Toilet Training in Children

Toilet training is one of the subjects on which families are most often compared with one another. The sentence "ours was out of nappies at eighteen months" creates unnecessary alarm in the family of a child who is not yet ready.

Yet what determines toilet training is not chronological age but the child's readiness. Training begun before readiness takes longer, produces more conflict and can lay the ground for lasting problems such as constipation.

This article sets out the signs of readiness, a workable method, commonly encountered problems and when assessment is needed.

Key Points

• What matters is not chronological age but the signs of readiness.
• Starting early does not shorten the process; it lengthens it and produces conflict.
• Daytime and night-time control are separate processes; night-time develops much later.
• Constipation is the most common and most overlooked cause of toilet training problems.
• Forcing, punishing and shaming set the process back.
• Periods of stress (a house move, the birth of a sibling) are not suitable for starting.

Signs of Readiness

Before beginning toilet training, readiness is sought in three areas.

Physical Readiness

• The nappy staying dry for two hours or longer
• A regular and predictable pattern of bowel movements
• Being able to walk, sit down and stand up
• Being able to pull trousers down and up

Cognitive Readiness

• Being able to understand simple instructions
• Being able to indicate the need to go, by word or gesture
• Noticing the difference between wet and dry
• Being able to follow a simple sequence

Emotional Readiness

• Feeling uncomfortable about having a nappy changed
• Showing interest in the toilet, watching adults
• A wish for independence, saying "I'll do it"
• Not being in an intense phase of opposition

Most of these signs generally appear between eighteen and thirty months. A wide range is ordinary, however; not having started by the age of three is not in itself a problem.

When Not to Start

Starting in certain periods makes the process harder:

• Just before or after the birth of a sibling
• During major changes such as moving house or starting nursery
• During illness and recovery
• While there is intense tension in the family
• When a holiday or journey is imminent
• While the child is in an intense phase of opposition

Waiting a few weeks in these periods is far better than an attempt abandoned halfway. An abandoned attempt creates resistance in the child towards the subject.

How Is It Done?

The Preparation Stage

Before training begins, the environment and the language are prepared.

A potty or toilet seat adaptor and a step are obtained in advance; the child's feet resting on the floor or a step matters for bowel movements. Feet dangling in the air make it harder to push.

The child is introduced to the potty: first sitting on it clothed, seeing it during play, adopting it as their own possession. Picture books on the subject help at this stage.

A shared language is established within the family: which words will be used, who will respond how, and how alignment with the nursery will be arranged.

Putting It into Practice

Sit them at regular intervals. On waking, about twenty minutes after meals, before sleep. Because the bowel reflex is more active after eating, this timing works.

Keep it short. Three to five minutes is enough. Sitting for long periods creates resistance and turns it into a negative experience.

Praise the process, not the result. Saying "well done for sitting on the potty" is more workable than "well done for doing it", because what the child can control is the sitting.

Meet accidents calmly. Accidents are part of learning. "These things happen, let's clean up" is enough. Reacting lengthens the process.

Use comfortable clothing. Elasticated clothes the child can pull down and up alone support independence.

Be consistent. Nappies one day and pants the next creates confusion. Once a decision is made, continuity matters.

What Duration to Expect

Daytime control becomes established over a few weeks to a few months in most children. Bowel control generally comes a little after bladder control.

Regressions are ordinary. An increase in accidents during illness, tiredness, excitement or a period of change is expected and does not mean a lasting setback.

Night-Time Control Is a Separate Process

The point on which families are most often mistaken is expecting a child who has gained daytime control to stay dry at night too.

Night-time control is not a learned skill; it depends largely on maturation. Bladder capacity must increase during sleep and the night-time secretion of the hormone that reduces urine production must become established. This maturation occurs years apart from one child to another.

Bedwetting is considered ordinary up to the age of five and requires no treatment. A similar history in the family is very common.

What can be done in this period is limited: not overdoing fluid intake in the evening, including going to the toilet before bed in the routine, supporting the night with protective products, and not blaming the child.

For detail on night-time control, see our article on bedwetting and enuresis.

Commonly Encountered Problems

Refusing to Sit on the Potty

The most common cause is having started too early. If the child is not ready, the process turns into a power struggle and the toilet becomes an area in which the child can exercise control.

