Chapter  147:  The Effectiveness of Different Methods of Toilet Training for Bowel and Bladder Control

Introduction

Toilet training is the mastery of skills necessary for urinating and defecating in a socially acceptable time and manner. In many cultures, parents regard the achievement of independent toileting as a significant accomplishment and a step toward self-sufficiency. Bladder and bowel function is regulated by complex muscles and may be modified by physiological, psychological, social, and cultural factors. Currently, an all-encompassing definition of “toilet trained” is lacking, and there are no strict criteria stating how long a child must be bladder or bowel continent, or what components of the toileting process a child must accomplish independently, in order to be considered “toilet trained.”

Over the last 100 years, recommended toilet training methods have oscillated between rigid programs and child-oriented ones. In 1962, Brazelton developed the “child readiness” approach, which focused on gradual training. This approach described parameters of child and parent toilet training readiness. The Azrin and Foxx method emerged in 1971 as a parent-oriented method that emphasized structured behavioral endpoint training aimed at eliciting a specific chain of independent events by teaching the component skills of toilet training. These two methods differ with respect to goal development, endpoints, and emphasis on the child's self-esteem. Other methods include variations of operant conditioning, assisted infant toilet training, and the Spock method. The toilet training methods are described in Appendix H ^*.

Some factors believed to impact toilet training include sex, age at initiation, race, physical or mental handicaps, and constipation. While the majority of children are toilet trained without incident, approximately 2 to 3 percent experience an adverse outcome. Common adverse events are enuresis, encopresis, stool toileting refusal, stool withholding, and hiding while defecating. Toilet training children with special needs presents a unique set of challenges as impaired communication skills, reduced ability to process sensory information, and mobility and neurophysiological deficits add challenges to their toilet training.

Current published toilet training guidelines in North America recommend (1) a child-oriented approach, (2) not starting before 18 months because the child is not physically ready, and, (3) starting when the child displays interest.

Objectives and Key Questions

The American Academy of Pediatrics put forth the following four questions:

• 1

  What is the evidence for effectiveness of various toilet training methods to achieve bowel and bladder control?

• 2

  What factors modify the effectiveness of toilet training, such as age, sex, race, ethnicity, culture, age at initiation, constipation, or stool toileting refusal?

• 3

  What is the evidence for various toilet training methods as a risk factor for adverse outcomes, such as dysfunctional voiding, enuresis, encopresis, later problems, and psychological consequences?

• 4

  What is the effectiveness of toilet training methods for achieving bowel and bladder control among patients with special needs?

Methods

Results

Discussion

Toilet Training

Evolution of Toilet Training

Table 1

Trends in recommended infant training methods extracted (more...)

Table 1

Trends in recommended infant training methods extracted from three women's magazines from 1898-1948*

Year	Mother-determined Readiness	Early Readiness, Rigid Environmental Scheduling	Child-oriented Readiness (2–3 years)
1890	100%	0%	0%
1900	78%	22%	0%
1910	23%	77%	0%
1920	0%	100%	0%
1930	0%	75%	25%
1940	0%	33%	66%
1948	0%	0%	100%

*

Adapted from Vincent et al.¹⁰ and published in deVries 1977

In North America toilet training methods have oscillated over the last century (Table 1).³ In the late 1800s and early 1900s toilet training was considered a passive and permissive process and was primarily determined by parents. During the 1920s and 1930s a new generation of behavioral scientists emerged and toilet training was regarded as a rigid habit-training process, but it was still determined by parents. The objective of toilet training was to quickly alleviate the burden of infant wetting and soiling.⁵ In 1932 the American government publishedInfant Care and suggested that toilet training was to be completed by six to eight months of age.⁶ Training was coercive in nature; experts recommended the use of “soap stick” rectal conditioners to assist in bowel training. The importance of regularity and the scheduling of bowel movements were also stressed.

By the 1940s it was hypothesized that rigid toilet training resulted in the failure to achieve bowel and bladder continence and that it may elicit behavioral problems.⁷ In addition, research had shown that children do not develop voluntary bladder and bowel control until approximately 9 months of age. Toilet training reverted to a child-oriented approach and parents were advised to begin toilet training once the child displayed interest in the process. In 1962 Brazelton developed the “child readiness” approach.⁸ This was followed by the Azrin and Foxx method that focused on structured behavioral endpoint oriented training.⁹ As toilet training moved from rigid parent-driven methods to child-oriented ones, the age at which toilet training was initiated increased.

Objectives of this Review

Table 2

Summary of toilet training guidelines

Table 2

Summary of toilet training guidelines

Guideline	Year	Location	Recommended Method(s) and Special Needs Recommendations
American Academy of Family Physicians	2005	USA	Method: Begin when parent and child are ready (approximately 2 years). Use child-oriented approach, praise successes, do not express disappointment at accidents, and avoid punishment.
			Special needs: not mentioned
American Academy of Pediatrics	2000	USA	Method: Begin when developmentally ready and the child shows signs of readiness (approximately 2 years). Use child-oriented approach, praise successes with positive terminology, and avoid punishment or shaming. Make the process positive, natural and non-threatening. Do not force child.
			Special needs: not mentioned
Canadian Paediatric Society	2005	Canada	Method: Begin when child is physiologically and psychologically ready. Anticipatory guidance with child-oriented approach, praise successes, and do not punish or use negative reinforcement.
			Special needs: Assess readiness and degree to which child is hampered with the physician involved with care of the special needs child.
Pampers Parenting Institute Pediatric Roundtable	2006		Method: same recommendations as AAP
			Special needs: not mentioned

Although all children undergo toilet training, there is limited research that has examined the effectiveness of different methods. We were unsuccessful at finding clinical practice guidelines published by the following organizations: American Academy of Child and Adolescent Psychiatry, American Academy of Neurology, American Pediatric Society, Asian Society for Pediatric Research, National Enuresis Society, Society for Developmental and Behavioral Pediatrics, and European Society for Pediatric Research. To the best of our knowledge, the organizations listed above do not have toilet training clinical practice guidelines.

Figure 1. Analytical framework for the effectiveness (more...)

   Figure 1. Analytical framework for the effectiveness of different methods of toilet training for bowel and bladder control

Figure 1

Key Questions

The American Academy of Pediatrics put forth the following four questions:

• 1

  What is the evidence for effectiveness of various toilet training methods to achieve bowel and bladder control?

• 2

  What factors modify the effectiveness of toilet training, such as age, sex, race, ethnicity, culture, age at initiation, constipation, or stool toileting refusal?

• 3

  What is the evidence for various toilet training methods as a risk factor for adverse outcomes, such as dysfunctional voiding, enuresis, encopresis, later problems, and psychological consequences?

• 4

  What is the effectiveness of toilet training methods for achieving bowel and bladder control among patients with special needs?

Methods for the Systematic Review

Selection and Inclusion

Screening. Once all duplicate references were removed, two reviewers independently screened the electronic search output. The title and when available, the abstract were assessed for possible inclusion using general inclusion criteria (i.e., was it primary research assessing a toilet training method) and classified as “include,” “exclude,” or “unclear.” The full text of all “include” and “unclear” studies was obtained and formally assessed for inclusion.

Table 3

Inclusion and exclusion criteria for review on the (more...)

