The child-oriented approach to toilet training, developed by pediatrician T. Berry Brazelton in the 1960s, is a gentle, gradual approach that follows the child’s lead, emphasizes praise over shaming/punishment, and assesses child readiness at each step. [Brazelton: 1962] During child-oriented training, the child starts with sitting on the potty with clothes on and gradually moves through steps that culminate in the child voiding and having bowel movements in the toilet.

Some children with developmental delays, especially those children who are able to attain typical toileting readiness skills and behaviors, are able to toilet train using the child-oriented approach. However, training may start later and take longer than it would for a child without developmental delays.

Other children with more complex developmental or behavioral challenges are more likely to succeed with the more structured toilet training methods discussed below.

The behavioral approach, popularized by Azrin and Foxx’s “Toilet Training in Less Than a Day,” uses positive reinforcement (rewards, parental attention, candy) to reinforce toileting and removal of rewards and mild verbal reprimand to decrease accidents. It also uses a doll to model toileting. Children are given large volumes of fluids to encourage frequent urination and frequent “wet pants checks” to assess progress. This approach, which was initially used in adults with intellectual disabilities, has been modified for use in children with autism and other developmental disabilities. [Azrin: 1971] [Kroeger: 2010]

This intensive approach is the typical method implemented as part of an IEP or home behavioral program. During training, toileting becomes the child’s primary goal. If implemented as an IEP goal, training is initiated at school and transitioned to home once the child has success. The child is changed into underwear at the start of training. Initially, the majority of the day is spent in or around the bathroom, alternating periods of toilet sitting with playtime during which dry pants checks are performed with praise for being dry.

A health plan can be developed to ensure safely increasing hydration to give the child lots of chances to practice urinating on the toilet. Once the child is showing some success, they are gradually transitioned back into the classroom setting with continued dry pants checks. No other new goals should be pursued in the classroom until they have incorporated toileting into their day. Once successful in the classroom, the skill is transitioned to home. This process should always be positive, and accidents should be managed with a neutral affect. Any resistance or aversiveness on the child’s part should be recognized as a need to modify the program.

This approach is used when a child’s motor skills preclude the frequent transitions to and from the toilet used in the intensive approach or when an intensive approach is deemed not appropriate for the child due to functional level, behavior, or classroom readiness. This method involves checking the child at very frequent intervals for a couple of weeks to determine high-probability times for urination and bowel movements. Once the high probability times are determined, the child is taken to the bathroom at these times for 15 minutes. If the child goes to the bathroom, they receive praise or a reward, then return to usual activities and are taken back to the toilet at the next high probability time. If they do not go to the bathroom, they return to activities but are taken to the bathroom again every 15-20 minutes until they go to the bathroom (praise or reward provided) or they have an accident. As with the intensive behavioral approach, accidents should be treated neutrally; the child is changed and returns to usual activities until the next high probability time. Note this approach takes much longer, and the goal is toilet conditioning rather than independent toileting.

Timer or clock-assisted training helps a child recognize internal cues to toilet through frequent timed trips to the bathroom. The timer is initially set for every 20-30 minutes, and the time is lengthened as the child maintains dryness for longer periods. Older children can be provided a vibrating watch to allow more independence with toileting activities. This method can be used independently or in combination with other toilet training methods.

Cerebral Palsy
Motor challenges create additional support needs for many children with cerebral palsy (CP). Some children with CP may require adaptive equipment or caregiver support to transfer to the toilet, and occupational therapy or physical therapy consultation can be helpful for guidance on the equipment and assistance needed. Constipation and bladder spasticity (resulting in frequent urination) are also common in children with CP, and it is important that families work with their child’s doctor (and, in some cases, gastroenterology and/or urology) on optimal management of these conditions prior to beginning toilet training. For these reasons, toilet training generally occurs later in children with CP than in typically-developing children. Despite these challenges, toilet training is achieved for many children with CP, especially when provided with appropriate adaptive equipment and developmental therapies. Cerebral Palsy has detailed information about management, including therapies.

Neurogenic Bladder
Children with neurogenic bladder due to spina bifida or other medical conditions often do not develop adequate bladder awareness to use the toilet to urinate. Continence through bowel and bladder programming is an important goal. Bladder catheterization (by a parent when young and by the individual when they attain the skill), as well as use of bladder muscle relaxants, can result in urinary continence. A bowel program for regular emptying of the bowels (e.g., bulk agents or softeners, rectal stimulation, or suppositories) can be used to attain bowel continence. In some cases, an anterior enema port with daily emptying may be a way to attain this goal if a bowel program is not working.

