More Research on "Early" Toileting

Image credit: www.lilomaternity.com

  

   A few weeks ago, I published this post on some of the research on early toileting.  Truthfully, I wasn't overly happy with the post, mainly due to a mix of lack of time and lack of research that focused on age and toileting.  So, I decided that I would dedicate another Science Friday post to the topic and hopefully share a bit more of the limited information about age and also look at the research that explores the various methods of toileting.
   A quick google search of "potty training" will lead many parents to believe that young babies and toddlers are not capable of bowel or bladder control. Babycenter.com actually tells us "Before 12 months of age, children can't control their bladder or bowel movements..."  However, one study comparing bladder function in babies in Vietnam (where the babies rarely wore diapers) and Sweden (where all of the babies wore diapers) reveals that this isn't the case. How do you test for bladder control?  The researchers measured voided urine for newborn babies to those 12-months old and then used an ultrasound to determine the amount of "residual urine."  This reminded me of my first ultrasound when the technician told me that I needed to pee before I actual knew that I needed to.    Additionally, researchers looked for "interrupted voiding," the phenomenon of two urination episodes within 10 minutes of each other, with higher residual urine after the first urination.  Interrupted voiding may be caused by immature muscle control and tends to decrease with age and is typically stops when the child is potty-trained.
     The researchers discovered that the babies in Vietnam exhibited much more advanced bladder control than the babies in Sweden.  Instances of interrupted voiding stopped at 9 months for the Vietnamese babies, but continued until 27 months for some of the Swedish children. Additionally, instances of "incomplete emptying" which is measured by the residual urine ended between 9 and 12 months for the Vietnamese children (residual urine was just .7ml and .5ml, in case you are really interested).  For the Swedish children, residual urine instances were still very high at 9 to 12 months (averages were 7.4 ml to 7.1 ml).  Most Swedish children obtained complete bladder emptying at around 2 years old.  Using these data, the researchers conclude that the Vietnamese babies do exhibit bladder and bowel muscle control before 12 months and "can be considered potty trained much earlier than children in Western countries."
   Looking beyond when to potty train, the next question most caregivers ask themselves is, "how should I do this?"  Again, the research that has been conducted is not overly helpful.  While there has been substantially more research that examines potty training methods than examine the the best age for potty readiness, the research often does not compare the various methods, and instead focuses on the results of one method. However, within research circles, there are typically four accepted methods of toileting (these descriptions are meant to be very brief! Please do more research before following one!):

1. Child-oriented: Typically starting around 18 months, the child is introduced to the potty according to her timeline. Diaperless time is used as the child demonstrates they are comfortable sitting on the potty. No system of rewards or punishments are used.
2. Azrin-Foxx Method: Typically begins around 20 months of age.  Child and caregiver stay in a room with all necessary supplies and with minimal distractions (i.e. toys).  A doll that wets itself is used to demonstrate the potty method.  Child is given praise (snacks, verbal praise) for using the potty and reinforcements are removed when the child has an accident.  After an accident, the caregiver also uses the doll to demonstrate 10 "positive practice" sessions.
3. Early elimination: Starts within the first weeks of life or at less than 4-5 months.  Caregivers learn to read infants elimination cues and allow child to void in an appropriate place, providing feedback to the baby.  Through work with the caregiver, the child is expected to learn to communicate her need to use the toilet.  By the time the child can walk, she is expected take herself to the toilet.
4. Dr. Spock's Method: Typically around 2-2.5 years.  Allows the child to choose to potty train when they are ready.  Introduce potty chair and keep it insight.  Suggest to child she use it to eliminate.  When child shows interest, start to ask them to use the potty throughout the day.

   A large-scale research review of toileting methods for healthy children (it started by examining 772 studies of potential relevance!) discovered the following:

• No studies analyzing the results of elimination communication or early elimination.
• No "head-to-head comparasion" of the child-oriented method and the Azrin-Foxx method, making it impossible to truly compare the results.
• But, looking at the results of individual studies, the Azrin-Foxx method typically has faster outcomes when followed precisely, sometimes within days.
• For longer-term success (1 to 4 months of training) both Azrin-Foxx and child-led methods are successful for healthy children. 

