get a kid to use the toilet? Concluded Kiddoo, “In the absence of evidence, the treating physician must rely on expert opinion and should turn to the Canadian Pediatric Society and the American Academy of Pediatrics for advice for patients that is unlikely to cause harm.”

Which, I believe, is exactly what our pediatrician did -- and the process still wound up taking over a year.

Sigh. Until researchers get around to producing more studies on the matter, I won’t expect any magic-bullet solutions.

There’s a link to the commentary in CMAJ (subscription required) here.