Who’s training whom?
Article Outline
“How may a child be trained to be regular in the action of its bowels?
See related article, p 165
By endeavouring to have them move at exactly the same time every day.
At what age may an infant be trained in this way?
Usually by the second month if training is begun early.
What is the best method of such training?
A small chamber … is placed between the nurse’s knees, and upon this the infant is held, its back being against the nurse’s chest and its body fully supported. This should be done twice a day, after the morning and afternoon feedings, and always at the same hour. At first there may be necessary some local irritation, like that produced by tickling the anus or introducing just inside the rectum a small cone of oiled paper or a piece of soap, as a suggestion of the purpose for which the baby is placed upon the chamber; but in a surprisingly short time the position is all that is required. With most infants, after a few weeks the bowels will move as soon as the infant is placed on the chamber.
What advantage has such training?
It forms the habit of having the bowels move regularly at the same hours, which is a matter of great importance in infancy and makes regularity in childhood much easier. It also saves the nurse much trouble and labour.”
Luther Emmett Holt
The Care and Feeding of Children (1894)
The above advice to mothers followed the plan laid out in Holt’s classic textbook of pediatrics in which training regular bowel habits by 3 months of age was the goal.1 If placing the infant on the pot were an insufficient stimulus, then the judicious use of sticks, soap slivers, lubricants, enemas, stool softeners, laxatives, or cathartics could be used to facilitate the training. A worship of cleanliness with children being “trained” as early as 1 month of age—an instance “worthy of imitation”2—probably goes back to colonial times. The relation between cleanliness and godliness was not simply a popular religious association but was a firmly rooted belief: “Cleanness of body was ever deemed to proceed from a due reverence to God.”3 In the early twentieth century, it was further reinforced by the new science of behavioral psychology: Watson recommended that conditioned response training for daytime continence begin at 3 to 5 weeks of age.4 Cross-cultural studies went so far as to document the increased efficiency of sub-Saharan tribes in this achievement.5 Certainly some of this early child rearing advice now seems unrealistic if not cruel, and parental beliefs have become markedly more realistic.
In his 1930 parenting book, The Guidance of Mental Growth in Infant and Child, Gesell broke with the “toilet training from birth” school and recommended a later age for the initiation of toilet training. Gesell noted that extremely early personal-social achievements were most susceptible to regression and that such infant toilet training was frequently lost after 7 months of age because of developing resistance that could then continue up to 15 months.6 Early on, it “is almost as if the child’s nervous system were completed by his mother.”7 A developmental sequence that allowed the child to actually learn toilet training (rather than have it imposed) was more physiological between 15 and 18 months of age—although it could develop earlier in children with more advanced language skills. Supplementing Gesell’s physiological approach were Myrtle McGraw’s twin studies that showed attempts to accelerate toilet training were a waste of time. When one identical twin was systematically trained, the control twin achieved continence shortly before or after the trained twin.8
Working with a population of persons with significant cognitive limitations in the 1970s, Foxx and Azrin9 detailed the minimal developmental prerequisites for toilet training: ambulation, the motor skills to pull one’s pants down, and the ability to follow simple one-step commands. If these were present, then a person of any mental or chronological age could be toilet trained. If any of these were absent, then successful toileting was unrealistic and unlikely.
The achievement of bowel training still draws with it a complex web of associations including cleanliness, godliness, a sense of time, emerging responsibility, maturing self-control, an expression of love, and the ever-popular “breaking of the child’s will.” All of these ultimately evolve into a single common denominator: the adequacy of the mother, the competence of her parenting skills. The fact remains that the vast majority of American children complete toilet training between 30 and 36 months of age. How can one explain the difference between the previous recommendations for earlier training and the present age of achievement? There are three approaches to toilet training: (1) toilet training that begins in the first weeks of life is a reflex conditioning of the mother; (2) training started around 18 months of age is a reflex conditioning of the child; (3) training that is completed closer to the third birthday is more dependent on social imitative learning—in which the child decides to imitate “the way the big people do it” pretty much on his or her own without any conscious adult teaching/training.
In this issue of The Journal of Pediatrics, Horn et al10 find that African-American mothers seem to prefer approach 2, whereas white families lean more toward approach 3. A more detailed investigation of specific techniques will help clarify this distinction and whether it reflects a deeper difference in child-rearing philosophy.
The external pressure on mothers for their children to be toilet-trained has radically changed over the past half century. It is quite acceptable among mothers for a child under age 3 years to not yet be trained, and most day care/preschool placements for young children will not require such training until after 3. As a developmental milestone, toilet training combines a required neurologic substrate that has a relatively fixed timetable and a socially defined end point with a widely varying range of acceptable practice—all leading to an age of achievement that over the past century has actually increased by almost 3 years. Perhaps this is an example of maternal wisdom being impervious to child development research and pediatric sagacity.
References
- . In: The Diseases of Infancy and Childhood . New York: D Appleton and Company; 1897;p. 4–5
- . In: A Treatise on the Medical and Physical Treatment of Children . Philadelphia: HC Carey & I Lea; 1825;p. 237
- Francis Bacon. Advancement of Learning, II
- . In: Psychological Care of Infant and Child . New York: WW Norton & Co; 1928;p. 120
- . Childhood in Contemporary Cultures . Chicago: University of Chicago Press; 1955;
- . Infant and Child in the Culture of Today . New York: Harper & Brothers; 1943;
- The First Five Years of Life . New York: Harper & Brothers; 1940;
- . Neural maturation as exemplified in achievement of bladder control . J Pediatr . 1940;16:580–590
- . Toilet Training the Retarded . Champaign, IL: Research Press; 1973;
- . Beliefs about the appropriate age for initiation of toilet training (are there racial and socioeconomic differences?) . J Pediatr . 2006;149:165–168
PII: S0022-3476(06)00341-6
doi:10.1016/j.jpeds.2006.04.026
© 2006 Mosby, Inc. All rights reserved.
Refers to article:
- Beliefs about the appropriate age for initiating toilet training: Are there racial and socioeconomic differences?