The most workable approach here is to withdraw: returning to nappies for a few weeks, taking the subject off the agenda and removing pressure entirely. Once the resistance disappears the process usually moves forward by itself.

Withholding and Constipation

This is the most common and most overlooked cause of toilet training problems. A child who once has a painful or hard bowel movement begins withholding so as not to feel pain again. The withheld stool hardens, the next movement is more painful, and the cycle feeds itself.

Warning signs: standing on tiptoe, squeezing the legs together, straining while hiding, infrequent and very hard stools, crying while passing stool, abdominal pain and loss of appetite.

Here toilet training takes second place; the constipation is treated first. Dietary adjustment and, where a doctor advises, the use of a softener are needed. Training does not progress until the constipation is resolved.

Insisting on Using a Nappy for Bowel Movements

Some children will pass urine in the potty but ask for a nappy for bowel movements. This is common and usually arises from anxiety.

Rather than forcing, a graduated transition works: first putting the nappy on and going in the bathroom, then beside the potty, then with the nappy laid inside the potty. At each stage the child is allowed to progress at their own pace.

Differences Between Nursery and Home

A child managing at home but not at nursery is common. It usually relates to the difference in setting, concerns about privacy, or timing.

A joint plan with the nursery is needed: at what intervals the child will be taken, which words will be used, and how accidents will be handled. Having spare clothes and not shaming the child after an accident are essential.

Regression

Losing previously gained control after the birth of a sibling, a house move, a change of nursery or tension in the family is common.

This is not a matter for punishment; it is an expression of the child's difficulty. Rather than increasing pressure, adaptation to the change is supported, attention is increased and the process is calmly re-established.

Fear of the Toilet

In some children the source of resistance is not stubbornness but genuine fear. The most common causes are these.

The sound of flushing. A sudden, loud noise startles a young child. The solution is simple: flushing after the child has left the bathroom, keeping to this order until they get used to it.

Fear of falling in. The size of the toilet is frightening for a small child. An adaptor and a firm step largely remove this fear; supporting the feet also makes pushing easier.

Anxiety about loss. Some children perceive stool as part of their body and view its going with anxiety. This is an ordinary thought at around three; graduated familiarisation is needed rather than force.

Anticipation of pain. In a child who has previously had a painful bowel movement, fear has been learned. Here treating the constipation comes before resolving the fear.

Where resistance stems from fear, pressure deepens the picture. The approach is to identify the source of the fear, remove that factor and allow the child to progress at their own pace.

Soiling and Encopresis

A child past the age of four soiling their underwear is a situation families mostly interpret as stubbornness but which is almost never that.

The mechanism is this: in prolonged constipation a hard mass of stool accumulates in the bowel. The bowel gradually widens and its sensitivity decreases; the child does not feel full. Soft stool leaking around the mass soils the underwear without the child being aware.

In this picture the child often does not notice they have soiled themselves, and sensitivity to smell is also reduced. The answer to "can't they smell it?" is therefore genuinely no.

The first step in the approach is not punishment but clearing the accumulated mass under medical supervision. This is followed by long-term use of a softener, a regular programme of sitting on the toilet, and dietary adjustment. Treatment takes months and stopping it early leads to the picture recurring.

Behavioural support completes this process: not blaming the child, not turning cleaning up into a punishment, and not shaming them at school.

Toilet Training in Special Groups

Autism Spectrum Disorder and Developmental Delay

In these children toilet training generally proceeds later and in a more structured way. Using visual support rather than verbal instruction is decisive: a sequence card showing the steps in pictures works for most children.

Sensory factors are frequently overlooked. The sound, light or smell of the bathroom, or the coldness of the toilet, is a powerful reason for avoidance in some children. Reviewing these factors one by one explains most of what is taken for resistance.

Keeping the routine fixed and repeating the same sequence every time speeds up learning. Changes should be announced in advance.

Children Born Prematurely or with Chronic Illness

In children born prematurely, signs of readiness should be assessed according to corrected age. In children with a chronic illness or who have spent long periods in hospital the process may be delayed; this is expected.

In these groups the aim is not to finish at the same time as peers but for the child to progress along their own developmental line.