   So, how to choose your method?  We looked at the goals we have for our daughter and selected the child-led method.  We largely practice unconditional parenting, so a method that employs rewards and punishments is not in-line with our parenting practices.  Additionally, we strive for Q-ball to be in control of her own exploration to the greatest extent possible.  Again, this leads to the child-led method as we follow her signs of readiness and acceptance of the potty.  Along these same lines, I started observing Q-ball indicating self-knowledge of bladder functions around 13 months, so we decided to initiate potty-learning at this time.  At 15 months when she is not in a diaper, she typically indicates with sign language that she needs to eliminate.  Does this mean that we always make it to the potty?  No, but we are letting her take the led!

What method of potty training did you use, or do you plan to use?  What is your reasoning?

Sources:
Duong, T.H., Jansson, U., Holmdahl, G., Sille, U., & Hellstrom, A. (2010). Development of bladder control in the first year of life in children who are potty trained early. Journal of Pediatric Urology, 6, 501e505
Kiddoo D, Klassen TP, Lang ME, Friesen C, Russell K, Spooner C, Vandermeer B. The Effectiveness of Different Methods of Toilet Training for Bowel and Bladder Control. EvidenceReport/Technology Assessment No. 147. (Prepared by the University of Alberta Evidence-based Practice Center, under contract number 290-02-0023). AHRQ Publication No. 07-E003 Rockville, MD: Agency for Healthcare Research and Quality. December 2006.  Retrieved from http://www.ahrq.gov/downloads/pub/evidence/pdf/toilettraining/toilettr.pdf

Watch Her Grow

This Week's Focus: Language


Interactions with Materials

• Q-ball has been incredibly interested in using the computer keyboard and mouse.  We really use the computer very little in her presence, but it only took a few observations to make her really want to immediately grab them all the time.  So, care of the thrift shop, she now has her own keyboard and mouse.  She was super, super pumped with this big investment.  
• She's continued to love listening to music.  But, I returned one of the classical baby CDs to the library and got some more upbeat toddler tunes for a different twist, and she hated it!  She was crying and yelling at the CD player and manically making the sign for "music."  So, we quickly traded that CD for some gentle guitar songs. 
• She is also really enjoying working with simple puzzles.  She has points of frustration, but she's been able to work through them.

Interactions with Others

• It seemed as though she had come out of her shell a bit with other adults after Grandma and Grandpa's trip.  But, in the past few days, she seems to have closed herself off again.  Even poor Daddy was greeted with tears when he came home!

Interactions with Space

• Her desire to climb onto everything has continued. She also likes to climb out of things- especially her booster chair!  Mealtimes have gotten quite short as she's decided she likes to eat most of her food on the run.
• She can now reach the doorknobs and open doors!  We'll see how this goes...
• And, Q-ball climbed all the way to the top of the twirly slide at the park and then pretty much threw herself down the slide.  This even took Mama by surprise!

Interactions with Life 

• Yesterday she figured out how to take a bite off of a banana vs. eating the pieces that Mama gives her.  She thought it was very, very funny and laughed after every bite.
• We have had a few more potty successes, but are still certainly in early learning.
• Daddy is very happy that his daughter is not following in Mama's footsteps and has loved eating meat!  She loves natural hams and even ground beef!

This post is linked up with Melissa from Vibrant Wanderings. Check out the links to see what other fantastic kiddos are up to!
 
To see the rational and purpose for the Watch Her Grow series, please check out this post!

Less-Words Wednesday: Just Like Daddy

Q-ball loves putting things around her neck- it's not uncommon to see her walking around the house with a measuring tape draped over her shoulders that she discovered in a desk drawer.  Perhaps we'll finally have a seamstress in the family!  

She also loves draping Daddy's ties over her shoulders.  A few days ago Daddy actually tied a tie for her- what a treat!

Watch Her Grow...

This Week's Foci: Language


Interactions with Materials

• Q-ball is starting to be able to sit and look through a book on her own and "read" it aloud.  Before she always wanted someone else to read the book to her.
• She is starting to really clean up- i.e., throw small items around the house into the trash can.  We are looking for an alternative.
• She is also really starting to be drawn to stuffed animals.  She loves seeing them at the library and playing with Mama's old stuffed animals.
• She has again discovered the cats' tent and runs around the house with it on her head. 

Interactions with Others

• She had an excellent time last week with Grandma and Grandpa and her Aunt!  She quickly adjusted to them and especially loved being spoiled.  She was soon sitting in their laps, letting them pick her up, and even going out alone with them!  What fun!

