As I recount the various kinds of toilet training advice that I gave to my New York patients when I was in pediatric practice and that I wrote into different editions of Baby and Child Care, I struggled to find the best, the most surefire method, over a period of about forty years. It will illustrate the common hurdles to training young children to use the toilet successfully and that most babies are not ready to toilet train until after two years of age.
I was aware, from my own pediatric practice (which began in 1933) and from what my wife reported from conversations with other Central Park mothers, that many mothers in the 1930s tried to get started on bowel training in the first years of life. This was in line with the English tradition, brought to American cities by English nannies who wore blue capes and nurses’ caps. They were hired by the wealthy to care for their children because they had such firm ideas about health and discipline. They believed that regularity of movements was the very foundation of health and that the habit of regularity should be established as early as possible in the first year by early toilet training. They prescribed supporting the baby on the potty at the same time of day every day. One Central Park mother would boast, “My baby hasn’t had a dirty diaper since the age of six months.” Another mother would counter, “Well, my baby has been clean since four months.”
Careful analysis of these claims showed that it was really the mother who was trained—trained to catch the movement of a baby who had it at the same time of day. After a few weeks it becomes a conditioned reflex; when the baby felt the potty seat he pushed. But quite often in such a case the baby would rebel later—at fifteen or eighteen months. He would object to yielding control of this body function to his mother at this age when he was becoming more aware of his separateness and of his instinct to assert it. He would realize that this bowel movement (many parents call it “BM”) is his own possession, as his hand or nose is his possession. If his mother gets too bossy about trying to control the timing or the disposal of the BM, he has the impulse to hold it inside or release it in some hidden place like his diaper or, if he has no diaper on, perhaps behind the sofa, any way that would keep it from becoming his mother’s object to control.
The baby who was quite irregular during the first year was often difficult to “catch” and condition. Usually the mother would give up after a shorter or longer effort. She’d try again in a few months. But if it was the second year by then, she was likely to run into the increasing resistance to yielding the BM. If the mother became more insistent, keeping the baby on the potty, the baby’s resistance would grow enough to foil her. If she became grim, so would he. The conflict could sometimes last till three or four years of age and might, according to some psychiatrists, lead to excessively obstinate or compulsive character formation as they saw in some of their adult patients.
As a beginning pediatrician eager to help parents avoid emotional problems, I advised the first mothers who consulted me to avoid early and aggressive training efforts. I suggested, instead, starting at one year of age. This turned out to be poor advice, for some babies, because they were just getting to the stage of feeling more uncooperative or contradictory about yielding control to their mothers.
Why couldn’t I have consulted other professionals? There were none at that time who had really studied the problem in infancy. There were the English nannies who had a strong prejudice for early training, the psychoanalysts who didn’t see babies but who were vigorously opposed to early training because of what it might do to character, and the pediatrician who either had no opinion or who went along with early training because regularity of BMs was considered so important in those days.
Then, by coincidence, I was consulted by two mothers about other problems who said incidentally that they had stumbled on a perfect solution for toilet training. With their older children they had struggled long and hard to overcome vigorous resistance to training. When a third child came along they dreaded a repetition, and procrastinated. But by about two or two and one-fourth years these children, after observing their older siblings using the toilet, decided all by themselves to do the same and became trained not only for BMs but for bladder control! I enthusiastically passed this information on to mothers in my practice and in an early edition of Baby and Child Care. But I got grumpy responses from some mothers who complained that it hadn’t worked for them at all. Next I recommended that parents begin training at about two years of age, and emphasized tactfulness and gentleness, so as not to stir up an uncooperative attitude. But if it happened, I suggested dropping training for a while. Some mothers still complained that their babies became resistant.
At that stage I moved to Cleveland and worked in the same department with child therapists who had been trained by Anna Freud. In general, their attitude was a no-nonsense one. They were direct and very clear in dealing with their child patients. Since I hadn’t found that the advice I gave many of my own patients worked consistently, I took my cue from these child therapists and urged parents, once started on toilet training, not to give up but to persist in a firm but friendly manner. But still there were some failures.
Then in the mid 1970s, I read an article by T. Berry Brazelton, a Cambridge, Massachusetts, pediatrician and friend who reported remarkable success with what was essentially self training in fifteen hundred consecutive patients of his own, between the ages of two and one-fourth and two and three-fourth years. He emphasized first that the baby should have reached the stage of being interested in putting objects in containers, which normally occurs in the second year. Then at one and one-half or two years he suggests that the parents buy a baby’s toilet seat designed to fit over a potty on the floor, with a lid covering the opening. This is to be just the baby’s own chair to sit on and play with for the next few weeks or months, with no suggestion of its BM-catching function. To repeat, this is to ensure that the baby feels that it is his very own plaything and that it is not a scheme of the parents to get his BM away from him.
Then, after the child has accepted the seat for weeks as his personal furniture, and he is between the ages of two and two and one-fourth years, the parent can casually turn the lid up, revealing the potty, and say—still quite casually—that the child can use it for BMs, just the way mommy and daddy use the big toilet seat. No more than that. No urging him to sit down and try it. If he does sit on it momentarily and then gets up, don’t urge him to sit down again or to stay until he has a BM. The whole idea is to let the child have the feeling that he’s in charge, that he can use the seat as he wishes. It’s not part of the parent’s scheme. A parent may show him how the parent or an older child deposits a BM in the big toilet.
Dr. Brazelton found that a great majority of his patients came to proudly use the seat between the ages of two and one-fourth and two and three-fourths years old. Furthermore they went on to urinate, enthusiastically, while sitting on the open seat, within a few days. The most remarkable result of all was that very few of the children became chronic bed-wetters.
I asked Dr. Brazelton why he thought my recommendation of self-training in the 1930s often failed to work, whereas his method which was much the same in spirit had been such a success in the 1970s. He said he thought the mothers of the 1930s and early 1940s really expected success in training within the first year and showed impatience to their babies when they wouldn’t cooperate. But by the 1970s mothers had gotten over such ideas and were ready to wait with real patience until their children were over two years. I accept this explanation. In line with this interpretation is the fact that in England, the land of early training, bed-wetting in adulthood is one of the most common causes of rejection for the army.