Table 3

Inclusion and exclusion criteria for review on the effectiveness of different methods for bladder and bowel control*

Criterion	Toilet Training Review
Study Design	Include: RCT, CCT, prospective or retrospective cohort, case-control, cross-sectional or case-series of at least 5 children.
	Exclude: case studies or case-series of <5 children.
Participants	Include: infants, toddlers, or children with or without co-morbidities, neuromuscular, cognitive, and/or behavioral disabilities.
	Exclude: children with enuresis or encopresis and adults with special needs.
Intervention	One or more of the following methods: Azrin and Foxx method, child-oriented method, operant conditioning, assisted infant toilet training, or any other toilet training program or intervention aimed at achieving bladder and/or bowel control.
Outcome Measures	Bladder control, bowel control, successes, failures/accidents, adverse outcomes (e.g.: enuresis, encopresis, stool withholding).

*

RCT indicates randomized controlled trial; CCT, controlled clinical trials

Inclusion. A priori inclusion criteria were developed (Table 3) and the studies were assessed for inclusion using a standardized form (Appendix B). Two reviewers independently applied the inclusion criteria and all discrepancies were resolved through discussion or consulting with a pediatrician and a pediatric urologist.

Studies examining the treatment of children with enuresis and/or encopresis were excluded. Although treatment components of enuresis and encopresis are similar to toilet training, it was believed that an enuretic and/or encopretic child would have already experienced at least one method of toilet training. The treatment of enuresis and encopresis was considered to be outside the scope of this review and there are several published systematic reviews that address these topics. Studies that measured the development of enuresis or encopresis as the result of a specific toilet training method were included.

The studies must have been published in English and all study participants had to be children, defined as less than 18 years of age. With the special needs literature, studies have applied toilet training methods to both children and adults. If the pediatric and adult data were presented separately, the study was included. In addition, the exact condition or diagnosis of special needs was not required. For example, studies describing children as “severely retarded” or “profoundly retarded” were included.

A wide spectrum of toilet training programs was included. The study could examine a program specifically designed to toilet train children or, for example, an operant conditioning program that aimed to change several behaviors. The study was included as long as toileting was one of the targeted behaviors and a toileting outcome was measured.

When it appeared that outcomes on the same or a portion of the same cohort of children were reported upon in multiple publications, a primary publication was identified. In general, the largest, most recent publication was assigned as the primary publication. If it was unclear if the studies reported on discrete children, individual investigators were contacted.

Data Analysis

Due to extreme clinical heterogeneity with respect to study designs, interventions, populations, and outcomes, no statistical meta-analysis was performed. Each study was organized by population (healthy, mentally handicapped, and physically handicapped) and the toilet training program was grouped as Azrin and Foxx (also including modified Azrin and Foxx), child-oriented, operant conditioning, and other. Each study was qualitatively summarized and the vast majority of this summary was taken directly from studies themselves. However, there were a few instances where the authors did not perform a statistical analysis and a Fisher's exact test was used to compute a p-value to compare dichotomous data between two groups.

There were instances when the data were manipulated. When individual data were presented in tabular form, a standard deviation (SD) was calculated. There were situations when the baseline characteristics and outcomes were stratified by age or another variable. When possible, the data were combined by toilet training program using the following formulas:

When applicable, each study was analyzed with respect to its definition of a child being successfully toilet trained and graphical summaries of such information were presented. The studies varied in their definitions of success and we attempted to classify the patients in each study as to whether they were toilet trained, i.e.: a “success.” Definitions considered equivalent to “fully trained” included (among others) self initiated elimination in toilet, daytime continence for bowel and bladder, continued absence of wetting or soiling between toileting, and complete toileting with no prompts. Definitions that were considered partial successes included (among others) one or fewer accidents per month, reduced number of accidental daytime wettings, increased toileting in commode, and less than four bladder and two bowel accidents per week. Only those studies that reported these numbers and had a well-defined intervention were included in the graphs.

Statistical tests were calculated using StatXact (Version 7, Cambridge, USA) while the graphs were produced using S-Plus (Version 7.0, Seattle, USA).

Literature Search

Figure 2. Selection of Included Studies

   Figure 2. Selection of Included Studies

Figure 2

Seven hundred and seventy-two studies were identified as being potentially relevant. Studies were then excluded for the following reasons: inappropriate study design (n=303), inappropriate intervention (n=237), foreign language (n=43), incorrect study population (n=43), or inadequate data or outcomes not reported (n=4) (Appendix E ^*).

There were several instances where the same cohort children, or a portion of the same cohort, was included in more than one publication. In such cases, the most recent and complete study was chosen as the primary study and additional information was extracted from the related publications. A description of these multiple publications appears in Appendix C.

Description of Included Studies

Thirty-five studies were included in this systematic review. There were three instances of multiple publications that examined toilet training within the same group of children.

Observational Studies. The median year of publication was 1976.5. Half of the studies were conducted in the United States (13/26; 50 percent), followed by the Netherlands (4/26; 15 percent). One study was conducted in Japan³³, the only study occurring outside of the United States or Europe. The median sample size was 34.5; five studies included one hundred or more children.^{1 8 41 50 51}

The goals of the specific toilet training programs were summarized as self-directed daytime bladder control (5/26; 19 percent), daytime bowel and bladder control (4/26; 15 percent), daytime and nighttime bladder control (2/26; 8 percent), daytime and nighttime bowel control, prompted bladder and bowel control anytime (2/26; 18 percent), and self-directed daytime bladder and bowel control (2/26; 8 percent). The remaining studies examined a variation of daytime versus nighttime, self-directed or promoted, bladder or bowel control. Twenty of the included studies examined one toilet training program and the remaining six studies assessed two programs, for a total of 32 programs. The most common toilet training program was operant conditioning (8/32; 25 percent) and Azrin and Foxx (5/32; 16 percent). Child-oriented toilet training was assessed in three studies. The remaining studies examined ‘other’ toilet training programs, which often included components of reinforcement and increasing liquids.

The outcomes were heterogeneous. The primary outcome in 23 of the 26 (88 percent) studies measured success or failure of toilet training; however, ‘success’ had variable definitions, such as bladder and/or bowel continence, self-toileting, directed toileting, lack of accidents, etc. The outcomes assessed in the remaining three studies were lower urinary tract symptoms, enuresis, and stool toileting refusal.

The included populations were heterogeneous. Three of the trials included healthy children (38 percent), four included children with a mental handicap (50 percent); and one trial included children with Hirschsprung's disease (13 percent). All of the mentally handicapped children were recruited from a special care facility. Taubman et al. enrolled children from their clinical practice, while the remaining studies recruited children from the community.

The included trials had a range of toilet training objectives: mastery of daytime and nighttime bladder control (2/8; 25 percent), daytime bladder control (2/8; 25 percent), and self-directed daytime bladder control (2/8; 25 percent), self-directed and prompted daytime bladder control (1/8;l 13 percent), and self-directed daytime bladder and bowel control (1/8; 13 percent). The toilet training methods were diverse. Azrin and Foxx was the most common method and it was examined in at least one arm of four of the trials. In two trials, variations of the Azrin and Foxx method were compared to one another. The remaining trials used other toilet training methods, such as Spock's baby book⁵⁴, relaxation-tension exercise regimen⁵⁷, operant conditioning⁵⁵, praising defecation⁴⁴, and a biopsychosocial approach aimed to reduce defecation associated anxiety and stool avoidance. Two trials contained a control group that was comprised of no toilet trainng method (2/8; 25 percent).^{55 56}

Seven of the included eight studies measured a variation of toileting accidents or successes, such as the frequency or number of accidents/successes or proper use of the toilet. One study measured the development of stool toileting refusal.⁴⁴

Methodological Quality of Included Studies

Table 4

Summary of components of Downs and Black Score

Table 4

Summary of components of Downs and Black Score

	Reporting	External Validity	Bias	Confounding	Power	Overall
Maximum Score	11	3	7	6	2	29
Mean Score (SD)*	8.1 (1.3)	1.3 (1.1)	4.2 (0.8)	3.0 (1.0)	0.5 (0.5)	17.2 (2.8)

*

SD indicates standard deviation

The majority of the studies collected data prospectively (14/26; 54 percent). Seven studies (27 percent) reported their funding source: government agency (1/26; 4 percent), private industry (1/26; 4 percent), foundation (1/26; 4 percent), combination of government and foundation (1/26; 4 percent), or other (3/26; 12 percent).

