Click here to view next page of this article



To be independent in toileting, children must be able to signal the need before voiding, walk, climb, pull their clothes up and down, be dry for several hours during the day, understand what the toilet is for, and be motivated to model after adults and

On average, these skills come together around age 2 1/2, although 61% of cultures train at the age of walking or even during early infancy. However, such training generally requires much effort on the part of the parents. It is also important that parents who attempt early toileting not misinterpret the likely episodes of regression as behavior that must be punished. There is a wide range of normal for readiness; failure to be trained is not considered abnormal until after age 4 for potty training.

Problems associated with delays in toilet learning include relapses in training, toileting for only urine (or only stools), accidents, and fears of the toilet. Toileting is such a strong symbol of "growing up" that it often assumes great importance to both parent and child, resulting in battles over control. Parents who are either overcontrolling or underregulating frequently have children who have toileting problems during the preschool years. These problems cannot be resolved until the issues of control have been managed.

Relapses in toileting occur in 50% of children in the year after training. Many children, especially hyperactive ones, are too busy to sit or return from outdoors. Fears of the toilet can be due to accidents, but also may be developmental fears related to body integrity and magical thinking about the potential for disappearing down the toilet. The degree of modesty in the home or exposure to erotic media may need to be altered to relieve sexual tensions that exacerbate fears. Sexual misuse also should be considered when a new toileting problem develops.

Nocturnal enuresis is so common that it can be considered normal up to age 6. At age 5, 11% of girls and 14% of boys still are wetting the bed regularly. There is a 15% annual decrease in that event after that age. A return to enuresis after months of dryness is common around age 4. Stressors, presence of urinary tract infection, or signs of sexual abuse should be evaluated. The key task of the clinician during this age period is to assure that the child.