Interactions with Space

• Q-ball is still dancing and running all over the place.  She is also trying to start climbing up chairs and bookcases. 

Interactions with Life 

Longest wait ever....

• We are still working on new signs.  Q-ball was finally able to practice "rain" with real rain vs. rain in a book.  She immediately recognized it, and even asked Mama and Daddy if "rain" is "water".
• She says "bye" whenever we leave the a place or hang up the phone.  She also always tells Daddy "bye" at bedtime and bath time. 
• Small successes with potty learning.  She makes the sign for "pee" and will typically go within the next 10 minutes.  But, we still need to practice being on the potty at this time. 
• Q-ball is very good at helping Mama unpack the groceries.  It's actually quite amazing to see that she knows where most items go and will put them up with little help from me, as long as they don't go in the refrigerator (which she can't open.)  But, I can't decide if learning to gently unload beer bottles is a lesson for someone this age...

Do you have hints for getting an attached 14-month old to stay with an alternate caretaker? 

This post is linked up with Melissa from Vibrant Wanderings. Check out the links to see what other fantastic kiddos are up to!
 
To see the rational and purpose for the Watch Her Grow series, please check out this post!

Less-Words Wednesday Flags!

Q-ball has started to love flags.  It's fun for me to see all of the places she spots them.  As an adult, I find that I so often have tunnel vision and don't notice all of the bombardment/excitement around me. But, my curious child finds beauty or interest in everything! We see flags at the grocery store, church, on houses, in department stores, pretty much every place we go!

Here, she was very excited as she was surrounded by tons of flag poles with huge flags on top!  And, yes, it was very hot that day, but this is one thing she doesn't seem to notice!

Paternal Attachment

        Q-ball loves her Daddy!  She is blessed with a wonderful Daddy (and I’m blessed with a wonderful husband!)  But, it seems that dads often get a bad rap in the media and certainly are less likely than moms to be the primary care providers for children. In the past, I have focused on maternal attachment.  But, in recognition of Father’s Day, I wanted to look at some of the current research regarding paternal attachment and the influence of fathers on their children.  I know that I have heard a lot about the negative affect that dads can have on children, so for today’s Science Friday (although it's a day late...) I tried to find studies that focused on the positive effects that fathers can have on children or just facts about paternal attachment in general.

• Fathers who are present at the birth of their child are more likely to demonstrate more attachment behaviors (holding, verbalizing, touching, etc.) with their newborn than fathers who were not present.
• While attachment studies tend to focus on the infant’s attachment to the primary caregiver (typically the mother), studies have also shown that a strong, positive relationship in the concordance of attachment patterns.  That is, infants who are securely attached to their mothers are very likely to be securely attached to their fathers. Likewise, infants who are insecurely attached to one parent are very likely to be insecurely attached to the other. While many theories exist to explain this relationship, the two I that liked are 1) mother and father learn together how to respond to their children and 2) one parent may serve as a model for the other parent.  I like the idea of mothers and fathers being a team!
• Fathers are more likely than mothers to interact with their children through physical play and to generate more excitement in children.
• Paternal sensitivity is related to the pattern of attachment that a father will have with his children.  Increased sensitivity is linked with a more secure attachment pattern.
• A father’s appropriate response to a young child’s emotions predicts positive social and emotional models of behavior in adolescence. 
• One study revealed the that the most significant predictor of empathy in children is paternal involvement in childcare as fathers establish clear boundaries for children, thus demonstrating how to respect other peoples’ boundaries.
• More and more fathers are providing child care as more mothers are working. Research has revealed that these children, when compared to children with mothers, another relative, or a non-relative as the care provider, are “no better or no worse.”  (This is still a positive note! Many of the researchers hypothesized that paternal care would be worse for the children than maternal care!)

Some researchers consider the father essential for the holistic development of the child.  I know this is true in our family!  It is obvious that Q-ball interacts with her father completely differently than she interacts with me.  While I am occasionally jealous of the fun they have, I am more often relieved to have a short break and am thankful for Q-ball’s opportunity to practice different interactions. 

Thank you for all the fun, Daddy!  Happy Father’s Day!

Does your child interact differently with his father than with his mother?  What role does the father play in your house?