Table D-8

Table D-8

Author-Year	Jadad Score	Allocation Concealment	Data Collection Method	Funding Source
Candelora 1977	2	Unclear	Questionnaire	NR
Edgar 1975	2	Unclear	Clinical review	Government
Hundziak 1965	2	Unclear	Clinical review	Government
Hyams 1992	2	Unclear	Interview	NR
Matson 1977	2	Unclear	Clinical review	Internal
Sadler 1977	2	Unclear	Other	NR
Taubman 2003	2	Unclear	Interview	Government
van Kuyk 2001	1	Unclear	Clinical review	Government

NR indicates not reported

Toilet Training Success

Figure 4. Reported success of toilet training among (more...)

   Figure 4. Reported success of toilet training among mentally handicapped children

The size of the shape is proportional to sample size.

Square=RCT, circle=prospective cohort, triangle=retrospective cohort.

Figures 2

4

Figure 3. Reported success of toilet training among (more...)

   Figure 3. Reported success of toilet training among healthy children

The size of the shape is proportional to sample size.

Square=RCT, circle=prospective cohort, triangle=retrospective cohort.

Figure 3

Figure 4

Figure 5. Reported success of toilet training among (more...)

   Figure 5. Reported success of toilet training among physically handicapped children

The size of the shape is proportional to sample size.

Square=RCT, circle=prospective cohort, triangle=retrospective cohort.

Figure 5

Direct Comparisons

Healthy children. There were four studies that examined head-to-head comparisons between methods among normal children.

Matson randomized ten children (age 20 to 26 months) into one of the following groups: Azrin and Foxx method with an experienced trainer or mothers training their children using a book to guide the toilet training process.⁵⁸ Four out of five children in the former group were successfully trained, while only one of five in the latter group was completely successful, one obtained partial success, the remaining three failed. The small sample size precludes statistical significance and would in even the most extreme case (80 percent success rate versus 20 percent success rate; p-value for Fisher's exact test (2 sided): 0.21).

The Azrin and Foxx method was also used in an RCT conducted by Candelora (1977) to compare it to the Spock method in 71 healthy children aged 18 to 35 months.⁵⁴ Three primary outcomes were examined: number of accidents, number of successes, and number of wet mornings. Three time periods were examined: pre-treatment, post-treatment, and at follow-up. When looking at difference in pre-training and post-training results as well as in pre-training and follow-up results, the Azrin and Foxx method was found to be superior to the Spock method in all three outcomes. However, there was no significant difference between the groups with respect to post-training and follow up. Using the Azrin and Foxx method, the number of accidents per child per day was reduced by 2.48 from pre-training to post-training under the Azrin and Foxx method and reduced an additional 0.70 at follow-up, resulting in a total reduction of 3.17. For the Spock method, there was a reduction of 1.37 in post-training and an additional 0.52 at follow up (1.90 total reduction). The number of successes per child per day was increased by 2.50 in post-training and by an additional 0.87 at follow-up, for a total increase of 3.37 when using the Azrin and Foxx method. For children trained using the Spock method, there was an increase of 1.12 in post-training and an additional 0.79 in follow-up (1.90 total increase). Finally, the percentage of mornings wet was reduced in the Azrin and Foxx group by 21 percentage points in post-training and an additional 10 points in follow-up (total of 31 percentage points), compared to a reduction in the Spock method of 6 percentage points in post-training and an additional 9 points at follow-up, for a total reduction of 15 percentage points.

Taubman enrolled 406 children aged 17 to 19 months in a toilet training study using a child-oriented approach, and the parents determined when toilet training would commence. The children were randomized into two groups: one group was given instructions to avoid negative terms to describe defecation or to a group who received no such direction.⁴⁴ The groups were equivalent in terms of number of children with stool toileting refusal (STR) (26 percent in the intervention group compared to 23 percent in the control group) but duration of STR was significantly longer in the control group (7.3 months compared to 5.1 months; p=0.03). No significant differences were found between the groups in terms of incidence of stool withholding (intervention 52 percent; control 55 percent) or incidence of hiding during defecation (intervention 68 percent; control 70 percent). The intervention group did find that toilet training was completed significantly sooner (intervention 40 months; control 43 months; p=0.04).

Bakker conducted a retrospective study that collected data on 4332 primary school age children and compared children who did and did not develop abnormal outcomes in bladder control.⁵⁹ There were 3404 children in the control group and 928 in the symptom group. The authors found that significantly more children in the control group had prompting from their parents during toilet training than those in the symptom group (68 percent versus 62 percent; p < 0.001). Parents of the symptom group tended to reward and punish more so than the control group (53 percent versus 46 percent). Parents reacted differently when an attempt to void was unsuccessful. Parents in the control group were much more likely to encourage the child to try again later (83 percent compared to 67 percent; p < 0.001). Those in the symptom group were more likely to make the child wait until voiding (8 percent to 3 percent; p < 0.001), make the child push or strain (13 percent to 5 percent; p < 0.001), make special noises (43 percent to 37 percent; p =0.002), and open a tap (26 percent to 21 percent; p=0.003).

Mentally handicapped children. There were eight studies that contained direct comparisons of interventions in mentally handicapped children: four were RCTs, two were multiple cohort studies, while the remaining two were single cohort studies.

Smith conducted an RCT to look at three methods of training fifteen severely mentally retarded children with social ages ranging from 0.94 to 2.2 years on the VSMS scale.⁶⁰ The first method was an intensive individual regular “potting” program, the second was group training with regular “potting” program and the third was an intensive individual timing training program. The primary difference between regular “potting” and timing training is in which the manner incontinent events are handled. In the timing training method, the child is promoted to toilet and positively reinforced for urinating after an incontinent event. An incontinent event among the regular “potting” group resulted in a reprimand and 10 minute timeout. The number of children who achieved independent toileting at the end of training was 5/5 in the first method, 1/5 in the second method, and 4/5 in the third method. Despite the small sample sizes, the exact three-way test for independence is approaching significance (p=0.051). In addition, the comparison of method 1 versus 2 does show a significantly greater odds of being trained in group 1 (Fisher exact p-value=0.048). Looking at percentage reduction in incontinence and the end of the 12-week study, methods 1 and 3 (about 97 percent and 80 percent respectively) did achieve greater reductions than method 2 (about 45 percent), although the difference was not significant (F p-value=0.10). The authors competed a 10-year follow-up study.⁵³ Only one child (in method 1) was still independent after 10 years. The authors also examined incontinence reduction both after the initial study and at the 10-year follow-up, although no comparisons among groups were presented. The first method showed a 99 percent reduction in incontinence after initial training and this dropped to 88 percent after 10 years. For the second method, incontinence was initially 39 percent and improved to 52 percent after 10 years. For the third method, incontinence decreased from 80 percent to 74 percent after 10 years.

Edgar completed an RCT of 20 severely and profoundly retarded children (developmental ages between 15 and 23 months) to examine relaxation methods versus a control group.⁵⁷ Among the children who received relaxation exercises, there was a significant reduction in accidents and toilet training was successful (8/10 versus 2/10; p=0.02). Self-initiated toileting was identical in the two groups: two children from each group eventually achieved it. Compared to the control group, the relaxation group also showed significant reduction in accidental urination and improvement in appropriate urination.