Developmental

Developmental Delay
Children with cognitive and communication delays generally demonstrate toilet training readiness later than children without delays and take longer to toilet train. As discussed above, some children will train using a child-oriented approach, some may need an intensive approach, and some will do best with initially scheduled toileting. Parents may need guidance in deciding which approach may work best for their child. Regardless, a stepwise approach that teaches one skill at a time (sitting on the potty, pulling pants up and down, washing hands, etc.) can be helpful. Some of these skills can be taught even before a child develops bladder awareness and control. Visual schedules of the toileting routine are also helpful. Children with communication delays benefit from working with a speech-language pathologist to develop functional communication skills both in general and specifically around toileting.

Autism Spectrum Disorder
Core communication, behavioral, and sensory differences in autism spectrum disorder can result in complex toilet training difficulties. Children with autism often have sensory sensitivities, and it is helpful to assess their sensory experiences around toileting if they are resistant to toilet training (see Sensory Differences below). Children with autism also may have significant difficulties with routine changes making the transition from diaper to toilet challenging and even distressing. Visual schedules, ample preparation (books and television programs about toileting, for example), and a gradual, stepwise approach can help children adjust. In some cases, the child’s ABA therapy program can provide guidance and support to parents as they work on this goal in the home. In other cases, it may be more appropriate to work on it as part of the IEP at school first and then transition home. Behavioral, occupational, and/or speech therapy may be needed to help the child develop skills around restricted behavior, sensory sensitivities, and communication delays that interfere with toileting (see Behavioral Therapies (see RI providers [35]), Occupational Therapy (see RI providers [24]), and Speech - Language Pathologists (see RI providers [35])). Autism Spectrum Disorder has detailed information about management, including behavioral therapy.

Behavioral

Children with behavioral challenges are generally harder to potty train than children without behavioral difficulties. Parents and caregivers of these children are often unable to find professional support because formal diagnoses (such as attention-deficit/hyperactivity disorder or oppositional defiant disorder) are not usually provided until the preschool years or later. Even when behavioral challenges are recognized, the limited availability of therapists who work with very young children and lack of funding can impede access to behavioral supports. However, if the behavioral difficulties are recognized and behavioral guidance is given, many children will respond with progress toward successful toilet training.

Children with behavioral difficulties may not respond to positive reinforcement in the same ways as other children. They may have more intense tantrums in response to changes in routine or task demands. Breaking the toilet training goal into small steps, implementing a variable positive reinforcement plan, managing mood and attention, and helping the child decide that they want to achieve the goal can foster success. It is especially important to tailor goals and rewards to the child’s current ability. For example, a child may not be motivated by a reward to urinate in the toilet if that task is too overwhelming or difficult. However, if the goal is changed to something more achievable (e.g., sitting on a small potty with the diaper on), the child may respond more positively. Goals can advance as the child develops mastery. If the child is resistant to even gradual measures, it may be helpful to wait a few weeks or months and try again.

The primary care clinician can plan an important role in recognizing behavioral challenges and linking the family to appropriate support. Families should consult with their pediatrician to screen for co-occurring neurodevelopmental disorders, such as autism or communication disorders, which often present with behavioral problems but require developmental interventions in addition to behavior supports (see Developmental section above).

Sensory Differences

Blindness and Vision Impairment
Children with significant vision impairments do not use the visual tools and cues that are cornerstones for children without these impairments, such as visual observation of parent and sibling toileting behavior and toilet-themed picture books. They depend more on cognitive and communication skills for potty training and, as a result, often potty train later than children without vision impairments. These children benefit from supervised and narrated tactile exploration of the bathroom and toilet and initial guided support of the toileting process (pulling pants down, sitting on toilet, using toilet paper, pulling pants up, washing hands, etc.). A small potty on the floor is likely to be more accessible than a potty seat on the adult toilet, and it is important to keep the small potty in the same place in the bathroom so that the child can always locate it. Children’s audiobooks about toileting help support the learning process.

Deafness and Hard of Hearing
Children with hearing loss often toilet train at a similar age to children without hearing loss, using the same visual cues and then signing and gesturing to communicate. Children with hearing loss and co-occurring developmental or communication delays generally toilet train later and benefit from a stepwise approach (see Developmental section above). For detailed information about delays and other management information, see Hearing Loss and Deafness.

Sensory Integration/Processing Difficulties
Children with sensory sensitivities (common in autism spectrum disorder and also occurs in children without autism) are often sensitive to many aspects of the toileting process (toilet flushing, bathroom odors, the sensation of clothing, etc.). These sensitivities may manifest as anxiety around toileting, tantrums, and toilet training resistance. Caregivers should evaluate their child in the toilet environment to identify sensory-related triggers. For some children sensitive to toilet-flushing sounds, being allowed to flush the toilet without any expectations to use it can be a low-pressure way to help the child adjust to this sound. Other children benefit from noise-blocking headphones. Frequent practice in pulling up and down pants may exacerbate sensitivities to fabrics; soft, elastic waist sweatpants can help (and are generally easier to manipulate for all children). Consultation with an occupational therapist can be very helpful in evaluating and managing sensory sensitivities around toileting.