Sources:

Averett, S.L. Gennetian, L.A., & Peters, H.E. (2005). Paternal child care and children's development. Journal of Population Economics, 18, 391-414.   

Fox, N.A, Kimmerly, N.L., & Schafer, W.D. (1991).  Attachment to mother/attachment to father: A meta-analysis. Child Development, 6(1), 210-225.

van IJzendoorn, M. & de Wolff, M. (1997). In search of the absent father-meta-analyses of infant-father attachment: A rejoinder to our discussants. Child Development, 68(4), 604-609.

Millar, D. (9 October 2006). The impact of a father on a child’s socio-economic development.  Retrieved from http://fathersmatter.wordpress.com/tag/attachment-theory/

Miller, B.C. & Bowen, S. (1982). Father-to-newborn attachment behavior in relation to prenatal classes and presence at delivery. Family Relations, 31(1), 71-78.

Our Montessori Environment for a Young Toddler

  I have not shown off any of the changes we have made to our Montessori environment since Q-ball has become a young toddler.  At nearly 15 months old, she is extremely mobile (running and jumping are favorites), can reach for doorknobs, opens cabinets, and just generally gets into anything she can get her hands on.  So, we certainly needed a few updates from the treasure baskets that she used to love.  Here is her new space!

In the kitchen: Q-ball does still have a kitchen treasure basket on the bottom kitchen shelf. She is able to access the bowls and containers on the other shelves to stir and/or bang while Mama is cooking.

Q-ball's table. She loves playing musical chairs! And her stacking tree!

This is her active corner. A basket full of different sized balls to toss, roll, and kick. And, her constant favorite walking wagon which is uses to run circles around the room.

This shelf gives her the opprotunity to practice her new favorite activities: "vrooming" cars and practicing fine motor skills with a Montessori-inspired coin box.

In the living room: Q-ball has six shelves.  They allow her to explore sound, touch, and sight.

A nature basket, homemade rattles, a dressing frame with a zipper made by Grandma, a simple puzzle, and lots and lots of books! ( We love reading right now!)

And, my beautiful homemade mobile above her table.  She's impressed, at least!

What are your young toddler's favorite activities?

The Science Behind "Early" Toliet Learning

   We recently bought a potty for our 14-month-old.  For many in our culture, this may seem futile or even crazy.  However, many non-Western cultures begin the process of pottying at birth, raising children who never wear diapers.  Even within Western cultures, however, the average age that children achieve potty training has increased in the last 50 years.  In the 1980, the mean age was 26 months, while in 2003, the average age was 36.8 months.  The most recent numbers I can find seem to indicate that currently the average age of toilet training  is 35 months for girls and 39 month for boys.  As for the current advice from the medical community, the AAP states the following: "most children start to show an interest between the ages of 18 months and 24 months...Some children are not ready until they are 2 1/2 years old."

    We made our decision to initiate potty learning (I use this phrase in lieu of potty training in that we are not using any system of rewards or punishments, and we are using a very-child led method.) as Q-ball was signaling when she urinating, a clear readiness indicator. Following Dr. Montessori's idea of a sensitive period in which to master skills, I wanted to take advantage of this opprotunity. At least two Montessori resources (Montessori From the Start: A Child at Home from Birth to Age Three and How to Raise an Amazing Child the Montessori Way) list 12 to 18 months as the sensitive period of toileting.  However, given the mean ages of toileting for children in the Western world, this seems to challenge conventional wisdom.  So, for this Science Friday, I wanted to explore any research on the effects of "early" toileting. (A note- some parents practice infant potty training or elimination communication. While we are using some of the methods used in this practice, I would not say that we are practicing elimination communication with Q-ball as the optimal time frame for this method is between 4-5 months of age.  However, the research I found can be used when considering elimination communication.)

     I must say that I honestly had no idea what I would find in the research.  If anything, I thought that research would lead to be believe that we were starting too early, given that I've always heard that the "perfect time" to potty train is around age two because of muscle control.  However, little research has been conducted on the effect of age in toilet training, and the studies that have been conducted seem to focus on the effect of late starters (usually defined as after 32 months), not the effectiveness of infant potty training.   

Our new morning routine!