Hundziak randomized 29 severely mentally retarded boys with a social quotient between 8 and 33 months to one of three interventions: operant conditioning, conventional training, or a control group.⁵⁵ Scores for defecation and urination in toilet were determined and non-parametric tests conducted. The operant conditioning group advanced significantly more in both defecation and urination than the conventional training group, and more in defecation (although not in urination) than the control group. There were no significant differences between the conventional and control groups. The authors concluded that the operant conditioning method is useful in training severely retarded children.

Sadler conducted an RCT among 14 severely retarded children aged 7 to 12 years.⁵⁶ Children were randomized to Azrin and Foxx method, a no training group, or a scheduling toilet training method. The primary outcome was the number of accidental urine-dampened pants and was analyzed using a repeated measures ANOVA while controlling for time. Compared to both the no-training group and the scheduling method, the Azrin and Foxx method proved to significantly reduce dampened pants (3 months and 4 months, p < 0.01 in all comparisons). As the experiment continued to its second phase, the scheduling group and half the no-training group were moved to the Azrin and Foxx group, which had a significantly lower number of dampened pants than the remaining no-training group (p < 0.01).

Kimbrell examined 40 severely retarded female children (VSMS range 6 to 28 months).⁶¹ Based on age, race, length of institutionalization and VSMS, children were systematically allocated to an operant conditioning behavior modification intervention or a control group. Compared to children in the control group, the children receiving operant conditioning had significantly greater gains in the toilet training score component of the VSMS (gain of 4.10 versus 0.30, p < 0.001).

Tierney studied 36 mentally subnormal children with mental ages between 4 and 22 months.⁶² Age, mental age, level of functioning, degree of incontinence, and degree of mobility were used to systematically separate the children into an operant conditioning behavior modification group and a control group. Seven patients in the operant conditioning group achieved consistent continence while an additional seven showed a marked improvement. The remaining four patients failed to improve. None of the eighteen control patients improved. The differences in both achievement of consistent continence and improved continence were significant (Fisher's exact test: p < 0.0001 and p=0.008 respectively).

Connolly looked at nine children between the ages of 3 and 18 years that exhibited moderate to severe mental handicaps.⁶³ Four children who were already toilet trained were included as controls. The toilet training program consisted of a three-stage operant conditioning process that involved both positive and negative reinforcement. The amount of soiling and wetting from baseline to program completion improved by 15.8 percent and 75.0 percent respectively. Improvements were still evident at the six-week follow-up; however, they had decreased to 14.0 percent and 25.0 percent respectively. Two of the nine children were considered fully trained.

Lancioni describes two separate experiments on toilet training autistic, retarded children.⁶⁴ The first looked at 5 children (aged 10.6 to 14.6 years) that were divided into two similar interventions. For the 3 children assigned to intervention A, 25 potties were placed throughout the room and there were no potties placed in the room for the 2 children in intervention B. The other aspects of the toilet training program were identical. All three subjects in A showed independent toileting, while neither of the two subjects in B did. For the second phase of the study the two B children were transferred to intervention A and achieved independent toileting. The second study was almost identical in design to the first with the exception that no negative reinforcement was employed. Four children (ages 11.0 to 13.8 years) were put into the two interventions A and B (two in each intervention). Once again the subjects in A exhibited independent toileting, while those in B did not until moved into intervention A for the second phase. The authors conclude that intervention A, with or without negative reinforcement, is effective in promoting independent toileting for autistic, retarded children.

Physically handicapped children. There was only one study that contained direct comparisons of interventions involving physically handicapped children. Van Kuyk (2001) randomized 27 children (aged 2 to 12 years) with Hirschsprung's disease to either a multidisciplinary behavior treatment or a waiting list control.⁵² An ANOVA was performed on the change scores for six different outcomes and the intervention group was found to be significantly superior to the control group in all outcomes. There were three scores used to measure toileting: the Templeton score (intervention: 1.1 reduction; control: 0.0 reduction), the Wingspread score (intervention: 1.3 reduction; control: 0.1 reduction) and the Wingspread constipation score (intervention 0.7 reduction; control: 0.1 reduction). The remaining three outcomes were percent of feces in toilet (intervention: 53.7 percent increase; control: 2.3 percent decrease; p<0.001), number of days without soiling (intervention: 8.4 day increase; control: 0.7 day increase; p<0.001), and scale determining parental judgment incontinence (intervention: 5.2 reduction; control: 0.9 reduction; p<0.05).

Single Cohorts

Healthy children. Five studies examined toilet training in healthy children: three studies assessed a child-oriented approach and the remaining two evaluated Azrin and Foxx methods.

Three studies examined the child-oriented approach to toilet training. Stool toileting refusal of at least one month duration occurred in 22 percent of the children (106/482) and 29 children required an intervention, such as returning the child to diapers or using suppositories. Stool toileting refusal was associated with presence of a younger sibling and the parents' inability to set limits for the child. The study was conducted in a private pediatric practice of middle and upper class families. In a second study, Brazelton describes 1170 children who were toilet trained during ten years of his pediatric practice.⁸ All children were trained using a child-oriented approach and training occurred in a pressure-free environment and only begun once the child has expressed interest (at approximately 18 months of age). The clinical population consisted of primarily upper-middle class families. For the majority of children, bowel and bladder training occurred simultaneously (930/1170; 79.5 percent). Daytime continence was achieved at a mean age of 28.5 months and nighttime continence by 33.3 months. While males and females completed daytime training at the same age, girls achieved nighttime continence approximately 2.46 months sooner than boys. Sixteen children were not trained by five years of age and suffered from at least one of the following: 12 had enuresis, 4 soiled in stressful situations, and 8 suffered from chronic constipation. Finally, Kaffman examined children living in one of twelve kibbutzes in Israel.⁵⁰ Toilet training is conducted by at least six people and is led by the the head metapelet (caregiver). The toilet training program is child-oriented and is tailored to the child's temperament, emotions, and neurophysiological development. Enuresis was defined as a lack of complete bladder control by the age of three and half years and the prevalence was 13.9 percent (192/1376).

Two studies assessed the Azrin and Foxx method in healthy children. Foxx et al. identified 34 children who previously attempted toilet training. The children were assessed with a screening test to ensure their ability to follow the toilet training program.⁹ Two trainers applied the Azrin and Foxx method and the children were toilet trained with a mean time of 3.9 hours. Older children (aged 26 to 36 months) completed unprompted toileting within 2.3 hours, whereas the younger children required approximately 5 hours. After the Azrin and Foxx method, bladder and bowel accidents were reduced by 97 percent and this success was maintained at four months follow-up. With the exception of one parent, the parents were pleased with their child's progress; however, the parent's displeasure was not related to the toilet training method. A second study examined 49 children toilet trained according to Azrin and Foxx's Toilet Training in Less than a Day program. Parents went to three weekly classes where they were taught the principle of the Azrin and Foxx method. Ten children failed to achieve continence within the intensive training session; nine of the children were less than 25 months of age. Reasons for failure include the child's severe emotional reaction (n=6) and parents quitting the program (n=4). The average toilet training time was 4.5 hours. At 8-week follow-up, bladder and bowel control continued to improve, but many children were lost to follow-up.

Mentally handicapped children. A total of ten studies examined toilet training methods among mentally handicapped children. Four studies assessed variations of the Azrin and Foxx method and six utilized operant conditioning programs.

