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

Positive Discipline with a Young Toddler

   Within the last Science Friday, in response to the criticisms that claim AP parents do not discipline their children, I promised to share as of the aspects of positive discipline that we are practicing with Q-ball. Q-ball is a little shy of 14 months, so we certainly have not handled every issue that we will face in toddlerhood.  However, she has been walking since 10 months, meaning she is now very mobile and for about the past month she has been exhibiting early signs of frustration with her inability to explain her wants and needs, which has led to more than a few tears.

   Before sharing tips, it is necessary to define discipline.  While the word discipline tends to carry a negative connotation and is commonly confused as punishment.  The word discipline, however, means to teach or train.  Within our household, we always ensure that our actions are a way to teach Q-ball behaviors that are developmentally appropriate for her and respect her rights as a person.

Cleaning up!

   About 8 weeks ago, I began to encourage Q-ball to "clean up, clean up, clean up" when she was done with any of her materials. She caught on to the phrase quickly, but certainly needed many verbal cues. Within the last few days, she has started cleaning up even without a verbal reminder and even when she does not know I'm watching!  The tips below will show how we used positive discipline techniques to do this. 

1. Establish and maintain appropriate expectations for your child.  I felt this was an appropriate time for her to take on this responsibility as she had the necessary motor skills and was able to comprehend my verbal cues.  I also knew that this practice would not become habit overnight, so I maintained the expectation that I would face many strewn books and blocks along the road to a better maintained space. The later expectation prevents me from becoming (overly) frustrated with Q-ball's learning process, while honoring the skills my daughter possesses.
2. Model the behavior.  Of course, I cannot expect Q-ball to clean up her materials if I do not clean up with her or do not clean up after myself!  As Q-ball currently thinks I'm the 2nd coolest person in the world (Daddy takes top spot), she wants to do what I do. And, our house could certainly use some more tidying! 
3. Repeat, repeat, repeat.  When Q-ball does not clean up after herself, she is not punished or scolded.  Instead, I just verbally remind her and work with her to clean up.  If she has run off to a completely different activity or cannot be brought back to her previous workspace, I'll happily announce, "I'm cleaning this up!" Or, we come back later and clean up together.
4. Avoid praises. When Q-ball does clean up, I do not say "good job!" or provide any other overly positive reinforcement.  I simply say, "thank you!" Our goal is to foster an intrinsic desire for her to clean-up. Obviously, we are proud of her behavior, but given that this is a behavior that should be routine, we do not believe it needs to be celebrated.

Dr. Montessori on Rewards and Walking

    This past weekend was a very exciting weekend in our household; Q-ball started walking!  But, because of our belief in Dr. Montessori's methods as well as a the desire to follow principles of positive discipline and unconditional parenting, Daddy and I worked to ensure that we did not let our excitement diminish Q-ball's own excitement, sense of accomplishment, and desire to continue to work towards mastery. Watching Q-ball learn to walk has allowed me to observe two of Dr. Montessori's ideas firsthand- 1) her reservations towards rewards and 2) her concept of a sensitive period towards walking.

Rewards   

    I believe that Q-ball had been mentally preparing for her attempt throughout the evening. She demanded to get down from her high-chair during dinner and speedily crawled to a wide-open space. Suddenly, although wobbly, she was on her feet with arms flapping. And, then she was on her rear.  But, then she was up again with arms flapping, and then she took three steps! And, then she was on her rear.  She did not look to Mama and Daddy for a verbal reward or encouragement.  In fact, she did not realize that we were watching.  She was so focused on the work of walking that she hardly cared what we were doing.

    Instead of rushing towards her and showering her with "way to go," "good job," and "you are the world's best (and cutest!) baby!" (which would have, no doubt, knocked her over anyways...), we simply looked at each other with happy disbelief and continued our conversation. But, Q-ball was already on her feet to try again. 

   This expereince is very similar to the observations that Dr. Montessori describes in The Discovery of the Child that encouraged her to shy away from a system of rewards and punishments (i.e. praise, grades, threats, and criticism)  within an educational and developmental environment.  In one of her Children's Homes, Dr. Montessori observed two children- one being punished by time-out (or "forced isolation" in the words of Unconditional Parenting's Alfie Kohn) and the other had been rewarded with a large star to wear on his chest. The "good" child was allowed to continue his work and, while busy with his materials, dropped his star.  This child did not even notice he had lost his reward, but the "bad" child quickly asked to pick it up and have it.  The rewarded child was "[indifferent]" to his reward and gave it away without a care. Dr. Montessori concluded, "This pendant could satisfy the naughty one, but not the child contented with his work!"  

   Q-ball does not need us to give verbal praise for her accomplishment. Ultimately, most people provide praise as a means to getting a behavior to continue.  However, the fact that she immediately gets up from falling with a huge smile on her face, ready to try her next steps, indicate that she is internally driven and satisfied with her work.  No additional, exaggerated praise necessary.

   Which leads to the second observation of Dr. Montessori's work...

The Sensitive Period for Walking

     Dr. Montessori believes that very young children undergo a number of "sensitive periods" during which they are especially excited and willing to learn specific skills.  The sensitive period for walking is somewhere between one and two years. Dr. Montessori saw walking as a critical development for children as it provides them with a new sense of independence.  But, she believed that children who are learning to walk view the activity in a very different way than adults do.  While we walk to get to a specific destination or to reach a goal, children walk just to walk.  "The small child walks to develop his powers, he is building up his being. He goes slowly. He has neither rhythmic step nor goal. But things around him allure him and urge him forward."  Q-ball's walking over the last few days has certainly demonstrated this.  

   We have also worked to honor Q-ball's work in developing her walking skills by letting her always lead the way.  We rarely have "helped" her walk since she took her first step (although when a baby is clinging to one's leg as one is frantically trying to finish dinner, one doesn't want to just knock baby to the ground.)  Dr. Montessori also saw this respect for allowing the child to lead while working towards mastery of walking when she said, "If the adult would be of help, [the child] must renounce his own rhythm and his own aim."

   It's amazing to watch Q-ball push herself as she is learning to master a new task. While I'm avoiding providing too many rewards in her presence, I'll happy use this medium to say, "Way to go, Q-ball!  You are the best baby ever!!!"  (Alas, avoiding giving praise is tough!)  

Sources:

Crain, W. (2011) Theories of development: Concepts and applications. NY: Prentice Hall.

Montessori, M. (1936). The secret of childhood. (M.J. Costelloe, trans.). NY: Ballantine Books, 1966.

Montessori, M. (2004) The discovery of the child. Dehli, India: Aakar Books.

What was it like watching your child learn to walk or master another milestone? Did you provide them with reinforcement?