   One clear finding concerning age and potty training is that late starters typically take longer to achieve bladder and bowel control.  Beyond this, late training, even when controlling all other characteristics, is typically associated with increased in stool refusal, hiding while having bowel movements, constipation, and even delayed language development.   As I've stated, children in Western cultures are achieving toilet training later and later.  With this, constipation and stool refusal are also on the rise (Visits to the pediatrician for constipation doubled between 1958 and 1986.)  The research I read was not sure of the direction of causality as there are so many factors involved.

   One topic that is currently hot within pediatric urology is the possible relationship between later toileting and urinary track infections and other bowel problems.  I was very surprised to  read about this research.  One of the studies I found did find that late initiation of toileting is significantly related to urge incontinence later in life, but other studies are not as conclusive.  That being said, I did not see any studies that stated there is not a relationship between the two.

   I certainly did not find the amount of research that I would have liked.  However, given what I did find, I am happy with our decision to initiate potty learning now. Studies do agree that readiness indicators are important for initiating potty learning or training.  So, while we have yet to get any pee in our potty, I'm sure that Q-ball will get it one day soon!

Sources:

Barone, J.G., Jasutkar, N., Schneider, D. (2009). Later toilet training is associated with urge incontinence in children. Journal of Pediatric Urology  5, 458e461
Blum, N., Taubman, B., & Nemeth, N. (2004). Why is toilet training occurring at older ages? A study of factors associated  with later training. Journal of  Pediatrics (145) 107–11.

Bouke, L. (2002). Infant potty training. White Bouke Publishing: Lafayette, CO.

Duong, T.H., Jansson, U., Holmdahl, G., Sille, U., & Hellstrom, A. (2010). Development of bladder control in the first year of life in children who are potty trained early. Journal of Pediatric Urology, 6, 501e505

It's Potty Time! (5 June 2012). HealthyChildren.org

Kiddoo D, Klassen TP, Lang ME, Friesen C, Russell K, Spooner C, Vandermeer B. The Effectiveness of Different Methods of Toilet Training for Bowel and Bladder Control. EvidenceReport/Technology Assessment No. 147. (Prepared by the University of Alberta Evidence-based Practice Center, under contract number 290-02-0023). AHRQ Publication No. 07-E003 Rockville, MD: Agency for Healthcare Research and Quality. December 2006.  Retrieved from http://www.ahrq.gov/downloads/pub/evidence/pdf/toilettraining/toilettr.pdf

Watch Her Grow

This Week's Foci: Language


Interactions with Materials

• We did major toy rotation this week, so Q-ball's area was all so interesting for her!  She loved exploring a wooden bus, the Montessori-inspired coin bucket, and a seashell. (More info on Monday about our new materials!)

Interactions with Others

• It's been about 8 weeks since we have tried to leave Q-ball in the nursery during church.  Currently, Daddy is staying with her to prevent any major breakdowns. (There are still breakdowns, even with him there.)  She still starts screaming or tenses up when she sees the caretaker.  Maybe one day!

Interactions with Space

• Q-ball is almost tall enough now to sit her the chairs she got for her birthday without help. (Although, she always seems to prefer help right now...)They grow so fast!

Interactions with Life 

Corn on the cob- great for teething! And, she was super excited when she figured out the "right" way to eat it!

• We are still trying potty learning.  Right now, I just have her diaperless for about 1-3 hours a day, depending on our schedule.  So far, no luck on my part to "catch" any pee, despite lots of reading on the potty. She seems to stand up right before she pees every time!
• Again, it is amazing to see her ability to recognize the world around her.  She has loved the snoring sound when we see "ZZZZ" in books.  This week she pointed to the word "zoo" and made her version of snoring.  I would have never imagined! 
• And, she is really exploring her sign language now.  In addition to demanding to go "outside" all day, she always wants to see "butterflies."  I've also been impressed about the ability to recognize "water" in various forms- from a house, in her cup, in a river.  It's amazing that babies can identify the items, despite the different uses.

Do you have hints for getting an attached 14-month old to stay with an alternate caretaker? 

I always fail to mention, but I always link this post up with Melissa from Vibrant Wanderings. Check out the links to see what other fantastic kiddos are up to!
 
To see the rational and purpose for the Watch Her Grow series, please check out this post!

Less-Words Wednesday

It's been a few weeks since I've gotten to share photos through this post!  We've been busy!  Because of the heat and sun, Q-ball and I have been trying to go to the park first thing in the morning.  Here are some shots from this morning's fun!

She is enjoying the swing more than she used to!  She loves looking around!