Five studies examined variants of operant conditioning programs. Van Wagenen used forward-moving series toilet training to toilet train nine mentally handicapped children.⁶⁵ The children wore an alarm that sounded at the time of urination. The trainer then said “no,” led the child to the toilet, and placed the child on the toilet where the child continued to urinate. Once this sequence was established, the alarm was replaced with cotton underwear and the children were taught to dress and undress. All of the children were successfully trained with this method and toileting skills were maintained in different toileting facilities. In the second study, Ando utilized operant conditioning techniques to toilet train five institutionalized autistic boys.³³ Positive reinforcement for correct toileting included candy, praise, and affection, while physical and verbal punishment was used to negatively reinforce improper toileting behavior. The children were toileted every two hours or when they appeared to have to urinate. Three of the children improved self-initiating toileting (approximate improvement ranged from 30–60 percent). One child had minimal improvement; self-initiating toileting increased from 0 to 20 percent after twelve months of training. The fifth child failed to increase self-initiating toileting and the child did not respond to any of the positive or negative reinforcers. In the third study Giles et al. attempted to toilet train five severely and profoundly mentally retarded children who rarely displayed self-initiated toileting.¹¹ Bladder training was only initiated after some bowel continence was achieved. Correct toileting behavior was positively reinforced. If positive reinforcement did not produce behavior modification, aversive consequences in the form of physical restraints were used to correct inappropriate toileting behavior. The length of the training program was eight weeks. All five children were successfully toilet trained. In the fourth study, Spencer attempted to establish bowel control in nine severely and 29 profoundly retarded boys.⁶⁶ The operant conditioning program consisted of positive reinforcement for defecating in the toilet and sitting on the toilet (providing the boys were incontinent at least half of the time). The program was 6 weeks in length. Achieving bowel control was not significantly correlated to mental age, chronological age, leg coordination, sociability, negativism, emotionality, bowel movement frequency, brain damage or, time in institution. Spontaneous toileting increased by 9 percent and accidents decreased by 17 percent. Improvement was more profound in children with a higher degree of incontinence. Using an operant conditioning program, Colwell attempted to improve toileting, dressing, and eating behaviors among 47 profoundly and severely mentally retarded children.⁶⁷ The objective was to bring these behaviors under verbal control. Initially, tangible items were used to positively reinforce proper behavior and were then replaced with social praise. A 23-item toileting scale was used to measure changes in behavior. Follow-up ranged from 3 to 12 months. Thirty-three of the 47 children increased their toileting skills, 3 children decreased toileting skills and the remaining 8 children experienced no change. The mean toileting score improved from 6.0 out of 18.0 at baseline (goes to bathroom area when asked, requires assistance with clothing, and has accidents) to 10.1 after the intervention (toilets on command, manages own clothing, and has few or no accidents).

Four studies evaluated variations of the Azrin and Foxx program. Didden attempted to achieve prompted bowel and bladder control with six children diagnosed with Angelman syndrome.⁶⁸ The daily 6-hour training sessions included walking to the bathroom, drinking every 30 minutes, scheduled toileting in 30-minute intervals, remaining on toilet until elimination or 20 minutes expires, positive reinforcement for successes, and self-dressing. If the child had an accident, the child was reprimanded, changed clothing, cleaned the soiled area, was denied toys, and had a one-hour timeout. Children were followed up at 2.5 years. At baseline, the average frequency of correct daily toileting was 0.8 (SD 0.95). This increased to 3.5 (SD 1.23) at post-treatment and similar results were observed at follow-up (3.1; SD 0.57). The mean time spent toilet training was 108.2 hrs (30.6). In the second study, Lancioni used the Azrin and Foxx method to toilet train nine profoundly deaf and blind children who had never shown any signs of self-initiated toileting.⁶⁹ The training program consisted of increased liquid and decreased food, positive reinforcement for proper toileting behavior and remaining dry, punishment for accidents, increasing distance from the toilet, and removing environmental stimulus. Training was conducted in three phases and followed by a maintenance phase. At day 44 of follow-up, eight of the nine children exhibited self-initiated toilet training. In the third study, Smith retrospectively examined 13 mentally retarded children who were toilet trained by the Azrin and Foxx method.⁷⁰ The children wore a urinary training device, fluid intake was increased, and operant conditioning techniques were used to elicit the desired toileting behavior. At baseline, the children had a 50 percent frequency of wetting accidents, which was reduced to approximately 10 percent by week 5 to 6. All three of the higher social-aged children and three of the five lower social-aged children maintained a near-zero accident rate at follow-up (6 to 18 months). The remaining children experienced a slight increase in accidents. In the final study, a toilet training method similar to that of Azrin and Foxx was used to toilet train nine mentally handicapped children.⁷¹ The Azrin and Foxx method was augmented with the Big Kids book, which was read to the children at least once a day. There was no punishment or reinforcement of accidents. Follow-up measurements were taken at 2, 4, and 6 weeks. The authors found an increased number of success and a decreased frequency in the number of accidents. When compliance to each component of the toilet training program was measured, there was poor compliance to the Big Kids book and was deemed an unnecessary component to toilet training. In the final study, the population consisting of three healthy children and five mentally handicapped children.⁷² The children were subjected to a two-step operant conditioning program aimed at establishing all components of toileting behavior. During the first step, the children responded to physical, verbal, and auditory stimuli. Prompts were then elicited by the auditory stimulus alone. Seven of the eight children were successfully toilet trained with this method.

Physically handicapped children. Five studies examined toilet training among children with various physical handicaps. All toilet training methods were classified as “other” and, with the exception of two papers,^{73 74} the toilet training programs were different.

Van Kuyk conducted two studies that retrospectively assessed a multidisciplinary toilet training program among children diagnosed with anal atresia⁷³ and Hirschsprung's disease.⁷⁴ The toilet training program aimed to teach adequate defecation behavior by reducing fear and anxiety concerning defecation and stool withholding, learning how to use the lower body to defecate, improving straining techniques, and defecating on a regular schedule. The program was conducted by a variety of health care professionals, including a child psychologist, pediatric physiotherapist, and pediatric surgeon. Among the 43 children with anal atresia, there was a significant improvement in the three-point continence score after treatment compared to baseline (Templeton score at baseline: 2.2 ± 0.45; post treatment: 1.6 ± 0.59). The Templeton score measures awareness of impending defecation, occurance of accidental defication, need for additional underwear or diaper liners, presence of diaper rash, social problems, and restriction of phycial activity. There were also significantly fewer children suffering from constipation (18 versus 8). Among the 16 boys diagnosed with Hirschsprung's disease, there was significant improvement in Templeton score after completing the toilet training treatment program. After treatment, the Templeton score decreased to 1.1 (SD 0.34) from 2.7 (SD 0.48). The number of constipated children was reduced from 12 to 4. The treatment was effective, regardless of the age of the child or the specific physical handicap.

