Instruction, timeliness, and medical influences affecting toilet training.

Contemporary toilet training derives from two accepted models: child-oriented gradual training and structured-behavioral, endpointoriented training. The former approach views toilet training as a process by which a parent systematically responds to a child’s signals of toilet “readiness,” whereas the latter views toilet training as a process of eliciting a specific chain of independent toileting behaviors. Practically speaking, contemporary theoretic constructs of toileting behavior diverge with respect to training endpoints (ie, defined differently or deemphasized altogether), emphasis on selfesteem, development of goals, and timing of initiation. A scientific basis cannot be established for a universal timeline for toilet training, because each method has its own definition of the toilet training process. It remains unclear, for example, how long children must remain boweland bladder-continent to be considered trained, and to what extent children should be able to toilet themselves independently of caregivers.1 Both child-oriented gradual and structured-behavioral approaches to toilet training evolved in the United States during the past 40 years within a scientific milieu that came to accept toilet training as a developmental milestone requiring a child’s active participation. This common view of toilet training as a developmental process has provided clinically useful overlapping concepts of mature toileting behavior. The child-oriented gradual method, proposed by T. Berry Brazelton in 1962, defined the parameters of toilet readiness; a decade later, N.H. Azrin and R.M. Foxx designed a structured-behavioral method that detailed the components of independent toileting. Widespread acceptance of readiness and independent toileting have since been supported by clinical experience and resulted in agreement that a child should be ready to participate in toilet training at approximately 18 months of age and be trained completely by 2 or 3 years old. Global trends continue to support this concept despite technologic advancements and conveniences such as diapers, which have enabled delayed training. Toilet readiness is a powerful conceptual tool and requires an objective look both at a child’s willingness to begin and progress with training and at the parent’s preparedness for training the child. In addition to readiness, it is important for the practitioner to recognize other extenuating issues and conditions that can complicate the toilet training process. These may include the child being separated from the parent for many hours each day, such as when in day care, or health conditions such as developmental delays, chronic illness, or disabilities. The clinical community (including physicians, pediatric nurse practitioners, child psychologists, and other child care experts) concedes that although no one theory or method can address every toilet training problem, the individual practitioner who becomes familiar with a child and family situation can effectively advise parents during the process. Objective guidance from the care provider therefore requires an understanding of toilet training theories and methods, as well as the practical issues surrounding the timing of toilet training. Establishing each child’s best “window of opportunity” can be crucial for toilet training success.