What Not to Do

• Punishing, scolding, shaming
• Making them clean up as a punishment for soiling
• Comparing with other children
• Forcing them to sit on the potty for long periods
• Discussing accidents in front of others
• Presenting a return to nappies as failure
• Taking a reward system to excess

These practices do not work even in the short term; they create shame in the child and lay the ground for constipation by increasing withholding.

When Is Assessment Needed?

• No progress at all in daytime control by the age of four
• Painful bowel movements, hard and infrequent stools, blood in the stool
• Lasting loss of previously gained control
• Soiling of underwear over the age of four
• Frequent daytime wetting, constant dampness
• Pain or burning on passing urine, frequent urinary tract infections
• Marked fear, refusing to enter the bathroom at all
• Accompanying developmental delay or neurological signs

Where these findings are present, a medical cause should be investigated before focusing on toilet training.

Assessment and Approach

In Assoc. Prof. Mehtap Eroglu's approach, assessment begins with a simple two-week record: frequency and consistency of bowel movements, urinary pattern, the timing of accidents and the context at the time.

This record usually makes constipation visible; families generally overestimate the frequency of bowel movements.

Accompanying conditions are then screened for: anxiety disorders, developmental delay, autism spectrum disorder and changes within the family. Where indicated, joint assessment with paediatrics is arranged.

At the centre of the approach are removing pressure and, where present, treating constipation. A behavioural programme only works after these two steps.

Expert Opinion

According to Assoc. Prof. Mehtap Eroglu, the mistake families make most often is starting according to the calendar without waiting for signs of readiness. Training begun early does not shorten the process; it lengthens it and usually turns into a power struggle.

The second common mistake is missing constipation. In a substantial proportion of children presenting with toilet training problems there is unresolved constipation underneath. No behavioural programme works until the constipation is treated.

Assoc. Prof. Mehtap Eroglu also emphasises that the toilet must not become an arena for a power struggle. This area, concerning the child's own body, is one of the few places where they can exercise control; as pressure increases, so does resistance. Withdrawing is often the fastest route to progress.

Assoc. Prof. Mehtap Eroglu further emphasises that soiling of underwear over the age of four is almost never stubbornness. In this picture the child usually does not notice they have soiled themselves; the bowel's sensitivity has decreased because of prolonged constipation. Punishment only creates shame and delays treatment.

The fourth point is not confusing daytime and night-time control. Night-time control is not a learned skill but a process dependent on maturation; bedwetting is ordinary up to the age of five and is not something a child should be blamed for.

Assessment and Appointment Process in Ankara

Two different concerns come to the fore in referrals for toilet training in Ankara, and both are closely related to the prevalence of nurseries in Ankara. The first is toilet control being expected by the institution in the process of starting nursery; this expectation pushes families into starting early with a child who is not ready. The second is anxiety arising from comparison with peers.

In the assessment conducted by Assoc. Prof. Mehtap Eroglu in Ankara, the signs of readiness are reviewed first. Where the child is not ready, the intervention is not to begin training but to support the family and the institution in waiting.

A subject families in Ankara often raise is whether a reward system should be used. Small rewards that praise the process can be helpful; but when the system becomes complicated and result-focused it turns into pressure and has the opposite effect.

Another matter families in Ankara raise is the confusion created by differences in method in households where care is shared with grandparents. A child receiving different expectations from different people lengthens the process markedly; establishing a shared plan between caregivers is important.

What families in Ankara find useful to bring: a two-week record of bowel movements and urination, observations from the nursery, and any medication and advice previously used.

If you would like to arrange an assessment for your child's toilet training and related problems in Ankara, you can find information about the child psychiatry service and request an appointment.

In Summary

What determines toilet training is not chronological age but physical, cognitive and emotional signs of readiness. These signs generally appear between eighteen and thirty months, but the range is wide.

Starting early lengthens the process and creates a power struggle. Training should not be begun during periods such as the birth of a sibling, a house move or illness.

The most common and most overlooked cause of problems is constipation; no programme progresses until it is resolved. Night-time control is a separate process, and bedwetting is ordinary up to the age of five.

Punishment, shaming and comparison set the process back. When resistance is met, withdrawing is often the fastest route to progress.