Three studies developed toilet training programs for establishing bowel control in children with spina bifida.^{51 75 76} In the study by King, the toilet training program aimed to establish neurogenic bowel habituation.⁷⁵ It included training provided by a psychiatrist and establishing a set time for bowel elimination. Specifically, the bowel was cleaned and stool softeners, glycerin suppositories, bisacodyl suppositories, digital stimulation, and oral medication were incorporated to result in a timed defecation. The age range of the study population was 18 months to 29 years and results were stratified by age (≤6 years versus > 6 years of age). Among children less than or equal to 6 years of age, continence improved from 0 percent (0/17) to 65 percent (11/17) and further improved to 88 percent (8/9) among children who completed to the toilet training program. In the second study, Forsythe created a similar program for 47 children.⁷⁶ The children worked through the following steps sequentially until an intervention was successful: regular toileting after supper, daily enemas, enemas plus suppository or microenema before evening meals, and enemas and daily use of laxatives. At each stage, the prior intervention(s) were also used. Regular toileting resulted in bowel control in 8 of the 47 children (17 percent). Seven of the 39 children (18 percent) achieved bowel control with a combination of regular toileting and enemas; 2 other children experienced initial success but relapsed after 6 to 8 months. Of the 25 children treated with daily suppositories or micro-enemas, enemas, and regular toileting, only 5 children attained bowel control (20 percent). Glycerin suppositories were ineffective; three treatment successes occurred in the bisacodyl group and two in the microenema group. Twenty-seven children received a combination treatment of laxatives, enemas, and regular toileting. Among the 16 children using bisacodyl tablets, 12 were free from stooling accidents and were followed up from 9 to 24 months. All 15 children who received a laxitive syrup experienced bowel control and were followed up for at least 6 months. In the third study, a bowel and bladder toileting program was evaluated in 525 children with spina bifida and aged 1 to 18 years.⁵¹ The bowel training program consisted of five components: (1) untimed collection of a diaper or insert and cleaning by a primary care giver, (2) infrequent enemas, (3) small, rapid, low-level enemas, (4) suppositories, and (5) timed evacuation with or without digital stimulation. The control program was comprised of (1) diaper or pant insert, (2) penile collectors, and (3) urinary diversions with either timed bladder emptying with or with out medication or clean intermittent catheterization with or without medication. Dependent socially acceptable bowel control among children less than 3 years of age was best achieved with diaper care (15/41) and suppositories (14/41). Thirty-nine of the 41 children were trained. Among children over the age of 4 years, dependent socially acceptable bowel control was best achieved by suppository use (24/184) and expansion enema (12/184). The timed method was most successful for achieving independent socially acceptable bowel control (55/184), followed by suppository use (24/184). Regardless of age, 44 children failed to achieve socially acceptable bowel control. Among children less than 6 years of age, socially acceptable dependent training was most frequency achieved by a diaper/pants insert (32/57). Only one child achieved independent socially acceptable bladder control and this was achieved by clean intermittent catheterization. Socially acceptable independent and dependent bladder control was achieved by ileal diversion (23/158 and 27/158, respectively). In total, 62 children did not achieve socially acceptable bladder control.

Toilet Training Healthy Children

Toilet training for healthy children is not a subject that invokes passion among researchers; however, parents and pediatricians struggle with this seemingly minor problem on a daily basis. Pediatricians faced with the task of providing evidence-based advice have difficulty finding the literature to support the various approaches.⁷⁷

Most parents want to know the quickest, easiest approach to toilet training that does not result in adverse outcomes. Parents are inundated with media and lay information on various methods from the child oriented approach to the extreme and time intensive method of elimination communication where an infant may be diaperless from birth.⁷⁸ Despite this method's growing popularity in North America, we did not identify any studies that examined the elimination communication toilet training method. A method similar to this idea was used among the Digo people of East Africa; however, the article did not report any quantitative results and thus failed to meet our inclusion criteria. The author did state that toilet training success was achieved by infants 4 to 6 months old.⁵

In this review, we identified three randomized trials looking at toilet training methods in healthy children.^{44 54 58} Unfortunately, there were no head-to-head comparisons between the child-oriented approach⁸ and the Azrin and Foxx method⁹ and this prevented us from drawing definitive conclusions regarding one method's superiority over the other. The rather regimented Azrin and Foxx approach appeared to result in rapid success, Matson reported 50 percent success with 10 toddlers aged 20 to 26 months after 5 four-hour sessions. At the 10 week follow-up, one child had regressed to diapers due to parental problems.⁵⁸ Candelora found Azrin and Foxx to be superior at reducing accidents, increasing successes, and reducing the number of wet mornings than the Spock method.⁵⁴ In the one large study examining the child-oriented approach, the positive approach to bowel habits and avoidance of negative terminology in reference to defecation improved the time to fecal continence by 3 months; however, this may not be clinically significant.⁴⁴ These children were completely toilet trained at a much later age (3.5 ± 0.5 years) in comparison to those by the Azrin and Foxx method.

While single-cohort studies are a lower level of evidence, they do provide insight into outcomes, particularly when there is limited higher-level evidence available. The two cohort studies examining the effectiveness of the Azrin and Foxx method concurred with the Matson trial.^{9 79} Children seem to attain continence quickly, with a relatively high success rate and at a relatively early age. Following one day of training, Butler reported 74 percent success in 34 toddlers under 25 months and 93 percent success in 15 older toddlers; Foxx reported 100 percent success in 34 toddlers ranging from 20–36 months. Success at follow-up was 96 percent and 97 percent respectively. One of the larger studies was a prospective cohort of children who trained using the child-oriented approach.⁴¹ With this approach, 61 percent (292/482) were continent by the age of 3 years and 98 percent were continent by 4 years of age. The study does not state how long it took to achieve continence.

Unfortunately there is insufficient evidence to provide conclusive answers regarding the optimal toilet training method. Overall, we found that in the small studies evaluating the Azrin and Foxx method, success is relatively high and achieved soon after training. Follow-up at 1 to 4 months indicated success was maintained. Successes were also seen in the child-oriented approach, but they generally did not occur as quickly as those displayed by the Azrin and Foxx method. Brazelton's retrospective study reported that 94 percent of parents (1105/1170) started toilet training between 12 to 24 months and that 26 percent (304/1170) had completed day time training by 24 months.⁸ In general, both toilet training programs seem to have the ability to teach toilet training in healthy children. It appears from the literature that parents who want quick results should consider the Azrin and Foxx method of toilet training but must be prepared for a regimented approach and should use positive reinforcement. For parents who are not prepared to put as much focus into attaining continence, the child-oriented approach can be successful but may take somewhat longer. Until we have additional studies that compare the toilet training methods, it appears safe to tailor the approaches in healthy children to individual families. This recommendation is in keeping with Brazelton's review article.³

Toilet Training Mentally Handicapped Children

Many caregivers of mentally handicapped children want to know if the child will ever attain independent, successful toileting, and if so, what toilet training methods exist to facilitate this process. Our search strategy identified a limited number of comparative and single-arm studies. Many of them were from the 1960s and 1970s and the definition of mental retardation has undergone several revisions, mainly that the lower IQ limit decreased from 85 to 70. As such, some of the children who were classified as mentally retarded in these older studies may not meet the current definition.

One of the key questions was to identify toilet training strategies and/or outcomes of children with behavior problems. Unfortunately, no studies involving this population were identified. Some children with mental retardation can have behavior co-morbidities; however, in studies of mixed populations, results were not specified by the diagnoses. A small (n=5) prospective cohort of children with autism and mental retardation had some success with an operant conditioning method and toilet training was more successful in children with receptive language skills.³³ Another small (n=9) study in autistic mentally retarded children found that improved access to a potty could assist in toilet training.⁶⁴ Children who were mentally retarded secondary to Angelman syndrome had partial success in toileting using a modified Azrin and Foxx method.⁶⁸ Although this study did not specify the behavior problem(s), Angelman syndrome is often associated with hyperactivity and characteristic bouts of laughter. Given that many children who are otherwise healthy but have significant behavior problems, including but not exclusive to attention-deficit disorder and oppositional defiant disorder, future studies should be designed to examine toileting strategies and outcomes in these children.

