2.1.2.5: Toilet Learning/Training

The facility should develop and implement a plan that teaches each child how and when to use the toilet. Toilet learning/training, when initiated, should follow a prescribed, sequential plan that is developed and coordinated with the parent’s/guardian’s plan for implementation in the home environment. Toilet learning/training should be based on the child’s developmental level rather than chronological age.

To help children achieve bowel and bladder control, caregivers/teachers should enable children to take an active role in using the toilet when they are physically able to do so and when parents/guardians support their children’s learning to use the toilet.

Diapering/toilet training should not be used as rationale for not spending time outdoors. Practices and policies should be offered to address diapering/toileting needs outdoors such as providing staff who can address children’s needs, or provide outdoor diapering and toileting that meets all sanitation requirements.

Caregivers/teachers should take into account the preferences and customs of the child’s family.

For children who have not yet learned to use the toilet, the facility should defer toilet learning/training until the child’s family is ready to support this learning and the child demonstrates:

1. An understanding of the concept of cause and effect;
2. An ability to communicate, including sign language;
3. The physical ability to remain dry for up to two hours;
4. An ability to sit on the toilet, to feel/understand the sense of elimination;
5. A demonstrated interest in autonomous behavior.

For preschool and school-age children, an emphasis should be placed on appropriate handwashing after using the toilet and they should be provided frequent and unrestricted opportunities to use the toilet.

Children with special health care needs may require specific instructions, training techniques, adapted toilets, and/or supports or precautions. Some children will need to be taught special techniques like catheterization or care of ostomies. This can be provided by trained staff or older children can sometimes learn self-care techniques. Any special techniques should be documented in a written care plan. The child care health consultant can provide training or coordinate resources necessary to accommodate special toileting techniques while in child care.

Cultural expectations of toilet learning/training need to be recognized and respected.

RATIONALE

A child’s achievements of motor and cognitive or developmental skills assist in determining when s/he is ready for toilet learning/training (1). Physical ability/neurological function also includes the ability to sit on the toilet and to feel/understand the sense of elimination.

Toilet learning/training is achieved more rapidly once expectations from adults across environments are consistent (3). The family may not be prepared, at the time, to extend this learning/training into the home environment (2).

School-age and preschool children may not respond when their bodies signal a need to use the toilet because they are involved in activities or embarrassed about needing to use the toilet. Holding back stool or urine can lead to constipation and urinary tract problems (4). Also, unless reminded, many children forget to correctly wash their hands after toileting.

COMMENTS

The area of toilet learning/training for children with special health care needs is difficult because there are no age-related, disability-specific rules to follow. As a result, support and counseling for parents/guardians and caregivers/teachers are required to help them deal with this issue. Some children with multiple disabilities do not demonstrate any requisite skills other than being dry for a few hours. Establishing a toilet routine may be the first step toward learning to use the toilet, and at the same time, improving hygiene and skin care. The child care health consultant should be considered a resource to assist is supporting special health care needs.

Sometimes children need to increase their fluid intake to help a medical condition and this can lead to increased urination. Other conditions can lead to loose stools. Children should be given unrestricted access to toileting facilities, especially in these situations. Children who are recovering from gastrointestinal illness might temporarily lose continence, especially if they are recently toilet trained, and may need to revert to diapers or training pants for a short period of time. Children who are experiencing stress (e.g., a new infant in the family) may regress and also return to using diapers for a period of time.

For more information on toilet learning/training, see “Toilet Training: Guidelines for Parents,” available from the American Academy of Pediatrics (AAP) at http://www.aap.org and the AAP Section on Developmental and Behavioral Pediatrics at http://www.aap.org/sections/dbpeds/.

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

3.2.1.5 Procedure for Changing Children’s Soiled Underwear, Disposable Training Pants and Clothing
5.4.1.1 General Requirements for Toilet and Handwashing Areas
5.4.1.2 Location of Toilets and Privacy Issues
5.4.1.3 Ability to Open Toilet Room Doors
5.4.1.4 Preventing Entry to Toilet Rooms by Infants and Toddlers
5.4.1.5 Chemical Toilets
5.4.1.6 Ratios of Toilets, Urinals, and Hand Sinks to Children
5.4.1.7 Toilet Learning and Training Equipment
5.4.1.8 Cleaning and Disinfecting Toileting Equipment
5.4.1.9 Waste Receptacles in the Child Care Facility and in Child Care Facility Toilet Room(s)

REFERENCES

1. Mayo Clinic. 2009. Potty training: How to get the job done. http://www.mayoclinic.com/health/potty-training/CC00060/.
2. American Academy of Pediatrics. 2009. When is the right time to start toilet training? http://www.aap.org/publiced/BR_ToiletTrain.htm.
3. Anthony-Pillai, R. 2007. What’s potty about early toilet training? British Med J 334:1166.
4. Schmitt, B. D. 2004. Toilet training problems: Underachievers, refusers, and stool holders. Contemporary Pediatrics 21:71-77.