Based on single-arm studies, mentally handicapped children had some degree of success regardless of the toilet-training method used. From the comparative studies, the Azrin and Foxx method, operant conditioning, and relaxation techniques were all superior to not using a toilet training method. Unfortunately, none of the studies did a head-to-head comparison between the different toilet training methods. Furthermore, the child-oriented method was not used in any of the studies on mentally handicapped children.

Even though studies are few and have small sample size, the evidence suggests that some mentally retarded children can attain at least partial success with toilet training. At present all of the strategies seem equivocal, thus caregivers and health care providers can try any of the methods. Success may be optimized among those with receptive language skills and easy access to a toilet.

Given there is a broad spectrum of function in mentally retarded children, often confounded by physical and behavior problems, caregivers and health care providers may need to be flexible when developing toilet training strategies.

Toilet Training Physically Handicapped Children

Children with physical handicaps face difficulties with bowel and bladder control related to the physiology and psychology of their conditions. In many conditions, such as Hirschsprung's disease and other congenital anal anomalies (e.g. anal atresia and spina bifida), children may not have the abilities to develop control with standard toilet training methods. We included this patient population into this systematic review in an effort to develop insight into toilet training this particular group of children.

The multidisciplinary approach to bowel control was also assessed in two retrospective cohort studies of children with anal atresia and Hirschsprung's.^{73 74} The results confirmed those of the trial and the belief among most specialists was that children with complex conditions required the expertise of many specialists in a interdisciplinary fashion. Children with spina bifida present with different elimination problems due to varying degrees of neurologic impairment at different spinal cord levels. With regard to the bowel, they can suffer from constipation and/or fecal incontinence. Urinary symptoms can include failure to empty as well as incontinence. Standard methods for toilet training rarely work in this patient population. The primary means to control these problems are timed evacuation as described in the three cohort studies.^{51 75 76} With timed elimination via clean intermittent catheterization, stool softeners, suppositories and enemas, children have the ability to become continent. The long-term success varied and few children were able to remain continent without some sort of medical intervention. Families of children with complex medical conditions should not expect their children to toilet train as per healthy children; however, there are many options to gain continence. Parents should be made aware of the difficulties and the potential solutions in order to avoid unreasonable expectations. Identifying support groups for families is often helpful in order to expose them to the unique solutions used by other children with complex medical conditions.

Modifying Factors that May Affect Toilet Training

While there were no studies that looked specifically at modifying factors, some common themes were found among the studies. Candelora found that certain parental variables improved outcomes, such as having older and more tolerant mothers, and higher socioeconomic status.⁵⁴ Butler and Taubman's studies revealed quicker training in girls than boys.^{41 79} On the other hand, Brazelton did not report a difference in attaining daytime continence between sexes but did observe a quicker attainment of nighttime continence in girls.^{8 44} Taubman et al. also revealed an association between the presence of younger siblings and a higher incidence of stool toileting refusal.⁴⁴ While race and culture were not evaluated in these studies, they may play a role in expectations, choices of interventions, and accepted norms.

Adverse Outcomes Associated with Toilet Training

Only four studies specifically addressed the topic of adverse outcomes: two addressed bladder problems retrospectively,^{50 59} one examined bowel problems prospectively,⁴¹ and one reported unspecified residual problems also prospectively.⁸ Regarding long term bladder control, one cohort⁵⁹ determined that school age children with lower urinary tract symptoms (21 percent of the sample) were trained at a later age (>18 months) and that their parents had used more aggressive methods to provoke voiding (e.g. ran water, asked to push); however, no specific training methods were compared and data were collected via a questionnaire when the children were approximately ten years of age. The second study reported the frequency of enuresis in those that had been trained by multiple caregivers on a kibbutz; training began between 15 and 24 months.⁵⁰ At six to seven years of age, they had a higher incidence of enuresis than non-kibbutz raised children, but a lower incidence after age ten. On the topic of prolonged bowel incontinence the one prospective RCT reported an incidence of approximately 22 percent for stool toileting refusal.⁴¹ These problems were associated with the presence of younger siblings, parental difficulty in setting limits, and training at a later age; however, “later” was defined as children >42 months as compared to 18 months, which was used by Bakker⁵⁹. These children were trained in a child-oriented fashion. In contrast, Brazelton reported a 1.4 percent incidence of residual problems at >5 years of age following a child-oriented training approach.⁸ None of the operant conditioning or Azrin and Foxx studies reported these outcomes. The only other adverse effects mentioned in these studies were temper tantrums and child and parental refusals and frustration with the training method itself.

Limitations

There are a variety of limitations associated with this review, including bias, variation in study definitions, weak study design, variability in the toilet training programs, and lack of statistical analysis. Also, the majority of the studies were conducted between the 1960s to the 1980s.

As with all systematic reviews, there is a possibility of publication and selection bias. To reduce publication bias, an experienced medical librarian conducted a comprehensive search of the published literature for potentially relevant studies using a systematic strategy. This was augmented with hand searching of reference lists and conference proceedings and tracking forward sentinel articles. Overall, toilet training was a well-indexed subject and we are confident that the search located all the major literature on this topic. Despite these efforts, we recognize that unpublished negative studies may have been missed. Although the search was conducted without language restrictions, in the end the review was restricted to English articles due to difficulties in obtaining complete, accurate translations in more than ten non-English languages. It is likely that approximately three additional foreign studies might have been included. Selection bias was controlled by having two reviewers apply a priori inclusion criteria independently then resolve all discrepancies with a third party who had clinical expertise. We feel confident that the studies excluded were done so for consistent and appropriate reasons.

Prior to determining effectiveness, it is necessary to have a clear, specific, and measurable definition of the end result. In the case of toilet training, there is no all-encompassing definition and each of the included studies varied in their definition of success. The populations studied in this review displayed great heterogeneity; healthy children and those with special needs involving either mental or physical handicaps are included. As a result, the definition of success had to be modified. For some it meant total and lasting self-directed independent toileting, including recognizing elimination urges, going to a toilet, handling clothing, assuming proper positioning, attending to sanitation, and returning to activities without notifying anyone; other definitions were less inclusive regarding which aspects of the process must be complete and for how long before success was accorded. In institutionalized populations, improvement in frequency of toileting successes and reduced accidents resulting in less laundry and less staff time spent toileting and cleaning was reward enough for implementing a program although some participants did achieve independent toilet skills. For those with neurophysiological handicaps, attaining social acceptability, independently or not, and sometimes not until late teen years was the goal. Some of the populations had been subjected to previous unsuccessful attempts to toilet train; others were attempting training for the first time. These variations in populations, definitions of success and failure, and reported outcomes proved too disparate to permit pooling of results.

A second limitation of this review is the weakness of the study design that the majority of the studies used. There were only eight RCTs. Among the other studies comparing two or more toilet training programs, the majority of the interventions were non-randomized and the rationale for the intervention decision was largely unknown. The quality of included studies varied and was generally low. All RCTs received a low methodological score (1 or 2 of a possible 5 points); the only reported details were that group assignment was random (with the exception of one study) and withdrawals and dropouts were accounted for. How the randomization code was derived, concealed, and applied is unknown and the nature of intervention does not lend itself to double blinding. The cohort studies scored a mean of 16.9 ± 3.1 of a possible 29 (range 11–22). However, it should be noted that 70 percent of the studies were published before the CONSORT guidelines were introduced to improve reporting requirements particularly for RCTs; therefore, it is unclear if the poor reported methodological quality is a reflection of reporting omissions or true methodological quality.⁸⁰ Some of the prospective cohort studies that were dependent on observer evaluation made an effort to have two observers and calculated agreement to improve accuracy.

A third limitation is imposed by the variability in the programs themselves. The most studied intervention was the Azrin and Foxx method and this was assessed in nine studies; however, there was significant variation in which aspects were incorporated, who did the training, and the extent of training the trainers received prior to implementing the program. Four were conducted on healthy children (2 RCTs, 2 prospective cohorts). Three of these studies used the Toilet Training in Less Than a Day Program (TTLD); two involved parents (some pre-trained, some not, some supervised, some not) training the children at home; the other used qualified trainers who conducted the training in a separate facility. The toilet training success rate was lower when the child was trained by parents versus the qualified trainer: 50 and 78 percent compared to 100 percent. Parents reported a high incidence of negative emotional reactions to the procedure while the trainers reported that most children responded as if it were a very pleasant experience. Candelora reported the TTLD program was superior to Dr. Spock's recommendations.⁵⁴ The Azrin and Foxx method was used in five studies involving mentally handicapped children (one RCT, three prospective and one retrospective cohort); two used potty and pant alerts (success rates 60 and 89 percent), three did not (success rates 60 percent, 100 percent and significant improvement in successes). All studies modified the method to suit the particular population or staff availability and costs. Because of the heterogeneity in design, populations, implementation, the definitions of success, and outcomes reported, data results could not be pooled. In general, though, it can be said that the Azrin and Foxx method produced many more successes than failures with both healthy and mentally handicapped children.

The toilet training programs and populations were diverse and were assessed using a variety of study designs. A child-oriented toilet training method was used in four studies (1 RCT, 3 single cohort: 1 prospective, 2 retrospective) all involving healthy developing children. Parents were the sole trainers in three of the studies and were part of a multiple caregiver approach on a kibbutz in the other. Only one reported a training success rate (98 percent by age 4 yr). The other studies were investigating on-going bowel and bladder incontinence but training success can be assumed to be 80 percent without problems (generally by 3.5 yrs of age).⁸

An operant conditioning method was investigated in twelve studies (2 RCTs, 9 cohort: 5 single, 5 with a control group). All were prospective, eleven involved mentally handicapped populations, (one study used three healthy children as comparison group) and one was conducted among children with a physical handicap. Two investigators looked at the use of auditory signals to train children. Three of the healthy children were successful and four of nine mentally handicapped children achieved criterion success levels. Two programs involving ten children administered negative consequences for incontinent episodes in addition to positive reinforcement for appropriate actions. Five subjects achieved consistent self-initiated control, four improved between 18 to 60 percent and one did not respond. The remaining eight studies reported only positive reinforcement procedures were employed. Though results are reported in various ways and cannot be combined, they all indicated that operant conditioning interventions yielded improvements over control groups—toileting scores increased, wetting/soiling accidents decreased, laundry requirements decreased, and Templeton/Wingspread/constipation scores improved.

A fourth limitation lies in the fact that several of the studies did not perform a statistical analysis of their own data and only reported results in a descriptive fashion. A descriptive analysis has several limitations and provides the clinical reader with less information to guide future actions. This review provides a table describing the population, each intervention and a range of outcomes depicting success/partial success/and failure rates along with the authors' conclusions. A handful of studies address negative consequences of a program, thus leaving this topic largely unexplored. It allows the reader to draw their own conclusions but fails to answer specific clinical questions. Without a pooled statistical analysis it is difficult to draw conclusions that can be generalized to similar populations in the clinical setting. While we have made limited progress in determining whether one toilet training program is more effective than another, we do know that all programs elicited a measure of success and that the majority of children achieved a higher level of, if not complete, continence.

Future Research Opportunities

To date, toilet training research is hampered by heterogeneity and methodological flaws. The first step to improving the state of toilet training research is to standardize definitions related to toilet training, such as “toilet trained,” “successes,” and “failures.” Second, studies with larger sample sizes should be undertaken. Because almost all children are toilet trained, there is potential for large-scale research.

Given the findings of this systematic review, the following future research priorities are recommended:

• Definitions of toilet training should be standardized and where appropriate, cultural definitions should be developed. The same principles of standardization should be applied to outcome measures.

• While toilet training interventions do not lend themselves to double-blind trials, the methodological quality of future trials could be enhanced by having blinded outcome assessors and concealing allocation.

• The child-oriented approach requires further evaluation and the effectiveness of the elimination communication method needs to be determined.

• Few studies examined factors that may affect or modify toilet training. Additional research is required to examine the effects of modifiers such as maternal age, parenting experience, child temperament, and match or miss-match of parent-child relationship on toilet training success.

• Studies that directly compare two toilet training methods, such as Azrin and Foxx to child-oriented approach, within the same population should be undertaken to determine the most effective toilet training program.

• In an attempt to reduce bias, future studies should be randomized controlled trials or large prospective cohort studies.

• Among the studies examining toilet training among mentally handicapped children, very few described the exact mental handicap. The applicability of the study results would be enhanced if there were increased details concerning the nature of the handicaps.

• Few studies examined adverse outcomes associated with the particular toilet training method. There is a need for long-term follow-up that measures the occurrence of adverse events, such as enuresis, encopresis, stool withholding, stool toileting refusal, and other psychological consequences.

• It has been hypothesized that toilet training is more challenging among children with behavioral disorders, such as autism and attention deficit disorder; however, there is a paucity of evidence examining toilet training in this specific group of children. Toilet training programs should be assessed in children suffering from behavioral disorders.

Conclusions

Toilet training is an important milestone in pediatric development. There are several different toilet training methods; however, the individual programs have not been well researched. Few trials have examined the various toilet training programs and the existing trials tend to compare variations of the same program and not one toilet training method to another. A more popular study design among the toilet training literature is the single cohort: generally, a small group of children were toilet trained using the same method and continence was subsequently assessed. The individual studies were heterogeneous, as the children, toilet training interventions, measured outcomes, and definitions of ‘toilet trained’ were variable.

After a comprehensive search of electronic databases, conference proceedings, and reference lists of included articles, we identified 8 controlled trials and 26 observational studies that examined toilet training methods in healthy and handicapped children. Based on the evidence, the following conclusions can be made:

• The studies are heterogeneous and the methodological quality of the included studies is poor. For this reason, the results and conclusions should be interpreted cautiously.

• Both the Azrin and Foxx and child-oriented methods successfully toilet trained healthy children. However, although the effectiveness of variants of the child-oriented approach and Azrin-Foxx has been studied, the child-oriented approach has not been directly compared to the Azrin-Foxx method.

• No study evaluated the early communication method.

• Toilet training methods in children with behavioral or developmental handicaps were not well studied.

• There is some evidence that, among healthy children, the Azrin and Foxx method may train children sooner than the child-oriented approach but there was limited research to determine if the achieved continence was maintained. In addition, the two methods have not been directly compared to determine the time to achieving continence.

• Azrin and Foxx and operant conditioning toilet training programs were used to partially or completely toilet train mentally handicapped children.

• For children suffering from Hirschsprung's disease and anal atresia, a multidisciplinary approach to toilet training proved to be successful for achieving bowel continence.

• Timed evacuation also was successful for obtaining bowel control among children with physical handicaps.

• Few analyses have been conducted to identify effect modifiers; they were only assessed in studies that attempted to toilet train healthy children.

• There was mixed evidence regarding sex of the child and toilet training; two of the three studies concluded that girls trained earlier than boys, while the third study found that girls achieved nighttime continence before boys.

• Adverse outcomes were seldom assessed and only in the child-oriented approach. Later age of training (>42 months), younger siblings, and parents not being able to set limits for their child tended to be associated with adverse events.

• Later age of toilet training and aggressive toilet training methods were associated with subsequent urinary tract symptoms.

Reference List for Appendix C

Inappropriate Study Design

1.

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